How Doctors Choose a Specialty

People sometimes assume that every doctor feels a calling or has a special
skill for one area of medicine or another. But the truth is very
different for most doctors.

Old operating theater in London
Wikimedia Commons (Mike Peel, CC BY-SA 4.0)

When students begin medical school they don’t actually know what medicine entails. Maybe they’ve followed physicians around or worked in a lab. But that is completely distinct from being
in a hospital for twelve to fourteen hours a day writing notes, calling
consults, rounding on patients, operating, or delivering babies. And even
when young students do see these things, they
usually watch from afar and don’t fully understand what’s going on. The
hierarchy, the language, and the rapid exchange of information remain a
mystery.

Nevertheless, matriculating medical students still have ideas about what
specialties they want to practice. Walk around an auditorium during an
orientation and most budding physicians will say they’re interested in one
field or another. This is completely understandable; something motivates
people to apply to medical school. I thought seriously about
becoming an emergency-medicine doctor. I had worked as an EMT in New York and loved the excitement of
emergencies, the rush of adrenaline, and the range of patient presentations.
But I didn’t really know what it was like to work in an emergency room for
a twelve-hour shift.

Once medical school starts, things slowly change. As they study the
biological systems and dissect in the anatomy lab, some students realize
that they now feel dispassionate towards what they once loved. Suddenly, the eye
or the heart or the skin is not as interesting as the lungs or the brain or
the intestinal system. Granted, this is all still theoretical — it
is early, and the students have not been inside the hospital yet. But inklings
arise and ideas take hold. I enjoyed many of the educational blocks during
medical school and even had a particular affinity for hematology and

gastroenterology
, while taking a dislike, surprisingly, toward neurology (I am now a
neurology resident).

It is during the

third year of medical school
when professional ambitions take shape, as students work in the hospital and
clinic. They rotate through general surgery, psychiatry, emergency
medicine, and neurology, among other specialties, getting a quick but deep
sense about how these areas work. They participate in surgeries, clinic
appointments, and

hospital codes
. Decisions about a future specialty often form during these samplings.

But there is often much more to those decisions. I liked nearly everything during third year. I found the
operating room fascinating. You stand at the operating table and
assist the surgery residents and attending as they open up the
patient and take out parts of the intestine or the gallbladder. You
peer into a living human body in real time. You see the problem; you fix or
remove it; and then you sew the patient’s skin back together. Other
specialties are similarly awe-inspiring. On my obstetrics rotation I

delivered babies
. In the emergency room, I participated in

trauma codes
and watched the effects of

treating drug overdoses
. There is so much to marvel at in medicine that each rotation is appealing
in some way. How can a student settle on one specialty?

When faced with this impasse, another deciding factor is often
a teacher or mentor.
After all, the word “doctor” comes from the Latin verb docere, which means “to teach.” The degrees we receive when we graduate from
medical school read M.D., or Medicinae Doctor — “teacher
of medicine.” So when we speak of a

doctor’s purpose
 it is implied in the word that the purpose is not just to heal the sick but to teach the
next generation of doctors, and also one’s patients. Notice this passage from the

Hippocratic Oath
:

I swear by Apollo The Healer…. To hold my teacher in this art equal to my
own parents; to make him partner in my livelihood; when he is in need of
money to share mine with him; to consider his family as my own brothers,
and to teach them this art, if they want to learn it, without fee or
indenture; to impart precept, oral instruction, and all other instruction
to my own sons, the sons of my teacher, and to indentured pupils who have
taken the physician’s oath, but to nobody else.

Image via Flickr

These lines that deal with the doctor-student relationship come before the parts about
the doctor-patient relationship. It is one of the few professions left in this country that
still functions as an apprenticeship (somewhat similar, in a few respects, to being a Ph.D.
student under an adviser). One studies a specific topic very intensely for
an extended period of time with a group of professionals who teach you how
to do what they do. This means that who teaches you matters as much as what you’re
taught.

