Episode 8: Doctors in Training

What's a resident? Who are these people wearing white coats? Why are the coats all different lengths? Your questions answered and more!

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Transcript

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician.

You’re joining us today for our eighth episode, entitled “Doctors in training.” I was afraid to use that phrase, Doctors in training, because it was a well known medical education company back in the day, and I don’t wanna get sued…but it appears to have gone under, so I think I’m ok. RIP DIT. If you’ve ever been Inside the ER or a hospital and seen a line of people in short white coats following someone in a long white coat, then you may have asked yourself the alternative title for this episode: “Who the heck are all these people?” 

Last episode I said we’d be back in two weeks ish, ish, and since then my beautiful wife had a healthy baby girl…so by two weeks…I really meant four weeks! Forgive the delay but now we’re back!

Now if you haven’t listened to our previous episodes, you’re gonna be lost, so…eh do as you will. Also have any questions? Feedback? Suggestions for future episodes? Late night musings? Don’t hesitate to email at insidetheer@gmail.com

Today we’re going to talk about the stages of metamorphosis a physician undergoes, from student to resident to attending. So listen up because you’re gonna learn about the different levels of physician providers you may encounter Inside the ER. You may say to yourself, ugh uh, no need, I won’t go to a teaching hospital. Trust me, you can encounter a student or resident ANYWHERE. And that’s a good thing cause the more eyes on you as a patient, the better. 

Even if a hospital doesn’t house any teaching programs or residencies, outside students and residents may work there, including the ER. In fact, in some rural areas at night, you’ll find a lone ER resident managing the department. And, aren’t you a little interested to hear what physicians go through? C’mon!

We’ll start with the first stage, medical students. I’m not talking about pre-med, that’s like the pre-egg in this metaphor. Also, this a very American progression, so if you’re listening from elsewhere, just understand that besides a rare combined program, we have to go through a four year college/university program first before medical school. It’s a lot and quite inefficient.

Ok, so, the medical student, or the egg in this process. Called simply “med student” they have not yet finished their degree. Med school in the US is four years long and can be absolute hell. Please take pity on these poor souls. You’ll know them by their short white coat, I’m talkin’ hip length, informal name tag, and usually nervous demeanor. They should introduce themselves as a med student and will often just use their first name. If you’re seeing them Inside the ER, they’re probably in their second year or later. The first two years of medical school are more classroom focused, with a heavy shift towards clinical experience after that. 

Med students go through clinical rotations, also called clerkships, where they spend weeks working alongside doctors of a specific specialty. Since ER is a mandatory rotation, med students will come in all different varieties. A fourth year should be more skilled than a second year, except a second year actually interested in ER may surprise you while a fourth year forced to be in the ER may suspiciously disappear for long periods of time. 

If you find yourself Inside the ER and a medical student comes to see you, do not be worried! A med student’s preceptor is keenly aware of what they are capable of, and will only assign them patients they can handle. When I work with a student, difficult patients we’ll see together from the getgo but I will also try to find them the perfect patient. By perfect I mean someone not critically ill, who can communicate effectively and may have an interesting condition. The med student will see you like any provider would, present your case to the physician, and then they’ll decide a plan together. Make no mistake, the physician is the one in control and will see you just like normal after the med student, if not with. When there is a critical patient, the med student is another pair of hands, and I will direct them to assist without jeopardizing care.

The next stage, the larva, is the resident, also called resident physician. Now this is a big jump because the resident has finished medical school and earned their degree, either MD or DO, and so they are a doctor, a physician. You can spot them by their ID which will say doctor and resident or house staff or something, and longer white coat, just above the knee perhaps. Their title is doctor so and so and while perhaps lacking in confidence, especially that first year, they should introduce themselves as such. The major caveat here is that they are still training, and must practice under an attending physician’s license.

