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gwjib04

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Hi

M1 here.

We recently had a chance to diagnose standardized patients. This was the first time they had let us workup a patient and turn it into a diagnosis. I found it really exciting and realized that this is why I wanted to do medical school.

What are the best specialties or fields for doing this kind of work. Just simply meeting patients, hearing their stories, putting the clues together and diagnosing.

Is this family medicine or internal? General medicine or some specialty or maybe even path?

I'm really attracted to the Sherlock Holmes concept of a physician; detective work, clinical reasoning etc. I recently found out about Faith Fitzgerald and was super inspired by her lectures.

Thanks SDN
 
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emergency medicine

you get undifferentiated patients and start the workup to diagnose. The downside is that you don't really have followup unless you make the effort
 
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Goro

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Rheumatology

Hi

M1 here.

We were recently had to diagnose standardized patients. First time they had let us workup a patient and turn it into a diagnosis. I found it really exciting and realized that this is why I wanted to do medical school.

What are the best specialties or fields for doing this kind of work. Just simply meeting patients, hearing their stories, putting the clues together and diagnosing.

Is this family medicine or internal? General medicine or some specialty or maybe even path?

I'm really attracted to the Sherlock Holmes concept of a physician; detective work, clinical reasoning etc. I recently found out about Faith Fitzgerald and was super inspired by her lectures.

Thanks SDN
 
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DrBowtie

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emergency medicine

you get undifferentiated patients and start the workup to diagnose. The downside is that you don't really have followup unless you make the effort
It's more about what it's not than what it is in EM.
 
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gwjib04

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EM makes sense but it seems like they are more concerned with managing the patient and the consultants do the diagnosing. I guess most of the time you can only manage what you understand.

I don't know about Rheumatology especially without any explanation at all. Actually I'm suspicious of the specialties in general since the patients are already referred for a specific symptom so (minus mistakes) there would be a lot less detective work to be done...
 

HelpPleaseMD

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EM makes sense but it seems like they are more concerned with managing the patient and the consultants do the diagnosing. I guess most of the time you can only manage what you understand.

I don't know about Rheumatology especially without any explanation at all. Actually I'm suspicious of the specialties in general since the patients are already referred for a specific symptom so (minus mistakes) there would be a lot less detective work to be done...

General Internal Medicine. Definitely not EM. They stabilize and send out or admit to a service
 
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mmmcdowe

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You should also consider radiology/path, you may not be doing the examining yourself, but frequently they are the ones that determine the dx.
 
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Neuro Storm

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I am certainly biased but...without a doubt....Neurology!
 
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General internal medicine seems to have considerably more "thought debate" on dx more than the other fields I've been exposed to. In peds the differential is generally broader, but the discussions don't happen as often, much more bread and butter clear cut cases since there aren't myriad chronic conditions to muck the clinical picture

emergency medicine

you get undifferentiated patients and start the workup to diagnose. The downside is that you don't really have followup unless you make the effort

Nah. Stabilize, r/o this r/o that, dispo. Dx isn't EM priority

Rheumatology

Admittedly not had a lot of exposure to rheum, but seems like dx in the field is very criteria driven
 
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TBV

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IM and it's subspecialties
 
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Mad Jack

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I am certainly biased but...without a doubt....Neurology!
Neurology, the field where finding the lesion is 90% of the work and the other 10% is explaining that there's nothing you can do ;)
12+stereotypes+panel+02.jpg
 
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LostinLift

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EM makes sense but it seems like they are more concerned with managing the patient and the consultants do the diagnosing. I guess most of the time you can only manage what you understand.

I don't know about Rheumatology especially without any explanation at all. Actually I'm suspicious of the specialties in general since the patients are already referred for a specific symptom so (minus mistakes) there would be a lot less detective work to be done...

Once you get out of the ivory tower you'll see that's not how it works in the community (if you're a good doc).
 
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Mad Jack

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EM makes sense but it seems like they are more concerned with managing the patient and the consultants do the diagnosing. I guess most of the time you can only manage what you understand.

I don't know about Rheumatology especially without any explanation at all. Actually I'm suspicious of the specialties in general since the patients are already referred for a specific symptom so (minus mistakes) there would be a lot less detective work to be done...
They've ruled out the basics once a patient hits a specialist, but there's still a lot of digging, depending on the specialty. Allergy and immunology can present some interesting cases fairly frequently, although you might find many you'll never end up with a good answer at the end of the day (patients who come in with previous reactions that you can't find an allergen for etc).
 
