Best specialty for someone interested in diagnosis

[gwjib04]

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.

Hi StevieNicks, thanks for your post. I do know these things you mentioned and they are what inspired this post so you were right on the $. Agree, I don't know if I prefer making differentials or the definitive. I meant the former in my OP but maybe that will change. I recently read the Lisa Sanders book too and that's where I found out about Dr. Faith Fitzgerald who I mentioned in my post. Recommend you watch her "Last Lecture' if you haven't already. It's Bout an hour on YouTube. . Good luck on your app to med school.

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[StevieNicks]

Hi StevieNicks, thanks for your post. I do know these things you mentioned and they are what inspired this post so you were right on the $. Agree, I don't know if I prefer making differentials or the definitive. I meant the former in my OP but maybe that will change. I recently read the Lisa Sanders book too and that's where I found out about Dr. Faith Fitzgerald who I mentioned in my post. Recommend you watch her "Last Lecture' if you haven't already. It's Bout an hour on YouTube. . Good luck on your app to med school.

Haha, already did ages ago, very inspiring . Thank you!

 

[emergentmd]

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

Geez.... not this crap again. Atleast I don't have to beg an ER doc to come put a line, do an LP, Suture a cut on the floor.

 

[Wordead]

Geez.... not this crap again. Atleast I don't have to beg an ER doc to come put a line, do an LP, Suture a cut on the floor.

Are you saying that at your hospital ER docs leave the ER to go up to the floor and do procedures?

 

[Instatewaiter]

Geez.... not this crap again. Atleast I don't have to beg an ER doc to come put a line, do an LP, Suture a cut on the floor.

Of course you don't have to beg the ER doc to come put in a line on the floor. They checked out as soon as the patient was accepted by the floor. That or their shift is over... Please

Once that septic patient is accepted, they don't care they sent him up with just a 25 gauge IV in his thumb that doesn't work. Please call me the next time the ER puts in a central line or an Aline.

 

[Makati2008]

Of course you don't have to beg the ER doc to come put in a line on the floor. They checked out as soon as the patient was accepted by the floor. That or their shift is over... Please

Once that septic patient is accepted, they don't care they sent him up with just a 25 gauge IV in his thumb that doesn't work. Please call me the next time the ER puts in a central line or an Aline.

I've been called to put a central line as well as intubate a difficult airway on the floor with-in the last 2 weeks, and it's not an uncommon occurrence at least where I work.


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[Instatewaiter]

If you dont have internists, surgeons and intensivists who are able to place their own lines and intubate and need the ED to do it for them, remind me never, ever to get sick in your city (or ask for a transfer to an actual hospital)

 

[Makati2008]

If you dont have internists, surgeons and intensivists who are able to place their own lines and intubate and need the ED to do it for them, remind me never, ever to get sick in your city (or ask for a transfer to an actual hospital)

Why so condescending? Just a general question.


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[exsanguination]

Why so condescending? Just a general question.


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Sounds like typical academic ivory tower wankery. Probably hasn't stepped foot outside of the University of *insert city of population greater than 500k*

Everybody needs doctors Instatewaiter, and there are clearly not enough for all parts of the world. Not everybody lives in Seattle, New York, San Francisco, Chicago.

 

[Zebra Hunter]

Of course you don't have to beg the ER doc to come put in a line on the floor. They checked out as soon as the patient was accepted by the floor. That or their shift is over... Please

Once that septic patient is accepted, they don't care they sent him up with just a 25 gauge IV in his thumb that doesn't work. Please call me the next time the ER puts in a central line or an Aline.

Where are you that the ER does not put in central lines for pts that require them? That is a bread and butter procedure for us. Also, what is with the unnecessary hostility? I can list off a million different ridiculous things I have seen cardiologists do or say, but I could also do that with every single specialty in the hospital, including my own.

 

[Tenk]

Of course you don't have to beg the ER doc to come put in a line on the floor. They checked out as soon as the patient was accepted by the floor. That or their shift is over... Please

Once that septic patient is accepted, they don't care they sent him up with just a 25 gauge IV in his thumb that doesn't work. Please call me the next time the ER puts in a central line or an Aline.

