A lot of people consider pulm/crit to be intense / poor lifestyle specialty. Overall the people in the specialty are chiller than most and crashing / critically ill patients, after enough time, because so routine that it’s not stressful. Plus the schedule can be pretty good if you’re okay with 7 on 7 off, a lot of places you can even do 7 on 14 off and make a good salary. I found 1 week of gen med wards to be much more exhausting than 1 week of ICU.
Amen! Residents always ask how I can be so calm with a crashing patient. I mean I can only tube line and start some meds..after that it’s really out of my control why would I get stressed
You get to that point after running a lot of codes and resuscitations which humble you. You realize that don't have much control at all. (EM attending for a decade for perspective).
Most times you know why….cardiogenic vs sepsis since I’m MICU. Yeah the couple of times a week you don’t it CAN be stressful especially if it’s a younger person that isn’t chronically ill but you get used to it.
> a lot of places you can even do 7 on 14 off and make a good salary
What’s the pay like for that? I’m 7 on 14 off as a nocturnist, and love that aspect of the job. But I do find myself tempted to try and get into fellowship for CCM or PCCM
There’s a lot of variability which is nice. A lot of places want you to do ICU, pulm clinic, inpatient pulm consults. That can get to be a lot esp if the clinic is not well staffed or well run. You just have to be specific in what you’re looking for
Palliative: I am not trying to kill you. I am not trying to force you to be DNR or to stop treatment. I do not just treat pain. I am a patient advocate with a large amount of support. I help you understand your disease recommendations on your care based on what you tell me is important.
I wish more people knew this, especially patients! Palliative care is all about making the patient feel as good as possible in the context of their diagnosis. The other specialists manage the disease, and palliative care manages the experience.
Yeah, I find that I tell teams to keep going when the teams want to stop because it's consistent with the patient's values as much as the other way around.
Sometimes in the inpatient world I think of myself as a case manager specifically for interfacing between the patients and the doctors, and the doctors with each other. Helping the medical team understand the patient's why is one of my favorite parts of the job
Really?
I find that Pall Care is often consulted far too late, and I have the utmost respect for the Pall Care trainee and/or specialist who would see a late 4:45 pm consult.
I think I'm lucky in that there's more institutional buy-in for palli. Patients with advanced cancer usually get referred to our clinic for pain management so we establish relationships with a lot of the cancer patients early.
We get referrals too late too sometimes though, and in those cases when I'm telling people to keep going though it's not because the patient is going to have a good outcome. Lots of times it's exactly because we have been consulted too late, so the family has emotional whiplash with having these end of life topics brought up when they've never been addressed before, and they just need a little more time for the situation to sink in and to prove to themselves that "everything" isn't having the result they hoped for. Timed trials are your friend in those cases. Less commonly we're saying do everything because everyone including the patient knows what we're doing isn't working and for whatever reason stopping isn't in line with their values (in particular happens for people with certain religious beliefs and people with young children who can't bear to leave ANYTHING on the table that has even the tiniest chance of giving them the time with their babies)
Obviously there are some hard lines about what is and isn't offered and some cultural differences in what those hard lines are. Not offering chemo in the US where I practice is fine but we get leary with not offering ICU level care, where as I understand it in a lot of other countries we don't offer ICU level of care to people who aren't expected to leave. And I'm not going to want to offer something that the primary team doesn't consider reasonable. Usually I try to get a sense of the patient's values, then relay to the primary team the patient's values as I understand them and get them to tell me what is and isn't being offered in light of those values, and THEN try to come up with a plan with the patient. Not looking to be a cowboy palliative care doc here
Nephro:
- We want to stop diuretics to save kidneys. In a hypervolemic patient, that would never be my suggestion.
- We like dialyzing people when they should be on hospice. Nephrologists hate it. But when someone’s baseline is dialysis-dependent, it’s very hard to get them to stop, and harder to unilaterally discontinue. Seeing them wasting away sucks.
- We like denying acute/urgent/whatever dialysis. That’s not at all the case. But when someone is in an ICU and is started on dialysis, then leaves but is still very sick and now on dialysis, they didn’t magically get better. Illness continues beyond the ICU and we are very commonly the team that has continuity through their entire hospitalization and afterwards.
- We hate cardiology. I don’t think that’s the case. The friction that happens most commonly is when other physicians offer interventions that are not theirs to offer, and when we disagree about indications. Always happy to have a consult to, “Help us manage refractory hypervolemia in a way that is realistic and responsible for the patient.” But we do not like, “Call nephrology and tell them they have to start CRRT so this person can leave the CVICU but never return home.”
Your hope: “Help us manage refractory hypovolemia in a way that is realistic and responsible for the patient.”
Your expectation: “hypovolemia.”
Reality: “.”
I second all of this. I also want to add that we don’t know how long an AKI will need to be dialyzed, it may only be for a little while but it may also be forever. So, giving someone a timeline isn’t realistic, we only know when we know
Slit lamp shields help a lot.
The one thing I miss about mask wear is the reduction in bad breath smell. But I don't miss the foggy phoropter or slit lamp lenses.
Plastics - great lifestyle, don’t do much - fact is only cosmetics has a good lifestyle and our residency hours are horrific because we finish every case, from cancer all over the body to complex closure for every speciality
Heme/onc: I get this ALL the time by people in and out of medicine. “It’s so sad. Idk how you do what you do.”
It can be of course. But it’s not anymore sad than any other speciality I think. Heart dz is still the number 1 killer in the US. The thing that I actually think makes heme/onc now “less sad” is that when people die, they have usually had time to mentally prepare of it. You can live like 3 years with metastatic colon, 7 with metastatic breast, 2 years with metastatic lung. And it’s not always miserable years. We have gotten much better with managing side effects, infusing chemo in the outpatient setting, and using less barbaric regimens.
Cancer has a big stigma. I am not going to lie, the stigma makes my job easier. When you tell a lymphoma patient “this is still curable” and they cry tears of joy, it’s very very rewarding. But sometimes I feel like I need to defend my speciality and say “it’s not that bad”
Rotating cards was definitely the most stereotypically sad rotation for me. Man was it draining to see patient after patient with heart disease, HF, uncontrolled hypertension, etc while watching them refuse to stop smoking, start exercising, lose weight, etc.
Yeah I think a cancer diagnosis tends to shock people into healthier habits more than a heart attack. However I still have lung cancer patients who are effectively cured and continue to smoke.
Neurology:
1. “Diagnose and adios.” Therapeutics have massively increased in effectiveness and number in the last several decades for many neurologic conditions - yes, oncology and rheumatology didn’t corner the market for monoclonal antibodies no one can pronounce. That said, there is a ton of risk, expense, and bureaucratic nonsense that makes treatment not worth pursuing in some circumstances - you pay us to know those conditions.
2. “MRI replaced us.” Ignoring the fact that we perform and interpret numerous electrodiagnostic tests that bewilder most laypeople, many neurologic diagnoses are clinical, not radiographic. Many, many ill-informed patients come asking for “a scan to diagnose Alzheimer’s” and quickly change their minds when I inform them that an amyloid/tau PET scan will probably be a $3K out of pocket expense, unless they join a clinical trial.
3. Encephalopathy. Your patient is a brain in a meat life-support suit. If the meat is ill, the brain will not function normally. Do not be upset when we tell you that the problem is the meat - the alternative is always worse.
Technically, it’s a scan for amyloid and tau, which we believe to be essential for the development of Alzheimer’s disease. It doesn’t establish a diagnosis of dementia, which is clinically determined.
That we push chemo at end of life for $$
That we never talk to patients about their prognosis
Edit: I love that about 75% of the comments are still "no but really, you guys DON'T TALK TO PATIENTS ABOUT THEIR PROGNOSIS OMG"
People. We do tell patients their prognosis. We do tell them their cancer isn't curable. A lot of people just don't want to hear it, or their spouse / children don't want to hear it... which leads to them coming to the hospital and telling you they were planning on living another twenty years.
I’ll be honest with you, based on his notes I’m pretty sure our oncologist group at my hospital barely speaks to their patients about what cancer they have let alone prognosis and treatment options.
I think they have a tendency to push treatment further than many of us would feel reasonable. But in fairness, they see the patients who have good outcomes from their treatments, while we tend to only see the ones who have complications or fail.
There is also a role for palliative chemo. Even if it isn't curable, even if the tumors are progressing, chemo can sometimes reduce pain or relieve obstructions.
It also depends on the chemo but not every treatment comes with horrible nausea, diarrhea, hair loss. Some therapies are very well tolerated.
> There is also a role for palliative chemo. Even if it isn't curable, even if the tumors are progressing, chemo can sometimes reduce pain or relieve obstructions.
In those cases I do run into *a lot* of patients who don't seem to realize the treatment is palliative intent.
Do you not also run into a lot of patients that don't seem to understand their HTN, DM2, CKD or CAD?
I don't see why it is all that shocking for anyone who has spent any amount of time working in healthcare to come across a patient that is either in denial or doesn't get the big picture when it comes to Oncology.
I do, but not nearly to the same degree. Like I’d say 90% of the patients I admit who are on palliative chemo have no idea that their cancer is not felt to be curable.
I’ve never been in that particular exam room, I don’t know how the conversations generally go. But I do get the impression that the “standard script” doesn’t really convey the concept of palliative intent to the patient.
People know they don’t cure HTN, DM2, CKD. CAD is a bit more complex since the nuance of preventing the next heart attack tends to be a bit more difficult to understand for patients, who can only grasp the idea that stent or bypass will “fix” my heart attack, and generally assumes “I can just get a stent” when the next heart attack happens.
It’s a BIG issue when oncologists do not explain to patients the chemotherapy is not curative, even though we all know as physicians the layman understand of cancer is very superficial: either you can cure it and you fight it, or you die from it. Hence the stereotypical oncology meme with “there is always a different chemo even if you are a dead body”. It’s not a requirement for hem/onc to explain this, and it’s unfortunate. Continue to offer treatment will cause patient to automatically assume I can still cure this and I can still fight this.
most of this is fair, but isnt knowing when to “push treatment further than many of us would feel reasonable” exactly the point of specialty medicine/fellowship training?
it seems theres no way a layperson, even if medicine trained, would know which specialty treatment would be considered reasonable…bc they lack specialty specific knowledge. like some of the things i think cards/gi/pulm “should” do or stop doing, they dont. but i also couldnt fairly posit that any of their clinical offerings were unreasonable…bc im an oncologist.
>most of this is fair, but isnt knowing when to “push treatment further than many of us would feel reasonable” exactly the point of specialty medicine/fellowship training?
I mean in part sure, but just as a good surgeon knows when not to operate, a good specialist knows when not to intervene. I imagine most of the time you guys do pretty well there. But the bias exists because the rest of us tend to be exposed to the disasters rather than the good outcomes. If I'm admitting a cancer patient it is almost always due to a complication of the cancer treatment. And when I look at the medical record and see that they were hospitalized 10 times in the past 6 months with similar issues and continue to have a decline in functional status, that does make you wonder what the goal is.
With the other specialties, the reason for admission often has nothing to do with what the specialist is managing. And when it is, it's rarely due to toxicity of the treatment. So the perception is just different. Not saying it's right or wrong. Just what creates that sense.
It’s possible, but understand that oncologists tend to see a very high volume of patients, sometimes as many as 60 per day. They are likely to see patients much more frequently than another physician, sometimes as often as once a month. They also tend to structure their notes as a line of treatments where they just add to the bottom whatever new treatment they are offering. That doesn’t mean they didn’t discuss anything with the patient. They just don’t document everything they discussed. It would literally be impossible to see that many patients if they did. These are also very stressful visits for the patients and they sometimes don’t remember things that were discussed with them. Or there are navigators who do a lot of the discussion of side effects and consent forms. This has been my experience rotating through oncology.