This training is the residency that newly graduated physicians go through to learn the skills and gain the experience needed to practice on their own. The process of matching into a residency is a whole thing but I’ll briefly say that med students apply to residency programs, interview, rank their choices, get ranked themselves by the programs, and then a computer program determines your future. On match day, everyone finds out where they’re headed and if you don’t like it, tough noogies. If a student really dislikes a program, then best not rank it at all.

Most students apply to a single specialty. I only applied to emergency medicine residencies, while others apply for internal medicine, pediatrics, you get it. Other students know that they’re applying to a very competitive specialty, like plastic surgery, and there’s a chance they may not get a spot. So they also apply for less competitive but similar residencies, like in general surgery, and rank them lower on their list.

It was first called residency because back in the day it was expected you’d practically live at the hospital, rarely going home. People later realized that sleep deprived and depressed doctors make more mistakes and so things have thankfully changed for the better. My residency was nowhere near as brutal as yesteryear, but the physical and emotional stress residents suffer from is still very much present. 

It’s time for a break, we’ll be right back after a word from our sponsor.

Are you currently Inside the ER? Are you waiting to be seen? Then listen up because today’s sponsor of Inside the ER is you and your insight that the more eyes on you the better! 

Some patients scoff and try to turn away med students, but that’s not you, because you know that another set of eyes on you is a good thing so nothing gets missed.

Some patients try to demand the attending only when a resident walks in first, but that’s not you! You know that residents are physicians too and the more physicians that see you, the safer you’ll be. 

You also know that residents and students are still in the thick of their book learnin’, while the attending is years away and has probably forgotten most of it. So let ‘em all in you say, the more patients they see, the better we’ll all be!

Now, back to the show:

The plight of the resident is interesting as compared to a medical student. As a medical student you are constantly studying, taking tests, cycling through different specialities and preceptors. You receive very little respect but also not much is expected of you, so it can balance out. As a medical resident, you are still studying and taking exams, but suddenly have an immense amount of clinical responsibility and expectation heaped upon you. Coupled with a much tougher schedule, people are still working 30 hour shifts these days, and it can make for a miserable experience. 

Emergency medicine is not the worst when it comes to residencies. It’s only three or four years long, I did a three year, more efficient! Our time in the ER is very intense but since we work shifts that are 12 hours maximum, we have built-in off time that other specialities envy. But, don’t worry, I still had to do terrible rotations in other specialities with insane hours. Perhaps we’ll get into this in a later episode, but physician depression is a serious problem. Over the course of my residency in New York City, three residents from different NYC programs jumped off of buildings. One per year on average. It was shocking and horrifying. So, just as with the students, show some compassion to these poor newbie doctors.

OK I’m getting sad, let’s move on.  If you go to an ER with an emergency medicine  residency, then likely you’ll be seen by residents primarily. You may hear that first year resident be referred to as an intern or junior resident, or PGY1, that’s post graduate year one. Often the first year will see you, then the senior resident, and maybeeee the attending. Don’t get me wrong, the residents will present your case to the attending, but the residents will do most of the work. There are of course exceptions. In my residency, the ER was simply too busy so attendings would occasionally see patients on their own as well. 

If you go to an ER without an ER residency, you may still encounter residents, either ER from a different hospital, or in-house residents of a different speciality, usually internal medicine. Where I am now, I will occasionally work with an internal medicine resident and just like with a student, I am mindful about where I send them and how I use them.

In fact, I’ll share with you the ground rules I set whenever I meet a new student or resident. We’ll do some roleplaying. You’re the student/resident, and I’m me. 

1. If the patient looks deathly ill, immediately come find me. No playing hero first.
2. Do not promise any specific test or treatment to the patient. If you tell the patient we’re doing a test that we ain’t doing, then I gotta go have awkward conversation.
3. If you hear an alert over the intercom, like a cardiac arrest, come running. That high stress situation is the best time to learn.
4. Tell me your assessment of the patient and your plan, as in what you think could be going on and what you wanna do about it. Even if it’s a bad plan, it’s still important to come up with one and then we can modify it.
5. Never document something you’re not going to address. If you write in the chart that the patient could have a blood clot, then you need to address that with a test or explanation.
6. And lastly: stay hydrated, eat, go to the bathroom, and go home when I tell you to.

