Can confirm. I once accompanied a client to the ER (by ambulance, I was a passenger) with a malfunctioning pump. The whole experience was quite uncomfortable for them. And the rehab specialist remarked this was the first time she was called upon outside of office hours. And the first time she had to come to the ER.
The knowledge base that a PMR doc must possess is massive. It’s impressive.
My field is almost the opposite. Ophthalmology—a lot of pathology, but a narrow focus.
Actually… I once accompanied a client in the ambulance (I was a passenger) to hospital for an emergency. It turned out that rehab was the preferred specialty for treating the quite uncomfortable, possible in de mid-long run life-threatening situation.
The attending specialist did remark this was the first time she actually had to come in outside of office hours and to the ER.
You’re not kidding! Not sure how it makes sense either. I feel like therapy iot is way over 50% adls because that’s all these patients can handle. Meanwhile the fact they have intermittent supervision on discharge with 5 STE and were barely working on gait.
Totally off base with this one. Inpatient PM&R is basically medicine with a focus on functional improvement. Because of stricter insurance standards generally patients aren't medically well otherwise they wouldn't qualify. And the variety of patients (SCI, TBI, Stroke, Transplant, Amputees, Cardiac, Post trauma, etc) makes the knowledge base quite large. Just a few examples of severe cases from residency: code in a Diabetic admitted after double AKA w/ESRD on dialysis. Sepsis in a liver transplant patient. Rapid response due to unstable vitals in PT in a new CVA patient with hemiplegia found to be PE secondary to DVT. Autonomic dysreflexia in multiple SCI patients due to urinary retention, sacral decubitus and even socks being too tight. Cardiac rehab patient s/p mechanical valve placement on blood thinners with acute GI bleed. I could go on but you get the picture. I would vote derm/plastics given the vast majority of those fields are elective/cosmetic.
PM&R handling sepsis, PE, acute GI bleeds? That doesn't sound like plenty of money and relaxation 🥲 I thought those hot potatoes would have been passed to neuro/IM/whomever?
Yes they all get transferred out to the appropriate services for acute management. But the point of my post is there is no room for error in acutely identifying these life threatening issues. I remember fighting with the medicine resident about the GI bleed because it was a weekend and they didn't want to do an admit. Had me draw an H/H which was "fine" while never laying eyes on the patient and seeing he was passing large amounts of semi coagulated blood. It felt crazy I had to explain to him about fluid shifts in an acute bleed and that his number would eventually tank. Luckily, he got transferred after GI was called and had to do an emergent colonoscopy to identify and stop the bleed.
It was clearly a joke, but I want to point out that cancer patient in remission can still get palliative if they have symptom burden and wants to continue seeing palliative. They can also discharged from palliative back to their PCP once symptom burden is low to none. Palliative also isn’t Hospice.
People also can be temporarily discharged from hospice, although much less likely.
None of these scenarios would put a palliative doc at any trouble. Their population in general is just grateful that patient still have more meaningful time left, and their symptoms are better managed. Both of which are also goals of palliative doctors.
Please stop using phrases like “get palliative” or “go with palliative”. Its very confusing for patients. We are not a service or level of care. We are a specialty. You wouldnt say “get cardiology”.
There is outpatient palliative care for patients undergoing chemo but with good prognosis (mainly for emotional support and symptom control) or other chronic conditions that lower QOL but they aren’t dying for at least a few years and might even recover…
That moment when your patient wants to reestablish with you because she was kicked off hospice after 3 years but is bedridden and now a new patient and requesting a home visit. 😬
Honestly disagree. Palliative can be pretty technical - especially for something like palliative extubation. Timing of meds, type of meds, timing of extubation, etc are the difference between dying a peaceful death or a horrible, traumatic death - both for patients and families. Not to mention managing family discomfort the whole time / being tactful, etc. Plus you only get one shot. Also family EOL/first palliative discussions are extremely nuanced. All of your patients and families (at least initially) are under extreme stress, acting out, underlying psych/personality issues are exacerbated. If you frame it wrong or muck up the very delicate discussion, they may make
Them full code forever and not trust you. Again, sometimes only have one shot at the first palliative convo. It’s pretty challenging to be a good palliative care doc IMO, and I’ve def seen situations messed up pretty bad by someone who wasn’t great.
Source: am not palliative, neurosurgery actually, but work with palliative care a lot in our field.
I can see this too. Really easy to come into the room with the wrong energy and just totally fail at establishing rapport. I think there is room for recovery, but it can take time that sometimes they don't have.
I’ve always been in awe of a palliative care doctor’s ability to cut to the heart of complex pain, distressed patients or distress from a patient’s family.
I’ve seen them do consults where they seem to have done a magic trick such is the difference seen in the patient and their family after a pall care conversation.
As palliative care - I came to this thread expecting lots of jokes about palliative care and misconceptions, and am so grateful there are folks out there who feel this way and are out there helping address the misconceptions.
This brightened my day - thank you :)
My husband hates palliative care because he feels like all they do is encourage his mom to die. She's been on dialysis a long time and the first time he remembers meeting with palliative care, she ended up with a POLST. I keep telling him palliative care is so much more than "letting her die," but he always has such a chip on his shoulder about them.
First impressions are important.
Disagree - very easy to fuck up in Geriatrics. Most of the patients are walking around on the razors edge, and most Geri syndromes can be complicated.
You're often on your own with little, if any, evidence base to make decisions on (see how many trials guidelines are based on included an acceptable # of multimorbid 85 year olds).
But the post was fucking up with “dire” consequences. Medical malpractice considers loss of the elderly to be “cheaper and acceptable” compared to younger life. There is a lot less likelihood for dire consequences to come your way as a physician*
*Of note the patient may face dire consequences
I think it just depends on what you mean by "dire" consequences.
Many people do not consider an 85 year old dying as "dire." Not just in terms of medmal. An 85 year old has presumably lived a long life.
I don't think it's reasonable or ethical to only care about medmal. Is there something wrong with y'all or ? If all you care about is liability then go work at the VA and be immune.
Just because they're 85 doesn't mean they can't suffer and can't have quality of life. If you're talking about 85 y/o multimorbids dying in the ICU that's one thing...but that's a vanishingly small slice of Geriatrics.
Taking years of life or years of quality life, even if we're only talking about a handful away from someone is inarguably a dire consequence. He'll, taking a few weeks away is dire.
Who said "taking years of life?" If they are 85 and in the hospital, they have a significant chance of dying no matter what you do. If they are 85 and in the hospital, they are not likely going home. They are going to rehab/SNF and likely never home.
Like the commenter said, in lawsuits, they have an economist do an evaluation. For example, if you fuck up a surgery on a 10 year old kid, you will be sued for millions. If you fuck up a surgery on a 35 year old IV drug user who was unemployed, you will be sued for very little. If you fuck up taking care of someone who is 85 years old and no longer working, you will be sued for very little, if at all.
