The two years of studying you've done were worthless. You may know the entire TCA cycle, but that won't help you write your progress note. Accept the fact that you know nothing and try to soak everything in. If you insist that you actually know something, you'd better know it. Because you can bet your shiny new stethoscope that you're gonna get pimped on it.

corollary a.   There's always someone who knows more than you.
corollary b.   You never know everything (about a subject or patient).

You're actually going to be trusted with patient care. That means that you play a part in patient outcomes. That means you're going to be doing things that affect whether a patient lives or dies. And God help you when you're sent to do a consult on a patient that's in florid DT's or when you get your morning labs back and your patient has a 6.5 potassium, since you know nothing (see Rule #1).

corollary a.   You will fuck up.
corollary b.   You may just kill someone.

You will be entrusted with jobs that no one wants to do. You will do wet to dry dressing changes. You will do rectal exams. You will insert foleys. You will do every disgusting and despicable job that can be done. You will be the one who is sent on errands. You will be sent to look up labs or find the chart or check on the X-rays or get your attending a cup of coffee. This is because you are a scut monkey. Be a good scut monkey, and you will be rewarded.

corollary a.   When you're told to do something, you DO IT.

You've got work to do. You will do it. If you feel like complaining, you're not going to win any sympathy from the residents or the attending. Probably not from the nurses either. You shut up and learn to deal.

If you didn't do something, say so. If you don't know the answer, say so. If you're presenting a patient and didn't do a physical exam, say so. If you lie, it is certain death, and no one will help you out of this, because you don't jump onto a sinking ship (see Rule #11).

You will be pimped. If you haven't yet, just wait. You'll be asked something impossible, like differentiating giant cell arteritis and temporal arteritis, or describing an Ingram bicycle. It will happen to you. It'll happen to your friends. It'll happen to the interns and residents and even fellows. It'll happen to your attending too, except it'll be called M & M. Everyone gets pimped. Learn to deal (see Rule #4).

corollary a.   There is no right answer.
corollary b.   If no one asked you, don't answer.
If another CC3 is being pimped (or a resident), do NOT chime in with an answer until you're called upon. I don't care if your fellow CC3 is going to be impaled if he can't answer the question. You do not jump onto a sinking ship (see Rule #11).

For the love of Christ Almighty, you do NOT show up your residents. I don't care if your resident is the most incompetent moron on God's green Earth. Your attending may be the big dog, but your resident is the one who decides how much work you're going to do, so you bow to the residents. Your purpose in life is to make them look good. If you make them look good, they'll get you back.

The nurses are the only people who actually spend time with the patients. You'll have to deal with them every day. They are well-versed in making the lives of med students into living Hells. You will obey the nurses. You will get free pens for the nurses, the nice metal ones. You will grab an extra couple free lunches for the nurses. You will love nurses.

You know nothing. Your residents know more than you, and the attendings know more than them. So if you have a question, you ask the resident, you ask the attending. You NEVER question treatment decisions or the judgement of your residents or attendings in front of a patient. This is certain death. No one will help you out of this (see Rule #11). Your attendings and residents will be happy to explain their rationale if you ask nicely.

corollary a.   The attending is always right.
I don't care if the attending told you that the heart pumps food from your stomach to your elbow, because even if the attending is wrong, he is the big dog. You are the scut monkey (see Rule #3). And always remember, evaluations are the CC3 version of revenge (see Rule #13).

When you're in the hospital, you've got no one looking out for your except yourself and your fellow students. So it's your duty to give them a heads up on things. You tell your classmates about good and bad rotations, what AHECs are worthwhile, and you cover for your classmates if something's up. No one's saying to jump on a sinking ship here (see Rule #11), but you've got to lend a hand if things get hairy. And it may mean doing a consult for someone else, or getting the labs or seeing a patient that's not yours. That's life. You've got to look out for your fellow CC3's.

A habit you've got to learn is that when someone's going down, let them go. If your resident is getting dressed down by your attending during rounds, don't get in the way. If one of your fellow students is getting a new one ripped open for incorrectly documenting something, don't interject. Just let it go. Because shit happens, and there's more than enough to go around, so there's no reason to invite the hurt on yourself.

When someone shows you how to do something, they actually expect you to remember how to do it. So, pay attention! Because you'll be expected to do the next one. And after you've done one, you'll be expected to be proficient enough at it to show someone else how to do it.