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Mad Jack

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Also, I will say that neurology is probably one of the more interesting fields in regard to diagnosis, all jokes aside. Treatment can also be quite challenging, particularly in regard to epilepsy.
 
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Lol I love that cartoon. It's true that our limiting factor is treatment. This post, however, inquires about diagnostics. We are without a doubt the best :). With regards to gen IM, they may arrive at a diagnosis of "abnormal movements during sleep" (I've seen this on the chart) or "seizure like activity". We will read the sleep study and EEG and actually diagnose the person with a specific syndrome. We can also tweek tx modalities based on our diagnosis. Example, I recently had a guy with a non-convulsive generalized epilepsy. He was on carbamazepine for mood stabilization (bipolar). This class of drugs is known to worsen generalized epilepsies. We switched him to epilepsy dosed Depakote and voila..problem solved.

Another example is our ability to perform EMG/NCS. Gen med/family med may arrive at the assessment that someone has a lower motor neuron syndrome but will never make an "eye ball" diagnosis of multifocal motor neuropathy with conduction block which, often, is completely reversed with IVIG. We are the ones who will stop the hospitalist's steroids on a suspected "myasthenia" case and diagnosis them with the miller fisher variant of GBS switching them to IVIG or plasma exchange, effectively, saving their life.

We usually can outread our non-neuroradiology radiologists because we have the advantage of our examination and know where to look and how to modify the study accordingly (thin cuts through an area, different sequence, etc). We perform LPs and test based on a much bigger differential diagnosis then the medicine team does and can perform a solid fundoscopic examination which an alarming amount of physicians cannot do.

We perform cerebral angiograms, stent, coil and pull clots out of people, often times lowering their NIHSS to zero. (actually I ironically just finished assisting my attending in a left MCA thrombectomy and placed a stent in the Lt ICA on the way down after he received Iv tPA from our stroke team...how's that for no treatment?).

We deal with the sickest patients, have the biggest differential diagnoses and have basically every hospital in the country rushing to build a multi-million dollar neuroscience center at their facility. Then again, I am biased :). Btw I do love my gen med colleagues but a general field is not going to gear you towards making the complicated diagnosis. It does offer other wonderful skill sets that specialists won't have but not this one.

Other solid diagnosticians are Infectious disease doctors and Rheumatologists.
 
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Cytarabine

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IMO not to sound rude, but this is the kind of interest that naturally fades with experience and increased clinical exposure.

There is a lot of novelty to the unknown as a medical student. But regardless of the field you choose, the overwhelming majority of the time you will be dealing with the known. Common things are common. Medicine residents' notes may ruminate on the differential diagnosis of rare zebras, but the majority of their admissions will be for pneumonia, COPD exacerbations, heart disease, cellulitis, and other garden variety issues.

You develop pattern recognition after thousands of admissions and diagnoses.

If you specialize, the overwhelming majority of patients will be coming to you packaged with a diagnosis already made. If you stay a generalist, you will spend far more of your time with the common issues than the rare or unfamiliar ones.

I agree with the gist of this post, but just going to pick at one thing. Interesting discussion around diagnosis doesn't necessarily revolve around considering the zebra. E.g. the patient with a history of copd, chf, and an extensive smoking history who comes in with labored respiration, borderline pressures, and some degree of AMS, work up shows a borderline white count, questionably dirty urine, CXR with bilateral interstitial infiltrates and maybe a focal patch of consolidation. Think about the respective roles urosepsis vs acute on chronic chf vs copd exacerbation vs pneumonia could be playing in the clinical picture. A large part of that is certainly still pattern recognition, the patient may end up being treated for multiple possible etiologies, and a firm diagnosis of whatever was the true key factor may never reallllly be arrived at, but it's still lots of thinking with regard to diagnosis while still being "just bread and butter medicine"
 
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Instatewaiter

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Rheumatology

Agree. That was my first inclination

Pathology is another one- you are the one who really makes the diagnosis that everyone else has missed.
 
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Instatewaiter

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General Internal Medicine. Definitely not EM. They stabilize and send out or admit to a service

Agree. In my experience, EM becomes more about dispo and not missing life threatening things than making the diagnosis.
 

