Best specialty for someone interested in diagnosis

[Law2Doc]

If you clarified what you mean by being Sherlock...

A pipe smoking, tweed wearing, drug addict detective, what else.

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[235009]

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

You think you diagnose 80%. How often do you follow up on admitted patients to see if your diagnosis was correct? Probably < 10%. Once they're out of the ED they're out of your mind. As mentioned above altered mental status, hypoxia, fall, shortness of breath, etc are not diagnoses. But on top of that I've gotten a bunch of patients from the ED where the diagnosis was completely incorrect. Some recent examples:
1) elderly lady admitted for cellulitis, no errythema or warmth to speak of, after a quick history and exam diagnosed her with acute gouty arthritis, stopped the abx and gave her a dose of prednisone. She had a history of crystal proven gout in the past.
2) guy admitted with "fall, unable to ambulate", found to be massively fluid overloaded and spends 2 weeks in the hospital on a lasix drip
3) patient admitted for pneumonia because there was "a little something" on the CXR that the ED doc overread because he already decided the pt had a pneumonia, actually has heart failure

This kind of stuff happens fairly often. ED docs are masters of anchoring bias and premature closure. Add to that the "abdominal pain" patients for instance who are initially triaged to medicine while waiting for the ultrasound/CT scan and then end up having a surgical issue (chole, appy, etc). Also you can't exactly take credit for reading a radiology report that gives you the answer or finding an abnormal lab in the panel of tests you order with anyone who complains of pain anywhere in their chest/abdomen/pelvis.

Don't get me wrong I really appreciate ED physicians. They have to put up with A LOT of crap. But thinking you're some sort of master diagnostician is silly. The point is to find out whether the patient has something life threatening then get them out of the ED.

 

[Rumalum]

Peds genetics /thread

 

[gwjib04]

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

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.

Your description of EM was helpful, thanks. Also good to be reminded that in academic medical centers there would be"half a dozen subspecialty services consulting" but I wonder if this would be true after training.

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.

Great point. I don't have enough experience to say one way or the other but this is a helpful way to separate the 2. My experience so far has been more like an initial meeting workup from scratch. It may turn out that coming up with a more definitive dx is more interesting and that's in the path rads specialist direction. Again thanks for this point

A pipe smoking, tweed wearing, drug addict detective, what else.

EXACTLY

 

[takeurmeds02]

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.

haha that was a good one

 

[NurWollen]

.

 

[NurWollen]

You think you diagnose 80%. How often do you follow up on admitted patients to see if your diagnosis was correct? Probably < 10%. Once they're out of the ED they're out of your mind. As mentioned above altered mental status, hypoxia, fall, shortness of breath, etc are not diagnoses. But on top of that I've gotten a bunch of patients from the ED where the diagnosis was completely incorrect. Some recent examples:
1) elderly lady admitted for cellulitis, no errythema or warmth to speak of, after a quick history and exam diagnosed her with acute gouty arthritis, stopped the abx and gave her a dose of prednisone. She had a history of crystal proven gout in the past.
2) guy admitted with "fall, unable to ambulate", found to be massively fluid overloaded and spends 2 weeks in the hospital on a lasix drip
3) patient admitted for pneumonia because there was "a little something" on the CXR that the ED doc overread because he already decided the pt had a pneumonia, actually has heart failure

This kind of stuff happens fairly often. ED docs are masters of anchoring bias and premature closure. Add to that the "abdominal pain" patients for instance who are initially triaged to medicine while waiting for the ultrasound/CT scan and then end up having a surgical issue (chole, appy, etc). Also you can't exactly take credit for reading a radiology report that gives you the answer or finding an abnormal lab in the panel of tests you order with anyone who complains of pain anywhere in their chest/abdomen/pelvis.

Don't get me wrong I really appreciate ED physicians. They have to put up with A LOT of crap. But thinking you're some sort of master diagnostician is silly. The point is to find out whether the patient has something life threatening then get them out of the ED.

 

[Stagg737]

A pipe smoking, tweed wearing, drug addict detective, what else.

 

[Siggy]

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

...and then follow the workup right up to the point where you can confidently triage the patient to admit or discharge.

 

[Siggy]

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?

I hope you didn't break a sweat diagnosing the dude with a productive cough for a week, fever, and infiltrates on the CXR.

/meanwhile I'll be in radiology resuscitating the patient with DKA that the ED sent for a VQ scan to rule out PE.

//Isn't there like a thread every 2 months in the EM forum about other specialties crapping on EM... and yet here's EM crapping on other specialties because they can hit the admit button when lab calls about that elevated troponin?

