What are some things you don't realize about medicine until you become a physician?

[medinquirer]

It's common for premed students (like me) to learn important aspects about medicine by shadowing, volunteering, working, etc.

But I'm wondering, what are some things that you don't realize about medicine until you become a full-fledged physician?

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[SurfingDoctor]

It's common for premed students (like me) to learn important aspects about medicine by shadowing, volunteering, working, etc.

But I'm wondering, what are some things that you don't realize about medicine until you become a full-fledged physician?

Because no one teaches you about billing, prior-authorizations, etc. until to have to do them. There is no real "education" in those endeavors, but they are part of the system and a requirement of the job. Probably would be less applicants if they were just educated about paperwork and bureaucracy (while necessary, can be painful to do/deal with).

That goes for any job FYI, that's why it is called "work" and not "paid free fun time". The goal is to maximize the "fun time" and minimize the "work" to ones best abilities.

 

[giantswing]

I never realized how much I'd have to study/learn in residency. It's like medical school, with less time.

It's hard. It's easy to say, I'll take it! but then you get in the thick of things, and it's HARD.

 

[InvestingDoc]

Things that I learned:

1. Enjoy time in undergrad and try to have some fun. I had a little bit of fun in undergrad but I was too worried about my future and finances. I went straight from class to work with little time for fun and missed out on much of the college experience. Don't forget to be young.

2. Stereotypes as specialties are true to a large degree.

3. Chasing money will lead to a fat bank account but also rip your relationships and moral to shreds

4. The stress level was much higher than I anticipated. I always had my attending as back up till I was on my own as an attending. The learning curve from resident to attending was the largest one by far with med student to intern a close second.

5. The doctors lounge has free food all the time!!! My residency had NO free food and we had paid parking. Now I get to park in a special lot up front. I proudly park my beater right up front next to the CT surgeons GTR

6. I lived frugally and am reaping the benefits. My friends who took out >300k in debt are having a hard time figuring out if they should even consider buying a house since they have so much debt.

7. I was busy as a resident but now as an attending Its not uncommon for me to see up to 40 patients a day with a NP seeing 15 of them. Its a lot of stress to be in charge of that many patients medical care.

 

[ACSurgeon]

The most significant thing for me was the shear volume of medical conditions and patients we are unable to cure, but rather patch up and move along. I think most premeds (or maybe just me), only went to the doctor for acute "fixable" problems such as strep throat, and thus, have this impression that as a doctor people come to you with a problem and you give them a solution and they walk out relieved. In reality, that's not the case for most specialties or patients.

 

[operaman]

Still a resident so this list is evolving:

1) making the diagnosis is often easiest and fastest part. I had anticipated a little more Dr. House style (maybe without the breaking and entering) sleuthing, but in reality the diagnosis is obvious within the first few seconds of the encounter on most occasions.

2) medicine practiced really well is and should be fairly "boring." When things start getting crazy and exciting, it usually ends badly for the patient. Good medicine is seeing the patient early and recognizing the signs of impending doom while they are still nice and stable; the PEA arrest and emergent airway later may be more exciting but usually means the patient either dies in front of you or six months later in an LTAC with a trach/PEG.

3) writing is a much bigger part of the job than I knew. Whether it's documentation or papers or just communicating with people, I find myself doing a lot of it.

4) in line with #1 above, the softer aspect of being able to communicate well and get buy in from patients and families is much more of the job than diagnostics. This the part which makes me say (truthfully) that I use more of the skills on a daily basis that I learned as an artist than what i learned in medical school. That ability to read people, to listen powerfully, to improvise effectively, to teach and tell a compelling story - that is a big part of the job.

 

[Psai]

You think that you will run things and be the big boss of the hospital. Then you realize that useless administrators will leech off as much of your reimbursements as they can while doing their best to make your life harder.

Documentation is a pain in the ass and takes away time from patient care.

 

[mimelim]

Because no one teaches you about billing, prior-authorizations, etc. until to have to do them. There is no real "education" in those endeavors, but they are part of the system and a requirement of the job. Probably would be less applicants if they were just educated about paperwork and bureaucracy (while necessary, can be painful to do/deal with).

That goes for any job FYI, that's why it is called "work" and not "paid free fun time". The goal is to maximize the "fun time" and minimize the "work" to ones best abilities.