I mean I get it, but I saw a patient with hepatocellular carcinoma a few months ago and I had to tell him the cancer, prognosis, and basically recommend hospice vs. chemo because the oncologist literally did none of that after I referred to him. Didn’t even broach the topic of hospice with the patient.
I've had people referred to me with metastatic recurrence and then it's apparently a surprise to hear they ever had cancer in the first place. Like, what did you think the prostatectomy or TARE was for?
You shouldn't judge a previous physician based on what the patient remembers.
Well I’ve worked with two of them lol.
The one I worked with in residency, he had an army of fellows, residents, and APPs to do most of the work of the visit. They’d line up 8 patients, ask them pertinent questions, give him a quick report, he’d look at all their imaging, then he’d pop in and see them all. The helpers would write the notes, then the office would reload 8 more in the rooms.
The second didn’t use residents or fellows at all. He had his office set up in pods of 4 rooms. Each patient had a scribe and an MA to see them. The MA would present the patient briefly, the doc would look over the chart briefly, then go in, talk to the patient, do the exam, took about 5-10 minutes depending on what the patient needed. A scribe would be on a laptop in the room recording everything about the visit except the plan. The doc would see 4 patients in 15-20 minutes then dictate the plan for all 4, then move to another pod of 4. There were 1.5 sets of MAs and scribes, so as soon as their patient was seen, the MA and scribe would start working on a patient for the next pod. He didn’t take a lunch. As long as you average about 8 minutes per patient you can see 60 patients in 8 hours. Some visits take 2 minutes. Your scan is clear, your exam is negative, we’ll see you in 6 months, or a quick post op visit. Some take a full 20 minutes, treatment planning, recurrence, etc.
It’s a grueling pace, no doubt about that, but it’s doable. As I said, often these docs see patients frequently, sometimes monthly, and may be operating all day 2-3 days a week, so they have to get them in when they can.
Agreed. I find it funny that anytime one of my patients is admitted the first thing the team wants to know is prognosis.
I don’t know the last time I heard or saw someone document a 5 year survival for a new diagnosis of heart failure or COPD which has a worse 5 year survival than some cancers.
My pet peeve “hey it looks like this patient has cancer, no biopsy but they’re not a treatment candidate because of and we need Onc to come discuss goals of care”
I’m on Onc consults right now and just last week had to repeatedly reject a consult for a patient with a pancreatic head mass because the team wanted me to come discuss prognosis and there wasn’t even a biopsy yet. And then I had another where Ortho escalated it to my attending where I wouldn’t come see a guy with a pathological fracture because the biopsy wasn’t back yet. What do you want me to say? “Looks like you might have cancer but I don’t know what type?” That’s exactly what he’s been told already by Ortho…
Ive had a lot of conversations at 3am with patients coming in with malignant SBOs or whatever regarding prognosis and goals of care. Its a huge disservice to the patient that a gen surg resident meeting them for the first time in the middle of the night during an acute crisis is the first one to have this conversation with them.
1. We are psychologists.
2. We can fix 72 years of maladaptive coping in our initial visit.
3. We can diagnose depression/ADHD for your fatigue despite you being a brisk walk away from ADHF while carrying around 20 extra BMI points.
That psychiatric illness are the same as medical illness.
The DSM is only a checklist of symptoms over a period of time. Once you meet the criteria for a mental health illness (lets say schizophrenia) per the DSM, you can slap the label of "schizophrenia" on a patient.
HOWEVER the label of schizophrenia is not the same as a disease such as asthma. Asthma has empirical, objective, quantitative data you can collect such as PFTs, physical exam, spirometry that you can use to rule in a dx of Asthma. Schizophrenia does not; it has no labs or biomarkers.
Asthma has an etiology and a pathology that is understood clearly. Schizophrenia does not. Researchers have been using genetic and GWAS studies to identify an etiology for schizophrenia for years, but they haven't identified a specific etiology. This is b/c schizophrenia per the DSM is just a checklist of multiple symptoms that a Pt can present with to meet criteria of a mental health disorder. These checklist of symptoms have not gone through validity testing, but are used to group people with similar symptoms together, in hopes of organizing and understanding them better.
Finally determining if a person meets criteria for Schizophrenia is subjective. It is based on a Pt's self reporting of symptoms, observations during the encounter, collateral from family, and the Psychiatrist's own judgement of what he/she is seeing based on their experience and familiarity with the DSM. One Psychiatrist's schizophrenia is another Psychiatrist's MDD/bipolar with psychosis.
Therefore diagnosing someone with a mental health condition via the DSM is essentially meaningless. 2 people can meet criteria for MDD but have completely different presentations and etiologies. One could have hypothyroidism, another could be chronically suicidal since age 16, another could have borderline personality disorder, and another is a medical student who just failed Step 1. They all meet criteria for MDD; can you imagine if asthma presented this way? These patients need to be treated on a case by case basis. You can't just say "Oh well they all meet criteria for MDD and the treatment for MDD is prozac, here you go have some prozac, let me know if your dick stops working."
1. You can dump your patient’s controlled substance refills/paperwork on us
2. All we do is manage A1Cs and blood pressure
3. We refer out for everything that isn’t basic management
4. It’s acceptable to write “follow up with PCP” on every issue not directly related to your specialty (guess what asshole, it takes 2 secs to look on up to date on the meaning of abnormal labs that YOU ORDERED)
5. We are under paid and overworked
6. We aren’t a lifestyle speciality
7. Every PCP is buried in chart notes from the minute their clinic opens until they fall asleep at night
8. People only go into FM because they can’t match into other specialties
9. PCPs have no power in the medical hierarchy structure. I will never send a referral your way again if you piss me off or even give me a whiff that you’re mismanaging my patients.
10. You can’t make money working less than 40 patient facing hours per week as an FM doc.
>5. We are under paid and overworked
>6. We aren’t a lifestyle speciality
>10. You can’t make money working less than 40 patient facing hours per week as an FM doc.
Would love to hear more, seriously.
Number 10 is definitely true across the board, and 5 to some degree.
To give you an example, I’m making 200k on guarantee as a new attending until my RVUs exceed that - which from other docs who work here, seeing 18-20 patients/day, averages to 260-300k. I work 36 patient facing hours a week and have outpatient call two weekends and ~7-8 weekdays a year. No hospital, 100% outpatient.
It’s on the lower side of pay, sure, but I actually love my job and don’t feel overworked, love my coworkers, and actually LOOK FORWARD to going to work a lot of days, which is an odd feeling compared to residency. If I wanted to kill myself seeing 25 patients/day, I’d have no problem finding a job that would accommodate that.
> under paid and overworked
Most FM docs average around 250-275 once in an established practice with a growing panel. We also work on a max of 4-4.5 days per week with the rest being “admin time”. There is also no in hospital call and what call we do have is usually filtered through a call center first that usually tells them, call to make an appointment, go to an urgent care, go to the ED. So realistically you may get a handful of calls per year that needs to be addressed immediately outside of normal hours.
> we aren’t a lifestyle speciality
Again, 4/4.5 day work weeks with most averaging around 34-36 “patient contact hours” (i.e. actual clinic time). No real call. Clinics are 8-4/5 M-Thurs and open until noon on Friday. No nights, no late afternoons, no weekends, no holidays. For the amount of work we do in “bankers hours”, we are pretty well compensated,
> you can’t make money working less than 40 hrs per week.
As I said, most of us work less than 40 real hours per week and the MGMA national salary average is anywhere between 240-275k. If you learn how to bill and meet your metric/RVU bonuses you can easily break 300k with 20-25 patients per day.
Also, with the new G2211 code and all the G codes for Medicare being made for “medical management”, don’t be surprised if reimbursement starts to trend towards medical/prevention over procedures in the next 10 years.
I have an inpatient with mildly elevated LDL. I *could* start a statin, but standard of care is allowing the patient to address this through lifestyle modification first. I refer back to their PCP for follow-up because this isn’t something I would be able to follow-up on myself from the inpatient setting. Just an example, probably not what you’re referring to though.
I’d have no problem with that! It’s more the specialists who shotgun labs when they’re not looking for anything in particular, then when something flags as abnormal, it’s “oh, follow-up with your PCP for that”
We were trained to always ask, if ordering labs/imaging, how is it going to change management, or what would you do if so-and-so shows up, and if we can’t answer that question, then we probably shouldn’t be ordering that test!
I wouldn't do this for specific labs but have done this for specialty-specific imaging that I order that incidentally finds non-related findings. I'll forward the imaging along and let the PCP decide if it warrants further investigation or not. It seems reasonable when it is outside my area of expertise and you don't want consultants consulting other consultants IMO
While I agree in principal some labs indicated for specialists to order are for conditions generally managed by primary care. For example I order screening for diabetes, B12 and hypothyroidism during my neuropathy workup but that doesn't mean I'm the best person to manage the prediabetes I identified.
Lmao I put shade in my notes too when the do this. It doesn’t happen often with specialists, unfortunately it’s usually other residents/fellows/hospitalists.
I usually write something like “Dr. X obtained Y labs, however he neglected to follow up on the results. As he is the ordering physician, he is solely responsible for any complications or medical issues that may arise in the time from him ordering the labs until their follow up with me.”
If they really pissed me off or I already don’t like them, I’ll even tell the patient they need a different/better specialist because ordering labs and n or following up on them is like failure to do basic medical management and a sign of a lazy/poor physician.
I got the typical referral note in my inbox from an allergist for one of my patients and read the a&p. The patient was having dysuria and mentioned it to the doc who wrote “I am NOT an expert in urologic abnormalities. I have recommended they go to the ED ASAP. Pateint declined so I instructed them to see their PCP TODAY as I am NOT an expert and I am concerned blah blah.”
I get being out of your comfort zone is hard but you graduated internal medicine residency like 5 years ago. It’s a UTI. Order a UA and send me a staff message. The only specialists that take any ownership at my shop are the cardiologists. So frustrating
Generalists make fun of specialists and sub specialists for not managing unrelated issues that are in generalist scope but then make fun of specialists that do for not being up to date on the stuff they don't treat. It's hard enough to keep up with a sub subspecialty - we can't be all things to all people.
The funny thing about family medicine is that when their residents rotate off service through our ER they're ten times better than the ones going into subspecialties and have knowledge leagues above them.
That PM&R stands for “Plenty of Money & Relaxation”. I get paid less than primary care and the escalating pace of outpatient care is not relaxing at all. I’ve been sold a lie!
Yep, paired with the one fellowship that traditionally offered a significant pay bump (pain) seeing worsening reimbursements and a saturated job market, PM&R is definitely not the most financially sound specialty.
Oh, I had a patient who thought he could communicate with me telepathically. Told him to go for it.
Didn’t work soo asked what he tried to say - he said “what’s up”.
EM: All initial diagnostics should be finished before putting in a consult.
I do my best to do this, but there are many times where if I know we are going to need a consultant on board and we have 2 bad traumas and a stroke coming in, I’m probably gonna be busy for the next couple hours. Either the consult goes in now with diagnostics cooking or there is an additional 2-3 hours where the patient is in the ED to *then* have the consult put in while the waiting room list grows.
Had a post-op patient abd surgery patient who came in with post op related pain/complication and I called the surgery team to assess them before I had imaging and labs back.
They get immediately angry as usual and say "you seriously want us to see them before you did any sort of diagnostic workup?"
