'Real' Medicine

I am one week into my first 'real' medicine rotation (I use this expression with tongue in cheek, because the undifferentiated patient and all their issues and concerns encountered in general practice is in many ways truly patient focused medicine). It is great though. It is interesting to see really sick patients and the accompanying end of life issues and to see someone improve or get worse so quickly. Pathology and treatments are discussed in much more depth, and because everyone is teaching and learning education is a high priority.

General impression of how things run...

Team work is the rule, however it is far from a democracy. For those who don't know the (medical) hospital hierarchy is as such:

• Specialist/Consultant
• Fellow - extra post fellowship training (1-2 yrs) Optional
• Registrar (training to specialize) OR Principle House Officer (not in training spot)
• Resident - Senior House Officer (PGY2+) then Junior House Officer (PGY2)
• Intern (PGY1)
• Med student

A consultant has the final say, directs treatment and has ultimate responsibility. He (or she) is in the position most of us aspire to eventually be in. A registrar (equivalent to a senior resident in the US) is the consultant's right hand man and as they have chosen that specialty (in this case General Medicine) they stay for longer periods and know the service well and function with a reasonable degree of autonomy depending on seniority.

Next is the Resident. He is either a Junior House Officer (JHO), who is 1st year after an intern, or Senior House Officer (SHO), second and subsequent years. They are still trying to get clinical experience, pass exams and get into a training position. They rotate every 10-12 weeks and the standards vary greatly depending on their experience and amount of learning they have done (some are real slackers) and so their responsibility is varied and they tend to do the after hours cover, relieving rosters etc. The intern (if present) also rotates about every 10 weeks and as they need to impress to get signed off and get a good recommendation for a JHO job, do the scut work (otherwise the RMO has to do it).

Then finally comes the medical students. There are often too many of us per team (2 in mine) and we walk around and generally get under peoples feet. Sometimes it seems we are treated better than the interns, about on par with the RMOs. Perhaps because we are outsiders/visitors and the consultants want to give a good impression/sell their discipline to encourage the best applicants try for their team. But it is pretty clear that we are outsiders, have no responsibility and so low in the pecking order we are not really in it. Allied health plays an important role and without speech therapists, occupational therapists and physios a service wouldn't run smoothly at all. The nurses are very important. They interact with the patient and do a lot of the dirty work.

Now this is just an observation...please don't lynch me!!
Often there seems to be an unsaid power struggle between Allied Health and middle level doctors. It is subtle and usually not a problem in well run units, but seems quite real, just under the surface. As the nursing staff and allied health staff are assigned to the ward and often don't change for a long time they are often trying to assert themselves against the more frequently changing doctors. The consultants have absolute say, they are rarely challenged. The registrars although newer to the service often have a great deal of training and knowledge and mostly come out on top. The resident though are usually not game to argue with Allied health or nurses outright and smart Interns usually don't even put up a fight, knowing that they have to get things done for the consultant and if the other staff don't want to play nice, it will be very hard for them.

Maybe it is all in my head...not sure though