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My dad has made some pretty crazy diagnoses (at least the way he tells the stories) in ID.
 
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Every specialty has interesting stuff to diagnosis. Just stick around in academic medicine and you'll be fine.

Doing private practice in the community is a different story.
 

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In terms of straight diagnosis, nothing beats pathology and radiology. It's just a matter of whether you're okay with—or maybe even prefer—not being "the doctor" to patients. For everything else diagnosis is but a component of the job description, whereas for path and rads it's the name of the game.

Re: rheumatology, I understand lots of rheumatologic disease presents in mysterious ways that often take a rheumatologist to sort out, but what portion of their practice is actually this kind of detective work vs how much is managing chronic, pre-established disease? I would think there's a ton more "your RA is getting worse, let's try this-here TNF inhibitor" than "omg this dude's got adult-onset Still's" type stuff.
 
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takeurmeds02

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emergency medicine

you get undifferentiated patients and start the workup to diagnose. The downside is that you don't really have followup unless you make the effort

I thought EM was a good idea... >_>
 

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Agree. That was my first inclination

Pathology is another one- you are the one who really makes the diagnosis that everyone else has missed.
Tell that to the urologist that sent that dead on balls accurate PNB sample to the lab
 
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emergentmd

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Agree. In my experience, EM becomes more about dispo and not missing life threatening things than making the diagnosis.

EM here. I would say I have a diagnosis on 80+% of my discharges. I have 80+% diagnosis on my admission.

I would say I diagnose a much larger Percentage of admitted patients than hospitalists. If I admit for pneumonia, CHF, MI, DVT, PE, Cellulitis then what is there left for the internist to diagnose?

Its more treating, consulting from the hospitalist standpoint
 
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Tenk

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EM here. I would say I have a diagnosis on 80+% of my discharges. I have 80+% diagnosis on my admission.

I would say I diagnose a much larger Percentage of admitted patients than hospitalists. If I admit for pneumonia, CHF, MI, DVT, PE, Cellulitis then what is there left for the internist to diagnose?

Its more treating, consulting from the hospitalist standpoint
Second this.

Can't imagine that phone call:

"Yeah I got a guy down here, I don't really know what is going on but I will let you diagnose that for me. Sending him up now!"
 
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ACSurgeon

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Second this.

Can't imagine that phone call:

"Yeah I got a guy down here, I don't really know what is going on but I will let you diagnose that for me. Sending him up now!"

Yep. Because we never get those calls.

Sorry, abdominal pain or nausea aren't diagnoses. They're symptoms.
 
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the argus

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Second this.

Can't imagine that phone call:

"Yeah I got a guy down here, I don't really know what is going on but I will let you diagnose that for me. Sending him up now!"
I'm only halfway through my IM intern year and I have heard this from the ED many times already. While many admissions already have a diagnosis, many do not. Examples might be electrolyte abnormalities, AMS, misc abd pain, rashes, etc. Hyponatremia isn't a diagnosis, it's a lab finding.
 
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ACSurgeon

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Hi

M1 here.

We were recently had to diagnose standardized patients. First time they had let us workup a patient and turn it into a diagnosis. I found it really exciting and realized that this is why I wanted to do medical school.

What are the best specialties or fields for doing this kind of work. Just simply meeting patients, hearing their stories, putting the clues together and diagnosing.

Is this family medicine or internal? General medicine or some specialty or maybe even path?

I'm really attracted to the Sherlock Holmes concept of a physician; detective work, clinical reasoning etc. I recently found out about Faith Fitzgerald and was super inspired by her lectures.

Thanks SDN

If Sherlock Holmes is what you're looking for, then forensic pathology is something to look into. We had a series of lectures in med school, and the guy was a doctor-detective combo. He knew a ton about ballistics, burn mechanisms, etc.
 
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Snoopy2006

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Medicine or med-peds at an academic hospital. If you like detective work, and spending long hours discussing cases, that would be my recommendation. Small sample size, but the med-peds attendings I had in medical school were particularly noteworthy for their incredible breadth of knowledge. I was almost swayed just based on how impressive and inspiring some of those attendings were.
 
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bc65

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None of the above. The closest might be derm or ID, but for both, they know lots of obscure conditions, but will see them rarely, if ever.