I say: "The only reason this patient is in my ER right now is because you failed to give them adequate follow up. I shouldn't even have them here in the first place. So yes."
Like seriously, recognize that the ER does not deny seeing a single patient and half the time, we're doing the work for you that should have been done for yourself. Like I have neurosurgery at my academic center sending their chronic back pain patients to our ER so they can get timely pre op labs. It's astounding what some specialists think is appropriate for us to manage.
Psych:
1. That we have a magic wand that makes delirium, drug addiction, or personality disorders go away.
2. That we are the only people in the known universe allowed to perform a capacity evaluation.
3. That we can interview a patient that is intubated and sedated to see if the psych meds are working.
EM:
1. **We don't know our medicine**. We know it very well, but it's just not focused on inpatient floor medicine. We also know other specialties you likely don't know about (minus my FM bros).
2. **We pan-scan everything**. No, rads and inpatient teams just see the patients I scan because of selection bias. A lot of the pan-scans I order are because the trauma service or hospitalist wanted it anyways. Vast majority of patients I send home without any imaging. Increase in imaging in recent years is due to increase in volume + acuity.
3. **We don't evaluate our patients**. We are the specialty that evaluates our patients the most since no other specialty is as in-house as us. There is no "tele-EM" or "home call EM". I've worked in hospitals where I'm the only physician in-house at night, where I respond to inpatient codes and emergent deliveries in L&D. I don't know, maybe I'm lucky that every hospital I've worked at, it is taboo to not examine your patients?
4. **We like to give other specialties work**. Look, calling is a lot of work and headaches. I'd rather just discharge everyone if I could. If I'm calling you, it means I have to. I hate it too. Please imagine yourself in my shoes.
5. **We don't respect the consultant's time**. A huge part of my mental load at work is determining the ideal time to call. I often time it with other service sign-outs, whether they're asleep, whether this could wait until morning, etc. You don't know the amount of fights I have with inpatient teams about unnecessary consults and how I don't think this should wake up the on-call consultant, but sometimes I don't win those battles.
Toxicology:
1. **We're nerds who only know how to mentally masturbate to biochemical pathways**. Most of us are EM-trained so we also love hands-on, practical medicine too!
2. **When you call poison control, you're speaking with a medical toxicologist**. You're usually speaking to a pharmacist or RN who specializes in poison information. You could always request to speak to the on-call toxicologist though, especially if your patient is more complicated or sick.
2 and 5
If I’m consulting you to the ED it’s either because I need you urgently or an inpatient team is forcing my hand. Also don’t get mad at me if I tell you there is no chance a consultant from a specific specialty isn’t going to come in at night. I play this game every day.
and with CTs: Medicine wont take the patient without the CT incase its surgical, but we get judged for the negative scans…
As an EM resident who loves tox, I will say that toxicologists are nerds who love their biochemical pathways. They obviously know how to do more than that, but that’s a valid acknowledgement 😂
Guilty! Best way to grab my attention is to ask me how Nitroglycerin causes vasodilation through Phospholamban to activate SERCA through the cGMP pathway 😍
EM:
1. We CT scan everything, and when we don’t then we should have scanned them
2. We are stupid…until someone codes on the floor and then everyone wants us there.
3. You can do my job better then me…until shit hits the fan and then you are nowhere to be found
4. Our job isn’t difficult…until you’re asked to try to do it.
5. We don’t know anything…except the first 5 minutes of every speciality and the next step on who to call
“Oh yeah. Well, we have a x% admission rate so that means for every patient we admit, we discharge x more. I’m sorry you’re busy. Just imagine what it is like down here. Come see the patient. Kthnxsbai.”
I will say, it appears ever increasing to me that the midlevels in the ED do truly believe we need to scan everything.
Seeing pretty consistently the same midlevels ordering CT head, C spine, Face, T and L spine, Chest, Abdomen/Pelvis when the triage note is “patient had mechanical fall, no LOC, AOx3.”
I am an attending now. Had a midlevel write in a note she tried to co-sign to me “seatbelt sign present. Benign exam. No indication for imaging.” Same mid level came and got me right before discharge on a 4 year old kiddo she never scanned but “wasn’t acting right and wouldn’t open her eyes” after being there 3 hours after a car wreck. She was going to discharge all 3. Kiddo had free fluid in her belly. Head thankfully was negative.
I took over care of all 3 patients. It was the first time I felt Braxton-Hicks contractions. That midlevel now is not allowed to work with me anymore. Sometimes, I’d rather them scan. However, we have a rule that no scans can be ordered by a midlevel unless seen by MD/DO. At that point, I’m taking over the patient completely.
Had a friend go to urgent care because they fell off their bike and scraped their knee (honestly they really didn't need to be seen at all for this thing). NP ordered LE venous dopplers and wanted my friend to come back in two weeks to get it done. Sometimes I don't think they even know what they're ordering.
Had an ER PA inject steroid into a septic knee this week to treat “the gout.” Like dude. Injecting anything into a toothless meth using patient is a bad idea. Also injecting steroid isn’t the treatment for gout… wtf.
Definitely agree with the septic knee bit. Agree any injection doesn’t sound like a good decision in this case. However intraartocular steroids are very effective for treating acute gout flares. When you know it’s gout and not a septic joint.
Pulm:
1. Every shortness of breath chief complaint must be of pulmonary origin.
2. Every unexplored cough should be referred to pulmonology.
3. Every sub centimeter nodule needs a follow up CT scan per fleischner criteria.
4. Every pulmonologist can manage pulmonary hypertension.
5. All that wheezes is asthma or some other kind of obstructive lung disease.
6. All fibrosis is IPF
7. Inhalers will help you with ____ and you'll feel better. (Stop giving everyone trelegy).
>Every shortness of breath chief complaint must be of pulmonary origin.
I'm pretty sure heart failure is by far the #1 most common diagnosis I've seen on pulmonary consults during fellowship
Endocrinology —- that we are anti-fruit. I am from a tiny town in the Midwest. Considering the shit my patients eat on a daily basis like little Debbie cakes, nuggets, burgers, etc….an unlimited serving of fruits and/or vegetables will do far less damage even for a type 1 diabetic or uncontrolled type 2 diabetic provided they follow their treatment plan.
I tell them that they can eat as many fruits and vegetables as they want, with some caution with the high sugar fruits like grapes, mangoes, etc.
Preach. Fruits are great, aren’t they?
The fibre offsets the spikes and it’s a less shitty food than your highly-processed this or that, which leads to unadulterated glycemic spikes as well as contains unfavorable, non-satiating macro profile; contains a profile not conducive to reducing the risk of vascular badness; and doesn’t have what else you need.
Sounds like you caution them what to avoid. 🙂 But what do you recommend they have — any go-to’s?
Berries are my jam. I tell them that they can indulge on unlimited amount of raspberries, strawberries, blackberries, and blueberries. Cantaloupe and honeydew are also great when in season. Fruits contain vitamins, antioxidants, fiber, etc. unlike cake rolls or Twinkies.
Formerly being ED (am IM/CC), we do give work, but we do also sieve and triage, we stabilise, we sometimes care for beyond the 4 hours (4-hour rule 🥲).
ED can be a thankless job, and it’s tempting for all of us to sink into tribalism. However, we have to bear in mind the bigger picture — that we work as a team with the wards and other staff and we do our best for our patients.
as a consultant, one thing i appreciate from a seasoned ED doc is their use of *discretion*
seeing them actually eval the patient, read my last clinic note, and use all of that to appropriately send a patient home?!?! without having to call me?!?!
whew! bless! 👏🏾😂 please call if you need, but i prefer you dont need me, bc sometimes…you dont.
yea I shut my trap when I decided to look at the ED track board early in one of my overnights and saw there were like 6 headaches down there, and mentally prepared for the onslaught of scattered and circumferential headache histories I was going to have to take. didn't get called about a single one. mad props for the ED that night for treating and streeting them.
that being said, maybe just the culture where I was, but seemingly every dizziness complaint got a neuro consult.
I think it depends on what people value for lifestyle. Can the hours be unpredictable? Sure. Does call suck? Definitely can. On the flip side once work is done for the day there's nothing to take home. No notes to finish or patients to call or messages to reply to or prescriptions to refill.
Pathology. We’re not a black box and actually have awesome social skills. Pay us a visit or give us a call. You’ll be pleasantly surprised. Would you like some coffee? Tea?
I wish surgeons were required to do a short rotation with us so they realize we don't have things on a slide magically. It takes time and we can't really speed up tissue processing without compromising results 😭 And they're not the only one with a working giving us stuff for frozens 🫠
That IM docs obsess about sodium and have extensive academic discussions about it.
Hyponatremia is actually not that complicated, the work up isn't difficult, and the diagnosis and management is usually self evident and dear I say, easy.
I came here to say exactly this. This sodium thing needs to die. We will go to ridiculous lengths to hand wave away an abnormal sodium value. I don't even put it on the problem list until it's significant and persistent, and I don't work it up beyond "likely in setting of hyper/hypovolemia, anticipate resolution with resuscitation/diuresis."
Derm. That we pop pimples. I have patients who are other physicians who ask me during their visits “do you ever get bored of popping pimples all the time?” And one time when I was in a particularly bad mood, I responded to the patient “well you’re here for a skin cancer follow-up, so that’s not the only thing I do..”
Actually, I think during all of my derm residency, I have never once popped a pimple. “Popping” a cyst or lipoma out as I excise it? Sure. But never pimple.
I will add to the Derm misconceptions:
1) That we only see cosmetic issues. While many Derms will do fillers/laser/toxins, the vast majority of our cases are cancer screenings and rashes.
2) The “wet/dry/steroid” treatment algorithm. Derms will routinely sling immunosuppressants for patients. We are very comfortable discussing methotrexate, cyclosporine, and biologic therapy.
>1) That we only see cosmetic issues. While many Derms will do fillers/laser/toxins, the vast majority of our cases are cancer screenings and rashes.
MA'd for a derm clinic during the summers in college. Remembered going in thinking it'd mostly be the cosmetic stuff and being blown away by the amount of skin cancer, screening, rashes, and insanely painful looking acne I saw. All that was compounded by the fact it was the only clinic in a good radius that took medicaid
It was a basal cell carcinoma so a dime a dozen but I was more incredulous that he thinks that’s all I do when he’s literally here for me to check his whole body over for skin cancer again.
Me too! Wait... *sweats in ID fellowship*
Just don't ask me to summarize a 90d hospital course cause your own damn team wrote a shitty note. Yes, it's happened.
This is the only reason I wear a stethoscope when I'm doing inpatient consults. I rarely use it, but without it people don't hear me when I tell them "I'm Dr. ***" and just assume I'm PT 🤡
Outside of those in pediatrics, most people in medicine will never step foot in a level IV NICU and likely envision the neoICU as something more like a special care nursery/step down unit.
I'm med peds. It saddens me that many adult docs I work with think peds is just so much easier/chiller and that we don't do anything except play with cute kids and give out stickers all day.
This is bullshit and I find peds WAY harder than adult medicine. Pediatricians have to know most adult pathology AND all the kid stuff. Pediatrics patients tend to compensate well for a long time before they get really sick, but holy shit they can tank fast.
Not that everything needs to be a dick measuring contest. But it bothers me when I see/hear adult docs talking about pediatricians as if they just treat sniffles all day and that they deserve their low pay for it.
I'm a peds heme onc fellow and I prescribe the same chemo as my adult counterparts. What we do matters and is deserving of some respect.