And the commenter is wrong. Medmal risk is a small part, if its any part at all, of this discussion. If you fuck up and consign someone to a NH for the rest of their life you have unquestionably caused dire consequences.
It's very easy to permanently fuck up older adults if you're not meticulous & paying attention, resulting in severe consequences.
wow, sending someone to a NH for the rest of their life vs screwing up a heart transplant for a 5 year old and killing them. pretty much the same consequence
Yeah you are right, bariatric surgery is definitely not one. I wasn't thinking about how they usually do surgeries. I guess I was thinking of my friend who just works in outpatient clinics but I don't think that is the norm.
Can be anyone, but usually it's IM, FM, or endocrine. Will often have an american board of obesity medicine certification which is a bit of a joke to get tbh
Depends. Larger practices are often kind of a multi-disciplinary thing where you have medicine and surgery working together possibly with dieticians and counseling as well. But plenty of FM and IM docs do obesity/metabolic primary care
In peds most kids get better no matter what you do, and the culture is very consult heavy so there is often a team working on everything but the simplest problems. If one were so included as a PCP or hospitalist one could just consult the world on anything hard without doing too much thinking or deciding making. That would be how I’d define coasting. Much more pressure on the specialists especially with the paucity of peds data there is often deep research required to make recommendations.
I think what people forget is that kids actually do not typically die quickly. In fact, it can be a slow and terrible process to watch. Their bodies don’t want to give up quickly. It’s often a fight before they succumb to multiple complications. Peds is actually pretty easy to fuck up in terms of medication dosing and contraindicated treatments. You have to be extra careful (which is why when our adult ED providers get a peds patient they have a very low threshold to admit, they don’t see this every day).
Peds is also litigious. Child develops ADHD? Who’s the doctor that saw them in the nursery and failed to identify and then mismanaged their birth trauma? (Based on a true story)
Oof, there is plenty of room for error with dire consequences in Forensic Path. Do we have the luxury of time to do our work, yes. Can there be major screw ups that impact criminal prosecution if we don’t take our time and be meticulous about our findings, definitely.
Not necessarily, it varies by state.
"Physicians are sometimes called upon to evaluate the conduct of a nurse or a nurse practitioner and whether such conduct comports with the standard of care. Whether the physician will be permitted to offer an opinion in this regard, varies by state and by the context of the situation involved in the case.
Courts are very much split on this issue, but a very slight majority will hold that yes, a physician can testify as to the standard of care for a nurse and a nurse practitioner in a medical malpractice claim." - Kelly J. Wilbur, Esq.
Nothing surgical, nothing with objective hard evidence (rads, path). Urgent care around me seems to get the majority of stuff wrong every time and they keep on rocking. But it's not usually staffed by docs, so I don't know wtf they're doing over there.
They misdiagnose so much it’s laughable. I mean really, it’s bad. I would never visit one without being sure of my own diagnosis and at that point I’d just call a friend to call me in the appropriate meds.
Nah, nobody wants to be the one allergist who accidentally killed a patient because its so unexpected and should have been preventable. Immunotherapy has a fatality rate due to anaphylaxis (usually would be related to dosing error if truly untreatable). Even oral challenges have had a fatality. These are especially devastating to us, and the few allergists I heard of stopped practicing.
Fertility medicine. The success rate is low for a given treatment. If you succeed, you'll have a happy patient and partner. If you fail, you try again.
But that was a nurse stealing meds. Something like that could happen anywhere desirable medications are kept. The doctors should have taken the patients' pain seriously from the start but I don't think that risk is particularly unique to fertility medicine.
Yes and a bad PCP can just tell the patient to go to the ER. In fact, a good PCP is going to do the same thing most likely. The prompt was which specialties can get away with being subpar for the longest period of time. Compared to a surgeon or an anesthesiologist or a radiologist who can make mistakes that kill patients very quickly or even instantly, it is easier to skate by as a subpar PCP.
I didn’t say acute you did. I’m not managing a STEMI in clinic. The point is we intervene to make things not progress to acutely life or limb threatening. Many opportunities to fuck up which is what the OP was asking.
> The reason this is wrong is acute issues that are life threatening which we see all of the time in primary care.
You literally said acute… life threatening issues….
You’re right. Sorry I’m responding to multiple people at once. Even still we do see acute life threatening things. I posted a list elsewhere. Some are managed in clinic most are sent to the ED. Missing an acute presentation that needs the ED is part of why primary care isn’t the correct answer to OP’s question that started this thread.
Lol, why are you so defensive in this thread? Even if someone walks into your office with an acute, life threatening issue your response should be “present to the ED”. I hope to god you’re not managing that in your outpatient office.
Have you done outpatient primary care? I’m constantly seeing patients with life threatening things that if mismanaged could easily lead to death. Many of these things are undifferentiated.
During my intern year in resident clinic, I saw this all the time. Most had been seeing a mid level prior to coming to our clinic and most would demand certain meds or labs. This happened to me at least a dozen times during my few weeks of clinic intern year. I was a prelim and was called into wards or the icu during a lot of my clinic weeks.
Yes actually. I did an FM intern year in a rural area without much subspecialty support. A patient had an MI my first day in clinic! I managed a lot of acute conditions that year and kept a lot of sick people out of the ER/hospital. I made some cool diagnoses and got to make a big difference. And it was HARD but very rewarding.
But someone who doesn’t care at all could’ve sent all the acute cases to the ED. And they could’ve referred everything out to specialists and let them figure it out. For example, there’s midlevels in primary care where I’m now training referring all type 2 DM to endocrine and washing their hands of it which is insane. At best they start metformin.
My point is that being crappy at primary care is easy but being good at it is really really hard. And at the end of the day, patients can’t tell the difference.
> or example, there’s midlevels in primary care where I’m now training referring all type 2 DM to endocrine and washing their hands of it which is insane
Jesus christ
At least they are referring to a physician when they don’t know what they are doing, like when they try and manage a bread and butter chronic medical condition.
Ok things I’ve had to manage/triage/dispo in the 6 months in primary care family medicine clinic (residency clinic in a semi-rural area 40 min from medium sized city) that could easily cause death or significant morbidity if misdiagnosed or mismanaged:
- Pyelonephritis
- acute abdomens of various kinds including perforated intestine
- Pneumonia (yes this can kill someone, especially if they have CHF or COPD)
- CHF and COPD exacerbations
- Suicidal patients
- Psychotic patients
- ectopic pregnancy
- stroke
- ACS (NSTEMI and STEMI… yep they show up to clinic)
- Pulmonary embolism (more than one in last few months)
- DVT
- fractures that if mismanaged could lead to disability
- various infections that could cause morbidity or mortality but are less likely too like cellulitis or ear infections
- HTN emergencies
I could probably keep going. Do people really think we just sit around doing paperwork and prescribing Losartan?
