Improve Medical Culture

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Background for nonmedical readers
also helpful for med students

Below are some commonly asked questions that would be of benefit to a patient or a medical student. I link sources to underlined words as further reference. If you have a question you think would be helpful to non-doctors, please email

What is a resident? 

The word resident comes from the fact that these doctors would "reside" in the hospital.

What is the difference between a resident and a doctor?

There isn't one.

I went to undergraduate school (college/university) for three years. I graduated a year early because I took so many classes by my third year I was able to graduate. You have to work your tail off if your goal is to become a doctor. I then went to graduate school and got my master’s in biology. Next, I went to medical school. This is where the admission rate was less than 3%. Four years later, I graduated. In July of 2014, I began residency. Once you graduate from medical school you are a doctor. Don't let anyone tell you otherwise. Some organizations out there want med students to think that they need to do a residency before applying for a "real" job as a physician. This is not always the case. What is really needed is a medical license and in most states you can get one after completing intern year (the first year of residency). One reason a doctor has a hard time finding a job without completing residency is because it is unlikely anyone will support that doctor after they leave. This is because, unfortunately, some systems want a doctor to be a resident (or in other countries what is called a “registrar”) so they can use the doctor for cheap labor. Residents usually do not make enough money  (I was making about $10/hour as I was working 100 hour weeks) to pay off even the interest on their student loans every month.  

Each specialty has its own residency program which is usually   3 or 4 years long. This is a time where they are a doctor but yet, they can feel trapped as  indentured servants . They are told what state they will be living in and what specialty they will in by the results from the Match Program.  Residents have very few legal rights. Through my case, I have found that the system is set up so that if something happens to the resident and it is to their benefit to be counted as a student they are instead counted as an employee. If there is a situation where it would be to the resident's advantage to be counted as an employee they are counted as a student. I completed two years of residency before being fired. Most people in my position would become destitute as there would be no way for them to pay off hundreds of thousands in loans. Fortunately, I saw this coming and worked to obtain my full medical license before they could fire me.  After a 3 or 4 year residency, the resident can go on to subspecialize and do a fellowship (optional). For example, if the resident completes a 3 year internal medicine residency, they may continue on to do a 3 year fellowship in cardiology. Don’t get me wrong, some institutions actually do teach during these years. But, sadly others just use their residents. Once these limbo years are completed you become an attending or, as they say in the UK, a consultant. 

