Looking Out for Number One

Let me explain the hierarchy of medical learners within an academic hospital, to give you a context for my rant:

    1. Staff Physician – the know all be all who probably has more years of experience working than you have had living
    2. Fellow – A Physician who has finished their medical training as a resident
    3. Chief Resident: Resident in their last year of training. Basically walking textbooks, knowing not only general medical knowledge, but minute details of obscure diseases you’ve never heard of. They’re on their final year, and are in charge of other residents of their program (whether it be general surgery, plastics, ophthamology, urology, etc.).
    4. R3: 3rd year resident, again more training exclusively in their field of interest.
    5. R2: 2nd year resident, usually start training exclusively in their field of interest
    6. R1: 1st year resident. Freshly minted and completed medical school. Most R1’s from all specialties (e.g. Family Medicine, Obstetrics/Gynecology, etc.) complete the same first year. They rotate through different services within the hospital for several weeks/months. Know the least amount of information compared to their upperclassman.
    7. Clinical Clerk: 3rd or 4th Year Medical Student who spends 4-6 weeks rotating through different medical specialties. Knowledge is minimal in comparison.
    8. Physician Assistant Clerk: Me. I’ve finished one year of medical foundations, and am half way through my clerkship. I’ve done rotations in Family Medicine, Pediatrics, NICU, Emergency, Psychiatry and now am doing General Surgery. Pretty much comparable to a clinical clerk in terms of experience and medical knowledge.

A clinical clerk gave me enlightment about the residents managing our team today in the hospital cafeteria for lunch. He told me this particular facility calls themselves an “academic centre”, but staff are not concerned with student education or learning. “Residents don’t care unless it gets them more OR time. The fellows are concerned about getting OR time, and the physicians don’t care about the clinical clerks.” So us clerks have to look out for ourselves, arrange our own learning sessions, and teach each other – which is the essence of problem based learning.

However, I was at a famous teaching hospital just a few months ago. The one-on-one time I got with physicians and residents was phenonemenal. I got challenged, had docs making me working through my thought process about how to get through a differential. And they had me justifying why I should do certain tests, or what lab work reveals about a patient’s disposition.

Nope, not really any of that here. Rounds consist of scribing for the residents, while they completely manage. Since we are competing with so many learners (fellows, residents and other clinical clerks), we can’t be surgical first assist, or even have the priviledge to “retract” during surgeries.

“Residents look out for number one.” At least at this facility. I hope this experience makes me appreciate teaching that I got, and to be able to hand off learning to medical / physician assistant students in the future. My next rotation is Internal Medicine, from which I hear that the learning experience isn’t that great. Here’s hoping for the best.


Me and My Surgery On-Call Adventures

Today, I helped put a nice man’s bowels back into his abdomen.

I’m sitting in the operating room lounge, its 10:42 PM, we just finished one appendectomy for an acute appendicitis, which was perforated (leaking purulent material into the peritoneal cavity), and an evisceration of an abdominal wound. So, a gentleman had a not-so-closed wound from a previous procedure, and now his bowels were pushing through gaping holes in the wound.

The surgical fellow (and chief resident) asked me to scrub in, which I did. The scrub nurse yelled at me to not touch anything on her table where she hands the surgeon on all the tools. The chief resident leaned over and reassured me that all of them had been yelled at for doing so before. She did a great job explaining different parts of the procedure, and answered all of my questions. 

My resident, a Plastics Resident Year 1, seems to take more time teaching me at night than he does during the day. This is still more exciting than my psychiatry rotation / on-call nights – where we had decompensated schizophrenics high on some kind of drug.

Still, I love clerkship, and everything I’m learning. I don’t think surgery is a career I would want to get into as a PA, but I’m learning a lot of useful things I can use if I end up in Family Medicine or Emergency. I’m trying my  best to get into a urology for my surgery selective (2 weeks of a surgical specialty of our choice during our 6 week surgical rotation). I figure that there will be plenty of patients who come in with urinary symptoms and emergencies, it’d be useful to know.

This entry doesn’t make much sense, but I started my day at 5 am this morning.

The night is quiet now, so I’m going to head to my call room to hopefully get some shut eye before we get another consult, and that oh-so-unpleasant pager goes off.

Surgery Gunners

Surgery Gunners, thats what the med students term their peers that are going for a surgery residency. Having worked with them for 2 weeks thus far, there’s definitely a few qualities about these students that separates them from the rest.


  • The first to arrive (we start our mornings at 6:30 doing rounds)
  • They stay 4 or 5 hours after being done (we finish at 5 pm, I often see them leaving at 8 or 9 pm).
  • They are involved in surgery-related research with other preceptors
  • All of their electives, horizontal electives/observerships are in surgery
  • They read read read about everything surgical, even fictional books and autobiographies of surgeons
  • Both of the surgery gunners in our medical team have iPad 2’s, which they carry with them. 18 textbooks loaded in pdf form.
  • One is compiling his own online textbook on surgery topics.
  • They are quick to build relationships with their preceptors – receiving mentorship early on in their medical education.