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The Nine Circles of Medical School (read: Hell)
The Circles of Hell
Third Year introduces the medical student to the nine circles of Hell. The circles in third year occur for each individual in no particular order but it is easily determined that some are far worse than others, though they all represent varying degrees of torment and misery for medical students, house officers, and patients alike. Each circle's house staff are punished in a fashion fitting their personality, and mean-spirited personalities predominate more and more as one descends through the circles. People who were foolish enough to enroll in medical school but realized before it was too late how punishing clinical medicine is end up in Purgatory, this is to say, Pathology and Radiology. Those in Hell are the M.D. graduates who cling to the notion that patient care is a rewarding endeavor.
"Abandon all hope, ye who enter here."
LIMBO
First Circle: Outpatient Clinic
Here reside the well patients, who need only a brief check-up. Here also reside the not so sick. These patients are ambulatory and one only has to spend 20 minutes to diagnose and treat a simple problem, or follow up on management of one or more chronic conditions. Thus, the medical students are not punished in an active sense, but rather grieve only the occasional walking personality disorder patient. This is the most benign of the 9 circles, and very frequently is even rewarding.
Beyond the first circle, all the others involve overt punishment of the medical student. They may be grouped into 3 categories (similar to Dantes incontinence, violence and fraud). The first involves basic care of the inpatient and is the least punishing. The second involves care of the very ill, and the third and lowest level of hell involves active interventions that require one to scrub in.
UPPER HELL
Second Circle: Psychiatric Hospital
The psychiatric hospital represents the most benign form of inpatient rotation. Though students may be occasionally screamed at by the mentally ill, there is usually no physical exam required and rounds move quickly. A good assessment and plan is something like, Assessment: patient still crazy. Plan: go up on the anti-psychotic du jour. Psych attendings are rarely if ever mean and tend to have entertaining and wacky personalities. Best of all, one can be done for the day in less than 6 hours.
Third Circle: Consult Service
The consult service is usually a subspecialty like infectious disease, cardiology, rheumatology, neurology, etc. This is the highest level of hell that involves being in a regular hospital. While consult services are plagued by a relatively unpredictable schedule (primary teams can call whenever), they are not burdened with overall responsibility for the patient. They deal only in one specific area, and while they may follow up, they do not take call and often do not accept consults after 5 pm. As they are almost always a specialty service, they do not have to deal directly with management of the patients comorbidities, a definite added advantage.
Fourth Circle: Pediatric Floor
In the fourth circle, one is part of the primary team, meaning that this team bears the ultimate responsibility for the patient and must deal with the patients multiple problems. In pediatrics, the patients frequently only have one diagnosis, which is an acute diagnosis, and little past medical history. In addition, the attendings and house staff are considerably nicer than those on medicine. The patients, being mostly cute little kids, are intrinsically more likeable. For these reasons, if one must be on a primary team and suffer the scourge of overnight call, pediatric floor is the least punishing.
Fifth Circle: Medical Floor
In theory, this is the same as pediatric floor, only for adults. However, there are several reasons why the medical floor is a lower level of hell. The patients often have many, many medical problems that must all be managed in concert. The history and physical is thus quite a burdensome endeavor and includes a significant amount of past medical history. In addition, the patients themselves may be combative and non-compliant. Not infrequently they are demented and cannot give a good history. While pediatric patients may not be able to give a history, the parent can give a very detailed history in 90% of cases. In addition to the patients, the culture of internal medicine is not near as friendly and welcoming as that of pediatrics. Though medicine attendings may not be overtly mean and yelling at people, they often have a giant stick up the butt and are never satisfied with anyones presentations or fund of knowledge. Add to this the 4 hours of rounding each day and it is self-evident that medicine floor is truly the 5th circle of hell.
MIDDLE HELL
Sixth Circle: Emergency Room
In the emergency room, one is constantly assaulted by an undending barrage of patients, ranging from the scarily critically ill to the very frustrating patient who just wants to ask for vicodin or has a cold and didnt feel like waiting until the next day to be seen by primary care. Thus, one is condemned to feeling either panicked or irritated 100% of the time. With ER patients, there is no winning. In addition, ER nurses are famously mean to everyone, not just students, but residents and attendings as well. Then there are the services to which ER tries to admit patients. When ER calls a service to admit a patient to their floor, the intern on call WILL be pissed, no matter how legitimate the admission. ER house staff have to burn off this frustration somehow, and will often take it out on the defenseless medical student.
Seventh Circle: Intensive Care Unit
The intensive care unit houses the sickest patients in the hospital, and many will expire here. In order to even be admitted to an ICU one has to be more or less trying to die. Thus the first thing that you will notice upon entering the ICU is an eerie stillness. Patients are all obtunded and hooked up to many, many machines and tubes. Here the medical student will often rapidly spiral into depression. Withdrawal of care occurs on a regular basis. When the ICU is not depressing, it is anxiety provoking, as patients code on a daily basis here. The ICU is the lowest level of hell that does not involve the torture of scrubbing in.