This is one of the reasons that I am glad that my residency, while highly academic from a research side has a very 'private' feel to it. It is expected that residents learn how how billing works and that they know how their documentation turns into billable numbers that can be processed by the coders/billers. Sure, it is more work to learn, which can be painful when you are working the hours that we do, but you can't replace having several years of experience before you have to go out and do it yourself. While many academic/hospital based jobs will have a robust support structure to coach you along when you start out, that isn't how the vast majority of doctors practice. Honestly, it comes down to the culture of the program that you are in. I'm going to give junior residents feedback on their consult notes if they are lacking what should be documented because, it does matter, even if they aren't the ones reaping the benefits now. Learning good, effective and efficient habits now pays off in the long run.

Regarding things I didn't know: I didn't know what a PA or NP was before starting residency. I didn't know that the vast majority of physicians don't think/function like they do in major academic centers/at universities/at residencies.

 

[DrSnips]

1) How so much of inpatient medicine has nothing to do with medicine. It doesn't really take an MD to look after a demented patient until a nursing home can be found, yet our society lacks an alternative and so you end up babysitting them for weeks at a time.

2) How most patients have never even learned the basics of their chronic medical conditions. You'll be confronted with end-stage COPD, CHF, etc. patients who have absolutely no clue about their horrible prognosis. The patients and their families are often surprised to hear how sick they are once they get hospitalized.

3) How willing the medical community is to provide futile care to patients with no quality of life, rather than say no to someone who is asking for care that has no chance of making things better.

4) How little you can actually fix and that mainly you are trying to get patients "back to baseline".

5) How the patient with two active subspecialty issues will not be on a subspecialty service with one consultant, but instead on gen med with two consultants.

6) Corollary to #5: People in other fields of medicine know laughably little about proper management of patients within your field. Unfortunately, this also means you don't know much about management in their fields.

7) If you think a patient lacks capacity, your psychiatry consult will determine they have capacity and vice-versa.

8) Patients don't give informed consent for receiving potentially dangerous medications, but do give consent so that a PICC line can be placed, even though I have yet to see the latter cause substantial harm to anyone.

9) The administration would like you to expedite discharges when the hospital is full, because apparently you weren't already doing this.

10) You are guaranteed to run into people completely unqualified to do your job who think they can do it better than you

 

[SansaStarkMD]

95% clicking boxes and following protocols

 

[Shikima]

There is no autonomy and you're seen as an expendable resource, much like a mechanic.

 

[mimelim]

95% clicking boxes and following protocols

Seems like something that mid-levels could do pretty easily.

 

[Yadster101]

Have any of you had realizations like it's hard to park both the Porsche and the Benz in the garage when you have an ATV and jetski inside? Or that, for some dumb reason, you have more bed rooms in your vacation than your real house. I'm not a doctor yet but I'd think those kinda problems could come up.

 

[nlax30]

Last year of fellowship but so far....

1. Medicine/training can and likely will change you. Sometimes for the better and sometimes not but it will change you. Especially in this last year I've found myself more stressed than every and getting a temper I've never had before and have had to really learn when and where to speak up about an issue that matters and when not to. I know that's vague... I significantly underestimated, and honestly had no idea about the amount of stress that can occur.

2. The politics inside a hospital can be absolutely horrible, whether it's between administration and clinical staff or amongst physicians/groups.

3. Administration will lie to you.

4. Don't take anyone's word for anything... whether it's a another doc, a nurse or whoever. Verify for yourself or you can get burned.

5. Listening, communicating well and having a good bedside manner will make you a star in your patients' eyes. You don't have to spend 45 min with them but actually listening and responding goes a long way, even if you have no idea what's going on.

6. Having a truly appreciated patient hand write a letter of gratitude to you can make you feel on top of the world..... those moments just don't come often enough.

7. You'll get comfortable doing procedures and interpreting things that you would not have thought possible just a few years prior.

 

[GoodWillShunting]

I didn't know that the vast majority of physicians don't think/function like they do in major academic centers/at universities/at residencies.

This is interesting. Any examples?


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[themockjock]

This is interesting. Any examples?


