Family vs Neurology

[MooCowJoe]

Hello, I'm currently an MS3 close to having to decide on fourth year schedules and wanted to ask for advice in regards to choosing to go into neurology or family medicine. I posted this earlier in the neurology forum but wanted to see what those in family medicine thought.

A little background on my current position, etc. I'm currently at an allopathic school, have done all of the core rotations and neuro with only surgery left and have gotten honors so far for the year. I have pretty extensive community service work, a step 1 in the 230's, and a first author pub and a couple others. I really want to have an outpatient based practice, see my own patients, follow them long term, and develop relationships with each of them. I think that because of the decline in starting a private practice, joining a group of physicians and joining up in partnership would probably be ideal. Lifestyle is also pretty important to me, as family becomes a greater piece of my life. I really desire something that's stable, 40-50 hours a week, and without much call. I know pay would probably suffer in both specialties, but I'm not really worried as growing up in a single parent home comfortably on 50k a year reassures me that with either specialty I wouldn't be wanting for much after making at least 3-4x that.

Long story short, I think these are the pros and cons that I am weighing in choosing between the two:

Neuro
My first rotation of third year was neurology, and I really put it first because I hated the class during second year and just wanted to get over the requirement. Going through it though, I realized that I really enjoyed the subject matter in clinical practice. I enjoyed being able to use a quick exam and deduce the localization of a patients lesion and come up with differentials on the pathology, while being reaffirmed with imaging/studies. I also enjoyed being on the team that was being consulted, and in that regards having the answer most of the times at the end.

Some things that have cropped up that I've heard/thought about however are things like degenerative diseases. I know that things like GBS, myasthenia, and MS have come along way, but I'm currently involved in a parkinson's project that follows the patients throughout their clinical course and it worries me that many diseases in this field have this sort of prognosis. I'm also worried about becoming too specialized and losing the breadth of medicine that I have acquired or have the potential to acquire. This also inspired something that is somewhat counter intuitive to those who think family is boring, as I'm worried that the diseases and treatments for those seen in neuro might become too routine. Also, after talking to a private general neurologist I am concerned about the lifestyle after he mentioned that almost all private neurologist require hospital privileges and have to be on call for admissions, ED coverage, and rounding in the morning pushing work hours even greater. (Is this pretty much true? I know there are probably the few unique jobs that are the exception, but is this pretty regular? What are the work hours like for those practicing in the field?) Lastly, I'm worried about some who say that chronic pain and psychosomatic complaints make up the majority of a general neurologists day.

Family
I love the variety that each day and patient brings. I enjoy how one room can be the 60 year old COPD, chronic hypertension, and a-fib, while 15 minutes later a 2 month well child, and 15 minutes later a pregnant woman for pre-natal care. I like that you never have to say something like "you're going to have to bring that up with your PCP", as if someone has 10 questions you could probably answer 8/10 and know the two people they need to go to for the other 2 while helping them make arrangements for it. I enjoy how you get to grow with your patients, and that sometimes you even get to know an entire family. The treatable psych cases of depression and anxiety are also a plus. I also really like the prospects of the lifestyle (8-5, no call, and no weekends). The small procedures that don't last for hours and can be done in the office are also a plus (skin biopsies, small lacerations, endometrial biopsies, etc).

Some downsides I've found are that there is a lower assumed prestige among other specialist (had an ophthalmologist tell me I should have gone to PA school if I was gonna do family for example), more competition than neuro among PA's and NP's. I'm also not too keen on OB (though I know many family docs who don't do any OB). I'm also slightly afraid to not choose/lose neurology, I'm not sure why, but maybe its the finality of the decision and being afraid of being the guy who "only manages blood pressure and diabetes."

Thank you in advance for reading this long winded dilemma I've hit in choosing what I want to go into. I appreciate you taking the time to read this, while helping to share your opinions. I've been mulling this over for quite some time, and now as the time draws nearer to finalize our fourth year schedules its causing me greater worries. Lastly, if this is not the right area for this post, I'd appreciate the help of anyone moving it!

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[TableMD]

Hey

Reasonable questions. I think that neuro is a great specialty, one of the many that I thought about. You can, like all specialties, find a practice style and niche that suites your needs. If you want to be an outpatient neurologist, there is enough need that I am sure you would find a practice setup that made sense. You might have to make a trade off with salary or location, but I am certain you could find an area of interest without the inpatient component that you seem to wish to avoid. That could change and you may wish to do, Neuro ICU. What matters is whether you find the subject matter interesting.