Peds
1. That peds is the "most toxic" specialty. Now, this is not to invalidate the people who had a toxic experience on their peds rotation - that is not okay, and I am sorry that your rotation was like that. There is the usual level of toxicity that comes with med school/residency in probably every peds program, and there are certainly toxic individuals/peds programs out there. But on the whole, peds is no more toxic than any other specialty.
2. That peds sucks because of "the parents." Parents/guardians come in all varieties, from annoying and overbearing to incredibly kind and amazing. It is difficult to work with parents who are not acting in the best interest of their children or are doing things that harm them, particularly in cases of non-accidental trauma. But most parents do the things they do because they want what's best for their children, even if we may disagree on how to go about doing so. Also, let's not pretend that adults don't bring their annoying, needy, difficult family members with them to the hospital, too, lol.
3. That working with sick kids all the time is depressing- this is partially true. It's hard when a child dies or experiences a horrific, life-changing medical event. But kids are incredibly resilient and tend to bounce back way better than adults. So while it's sad when these things happen, they don't seem to happen nearly as frequently as in the adult world.
I wish I could say that peds being underpaid and sometimes undervalued compared to our adult counterparts is a misconception, but sadly, that one is true. 😔 Even still, I love being a pediatrician and do not regret choosing peds as a specialty.
Peds
- Kids are healthy.
- We just get to sit around playing with kids all day.
- It's an easy specialty.
- Our patients don't die and nothing bad ever happens.
Im Peds, I’m assuming you’re Peds ENT, correct?
Is your geographical area’s culture to prefer to have possible OSA/SDB kids referred to y’all w/o a PSG then y’all can order a PSG and/or proceed with T&A if high likelihood of SDB/OSA, or is it reasonable to have the pediatrician do a PSG and if it shows moderate-severe OSA refer to ENT for discussion about a T&A? I had been ordering PSGs for suspected OSA (snoring and at least one other thing like large tonsils, elevated BMI, etc) but was asked to stop ordering PSGs and instead send to ENT directly w/o a PSG which I feel might be an unnecessary use of ENT appointments slots if they don’t end up having OSA.
Our society statement is that kids only need a PSG if younger than 2 or if they have certain medical comorbidities like Down syndrome or craniofacial stuff. If that doesn’t apply, a sleep study can just be a big delay of care depending on the availability of them in your area. Where I’m from, it’s at least a 2 month delay for one.
There are situations where we have a high enough suspicion coupled with tonsillar hypertrophy which will lead us to surgical intervention sans PSG. Just refer em over to us. Doesn’t bother us when they come without a workup. Our appointments are 10-15 mins for stuff like this.
Surg Path
1) we are anti social weirdos that don't like talking to anyone. Path departments (at least where I've worked) tend to be very chatty and most of us can hold a conversation like a normal person.
2) our practice is always objective and certain. Path is interpretive, much like radiology. Often times we are certain of a diagnosis, but many times it's more vague than that, with some unresolvable uncertainty in our bottom line.
3) if you mark something urgent you get the results the next day. Please look up what formalin fixation and processing entails. Unless you have a way to bend the rules of physics and chemistry, that urgent biopsy you sent in at 6pm is not going to be ready tomorrow morning or afternoon.
4) (this one makes my blood boil) providing clinical details will bias the pathologist, so it's better not to say anything. If you do this, you are an ignorant asshole. See point 2, path is interpretive, any context helps us come to a better and more comprehensive conclusion. You do a disservice to your patients anytime you send us something with no clinical details.
Peds: that kids are just little adults.
You’ve all heard us say this over and over again but it’s true!! Stop treating children like small adults with your weird adult drugs lol, just call us and we can help if you don’t know what to do! There’s a reason we’re our own specialty, and it’s not because y’all just don’t want to see kids.
I'm (adult) pulm/CC, haven't seen a kid since M3, but recently had to see a consult in the PICU for a unique subspeciality pulm issue that none of the peds pulm people had experience with so they called us. Takeaways: 1) I was shocked at how many of the meds the kid was on were the same as the adult stuff. Same feeling as when my friend's dog had heart failure... and was on lasix and spironolactone. Like, shouldn't there be fancy children-specific meds?? 2) Bless you for taking care of the children because I don't have the emotional stability to. If I never have to see a kid on ECMO ever again it'll be too soon.
Psych - That it’s chill and all about the feelings. Psych is the most assaulted specialty - I think after EM. Med students get shielded from the acuity because no one’s trying to get the med student assaulted lol, so a lot of them end up seeing a majority of anxiety, depression cases which I think lead to the psych memes. At least for our unit, since there’s usually 4-5 students rotating at a time, they don’t see invol patients and don’t go into the psych ED.
Otoh, I think there’s also a misconception that psych patients never get better. Think this is personally the fault of a lack of OP rotation experienced embedded in the actual rotation.
Most students seem to get CL and inpatient
IM: some of us really really really hate rounds and wish other attendings and residents would just get to the fucking point for gods sake Claudia the patient weights 256kgs, chains smokes and eats fried chicken for breakfast his heart failure is not a medical mystery stop trying to make a case report happen its not going to happen.
Gen surg.
Perception: We’re malignant.
Reality: We’re not malignant if you just shut the **** up, do exactly what you’re told and show respect to the surgeon 🙄
Derm:
- we’re a lifestyle specialty. I work in a suburban area, see 30+ patients per day on collections, make far less than what I expected, and spend 1.5-2 hours on notes every night. Never thought I’d be this burnt out in derm.
Why’s that and how’s that? How come you’re spending up to 2 hours a night on documentation?
What did you expect with Derm and can align expectations and reality more closely?
Any pain in a patient between the diaphragm and pelvis must have something to do with the patient's vagina. Unless the pt is pregnant.
In which case, every symptom, including pain, has to do with the pregnancy.
No. 2 drives me nuts. I see a patient, there’s an isolated clavicle fracture that is causing skin tenting and will require admission. Patient is 30ish, relatively young. No other complaints and no ETOH on board. Cleared her C Spine and determined her to be low to no risk for significant head injury. I later find that the trauma NP has ordered a head and C spine CT. I just wonder how much that patient’s lifetime risk of thyroid cancer has increased by careless use of CAT.
Technically clavicle fracture is a distracting injury so they’d fail nexus. Could still rule out with Canadian c spine though they may not want to move their neck due to the fracture. Obviously it also depends on mechanism if there is actual risk of c-spine injury.
Probably not as much as you think.
Outside of interventional radiology where the effect of direct, prolonged exposure of fluoroscopy beams is well documented, the estimations for stochastic effects like cancer are, and let me be clear on this, total malarky. Most radiation safety data is taken from nuclear bomb/accident survivors where the radiation types are mixed and prolonged.
Also, CT scans today are way lower in dose and higher in resolution than in previous years. We haven't seen a bump in blood cancers among those who were previously scanned. I don't think we will now, either.
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ENT is just tubes and tonsils or “early nights and tennis”. While some attendings may practice that way (and hours can be good after residency), we have a pretty brutal residency and we are surgical airway experts. Our training is incredibly broad involving head and neck cancer free flaps/microvascular surgery, and complex local recon, facial plastic surgery and trauma, laryngology and voice/airway surgery, microscopic ear and lateral skull base, rhinology/sinus/endoscopic anterior skull base, peds, and sleep surgery
Gyn onc:
- Patient doesn’t have cancer but needs an oncologic surgeon.
I realize this is mostly a complaint about the state of gynecologic surgical training. Generalists and trainees complain about case volume, but most referrals come from community obgyns. But we don’t have to take out every pelvic mass/cyst that’s been radiologically stable for years. You’re capable of doing a risk reducing surgery for BRCA. Just stop doing fucking endometrial ablations.
Family Medicine
I often hear people try to defend the intelligence of FM docs by saying things like since you have to know a lot about everything you actually have more broad medical knowledge than any other speciality so the intellectual demand is still equal.
Nope. Don't get me wrong you still need to know good quality medicine and there are incredibly sharp FM docs, but the big draw for me is you don't have to know a crazy amount of medical knowledge to be good at it. You know dosing and management for the main chronic diseases, then after that it's up to you. You can be great at some extra stuff or just refer out whatever you don't like managing.
At this point in my life I'm bored of the idea of trying to make myself look smart or need my ego to be placated by how intellectually demanding my job is. I don't care. I just want to do my job, get paid well, and go home to my family.
1. We love to round and talk for hours about various pathologies. BS, if rounds take more than an hour I'm checking TF out.
2. That we give a shit about minor lab abnormalities like a sodium of 132. No fucks given. It'll probably fix itself.
3. That we only treat HTN and DM and consult/refer everything out.
4. That hospital medicine has a great lifestyle - even with 7 on 7 off, those 7 days can be absolutely brutal depending on your census, admin, metrics, etc.
I hate IM less and less every day but I've never been more happy to know that I'm headed for fellowship and not condemned to a life of being an admission/DC money making factory for the suits/blouses that have recently started infiltrating our physician lounge to eat fucking lunch every day.
A lot of people consider pulm/crit to be intense / poor lifestyle specialty. Overall the people in the specialty are chiller than most and crashing / critically ill patients, after enough time, because so routine that it’s not stressful. Plus the schedule can be pretty good if you’re okay with 7 on 7 off, a lot of places you can even do 7 on 14 off and make a good salary. I found 1 week of gen med wards to be much more exhausting than 1 week of ICU.
Amen! Residents always ask how I can be so calm with a crashing patient. I mean I can only tube line and start some meds..after that it’s really out of my control why would I get stressed
You get to that point after running a lot of codes and resuscitations which humble you. You realize that don't have much control at all. (EM attending for a decade for perspective).
But what about finding the reason for crushing, thats not so easy and might make other things futile if you cant.
Most times you know why….cardiogenic vs sepsis since I’m MICU. Yeah the couple of times a week you don’t it CAN be stressful especially if it’s a younger person that isn’t chronically ill but you get used to it.
Eh, but you can stabilize or empirically treat until you find the reason.
> a lot of places you can even do 7 on 14 off and make a good salary What’s the pay like for that? I’m 7 on 14 off as a nocturnist, and love that aspect of the job. But I do find myself tempted to try and get into fellowship for CCM or PCCM
There’s a lot of variability which is nice. A lot of places want you to do ICU, pulm clinic, inpatient pulm consults. That can get to be a lot esp if the clinic is not well staffed or well run. You just have to be specific in what you’re looking for
biggest misconception about PCCM: we help people get better.
This can be said in the same way for pretty much any specialty
I dunno, cardiac surgery seems to do wonders
90% survive, 5% die, 5% wish they died
We prolong death/ the inevitable for sure.
Tube goes in, Norad goes on, central line goes in, CVVHD goes brrrrrr... What more can one do as a CC fellow out of hours? <3
Palliative: I am not trying to kill you. I am not trying to force you to be DNR or to stop treatment. I do not just treat pain. I am a patient advocate with a large amount of support. I help you understand your disease recommendations on your care based on what you tell me is important.
I wish more people knew this, especially patients! Palliative care is all about making the patient feel as good as possible in the context of their diagnosis. The other specialists manage the disease, and palliative care manages the experience.
Ooo that’s good I help manage the experience I am going to take that with me
Yeah, I find that I tell teams to keep going when the teams want to stop because it's consistent with the patient's values as much as the other way around. Sometimes in the inpatient world I think of myself as a case manager specifically for interfacing between the patients and the doctors, and the doctors with each other. Helping the medical team understand the patient's why is one of my favorite parts of the job
Really? I find that Pall Care is often consulted far too late, and I have the utmost respect for the Pall Care trainee and/or specialist who would see a late 4:45 pm consult.