When I rotated through neurology, the subject area excited me, but I was particularly impressed by everything about
the doctors. They took the time to explain things to students, which in the
busy context of the hospital and clinic isn’t always a priority. They
treated patients with great respect and kindness. They knew an impressive
amount about the subject and beyond. I felt inspired. Though many
other physicians in internal medicine, pediatrics, and elsewhere were
similarly impressive, my experiences were more mixed in those departments.
This at least was my unique experience; colleagues of
mine reached different conclusions.

The physician teachers also affect the culture of each department. For example, emergency medicine doctors are frequently seen as adrenaline
junkies. They love going rock climbing, bungee jumping, racing in triathlons,
and so forth. This is not true across the board, but one likely finds a
higher proportion of people who have those hobbies in emergency medicine. Specialties fit certain personalities or interests. I found that more
neurologists shared my interests — many of them study human consciousness,
autonomy, and free will, which tie into my fascination with the humanities.

The last element that helps medical students choose a specialty is
lifestyle, or how much time one has outside of the hospital. Surgeons
seemingly live at work even when they’ve graduated from residency programs.
Surgeries can be long and tedious; unexpected disasters occur during
operations; patients need emergency surgeries; and many post-operative
patients need close monitoring to make sure there are no complications. Pediatricians, by contrast,
tend to have much more normal lifestyles. They can work in an outpatient clinic
from, say, 8 a.m. to 5 p.m. Any child with an emergency goes to the emergency room, not
to the outpatient clinic, and pediatric patients tend not to have as many
chronic, difficult-to-manage illnesses as adults (like heart disease or high blood
pressure). Pediatricians focus more on preventative measures,
such as well visits and vaccines. As a pediatrician it is much easier to keep up with
family or hobbies outside of medicine. I loved surgery, but I could not see
myself putting in the hours to do it every single day for the rest of my
life. Neurology, on the other hand, like pediatrics, often involves a more
balanced lifestyle.

And this is how we choose: subject material, mentor and teacher experiences,
department personalities, and lifestyle. But the truth is that
many of us who go into medicine could be happy in a number of specialties,
which is an important perspective to have. It means that we love, broadly,
the subject and practice of medicine, and that our curiosity about disease
processes and treatments does not start and stop in one specialized silo or
another, just as most diseases do not stop in one body part or another. It’s what makes medicine such an enthralling and difficult field.

A Day in the Life, Part 1

My editors here at The New Atlantis suggested I write about what a day is like for me and other members of the medical team. What exactly (aside from
rounding) do we do all day? When do we have to be in? When do we leave? What goes on when we’re not rounding?

We can divide the third year of medical school into three distinct categories of rotations. There are inpatient weeks (hospital work), outpatient weeks
(doctor’s office work), and the Emergency Department, or ED. The roles differ as do the schedules. I have already described a bit about how the ED works here. The hospital is for patients who need urgent medical attention or
medical procedures. If a patient is having a heart attack, for instance, a cardiologist in the hospital will make sure the patient does not suffer
complications from the disease process. Outpatient work, by contrast, involves less urgent medical problems, like adjusting blood pressure medications or prescribing antibiotics for an ear infection. Let me take you through a day on inpatient and outpatient medicine.

Inpatient

On an inpatient service the interns arrive at approximately 6 a.m. or, if on a surgical service, at 5:30 a.m., and print out a patient list from the electronic
health record. This list of patients contains the patient names, chief complaints, possible diagnoses, ages, and other basic information of the patients we
need to see. It contains a summary of tests and test results as well. It may seem a bit silly that physicians need a reminder about which patients they are
taking care of; however, the hospital experiences quick turnover. A patient may be present for only a couple of days before leaving. Then, a new patient
with a new history and a new problem takes his or her place. Additionally, when there are sixteen patients on the list it is difficult to keep up with
every story.