Family
- I love what I do, I am a resident and I am very happy, so obviously I am biased.
- I would not chose family because of life style, I think we work quite hard, perhaps I am again biased due to residency, but I dont think it is any more of a "life style field" than any other non-surgical discipline. I do think that a 9-5 is very doable as a family doc, but I would not give up a specialty I liked more for those hours, since it is alot of hours to be doing something you are not 100% about.

Prestige:
- once you are working, taking care of patients, all that med school "how did you do on the exam, did Step I go ok, how many publications do you have?" garbage goes out the window. All you will care about is your patients, learning, spending time with your family and some hobbies and exercise. If you can do that, then you have succeeded at life. I am still very much a work in progress on those fronts. You will be too busy taking care of people who have been waiting to see you, to worry about that.

NP/PA take over.
- sigh. Ill leave that for people who have completed their training to comment on

 

[JustPlainBill]

Some downsides I've found are that there is a lower assumed prestige among other specialist (had an ophthalmologist tell me I should have gone to PA school if I was gonna do family for example), more competition than neuro among PA's and NP's. I'm also not too keen on OB (though I know many family docs who don't do any OB). I'm also slightly afraid to not choose/lose neurology, I'm not sure why, but maybe its the finality of the decision and being afraid of being the guy who "only manages blood pressure and diabetes."

Thank you in advance for reading this long winded dilemma I've hit in choosing what I want to go into. I appreciate you taking the time to read this, while helping to share your opinions. I've been mulling this over for quite some time, and now as the time draws nearer to finalize our fourth year schedules its causing me greater worries. Lastly, if this is not the right area for this post, I'd appreciate the help of anyone moving it!

1) Spoken by a specialist who only has to be conversant in one body system and most likely doesn't do peds optho; When I was only focusing on one thing, my scores, etc. went up also --- So go ask him about DiFranzo's Terrible Octet and then ask him to comment on the latest debate regarding usefulness of PSA and DRE and then go ahead and switch topics to the value of Homan's maneuver in ruling out a DVT or WTF a Thessaly maneuver tells you, and then ask him regarding the rule of 1800 and how it applies? You can continue by asking about the workup of abnormal AST/ALT in an otherwise asymptomatic patient and then ask him how you find the correct location for a knee/shoulder injection and how it's different from finding the correct spot to inject a bursa -- while you're at it, you can ask how to do a proper shoulder exam and how each maneuver isolates various complaints and we haven't even started on Ob/Gyn, well woman/man exams or peds at this point much less end of life care -- heck, check with Cabinbuilder who's basically a go anywhere, do anything doc for hire -- they're a real gunslinger and has done/seen some crazy stuff -- lots of practical knowledge there -- or check with BlueDog or VAHopefulDr -- both of them are a wealth of knowledge and well thought out commentary, if you want a taste of a different model, check with AtlasMD

don't forget-- as an FM doc (aka General Practitioner) you can make your life what you want -- if you want to sit around all day diagnosing neuro lesions and dealing with a limited subset of disease processes, more power to you-- I'd go stir crazy.

2) and I think #1 above begins to answer the second issue ---

3) I've added this after I saw BDs comment re: prestige -- The small minded one's will talk trash behind your back -- it's really quite childish and makes me wonder if they were abused as children, but I digress -- the real key once you're out in practice is this -- take a wild guess as to who is sending whom Christmas goodies, Thank You cards, lunches, bottles of wine, etc? it sure isn't the FM docs sending them to the specialists -- the specialists fall all over themselves making sure we know we're appreciated --- I'm relatively new in practice but I had a catered lunch, a basket of Giardelli chocolate, a box of truffles, a battery recharger for my phone and I'd only been in the practice about 10 weeks. Other docs were bombarded with all kinds of neat stuff, food, goodies etc. The specialists have no illusions about who needs who -- if you really think about it, as a GP, you really can manage most of what a specialist does, it's just a matter if you want to or not -- heck, if you really LIKE neuro, manage it in your office -- if you're good at it, you'll get a reputation within the patient community and it may take a while, but you'll get referrals -- I'm getting them for non-HVLA osteopathic manipulation ---

do what you love -- I got too bored in each "specialty" to be happy anywhere else but FM or ER -- ER got ruled out when I realized it was FM at 3AM and everyone I cared about was at home asleep and off during the weekends, so FM was a natural fit ---

 

[deleted87716]

ER got ruled out when I realized it was FM at 3AM and everyone I cared about was at home asleep and off during the weekends, so FM was a natural fit ---

ER also has the bonus of drug seekers out the yin-yang.

