Climbing the Medical Ladder

An older doctor looks back—and ahead—at the “medical hierarchy”

by Dr. S. Fitzgibbons MD, FACP

“That poor youngster has such a long way to go.”

You probably heard that when you got accepted to med school: the common idea that you are starting a long struggle up a steep ladder before you arrive at where you want. As you take classes and start interacting with actual patients, though, you are starting to realize that this is not always a struggle.  In fact, it’s often fun. The subject is fascinating. Making sick people better is a thrill. Even in the tragedies there’s a chance to do some good.

But still there’s that ladder. How are you going to fit in? Which parts are the hardest? Don’t you have to worry about falling off?

Looking back over the years since I started med school in 1977, let me describe the stages you’ll go through, with some ideas on how to handle the adjustment.

Out on the Wards

Well, we don’t have many actual wards anymore, but your first clinical rotation is still a milestone. Most of your teaching will come not from faculty but from the residents and nurses who teach you the rules of the hospital, from hygiene to etiquette. Try to learn from everybody: the guy who mops your patient’s floor may have had an aunt with a similar illness and be able to explain what the family is going through better than the attending oncologist. And every doctor I know learned how to scrub for the OR from a nurse who was more interested in doing it right than in our lofty ideas about the “big picture” or our differential diagnosis.

You’ve spent most of your life on the honor roll or dean’s list and been pretty sure that if you work hard enough, you’ll get the A. Your first patient tragedy will hit you hard, whether it’s a death, a late miscarriage or a young person with permanent disability. As a med student I found that it helped more to talk about it with residents, for whom it was still a relatively new experience, than with older teachers. Sharing our memories of what happened over a cup of hospital coffee and knowing that somebody else had recently gone through the same thing didn’t change what had happened, but at least we felt less alone.

Residency and Fellowship

If the first year out of med school doesn’t scare you, maybe you should be in a different line of work. Having people call you “doctor” and mean it reaches into childhood memories—usually of Mom telling you that the doctor was there to keep you healthy and fix all the bad things. It makes you wonder if anybody realizes that you’re just you, not some miracle worker. Even the top member of your class gets a little sweaty at having to make actual decisions and write orders that nobody has to cosign, and if your internship is in a new place it’s even harder.

Carry that therapeutics manual or download with you everywhere. Ask for help when you need it. Remember that you have backup: nurses who will question orders with an extra zero, senior residents you can call for advice, and in private hospitals the attending physician who checks what you do even when you don’t realize it. The attending was an intern once too, and probably carries the memory of blunders as bad as any of your nightmares.

Thanks to limits on residency hours and patient loads, sleep deprivation won’t be the problem it once was. Follow the old rule anyway: eat when you can, sleep when you can…and for the love of sanity, spend time with your family when you can. Residency is the period when your life is most likely to be swallowed up by the practice of medicine, and spending time with normal people will help to keep your humanity intact.

Respect your teachers, but don’t be intimidated by them—even senior professors put their socks on one at a time. Talk to older doctors who are not academics about what their practices are like, and look ahead to where you want to be when you get out of residency or fellowship. If your attending takes you to lunch in the doctors’ lounge, eavesdrop shamelessly and ask questions about the relationships among medical staff members. It will help you understand the ecology you’ll be living in a few years from now.

Stepping into the senior resident role is an easier adjustment, since you’ve had plenty of role models and by then you will probably already have some ideas as to how to handle the job. Start looking ahead your next to last year, to actual practice, when you won’t have limits on how many patients you can see or the number of hours you work. Develop good time-management skills, because you won’t have nearly as much time per patient once you join a busy group. Learning to prioritize and be efficient will save you sleep, time and frustration in the years ahead.

“Hey! Where’d My Ladder Go?”

After being a trainee all your life it’s a shock to realize that you are now a “staff physician”, regardless of the practice setting. And even more of one when a doctor twenty years older than you asks your opinion on something.

If you’re in an academic setting you still have a ladder with instructors on the bottom and full professors on top. But when you’re taking care of patients you can no longer look to somebody else to handle tough situations: you are the person in charge of care, and while consultants may advise you they don’t make final decisions.

As a very junior attending at a Houston teaching hospital I ran into one of those situations, in which the patient had both bleeding and clotting problems. If we gave anticoagulants she might bleed to death, but if we stopped them she would have a pulmonary embolus or stroke.

I turned to the senior (and very wise) critical care specialist who ruled the MICU and asked him what our next step was.

“Wrong question,” he answered. “What is YOUR next step? Your name is on the chart, you are the attending physician, and I can make suggestions but I’m not the one making decisions here.”

This is two lessons in one: not only are you the primary doctor on the case, other doctors are not, no matter how senior they are or what comments they may make. The ladder disappears when it’s your patient and your responsibility.

Gray Hair Isn’t All Bad

Keep your resume up to date, and all your paperwork where you can assemble it for job hunting. Odds are you won’t settle into a single medical practice and stay there your entire career: the group that looks like a good setting when you’re fresh out of training may change, or it may no longer be a fit once you’ve had more experience and looked at other options. In signing your first contract, watch for clauses that mean you’ll have to leave town to find a second practice or pay the “tail” on malpractice insurance yourself.

Whatever you do, don’t get too comfortable. The best practice for you is one that allows you not only to keep learning but to keep meeting challenges, and the confidence you gain from those will gain the respect of whatever medical community you enter. And by the time you have enough gray hairs to notice, you (and others) will feel that you earned them.