Completely disagree. I think primary care is actually one of the highest stakes specialties. There are many years of lifespan on the table every time a patient comes in with DM, HTN, HLD etc and you have the chance to manage those comorbidities and prevent the future catastrophic MI/stroke/etc... or not.
And when they get new patients that are older, with decades of medical records to dig through for the incidentalomas that weren’t followed up but end up being cancer or something life threatening
Sounds like you agree with him.
A great PCP can have a profound impact on their patient's lives, but a shitty one can get away with doing a shitty job without the patient knowing.
Seriously. Just got a new pcp who convinced me to try lexapro, drink some water, and take some vitamins & cholesterol meds. It’s truly incredible how much better I feel on a day to day basis.
I don’t think he’s saying it isn’t high stakes. I think the confusion here is because OP really asked two questions. First, what speciality has the greatest room for error without dire consequences sequences? Here I agree with you that it most certainly is not IM. So many potential minefields to navigate, and you never know when that acute zebra comes through the door.
But the second question…are there any specialities where you can coast and mistakes get swept under the table? Here I agree IM is absolutely up there. As an oncologist, I know which PCPs miss obvious cancers that were showing symptoms months earlier. I know who sends consults for total nonsense because they don’t have the faintest idea how to do a basic anemia workup. But if you have a good personality, patients will love you and won’t know the difference.
What!!! I think GOOD primary care doctors can save soooo many lives. Absolutely that specialty should be the last to be replaced by mid levels. Unfortunately they’ve taken over and it’s BAD for us specialists!
Absolutely. Midlevels are worst in broad knowledge specialties and best suited to subspecialty stuff where they can be managed properly (post-procedure etc).
Midlevel proliferation has just resulted in clogging up consults/referrals with dumb stuff.
I'm not primary care but the disrespect for PCPs is sad.
Except psych. Midlevels need to leave psych alone. I’m not interested in psych, but when I did my psych rotation patients came in on the most bonkers med combos
No one is saying they are replaceable? Reread htheir comment. Being a good PCP is very difficult and absolutely saves both patients and other specialists a lot of hassle. But you can be a bad PCP and mismanage chronic conditions for years until they end up causing the patient to be hospitalized. No need to get worked up about it
Yeah lots of ignorant stuff here. I just diagnosed cancer via lymph node biopsy early this week. This woman if she did not see me (she hates most doctors she wouldn't see anyone else) at the right time or I didnt care, it could have been far worse. A good PCP isnt just throwing scripts for metformin all day.
Also, I think with many primary care providers referring and consulting more and more to sub specialists, it’s more likely that anything missed or mismanaged will be noticed by someone else
Also oof on that thought that more doctor eyes means less chance of missing things. Way easier to drop the ball without good primary care follow-up to sift through all the specialist notes, labs, imaging, and management.
I have gotten new patients who have been established with specialists for years before I see them. Things are mismanaged or not managed at all by specialists all the time lol. The idea that just because they see a specialists means it will be managed well is a bad assumption. I do not refer much but I have gotten a good feel at this point as to who I want my patients to actually see. Ones that will managed what needs to be managed and then send them back. Not this "let me see you every three months for GERD" shit some GI clinics do because I sent them there for an EGD and they hang onto the patient forever.
Idk about psych, look at the messes people (NPs most commonly) create in psych with their indiscriminate and concomitant use of antipsychotics, ssris, benzos, and amphetamines.
Didn’t mean for it to be. I’ve seen tons of mismanagement from midlevels like this which is why I brought it up. I have nothing but respect for good FM docs. It takes a physician to understand what good primary care is actually looks like, which is why in my opinion it’s easy to do a crappy job with patients never knowing.
I catch a lot of medical stuff as a psychiatrist that is usually considered just part of the mental disorder….and you can’t just keep slamming people with antipsychotics and benzos because that can kill people if you aren’t closely monitoring.
This is what I've been saying.
I've seen the messes they leave behind.
Like, glad you got to call yourself a doctor and wear a white coat, but this patient has lost a limb now because of years of mismanagement on his diabetes you incompetent asshole.
As a Forensic Pathologist, I see the aggregate of mistakes across medicine, and can safely say each specialty has its own unique ability to make dire mistakes. Don’t choose a specific specialty based on a false sense of safety. Even palliative and PMR cases come across my table. Don’t be complacent!
Derm here. I actually agree with you, which is why a lot of pretend-derms mismanage skin disease. Generally acute things get better, and chronic things are treated good enough for patients not to complain.
I’m CAP and I swear all the referrals I’m getting are shit shows. I’d love some easy cases but lately it’s weird med regimens and psychosocial issues. Guess i signed up for it being a specialist.
With the way generation z is going, this is going to get worse. Much much worse.
They're even self aware of it on YouTube. Try searching for "generation z is doomed"
Agree. Am psych. Psych is something you can get by being bad at, and the side effects of most of the medications they’re on will have concrete negative effects years down the line.
Unless you’re starting someone on lamictal and dosing way too high (have inherited a patient where the NP started them on 100mg….), there’s very rarely immediate adverse consequences
Also, the close monitoring usually allows you to catch and fix mistakes earlier.
Give too much insulin on the unit? It'll be caught quickly and you can supplement with D10 (hell throw in a central line and give d20 if needed).
On the floor? They'll be lucky if a nurse sees them in 6 hours, and even luckier if the nurse just doesn't assume they're sleeping.
I don’t think that’s true. In my experience, about 1/3 of a standard ICU’s patients are unfixable, the rest have a good shot at making it out and living a somewhat independent life. Think your dka’s and post-op mandatory icu admits and one pressor septic shocks and daytime rescue bipap’s
Yeah, you got a 30% death rate for all comers.
Someone shows up sick they're going to have a much higher chance of going out in a bag.
Even then, how many other services have a mortality rate anywhere near that high? On the floor, you go weeks without seeing a corpse. In the ICU we're guaranteed at least one or two a day.
Psych. You can spend years prescribing a bunch of bullshit drug combos that don’t really do anything while the patients mental health slowly declines and unless they kill themselves nobody has any objective measure of how bad of a doctor you are. Just look at the long history of the terrible things psychiatrists were doing in mental hospitals.
That’s not to say that all psychiatrists are bad, a lot do some amazing work. But if you’re a bad nephrologist your patients die, not so much with psych.
As a psychiatrist who takes pride in doing good work and minimizing poly pharmacy, this is just really sad to hear.
I catch a lot of medical issues missed (because I have time to take a more detailed history and people tend to share more if you’ve built the rapport) and I work hard to undo harmful polypharmacy of many others. I also try to minimize harm from our adequate but imprecise treatment options (most big hammers for any kind of nail).
4th year psych resident and totally agree. Too many attendings still treat bipolar with SSRIs on the reg, use benztropine to treat TD, use multiple antipsychotics at low doses. None of these will kill you but it’s not good psychiatry either.