 

[Tenk]

I hope you didn't break a sweat diagnosing the dude with a productive cough for a week, fever, and infiltrates on the CXR.

/meanwhile I'll be in radiology resuscitating the patient with DKA that the ED sent for a VQ scan to rule out PE.

//Isn't there like a thread every 2 months in the EM forum about other specialties crapping on EM... and yet here's EM crapping on other specialties because they can hit the admit button when lab calls about that elevated troponin?

You salty.

 

[HelpPleaseMD]

You think you diagnose 80%. How often do you follow up on admitted patients to see if your diagnosis was correct? Probably < 10%. Once they're out of the ED they're out of your mind. As mentioned above altered mental status, hypoxia, fall, shortness of breath, etc are not diagnoses. But on top of that I've gotten a bunch of patients from the ED where the diagnosis was completely incorrect. Some recent examples:
1) elderly lady admitted for cellulitis, no errythema or warmth to speak of, after a quick history and exam diagnosed her with acute gouty arthritis, stopped the abx and gave her a dose of prednisone. She had a history of crystal proven gout in the past.
2) guy admitted with "fall, unable to ambulate", found to be massively fluid overloaded and spends 2 weeks in the hospital on a lasix drip
3) patient admitted for pneumonia because there was "a little something" on the CXR that the ED doc overread because he already decided the pt had a pneumonia, actually has heart failure

This kind of stuff happens fairly often. ED docs are masters of anchoring bias and premature closure. Add to that the "abdominal pain" patients for instance who are initially triaged to medicine while waiting for the ultrasound/CT scan and then end up having a surgical issue (chole, appy, etc). Also you can't exactly take credit for reading a radiology report that gives you the answer or finding an abnormal lab in the panel of tests you order with anyone who complains of pain anywhere in their chest/abdomen/pelvis.

Don't get me wrong I really appreciate ED physicians. They have to put up with A LOT of crap. But thinking you're some sort of master diagnostician is silly. The point is to find out whether the patient has something life threatening then get them out of the ED.

this x 1000

 

[Tenk]

You think you diagnose 80%. How often do you follow up on admitted patients to see if your diagnosis was correct? Probably < 10%. Once they're out of the ED they're out of your mind. As mentioned above altered mental status, hypoxia, fall, shortness of breath, etc are not diagnoses. But on top of that I've gotten a bunch of patients from the ED where the diagnosis was completely incorrect. Some recent examples:
1) elderly lady admitted for cellulitis, no errythema or warmth to speak of, after a quick history and exam diagnosed her with acute gouty arthritis, stopped the abx and gave her a dose of prednisone. She had a history of crystal proven gout in the past.
2) guy admitted with "fall, unable to ambulate", found to be massively fluid overloaded and spends 2 weeks in the hospital on a lasix drip
3) patient admitted for pneumonia because there was "a little something" on the CXR that the ED doc overread because he already decided the pt had a pneumonia, actually has heart failure

This kind of stuff happens fairly often. ED docs are masters of anchoring bias and premature closure. Add to that the "abdominal pain" patients for instance who are initially triaged to medicine while waiting for the ultrasound/CT scan and then end up having a surgical issue (chole, appy, etc). Also you can't exactly take credit for reading a radiology report that gives you the answer or finding an abnormal lab in the panel of tests you order with anyone who complains of pain anywhere in their chest/abdomen/pelvis.

Don't get me wrong I really appreciate ED physicians. They have to put up with A LOT of crap. But thinking you're some sort of master diagnostician is silly. The point is to find out whether the patient has something life threatening then get them out of the ED.

You forgot that most hospitals have somewhere around a 20% ED hospital admission rate. Meaning that you don't even see around 80% of the patients that come to the ED. We see 100%. You see even less because some are pediatric, surgical or OB.

So yeah... that 80% is actually correct, it just takes into account everyone we see. You aren't. No need to be a dick about it.

I can tell that you are a resident at an academic hospital because of the "triaged to medicine" comment. In the real world that doesn't happen and I don't call consultants until my workup is done and I either have a diagnosis or I need an inpatient test to r/o or r/i something else. But hey man, keep this condescending attitude when you are an attending. I would have a lot of fun waking you up 10 times during the night making your life a complete miserable hell while I watch netflix. What goes around comes around my friend. Remember, you have the pager. I don't.

 

[Siggy]

No need to be a dick about it.

What's the line again?

You salty.

I can tell that you are a resident at an academic hospital because of the "triaged to medicine" comment. In the real world that doesn't happen and I don't call consultants until my workup is done and I either have a diagnosis or I need an inpatient test to r/o or r/i something else. But hey man, keep this condescending attitude when you are an attending. I would have a lot of fun waking you up 10 times during the night making your life a complete miserable hell while I watch netflix. What goes around comes around my friend. Remember, you have the pager. I don't.