JPB speaks the truth.

Most of us in FM went into FM because we found specialities to be too limiting. That was certainly the case with me. Knowing more about a little doesn't make you a better doctor. It doesn't even make you a richer doctor (neurology is one of the lowest paid specialties, FWIW).

"Prestige...?" LOL! That, plus four dollars, gets you a cup of coffee at Starbucks.

 

[primadonna22274]

Here's my perspective as an FM PGY2 who practiced FM and EM as a PA for 11 years prior to med school.
I also love neuro and thought about it seriously. I love geriatrics, dementia, movement disorders. I also love complex medicine, chronic care and growing a strong doctor-patient relationship. I had a serious discussion with one of my mentors in med school, a neurologist I admired very much, and she asked me whether I would be able to give up "ownership" of my patients and turn them back to their PCP. I thought about that long and hard, and realized I could not. I've worked too hard to learn all that I have to limit myself to one system--even something as marvelous as the brain and nervous system. And quite frankly I'm damn good at doing some of everything and I love what I do.
I thought for sure that I would NOT go into FM when I went back to med school. I didn't want to be "replaced" by a PA or NP, even a smart go-getter like myself Thing is, the longer I do this, the more I realize that I am only as replaceable as my skill set, which has grown leaps and bounds in residency, with the credentials to match. FM is about as unlimited as you make it.
Best wishes

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[NurWollen]

It's nice reading these comments. I'm not sure what specialty I am going into (considering FM and a few others), but I will say that I think family physicians have been some of the most impressive physicians I've had the privilege of interacting with through med school

 

[Ericslv]

You might get bored with neuro or get tired of all the hand holding with diseases that may not have a cure.

In FM you can choose to make part of your practice neuro cases. Such as a headache clinic. So you still get variety in FM and your neuro fix.

You won't have to do OB after residency but Gyn will be part of your day. Perhaps not everyday.

Sleep medicine is an option from neuro and FM but I understand that neuro has an easier path of getting into sleep medicine.

And remember you are asking this question in the FM forum.

 

[MooCowJoe]

Hey

Reasonable questions. I think that neuro is a great specialty, one of the many that I thought about. You can, like all specialties, find a practice style and niche that suites your needs. If you want to be an outpatient neurologist, there is enough need that I am sure you would find a practice setup that made sense. You might have to make a trade off with salary or location, but I am certain you could find an area of interest without the inpatient component that you seem to wish to avoid. That could change and you may wish to do, Neuro ICU. What matters is whether you find the subject matter interesting.

Family
- I love what I do, I am a resident and I am very happy, so obviously I am biased.
- I would not chose family because of life style, I think we work quite hard, perhaps I am again biased due to residency, but I dont think it is any more of a "life style field" than any other non-surgical discipline. I do think that a 9-5 is very doable as a family doc, but I would not give up a specialty I liked more for those hours, since it is alot of hours to be doing something you are not 100% about.

Prestige:
- once you are working, taking care of patients, all that med school "how did you do on the exam, did Step I go ok, how many publications do you have?" garbage goes out the window. All you will care about is your patients, learning, spending time with your family and some hobbies and exercise. If you can do that, then you have succeeded at life. I am still very much a work in progress on those fronts. You will be too busy taking care of people who have been waiting to see you, to worry about that.

NP/PA take over.
- sigh. Ill leave that for people who have completed their training to comment on

Hey, thank you very much for the reply. I enjoyed your perspective as a resident and it was super helpful to hear all of that. I did think about all those options as a neurologist, but I agree that finding the subject matter that interests me the most has got to be number one. I also agree on the lifestyle. Many of the family docs I rotated with elected to see patients through their lunch hour and really just took a five minute lunch to eat, and many times it was by choice in order to spend more time with patients which I thought was amazing. Thank you.

