It happened again.
A book came highly recommended – a lovely romance, with intelligent characters and a grown-up perspective. The set-up was fantastic; the dialogue was hysterical. The hero, however, wasn’t a surgeon. I mean, the author said he was a surgeon, but he had two weekends off in a row.
Not a surgeon.
I almost bailed on the book at 50%, because I had such since problems with the way the author messed around with the rules of healthcare, both clinical (nope, kids don’t get to eat if their surgery is delayed) and social/cultural (don’t get me started). Despite that, I stuck with the book, and by the time the couple found their happily-ever-after, I sincerely had a tear in my eye…
…in part because in the scenes right before they kissed and made up, the “surgeon” was so unhappy he acted like a jerk to his patients and coworkers. That part was believable.
Seriously though, not all surgeons are jerks, but when they’re not in the OR, they generally spend most of their life with their nose in a book….or, more accurately, a medical journal or a laptop. If you’re going to convince me that they’re also charming and funny and have great social skills, you better get every other detail right: things like their training, hospital culture, and the reality of working only 60 hours on a good week.
And that’s where I want to help! My perspective may be somewhat skewed – I’ve worked primarily in academic medical centers where the physicians rotate between clinical work, research, and teaching – but for a long time now, I’ve wanted to pull together a talk to help authors navigate the world of medicine. Which is a LOT to cover, so let’s get started.
First stop: hospitals. So, you want to have your mind blown? Think about this: people get admitted to hospitals because they need nursing care, not medical care. If all you need is a doctor, you can be seen in a clinic. (More about nurses later.)
The other thing to know? Hospitals are incredibly expensive. They can’t afford to admit someone “to run a few tests”, and they’ll discharge you as soon as possible. Like, when my 80-some year old mother-in-law fractured her hip, she was sent back to her adult family home two days (TWO DAYS) post-op. (I was horrified, but everything went okay.)
Obviously I don’t have space to list every diagnosis that’ll get your character a hospital bed, but if your plot goes there, make sure the patient has something they couldn’t take care of at home, and expect them to be discharged before anyone is really ready for it. (WebMD is a good reference for clinical questions and concerns.)
Also, leaving hospitals AMA – against medical advice – is a thing, and can be a dramatic plot device. Just know that in the real world, insurance companies generally won’t cover a stay when the patient leaves AMA, so if your police detective or otherwise employed and insured main character is contemplating that move, there are real-world consequences.
As I implied earlier, hospitals are run by nurses, and nurses come in a variety of types. Nurse techs or nurse assistants have completed a certificate program and can assist with basic patient care tasks. They’re often nursing students trying to get some real-world experience before they take their boards.
Licensed practical nurses (LPNs) have completed a one-year program and passed a certification test. They function in much the same way registered nurses do, with some minor variations in the tasks they’re allowed to perform.
Registered nurses (RNs) are the backbone of the place. They’ve completed either a two or four-year program and passed their State Board exam. They also often have additional training &/or certification in a specialty area, and they are required to keep current on their continuing education credits to maintain their licenses.
Nurse practitioners are registered nurses who have completed either a masters degree program or a doctor of nursing practice degree. An NP is a specialist – I’m licensed as an NNP, or neonatal nurse practitioner, which means I take care of preterm or sick infants. We work from a medical model, which means we do many of the things physicians do. Generally NPs have a couple years clinical experience in their specialty area, so we bring bedside nursing assessment skills to our medical decision-making.
Word to the wise: don’t confuse nurse practitioners and licensed practical nurses. I read a book where the NP was passing out patient meds, which…no. NPs write the orders, LPNs pass out the meds. Got it? Good.
There are a number of other people who are directly involved in patient care. Respiratory therapists (RTs) focus on the patient’s cardiopulmonary health by directly assessing the patient’s breathing and by managing the medication and equipment required to support them. Like with nursing, RTs complete a two- or four-year program and must pass a certification test.
Social workers provide invaluable support for patients and their families, connecting them with necessary resources while they’re in the hospital and after discharge. (So no, your surgeon hero doesn’t need to drag his new girlfriend into a patient’s room where she can instantly connect with the family and identify their needs. Find another way to prove she’s a decent human being. Ahem.)
Physical therapists, occupational therapists, and speech therapists all provide key support to a patient’s recovery, as do nutritionists and pharmacists. In the interest of space, I’m not going to specify the range of academic preparation and certification required to function in these roles, but every professional involved in patient care contributes a unique and valuable perspective.
Other random thoughts...
Not all hospitals have residents. Most academic or teaching centers (the ones with interns and residents) are associated with universities, though some private hospitals run selected residency programs.
Most (all?) hospitals have adopted computer based charting. THERE ARE NO PAPER CHARTS AT THE PATIENTS’ BEDSIDE. Also, HIPAA – the national law around patient privacy – is a thing. It affects who can be at the patient’s bedside, and how patient information can be communicated.
So if your characters want to brainstorm in the elevator, make sure they don’t drop names or other identifying patient information.
Hospital administrators exist in their own world – and it’s usually pretty classy. Most, but not all, have been involved in patient care in one way or another, but the higher they get on the ladder, the less clinical work they’re responsible for. In addition to the RN or MD on their resume, they’ll usually have an MBA or MHA (master of hospital administration).
Since I started by bitching about doctors, I’ll close the circle with them. To become a doctor, a person must complete a bachelors degree (4 years), score well on the MCAT (sort of like the SAT but HARDER), and complete three years of medical school. By the end of their second year of medical school, most have decided on which area they want for residency.
First year residents are called interns, and residency programs are usually three or four years long. After residency, some will continue their training by applying to a fellowship program. These are in specialty areas; for example, pediatricians have completed a 3-year pediatric residency program, but pediatric cardiologists did a 3(?) year fellowship in cardiology after residency.
Do the math. Four years of undergrad + three years of medical school + ~ three years of residency, at a minimum. That means most new physicians are around 30 years old, older if they did a fellowship. Some programs – surgery or neurosurgery, for example – take substantially longer.
I do love my day job, and I could probably keep going, but I’m going to stop here. If you have questions, leave them in the comments, and thank you for reading along. There’s no reason for fictional malpractice!!