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We rotate through some community hospitals on to do vascular and gen surg. You will see hospitalist notes that end like this:

Assessment:
Abdominal pain, ESRD, PAD

Plan:
See orders
Consult general surgery
Consult gastroenterology
Consult nephrology
Consult vascular surgery

Granted, this kind of pan consult, minimal work in documentation while still being able to bill for the encounter is not entirely the fault of the hospitalists. Their census can easily run in the 50-60 patient range for a single physician and they are expected to move meat and get things done with extremely limited time and resources. Panconsulting then allows for way higher volumes because actually working all of these issues up in a timely manner when you have 60 other patients waiting to be seen is nearly impossible. OTOH, when you're an attending overseeing a resident run IM service that caps at 20 patients, you and the residents have orders of magnitude more time to see patients, come up with a coherent plan, document well said plan, and then only consult prn.

The other thing I've realized is that in contrast to resident services, in PP, consults are welcomed. Residents hate consults because they generate more work and occasionally are kind of dumb. They distract from going to the OR, etc. A PP surgeon, on the other hand, gets paid for each consult seen and more importantly, consults can frequently generate new patents and can be a nice way to grow one's practice...

 

[VisionaryTics]

This is one of the reasons that I am glad that my residency, while highly academic from a research side has a very 'private' feel to it. It is expected that residents learn how how billing works and that they know how their documentation turns into billable numbers that can be processed by the coders/billers. Sure, it is more work to learn, which can be painful when you are working the hours that we do, but you can't replace having several years of experience before you have to go out and do it yourself. While many academic/hospital based jobs will have a robust support structure to coach you along when you start out, that isn't how the vast majority of doctors practice. Honestly, it comes down to the culture of the program that you are in. I'm going to give junior residents feedback on their consult notes if they are lacking what should be documented because, it does matter, even if they aren't the ones reaping the benefits now. Learning good, effective and efficient habits now pays off in the long run.

Regarding things I didn't know: I didn't know what a PA or NP was before starting residency. I didn't know that the vast majority of physicians don't think/function like they do in major academic centers/at universities/at residencies.

I wish I had more teaching on billing.

I showed up at the VA as a PGY3 and was shocked that I needed to fill out billing codes after signing my notes.

I still have no idea what they mean. My reasoning is generally, "Eh, I kind of half-assed this note, let's call it a level 2 or 3" or "I spent forever with this guy and have like six assessments plus a procedure, level 5".

What resources does your program use to teach you guys this stuff?

 

[mimelim]

This is interesting. Any examples?


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Egos are generally suppressed because it is harmful. Business and compensation are driven by referrals. Consultants must be kept happy or you simply will not make money. Nursing staff and ancillary staff are the eyes and ears on the ground, not residents. Developing a strong working relationship with them is incredibly important if you want to excel. The attitude is less, "lets figure it out" and more "lets get this done".

I wish I had more teaching on billing.

I showed up at the VA as a PGY3 and was shocked that I needed to fill out billing codes after signing my notes.

I still have no idea what they mean. My reasoning is generally, "Eh, I kind of half-assed this note, let's call it a level 2 or 3" or "I spent forever with this guy and have like six assessments plus a procedure, level 5".

What resources does your program use to teach you guys this stuff?

Residents/fellows dictate all operative reports, even if you are an intern. We have a copy of this in our office: Amazon product in the 3rd edition 2 of our residents (including yours truly) are authors. It is a reasonable starting point, but we also have a large library of our own specific op note templates that are broken down into components based on billing/coding needs. But, it isn't enough. It takes a lot of dedicated teaching time by faculty and senior residents to coach juniors on why their notes need work. The main filter for us are our coders, we have 4 working with us and they sit in the office next to ours (ie a 5 second walk). When you start as an intern with us, you get to know them quickly because they will send you (not the attending) questions about your consults/op notes. It is infuriating when you first start out because you just want to get your work done and a lot of the time you don't understand what was going on in the first place and now you have to document it, so of course it looks like crap. But, like everything practice isn't enough, perfect practice is what you need. That feedback loop is what makes our seniors comfortable with the process, at some point it becomes second nature and you can't help but see the holes in documentation.