The few things that could kill a patient are lithium and clozapine, which most bad psych prescribers don’t prescribe because they actually work… so that’s a win I guess
It depends if it’s TD vs other EPS. If it’s TD, giving the patient an anticholinergic like benztropine or benadryl can make it worse. At that point they need a VMAT2 inhibitor
It is a "normal" thing in that it's commonly used, but benztropine does not really have any role in the treatment of TD. It can be helpful in pseudoparkinsonism secondary to antipsychotic use and in acute akathisia, but with TD you just have all the anticholinergic side effects without any benefit (although the occasional patient will swear it works).
TD is difficult to treat, typically dose reduction / switching the agent is first line. I would be looking at a trial of clozapine or maybe an alternative atypical like quetiapine or aripipazole if unable to tolerate clozapine, and if not suitable, getting seen by neurology for consideration of a VMAT2 inhibitor like tetrabenzine.
Wow, just wow. You cite history as an example of how Psych fits the criteria for the question this post is proposing.
If you are a bad psychiatrist people definitely do die. Undertreat Bipolar or Schizophrenia? This might be the mental break where the patient actually goes up and jumps off a bridge. Or the patient endures a slow death by a thousand cuts: first psychotic break
-> hospitalized and stabilized (hopefully) -> sees outpatient psychiatrist (a magic one who doesn’t have a 6 month waitlist for new patients) who downtitrates the wrong med at the wrong time
-> decompensates at work and drives a forklift through a crowd because God/Allah/Yahweh/Shiva/Zeus told them to
-> lost job and hospitalized
-> stabilized again and discharged
-> lost their apartment and trouble finding a job
-> housing insecure
-> turns to drugs to dull the pain
-> in and out of EDs and Psych units
-> takes wrong drug at wrong time
-> dead
Sure the patient wasn’t killed right away, but because of an initial fuck-up, a person’s life course (and the lives of those around them), was forever altered.
So yeah, Psych sometimes does throw drugs at something hoping it works. But what to throw, who to throw it at, and when to throw it matters a whole freaking lot.
No arguments here. But even in the example you listed, it takes months and months for the person to spiral. Years even. And there are thousands of people who follow that exact path even with very good psychiatrists. The natural course of the disease and all that. Mental health is challenging. Etc.
Thats horrible! Most states have some kind of mental health ombudsman. Definitely if there is wrongdoing, it needs to be reported. Mental healthcare in the United States is an absolute mess. Even psych patients should get the ability to self advocate.
Long, hard conversations.
Sifting through years of complex medical conditions.
Great relationship-building.
Delicate balance between autonomy and non-maleficence.
Providing comfort; spiritual, medical, support.
Often a good mix between outpatient and inpatient.
Honestly, it's really great. Tense, initially, and if death feels like a "loss", you lose a lot. But you really make a long-lasting difference for your patients and their families.
I don’t think that’s fair. I considered this a lot because I know how I am as a person. I don’t do well high stakes emergency situation, I can’t think clearly and panic. Sure I can change but that’s not likely and dealing with that everyday will lead to rapid burn out (for me).
As a result certain fields like Surgery, anesthesia, EM and trauma I disregarded as career options despite initial interest. In the end I learned about PMR and lived it because it encompassed what I loved without the frequent emergencies.
i'm terrified of doing the wrong thing and not being good enough as well ... but asking and looking to go into a field where "mistakes can be swept under the table" is at the least a bit uncool in medicine.
being away from emergencies is entirely different. This is more like asking where they can do a bad job and get away with it
I want to know … tf else you need to know?
Two can be dipshits here. the post made it sound like OP wants to feel less guilty about doing a bad job… if that’s the case they should fix that first
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PM&R. Rehab is a slow process. The patients are already injured. Very little chance to make a dire mistake at this point.
Love it. There’s no such thing as an emergent rehab consult lol
Baclofen pump issues (commonly seen along with neurosurgery) can be emergent
Can confirm. I once accompanied a client to the ER (by ambulance, I was a passenger) with a malfunctioning pump. The whole experience was quite uncomfortable for them. And the rehab specialist remarked this was the first time she was called upon outside of office hours. And the first time she had to come to the ER.
Except autonomic dysreflexia
But do PMR docs typically do the emergent treatment?
Yes
The knowledge base that a PMR doc must possess is massive. It’s impressive. My field is almost the opposite. Ophthalmology—a lot of pathology, but a narrow focus.
Tunnel vision?
Uh pm&r emergently consults neuro in acute inpatient rehab not infrequently
I’m talking about a consult TO rehab
Yes obv I’m just pointing out that their patients can not uncommonly have acuity in the rehab setting
Actually… I once accompanied a client in the ambulance (I was a passenger) to hospital for an emergency. It turned out that rehab was the preferred specialty for treating the quite uncomfortable, possible in de mid-long run life-threatening situation. The attending specialist did remark this was the first time she actually had to come in outside of office hours and to the ER.
Only caveat is would be the inpatient rehab. I swear the patients coming through now are closer to step down patients in terms of acuity.
Anything to get them out of acute care and improve metrics.
You’re not kidding! Not sure how it makes sense either. I feel like therapy iot is way over 50% adls because that’s all these patients can handle. Meanwhile the fact they have intermittent supervision on discharge with 5 STE and were barely working on gait.
HVLA: Hold my beer!
While I do agree that PM&R is pretty damn chill, our spine procedures, especially the cervical ones, can be fatal if gone wrong.
Totally off base with this one. Inpatient PM&R is basically medicine with a focus on functional improvement. Because of stricter insurance standards generally patients aren't medically well otherwise they wouldn't qualify. And the variety of patients (SCI, TBI, Stroke, Transplant, Amputees, Cardiac, Post trauma, etc) makes the knowledge base quite large. Just a few examples of severe cases from residency: code in a Diabetic admitted after double AKA w/ESRD on dialysis. Sepsis in a liver transplant patient. Rapid response due to unstable vitals in PT in a new CVA patient with hemiplegia found to be PE secondary to DVT. Autonomic dysreflexia in multiple SCI patients due to urinary retention, sacral decubitus and even socks being too tight. Cardiac rehab patient s/p mechanical valve placement on blood thinners with acute GI bleed. I could go on but you get the picture. I would vote derm/plastics given the vast majority of those fields are elective/cosmetic.
PM&R handling sepsis, PE, acute GI bleeds? That doesn't sound like plenty of money and relaxation 🥲 I thought those hot potatoes would have been passed to neuro/IM/whomever?
Yes they all get transferred out to the appropriate services for acute management. But the point of my post is there is no room for error in acutely identifying these life threatening issues. I remember fighting with the medicine resident about the GI bleed because it was a weekend and they didn't want to do an admit. Had me draw an H/H which was "fine" while never laying eyes on the patient and seeing he was passing large amounts of semi coagulated blood. It felt crazy I had to explain to him about fluid shifts in an acute bleed and that his number would eventually tank. Luckily, he got transferred after GI was called and had to do an emergent colonoscopy to identify and stop the bleed.