 

[MooCowJoe]

1) Spoken by a specialist who only has to be conversant in one body system and most likely doesn't do peds optho; When I was only focusing on one thing, my scores, etc. went up also --- So go ask him about DiFranzo's Terrible Octet and then ask him to comment on the latest debate regarding usefulness of PSA and DRE and then go ahead and switch topics to the value of Homan's maneuver in ruling out a DVT or WTF a Thessaly maneuver tells you, and then ask him regarding the rule of 1800 and how it applies? You can continue by asking about the workup of abnormal AST/ALT in an otherwise asymptomatic patient and then ask him how you find the correct location for a knee/shoulder injection and how it's different from finding the correct spot to inject a bursa -- while you're at it, you can ask how to do a proper shoulder exam and how each maneuver isolates various complaints and we haven't even started on Ob/Gyn, well woman/man exams or peds at this point much less end of life care -- heck, check with Cabinbuilder who's basically a go anywhere, do anything doc for hire -- they're a real gunslinger and has done/seen some crazy stuff -- lots of practical knowledge there -- or check with BlueDog or VAHopefulDr -- both of them are a wealth of knowledge and well thought out commentary, if you want a taste of a different model, check with AtlasMD

don't forget-- as an FM doc (aka General Practitioner) you can make your life what you want -- if you want to sit around all day diagnosing neuro lesions and dealing with a limited subset of disease processes, more power to you-- I'd go stir crazy.

2) and I think #1 above begins to answer the second issue ---

3) I've added this after I saw BDs comment re: prestige -- The small minded one's will talk trash behind your back -- it's really quite childish and makes me wonder if they were abused as children, but I digress -- the real key once you're out in practice is this -- take a wild guess as to who is sending whom Christmas goodies, Thank You cards, lunches, bottles of wine, etc? it sure isn't the FM docs sending them to the specialists -- the specialists fall all over themselves making sure we know we're appreciated --- I'm relatively new in practice but I had a catered lunch, a basket of Giardelli chocolate, a box of truffles, a battery recharger for my phone and I'd only been in the practice about 10 weeks. Other docs were bombarded with all kinds of neat stuff, food, goodies etc. The specialists have no illusions about who needs who -- if you really think about it, as a GP, you really can manage most of what a specialist does, it's just a matter if you want to or not -- heck, if you really LIKE neuro, manage it in your office -- if you're good at it, you'll get a reputation within the patient community and it may take a while, but you'll get referrals -- I'm getting them for non-HVLA osteopathic manipulation ---

do what you love -- I got too bored in each "specialty" to be happy anywhere else but FM or ER -- ER got ruled out when I realized it was FM at 3AM and everyone I cared about was at home asleep and off during the weekends, so FM was a natural fit ---

Thank you very much. I do have to admit that while that guy was saying those things I was thinking that he was kind of a d-word. I don't think I'll be visiting him again, but even reading your comments of the various things gets me excited because I think the variety of patients and issues you get day by day is something that really attracts me to family. Also reading your comments on the prestige, I think it's pretty silly too. It reminds me a lot of the whole MD/DO thing in pre-med, which is ridiculous.

I appreciate hearing about it from someone who's recently started practicing. Can you tell me a little bit more about what it was like in searching for a job and what your day to day life is like (schedule, patient base, etc.)? Thank you in advance and thank you for reading my long post and replying.

 

[MooCowJoe]

ER also has the bonus of drug seekers out the yin-yang.

JPB speaks the truth.

Most of us in FM went into FM because we found specialities to be too limiting. That was certainly the case with me. Knowing more about a little doesn't make you a better doctor. It doesn't even make you a richer doctor (neurology is one of the lowest paid specialties, FWIW).

"Prestige...?" LOL! That, plus four dollars, gets you a cup of coffee at Starbucks.

Thank you. The fear of being too limited kind of struck me while I was working on my current research project which deals with different treatment algorithms for parkinson's. It was/is really cool and I still am carrying it out, but while working on it (this is kind of silly) I guess it kind of dawned on me that if I were to become a movement specialist, all I would see is parkinson's and really the same pathology day in and day out. It then kind of transgressed to where I thought about general neuro, but again I'm worried that I'd be surrounded by the same 20 or so conditions.