Wait, what is the difference between a consultant and a consulting physician?
A consultant is a term used in other countries to mean "attending." It shouldn’t be confused with a consulting physician in the US (the terms are used interchangeably). The consulting physician is a specialist doctor who is asked a question. A doctor in one specialty “consults” with the consult physician in another specialty about their patient for an issue that is outside of their field. For example, if a surgical patient starts having seizures the surgeons will consult a neurologist for help with the seizures. In this case, the surgical team is the primary team and the neurology team is the consulting team.
In the hospital, (at least, at every teaching hospital I have worked in - about 10 different hospitals) this is typically what happens during a consult: When a doctor (the primary team physician) is the one calling to ask a question aka "calling a consult," they expect to get an earful. No one wants extra work and the consult physician will try to dodge the question. Alternatively, if a doctor is the one getting called for a consult (they are the consulting physician), they expect the question on the other end to be one that could easily be answered by the doctor who is calling them, but is too lazy to look into it. The thing about it is that it literally can’t be both ways. In actuality, what happens is that both sides are extremely overworked, so being interrupted with a question or having your question blocked (blocked is a term we use frequently when the consulting physician won't answer the question) takes up your time and understandably makes you angry. Why would the general population care about this? Because this arguing makes for poor patient care.
Taking a consult
When I was a consulting physician in psychiatry, I would get called with the strangest questions or no questions at all - just odd statements. For example: “Hello, this is Dr. Stephanie with psych. What is your consult question?” To which I would they respond “Help, this is Dr. McScared from surgery, I have a patient who is looking at me funny.” Or “It’s Dr. McBusy in the ER, there is a patient who came in because she can’t find her credit card.” The doctor making the consult is supposed to ask a question and the doctor receiving the consult is supposed to answer it. I couldn’t very well answer a statement so I would turn these statements into questions. I printed off a word document I created explaining how to do this and passed it out to the other doctors so instead of yelling incomprehensibly back and forth, one could make a logical guess as to what the question is. For example to Dr. McScared I would say “You think the patient is looking at you with anger and you are asking me to do an assessment for homicidality?” And to Dr. McBusy I would say “You think coming to the ER for a lost credit card is bizarre and you would like me to evaluate them for psychosis?” See! Much better than getting into a fight over the phone and it teaches the other side what to say for next time. I jokingly created the slogan “Hello, this is psych consult where you don’t have any questions but we have all the answers!” I obviously never actually said that to an incoming caller but had to take my frustration out somehow – humor, the mature defense mechanism. There really is no need for the name calling and attitude. Improve medical culture!
Calling a consult
When I was an intern (first year resident), before I knew I had kidney cancer, I was on an internal medicine rotation. I had a patient who came in for an infected kidney tube which he said “needed to be capped.” Common sense tells me I should just clamp down the tube, disconnect the bag and then screw on the cap. But it was infected --do I need a different cap? How do I know it’s the right one? Does the tube need to be flushed with something? Should I change the dressing? I asked my senior resident (second or third year resident) what exactly the steps were. He told me he had no clue and that urology is supposed to do that sort of thing. So, I called urology for a consult, “Hello, this is Dr. McPissy with urology what do you want?” “Um, this is Dr. Stephanie I have a patient that needs a cap on their nephrostomy tube but it is infected. Can you please help me?”  “You must be dumb. Watch it on Youtube. It’s easy. Bye.” He probably thought I was being lazy and just wanted him to do my work for me. I was thinking that, yeah, it probably is pretty easy and I was very good at procedures, but, if it was as easy as I thought why would he not just tell me how to do it over the phone? It’s infected and I genuinely thought it would be better for the patient if Dr. McPissy did it and I actually learned how first. I called back again and explained that I did look it up but still was not comfortable with it due to the infection. He said “Fine, I’ll do it.” He never called me to tell me when he came but later I saw his note (we have to write a note about everything). It was not signed over to an attending. When I read it I realized why. It was very passive aggressive and belittling. He wrote that he was consulted due to the primary team’s “lack of understanding of gravity.” He then went on to explain in fine detail how gravity works and how we need to learn to use Google. Needless to say, this did not teach me how to do it for the future. Five months later, I went to my urologist for a cancer follow up and who walks in? Well if it wasn’t Dr. McPissy! He doesn’t recognize me but I recognize him. I “learned to use Google” and Googled him so I knew what he looked like. I thought to myself, “If I get one, I should request that only he cap my nephrostomy tube --since I never learned how.”
To see some hilarious examples of consults check out the xtranormal videos. Click any specialty vs. any specialty. For example, Surgery vs Radiology. Ortho vs Psychiatry. Ortho vs Anesthesia etc. Apparently, you CAN learn a lot from Youtube!

What is the difference between and intern and an internist?

An intern is a first year resident. They are also known as PGY1s, in their transitional year, or in a preliminary year. An internist has finished three years of an internal medicine residency. Hey, I didn't come up with the names.

What specialty is internal medicine? 
Internal medicine, general medicine, or just "medicine" is the specialty that deals with the diagnosis and treatment of undifferentiated or multi-system (many organs) disease processes in adults. While all specialties are considered to be in medicine (yes, even psychiatry - we go to med school and deliver babies like all other doctors), when you hear someone referred to as a "medicine resident" it means they are doing a residency in internal medicine. At most teaching hospitals, the majority of the residents are in an internal medicine program.
What is a categorical residency? 
A program that you can enter into after med school and subsequently complete is called a categorical residency. Examples include, internal medicine (3 years), pediatrics (3 years) psychiatry (4 years), pathology (4 years), and general surgery (5 years). After completing a three year residency in internal medicine, the doctor is known as an internist.  They can go on to fellowships such as gastroenterology or cardiology to further specialize if they choose. Other specialties that are not categorical such as neurology, radiology, and anesthesiology require you to complete a year of residency (intern year, PGY-1, transitional year, preliminary year) beforehand and this first year is typically done in internal medicine.