I have been given impressive accurate diagnoses over the phone from rheumatology, ID, derm and others, done just based on a couple of findings. Those physicians were all very impressive to me. However, in all these cases, it wasn't challenging to those specialists. It's obviously their boring, everyday, bread and butter cases. That's the whole point of specialization.

The cases that are truly difficult to diagnose often never get satisfactorily diagnosed, or as others noted, end up with several possible or combined diagnoses.
 

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We deal with the sickest patients

The problem with really sick neuro patients is they all die - either on their own or after a long, awful family meeting. I managed to scam my way into doing my entire month of neuro in the Neuro ICU (sorry Neuro storm but neurology floors was a fate worse than death for me) and AT BEST the patients went trached and pegged to an LTAC. Our Neuro ICU director straight up said that he was mostly a palliative care doc.

When the brain bleed is big enough for the janitor to diagnose from across the room, really the only thing left to do is figure out when to turn off the vent. Which is fine if that's what you're into (believe me, our pall care docs are absolute saints), but that's a very different thing than finding subtle clues on an MRI and using your reflex hammer like a ninja to diagnose something named after a bunch of dead German (or French) neurologists that heretofore has only been found in one family of Samoan island natives.
 
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Law2Doc

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I thought EM was a good idea... >_>

EM has the goal of appropriate disposition. This may involve getting to the ultimate diagnosis, or it may involve figuring out who to consult. As suggested, diagnosis is largely a team approach. Unlike the TV show House, where one group of people just sit in a room and work it out, on difficult cases more often there's an admitting team and multiple consulting services, radiologists, pathologists, who all have a hand in it.

As for EM, there's a very old joke -- three doctors are on a duck hunting trip, an IM doc, EM doc, and a surgeon.
They hear a flutter overhead.
The surgeon levels his gun announces "it's a duck" and shoots the bird dead, without second thought. (Pathology later confirms that it was, indeed, a duck).
There's a second flutter overhead, and the IM doctor levels his gun but mulls "it looks like a duck, but might be an eagle" and by the time he is ready to pull the trigger, the bird has flown away.
There's a third flutter overhead and the EM doc quickly fires his gun, hits the bird, and then turns earnestly to the other two and says "was it a duck?"
 
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VisionaryTics

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IMO not to sound rude, but this is the kind of interest that naturally fades with experience and increased clinical exposure.

There is a lot of novelty to the unknown as a medical student. But regardless of the field you choose, the overwhelming majority of the time you will be dealing with the known. Common things are common. Medicine residents' notes may ruminate on the differential diagnosis of rare zebras, but the majority of their admissions will be for pneumonia, COPD exacerbations, heart disease, cellulitis, and other garden variety issues.

You develop pattern recognition after thousands of admissions and diagnoses.

If you specialize, the overwhelming majority of patients will be coming to you packaged with a diagnosis already made. If you stay a generalist, you will spend far more of your time with the common issues than the rare or unfamiliar ones.

Agree. This is one of the most important facets in recognizing what you want to do for a career.

Rheumatology? Better like osteoarthritis and rheumatoid. You might pick up a IgG4-related systemic disease once in a blue moon.

Neurology? Headache, headache, stroke, stroke, vertigo, diabetic neuropathy. Life isn't an Oliver Sacks book.

EM? Chest pain nos, abdominal pain nos, nausea, nausea, dizzy all over, pain all over.

ENT? Nasal obstruction, vertigo, reflux, TMJ, "sinus".

Surgery? Gallbladder, lipoma, hernia.

Look at the "steak" of the different specialties, not the sizzle. Odds are, that will be the majority of your practice.

In terms of diagnosis, there is diagnosis in practically every field. Even orthos are reading films, checking joint laxity, and diagnosing a tear. Diagnosis is one of the things that lead to me ENT; new patients in clinic are often undifferentiated vertigo (which I hate along with all ear related complaints), dysphagia, nasal obstruction, neck mass, dysphonia, etc.
 
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repititionition

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People are conflating % zebras with the OP's goal of doing a lot of "interesting" diagnosis.

The most diagnostic specialties have been mentioned:

- radiology
- pathology
- ID
- derm

and I'd add heme (- onc)
 

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Hi

M1 here.

We were recently had to diagnose standardized patients. First time they had let us workup a patient and turn it into a diagnosis. I found it really exciting and realized that this is why I wanted to do medical school.

