Medical Hierarchy

As everyone knows, medicine is hierarchical. On the bottom is the third year medical student who sees the patient first (and sees the glare in the eyes of the grumpy entitled ones who don’t want anything to do with anybody but the attending) and makes all the mistakes of forgetting to ask about pertinent re­view of systems or failing to perform all the relevant special exam skills. Next up is the intern or PGY-2 resident, who guides the student along and gives them advice. They ask you the questions you forgot to ask the patient, and only after your one hundredth time responding with, “I don’t know,” do you finally remember to ask the one hundred and first patient that question. But the residents are often strung out from overnight call or getting dumped five new patients in an hour and don’t always have the time to teach you in a forgiving manner. They can be blunt. They can ignore you. Both suck. Above them are the senior residents, above them are the fellows, and above them are the attendings. They have even less time for you.

That’s how it works for the hospital anyway. In the outpatient setting, it’s completely different. It’s just you and the physician and he has himself overbooked in order to see 20 patients per day. You go in, do a focused exam, report your findings, explain what you think it is, and define a treatment plan. All in 10 minutes; after that, the physician makes sure everything you said is correct, writes the prescriptions, and sends them off on their merry way just in time for you to see the next patient. If they’re running late, you end up shadowing the physician until he catches up, which may take the rest of the day. Then he has to write his notes for the day, but he doesn’t want to keep you around doing nothing, so he kicks you out quickly. It’s almost impossible to find the time to get constructive criticism and feedback.

From the patient’s point of view, I’m sure it can be exasperating. They wait in the room for fifteen mi­nutes (outpatient) or half a day (inpatient), and the person they see peek their head behind that door is very different from the person they expected to see—and usually much younger. The medical student isn’t as skilled at determining what parts of the history and physical are important. They ask questions out of order, they fumble with how to frame the question correctly, and they make the patient stand up and sit down and stand up again because they haven’t yet gotten fluid with the exam. Then the student leaves, the patient doesn’t know what the diagnosis or management plans are, and is left waiting another ten minutes (outpatient) or three hours (inpatient). The attending finally comes in, the patient corrects any mistakes in their story (embarrassing the poor med student in the meantime), and wonders why the physician is doing all these weird things to his body that the student never did. That’s how it goes for a mediocre student (I would know). For an excellent student, the patient may just experience déjà vu: the physician asks the same exact questions the student did and performs the same exact exam maneuvers.

But I wouldn’t have it any other way. Going in there and making mistakes is the best way to learn. It’s in correcting your mistakes that you learn best, and it gives you that innate, unshakeable knowledge of disease, of diagnosis, and of patient care. That’s what you need to be a doctor.