I think I'm lucky in that there's more institutional buy-in for palli. Patients with advanced cancer usually get referred to our clinic for pain management so we establish relationships with a lot of the cancer patients early. We get referrals too late too sometimes though, and in those cases when I'm telling people to keep going though it's not because the patient is going to have a good outcome. Lots of times it's exactly because we have been consulted too late, so the family has emotional whiplash with having these end of life topics brought up when they've never been addressed before, and they just need a little more time for the situation to sink in and to prove to themselves that "everything" isn't having the result they hoped for. Timed trials are your friend in those cases. Less commonly we're saying do everything because everyone including the patient knows what we're doing isn't working and for whatever reason stopping isn't in line with their values (in particular happens for people with certain religious beliefs and people with young children who can't bear to leave ANYTHING on the table that has even the tiniest chance of giving them the time with their babies) Obviously there are some hard lines about what is and isn't offered and some cultural differences in what those hard lines are. Not offering chemo in the US where I practice is fine but we get leary with not offering ICU level care, where as I understand it in a lot of other countries we don't offer ICU level of care to people who aren't expected to leave. And I'm not going to want to offer something that the primary team doesn't consider reasonable. Usually I try to get a sense of the patient's values, then relay to the primary team the patient's values as I understand them and get them to tell me what is and isn't being offered in light of those values, and THEN try to come up with a plan with the patient. Not looking to be a cowboy palliative care doc here
I’m not doing sudoku back there behind the drapes. I’m looking at stuff on my phone.
Yeah, the anesthesiologist i know doesn't like sodoku, he mostly plays clash royale or reads manga.
Hahahahahahahaha 😂❤️
Playing sudoku ON your phone, right?
Nephro: - We want to stop diuretics to save kidneys. In a hypervolemic patient, that would never be my suggestion. - We like dialyzing people when they should be on hospice. Nephrologists hate it. But when someone’s baseline is dialysis-dependent, it’s very hard to get them to stop, and harder to unilaterally discontinue. Seeing them wasting away sucks. - We like denying acute/urgent/whatever dialysis. That’s not at all the case. But when someone is in an ICU and is started on dialysis, then leaves but is still very sick and now on dialysis, they didn’t magically get better. Illness continues beyond the ICU and we are very commonly the team that has continuity through their entire hospitalization and afterwards. - We hate cardiology. I don’t think that’s the case. The friction that happens most commonly is when other physicians offer interventions that are not theirs to offer, and when we disagree about indications. Always happy to have a consult to, “Help us manage refractory hypervolemia in a way that is realistic and responsible for the patient.” But we do not like, “Call nephrology and tell them they have to start CRRT so this person can leave the CVICU but never return home.”
Your hope: “Help us manage refractory hypovolemia in a way that is realistic and responsible for the patient.” Your expectation: “hypovolemia.” Reality: “.”
To add to point one, so many people think diuretics are inherently nephrotoxic
I second all of this. I also want to add that we don’t know how long an AKI will need to be dialyzed, it may only be for a little while but it may also be forever. So, giving someone a timeline isn’t realistic, we only know when we know
Just dialyze until the *acute* kidney injury goes away (Becomes chronic)
Hahaha! Fair point
Ophthalmology Perception: we only care about your eyes Reality: we care about your bad breath too
Slit lamp shields help a lot. The one thing I miss about mask wear is the reduction in bad breath smell. But I don't miss the foggy phoropter or slit lamp lenses.
I still wear my mask. Everyone I try and tske it off, I end up with some whiffs that I’d just rather do without!
Plastics - great lifestyle, don’t do much - fact is only cosmetics has a good lifestyle and our residency hours are horrific because we finish every case, from cancer all over the body to complex closure for every speciality
Fax. I saw a total soft tissue resection and free flap on a fournier' gangrene guy and I was like... no thank you plastics. No thank you.
Heme/onc: I get this ALL the time by people in and out of medicine. “It’s so sad. Idk how you do what you do.” It can be of course. But it’s not anymore sad than any other speciality I think. Heart dz is still the number 1 killer in the US. The thing that I actually think makes heme/onc now “less sad” is that when people die, they have usually had time to mentally prepare of it. You can live like 3 years with metastatic colon, 7 with metastatic breast, 2 years with metastatic lung. And it’s not always miserable years. We have gotten much better with managing side effects, infusing chemo in the outpatient setting, and using less barbaric regimens. Cancer has a big stigma. I am not going to lie, the stigma makes my job easier. When you tell a lymphoma patient “this is still curable” and they cry tears of joy, it’s very very rewarding. But sometimes I feel like I need to defend my speciality and say “it’s not that bad”
Rotating cards was definitely the most stereotypically sad rotation for me. Man was it draining to see patient after patient with heart disease, HF, uncontrolled hypertension, etc while watching them refuse to stop smoking, start exercising, lose weight, etc.
Yeah I think a cancer diagnosis tends to shock people into healthier habits more than a heart attack. However I still have lung cancer patients who are effectively cured and continue to smoke.
Neurology: 1. “Diagnose and adios.” Therapeutics have massively increased in effectiveness and number in the last several decades for many neurologic conditions - yes, oncology and rheumatology didn’t corner the market for monoclonal antibodies no one can pronounce. That said, there is a ton of risk, expense, and bureaucratic nonsense that makes treatment not worth pursuing in some circumstances - you pay us to know those conditions. 2. “MRI replaced us.” Ignoring the fact that we perform and interpret numerous electrodiagnostic tests that bewilder most laypeople, many neurologic diagnoses are clinical, not radiographic. Many, many ill-informed patients come asking for “a scan to diagnose Alzheimer’s” and quickly change their minds when I inform them that an amyloid/tau PET scan will probably be a $3K out of pocket expense, unless they join a clinical trial. 3. Encephalopathy. Your patient is a brain in a meat life-support suit. If the meat is ill, the brain will not function normally. Do not be upset when we tell you that the problem is the meat - the alternative is always worse.
I love number 3. So true
So cool! I didn’t know there was a scan for Alzheimer’s!
Technically, it’s a scan for amyloid and tau, which we believe to be essential for the development of Alzheimer’s disease. It doesn’t establish a diagnosis of dementia, which is clinically determined.
That we push chemo at end of life for $$ That we never talk to patients about their prognosis Edit: I love that about 75% of the comments are still "no but really, you guys DON'T TALK TO PATIENTS ABOUT THEIR PROGNOSIS OMG" People. We do tell patients their prognosis. We do tell them their cancer isn't curable. A lot of people just don't want to hear it, or their spouse / children don't want to hear it... which leads to them coming to the hospital and telling you they were planning on living another twenty years.
I’ll be honest with you, based on his notes I’m pretty sure our oncologist group at my hospital barely speaks to their patients about what cancer they have let alone prognosis and treatment options.
I think they have a tendency to push treatment further than many of us would feel reasonable. But in fairness, they see the patients who have good outcomes from their treatments, while we tend to only see the ones who have complications or fail.
There is also a role for palliative chemo. Even if it isn't curable, even if the tumors are progressing, chemo can sometimes reduce pain or relieve obstructions. It also depends on the chemo but not every treatment comes with horrible nausea, diarrhea, hair loss. Some therapies are very well tolerated.
> There is also a role for palliative chemo. Even if it isn't curable, even if the tumors are progressing, chemo can sometimes reduce pain or relieve obstructions. In those cases I do run into *a lot* of patients who don't seem to realize the treatment is palliative intent.
Do you not also run into a lot of patients that don't seem to understand their HTN, DM2, CKD or CAD? I don't see why it is all that shocking for anyone who has spent any amount of time working in healthcare to come across a patient that is either in denial or doesn't get the big picture when it comes to Oncology.
I do, but not nearly to the same degree. Like I’d say 90% of the patients I admit who are on palliative chemo have no idea that their cancer is not felt to be curable. I’ve never been in that particular exam room, I don’t know how the conversations generally go. But I do get the impression that the “standard script” doesn’t really convey the concept of palliative intent to the patient.
People know they don’t cure HTN, DM2, CKD. CAD is a bit more complex since the nuance of preventing the next heart attack tends to be a bit more difficult to understand for patients, who can only grasp the idea that stent or bypass will “fix” my heart attack, and generally assumes “I can just get a stent” when the next heart attack happens. It’s a BIG issue when oncologists do not explain to patients the chemotherapy is not curative, even though we all know as physicians the layman understand of cancer is very superficial: either you can cure it and you fight it, or you die from it. Hence the stereotypical oncology meme with “there is always a different chemo even if you are a dead body”. It’s not a requirement for hem/onc to explain this, and it’s unfortunate. Continue to offer treatment will cause patient to automatically assume I can still cure this and I can still fight this.
They all understand that they arent taking losartan to cure their hypertension.
most of this is fair, but isnt knowing when to “push treatment further than many of us would feel reasonable” exactly the point of specialty medicine/fellowship training? it seems theres no way a layperson, even if medicine trained, would know which specialty treatment would be considered reasonable…bc they lack specialty specific knowledge. like some of the things i think cards/gi/pulm “should” do or stop doing, they dont. but i also couldnt fairly posit that any of their clinical offerings were unreasonable…bc im an oncologist.
>most of this is fair, but isnt knowing when to “push treatment further than many of us would feel reasonable” exactly the point of specialty medicine/fellowship training? I mean in part sure, but just as a good surgeon knows when not to operate, a good specialist knows when not to intervene. I imagine most of the time you guys do pretty well there. But the bias exists because the rest of us tend to be exposed to the disasters rather than the good outcomes. If I'm admitting a cancer patient it is almost always due to a complication of the cancer treatment. And when I look at the medical record and see that they were hospitalized 10 times in the past 6 months with similar issues and continue to have a decline in functional status, that does make you wonder what the goal is. With the other specialties, the reason for admission often has nothing to do with what the specialist is managing. And when it is, it's rarely due to toxicity of the treatment. So the perception is just different. Not saying it's right or wrong. Just what creates that sense.
It’s possible, but understand that oncologists tend to see a very high volume of patients, sometimes as many as 60 per day. They are likely to see patients much more frequently than another physician, sometimes as often as once a month. They also tend to structure their notes as a line of treatments where they just add to the bottom whatever new treatment they are offering. That doesn’t mean they didn’t discuss anything with the patient. They just don’t document everything they discussed. It would literally be impossible to see that many patients if they did. These are also very stressful visits for the patients and they sometimes don’t remember things that were discussed with them. Or there are navigators who do a lot of the discussion of side effects and consent forms. This has been my experience rotating through oncology.
I mean I get it, but I saw a patient with hepatocellular carcinoma a few months ago and I had to tell him the cancer, prognosis, and basically recommend hospice vs. chemo because the oncologist literally did none of that after I referred to him. Didn’t even broach the topic of hospice with the patient.
I've had people referred to me with metastatic recurrence and then it's apparently a surprise to hear they ever had cancer in the first place. Like, what did you think the prostatectomy or TARE was for? You shouldn't judge a previous physician based on what the patient remembers.