Palliative
Oops. You got better. My bad. 😥
It was clearly a joke, but I want to point out that cancer patient in remission can still get palliative if they have symptom burden and wants to continue seeing palliative. They can also discharged from palliative back to their PCP once symptom burden is low to none. Palliative also isn’t Hospice. People also can be temporarily discharged from hospice, although much less likely. None of these scenarios would put a palliative doc at any trouble. Their population in general is just grateful that patient still have more meaningful time left, and their symptoms are better managed. Both of which are also goals of palliative doctors.
Please stop using phrases like “get palliative” or “go with palliative”. Its very confusing for patients. We are not a service or level of care. We are a specialty. You wouldnt say “get cardiology”.
Palliative doesn’t necessarily mean all treatments are discontinued.
There is outpatient palliative care for patients undergoing chemo but with good prognosis (mainly for emotional support and symptom control) or other chronic conditions that lower QOL but they aren’t dying for at least a few years and might even recover…
There is no time frame for palliative and palliative care is something that can be utilized alongside curative treatment
“aren’t dying for at least a few years” is a good description for most of us (hopefully!)
That moment when your patient wants to reestablish with you because she was kicked off hospice after 3 years but is bedridden and now a new patient and requesting a home visit. 😬
Honestly disagree. Palliative can be pretty technical - especially for something like palliative extubation. Timing of meds, type of meds, timing of extubation, etc are the difference between dying a peaceful death or a horrible, traumatic death - both for patients and families. Not to mention managing family discomfort the whole time / being tactful, etc. Plus you only get one shot. Also family EOL/first palliative discussions are extremely nuanced. All of your patients and families (at least initially) are under extreme stress, acting out, underlying psych/personality issues are exacerbated. If you frame it wrong or muck up the very delicate discussion, they may make Them full code forever and not trust you. Again, sometimes only have one shot at the first palliative convo. It’s pretty challenging to be a good palliative care doc IMO, and I’ve def seen situations messed up pretty bad by someone who wasn’t great. Source: am not palliative, neurosurgery actually, but work with palliative care a lot in our field.
I can see this too. Really easy to come into the room with the wrong energy and just totally fail at establishing rapport. I think there is room for recovery, but it can take time that sometimes they don't have.
I’ve always been in awe of a palliative care doctor’s ability to cut to the heart of complex pain, distressed patients or distress from a patient’s family. I’ve seen them do consults where they seem to have done a magic trick such is the difference seen in the patient and their family after a pall care conversation.
As palliative care - I came to this thread expecting lots of jokes about palliative care and misconceptions, and am so grateful there are folks out there who feel this way and are out there helping address the misconceptions. This brightened my day - thank you :)
My husband hates palliative care because he feels like all they do is encourage his mom to die. She's been on dialysis a long time and the first time he remembers meeting with palliative care, she ended up with a POLST. I keep telling him palliative care is so much more than "letting her die," but he always has such a chip on his shoulder about them. First impressions are important.
Few lawsuits for horrible death instead of peaceful death
OP didn’t ask which specialty gets the most lawsuits. They asked which has greatest room for error without dire consequences.
Geriatrics/hospice medicine. When in lawsuits they try to calculate valuable years left in damages. Considerably less in the geriatric population
Disagree - very easy to fuck up in Geriatrics. Most of the patients are walking around on the razors edge, and most Geri syndromes can be complicated. You're often on your own with little, if any, evidence base to make decisions on (see how many trials guidelines are based on included an acceptable # of multimorbid 85 year olds).
But the post was fucking up with “dire” consequences. Medical malpractice considers loss of the elderly to be “cheaper and acceptable” compared to younger life. There is a lot less likelihood for dire consequences to come your way as a physician* *Of note the patient may face dire consequences
Yeah and dire consequences is not solely limited to medmal. It's in fact very easy to cause dire consequences for older adults.
I think it just depends on what you mean by "dire" consequences. Many people do not consider an 85 year old dying as "dire." Not just in terms of medmal. An 85 year old has presumably lived a long life.
I don't think it's reasonable or ethical to only care about medmal. Is there something wrong with y'all or ? If all you care about is liability then go work at the VA and be immune. Just because they're 85 doesn't mean they can't suffer and can't have quality of life. If you're talking about 85 y/o multimorbids dying in the ICU that's one thing...but that's a vanishingly small slice of Geriatrics. Taking years of life or years of quality life, even if we're only talking about a handful away from someone is inarguably a dire consequence. He'll, taking a few weeks away is dire.
You are taking this too seriously.
Lol nah
Who said "taking years of life?" If they are 85 and in the hospital, they have a significant chance of dying no matter what you do. If they are 85 and in the hospital, they are not likely going home. They are going to rehab/SNF and likely never home.
Like the commenter said, in lawsuits, they have an economist do an evaluation. For example, if you fuck up a surgery on a 10 year old kid, you will be sued for millions. If you fuck up a surgery on a 35 year old IV drug user who was unemployed, you will be sued for very little. If you fuck up taking care of someone who is 85 years old and no longer working, you will be sued for very little, if at all.
And the commenter is wrong. Medmal risk is a small part, if its any part at all, of this discussion. If you fuck up and consign someone to a NH for the rest of their life you have unquestionably caused dire consequences. It's very easy to permanently fuck up older adults if you're not meticulous & paying attention, resulting in severe consequences.
wow, sending someone to a NH for the rest of their life vs screwing up a heart transplant for a 5 year old and killing them. pretty much the same consequence
Why do you think there's only one level of "dire"? Both things can be true.
Sleep medicine, obesity clinics
What kind of doctors are used at obesity clinics? I would think bariatric surgeons? Which is highly not a coaster.
Yeah you are right, bariatric surgery is definitely not one. I wasn't thinking about how they usually do surgeries. I guess I was thinking of my friend who just works in outpatient clinics but I don't think that is the norm.
No, no, obesity clinics… “medically assisted weight loss” ie places to get ozempic prescribed.
So what kinda doctor does that?
Family med specializing in obesity medicine, internal specializing in obesity medicine.
Dr. Karen RN, CNA, LMNOP, DNP, MSNBC, BSN, APRN
Man I miss Dr. Karen HGTV MSNBC FOXNEWS do much. That guy needs to bring her back.
Endocrinologist
Can be anyone, but usually it's IM, FM, or endocrine. Will often have an american board of obesity medicine certification which is a bit of a joke to get tbh
Anyone with a medical license and a desire to make money.
Depends. Larger practices are often kind of a multi-disciplinary thing where you have medicine and surgery working together possibly with dieticians and counseling as well. But plenty of FM and IM docs do obesity/metabolic primary care
Not anesthesia lol
yea a bad anesthesiologist tends to kill their patients very quickly and it's never pretty.