What are the best specialties or fields for doing this kind of work. Just simply meeting patients, hearing their stories, putting the clues together and diagnosing.

Is this family medicine or internal? General medicine or some specialty or maybe even path?

I'm really attracted to the Sherlock Holmes concept of a physician; detective work, clinical reasoning etc. I recently found out about Faith Fitzgerald and was super inspired by her lectures.

Thanks SDN
Neurology or ID
 
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Tenk

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Yep. Because we never get those calls.

Sorry, abdominal pain or nausea aren't diagnoses. They're symptoms.
You will. But these are rare calls. They are also accompanied by: I have done x, we now need to do y for this patient and I can't do this in the ED. Hence why that number was not 100%. Even rarer if you work outside of academic medicine.

Like it or not the ED makes the vast majority of diagnoses. That's just a fact.
 
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gwjib04

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Wow this thread turned out to be really helpful, thanks everyone.

The tally so far:
EM - 3
Rheumatology - 2
General IM - 6
Rad or Path - 4
Neurology - 4
ID - 4
Academics - 1
Forensic Path - 1
Derm - 2
Transfusion med path - 1
Heme-onc - 1

IMO not to sound rude, but this is the kind of interest that naturally fades with experience and increased clinical exposure.

There is a lot of novelty to the unknown as a medical student. But regardless of the field you choose, the overwhelming majority of the time you will be dealing with the known. Common things are common. Medicine residents' notes may ruminate on the differential diagnosis of rare zebras, but the majority of their admissions will be for pneumonia, COPD exacerbations, heart disease, cellulitis, and other garden variety issues.

You develop pattern recognition after thousands of admissions and diagnoses.

If you specialize, the overwhelming majority of patients will be coming to you packaged with a diagnosis already made. If you stay a generalist, you will spend far more of your time with the common issues than the rare or unfamiliar ones.

This is good to keep in mind. It's a bit "glass half full" but I recognize that a 1st year medical school perspective is not the best basis for l/t decisions. Anyways, thanks.

I agree with the gist of this post, but just going to pick at one thing. Interesting discussion around diagnosis doesn't necessarily revolve around considering the zebra. E.g. the patient with a history of copd, chf, and an extensive smoking history who comes in with labored respiration, borderline pressures, and some degree of AMS, work up shows a borderline white count, questionably dirty urine, CXR with bilateral interstitial infiltrates and maybe a focal patch of consolidation. Think about the respective roles urosepsis vs acute on chronic chf vs copd exacerbation vs pneumonia could be playing in the clinical picture. A large part of that is certainly still pattern recognition, the patient may end up being treated for multiple possible etiologies, and a firm diagnosis of whatever was the true key factor may never reallllly be arrived at, but it's still lots of thinking with regard to diagnosis while still being "just bread and butter medicine"

Thanks Cytarabine for the "glass half full" perspective on this one. Super helpful.

Once you get out of the ivory tower you'll see that's not how it works in the community (if you're a good doc).

Could you explain what you mean and what you're referring to? Are you referring to my comment about EM?

If Sherlock Holmes is what you're looking for, then forensic pathology is something to look into. We had a series of lectures in med school, and the guy was a doctor-detective combo. He knew a ton about ballistics, burn mechanisms, etc.

Will look into this, hadn't thought about it at all.
 

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The problem with really sick neuro patients is they all die - either on their own or after a long, awful family meeting. I managed to scam my way into doing my entire month of neuro in the Neuro ICU (sorry Neuro storm but neurology floors was a fate worse than death for me) and AT BEST the patients went trached and pegged to an LTAC. Our Neuro ICU director straight up said that he was mostly a palliative care doc.

When the brain bleed is big enough for the janitor to diagnose from across the room, really the only thing left to do is figure out when to turn off the vent. Which is fine if that's what you're into (believe me, our pall care docs are absolute saints), but that's a very different thing than finding subtle clues on an MRI and using your reflex hammer like a ninja to diagnose something named after a bunch of dead German (or French) neurologists that heretofore has only been found in one family of Samoan island natives.