Beyond that, it is culture, pure and simple. I know the cost of every single item in the OR from my EVAR stent to the wires to the sterile gloves. Why? Because our decision making IS influenced by it. Being able to do an entire case with one wire makes your practice more economical and efficient. Sure, a single case may not make a big difference, but when you do 3-4 cases a day over a career, it adds up pretty darn quick.

 

[TooMuchResearch]

Contracts.
Documenting for coding and billing.

 

[girlofgrace7]

1) We don't really allow ourselves to be human. It's not uncommon to have people at work throwing up between patient rooms or working with pneumonia and almost passing out from low O2 level because it's a huge inconvenience for coworkers when you call in sick. Plenty of days involve not eating or using a bathroom from 6 am to 9 pm because there are patients that need to be seen, and you feel guilty making them wait.

2) Your patients' nurses will make or break you. They are your eyes and ears on the floor, and you have to be able to trust them to call you when you need to be called (and hopefully not to call you or the code team for stupid things like a patient who just got Ativan being sleepy). They will either back you up to an attending and patients or throw you right under the bus in front of either. Learn who to trust and who not to, but be nice regardless.

3) You will get jaded. Especially when you haven't had a decent night's sleep in weeks and you're seeing an ER full of screaming families and melodramatic patients who think their unchanged abdominal pain for the last 3 years justifies a full workup complete with consultants and MRIs at 3 am. But a genuine thank you or a compliment from a patient or their family (though few and far between) really can make everything worth it again.

4) You catch more flies with honey than vinegar. Though I like to think I give everyone the same high level of care, I'm much more willing to go check in on patients who are nice to me when I have a few minutes of downtime than I am the patient and family who screams and berates everyone who walks into the room. I'm also going to be much more likely to take their opinions and suggestions into account, and I'm probably going to be less stingy with things like pain medication when they are reasonable rather than demanding. This also applies to consultants... if I want IR to come in to do a procedure on Thanksgiving at 11 pm, I'm going to get a lot further by explaining how much it would help the patient and how grateful I will be than by demanding they do their job.

5) I never thought I'd factor lifestyle into career choice, but there's something to be said for a 9-5 specialty after years of exhaustion.

6) Communication is the mark of a great physician. It doesn't matter how intelligent you are. If you can't make the patient understand their condition and what needs to be done, they will have bad outcomes. If you can't explain why you are not concerned that a child has a fever of 101 or has thrown up twice a week ago, you will be seeing them over and over in the ER. If you can't explain to a nurse your rationale for an order or lack of an order, you are going to have your orders ignored or they will go over your head.

7) No matter how great your support staff is, you will wind up wearing many hats. Even if you don't really have the time to do it, you will be tracking down blankets and juice cups now and then, playing chaplain to a grieving family, playing social worker trying to find someone placement. You'll get further in your career if you lose your ego and the phrase "that's not my job" right now.

8) The media, your family, your friends, and your patients outside of the medical field will all have an idealized view of what you do. Medicine isn't glamorous, especially while still in training. You will work long, hard hours for little pay while having a lot of loans. Everyone will talk about how you probably have a private jet and sports car or will after training.

9) Patients, especially ones from low SES families, are jaded by medicine. Most will not believe you have their best interest in heart. It will take a lot of time and effort to try to change their minds, and it's tough to accept that many times you won't.

 

[Anicetus]

It's common for premed students (like me) to learn important aspects about medicine by shadowing, volunteering, working, etc.

But I'm wondering, what are some things that you don't realize about medicine until you become a full-fledged physician?

Not a physician yet, but have realized how little control we have over our destinies in terms of locations. Every physician I talk to seemed to have no control of where they ended up when they originally intended to practice in a bigger coastal city. As some of them whither into their 50's they tell me "one day I'll move to Boston to practice".

 

[meister]

Medicine/training can and likely will change you. Sometimes for the better and sometimes not but it will change you. Especially in this last year I've found myself more stressed than every and getting a temper I've never had before and have had to really learn when and where to speak up about an issue that matters and when not to. I know that's vague... I significantly underestimated, and honestly had no idea about the amount of stress that can occur.

Definitely agree with this. I'm not sure everyone experiences it but many do. I've definitely grown more bitter and cynical.

 

[nlax30]

Definitely agree with this. I'm not sure everyone experiences it but many do. I've definitely grown more bitter and cynical.