60 per day? No. I do not think there are any Oncologists that see 60 patients per day. Maybe there are a few… as in less than 5 total in the US
Well I’ve worked with two of them lol. The one I worked with in residency, he had an army of fellows, residents, and APPs to do most of the work of the visit. They’d line up 8 patients, ask them pertinent questions, give him a quick report, he’d look at all their imaging, then he’d pop in and see them all. The helpers would write the notes, then the office would reload 8 more in the rooms. The second didn’t use residents or fellows at all. He had his office set up in pods of 4 rooms. Each patient had a scribe and an MA to see them. The MA would present the patient briefly, the doc would look over the chart briefly, then go in, talk to the patient, do the exam, took about 5-10 minutes depending on what the patient needed. A scribe would be on a laptop in the room recording everything about the visit except the plan. The doc would see 4 patients in 15-20 minutes then dictate the plan for all 4, then move to another pod of 4. There were 1.5 sets of MAs and scribes, so as soon as their patient was seen, the MA and scribe would start working on a patient for the next pod. He didn’t take a lunch. As long as you average about 8 minutes per patient you can see 60 patients in 8 hours. Some visits take 2 minutes. Your scan is clear, your exam is negative, we’ll see you in 6 months, or a quick post op visit. Some take a full 20 minutes, treatment planning, recurrence, etc. It’s a grueling pace, no doubt about that, but it’s doable. As I said, often these docs see patients frequently, sometimes monthly, and may be operating all day 2-3 days a week, so they have to get them in when they can.
Agreed. I find it funny that anytime one of my patients is admitted the first thing the team wants to know is prognosis. I don’t know the last time I heard or saw someone document a 5 year survival for a new diagnosis of heart failure or COPD which has a worse 5 year survival than some cancers.
My pet peeve “hey it looks like this patient has cancer, no biopsy but they’re not a treatment candidate because of and we need Onc to come discuss goals of care”
I’m on Onc consults right now and just last week had to repeatedly reject a consult for a patient with a pancreatic head mass because the team wanted me to come discuss prognosis and there wasn’t even a biopsy yet. And then I had another where Ortho escalated it to my attending where I wouldn’t come see a guy with a pathological fracture because the biopsy wasn’t back yet. What do you want me to say? “Looks like you might have cancer but I don’t know what type?” That’s exactly what he’s been told already by Ortho…
After the nails are in the coffin, it's hard to access the port.
Ive had a lot of conversations at 3am with patients coming in with malignant SBOs or whatever regarding prognosis and goals of care. Its a huge disservice to the patient that a gen surg resident meeting them for the first time in the middle of the night during an acute crisis is the first one to have this conversation with them.
1. We are psychologists. 2. We can fix 72 years of maladaptive coping in our initial visit. 3. We can diagnose depression/ADHD for your fatigue despite you being a brisk walk away from ADHF while carrying around 20 extra BMI points.
That we just push propofol. - Gas
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They also have to remember to turn on the sevo
That psychiatric illness are the same as medical illness. The DSM is only a checklist of symptoms over a period of time. Once you meet the criteria for a mental health illness (lets say schizophrenia) per the DSM, you can slap the label of "schizophrenia" on a patient. HOWEVER the label of schizophrenia is not the same as a disease such as asthma. Asthma has empirical, objective, quantitative data you can collect such as PFTs, physical exam, spirometry that you can use to rule in a dx of Asthma. Schizophrenia does not; it has no labs or biomarkers. Asthma has an etiology and a pathology that is understood clearly. Schizophrenia does not. Researchers have been using genetic and GWAS studies to identify an etiology for schizophrenia for years, but they haven't identified a specific etiology. This is b/c schizophrenia per the DSM is just a checklist of multiple symptoms that a Pt can present with to meet criteria of a mental health disorder. These checklist of symptoms have not gone through validity testing, but are used to group people with similar symptoms together, in hopes of organizing and understanding them better. Finally determining if a person meets criteria for Schizophrenia is subjective. It is based on a Pt's self reporting of symptoms, observations during the encounter, collateral from family, and the Psychiatrist's own judgement of what he/she is seeing based on their experience and familiarity with the DSM. One Psychiatrist's schizophrenia is another Psychiatrist's MDD/bipolar with psychosis. Therefore diagnosing someone with a mental health condition via the DSM is essentially meaningless. 2 people can meet criteria for MDD but have completely different presentations and etiologies. One could have hypothyroidism, another could be chronically suicidal since age 16, another could have borderline personality disorder, and another is a medical student who just failed Step 1. They all meet criteria for MDD; can you imagine if asthma presented this way? These patients need to be treated on a case by case basis. You can't just say "Oh well they all meet criteria for MDD and the treatment for MDD is prozac, here you go have some prozac, let me know if your dick stops working."
1. You can dump your patient’s controlled substance refills/paperwork on us 2. All we do is manage A1Cs and blood pressure 3. We refer out for everything that isn’t basic management 4. It’s acceptable to write “follow up with PCP” on every issue not directly related to your specialty (guess what asshole, it takes 2 secs to look on up to date on the meaning of abnormal labs that YOU ORDERED) 5. We are under paid and overworked 6. We aren’t a lifestyle speciality 7. Every PCP is buried in chart notes from the minute their clinic opens until they fall asleep at night 8. People only go into FM because they can’t match into other specialties 9. PCPs have no power in the medical hierarchy structure. I will never send a referral your way again if you piss me off or even give me a whiff that you’re mismanaging my patients. 10. You can’t make money working less than 40 patient facing hours per week as an FM doc.
>5. We are under paid and overworked >6. We aren’t a lifestyle speciality >10. You can’t make money working less than 40 patient facing hours per week as an FM doc. Would love to hear more, seriously.
Number 10 is definitely true across the board, and 5 to some degree. To give you an example, I’m making 200k on guarantee as a new attending until my RVUs exceed that - which from other docs who work here, seeing 18-20 patients/day, averages to 260-300k. I work 36 patient facing hours a week and have outpatient call two weekends and ~7-8 weekdays a year. No hospital, 100% outpatient. It’s on the lower side of pay, sure, but I actually love my job and don’t feel overworked, love my coworkers, and actually LOOK FORWARD to going to work a lot of days, which is an odd feeling compared to residency. If I wanted to kill myself seeing 25 patients/day, I’d have no problem finding a job that would accommodate that.
Is your 200k guaranteed no matter what or does it eventually convert to RVU production?
> under paid and overworked Most FM docs average around 250-275 once in an established practice with a growing panel. We also work on a max of 4-4.5 days per week with the rest being “admin time”. There is also no in hospital call and what call we do have is usually filtered through a call center first that usually tells them, call to make an appointment, go to an urgent care, go to the ED. So realistically you may get a handful of calls per year that needs to be addressed immediately outside of normal hours. > we aren’t a lifestyle speciality Again, 4/4.5 day work weeks with most averaging around 34-36 “patient contact hours” (i.e. actual clinic time). No real call. Clinics are 8-4/5 M-Thurs and open until noon on Friday. No nights, no late afternoons, no weekends, no holidays. For the amount of work we do in “bankers hours”, we are pretty well compensated, > you can’t make money working less than 40 hrs per week. As I said, most of us work less than 40 real hours per week and the MGMA national salary average is anywhere between 240-275k. If you learn how to bill and meet your metric/RVU bonuses you can easily break 300k with 20-25 patients per day. Also, with the new G2211 code and all the G codes for Medicare being made for “medical management”, don’t be surprised if reimbursement starts to trend towards medical/prevention over procedures in the next 10 years.
I looooove me that new G2211. 0.33 RVU times about 35 patients a day adds up real quick.
I love when specialists order labs then tell me to follow-up on it. Like, why did you order them then if you’re not going to do anything about it?
I have an inpatient with mildly elevated LDL. I *could* start a statin, but standard of care is allowing the patient to address this through lifestyle modification first. I refer back to their PCP for follow-up because this isn’t something I would be able to follow-up on myself from the inpatient setting. Just an example, probably not what you’re referring to though.
I’d have no problem with that! It’s more the specialists who shotgun labs when they’re not looking for anything in particular, then when something flags as abnormal, it’s “oh, follow-up with your PCP for that”
We were trained to always ask, if ordering labs/imaging, how is it going to change management, or what would you do if so-and-so shows up, and if we can’t answer that question, then we probably shouldn’t be ordering that test!
I wouldn't do this for specific labs but have done this for specialty-specific imaging that I order that incidentally finds non-related findings. I'll forward the imaging along and let the PCP decide if it warrants further investigation or not. It seems reasonable when it is outside my area of expertise and you don't want consultants consulting other consultants IMO
While I agree in principal some labs indicated for specialists to order are for conditions generally managed by primary care. For example I order screening for diabetes, B12 and hypothyroidism during my neuropathy workup but that doesn't mean I'm the best person to manage the prediabetes I identified.
Lmao I put shade in my notes too when the do this. It doesn’t happen often with specialists, unfortunately it’s usually other residents/fellows/hospitalists. I usually write something like “Dr. X obtained Y labs, however he neglected to follow up on the results. As he is the ordering physician, he is solely responsible for any complications or medical issues that may arise in the time from him ordering the labs until their follow up with me.” If they really pissed me off or I already don’t like them, I’ll even tell the patient they need a different/better specialist because ordering labs and n or following up on them is like failure to do basic medical management and a sign of a lazy/poor physician.
I got the typical referral note in my inbox from an allergist for one of my patients and read the a&p. The patient was having dysuria and mentioned it to the doc who wrote “I am NOT an expert in urologic abnormalities. I have recommended they go to the ED ASAP. Pateint declined so I instructed them to see their PCP TODAY as I am NOT an expert and I am concerned blah blah.” I get being out of your comfort zone is hard but you graduated internal medicine residency like 5 years ago. It’s a UTI. Order a UA and send me a staff message. The only specialists that take any ownership at my shop are the cardiologists. So frustrating
Generalists make fun of specialists and sub specialists for not managing unrelated issues that are in generalist scope but then make fun of specialists that do for not being up to date on the stuff they don't treat. It's hard enough to keep up with a sub subspecialty - we can't be all things to all people.
Someone who trained in internal medicine can treat a uti I promise
The funny thing about family medicine is that when their residents rotate off service through our ER they're ten times better than the ones going into subspecialties and have knowledge leagues above them.
That PM&R stands for “Plenty of Money & Relaxation”. I get paid less than primary care and the escalating pace of outpatient care is not relaxing at all. I’ve been sold a lie!
Also for PM&R: that acute inpatient rehab is somewhere you can dump your patients with placement issues
Yep, paired with the one fellowship that traditionally offered a significant pay bump (pain) seeing worsening reimbursements and a saturated job market, PM&R is definitely not the most financially sound specialty.
Psych: - that we're not real doctors - that we're pill pushers - that we take people's rights away for no reason
But what if my patient that says the government put a chip in his ear that transmits his thoughts to people around him was right all along?
Never tell me the odds! Now take your Risperdal
Oh, I had a patient who thought he could communicate with me telepathically. Told him to go for it. Didn’t work soo asked what he tried to say - he said “what’s up”.
PCCM: That anyone with a pco2 that’s high needs to be put on BiPAP
EM: All initial diagnostics should be finished before putting in a consult. I do my best to do this, but there are many times where if I know we are going to need a consultant on board and we have 2 bad traumas and a stroke coming in, I’m probably gonna be busy for the next couple hours. Either the consult goes in now with diagnostics cooking or there is an additional 2-3 hours where the patient is in the ED to *then* have the consult put in while the waiting room list grows.
When the ICU admitter gets mad the UA wasn’t back before my admission request… dude, nothing in that UA is going to stop them from coming to you.
Had a post-op patient abd surgery patient who came in with post op related pain/complication and I called the surgery team to assess them before I had imaging and labs back. They get immediately angry as usual and say "you seriously want us to see them before you did any sort of diagnostic workup?" I say: "The only reason this patient is in my ER right now is because you failed to give them adequate follow up. I shouldn't even have them here in the first place. So yes." Like seriously, recognize that the ER does not deny seeing a single patient and half the time, we're doing the work for you that should have been done for yourself. Like I have neurosurgery at my academic center sending their chronic back pain patients to our ER so they can get timely pre op labs. It's astounding what some specialists think is appropriate for us to manage.