LOWER HELL
Eighth Circle: Operating Room
The operating room punishes the medical student in a very ritualistic, unforgiving fashion. First, the student engages in a ritual reminiscent of Lady MacBethscrubbing in. This involves rubbing each side of each finger 10-15 times with harsh iodine soap. One must wash in a precise fashion from distal to proximal and rinse in the same fashion. Then entering the OR without touching anything the towel is used to dry the hands in a similar regimented way (careful! The air above your shoulders is contaminated so dont put your hands up too high!). Afterwards, the gown and gloves are donned and the student is hereafter confined in his own little prison, unable to touch anything except the operating table. Once (s)he is standing in the proper location (usually one where the operation is difficult or impossible to see), the student must remain motionless for the duration of the operation, often more than 4 hours. In some cases the student may have to retract this whole time. Thus the main form of punishment in this level of hell is immobility and inability to eat, drink, pee, or itch. One often sees only through a fog, as splash guarded masks are employed to add to the punishment, despite the fact that in non-trauma cases there is virtually no risk of any splash. The student is usually interrogated at some point by the attending and/or house staff on medical facts, most commonly anatomy, but this is a much less severe form of punishment than the complete imprisonment of being scrubbed in.
Ninth Circle: Labor & Delivery
Hell & D is the lowest circle of hell. The rotation involves scrubbing in on vaginal deliveries, which means holding up a patients leg and telling her to push for hours and hours, followed by an acrid shower of feces, urine, amniotic fluid, etc. The smell in the room is often nearly unbearable. After all this one may have to deliver the baby, a panic-inducing endeavor if there ever was one. If lucky enough to avoid this, the student will surely be asked to deliver the placenta (since this task is beneath the residents dignity). But the main form of punishment on this rotation isnt the awkwardness, or the stench, or the fact that as soon as the baby is wiped off and made cute you never see it again. The most punishing thing about L&D is the house staff, analogous to the Harpies of Greek mythology. With surgeons, you can just shut the hell up and do what youre told and not get yelled at. No such luck here. Whatever you do is never, ever, EVER right. Even if youre quiet and deferential the house staff in this lowest level of hell WILL find some reason, any reason, to yell at you and generally try to make you miserable. If you dont mess up enough on your own they will put you in catch-22 situations to ensure it. Sending the student to get charts or labs when his/her patient is 9 cm dilated, then yelling at them for missing the delivery is a favorite. The harpies haunt their students incessantly, always screeching at them for anything they can think of. The ninth circle inspires many to quit medical school, and its general atmosphere of malignancy is ironic given that it is where life begins. I suppose it makes sense given that for many, life entails a generally painful existence.
The Circles of Hell
Third Year introduces the medical student to the nine circles of Hell. The circles in third year occur for each individual in no particular order but it is easily determined that some are far worse than others, though they all represent varying degrees of torment and misery for medical students, house officers, and patients alike. Each circle's house staff are punished in a fashion fitting their personality, and mean-spirited personalities predominate more and more as one descends through the circles. People who were foolish enough to enroll in medical school but realized before it was too late how punishing clinical medicine is end up in Purgatory, this is to say, Pathology and Radiology. Those in Hell are the M.D. graduates who cling to the notion that patient care is a rewarding endeavor.
"Abandon all hope, ye who enter here."
LIMBO
First Circle: Outpatient Clinic
Here reside the well patients, who need only a brief check-up. Here also reside the not so sick. These patients are ambulatory and one only has to spend 20 minutes to diagnose and treat a simple problem, or follow up on management of one or more chronic conditions. Thus, the medical students are not punished in an active sense, but rather grieve only the occasional walking personality disorder patient. This is the most benign of the 9 circles, and very frequently is even rewarding.
Beyond the first circle, all the others involve overt punishment of the medical student. They may be grouped into 3 categories (similar to Dantes incontinence, violence and fraud). The first involves basic care of the inpatient and is the least punishing. The second involves care of the very ill, and the third and lowest level of hell involves active interventions that require one to scrub in.
UPPER HELL
Second Circle: Psychiatric Hospital
The psychiatric hospital represents the most benign form of inpatient rotation. Though students may be occasionally screamed at by the mentally ill, there is usually no physical exam required and rounds move quickly. A good assessment and plan is something like, Assessment: patient still crazy. Plan: go up on the anti-psychotic du jour. Psych attendings are rarely if ever mean and tend to have entertaining and wacky personalities. Best of all, one can be done for the day in less than 6 hours.
Third Circle: Consult Service
The consult service is usually a subspecialty like infectious disease, cardiology, rheumatology, neurology, etc. This is the highest level of hell that involves being in a regular hospital. While consult services are plagued by a relatively unpredictable schedule (primary teams can call whenever), they are not burdened with overall responsibility for the patient. They deal only in one specific area, and while they may follow up, they do not take call and often do not accept consults after 5 pm. As they are almost always a specialty service, they do not have to deal directly with management of the patients comorbidities, a definite added advantage.