Would you also be wiling to comment a little bit about your day to day life? The patient base you see, your office setting, call schedule, +/-hospital duties, etc? I'd greatly appreciate it

 

[MooCowJoe]

Here's my perspective as an FM PGY2 who practiced FM and EM as a PA for 11 years prior to med school.
I also love neuro and thought about it seriously. I love geriatrics, dementia, movement disorders. I also love complex medicine, chronic care and growing a strong doctor-patient relationship. I had a serious discussion with one of my mentors in med school, a neurologist I admired very much, and she asked me whether I would be able to give up "ownership" of my patients and turn them back to their PCP. I thought about that long and hard, and realized I could not. I've worked too hard to learn all that I have to limit myself to one system--even something as marvelous as the brain and nervous system. And quite frankly I'm damn good at doing some of everything and I love what I do.
I thought for sure that I would NOT go into FM when I went back to med school. I didn't want to be "replaced" by a PA or NP, even a smart go-getter like myself Thing is, the longer I do this, the more I realize that I am only as replaceable as my skill set, which has grown leaps and bounds in residency, with the credentials to match. FM is about as unlimited as you make it.
Best wishes

Sent from my SAMSUNG-SM-N910A using Tapatalk

Hey, thanks a lot. I've been reading many of the posts that you've contributed to before and I just wanted to let you know that they were very helpful. I think that question your mentor brought up is a great one. It's something I've been thinking about, and I think it would drive me crazy to tell someone "I don't handle that" or "follow up with your PCP." It's been a crazy experience going back and fourth thinking about which specialty to choose, and quite honestly maddening, and I think you're point about limiting myself to one system is one of the things I keep agonizing over if I want to do. Thank you very much.

I wouldn't want you to name out your specific residency, but could you speak a little about what you looked for in a residency? I want to end up in the southeastern region and am really starting to think about these things more and am curious how the process was for you, especially with all that experience.

 

[MooCowJoe]

You might get bored with neuro or get tired of all the hand holding with diseases that may not have a cure.

In FM you can choose to make part of your practice neuro cases. Such as a headache clinic. So you still get variety in FM and your neuro fix.

You won't have to do OB after residency but Gyn will be part of your day. Perhaps not everyday.

Sleep medicine is an option from neuro and FM but I understand that neuro has an easier path of getting into sleep medicine.

And remember you are asking this question in the FM forum.

Thank you for the reply. I do agree that the diseases that don't have a cure really worry me, even though the progression of neurology has come up with a treatment for some. How easy/difficult would it be to tailor your practice to a specific specialty while still getting the other variety? I hear all the time that group practices end up having one OB person, one peds person, etc. though they all still see everything else.

Would you also be willing to comment on your day to day life as an attending? The patient base you see, your office setting, call schedule, +/-hospital duties, etc? Thank you for reading and helping out!

 

[MooCowJoe]

It's nice reading these comments. I'm not sure what specialty I am going into (considering FM and a few others), but I will say that I think family physicians have been some of the most impressive physicians I've had the privilege of interacting with through med school

I definitely agree. All of the family med docs that I've run into are just amazing people and have such great relationships with their patients. Good luck on finding what you want to do as well!

 

[primadonna22274]

I'm proud of my residency and happy to name it. McLeod Family Medicine Residency in Florence, SC--look us up. One of the lesser-known gems in the southeast. Unopposed FM in a 550-bed regional medical center, Level 2 trauma, we serve a 1 million population in a 15-county area that is primarily rural. We see LOTS of SICK patients--very good for honing your craft. A huge amount of geriatrics and inpatient, which is what I wanted in a program. I had my eye on this residency before I started med school and in fact spent a day with them as a PA just to see what they did. They treated me as a peer and I was impressed with how much the residents did and the complexity of their cases.
Good luck in your journey.

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[JustPlainBill]

Thank you very much. I do have to admit that while that guy was saying those things I was thinking that he was kind of a d-word. I don't think I'll be visiting him again, but even reading your comments of the various things gets me excited because I think the variety of patients and issues you get day by day is something that really attracts me to family. Also reading your comments on the prestige, I think it's pretty silly too. It reminds me a lot of the whole MD/DO thing in pre-med, which is ridiculous.