Such a team player here guys. Look at that, someone doesn't bow down to the "greatness" of EM and the veiled threats of, "Well, screw you then, I just won't even make an attempt at doing my job anymore (appropriate disposition) and just keep paging you while I eat popcorn and watch movies!" Why the insecurity? Oh, and "need an inpatient test" means that "chest pain, R/O ACS" isn't a diagnosis. I'm not saying I expect the ED to be a cardiac obs unit and board patients for serial troponins, but it does hut the, "We always have a diagnosis prior to admit" part.

 

[DetectiveAlonzo]

Come on guys! @Siggy @Tenk

We can all get along here. Don't let the patients tear our EM and IM brethren apart! Unite! It's not ussss... it's them!

 

[CherryRedDracul]

Come on guys! @Siggy @Tenk

We can all get along here. Don't let the patients tear our EM and IM brethren apart! Unite! It's not ussss... it's them!

Patients are the worst. That's why I'm going into radiology.

 

[Tenk]

Such a team player here guys. Look at that, someone doesn't bow down to the "greatness" of EM and the veiled threats of, "Well, screw you then, I just won't even make an attempt at doing my job anymore (appropriate disposition) and just keep paging you while I eat popcorn and watch movies!" Why the insecurity? Oh, and "need an inpatient test" means that "chest pain, R/O ACS" isn't a diagnosis. I'm not saying I expect the ED to be a cardiac obs unit and board patients for serial troponins, but it does hut the, "We always have a diagnosis prior to admit" part.

It was a joke, chill. Although, there is a great deal of truth to it.

Once you are no longer a resident in an academic world, I highly suggest you lose the chip on your shoulder and learn to love your ER colleagues because if you actually read EMTALA and your hospital bylaws you will sadly find that the ER holds all the power and consultants hold next to none. Which is only half true, your hospital administrators hold all the power but they will more than likely side with the ER because it means more $ for them.

Sorry if I upset you. Good luck.

 

[Cognovi]

The only specialty with diagnostic in its name: diagnostic radiology

 

[Tipsy McStagger]

The only specialty with diagnostic in its name: diagnostic radiology

If they make so many diagnoses then why must I correlate everything clinically!?! WHY?!




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[Mad Jack]

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.

To me the hardest part of neuro CC isn't the patients that die, it's the ones that live. You've got so many survivors with substantially reduced or nonexistent quality of life, I just couldn't, it's too painful.

 

[badasshairday]

While neurology and the neuro exam are nice for the mental exercises of thinking about lesion locations; let's not kid ourselves where the vast majority of diagnostics is in neuro.

MRI.

 

[gwjib04]

While neurology and the neuro exam are nice for the mental exercises of thinking about lesion locations; let's not kid ourselves where the vast majority of diagnostics is in neuro.

MRI.

Wonder what Neuro Storm and Mad Jack have to say about this...

 

[Neuro Storm]

While neurology and the neuro exam are nice for the mental exercises of thinking about lesion locations; let's not kid ourselves where the vast majority of diagnostics is in neuro.

MRI.

In the EMG/NCS lab, angio suite, autonomic lab, Epilepsy Monitoring unit, sleep lab, & MDA clinic (to name a few) none of the diagnosis come from MRI. This post reflects a poor understanding of and exposure to Neurology. That very deficiency you just showed us, however, does translate into job security for me. Again...there is a reason why everyone is building multimillion dollar Neuro ICUs and neuroscience centers all over the country.

Go Neuro. Let's keep this thread clear of low swag answers...and lay off the EM docs guys .

 

[Neuro Storm]

To me the hardest part of neuro CC isn't the patients that die, it's the ones that live. You've got so many survivors with substantially reduced or nonexistent quality of life, I just couldn't, it's too painful.

You are right that some patient's leave the NICU in bad shape. I think it is becoming the minority however. I would say that we have kept stats (modified Rankin scale, etc) on functional outcome and the majority of our patients can complete their ADLs and IADLs at the 6month and 1 yr mark. I think this is fulfilling because, by definition, if I am seeing a patient in the neuroICU, they are typically among the sickest people in the hospital and, thus, in need of the most help and expertise. Also, our population is mixed and trauma is the minority. We have many myasthenics and GBS patients who are intubated, improve, and usually go home in the same shape they were in prior to their illness. Ive mentioned the amazing outcomes in post tPA and thrombectomy patients, our status epilepticus patients (carries a 20% mortality if not stopped) are almost always controlled and lead normal lives, our neuroinfectious patient's tend to do well and leave the hospital in good shape (HSV, Meningitis, etc). Many of our bleeds do well, especially if the ICP is relieved before they infarct. So it is looking up and you feel great when you exchange blows with some of the most terrifying disease states that exist...and win. Mad Jack...I think you'd be a huge asset to the Neuro world...consider coming over to the squad.