Medical students arrive shortly after the interns (the residents are a bit like our supervisors, letting us know when we can leave and when we ought to
come in). Given how early in the day we usually have to be in, there is little time in the morning to do anything but eat a quick breakfast while
bleary-eyed before driving to the hospital in the dark. If we’re there early enough, we receive checkout from the night intern. The night intern goes
through each patient on the list and discusses the latest news on each patient. Did the patient vomit? Did he or she have trouble breathing? What
interventions, tests, or treatments were done? Additionally, if the night intern admitted new patients overnight, what is the story behind the hospital
admission? These questions are vital to the care of each patient. If the day resident does not know, for example, that a patient was having trouble
breathing or received an imaging study then the resident does not know to look at the results of that study, potentially missing a life-threatening problem
like a collapsed lung or a heart attack. In an ideal world, the transition between resident shifts is so seamless that it is as if the day resident took
care of or admitted patients during the night.

Subsequently, the interns assign medical students to “follow” one, two, or three patients (depending on how far along we are during our third year). Following a patient
means knowing the vital signs daily and keeping up with the results of x-rays, CT scans, and lab tests. It also means we come up with a plan for that
patient’s care and propose it to the attending and residents. In truth, the residents and attendings already know what they are going to do for the patient
and our proposals are merely an exercise for our own edification.

After these assignments, we go through the chart on the electronic health record and read about the patient’s history. We read the night intern’s note on
the patient and we look at the labs (tests) that the intern ordered. These notes give us a sense of what the residents or attendings thought the patient had and
needed. For example, if the patient came into the ED with a fever and a cough, the notes will usually mention a workup and treatment for a possible pneumonia, or lung infection (which includes a chest x-ray, sputum culture, and
empiric antibiotics). More importantly, students and residents look at the vital signs of the
patients we follow. These indicate if the patient needs immediate treatment. Is the blood pressure too low with a fast heart rate and a high body
temperature? This indicates a possible blood infection and we take blood cultures and administer antibiotics.

Despite the fact that the sun has not yet peeked through the hospital windows, we subsequently visit patients in their rooms to do a physical exam. We look
at new rashes that patients have, listen to hearts and lungs with stethoscopes and perform neurological exams. We target our exam at the patient’s
presenting illness. For a patient with pneumonia, we listen closely to the patient’s lungs for abnormal breathing sounds due to the infection. All this, of
course, entails waking the patient up. And since residents, appropriately, will come in after us to make sure that we have done the physical exam correctly
and that the patient is in no distress, we unfortunately wake the patient up at least twice during the early morning hours. This is separate from the
instances where the nurses wake the patient up to draw blood for morning labs. Such is one difficulty of being a patient at a teaching hospital, something
I will discuss in future posts.

Image via Shutterstock

Once we’re finished seeing the patients, we have a little bit of time left before rounds start at 8 a.m. We look up information about the illnesses our patients have. We also write down the information we will need to present the patient to the attending physician on rounds. I’ve written a bit about
patient presentations in this post, but in sum,
our presentations report the relevant medical information and treatment plan in an organized and concise matter.

At 8 a.m., the attending arrives and we round on patients. Aside from the few patient presentation(s) we do for the attending we remain silent and watch and
learn as I’ve described previously. Once we finish rounding
we go over the patient list in the physician work room. We make sure that we all agree on the plans for each patient for the rest of the day. Some patients
need to leave the hospital. Some need more IV fluids or medications. And some need an imaging study or a blood test.

After we’ve confirmed all of this, the residents write “notes” about each patient for the electronic health record. A note is similar in format to a patient
presentation. It contains a brief history of the patient’s chief complaint and illness as well as the blood test results, imaging test results, diagnosis,
past medical history, and past surgical history, as well as the treatment plan for the patient. These notes, though incredibly time-consuming, serve a
valuable purpose. First, legally, the note can help protect a physician from future lawsuits. The note documents a physician’s train of thought and
actions. It justifies the tests and treatments which patients receive in the hospital. Second, it is used for billing purposes by documenting what was done
for the patient. And third, when the patient goes for a follow-up appointment with another physician in clinic, the note acts as a standardized form of
communication to update the clinician on what was done in the hospital.