Fourth Circle: Pediatric Floor
In the fourth circle, one is part of the primary team, meaning that this team bears the ultimate responsibility for the patient and must deal with the patients multiple problems. In pediatrics, the patients frequently only have one diagnosis, which is an acute diagnosis, and little past medical history. In addition, the attendings and house staff are considerably nicer than those on medicine. The patients, being mostly cute little kids, are intrinsically more likeable. For these reasons, if one must be on a primary team and suffer the scourge of overnight call, pediatric floor is the least punishing.
Fifth Circle: Medical Floor
In theory, this is the same as pediatric floor, only for adults. However, there are several reasons why the medical floor is a lower level of hell. The patients often have many, many medical problems that must all be managed in concert. The history and physical is thus quite a burdensome endeavor and includes a significant amount of past medical history. In addition, the patients themselves may be combative and non-compliant. Not infrequently they are demented and cannot give a good history. While pediatric patients may not be able to give a history, the parent can give a very detailed history in 90% of cases. In addition to the patients, the culture of internal medicine is not near as friendly and welcoming as that of pediatrics. Though medicine attendings may not be overtly mean and yelling at people, they often have a giant stick up the butt and are never satisfied with anyones presentations or fund of knowledge. Add to this the 4 hours of rounding each day and it is self-evident that medicine floor is truly the 5th circle of hell.
MIDDLE HELL
Sixth Circle: Emergency Room
In the emergency room, one is constantly assaulted by an undending barrage of patients, ranging from the scarily critically ill to the very frustrating patient who just wants to ask for vicodin or has a cold and didnt feel like waiting until the next day to be seen by primary care. Thus, one is condemned to feeling either panicked or irritated 100% of the time. With ER patients, there is no winning. In addition, ER nurses are famously mean to everyone, not just students, but residents and attendings as well. Then there are the services to which ER tries to admit patients. When ER calls a service to admit a patient to their floor, the intern on call WILL be pissed, no matter how legitimate the admission. ER house staff have to burn off this frustration somehow, and will often take it out on the defenseless medical student.
Seventh Circle: Intensive Care Unit
The intensive care unit houses the sickest patients in the hospital, and many will expire here. In order to even be admitted to an ICU one has to be more or less trying to die. Thus the first thing that you will notice upon entering the ICU is an eerie stillness. Patients are all obtunded and hooked up to many, many machines and tubes. Here the medical student will often rapidly spiral into depression. Withdrawal of care occurs on a regular basis. When the ICU is not depressing, it is anxiety provoking, as patients code on a daily basis here. The ICU is the lowest level of hell that does not involve the torture of scrubbing in.
LOWER HELL
Eighth Circle: Operating Room
The operating room punishes the medical student in a very ritualistic, unforgiving fashion. First, the student engages in a ritual reminiscent of Lady MacBethscrubbing in. This involves rubbing each side of each finger 10-15 times with harsh iodine soap. One must wash in a precise fashion from distal to proximal and rinse in the same fashion. Then entering the OR without touching anything the towel is used to dry the hands in a similar regimented way (careful! The air above your shoulders is contaminated so dont put your hands up too high!). Afterwards, the gown and gloves are donned and the student is hereafter confined in his own little prison, unable to touch anything except the operating table. Once (s)he is standing in the proper location (usually one where the operation is difficult or impossible to see), the student must remain motionless for the duration of the operation, often more than 4 hours. In some cases the student may have to retract this whole time. Thus the main form of punishment in this level of hell is immobility and inability to eat, drink, pee, or itch. One often sees only through a fog, as splash guarded masks are employed to add to the punishment, despite the fact that in non-trauma cases there is virtually no risk of any splash. The student is usually interrogated at some point by the attending and/or house staff on medical facts, most commonly anatomy, but this is a much less severe form of punishment than the complete imprisonment of being scrubbed in.
Ninth Circle: Labor & Delivery
Hell & D is the lowest circle of hell. The rotation involves scrubbing in on vaginal deliveries, which means holding up a patients leg and telling her to push for hours and hours, followed by an acrid shower of feces, urine, amniotic fluid, etc. The smell in the room is often nearly unbearable. After all this one may have to deliver the baby, a panic-inducing endeavor if there ever was one. If lucky enough to avoid this, the student will surely be asked to deliver the placenta (since this task is beneath the residents dignity). But the main form of punishment on this rotation isnt the awkwardness, or the stench, or the fact that as soon as the baby is wiped off and made cute you never see it again. The most punishing thing about L&D is the house staff, analogous to the Harpies of Greek mythology. With surgeons, you can just shut the hell up and do what youre told and not get yelled at. No such luck here. Whatever you do is never, ever, EVER right. Even if youre quiet and deferential the house staff in this lowest level of hell WILL find some reason, any reason, to yell at you and generally try to make you miserable. If you dont mess up enough on your own they will put you in catch-22 situations to ensure it. Sending the student to get charts or labs when his/her patient is 9 cm dilated, then yelling at them for missing the delivery is a favorite. The harpies haunt their students incessantly, always screeching at them for anything they can think of. The ninth circle inspires many to quit medical school, and its general atmosphere of malignancy is ironic given that it is where life begins. I suppose it makes sense given that for many, life entails a generally painful existence.