 

[Tecmo Bowl]

You think you diagnose 80%. How often do you follow up on admitted patients to see if your diagnosis was correct? Probably < 10%. Once they're out of the ED they're out of your mind. As mentioned above altered mental status, hypoxia, fall, shortness of breath, etc are not diagnoses. But on top of that I've gotten a bunch of patients from the ED where the diagnosis was completely incorrect. Some recent examples:
1) elderly lady admitted for cellulitis, no errythema or warmth to speak of, after a quick history and exam diagnosed her with acute gouty arthritis, stopped the abx and gave her a dose of prednisone. She had a history of crystal proven gout in the past.
2) guy admitted with "fall, unable to ambulate", found to be massively fluid overloaded and spends 2 weeks in the hospital on a lasix drip
3) patient admitted for pneumonia because there was "a little something" on the CXR that the ED doc overread because he already decided the pt had a pneumonia, actually has heart failure

This kind of stuff happens fairly often. ED docs are masters of anchoring bias and premature closure. Add to that the "abdominal pain" patients for instance who are initially triaged to medicine while waiting for the ultrasound/CT scan and then end up having a surgical issue (chole, appy, etc). Also you can't exactly take credit for reading a radiology report that gives you the answer or finding an abnormal lab in the panel of tests you order with anyone who complains of pain anywhere in their chest/abdomen/pelvis.

Don't get me wrong I really appreciate ED physicians. They have to put up with A LOT of crap. But thinking you're some sort of master diagnostician is silly. The point is to find out whether the patient has something life threatening then get them out of the ED.

Make up of things I admit:
-50 % are chronic conditions with a known diagnosis (COPD, CHF, CAD, DM, etc.). Mostly caused by smoking, diet, and medication non-compliance. The healthcare system would likely have improved outcomes and decreased costs if instead of involving an internist we just got these patients a life coach, personal trainer and nutritionist.
-20% are dumps from other services with admission to medicine because the specialists hate dealing with all the social bull**** and/or don't want to come to the ER after 5pm and say "just admit to medicine."
-15% are social admits because our healthcare system sucks and instead of providing resources to EM docs to facilitate placement of patients, we instead have the 3 day inpatient rule for SNF placement.
-10% have actual acute medical problems through no fault of their own. The diagnosis of this is generally pretty straight forward.
-5% have something interesting/confusing that I truly need the broad differential of an internist to help me with before a specialist gets involved as once they get involved they will only be focused on their specialty.

In the ideal medical system most patients would fall under the last category and we would actually use our medicine colleagues for their diagnostic acumen. Instead, the medicine service is the dumping ground of the hospital system. The trash comes in through the ER front door and leaves through the back door which is the Medicine service. It is one continuous assembly line of processed ****, fueled by unrealistic consumer expectation and malpractice attorney cupidity. It's why i'm forced to admit that 85 year old with chest pain because god forbid that one 85 year old dies comfortably in her bed while sleeping from a massive STEMI. Instead we must send her to the assembly line for the million dollar workup only to die 6 months later from metastatic cancer after suffering 4 horrible months on chemo.

 

[sloop]

My real answer is that in most areas of medicine, you will get some odd cases that will be rewarding to work through.

My sort of "specialty advocate" answer—biased, of course—is that psychiatry is a great field if you like ambiguous presentations requiring diagnosis. I found consult psych to be especially like this. "Super sick patient on lots of drugs has mental status change—find the diagnosis"-type stuff. It's also a field where something as seemingly inconsequential as a person's dress or the type of imagery and allusions they use might be important for diagnosis.

People sometimes write psych off as some child's play specialty and I think it's unfair. I think being a good psychiatrist, perhaps more than most specialties, requires paying attention to a lot of different subtle cues.

 

[Chemdude]

Only 2 specialties make definite diagnoses in the hospital: radiology and pathology. Pathology has a very crappy job market and the pay is not that great. Radiology currently has an okay job market with excellent pay. Both specialties are cerebral and tend to attract intellectual types. Radiology also has procedures. Sub-specialists will tell you that radiology is an obsolete field because they can read their own imaging. Don't listen to them. If you want to be a diagnostician go into Radiology.