Yea I think it's hard not to get bitter and cynical about certain things, just the nature of seeing the types of scenarios we see on a daily basis. One positive for me though was I think this whole process gave me some needed confidence and made me a little more outspoken. I was never the typical "Type A" personality that people assume is the stereotypical med student/doctor and was more reserved and in the background. But now I've developed much more of a 'voice' and very comfortable with talks and presentations and actually don't mind giving them now. So I think you just have to recognize how you're changing and hopefully using some of it for good.

 

[masaraksh]

Egos are generally suppressed because it is harmful. Business and compensation are driven by referrals. Consultants must be kept happy or you simply will not make money. Nursing staff and ancillary staff are the eyes and ears on the ground, not residents. Developing a strong working relationship with them is incredibly important if you want to excel. The attitude is less, "lets figure it out" and more "lets get this done".



Residents/fellows dictate all operative reports, even if you are an intern. We have a copy of this in our office: Amazon product in the 3rd edition 2 of our residents (including yours truly) are authors. It is a reasonable starting point, but we also have a large library of our own specific op note templates that are broken down into components based on billing/coding needs. But, it isn't enough. It takes a lot of dedicated teaching time by faculty and senior residents to coach juniors on why their notes need work. The main filter for us are our coders, we have 4 working with us and they sit in the office next to ours (ie a 5 second walk). When you start as an intern with us, you get to know them quickly because they will send you (not the attending) questions about your consults/op notes. It is infuriating when you first start out because you just want to get your work done and a lot of the time you don't understand what was going on in the first place and now you have to document it, so of course it looks like crap. But, like everything practice isn't enough, perfect practice is what you need. That feedback loop is what makes our seniors comfortable with the process, at some point it becomes second nature and you can't help but see the holes in documentation.

Beyond that, it is culture, pure and simple. I know the cost of every single item in the OR from my EVAR stent to the wires to the sterile gloves. Why? Because our decision making IS influenced by it. Being able to do an entire case with one wire makes your practice more economical and efficient. Sure, a single case may not make a big difference, but when you do 3-4 cases a day over a career, it adds up pretty darn quick.

Man all of this sounds like a lot of work.

Can I be a surgeon in 1900 and just go in an open case with an unsterilized scalpel and some yarn and muck some stuff up?

 

[Bacchus]

The biggest thing I've learned/had an affirmation of is:

IT IS ABSOLUTELY WORTH IT.

I work in an office with excellent staff that follow their job descriptions. I get to see patients who trust and like me. I'm so glad I made it through because I am finally happy.

 

[Winged Scapula]

Not a physician yet, but have realized how little control we have over our destinies in terms of locations. Every physician I talk to seemed to have no control of where they ended up when they originally intended to practice in a bigger coastal city. As some of them whither into their 50's they tell me "one day I'll move to Boston to practice".

Huh? That's a bunch of BS of you ask me.

I'd venture that most of that is related to family issues, financial concerns or other restrictions they've put on their employment choices.

With very the exception of a few super specialties (which might only have a few places where its feasible to practice), there is little to no reason why someone couldn't "move to Boston to practice" provided they accept the job conditions offered there.

If you want to move to Yuma Arizona and practice Child Neurology or Psychiatry in Manhattan, you can -- you just have to accept that the job conditions/salary/social outlets etc may be better elsewhere.The truth is that competition and salaries tend to be lower in "bigger coastal" cities and some aren't willing to accept that but whine about "one of these days".

 

[Shorin-Ryu]

Egos are generally suppressed because it is harmful.

Once upon a time, during my medical student travels, I observed an interesting scene at one of the nationwide Medical Student Leadership Weekend Programs.

A medical student from the most amazing medical school in the world came up to another medical student, pointed out at that other medical student’s not so well-known medical school’s name and asked loudly in front of everyone, “Is this a DO school?”

The other medical student’s eyes sparkled and the medical student said with a spunky smile, “ No. Is yours?”

Needless to say that everyone around the two students broke into laughter, making the first student feeling quite awkward; and I thought that I would rather believe that the first student was simply curious about the other student’s medical school; however, the importance of thinking before saying had become obvious to me more than ever before now that we were entering one of the most challenging professions in the world.

Never too late to learn.