Ok roleplaying over. That last rule is all about wellness. These kids got it hard enough, I’m certainly not going to add to their misery but working them so hard they don’t have time to pee or keeping them over shift.

OK so with this silly metamorphosis metaphor, now it falls apart cause I don’t think the next stage, the fellow, fits being a pupa. Once a resident successfully completes residency, they can opt to start practicing, becoming an attending, or they can pursue a fellowship. A fellowship is an additional training program for doctors who wish to obtain specialized skills and knowledge. So an ER doctor after residency could start working as a regular ER attending, like me, or pursue a fellowship in uhh toxicology let’s say, to add to their knowledge, or may undergo a sports medicine fellowship and focus on outpatient care, completely changing their practice. Another example would be an internal medicine doctor. After residency they could begin practicing as an internal medicine attending or they could pursue a cardiology fellowship, becoming a cardiologist. 

And this leads right into the final stage, the adult, the butterfly, the attending physician! An attending has completed their training, passed their licensing exams, obtained their medical license, and are probably board certified. Oh, oh, I need to explain that! Every speciality has its own organization, it’s the American Board of Emergency Medicine for us, that certifies doctors as qualified to practice clinically. Basically we have keep studying and taking exams throughout our careers. A lot of time and money so we don’t get rusty. It’s not against the law or anything to practice medicine without board certification, but it’s a bit uhh…sus. Is that what the kids say?

Anyway, so, how do you recognize an attending? Their ID may indicate it and as I said earlier you may see them being trailed by a gaggle of students and residents. Or they may have a longer white coat still. Now you may be asking, Padraic, broski, how long is your white coat? Floor length? Does a medical student have to carry it behind you? Nah, trick question, it doesn’t exist! The last time I wore a white coat was for a headshot and it was a loaner. Like you know that blazer they make you wear at country clubs.

But yeah, I haven’t worn one Inside the ER since medical school. ER docs often don’t. We’re frequently encountering bodily fluids that been expelled from orifices both natural and created, there’s no need to bring white fabric into that. Also we need to be able to get our hands clean, then dirty, and then clean again at a moment’s notice. Long sleeves are a no-no. 

Whenever I see another attending of whatever speciality with that big ole white coat, I sometimes wonder if they’re just showing off, but then I remember there’s a caveat here, two of them in fact, and they’re big ones. The first is that for many attendings, wearing a white coat is an expectation. Either from the program they work for, the staff they work with, or the patients themselves. Patients understand that ER doctors prefer, nay deserve, to wear the glorified pajamas that are scrubs, but otherwise, people expect doctors to be uniform.

The other reason a lot of attendings decide to dress up like a butcher is to avoid misidentification. This is a big problem for doctors who are women, people of color, or just look young. I can’t tell you the number of times I’ve seen a female doctor be called “Nurse!” Or we’ll get a patient complaint after the visit saying “I never saw a provider” oh but they did…it just wasn’t an old white man.

I have a distinct memory of this happening during my first ER rotation in med school. I, the nervous, scruffy med student in a fresh white coat, trailed behind the ER resident with her ID and obvious doctor badge. There’s like a separate badge some people wear that says DOCTOR in big letters. She entered the room, introduced herself clearly and interviewed the patient as I quietly pressed myself into a corner. As a med student, one of your greatest fears is getting in the way.

Half way through the conversation, the patient, an older white man, loudly interrupted with “Can I see a doctor?” 

I, dumbfounded, raised my finger and pointed at the ER resident, a South Asian woman. Then speaking like a toddler I mumbled , “She…she’s a doctor.” Oof, very awkward.

Now go out there and use your newfound knowledge to spot doctors in the various stages of training. And be sure to show some empathy to those overworked and underslept students and residents. 

We’ll be back in two weeks, I think? I hope! We’ll see

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Thanks for listening and all the best.