Well you are definitely right about many of the sickest patients dying. I would not say that they ALL die. It is very fulfilling when i'm on neurocrit to intubate someone in the ED, make the diagnosis, not just of "brain bleed" but define them as subdural, SAH and intraventricular bleeds (changes the management), then do on to hyperventilate them, hit them with mannitol and hypertonic saline, place an EVD with my neurocrit attending or neurosurgery (yes neurologist trained neurocrit docs place EVDs) elevate the HOB, send them for crani and watch as your treatment prevents infarction leading to a great if not complete recovery. We hardly ever lose people to GBS anymore and certinaly have learned how to manage acute ischemic stroke comabting what was, at one point, the third leading cause of death in this country.

That being said I think the downfall of many students experiences is that they don't get a huge exposure to the outpt setting where we can really shine (keep someone with MS devoid of an exacerbation for 30 years) or keep myasthenia in check for decades, completely get rid of 30 days of headache for years, do an LP and start Diamox to knock out pseduotumor pain, etc.

That being said..the forum is about diagnosis and I think we rock at that :). But as I said, I am very biased. Path and Rads are certainly great but you won't see patient's like neuro/rheum/Id etc do.

I also think there was a great point made that, no matter what you do, you should like the "bread and butter" cases as the literature worthy diagnosis is not the norm. If you don't like Staph ulcers then Id is not for you, if you don't like RA and fibromyalgia rheum is not for you and if you don't like vertigo/headache/weakness/ataxia then neurology is not for you, if you don't like COPD/CHF/DM/HTN then primary care is not for you etc.
 
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Law2Doc

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Wow this thread turned out to be really helpful, thanks everyone.

The tally so far:
EM - 3
Rheumatology - 2
General IM - 6
Rad or Path - 4
Neurology - 4
ID - 4
Academics - 1
Forensic Path - 1
Derm - 2
Transfusion med path - 1
Heme-onc - 1



This is good to keep in mind. It's a bit "glass half full" but I recognize that a 1st year medical school perspective is not the best basis for l/t decisions. Anyways, thanks.



Thanks Cytarabine for the "glass half full" perspective on this one. Super helpful.



Could you explain what you mean and what you're referring to? Are you referring to my comment about EM?



Will look into this, hadn't thought about it at all.
Academics is not a medical specialty. Any of these specialties may be in academic medicine. Also a number of the subspecialties listed require you to go through IM first, for what that's worth.
 
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URHere

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The EM vs IM debate really depends on what kind of diagnosis you want to do.

If you want totally undifferentiated patients with no pre-existing imaging or labs (a truly blank slate), you get this is EM. You'll be able to tell what is going on with the vast majority of patients pretty quickly, but most lower acuity cases will be fairly mundane (hip fracture, cholecystitis, MI, acute intoxication). You also have to deal with a lot of substance abuse and psych patients, many of whom may get stuck in your ED for days at a time while waiting for psych beds. You do get trauma and some really nice acute care sprinkled in with your social issues though, so you are very rarely sitting around or bored.

The downside of EM is that while you may make the initial diagnosis of something like "sepsis" or "arrhythmia", you're pretty unlikely to figure out what the infection is or why the a.fib was triggered in that particular patient. There are also the small handful of patients who leave the ED with a sign-out along the lines of "this patient is barely stable, we have NO IDEA what is going on". Those are the internist's dream patients, and their work-up will happen on the floor (or the ICU). Even patients with mundane chief complaints often end up on the floor because they have crazy co-morbidities (recent chemo + dialysis + CHF + IDDM, etc) which can require some real mental gymnastics to manage. The downside of the floor is that the most interesting patients will have half a dozen subspecialty services consulting, so you may end up as more of a secretary than a diagnostician until after fellowship. There is a lot of time spent on the phone or in the workroom trying to coordinate those half dozen notes, conflicting orders, family wishes, etc.

I honestly loved both EM and IM. If you like diagnosis, you could find a lot of happiness with either of them.
 
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Stagg737

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If you clarified what you mean by being Sherlock and coming up with the diagnosis you'd probably get more accurate responses. If you mean you want to be the guy who confirms the diagnosis from a smaller list of differentials, then you'd probably be happiest in path, rads, or ID (maybe rheum, but idk enough about the field). If you want to be the guy that makes the initial list of differentials, you'd be better off in IM, EM, or FM, but you'd probably have to do quite a bit of follow-up to find out if your initial thoughts were correct as you'd commonly be referring patients to other specialists.
 
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