Chapter 1: Intersession 1
June 24: Monday
8:24 am: “Welcome to third year!” a smiling Dean of Something Educational boomed across the medical school’s packed auditorium. I didn’t hear many remarks past those beginning words of the requisite welcome speech because I became distracted in catching up with my friends. I’d recently returned from vacation with my longtime boyfriend, R. Casey Jones, and had not yet seen anyone. Aside from all my friends looking expectantly at me to share news that I do not have to share, while not so subtly glancing at my left ring finger, it is wonderful to see everyone.
9:17 am: All medical students are warned that the third year of medical school is the most stressful, exhausting, and confusing year in the whole process of becoming a doctor. I first learned this a few months ago when reading a 2009 study published in Academic Medicine entitled “The devil is in the third year: a longitudinal study of erosion of empathy in medical school.” Some disturbing phenomenon happens during this year where medical students morph from cheerful, motivated, optimistic future doctors into bitter, cynical individuals. Since reading that article, I’ve come across multiple other studies and reports highlighting the horror that is the third year of medical school. Even just last week I came across an article in Slate magazine ominously titled “The Darkest Year of Medical School,” which discusses how third-year medical students experience a dangerous rise in depression, suicide, and substance abuse.[ii]
I’m curious about how this happens and to what extent it will happen to my classmates and me. I intend to record this entire year on my iPad mini, which happens to fit comfortably in the pocket of my short white doctor’s coat. My goal is to subtly jot down notes throughout the day using the app “Notability.” I’ll be recording events not only as they unfold in real time, but also capturing how I interpret these events and how I react to them. Medical student secretly turned gonzo journalist!
At most schools, mine included, medical students spend the first two years hunkered down in hiding, memorizing textbooks. We learn basics such as chemistry, immunology, pathology, physiology, anatomy, etc. In stark contrast, years three and four of medical school are spent rotating through the different medical specialties, letting us try out each one for a month or two. Every medical student in the country completes the same core rotations: surgery, internal medicine, family medicine, neurology, psychiatry, pediatrics, and obstetrics and gynecology. The goal is to expose us to each of the major specialties, helping us determine which medical field we will enter.
10:30 am: Oh, I should probably listen now, the speaker is explaining how third year will work for us. There are three blocks of rotations this year; each block is 16 weeks long. At my school, the students are split into three large groups, and each group rotates through each of the blocks. Kicking off each block is an intersession week, where I am right now, designed to prep the students for their upcoming rotations. As my first block consists of internal medicine and surgery, my lectures this intersession will review common medical conditions (heart disease, diabetes, etc.), basic surgery skills (such as suturing and tying knots), and anatomy. There will be two other intersession weeks this year. Intersession two will precede my block of family medicine, neurology, and psychiatry. The third intersession week will be before my final block of pediatrics, and obstetrics and gynecology.
11:45 am: Immediately following the welcome lecture, we were treated to a talk about not letting residents and attending physicians physically, emotionally, mentally, and/or sexually torture you. Apparently, many med schools have poor track records when it comes to abuse of third year med students. At least my school is aware of this issue and is preparing us for potential exploitations? The speaker also casually mentioned that we’re not supposed to work more than 80 hours in a week or more than 28 continuous hours.
June 25: Tuesday
12:35 pm: In general, doctors all wear white coats. However, there is a well-established hierarchy in medicine and not all white coats are the same. Atop the totem pole is the attending physician. The attending has completed their entire medical training and is in charge. Next down are the fellows. Fellows have finished residency and are completing optional specialized training (one to three years) before becoming an attending. Fellowship is not required, and most residents go straight into being an attending.
The residents are next down on the ladder; residents are licensed physicians. The first year of residency is called intern year. Interns and residents see and examine patients, write orders for lab tests and prescriptions, and make decisions regarding patient care. The resident has more power than the intern, though the attending has the final say on all matters. Interns are more heavily supervised than other residents and tend to do the most scut work. Throughout residency (which is three to seven years, depending on the specialty), a newbie intern develops into a senior resident. Supervision gradually becomes less and less, with the senior residents having the most freedom.
Medical students are doctors-in-training. We have not yet graduated medical school, and we do not yet have our medical licenses. We can see patients and perform procedures under the supervision or direction of an intern, resident, fellow, or attending. First and second year medical students aren’t even on the totem pole since they’re locked away studying.
Visually, the totem pole looks like this:
Fourth year medical student
Third year medical student (my current location)
Teams are led by a single attending, but may include any combination of residents and students. Hospitals with residents and medical students are referred to as teaching hospitals.
2:15 pm: FYI, all medical students and residents move up the medical totem pole by one rung on July 1. Always. If you’re a patient, you may want to avoid teaching hospitals in July. We’re all new to our respective roles.
3:23 pm: Learning how to gown and glove for surgery is surprisingly more complicated than it appears.