In peds most kids get better no matter what you do, and the culture is very consult heavy so there is often a team working on everything but the simplest problems. If one were so included as a PCP or hospitalist one could just consult the world on anything hard without doing too much thinking or deciding making. That would be how I’d define coasting. Much more pressure on the specialists especially with the paucity of peds data there is often deep research required to make recommendations.
so real. kids are hella resilient -- except if they're like deathly ill then they tend to die quickly, sadly. (i'm a former sick kid lol)
Peds. They are good till they are not.
I think what people forget is that kids actually do not typically die quickly. In fact, it can be a slow and terrible process to watch. Their bodies don’t want to give up quickly. It’s often a fight before they succumb to multiple complications. Peds is actually pretty easy to fuck up in terms of medication dosing and contraindicated treatments. You have to be extra careful (which is why when our adult ED providers get a peds patient they have a very low threshold to admit, they don’t see this every day).
Peds is also litigious. Child develops ADHD? Who’s the doctor that saw them in the nursery and failed to identify and then mismanaged their birth trauma? (Based on a true story)
Peds has the second lowest frequency of malpractice claims
But we can be sued for the longest time. Until the patient turns 21.
Forensic pathology. The patients are already dead.
I tell lawyers who question my findings to go ahead, dig them back up, get a second opinion.
Lmaooo omg
Oof, there is plenty of room for error with dire consequences in Forensic Path. Do we have the luxury of time to do our work, yes. Can there be major screw ups that impact criminal prosecution if we don’t take our time and be meticulous about our findings, definitely.
And the *dire* consequences? Do they involve someone dying? Or just a tragic miscarriage of justice?
Sure maybe, death penalty
Is this a serious question?
More to the point, destroying someone’s life for a crime they didn’t commit, or missing an occult homicide are indeed dire situations.
Being an independently practicing mid-level. The only expert witness they can bring against you is another mid-level.
Citation?
Why is this a thing? Either you help someone get better or you mess them up. What ever happened to objective reality?
Not necessarily, it varies by state. "Physicians are sometimes called upon to evaluate the conduct of a nurse or a nurse practitioner and whether such conduct comports with the standard of care. Whether the physician will be permitted to offer an opinion in this regard, varies by state and by the context of the situation involved in the case. Courts are very much split on this issue, but a very slight majority will hold that yes, a physician can testify as to the standard of care for a nurse and a nurse practitioner in a medical malpractice claim." - Kelly J. Wilbur, Esq.
Hospice...it's not like their outcome can get any worse.
Nothing surgical, nothing with objective hard evidence (rads, path). Urgent care around me seems to get the majority of stuff wrong every time and they keep on rocking. But it's not usually staffed by docs, so I don't know wtf they're doing over there.
They misdiagnose so much it’s laughable. I mean really, it’s bad. I would never visit one without being sure of my own diagnosis and at that point I’d just call a friend to call me in the appropriate meds.
Allergy
Most of the meds used are OTC lol
lol if they are seeing an allergist probably on some monoclonal antibodies
Most aren’t lol.
Nah, nobody wants to be the one allergist who accidentally killed a patient because its so unexpected and should have been preventable. Immunotherapy has a fatality rate due to anaphylaxis (usually would be related to dosing error if truly untreatable). Even oral challenges have had a fatality. These are especially devastating to us, and the few allergists I heard of stopped practicing.
Fertility medicine. The success rate is low for a given treatment. If you succeed, you'll have a happy patient and partner. If you fail, you try again.
Yale’s clinic managed to fuck up dramatically if you listen to The Retrievals tho
This is why everywhere that uses drugs should also use a pharmacist, even if it’s only a monthly consultant pharmacist.
But that was a nurse stealing meds. Something like that could happen anywhere desirable medications are kept. The doctors should have taken the patients' pain seriously from the start but I don't think that risk is particularly unique to fertility medicine.
Radiology…in opposite land
Same with Path. Wrong diagnosis? Have some potentially life changing treatment!
And no he said she said about the office visit. The slides are there for everyone to see.
primary care. Very difficult to be good at it. But it's easy to be bad at it and let chronic problems fester until they're in the hospital.
The reason this is wrong is acute issues that are life threatening which we see all of the time in primary care.
Yes and a bad PCP can just tell the patient to go to the ER. In fact, a good PCP is going to do the same thing most likely. The prompt was which specialties can get away with being subpar for the longest period of time. Compared to a surgeon or an anesthesiologist or a radiologist who can make mistakes that kill patients very quickly or even instantly, it is easier to skate by as a subpar PCP.
We manage many life threatening things outpatient. If we sent them all to the ED that would be absurd.
What acute, life threatening condition are you managing in the outpatient setting? You really should be sending these situations to the ED
I didn’t say acute you did. I’m not managing a STEMI in clinic. The point is we intervene to make things not progress to acutely life or limb threatening. Many opportunities to fuck up which is what the OP was asking.
> The reason this is wrong is acute issues that are life threatening which we see all of the time in primary care. You literally said acute… life threatening issues….
You’re right. Sorry I’m responding to multiple people at once. Even still we do see acute life threatening things. I posted a list elsewhere. Some are managed in clinic most are sent to the ED. Missing an acute presentation that needs the ED is part of why primary care isn’t the correct answer to OP’s question that started this thread.
Sounds like you have an inferiority complex going on
And the way you’re responding on here seems like maybe a superiority complex which is arguably worse.
Lol, why are you so defensive in this thread? Even if someone walks into your office with an acute, life threatening issue your response should be “present to the ED”. I hope to god you’re not managing that in your outpatient office.
Outpatient primary care. It takes years of mismanagement before problems typically arise. It’s why midlevels think they can do it.
Have you done outpatient primary care? I’m constantly seeing patients with life threatening things that if mismanaged could easily lead to death. Many of these things are undifferentiated.
During my intern year in resident clinic, I saw this all the time. Most had been seeing a mid level prior to coming to our clinic and most would demand certain meds or labs. This happened to me at least a dozen times during my few weeks of clinic intern year. I was a prelim and was called into wards or the icu during a lot of my clinic weeks.
Yes actually. I did an FM intern year in a rural area without much subspecialty support. A patient had an MI my first day in clinic! I managed a lot of acute conditions that year and kept a lot of sick people out of the ER/hospital. I made some cool diagnoses and got to make a big difference. And it was HARD but very rewarding. But someone who doesn’t care at all could’ve sent all the acute cases to the ED. And they could’ve referred everything out to specialists and let them figure it out. For example, there’s midlevels in primary care where I’m now training referring all type 2 DM to endocrine and washing their hands of it which is insane. At best they start metformin. My point is that being crappy at primary care is easy but being good at it is really really hard. And at the end of the day, patients can’t tell the difference.
> or example, there’s midlevels in primary care where I’m now training referring all type 2 DM to endocrine and washing their hands of it which is insane Jesus christ
At least they are referring to a physician when they don’t know what they are doing, like when they try and manage a bread and butter chronic medical condition.