At lunchtime, medical students usually receive a lecture from a physician in the rotation. In pediatrics, for instance, we may listen to a lecture on
pediatric respiratory complaints from a pediatrician. Meanwhile, the residents remain in the workroom or, if they’ve finished with their notes, they can
grab a quick bite to eat in the cafeteria. Sometimes, though, the residents are swamped. They carry around pagers or phones, and nurses and other physicians
page or call throughout the day with questions about specific patients. A patient may get a headache or feel nauseous and the nurse may page the resident
to ask if it’s okay to give pain medication or antiemetics (medication for nausea or vomiting). Given
that there are a limited number of residents, if multiple patients fall extremely ill and need medications, it can be difficult for the residents to
respond to other more minor complaints. A cardiac arrest on the floor, for example, may prevent the resident from ordering pain medication for a patient
with a headache.

More on a day in the life, in a bit…

Whooping Cough and the Anti-Vaccination Movement

Pediatrics rounds are similar to what I described in one of my initial posts. We spend most of the morning
visiting each pediatric patient with the attending physician and deciding on a treatment plan with the parents. Frequently we encounter patients on
“contact precaution,” which means they have a highly communicable infection. In order to reduce the transmission of infection, before we enter the room we
put on disposable gowns that cover the arms, torso, and upper legs, as well as gloves, and a face mask if the infection is communicable via the air. We
fumble around outside the patient’s room, handing gloves, gowns and masks out to each other, donning them as we would some radiation suit. Upon exiting the
room, we remove these protective accoutrements and put them in the trash. The

CDC recommends this practice
, though in certain cases the efficacy of it is unclear.

One morning we saw a six-month-old child on contact precaution with whooping cough, a respiratory sickness caused by
the Bordetella pertussis bacteria. We stood outside the child’s room putting on masks
before we entered. Inside, the baby’s mother paced back and forth, holding and rocking her son as the infant experienced a series of coughing fits and
struggled for the air even to cry. Bacteria had attached to the cells of his upper airway and produced a toxin that prevented those cells from sweeping
foreign particles and dirt up out of his throat. Thus, he coughed in order to clear these alien elements that we normally clear silently. He coughed so
hard and for so long that he barely had time to breathe in and was perpetually short of breath. At times, he looked and sounded like he was about to die. This not-uncommon response to the infection disturbs us as we must watch an infant struggle for each breath without any effective treatment. We sit back with horror, anticipating the moment
when the child ceases to inhale.

At this point, he had already experienced the first stage of the whooping cough sickness, the catarrhal stage. This lasts for the first couple of weeks and
presents merely like a common cold, making it unrecognizable from a benign respiratory infection. But this is also the stage at which the bacteria are most
contagious, and the only stage at which antibiotics work in preventing progression of the sickness. Many parents unknowingly take their
children out into the community without being treated, thus spreading the infection.

The second stage of the disease is the stage our patient was struggling through — it’s called the paroxysmal stage. Though children or adults are less
contagious at this stage, their symptoms are far worse and this is the stage with the infamous whooping cough. Patients cough so forcefully that, desperate
for air, they take in a huge and sudden inspiration (the whoop) in order to compensate for lost breathing time. Antibiotics only prevent
the disease from spreading but have no mitigating effect on symptoms. During the second month of the infection, the disease resolves with the convalescent
stage.

Though the eventual outcome sounds benign, the disease does not always resolve as we expect. In fact, the sequelae of this disease are costly and deadly. Half of infants less than one year
old with this infection are hospitalized. And among those, 23% get pneumonia, 1.6% will have convulsions, 67% will have apnea (cessation or slowing of
breathing), and 1.6% will die. In adults who get pertussis, weight loss, loss of bladder control, syncope (passing out), and rib fractures from severe
coughing are also common. But a patient need not experience any of these symptoms, mild or severe, if he or she receives the vaccination against Bordetella pertussis.