 

[ACSurgeon]

My real answer is that in most areas of medicine, you will get some odd cases that will be rewarding to work through.

My sort of "specialty advocate" answer—biased, of course—is that psychiatry is a great field if you like ambiguous presentations requiring diagnosis. I found consult psych to be especially like this. "Super sick patient on lots of drugs has mental status change—find the diagnosis"-type stuff. It's also a field where something as seemingly inconsequential as a person's dress or the type of imagery and allusions they use might be important for diagnosis.

People sometimes write psych off as some child's play specialty and I think it's unfair. I think being a good psychiatrist, perhaps more than most specialties, requires paying attention to a lot of different subtle cues.

Except most things psych don't have an objective way to diagnose a problem. I wonder how many expert psychiatrists would arrive at the same diagnosis of a "difficult" psych patient after putting together all the "clues".

 

[StevieNicks]

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

Hi there! I'm just a premed, but I stumbled across this thread and found it interesting. I'm a bit of a Sherlock Holmes fan myself, and I'm really into medical mysteries. You probably already know this, but Holmes' character was inspired by the University of Edinburgh surgeon Dr. Joseph Bell. I'd definitely recommend reading "Every Patient Tells a Story" by Lisa Sanders in your free time, btw (ha, what free time?). It's all about the various strategies docs use to arrive at a diagnosis.

As for the pathology/radiology vs. IM/neurology debate, I think a lot of it depends on what you like about the diagnostic process. Are more into facts or patterns? Observations or deductions, or both? What's your tolerance for uncertainty (love it or hate it)? Even more importantly, what are your interests in medicine and what kind of relationship do you want to have with your patients? Do you want to see them improve when you arrive at the correct diagnosis and treatment? Or are you satisfied with knowing that you helped a colleague narrow down their differential?

I do kinda wonder why nobody voted for primary care/FM, especially in rural areas where access to subspecialists is limited. Obviously the majority of stuff is gonna be physicals, minor infections/injuries and common chronic conditions, but ultimately, the PCP is typically the gatekeeper to the subspecialists, unless the issue is particularly acute, and there are plenty of systemic issues that don't fit neatly into one subspecialty or another. When the subspecialists all shrug their shoulders, the diagnostic buck stops at the PCP (or the hospitalist when the ish really hits the fan). Personally I'm trying to decide between IM and FM.

 

[greg1184]

Only 2 specialties make definite diagnoses in the hospital: radiology and pathology. Pathology has a very crappy job market and the pay is not that great. Radiology currently has an okay job market with excellent pay. Both specialties are cerebral and tend to attract intellectual types. Radiology also has procedures. Sub-specialists will tell you that radiology is an obsolete field because they can read their own imaging. Don't listen to them. If you want to be a diagnostician go into Radiology.

Those "subspecialists" must be the minions/sheep of Ezekiel Emmanuel. I bet they wouldn't take liability for any subtle incidental findings that turn out to be significant (e.g. faint nodule in chest x-ray, lucent lytic lesion in msk x-ray "ruling out fracture", subtle asymmetry in a mammo). I am sure they are also experts in the appropriate protocols and physics of their studies.

Radiology is a great field for diagnosis and trying to solve puzzles, especially in the setting of a tertiary referral center where rare stuff come. Yes there are bread and butter cases, but many cases are challenging to diagnose.

As far as the hedging / clinical correlation thing, we are explicitly trained that that phrase is bad form and to avoid using it period. That phrase is just as inappropriate as "rule out X" or the vague "foot pain, abd pain etc" that some clinicians put in the history/indication of the study. If the study indeed has a differential diagnosis, "correlation with... (specific test, etc)" is more appropriate to provide the "next step".

That being said, all specialties have their merit and are an important piece to diagnosing disease. It is a matter of what type of environment you like. Other than radiology, I also enjoyed EM during medical school because of the pace.

 

[the argus]

Only 2 specialties make definite diagnoses in the hospital: radiology and pathology. Pathology has a very crappy job market and the pay is not that great. Radiology currently has an okay job market with excellent pay. Both specialties are cerebral and tend to attract intellectual types. Radiology also has procedures. Sub-specialists will tell you that radiology is an obsolete field because they can read their own imaging. Don't listen to them. If you want to be a diagnostician go into Radiology.

Have you actually ever seen a real radiology read? They rarely will ever make a diagnosis. They say a lot of "possibly representing," "consistent with," and "could represent 1 or 2." And they almost always say something to the tune of, "clinical correlation necessary."

I am in no way trashing radiologists. I have much respect for them and they play an extremely important role. But to say they are diagnosticians who make definitive diagnoses is ridiculous. Their job is to identify abnormalities, which they do very well. That's different than making a definitive diagnosis.

