Know Where You Stand: Life as a Third Year Medical Student

Interactions in the hospital are based on a very explicit hierarchy. At the top are attendings, doctors who have finished their residency and are done with their formal training. They are ultimately the decision makers. Next, are residents. Residents have finished medical school, but are learning their chosen specialty. Residency is between 3-7 years depending on specialty. Then come interns, who have just finished medical school and are equivalent to first year residents. At the bottom, as everyone knows, are medical students, years 1-4. Sometimes, the different years are part of the hierarchy as well, as in a 3^rd year resident will outrank a second year medical student.

What many people don’t understand is how many areas of hospital life the hierarchy affects. Obviously, disagreements about patients and their treatment are decided by hierarchy, however, there are many subtle manifestations. When we walk out of a patient’s room as a team, we leave by rank unless a higher rank tells you to go in front of them. When we scrub for surgery, the attending walks into the room first and is gloved and gowned while everyone else stands there, wet hands in the air. Chairs are always taken in order of rank. Medical students always stand on the periphery of any group and immediately step out of the way if a higher rank walks near you. Attendings expect this to such an extent that if I didn’t step aside, they would run into me and I would say “excuse me”. Attendings also set the mood anywhere. If they are laughing, you can laugh. If not, you remain focused. I was told recently not to tell stories in the operating room cause, “it’s just awkward when the medical student talks too much.” And that is very true. I would never tell a story in the OR.

The most extreme example I saw was on OBGYN when I was working nights on labor and delivery. This means we started work at 6pm and ended at 8am. No one knows what or when to eat and everyone is trying to make the time bearable in the extra seconds instead of studying like we usually do. I was with an intern and we had taken care of all our patients, meaning we had checked on all of them and written any new orders, so we sat down in the lounge and began to look at US Weekly. One of our attendings was in the room discussing another patient with a second year resident. They couldn’t figure out what some of the patient’s labs meant, so they both started researching on the Internet and discussing the case. My intern and I sat, reading about fashion and discussing which boots were cute. Later that night, the second year resident reprimanded the intern saying, “When your attending is learning, you should be learning. There’s no way you possibly know it if they’re looking it up, so you should be paying attention. It’s absolutely inappropriate to sit and talk about shopping in front of an attending.” And in the culture of medicine, she was right.

After that night, I thought I didn’t like hierarchy. I was shocked that residents only a year ahead in training could reprimand an intern. Then I went to another hospital where hierarchy wasn’t nearly as pervasive in their culture, and I found I missed it. Interns would hesitate to correct me, saying they were barely ahead of me. Even higher residents would ask me where I had read something before saying the correct answer. Although this may sound nice, I found it disconcerting. I wanted to ask, “But didn’t you learn anything between third year of medical school and intern year?” I think the willingness to teach and reprimand someone close to you in rank shows a respect for your training. It tells me that they are learning something everyday and that because they’re 365 days ahead of the next person down, they should know better. I do warn people that issues with authority should be worked out before going into medicine; however, I hope whoever’s shoes I’m filling respects their experience enough to tell me how to improve.