Why, if we have a perfectly good preventable measure against these bacteria, do we have six-month-olds gasping for air in the hospital? Unfortunately, in
recent years, a

popular anti-vaccine movement perpetuated by celebrities and based on shoddy science
 has discouraged many parents from vaccinating their children and made all of us, including the child I saw on rounds, more susceptible to infection with
these bacteria. Last year, Julia Joffe wrote an incisive and frightening piece in The New Republic about this issue. She explains the gravity of the problem:

Vaccinations work by creating something called herd immunity: When most of a population is
immunized against a disease, it protects even those in it who are not vaccinated, either because they are pregnant or babies or old or sick. For herd
immunity to work, 95 percent of the population needs to be immunized. But the anti-vaccinators have done a good job undermining it. In 2010, for example,
only 91 percent of
California kindergarteners were up to date on their shots. Unsurprisingly, California had a massive pertussis outbreak…. 
From 2011 to 2012, reported pertussis incidences rose more than threefold in 21 states. (And that’s just reported cases.
Since we’re not primed to be on the look-out for it, many people may simply not realize they have it.) In 2012, the CDC said that the number of pertussis cases was higher than at
any point in 50 years. That year, Washington state declared
an epidemic; this year, Texas did, too. Washington, D.C. has also seen a dramatic increase. This fall, Cincinnati reported a 283 percent increase in pertussis…. 
A
study recently published in the journal Pediatrics indicated that outbreaks of these antediluvian diseases clustered where parents filed non-medical
exemptions — that is, where parents decided not to vaccinate their kids because of their personal beliefs. The study found that areas with high
concentrations of conscientious objectors were 2.5 times more likely to have an outbreak of pertussis.

But these “personal beliefs” are not part of some novel and modern ideological movement. In fact, the arguments of the anti-vaccination movement of today
closely resemble those perpetuated when Europe first used vaccines in the 18th century. And when we consider the six-month-old in the hospital
and our current predicament outlined by Julia Joffe, this fact should give us hope.

The Chinese first used vaccines, inhaling powder from smallpox scabs on deceased patients, a method which eventually moved west to Britain
during the 18th century — the British rubbed scabs of smallpox victims into newly created scratches on their skin. And most of the time this
worked, even if there were risks involved. In fact, as

Dr. William R. Clark
, a former Professor of Immunology at UCLA, writes in his book on the immune system,

At War Within,

even in that era, “from a public health point of view, inoculation made great sense.” Nonetheless, many physicians and religious leaders at the time opposed this
method of preventive care for a few different reasons.

First, religious leaders spoke out against vaccination because they thought it interfered with God’s plan. In July 1722, Reverend Edmund Massey argued
in St. Andrew’s Church that humans were punished for their sins with illness, and that attempting to prevent these diseases with vaccines was a “diabolical operation.”

But that wasn’t all. According to some, the government and the wealthy used vaccines to subject, or profit from, the populace. As Clark recounts in his book, William Wagstaffe,
a physician at the time, wrote the following about Britain’s female ruling class, which first began to use the vaccines:

Posterity perhaps will scarcely
be brought to believe, that an Experiment practiced only by a few Ignorant Women, amongst an illiterate and unthinking People, shou’d on a sudden, and upon
a slender Experience, so far obtain in one of the Politest Nations in the World, as to be receiv’d into the Royal Palace.