I appreciate hearing about it from someone who's recently started practicing. Can you tell me a little bit more about what it was like in searching for a job and what your day to day life is like (schedule, patient base, etc.)? Thank you in advance and thank you for reading my long post and replying.

1) Searching for a job? -- Well, it really wasn't a matter of searching for a job, it was a matter of which one I wanted to take --While in residency I had, in my grubby paw, offers for $150K 8-5 with full benefits, no hospital, no Ob, 20 patient's per day from Baylor or $180K at a critical access hospital supposedly to run an outpatient clinic with admission privileges (turned into a hospitalist position which included running an "ICU" which was really a step down unit) or various positions in the outlying areas of Texas averaging $160-$180K with various types of clinics or Urgent Care --- I wound up taking the critical access hospital position and quickly left that for Urgent Care -- did that for a year to get some training and am now in a private practice partnership as a non-partner physician -- I'm the new guy running the after hours clinic noon to 7 M-F and half day Saturdays.

2) Day to day life is like (schedule, patient base,etc.) -- As I mentioned above, noon to 7 M-F and Saturday AM until 1PM --

So, day to day schedule --- usually up around 8:30 and get a nice breakfast, work on any charts left over from the day before, look over any labs that have come in, etc. I leave for work around 10:45 and last patient is scheduled at 6:40; I try to finish my charts as we go --some days are better than others and Mondays are usually a beast. Home by around 8pm -- I generally work on charts, grab a bite, deal with homework/school issues/talk to wife about the days issues from 8-9pm; I hit the gym from 9 to 10:30 and get home and am in bed by 11pm.

On Saturdays, I'm up at 6-6:15 and at work by 7:45 -- we see patients from 8 to 1pm; charts get finished as we go as much as possible. I use Saturday until about 4pm for charting -- we usually do Saturday dinner at our favorite Tex mex as a family (or burgers or a nice pizza joint); After that, if I have anything left over, it's Sunday Pm after church, lunch, grocery shopping but before and after dinner; I also try to squeeze in some CME on a weekly basis (I use Core Content Family Medicine) to stay current.

Patient base -- really, I see anything over 5 y/o's for most anything -- at my stage in my career, I refer a lot of things that old physicians would handle in house -- just had a sebaceous cyst that I didn't want to get in the middle of so it went to a general surgeon since the patient didn't want to go to another physician in the group. Also saw a case of psoriasis where the patient didn't believe the dermatologist and wanted my opinion -- gee, it looks like psoriasis, do what the dermatologist told you to do --

There's so much -- as a student, you really don't see everything that goes on -- if you could hear the inner monologue of the attending, you'd be shocked -- just for giggles, tell one of your FM attendings that you're seriously considering FM and then ask them if they wouldn't mind listing all the considerations that go through their head on a particular patient -- I know when I was a student it all looked so easy/routine -- but now:

1) physicals -- so now I need to know the difference between medicare vs Tricare vs all others and I need to be up on the ever changing recs for: women -- paps, breast exams, mammograms -- men: prostate screening -- PSA and DRE -- what are the current recs/arguments for each one to be able to discuss intelligently with my patients (with an eye towards being able to defend myself on the witness stand if things go bad) -- both: colonoscopy recs, especially if they find something.

for the PE part of that -- is that a benign discoloration or is that the start of DIC? is that a normal variant of lid lag or what?
for the lab part -- do I need to get excited about nucleated RBCs or not, what about a consistently low MCH value?

2) URI's and the like -- how much do I adhere to EBM and do I really want to take the time to educate my patients? or do I just throw a ZPack and steroid shot at it and move on?

3) Then there's the entire spectrum of IM to keep up with --- and it's not just Cards -- it's everything from Cards to rheum to endocrine to skin to ent to pulm to male/female repro -- now let's add in the age spectrum from 5 y/o and up

4) Gyn and beginning Ob (yes, you are pregnant, here's some prenatals and a few good OBs)

5) Geriatrics -- Enough said -- these people are retired with nothing to do but go to the doctor about things that have been bothering them for years, they've seen multiple docs and think you, as the new guy, are going to come up with some miracle fix for a drug side effect -- No, I am not kidding.