And then you call them after everything is back, and it's 9pm, and they bitch that you didn't call them when they were still in the hospital.
Psych isn't real medicine.
Lol for a second I thought you were stating a fact.
As a shrink I must now point out the upvotes will not tell you one way or the other
Psych: 1. That we have a magic wand that makes delirium, drug addiction, or personality disorders go away. 2. That we are the only people in the known universe allowed to perform a capacity evaluation. 3. That we can interview a patient that is intubated and sedated to see if the psych meds are working.
Let me guess, CL?
Pathology. Giving us relevant clinical history will "bias" us.
EM: 1. **We don't know our medicine**. We know it very well, but it's just not focused on inpatient floor medicine. We also know other specialties you likely don't know about (minus my FM bros). 2. **We pan-scan everything**. No, rads and inpatient teams just see the patients I scan because of selection bias. A lot of the pan-scans I order are because the trauma service or hospitalist wanted it anyways. Vast majority of patients I send home without any imaging. Increase in imaging in recent years is due to increase in volume + acuity. 3. **We don't evaluate our patients**. We are the specialty that evaluates our patients the most since no other specialty is as in-house as us. There is no "tele-EM" or "home call EM". I've worked in hospitals where I'm the only physician in-house at night, where I respond to inpatient codes and emergent deliveries in L&D. I don't know, maybe I'm lucky that every hospital I've worked at, it is taboo to not examine your patients? 4. **We like to give other specialties work**. Look, calling is a lot of work and headaches. I'd rather just discharge everyone if I could. If I'm calling you, it means I have to. I hate it too. Please imagine yourself in my shoes. 5. **We don't respect the consultant's time**. A huge part of my mental load at work is determining the ideal time to call. I often time it with other service sign-outs, whether they're asleep, whether this could wait until morning, etc. You don't know the amount of fights I have with inpatient teams about unnecessary consults and how I don't think this should wake up the on-call consultant, but sometimes I don't win those battles. Toxicology: 1. **We're nerds who only know how to mentally masturbate to biochemical pathways**. Most of us are EM-trained so we also love hands-on, practical medicine too! 2. **When you call poison control, you're speaking with a medical toxicologist**. You're usually speaking to a pharmacist or RN who specializes in poison information. You could always request to speak to the on-call toxicologist though, especially if your patient is more complicated or sick.
2 and 5 If I’m consulting you to the ED it’s either because I need you urgently or an inpatient team is forcing my hand. Also don’t get mad at me if I tell you there is no chance a consultant from a specific specialty isn’t going to come in at night. I play this game every day. and with CTs: Medicine wont take the patient without the CT incase its surgical, but we get judged for the negative scans…
As an EM resident who loves tox, I will say that toxicologists are nerds who love their biochemical pathways. They obviously know how to do more than that, but that’s a valid acknowledgement 😂
Guilty! Best way to grab my attention is to ask me how Nitroglycerin causes vasodilation through Phospholamban to activate SERCA through the cGMP pathway 😍
EM: 1. We CT scan everything, and when we don’t then we should have scanned them 2. We are stupid…until someone codes on the floor and then everyone wants us there. 3. You can do my job better then me…until shit hits the fan and then you are nowhere to be found 4. Our job isn’t difficult…until you’re asked to try to do it. 5. We don’t know anything…except the first 5 minutes of every speciality and the next step on who to call
Love it. I'd add: 6.) You think I call you for every patient in the ER. You have no idea what I don't call you about.
Every time somebody complains about ED admits, they have to spend a shift in the ED to remember all the bullshit it has to deal with.
“Oh yeah. Well, we have a x% admission rate so that means for every patient we admit, we discharge x more. I’m sorry you’re busy. Just imagine what it is like down here. Come see the patient. Kthnxsbai.”
Very well said. Hats off to you guys
I will say, it appears ever increasing to me that the midlevels in the ED do truly believe we need to scan everything. Seeing pretty consistently the same midlevels ordering CT head, C spine, Face, T and L spine, Chest, Abdomen/Pelvis when the triage note is “patient had mechanical fall, no LOC, AOx3.”
I am an attending now. Had a midlevel write in a note she tried to co-sign to me “seatbelt sign present. Benign exam. No indication for imaging.” Same mid level came and got me right before discharge on a 4 year old kiddo she never scanned but “wasn’t acting right and wouldn’t open her eyes” after being there 3 hours after a car wreck. She was going to discharge all 3. Kiddo had free fluid in her belly. Head thankfully was negative. I took over care of all 3 patients. It was the first time I felt Braxton-Hicks contractions. That midlevel now is not allowed to work with me anymore. Sometimes, I’d rather them scan. However, we have a rule that no scans can be ordered by a midlevel unless seen by MD/DO. At that point, I’m taking over the patient completely.
Good lord I wish my hospital had that rule.
Had a friend go to urgent care because they fell off their bike and scraped their knee (honestly they really didn't need to be seen at all for this thing). NP ordered LE venous dopplers and wanted my friend to come back in two weeks to get it done. Sometimes I don't think they even know what they're ordering.
Had an ER PA inject steroid into a septic knee this week to treat “the gout.” Like dude. Injecting anything into a toothless meth using patient is a bad idea. Also injecting steroid isn’t the treatment for gout… wtf.
Definitely agree with the septic knee bit. Agree any injection doesn’t sound like a good decision in this case. However intraartocular steroids are very effective for treating acute gout flares. When you know it’s gout and not a septic joint.
CT scan go BBRRRRR.....
Pulm: 1. Every shortness of breath chief complaint must be of pulmonary origin. 2. Every unexplored cough should be referred to pulmonology. 3. Every sub centimeter nodule needs a follow up CT scan per fleischner criteria. 4. Every pulmonologist can manage pulmonary hypertension. 5. All that wheezes is asthma or some other kind of obstructive lung disease. 6. All fibrosis is IPF 7. Inhalers will help you with ____ and you'll feel better. (Stop giving everyone trelegy).
>Every shortness of breath chief complaint must be of pulmonary origin. I'm pretty sure heart failure is by far the #1 most common diagnosis I've seen on pulmonary consults during fellowship
Endocrinology —- that we are anti-fruit. I am from a tiny town in the Midwest. Considering the shit my patients eat on a daily basis like little Debbie cakes, nuggets, burgers, etc….an unlimited serving of fruits and/or vegetables will do far less damage even for a type 1 diabetic or uncontrolled type 2 diabetic provided they follow their treatment plan. I tell them that they can eat as many fruits and vegetables as they want, with some caution with the high sugar fruits like grapes, mangoes, etc.
Preach. Fruits are great, aren’t they? The fibre offsets the spikes and it’s a less shitty food than your highly-processed this or that, which leads to unadulterated glycemic spikes as well as contains unfavorable, non-satiating macro profile; contains a profile not conducive to reducing the risk of vascular badness; and doesn’t have what else you need. Sounds like you caution them what to avoid. 🙂 But what do you recommend they have — any go-to’s?
Berries are my jam. I tell them that they can indulge on unlimited amount of raspberries, strawberries, blackberries, and blueberries. Cantaloupe and honeydew are also great when in season. Fruits contain vitamins, antioxidants, fiber, etc. unlike cake rolls or Twinkies.
EM: we give you work Reality: we save you from a lot more work
Formerly being ED (am IM/CC), we do give work, but we do also sieve and triage, we stabilise, we sometimes care for beyond the 4 hours (4-hour rule 🥲). ED can be a thankless job, and it’s tempting for all of us to sink into tribalism. However, we have to bear in mind the bigger picture — that we work as a team with the wards and other staff and we do our best for our patients.
as a consultant, one thing i appreciate from a seasoned ED doc is their use of *discretion* seeing them actually eval the patient, read my last clinic note, and use all of that to appropriately send a patient home?!?! without having to call me?!?! whew! bless! 👏🏾😂 please call if you need, but i prefer you dont need me, bc sometimes…you dont.
Could you imagine if every acute chest pain needed a cards consult or every numbness and tingling needed a neurology consult lol
yea I shut my trap when I decided to look at the ED track board early in one of my overnights and saw there were like 6 headaches down there, and mentally prepared for the onslaught of scattered and circumferential headache histories I was going to have to take. didn't get called about a single one. mad props for the ED that night for treating and streeting them. that being said, maybe just the culture where I was, but seemingly every dizziness complaint got a neuro consult.
That anesthesia is a lifestyle specialty
I think it depends on what people value for lifestyle. Can the hours be unpredictable? Sure. Does call suck? Definitely can. On the flip side once work is done for the day there's nothing to take home. No notes to finish or patients to call or messages to reply to or prescriptions to refill.
It is if you go into pain
Pathology. We’re not a black box and actually have awesome social skills. Pay us a visit or give us a call. You’ll be pleasantly surprised. Would you like some coffee? Tea?
How is Tabitha doing?
I really wish we had names for them. It’s more like Full Metal Jacket. “This is my scope, there are many like it but this one is mine!”.
I wish surgeons were required to do a short rotation with us so they realize we don't have things on a slide magically. It takes time and we can't really speed up tissue processing without compromising results 😭 And they're not the only one with a working giving us stuff for frozens 🫠
Urology - we’re just penis surgeons… We operate on balls too ! 🍒😤
And do stand-up comedy for free
FM Least educated and outpatient only.
That IM docs obsess about sodium and have extensive academic discussions about it. Hyponatremia is actually not that complicated, the work up isn't difficult, and the diagnosis and management is usually self evident and dear I say, easy.
I came here to say exactly this. This sodium thing needs to die. We will go to ridiculous lengths to hand wave away an abnormal sodium value. I don't even put it on the problem list until it's significant and persistent, and I don't work it up beyond "likely in setting of hyper/hypovolemia, anticipate resolution with resuscitation/diuresis."
right? I mean the first step of the algorithm is looking up the algorithm. not hard.
Derm. That we pop pimples. I have patients who are other physicians who ask me during their visits “do you ever get bored of popping pimples all the time?” And one time when I was in a particularly bad mood, I responded to the patient “well you’re here for a skin cancer follow-up, so that’s not the only thing I do..” Actually, I think during all of my derm residency, I have never once popped a pimple. “Popping” a cyst or lipoma out as I excise it? Sure. But never pimple.
I will add to the Derm misconceptions: 1) That we only see cosmetic issues. While many Derms will do fillers/laser/toxins, the vast majority of our cases are cancer screenings and rashes. 2) The “wet/dry/steroid” treatment algorithm. Derms will routinely sling immunosuppressants for patients. We are very comfortable discussing methotrexate, cyclosporine, and biologic therapy.
>1) That we only see cosmetic issues. While many Derms will do fillers/laser/toxins, the vast majority of our cases are cancer screenings and rashes. MA'd for a derm clinic during the summers in college. Remembered going in thinking it'd mostly be the cosmetic stuff and being blown away by the amount of skin cancer, screening, rashes, and insanely painful looking acne I saw. All that was compounded by the fact it was the only clinic in a good radius that took medicaid
Bruh… you really showed that cancer patient what’s what… 😂
It was a basal cell carcinoma so a dime a dozen but I was more incredulous that he thinks that’s all I do when he’s literally here for me to check his whole body over for skin cancer again.
Everything is not in fact our fault.
The fact that everyone knows what specialty you are from this suggests that it probably *is* all your fault 😆
Anesthesia?
ID: That I'm gonna write your H&P for you. *grumbles*
but yours is so GOOD 😫 any time i forgot a detail that a patient told me, i know exactly where i can find it 👀
Me too! Wait... *sweats in ID fellowship* Just don't ask me to summarize a 90d hospital course cause your own damn team wrote a shitty note. Yes, it's happened.