In other words,
ignorant leaders practicing inoculation took advantage of the ignorant citizens. J. M. Peebles, an American physician, wrote a book in 1900 entitled


Vaccination: A Curse and a Menace to Personal Liberty, with Statistics Showing its Dangers and Criminality
. In it, he explained, “The vaccination practice…has not only become the chief menace and gravest danger to the health of the rising generation, but
likewise the crowning outrage upon the personal liberty of the American system.” Further, the “vaccination syndicate” is “continually lobbying our
legislatures for an extension of privileges on the pretense that the public welfare will thereby be enhanced.” So, the pro-vaccine “syndicate,” using the
American government, forces its mendacious ideas upon American citizens.

And the harmful medical effects of the inoculations bothered scientists at the time who, according to Dr. Clark, “were concerned about the
risk, and not completely convinced that the protection was genuine or long lasting.” Peebles covered the vaccine’s deleterious effects in his book, too. The
“vaccine-poison,” he asserted, will take its time in killing its victim or do little to prevent death, “one year, ten years, this generation or the next; no matter, death has a mortgage
on the premises and will claim his own and receive it on demand.”

These objections sound entirely familiar. Dr. Suzanne Humphries, a nephrologist and homeopath,

has recently rewritten the religious argument for the International Medical Council on Vaccination
: “Vaccines are the template for the fear-based belief system that those who don’t know their history will easily fall for. The trajectory of fear removes
God from the picture. A fear-ridden populace couldn’t possibly credit God with any usefulness once the medical/pharmaceutical industry sets itself up in
God’s place.” This claim echoes Reverend Massey.

Professor Daniel A. Salmon, of the Johns Hopkins School of Public Health,

quoted in a New York Times article
, discusses many of the groups who refuse to vaccinate their children. He explains that some oppose vaccines because they distrust the government or
believe that government is in bed with the big pharma vaccine industry. Moreover, in an editorial post on the Alliance For Natural Health website, the group claims that the “cozy relationship of government with the drug companies may be why the CDC
is now recommending a cocktail of over ten different vaccines.” William Wagstaffe or J. M. Peebles could have written this.

And, of course, detractors argue that the side effects of the vaccines are too dangerous and may even cause autism. Jenny McCarthy, in a similar vein as J.
M. Peebles, made this argument. (She recently

attempted to paint herself as “pro-vaccine,”
 which is simply not true.)

But why should we be comforted by this current of familiar anti-vaccination arguments? Because despite the historical resistance to the smallpox
vaccination, eventually the vaccine was successful — so successful, in fact, that the World Health Assembly declared smallpox eradicated in 1980. Therefore, the
vaccine movement has won out in the past against similar arguments and can do so again. Will whooping cough be eradicated with successful vaccination? I
can’t say, but even a minute sway in opinion can make the difference between herd immunity and an epidemic. And that would decrease the number of six-month-olds and their parents who must suffer in anguish through those frightening moments on the precipice of breathlessness.

Residents and Rounds

Doctors practice “grand rounds,” ca. 1920s.
(National Library of Medicine)

This post is meant to provide a bit of background about how the day works and how a medical team functions so the references I make in future posts are clear. Let’s begin with the team. Nearly every medical team at an academic hospital consists of an attending physician, residents, interns, and medical school students. While these terms might sound familiar to anyone who has watched medical dramas on TV, it’s likely that most people don’t know what they mean. The attending physician is a bit like a tenured professor. He or she has the most experience and training in the operating room and the clinic, and has graduated from medical school, residency, and, in most cases, a fellowship program.

The residents, having graduated from medical school, are also physicians but, being less experienced, are “attendings-in-training,” learning the craft of a specialty via instruction from an attending physician. Residents are classified by the number of years they’ve spent in training, and different specialties will require a shorter or longer residency: there are chief residents (the most experienced residents), fourth-year residents, third-year residents, and so forth. Then there are the interns, physicians who have just finished medical school and are spending their first year out of school rotating through different specialties, learning how to enter orders for medications, writing progress notes on patient care and discharge notes to release patients from the hospital, and responding to immediate issues that arise during the course of the day. To do this an intern must know each patient in order to respond to questions about treatment from the patient and nurses.