And now let's not forget you're also dealing with your MAs, lab directors, billing people, superhot (never met an ugly one) pharmaceutical reps who just (in a husky, throaty -- I want you now, here, in this exam room, on the floor doing the wild thing voice) need a minute of your time doc ---

Plus, keeping your CME/board certification reqs intact so you can continue to keep your lifestyle going ----

Oh, almost forgot, patient phone calls --- ranges from legit request to "Are you freakin' kidding me?" --

So, there's a lot to being a good FM doc -- anyone who tells you an NP/PA can do the exact same work as a board certified FM attending is delusional and probably needs a psych eval -- I've gotten more excited about my profession and my chosen specialty as time goes by -- to tell you the truth, BD, VA HopefulDoc and CabinBuilder have inspired me quite a bit -- go read some of their posts and look at the thought process behind it -- heck, just take a look at a few of the threads where BD and VaHopefulDoc ruminate on the pros/cons of various therapeutic options and the nitnoy detail which is clinically relevant that these two pull out of nowhere -- I'm sitting there thinking,"where the heck did they come up with THAT?" --- it's colleagues like that that make me want to get better.....

Good luck to you -- you can PM me with any other questions ---

 

[cabinbuilder]

OMG, lets talk about a very strange, difficult skin case I had in urgent care today. 63 y/o WF with what looks like spreading bullous impetigo that started on both shins last week and is now on her arm. Very large lesions that are eating away at her skin from the ankles to the knees and one from the wrist to the elbow. Yellow crusting edges on all those lesions. Was seen in the ER and put on keflex almost a week ago. Was not given any topical bactroban and lesions have never been covered with dressings. Patient does us a lot of "natural medicinal teas" and "holisitic medicines".

Comes to urgent care today because she now has a very pruritic, fine rash on her torso and down the back of her legs since starting the keflex. Has a different more coarse intensely pruritic rash on her back that has just erupted in the past 2 days that looks more like severe acne/blackheads.

So to me it looks like 3-4 different skin lesions:
1) Bullous Impetigo that is not properly treated and is spreading
2) Drug rash on torso from the Keflex
3) Severe eczema in the flexures compounded by the very arid air here in Wyoming
4)Cutaneous manifestation of internal disease from the explosive lesions on her back. Almost matched Habif perfectly with signs of lesar-trelat..

Had a crazy busy day in urgent care but I didn't have the heart to send this lady back to the ER. Plus she looked overall well in spite of the skin lesions and being itchy.
For the impetigo: Gave 1gm IV vanco, started on vancocin. Bactroban to skin topically and cover with saran wrap since lesions are too large for practical bandages.
For the Drug Rash: stop the keflex
For the itching: 50mg of IV benadryl + IV zantac. Sent home with po vistaril
For the back lesions: CBC, CRP, CMP, ESR drawn - all normal. CXR was normal.
For the flexures: ok to try some aveeno eczema lotion to try to soothe some of the rough areas.

Had patient stop all funky teas and alternative medicines.
f/u with PCP next week to hopefully do additional labs and have a relook at her skin.
Nearest dermatologist is 150 miles away.
Was reading frantically the derm book and on line amidst seeing a ton of other patients. Wasn't sure what else I could do with me and one nurse working with 10 people waiting in the lobby and the wait time was pushing 2 hrs.

Thoughts?

 

[JustPlainBill]

OMG, lets talk about a very strange, difficult skin case I had in urgent care today. 63 y/o WF with what looks like spreading bullous impetigo that started on both shins last week and is now on her arm. Very large lesions that are eating away at her skin from the ankles to the knees and one from the wrist to the elbow. Yellow crusting edges on all those lesions. Was seen in the ER and put on keflex almost a week ago. Was not given any topical bactroban and lesions have never been covered with dressings. Patient does us a lot of "natural medicinal teas" and "holisitic medicines".

Comes to urgent care today because she now has a very pruritic, fine rash on her torso and down the back of her legs since starting the keflex. Has a different more coarse intensely pruritic rash on her back that has just erupted in the past 2 days that looks more like severe acne/blackheads.

So to me it looks like 3-4 different skin lesions:
1) Bullous Impetigo that is not properly treated and is spreading
2) Drug rash on torso from the Keflex
3) Severe eczema in the flexures compounded by the very arid air here in Wyoming
4)Cutaneous manifestation of internal disease from the explosive lesions on her back. Almost matched Habif perfectly with signs of lesar-trelat..