 

[Neuro Storm]

Only 2 specialties make definite diagnoses in the hospital: radiology and pathology. Pathology has a very crappy job market and the pay is not that great. Radiology currently has an okay job market with excellent pay. Both specialties are cerebral and tend to attract intellectual types. Radiology also has procedures. Sub-specialists will tell you that radiology is an obsolete field because they can read their own imaging. Don't listen to them. If you want to be a diagnostician go into Radiology.

I'm not knocking rads or path (in fact as a neurologist I regularly work closely with them) I just want to help some
Of the younger people reading this to understand that this is simply an untrue statement. No offense and I'm not trying to start a blog war or whatever but many specialties make definitive diagnosis. I could go down the list but Emg and eeg, sleep studies etc are definitive diagnosis.

Medicine docs make definitive diagnosis of SBP with a simple paracentesis.

ID docs make diagnosis all the time

Ophthalmologists diagnose cataracts, diabetic retinopathy, etc

cardiologists make several angiographic diagnosis. Electrophysiologists not only diagnose the arrhythmia the map it in the cath lab

Endocrinologists diagnose Graves' disease.

The list goes on and on. Btw I don't mean to sell those other specialties short as I know they make many many more diagnosis then the ones I listed but to tell the community of upcoming docs that these are the only two specialities that make definitive diagnosis is simply not true.

Btw I will definitely overread a radiologist (especially non-neuro rads) on a given day (not always but not infrequently) I also read my own nerve and muscle path...so yes the subspecialty community does rock.

Also big shout out to adding Psychiatry to the list. I didn't think of that before but they certainly do see very interesting cases and have to consider many interesting factors (clothes etc) in fact my psych rotation is part of the reason why I moved from internal medicine towards neurology as a student (I guess I thought it was kind of the "medicine arm" of psych so to speak).

 

[sloop]

Except most things psych don't have an objective way to diagnose a problem. I wonder how many expert psychiatrists would arrive at the same diagnosis of a "difficult" psych patient after putting together all the "clues".

I didn't interpret the OP's question as enjoying cookbook algorithmic medicine used to diagnose easy, cookie-cutter patients. It seemed like he enjoyed the difficult, ambiguous stuff and working through it to help the patient. I think psych epitomizes this.

Also, a lot of psych is objective—observation of behavior and such. Most of the MSE is documentation of what you see objectively.

 

[Mace1370]

Just going to give a quick shout out to pathology, the truly diagnostic specialty. And by pathology, I mean anatomic pathology. Forensic pathology is not my cup of tea and is a different beast entirely.

 

[maxxor]

Just going to give a quick shout out to pathology, the truly diagnostic specialty. And by pathology, I mean anatomic pathology.

Radiology always suggests diagnoses and often makes diagnoses, but pathology confirms diagnoses.

 

[DrBowtie]

I'm not knocking rads or path (in fact as a neurologist I regularly work closely with them) I just want to help some
Of the younger people reading this to understand that this is simply an untrue statement. No offense and I'm not trying to start a blog war or whatever but many specialties make definitive diagnosis. I could go down the list but Emg and eeg, sleep studies etc are definitive diagnosis.

Medicine docs make definitive diagnosis of SBP with a simple paracentesis.

ID docs make diagnosis all the time

Ophthalmologists diagnose cataracts, diabetic retinopathy, etc

cardiologists make several angiographic diagnosis. Electrophysiologists not only diagnose the arrhythmia the map it in the cath lab

Endocrinologists diagnose Graves' disease.

The list goes on and on. Btw I don't mean to sell those other specialties short as I know they make many many more diagnosis then the ones I listed but to tell the community of upcoming docs that these are the only two specialities that make definitive diagnosis is simply not true.

Btw I will definitely overread a radiologist (especially non-neuro rads) on a given day (not always but not infrequently) I also read my own nerve and muscle path...so yes the subspecialty community does rock.

Also big shout out to adding Psychiatry to the list. I didn't think of that before but they certainly do see very interesting cases and have to consider many interesting factors (clothes etc) in fact my psych rotation is part of the reason why I moved from internal medicine towards neurology as a student (I guess I thought it was kind of the "medicine arm" of psych so to speak).

You're examples don't really help your argument.

SBP - At my hospitals, paras are rarely done by hospitalists and sent to radiology for taps. The definitive diagnosis is made by pathology via fluid sample analysis.

ID make diagnosis based upon micro lab testing in pathology.

Endocrine makes Graves diagnosis based upon lab values from Pathology and RAIU scans from Radiology.