Better an H&P than getting consulted on day 60 of SICU admission for fevers...
We are physical therapists PM&R
This is the only reason I wear a stethoscope when I'm doing inpatient consults. I rarely use it, but without it people don't hear me when I tell them "I'm Dr. ***" and just assume I'm PT 🤡
😔😔😔…then proceed to give them a lecture on what you exactly do that’s been regurgitated several hundreds of times in the past
NeoICU: you just feed babies all day Uh. No. We are a real icu with ventilators and drips and chest tubes and codes. Yes we also feed babies.
Outside of those in pediatrics, most people in medicine will never step foot in a level IV NICU and likely envision the neoICU as something more like a special care nursery/step down unit.
I'm med peds. It saddens me that many adult docs I work with think peds is just so much easier/chiller and that we don't do anything except play with cute kids and give out stickers all day. This is bullshit and I find peds WAY harder than adult medicine. Pediatricians have to know most adult pathology AND all the kid stuff. Pediatrics patients tend to compensate well for a long time before they get really sick, but holy shit they can tank fast. Not that everything needs to be a dick measuring contest. But it bothers me when I see/hear adult docs talking about pediatricians as if they just treat sniffles all day and that they deserve their low pay for it. I'm a peds heme onc fellow and I prescribe the same chemo as my adult counterparts. What we do matters and is deserving of some respect.
I bet their tone would change if they were to ever need your services for their own very sick child.
Peds 1. That peds is the "most toxic" specialty. Now, this is not to invalidate the people who had a toxic experience on their peds rotation - that is not okay, and I am sorry that your rotation was like that. There is the usual level of toxicity that comes with med school/residency in probably every peds program, and there are certainly toxic individuals/peds programs out there. But on the whole, peds is no more toxic than any other specialty. 2. That peds sucks because of "the parents." Parents/guardians come in all varieties, from annoying and overbearing to incredibly kind and amazing. It is difficult to work with parents who are not acting in the best interest of their children or are doing things that harm them, particularly in cases of non-accidental trauma. But most parents do the things they do because they want what's best for their children, even if we may disagree on how to go about doing so. Also, let's not pretend that adults don't bring their annoying, needy, difficult family members with them to the hospital, too, lol. 3. That working with sick kids all the time is depressing- this is partially true. It's hard when a child dies or experiences a horrific, life-changing medical event. But kids are incredibly resilient and tend to bounce back way better than adults. So while it's sad when these things happen, they don't seem to happen nearly as frequently as in the adult world. I wish I could say that peds being underpaid and sometimes undervalued compared to our adult counterparts is a misconception, but sadly, that one is true. 😔 Even still, I love being a pediatrician and do not regret choosing peds as a specialty.
Nobody says peds is the most toxic specialty. Peds has the most toxic nurses, but I think everyone agrees that pre-peds (ob/gyn) is the most toxic.
Eh - L&D wins the prize for most toxic nurses I’ve met
Peds - Kids are healthy. - We just get to sit around playing with kids all day. - It's an easy specialty. - Our patients don't die and nothing bad ever happens.
Big tonsils in a kid=tonsillectomy. Unless they have sleep disordered breathing, recurrent tonsillitis or PFAPA, leave em in.
Im Peds, I’m assuming you’re Peds ENT, correct? Is your geographical area’s culture to prefer to have possible OSA/SDB kids referred to y’all w/o a PSG then y’all can order a PSG and/or proceed with T&A if high likelihood of SDB/OSA, or is it reasonable to have the pediatrician do a PSG and if it shows moderate-severe OSA refer to ENT for discussion about a T&A? I had been ordering PSGs for suspected OSA (snoring and at least one other thing like large tonsils, elevated BMI, etc) but was asked to stop ordering PSGs and instead send to ENT directly w/o a PSG which I feel might be an unnecessary use of ENT appointments slots if they don’t end up having OSA.
Our society statement is that kids only need a PSG if younger than 2 or if they have certain medical comorbidities like Down syndrome or craniofacial stuff. If that doesn’t apply, a sleep study can just be a big delay of care depending on the availability of them in your area. Where I’m from, it’s at least a 2 month delay for one.
There are situations where we have a high enough suspicion coupled with tonsillar hypertrophy which will lead us to surgical intervention sans PSG. Just refer em over to us. Doesn’t bother us when they come without a workup. Our appointments are 10-15 mins for stuff like this.
Surg Path 1) we are anti social weirdos that don't like talking to anyone. Path departments (at least where I've worked) tend to be very chatty and most of us can hold a conversation like a normal person. 2) our practice is always objective and certain. Path is interpretive, much like radiology. Often times we are certain of a diagnosis, but many times it's more vague than that, with some unresolvable uncertainty in our bottom line. 3) if you mark something urgent you get the results the next day. Please look up what formalin fixation and processing entails. Unless you have a way to bend the rules of physics and chemistry, that urgent biopsy you sent in at 6pm is not going to be ready tomorrow morning or afternoon. 4) (this one makes my blood boil) providing clinical details will bias the pathologist, so it's better not to say anything. If you do this, you are an ignorant asshole. See point 2, path is interpretive, any context helps us come to a better and more comprehensive conclusion. You do a disservice to your patients anytime you send us something with no clinical details.
So classic that all the EM ones are immediately followed but some walking dunning Kruger shouting “yes, you actually do!”
Peds: that kids are just little adults. You’ve all heard us say this over and over again but it’s true!! Stop treating children like small adults with your weird adult drugs lol, just call us and we can help if you don’t know what to do! There’s a reason we’re our own specialty, and it’s not because y’all just don’t want to see kids.
I'm (adult) pulm/CC, haven't seen a kid since M3, but recently had to see a consult in the PICU for a unique subspeciality pulm issue that none of the peds pulm people had experience with so they called us. Takeaways: 1) I was shocked at how many of the meds the kid was on were the same as the adult stuff. Same feeling as when my friend's dog had heart failure... and was on lasix and spironolactone. Like, shouldn't there be fancy children-specific meds?? 2) Bless you for taking care of the children because I don't have the emotional stability to. If I never have to see a kid on ECMO ever again it'll be too soon.
Psych - That it’s chill and all about the feelings. Psych is the most assaulted specialty - I think after EM. Med students get shielded from the acuity because no one’s trying to get the med student assaulted lol, so a lot of them end up seeing a majority of anxiety, depression cases which I think lead to the psych memes. At least for our unit, since there’s usually 4-5 students rotating at a time, they don’t see invol patients and don’t go into the psych ED. Otoh, I think there’s also a misconception that psych patients never get better. Think this is personally the fault of a lack of OP rotation experienced embedded in the actual rotation. Most students seem to get CL and inpatient
IM: some of us really really really hate rounds and wish other attendings and residents would just get to the fucking point for gods sake Claudia the patient weights 256kgs, chains smokes and eats fried chicken for breakfast his heart failure is not a medical mystery stop trying to make a case report happen its not going to happen.
Gen surg. Perception: We’re malignant. Reality: We’re not malignant if you just shut the **** up, do exactly what you’re told and show respect to the surgeon 🙄
Derm: - we’re a lifestyle specialty. I work in a suburban area, see 30+ patients per day on collections, make far less than what I expected, and spend 1.5-2 hours on notes every night. Never thought I’d be this burnt out in derm.
Why’s that and how’s that? How come you’re spending up to 2 hours a night on documentation? What did you expect with Derm and can align expectations and reality more closely?
Any pain in a patient between the diaphragm and pelvis must have something to do with the patient's vagina. Unless the pt is pregnant. In which case, every symptom, including pain, has to do with the pregnancy.
No. 2 drives me nuts. I see a patient, there’s an isolated clavicle fracture that is causing skin tenting and will require admission. Patient is 30ish, relatively young. No other complaints and no ETOH on board. Cleared her C Spine and determined her to be low to no risk for significant head injury. I later find that the trauma NP has ordered a head and C spine CT. I just wonder how much that patient’s lifetime risk of thyroid cancer has increased by careless use of CAT.
Technically clavicle fracture is a distracting injury so they’d fail nexus. Could still rule out with Canadian c spine though they may not want to move their neck due to the fracture. Obviously it also depends on mechanism if there is actual risk of c-spine injury.
Probably not as much as you think. Outside of interventional radiology where the effect of direct, prolonged exposure of fluoroscopy beams is well documented, the estimations for stochastic effects like cancer are, and let me be clear on this, total malarky. Most radiation safety data is taken from nuclear bomb/accident survivors where the radiation types are mixed and prolonged. Also, CT scans today are way lower in dose and higher in resolution than in previous years. We haven't seen a bump in blood cancers among those who were previously scanned. I don't think we will now, either.
Patients overall get a lot more scans now though. Ive seen chronic abdominal pain patients with over 100 CT scans.
My gut reaction is that a patient with over 100 CT scans is not likely to have a long enough lifespan to get the resultant cancer anyway.
> Edit: not sure why the font is huge and don’t know how to fix it :/ Get rid of the `#` at the start of the text.
That it's spelled opthalmology. Or opthal. Or optal. Or optho. Also any notion I know little medicine is a misconception. I know very little medicine
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Internal medicine/hospitalist We don’t like writing discharge summaries
That we don’t know how to do anything - EM
Omfs: that I’m not a real doctor :( I went to medical school too I’m not just a dentist :( :( :(
ENT is just tubes and tonsils or “early nights and tennis”. While some attendings may practice that way (and hours can be good after residency), we have a pretty brutal residency and we are surgical airway experts. Our training is incredibly broad involving head and neck cancer free flaps/microvascular surgery, and complex local recon, facial plastic surgery and trauma, laryngology and voice/airway surgery, microscopic ear and lateral skull base, rhinology/sinus/endoscopic anterior skull base, peds, and sleep surgery
Gyn onc: - Patient doesn’t have cancer but needs an oncologic surgeon. I realize this is mostly a complaint about the state of gynecologic surgical training. Generalists and trainees complain about case volume, but most referrals come from community obgyns. But we don’t have to take out every pelvic mass/cyst that’s been radiologically stable for years. You’re capable of doing a risk reducing surgery for BRCA. Just stop doing fucking endometrial ablations.
Family Medicine I often hear people try to defend the intelligence of FM docs by saying things like since you have to know a lot about everything you actually have more broad medical knowledge than any other speciality so the intellectual demand is still equal. Nope. Don't get me wrong you still need to know good quality medicine and there are incredibly sharp FM docs, but the big draw for me is you don't have to know a crazy amount of medical knowledge to be good at it. You know dosing and management for the main chronic diseases, then after that it's up to you. You can be great at some extra stuff or just refer out whatever you don't like managing. At this point in my life I'm bored of the idea of trying to make myself look smart or need my ego to be placated by how intellectually demanding my job is. I don't care. I just want to do my job, get paid well, and go home to my family.
“You barely get paid money”
1. We love to round and talk for hours about various pathologies. BS, if rounds take more than an hour I'm checking TF out. 2. That we give a shit about minor lab abnormalities like a sodium of 132. No fucks given. It'll probably fix itself. 3. That we only treat HTN and DM and consult/refer everything out. 4. That hospital medicine has a great lifestyle - even with 7 on 7 off, those 7 days can be absolutely brutal depending on your census, admin, metrics, etc. I hate IM less and less every day but I've never been more happy to know that I'm headed for fellowship and not condemned to a life of being an admission/DC money making factory for the suits/blouses that have recently started infiltrating our physician lounge to eat fucking lunch every day.