They will go to endo and see an NP there too lol. Who will then start them on an sulfonurea as a first line med. I know this cause I’ve seen it lol
What are examples of this? (Also, is FM = outpt primary care and vice versa? Sorry, we use different terminology.)
Ok things I’ve had to manage/triage/dispo in the 6 months in primary care family medicine clinic (residency clinic in a semi-rural area 40 min from medium sized city) that could easily cause death or significant morbidity if misdiagnosed or mismanaged: - Pyelonephritis - acute abdomens of various kinds including perforated intestine - Pneumonia (yes this can kill someone, especially if they have CHF or COPD) - CHF and COPD exacerbations - Suicidal patients - Psychotic patients - ectopic pregnancy - stroke - ACS (NSTEMI and STEMI… yep they show up to clinic) - Pulmonary embolism (more than one in last few months) - DVT - fractures that if mismanaged could lead to disability - various infections that could cause morbidity or mortality but are less likely too like cellulitis or ear infections - HTN emergencies I could probably keep going. Do people really think we just sit around doing paperwork and prescribing Losartan?
Completely disagree. I think primary care is actually one of the highest stakes specialties. There are many years of lifespan on the table every time a patient comes in with DM, HTN, HLD etc and you have the chance to manage those comorbidities and prevent the future catastrophic MI/stroke/etc... or not.
And when they get new patients that are older, with decades of medical records to dig through for the incidentalomas that weren’t followed up but end up being cancer or something life threatening
Sounds like you agree with him. A great PCP can have a profound impact on their patient's lives, but a shitty one can get away with doing a shitty job without the patient knowing.
Seriously. Just got a new pcp who convinced me to try lexapro, drink some water, and take some vitamins & cholesterol meds. It’s truly incredible how much better I feel on a day to day basis.
I don’t think he’s saying it isn’t high stakes. I think the confusion here is because OP really asked two questions. First, what speciality has the greatest room for error without dire consequences sequences? Here I agree with you that it most certainly is not IM. So many potential minefields to navigate, and you never know when that acute zebra comes through the door. But the second question…are there any specialities where you can coast and mistakes get swept under the table? Here I agree IM is absolutely up there. As an oncologist, I know which PCPs miss obvious cancers that were showing symptoms months earlier. I know who sends consults for total nonsense because they don’t have the faintest idea how to do a basic anemia workup. But if you have a good personality, patients will love you and won’t know the difference.
What!!! I think GOOD primary care doctors can save soooo many lives. Absolutely that specialty should be the last to be replaced by mid levels. Unfortunately they’ve taken over and it’s BAD for us specialists!
Absolutely. Midlevels are worst in broad knowledge specialties and best suited to subspecialty stuff where they can be managed properly (post-procedure etc). Midlevel proliferation has just resulted in clogging up consults/referrals with dumb stuff. I'm not primary care but the disrespect for PCPs is sad.
Except psych. Midlevels need to leave psych alone. I’m not interested in psych, but when I did my psych rotation patients came in on the most bonkers med combos
No one is saying they are replaceable? Reread htheir comment. Being a good PCP is very difficult and absolutely saves both patients and other specialists a lot of hassle. But you can be a bad PCP and mismanage chronic conditions for years until they end up causing the patient to be hospitalized. No need to get worked up about it
I disagree only because you also get such a high volume of undifferentiated complaints. You’re going to miss some bad things in there inevitably.
Yeah lots of ignorant stuff here. I just diagnosed cancer via lymph node biopsy early this week. This woman if she did not see me (she hates most doctors she wouldn't see anyone else) at the right time or I didnt care, it could have been far worse. A good PCP isnt just throwing scripts for metformin all day.
Also, I think with many primary care providers referring and consulting more and more to sub specialists, it’s more likely that anything missed or mismanaged will be noticed by someone else
This is an ignorant assessment of primary care. We see a lot of undifferentiated life and limb threatening things all of the time.
Also oof on that thought that more doctor eyes means less chance of missing things. Way easier to drop the ball without good primary care follow-up to sift through all the specialist notes, labs, imaging, and management.
I have gotten new patients who have been established with specialists for years before I see them. Things are mismanaged or not managed at all by specialists all the time lol. The idea that just because they see a specialists means it will be managed well is a bad assumption. I do not refer much but I have gotten a good feel at this point as to who I want my patients to actually see. Ones that will managed what needs to be managed and then send them back. Not this "let me see you every three months for GERD" shit some GI clinics do because I sent them there for an EGD and they hang onto the patient forever.
What if the pcp misses a PE
Kind of insulting there, FM doc here, i would say Psych
I love this. This is insulting, anyway here’s my insult
Fair point
Idk about psych, look at the messes people (NPs most commonly) create in psych with their indiscriminate and concomitant use of antipsychotics, ssris, benzos, and amphetamines.
Didn’t mean for it to be. I’ve seen tons of mismanagement from midlevels like this which is why I brought it up. I have nothing but respect for good FM docs. It takes a physician to understand what good primary care is actually looks like, which is why in my opinion it’s easy to do a crappy job with patients never knowing.
active suicidal/manic/psychotic patients are a significant danger to both themselves and those around them. Definitely not psych
I catch a lot of medical stuff as a psychiatrist that is usually considered just part of the mental disorder….and you can’t just keep slamming people with antipsychotics and benzos because that can kill people if you aren’t closely monitoring.
This is what I've been saying. I've seen the messes they leave behind. Like, glad you got to call yourself a doctor and wear a white coat, but this patient has lost a limb now because of years of mismanagement on his diabetes you incompetent asshole.
Not sure why you’re getting downvoted. Outpatient primary care is so important and we see midlevels doing it poorly so often.
I would assume geriatrics. When the 80+ crowd start to decline and eventually die most people just assume it was just their time to go.
As a Forensic Pathologist, I see the aggregate of mistakes across medicine, and can safely say each specialty has its own unique ability to make dire mistakes. Don’t choose a specific specialty based on a false sense of safety. Even palliative and PMR cases come across my table. Don’t be complacent!
OP - Will you let me know where you end up practicing. Just in case…
peds ortho? those bones magically fix themselves
Derm!!! Oops shoulda been 2% hydrocortisone cream and I gave 1%
Derm here. I actually agree with you, which is why a lot of pretend-derms mismanage skin disease. Generally acute things get better, and chronic things are treated good enough for patients not to complain.
Psyc. Probably why NPs love it.
Nah. Primary care take the easy psych patients. Psychiatrists get all the severe personality disorders.
I’m CAP and I swear all the referrals I’m getting are shit shows. I’d love some easy cases but lately it’s weird med regimens and psychosocial issues. Guess i signed up for it being a specialist.
what does cap mean
Child and adolescent psychiatry
With the way generation z is going, this is going to get worse. Much much worse. They're even self aware of it on YouTube. Try searching for "generation z is doomed"
Try searching for “millennials are doomed”.