Rads and Path are involved with virtually every patient in the hospital and nearly all cool cases require their involvement.

 

[URHere]

I think the medicine vs radiology/pathology thing is getting a little pedantic.

Yes - radiology and pathology may name the exact diagnosis, but people in medicine often still consider themselves heavily involved in the diagnostic process because they had a high enough suspicion for a specific disease to request a certain type of imaging or a biopsy in the first place. It's a bit like the difference between a detective who collects evidence and someone in forensics who then identifies a poison or exact cause of death. One provides exact data (evidence of fibrosis in this area consistent with X/Y/Z, adenocarcinoma, etc) while the other will try to put all of the data together (where does the patient live? how are they responding to medicines? what other diseases do they have? what are their allergies/exposures?) to figure out how to best treat the patient. These are both important and very much suited to different types of physicians.

 

[alpinism]

ITT:

OP asks which specialty is best for diagnosing rare and interesting diseases.

Everyone responds that their specialty is the best and everyone else sucks at diagnosis.

Welcome to Medicine.

 

[Instatewaiter]

I hope you didn't break a sweat diagnosing the dude with a productive cough for a week, fever, and infiltrates on the CXR.

/meanwhile I'll be in radiology resuscitating the patient with DKA that the ED sent for a VQ scan to rule out PE.

//Isn't there like a thread every 2 months in the EM forum about other specialties crapping on EM... and yet here's EM crapping on other specialties because they can hit the admit button when lab calls about that elevated troponin?

Holy **** don't get me started on the ED ordering worthless troponins.

I have this 90 year old down here who is on dialysis with a blood pressure that has been in the 60s for 6 hours at his nursing home. So we sent a troponin which is 0.2. That's positive so he's having a heart attack. Can you come down here and admit him?... Yeah he's febrile and has a white count of 20 and foul smelling pee that looks like chunky lemonade but the man's having a heart attack. Let's talk about what's important here

 

[Instatewaiter]

I'm not knocking rads or path (in fact as a neurologist I regularly work closely with them) I just want to help some
Of the younger people reading this to understand that this is simply an untrue statement. No offense and I'm not trying to start a blog war or whatever but many specialties make definitive diagnosis. I could go down the list but Emg and eeg, sleep studies etc are definitive diagnosis.

Medicine docs make definitive diagnosis of SBP with a simple paracentesis.

ID docs make diagnosis all the time

Ophthalmologists diagnose cataracts, diabetic retinopathy, etc

cardiologists make several angiographic diagnosis. Electrophysiologists not only diagnose the arrhythmia the map it in the cath lab

Endocrinologists diagnose Graves' disease.

Cards isn't really a diagnostic based specialty- more of a therapuetic specialty. Often the patients come to you with a very obvious diagnosis.

I still stand by path or rheum. Agree though that rads, psych and ID could easily be added.

 

[omn]

WHAT ? Not RADIOLOGY ? Pleaess add... what am I missing ... where you sit all day and examine supporting conditions for possible diagnoses..?

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)

... this sounds enlightened... do we check a profiles now?

 

[Neuro Storm]

Cards isn't really a diagnostic based specialty- more of a therapuetic specialty. Often the patients come to you with a very obvious diagnosis.

I still stand by path or rheum. Agree though that rads, psych and ID could easily be added.

While there are therapeutic interventions it is certainly diagnostic. TEEs/TTEs are diagnostic, Angiograms are diagnostic, interpretation of EKGs and troponins are diagnostic and CARTO mapping of cardiac arrhythmias are as well.

 

[Neuro Storm]

You're examples don't really help your argument.

SBP - At my hospitals, paras are rarely done by hospitalists and sent to radiology for taps. The definitive diagnosis is made by pathology via fluid sample analysis.

ID make diagnosis based upon micro lab testing in pathology.

Endocrine makes Graves diagnosis based upon lab values from Pathology and RAIU scans from Radiology.

Rads and Path are involved with virtually every patient in the hospital and nearly all cool cases require their involvement.

Paras are almost never sent to Rads (we have an internal medicine residency here and our ICU docs do their own along with GI fellows). The cytology may be read by path if you order it but the cells, etc are counted by a lab tech who types it into EPIC and the ordering physician interprets it in the context of the rest of the HPI, physical examination, clinical picture etc.

The lab values are not the only criteria for diagnosis (graves, etc) they may aid in diagnosis but someone actually had to take a history/perform an exam on the patient in order to order the test which may or may not support thier diagnosis.

EEG doesn't require path or rads nor does EMG/NCS.