Had a crazy busy day in urgent care but I didn't have the heart to send this lady back to the ER. Plus she looked overall well in spite of the skin lesions and being itchy.
For the impetigo: Gave 1gm IV vanco, started on vancocin. Bactroban to skin topically and cover with saran wrap since lesions are too large for practical bandages.
For the Drug Rash: stop the keflex
For the itching: 50mg of IV benadryl + IV zantac. Sent home with po vistaril
For the back lesions: CBC, CRP, CMP, ESR drawn - all normal. CXR was normal.
For the flexures: ok to try some aveeno eczema lotion to try to soothe some of the rough areas.

Had patient stop all funky teas and alternative medicines.
f/u with PCP next week to hopefully do additional labs and have a relook at her skin.
Nearest dermatologist is 150 miles away.
Was reading frantically the derm book and on line amidst seeing a ton of other patients. Wasn't sure what else I could do with me and one nurse working with 10 people waiting in the lobby and the wait time was pushing 2 hrs.

Thoughts?

Punch and send to path for a wtf moment?

 

[cabinbuilder]

Punch and send to path for a wtf moment?

Yeah, Right, in the middle of Wyoming? Not a chance.

 

[primadonna22274]

Yeah, Right, in the middle of Wyoming? Not a chance.

Why not? You don't necessarily need DermPath. The local hospital path should do. A simple punch takes a couple of minutes and can yield valuable diagnostic and prognostic information.
Not a critique of how you handled it--I'd have done the same--but I think we should do more punch biopsies than we do.

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[styphon]

FM and neuro are quite different in lifestyle, diseases, etc.

Similarities:
-can be outpt only, inpt only, or a mix. As a FM hospitalist you will be a generalist and ask for consults based on your hospital culture, as neuro you will either be a consult alone (carry no patients) or even a dedicated neuro service.
-are on the lower average pay among specialties.

Differences
-most FM are outpt only. FM can also be in the ER/urgent care
-FM procedures can widely vary based on training: skin biopsies, joint injections, GYN/OB procedures (vaginal deliveries, c/s, IUD placement), colonoscopies.. Neuro will mostly be EMG, trigger point injections, EEG (am I missing anything?)
-FM has a wide basis, usually the first point of contact. Neuro: although there is a wide basis of neuro diseases, you still are focused on one body system. You will often be the 2nd point of contact or even further down the chain.

 

[JustPlainBill]

Yeah, Right, in the middle of Wyoming? Not a chance.

Ok, you got me -- guess we'll have to use the Cossack approach

have the staff scrub a room with bleach as best they can, start the patient drinking a liter of vodka, get them lying down on the exam table supine with a bite stick nearby --
quick gunshot wound to the area in question -- then treat the gunshot wound by pouring vodka into the wound and cauterizing with fire -- then treat the burn wound --

voila' --- problem solved -- Cossacks knew how to treat burn wounds, so they just turned everything into a burn wound ---

 

[cabinbuilder]

Why not? You don't necessarily need DermPath. The local hospital path should do. A simple punch takes a couple of minutes and can yield valuable diagnostic and prognostic information.
Not a critique of how you handled it--I'd have done the same--but I think we should do more punch biopsies than we do.

Sent from my SAMSUNG-SM-N910A using Tapatalk

yes, but i had multiple different rashes all over her body

 

[primadonna22274]

Oh I know. I worked with an awesome derm PA early in my career who advised when in doubt, punch it and get a tissue diagnosis. A few random spots might be of use if no improvement with current treatment.

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[cabinbuilder]

Oh I know. I worked with an awesome derm PA early in my career who advised when in doubt, punch it and get a tissue diagnosis. A few random spots might be of use if no improvement with current treatment.

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This is true but I hate to start a biopsy work up when I am only there for 2-3 days. I like to have the whole follow through. Ya know?

 

[primadonna22274]

Totally get it. That's why I prefer the continuity of primary care myself. I can't stand not knowing what happens.

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[tirral]

Sorry to bump an old thread, but curious to see what OP decided. @MooCowJoe, what did you end up choosing? And how are you liking intern year?

 

[hamstergang]

Sorry to bump an old thread, but curious to see what OP decided. @MooCowJoe, what did you end up choosing? And how are you liking intern year?

OP was last seen on SDN 9/2016 so probably won't be answering you.