7:22 pm: Ouch. Rough afternoon. I spent the afternoon hours in anatomy lab being pimped by surgery residents and attending surgeons. “PIMP” stands for “Put In My Place;” it is a technique used throughout medical training whereby it is established that the superior has more knowledge and expertise than anyone below them on the totem pole. Pimping stems from the Socratic method of questioning a student, with the goal of leading them towards a correct answer. If the teacher poses questions in a logical and progressive manner then the student should ideally be able to work through the problem and come to a conclusion on their own, even if they did not initially think they knew the answer. The College of Medicine endorses the use of the Socratic method. Pimping differs from the Socratic method in that the goal of pimping is to point out that the student does not know as much as anyone senior to them. A student is asked questions repeatedly until they answer one incorrectly, at which point the teacher (be it a resident, or attending, or even a fourth-year medical student, if they’re being a total dick) can point out how little they know, deride them for not studying enough, or otherwise embarrass them. Ultimately, the student is reminded of their lowly stature on the totem pole. So yes, today I was pimped during anatomy lab.
June 26: Wednesday
11:15 am: Cancer, obesity, and genetics. A thoroughly depressing day of lectures.
2:10 pm: During lunch I received my schedule for the next eight weeks. I start with four weeks of inpatient internal medicine, followed by four weeks of outpatient medicine. Inpatient means the patient is admitted to the hospital and stays there overnight. Within the hospital, the sickest patients go to the Intensive Care Unit (ICU). Slightly less sick patients are in the Step-down unit; which is one tier less intense than ICU-level care. The most stable inpatients are on the floor, and are called floor patients. On the other hand, outpatient typically means a clinic, where a patient goes for doctors’ appointments or checkups. This may seem obvious to some people, but my mother, who has no medical background, has informed me that I need to explain these distinctions.
5:25 pm: Afternoon lectures on wound care provided us with some nasty images of pus-ridden infections and made me excited for my surgery rotation. I’ve never fainted at the sight of blood and guts, but we were just warned that third years happen to faint with alarming regularity. The professor informed us that it usually happens on days when we’re feeling really sleep deprived and haven’t eaten, drank, or sat down all day. Which apparently are most days of third year.
June 27: Thursday
11:53 am: Morning lectures were chock full of review about viruses, bacteria, and other infectious diseases.
5:43 pm: I decided to go to medical school at age 24. After studying art history and studio art in undergrad, I earned a master’s degree in counseling psychology and art therapy. I then worked at a top-notch hospital in Chicago. My mornings were spent on the inpatient psychiatry ward and in the afternoons I did bedside counseling and art therapy with children and young adults. Most of my patients on the various medicine wards were severely ill, often staying in the hospital for weeks at a time. I developed wonderful relationships with my patients and would inevitably bond with them. I mourned them when they died, attended their memorials, and cried with their family members; it felt as if my friends were routinely dying. I hated my job but loved being at the hospital, so, the abridged story is that I decided to go to medical school.
I left my job and forged ahead into the world of medicine, completing my pre-medical school requirements at Northwestern University. Casey matched to a teaching hospital called The General Hospital for his surgery residency. We packed up our lives in Chicago and relocated to this random Midwest City. I applied to medical school and was accepted to The College of Medicine, which is the medical school affiliated with The General Hospital. So now here I am. I’m a 29-year-old artist-former-counselor-turned-medical student from Long Island, NY, living in a random little Midwest City, about to start my third year of medical school.
June 28: Friday
7:30 am: I’ve kept journals since I was five years old. I have over 20 journals lined up on my bookcase, all penned in my terrible handwriting. I’ve never shared them with anyone. The idea of writing for a potential audience to read is terrifying.
However, writing a book has also been a lifelong dream of mine. Capturing the events of third year by journaling electronically seemed like the perfect set-up. To provide some distance, I’ve decided to refer to myself by a pseudonym, almost as if I am recording someone else’s story and not my own. After spending much of the week deliberating, I chose the name Silvia for myself in homage to my favorite song by the band Miike Snow.
12:15 pm: An all-morning review of the pharmacology of immunology is precisely as boring as it sounds. But no matter how boring, I have to know this stuff. At each rotation’s end is a multi-hour, nationwide, standardized flogging, politely known as a final exam. Our grades are used to compare us not only to each other, but also to all the other third-year medical students across the nation.
We also get graded on our clinical skills. This includes how well we interact with our patients, our competency doing procedures, and if we go above and beyond the requirements of the rotation. Our overall grade combines our exam score and our clinical grade for a final mark of fail, pass, high pass, or honors. Our grades influence our class rank, and where we will be able to match for residency. In order to get a residency spot, or ‘to match’ into a specialty, one must be a competitive candidate. As there are now more medical students graduating each year than there are residency positions, medical students tend to get über-competitive when it comes to grades and class rank.
2:15 pm: We’re back in the auditorium, sitting through a ceremony officially welcoming all the third-year students to our clinical years. Everyone looks prim, proper, and eager in freshly laundered white coats. We’re reciting the oath we took at our induction into the field of medicine at the start of medical school. Instead of reciting the Hippocratic Oath, a few students wrote an oath to represent our class and what entering medicine means to us at this time and place in our lives. The Dean of Something Important is back at the podium, spewing more warnings about third year. Right now she is reminding us to rely on each other and help each other through the year. She is telling us to reach out if we are drowning and need help. “Suicide is not the answer,” she informs us. I look at my closest friends, Piper, Sophia, Jane, and Maggie, and get the feeling I have no idea what I’m in for but I’m glad these women are sitting on either side of me. The Dean of Whatever concludes her speech with, “Congratulations on making it to third year. Thank you for listening, and good luck.”
Ipad in hand, down I go into the rabbit hole of third year.