I think path and rads are cool but we turn the "there is an area of hyperintensity in the left parietal lobe which could be ischemic, demyelinating, or neoplastic..correlate clinically" into "that's PML homie".....because we do in fact correlate clinically and, on occasion, break the glass and take the net home.

This again confirms that Neuro rocks and everyone should go into it......Again I am biased if you haven't noticed. Big shout to our Rads and Path colleagues. This is all just friendly back and forth.

 

[animando]

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.

after a few posts ...

While there are therapeutic interventions it is certainly diagnostic. TEEs/TTEs are diagnostic, Angiograms are diagnostic, interpretation of EKGs and troponins are diagnostic and CARTO mapping of cardiac arrhythmias are as well.

SDN members, stop losing your mind...
Dear OP: if you enjoy patient contact, doing H/P, and managing/diagnosing/treating patients, primary care or EM might be good calls for you.

 

[Instatewaiter]

While there are therapeutic interventions it is certainly diagnostic. TEEs/TTEs are diagnostic, Angiograms are diagnostic, interpretation of EKGs and troponins are diagnostic and CARTO mapping of cardiac arrhythmias are as well.

Yes you can make a diagnosis by TTE and occasionally by TEE. With angiograms you tend to have an idea of what is going on by the symptoms and this is confimratory. By the time you are doing a TEE you tend to have a good idea of what is going on. Same thing goes with mapping arrhythmias.

Every specialty makes diagnoses but the bent for cardiology is more toward therapeutics. Most people go into cardiology for the pathology and procedures rather than to diagnose coronary disease, cardiomyopathy or valvular pathology (btw I am a cards fellow)

 

[Shipping News]

Paras are almost never sent to Rads (we have an internal medicine residency here and our ICU docs do their own along with GI fellows). The cytology may be read by path if you order it but the cells, etc are counted by a lab tech who types it into EPIC and the ordering physician interprets it in the context of the rest of the HPI, physical examination, clinical picture etc.

The lab values are not the only criteria for diagnosis (graves, etc) they may aid in diagnosis but someone actually had to take a history/perform an exam on the patient in order to order the test which may or may not support thier diagnosis.

EEG doesn't require path or rads nor does EMG/NCS.

I think path and rads are cool but we turn the "there is an area of hyperintensity in the left parietal lobe which could be ischemic, demyelinating, or neoplastic..correlate clinically" into "that's PML homie".....because we do in fact correlate clinically and, on occasion, break the glass and take the net home.

This again confirms that Neuro rocks and everyone should go into it......Again I am biased if you haven't noticed. Big shout to our Rads and Path colleagues. This is all just friendly back and forth.

If anybody ordering the imaging gave a decent set-up for why the test is being ordered, the radiologist could easily narrowing the diff, especially in neurorads. But when "Altered mental status" is all you get and you have no time to look up the patient because there are a bunch of normal CT pulmonary embolism protocols to look at from the ED, it becomes a diff dealing game. BTW, who says "correlate clinically" anymore except clinicians snickering at radiologists?

 

[DRsmartypants]

Neurology is probably like the most "House-like" specialty since they see not only common but rare neurological diseases and presentations as well(particularly in academics), plus they can look at neuroradiology(of course the neuroradiologists are the experts). If you aren't big on patients, diagnostic radiology is also pretty cool, you will see just about everything and it is definitley a difficult specialty in my opinion. IM and subspecialties are also diagnostically oriented, but in my experience, a lot of my time was spent treating or trying to get a decent history, not actually figuring out what it was. It was a lot of common conditions for the most part.

 

[Save a life]

Maybe a hospitalist?

 

[Shipping News]

Neurology is probably like the most "House-like" specialty since they see not only common but rare neurological diseases and presentations as well(particularly in academics), plus they can look at neuroradiology(of course the neuroradiologists are the experts). If you aren't big on patients, diagnostic radiology is also pretty cool, you will see just about everything and it is definitley a difficult specialty in my opinion. IM and subspecialties are also diagnostically oriented, but in my experience, a lot of my time was spent treating or trying to get a decent history, not actually figuring out what it was. It was a lot of common conditions for the most part.

In my opinion, if you are interested in the diagnostic aspects of neurology...go into neuroradiology.

 

[gwjib04]

after a few posts ...
SDN members, stop losing your mind...
Dear OP: if you enjoy patient contact, doing H/P, and managing/diagnosing/treating patients, primary care or EM might be good calls for you.

Animando, I think you interpreted my question closest to what I meant so thanks for that.

Others have clarified that I should think about what I actually enjoy more, the formation of initial differentials or the final, definitive dx. I still need to think about that but the original post was about the initial differentials not the definitive.