Resist the urge to criticize your attendings or your residents. They GRADE you. Criticizing your residents and attendings is akin to medical student suicide. If your friends are worth anything, they'd tackle you before you could get your criticism out. While you're on service with someone, they are never to be criticized or humiliated by you.

corollary a.   Evaluations are the CC3 version of revenge
Bide your time, lick your wounds, and after your residents and attendings have gotten their evaluations in, let loose on that piece of paper known as the post-clerkship evaluation. Or, if you're so lucky, at your debriefing or exit interview. Till then, take comfort in the knowledge that the last laugh shall indeed be yours.

There are a couple rules I've learned that apply more to residency. The following are modified rules from The House of God, as the game's changed quite a bit since Shem's day.

Code status comes first
Placement does not come first, code status does. The most important question regarding patient outcomes is to determine as early as possible whether you're going to have to respond at 3AM when Mr. P stops breathing. Clarifying code status will make everything go more smoothly, and it's the Golden Rule now. It's good for patients too. If you think otherwise, you've obviously never been to a code before.
corollary a.   Placement comes second
Code status didn't apply in Shem's day, but placement is still true. One of the things you have to think about is where you're going to send your patient when you're doing mucking around with them. Get your nursing home beds lined up and in a row.
If you don't take a temperature, you can't find a fever
Most of Shem's rules are sarcastic. Remember, there will be plenty of times where ignorance is bliss. If you wanted to, you could find any number of problems that require medical attention in a patient. The key is knowing when to stop investigating. If a patient's ready to go home, let them go.
corollary a.   When all you have is a hammer, the whole world looks like a nail
By the same token, every problem looks the same to some doctors. Be careful that when you present your patient, you don't show your attending a nail head for them to drive in.

 

Celestial discharge, Transferred to pathology, Basement admission, Transfer to the 10th floor, Time to go fishing, Vitals have stabilized, Ready for a Y incision - All terms for someone that died. Pathology only takes corpses for autopsy. The morgue is invariably located in the basement. Transfer to the [one story higher than your hospital] floor means they're in Heaven. When it's time to go fishing, there's nothing for the patient to do but try to enjoy the last few days. Stable vitals can be good (patient's alive) or bad (flatlines). A Y incision is the standard autopsy cut to open the chest.

Buff a chart - Buffing is what it sounds like. You make the chart all shiny in relation to the patient. You make the chart into an arrow pointing to someone else. Buffing a chart is essentially washing your hands of it. The better you buff a chart, the less likely it will be to come back to you.

Turf a patient - Turfing is dumping a patient onto another service. For example, a patient is admitted to the Trauma surgery service. After 2 days, trauma turfs the patient to orthopaedics because the patient is no longer 'traumatic.' It is much easier to turf a patient if you've buffed the chart.

one point restraints - The nickname one of my attendings gave to the foley catheter. You can't leave the bed if you have a foley in place, unless you take the foley bag with you. I've actually seen 2 patients (men) who tore out their foleys.

GOMER - Get Out of My Emergency Room. The nickname given to patients that you're rather not see in your ER. In Shem's book, Gomers were elderly patients that kept coming back and you screamed every time they rolled back in. This is far more likely to happen on Fridays and Mondays, when nursing homes are trying to get rid of sick patients.

Frequent Flyer - Someone who comes into your ER or clinic so religiously that you'd swear they're getting mileage points. If you ever want to give your attending a dim opinion of both you and the patient, tell your attending that the patient is a frequent flyer.

Treat n' Street - A reference to Emergency medicine, where the goal of therapy is emergent treatment, followed by discharge. Thus, treat and street.

Curbside - Consulting someone informally, such as going down to radiology and asking a radiologist to take a peek at something without an official dictation. This is typically what passes for 'reading' X-Rays by the interns.

FOS syndrome - Short for Full Of Shit, a technical description of an abdominal series where the only positive finding is fecal matter from rectum to ascending colon, or just a simple fecal impaction. Also used to describe the resident ordering the abdominal series.

MDeity - I think that's pretty self-explanatory.

Incidentaloma - Almost always in reference to a suprarenal mass found on CT, found incidentally while looking for something else entirely. Most of the time, these things are nothing, but the potential that it's badness forces you to go full court press on it. Can refer to any such incidental finding of a mass or lesion.