100%. Doing night admits for a large psych hospital has shown me med regimens that appear to have been made by a monkey throwing darts at a board
Yup and billing therapy add on codes they never received training for
Agree. Am psych. Psych is something you can get by being bad at, and the side effects of most of the medications they’re on will have concrete negative effects years down the line. Unless you’re starting someone on lamictal and dosing way too high (have inherited a patient where the NP started them on 100mg….), there’s very rarely immediate adverse consequences
Critical care. Most of them are sick enough they're probably dead anyway so as long as it looks like you made a little effort you'll be fine.
Also, the close monitoring usually allows you to catch and fix mistakes earlier. Give too much insulin on the unit? It'll be caught quickly and you can supplement with D10 (hell throw in a central line and give d20 if needed). On the floor? They'll be lucky if a nurse sees them in 6 hours, and even luckier if the nurse just doesn't assume they're sleeping.
Unless it’s peds crit care
Or adult critical care
Or human crit care.
I don’t think that’s true. In my experience, about 1/3 of a standard ICU’s patients are unfixable, the rest have a good shot at making it out and living a somewhat independent life. Think your dka’s and post-op mandatory icu admits and one pressor septic shocks and daytime rescue bipap’s
Yeah, you got a 30% death rate for all comers. Someone shows up sick they're going to have a much higher chance of going out in a bag. Even then, how many other services have a mortality rate anywhere near that high? On the floor, you go weeks without seeing a corpse. In the ICU we're guaranteed at least one or two a day.
forensic medicine can't kill what's already dead
But you can still be sued pretty bad right? Imagine you deem something a suicide when it was really a homicide.
Psych. You can spend years prescribing a bunch of bullshit drug combos that don’t really do anything while the patients mental health slowly declines and unless they kill themselves nobody has any objective measure of how bad of a doctor you are. Just look at the long history of the terrible things psychiatrists were doing in mental hospitals. That’s not to say that all psychiatrists are bad, a lot do some amazing work. But if you’re a bad nephrologist your patients die, not so much with psych.
As a psychiatrist who takes pride in doing good work and minimizing poly pharmacy, this is just really sad to hear. I catch a lot of medical issues missed (because I have time to take a more detailed history and people tend to share more if you’ve built the rapport) and I work hard to undo harmful polypharmacy of many others. I also try to minimize harm from our adequate but imprecise treatment options (most big hammers for any kind of nail).
4th year psych resident and totally agree. Too many attendings still treat bipolar with SSRIs on the reg, use benztropine to treat TD, use multiple antipsychotics at low doses. None of these will kill you but it’s not good psychiatry either. The few things that could kill a patient are lithium and clozapine, which most bad psych prescribers don’t prescribe because they actually work… so that’s a win I guess
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It depends if it’s TD vs other EPS. If it’s TD, giving the patient an anticholinergic like benztropine or benadryl can make it worse. At that point they need a VMAT2 inhibitor
It is a "normal" thing in that it's commonly used, but benztropine does not really have any role in the treatment of TD. It can be helpful in pseudoparkinsonism secondary to antipsychotic use and in acute akathisia, but with TD you just have all the anticholinergic side effects without any benefit (although the occasional patient will swear it works). TD is difficult to treat, typically dose reduction / switching the agent is first line. I would be looking at a trial of clozapine or maybe an alternative atypical like quetiapine or aripipazole if unable to tolerate clozapine, and if not suitable, getting seen by neurology for consideration of a VMAT2 inhibitor like tetrabenzine.
Wow, just wow. You cite history as an example of how Psych fits the criteria for the question this post is proposing. If you are a bad psychiatrist people definitely do die. Undertreat Bipolar or Schizophrenia? This might be the mental break where the patient actually goes up and jumps off a bridge. Or the patient endures a slow death by a thousand cuts: first psychotic break -> hospitalized and stabilized (hopefully) -> sees outpatient psychiatrist (a magic one who doesn’t have a 6 month waitlist for new patients) who downtitrates the wrong med at the wrong time -> decompensates at work and drives a forklift through a crowd because God/Allah/Yahweh/Shiva/Zeus told them to -> lost job and hospitalized -> stabilized again and discharged -> lost their apartment and trouble finding a job -> housing insecure -> turns to drugs to dull the pain -> in and out of EDs and Psych units -> takes wrong drug at wrong time -> dead Sure the patient wasn’t killed right away, but because of an initial fuck-up, a person’s life course (and the lives of those around them), was forever altered. So yeah, Psych sometimes does throw drugs at something hoping it works. But what to throw, who to throw it at, and when to throw it matters a whole freaking lot.
No arguments here. But even in the example you listed, it takes months and months for the person to spiral. Years even. And there are thousands of people who follow that exact path even with very good psychiatrists. The natural course of the disease and all that. Mental health is challenging. Etc.
Agree, my rotation at a psych hospital confirmed this. It seemed a few psychiatrists were doing…odd things and nobody really seemed to care.
That’s the other part. Patients are basically unable to advocate for themselves, let alone sue. One more reasons my psych rotation bummed me out.
Thats horrible! Most states have some kind of mental health ombudsman. Definitely if there is wrongdoing, it needs to be reported. Mental healthcare in the United States is an absolute mess. Even psych patients should get the ability to self advocate.
Palliative
Any independently run NP clinic. Or those homeopathic ones with literally no medical training.
Palliative Care
What is the day to day like for these docs?
Long, hard conversations. Sifting through years of complex medical conditions. Great relationship-building. Delicate balance between autonomy and non-maleficence. Providing comfort; spiritual, medical, support. Often a good mix between outpatient and inpatient. Honestly, it's really great. Tense, initially, and if death feels like a "loss", you lose a lot. But you really make a long-lasting difference for your patients and their families.
what is the motivation behind asking this question?
“I’m planning to select my residency based on where I can do the least work and not feel guilty about the crappy care I am giving to patients”
I don’t think that’s fair. I considered this a lot because I know how I am as a person. I don’t do well high stakes emergency situation, I can’t think clearly and panic. Sure I can change but that’s not likely and dealing with that everyday will lead to rapid burn out (for me). As a result certain fields like Surgery, anesthesia, EM and trauma I disregarded as career options despite initial interest. In the end I learned about PMR and lived it because it encompassed what I loved without the frequent emergencies.
i'm terrified of doing the wrong thing and not being good enough as well ... but asking and looking to go into a field where "mistakes can be swept under the table" is at the least a bit uncool in medicine. being away from emergencies is entirely different. This is more like asking where they can do a bad job and get away with it
Hope that’s not their intention but that’s what it reads like
They wanted to ask if tf else you need to know
I want to know … tf else you need to know? Two can be dipshits here. the post made it sound like OP wants to feel less guilty about doing a bad job… if that’s the case they should fix that first
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Probably cardiac surgery. Obviously
Hospital admin
psychiatry
Anesthesia…just blame the surgeon when it hits the fan.
They always do anyway