Third-year medical students comprise the lowest rung of this ladder. We have little to contribute and plenty to learn. Frequently, we are assigned to follow a few patients and come to know as much as we possibly can about them. Once we know everything about our patients, it will be easier for us to think about what is most important regarding each patient’s care. We learn to pay attention to important details.

This team hierarchy, though it may seem stilted, is actually integral to the process of rounds, where the medical team visits each patient in its care. Rounding provides an opportunity for the healthcare team to speak with patients about how they are doing, to look at and physically examine them. The physical part of the exam is fundamental to healthcare. The abdomen, for example, can feel distended or stiff if there is a certain pathological problem, such as a bowel obstruction. Only by palpating — touching the patient’s body — can we know this. One cannot assess a patient’s progress until one examines a patient.

There are two official times to round during the day. One is immediately upon arrival at the hospital without the attending physician. This involves residents and medical students. And the other is with the attending physician later in the morning. While shuffling between different floors and patients, the hierarchy remains eminently clear. The attending physician leads the charge and behind him or her follows, in order of experience, everyone else: the third-year, the second-year, then the interns, then the medical students. There are usually about eight of us rounding together; to an untrained observer, we might look like the motorcade of a foreign diplomat. We all squeeze into each patient’s hospital room as the attending physician conducts the interview with the patient, assesses the patient, and tells the patient what the team’s plan is over the course of the day: Will a new medication be prescribed? Will the patient finally be able to eat food? Can the patient only drink liquids? As the attending explains this to the patient, one of the interns runs over to the computer inside the patient’s room and enters in the new medication orders or dietary orders. And on to the next patient. Over the course of the day, the new orders are confirmed and reconfirmed with the attending and upper level residents,

This daily pattern of rounding is actually a tradition as old as the American hospital system itself. In earlier days, there was a system of apprenticeship. So, if you wanted to be a physician in late-eighteenth-century America, you would be apprenticed to a doctor who would teach you all that you needed to know. You would then probably be offered a partnership with your teacher. But as the hospital and medical school system took root in the early nineteenth century, students pursued learning opportunities in hospitals in order to receive a more thorough practical education en masse. Individual physicians, after all, had very little time to apprentice aspiring doctors, and frequently the knowledge you received depended solely on one person. In order to teach medicine, hospitals created special programs where students would, as they do today, pay a fee for a basic science education (meaning anatomy, physiology, and pathology) and, eventually, a clinical one as well. Students rounded with residents (also known as house staff) and attendings in order to receive this practical experience in patient care. One description of rounds in Massachusetts General Hospital by Dr. James C. White in the 1850s sounds eerily familiar to me:

[The attending physicians] pass from bed to bed in the large wards, the students following. The house [officer] narrates any incidents in each patient’s condition during the previous twenty-four hours; the physician asks questions, makes the necessary explanations, and directs treatment. Over new and interesting questions much time is spent…. Students have nothing to do with the investigation of cases; they have only to look and listen.

My theory about this process as an educational tool is that it is suited to the role of each member of the team. The upper-level resident should be learning how to dictate orders and take charge of the team because soon he or she will be in that position. The attending, who knows this process well, educates the upper-level resident on whether the plan of care is correct and guides the fourth-year or chief resident. The mid-level resident follows closely on the heels of the upper level because he or she will soon occupy that position. And the interns need to learn how to manage patient care on a detailed level, writing notes and orders to improve at compounding a ton of information into a paragraph or two and assessing doses and units of medications.

And we, the medical students, observe and listen and ask questions when we can. Our purpose is to learn the language by observing patterns in patient care and disease. Thus far, it’s difficult to tell whether this strategy is working; it sometimes feels like I am back in French class on the very first day, listening to a language I’ve never heard before regarding dosages, plans of care, boluses, IV infusion rates, and so forth. But it is also comforting to know that this process has worked for more than a century and a half, and so perhaps we third-year medical students are right where we should be.