Give me your pager and I will call you every single time I put in a line. I'd give you my pager but I don't have one. 8)

 

[Wordead]

Where are you that the ER does not put in central lines for pts that require them? That is a bread and butter procedure for us. Also, what is with the unnecessary hostility? I can list off a million different ridiculous things I have seen cardiologists do or say, but I could also do that with every single specialty in the hospital, including my own.

Probably a matter of academic vs stronger community programs. We cover different hospitals and there is a big difference between the ER at the county hospital (which is very strong) and the university hospital where the ED docs cant wipe their own behinds without a consult. They certainly do not put in lines regularly - they call us to close baby lacerations all the time. Whereas at the county hospital, we dont usually get called unless the patient needs to go to the OR.

 

[gwjib04]

Request thread gets closed

 

[Rekt]

Of course you don't have to beg the ER doc to come put in a line on the floor. They checked out as soon as the patient was accepted by the floor. That or their shift is over... Please

Once that septic patient is accepted, they don't care they sent him up with just a 25 gauge IV in his thumb that doesn't work. Please call me the next time the ER puts in a central line or an Aline.

Lol wtf. Putting in central lines is EM bread and butter.

 

[Instatewaiter]

Lol wtf. Putting in central lines is EM bread and butter.

Probably a matter of academic vs stronger community programs. We cover different hospitals and there is a big difference between the ER at the county hospital (which is very strong) and the university hospital where the ED docs cant wipe their own behinds without a consult. They certainly do not put in lines regularly - they call us to close baby lacerations all the time. Whereas at the county hospital, we dont usually get called unless the patient needs to go to the OR.

Perhaps this could explain it... I can count on one hand how many patients I've had come up from the ED with central lines.

 

[Druggernaut]

I don't understand why everyone has to pile on and be petty. I'm an EM resident, and I'll freely admit I had to ask one of the IM residents how to go about starting the workup for hyponatremia (apparently it's more nuanced than getting urine electrolytes, which I'd also have to look up how to interpret). But then I also have to bail out the upper level IM guys in the ICU on lines, one of the EM upper levels got called upstairs to put in a chest tube after a cardiology fellow dropped a lung putting in a central line, I'm continually horrified by non-EM/anesthesia airway management, I've had to calmly insist that something more was going on than simple Bell's palsy to the irritable neurologist who balked at seeing a patient with facial droop who he then quickly admitted once he actually assessed, the psych guys nervously ask if a little abnormality in the labs is something they have to worry about, ortho will occasionally actually admit a patient to their service with another medical problem and ask how to manage it until their consultant sees the patient the next morning, and interventional radiology forgets that heparin and anti-platelet agents aren't interchangeable and we can't transition off the latter to the former, hold it for an hour or two, then let them do their procedure before restarting it. EM deals with a limited aspect of medicine, just like everyone else, and we're all (hopefully) good at our slice of it.

Meanwhile, one of the critics here failed to match EM and had to fall back on IM, another thumps his chest that the ED was wrong and he had to put a pneumonia on a Lasix drip (you know Lasix isn't really a titratable medication like esmolol or norepinephrine, right?). I'll concede the Hopkins IM guys are probably pretty solid all-around, but I'll promise they don't know it all.

OP, I'd ask yourself if you want to see a lot of patients with a variety of complaints and diagnose them, or if you want to be the subspecialist with a narrow scope that other people send your way and go from there.

 

[Instatewaiter]

Meanwhile, one of the critics here failed to match EM and had to fall back on IM, another thumps his chest that the ED was wrong and he had to put a pneumonia on a Lasix drip (you know Lasix isn't really a titratable medication like esmolol or norepinephrine, right?). I'll concede the Hopkins IM guys are probably pretty solid all-around, but I'll promise they don't know it all.
.

So perhaps nit-picky but lasix is titratable. You rise above the threshold dose and after this there is a dose dependent relationship. Lasix drips are titratable and are pretty useful. You keep a patient at steady state without the same kinds of rise and falls in lasix level which means you can maintain diuresis at the rate of re-absorption of peripheral edema,This is commonly done by the cardiomyopathy folks. Perphaps less useful in the ED but great for longer term diuresis when you have 20, 30, 40 lbs to diuese.

 

[LabMonster]

This has been a spirited debate! I see lots of residents, attendings and medical students adding points. So, to the OP, to the reason we are typing pages and pages... I agree that radiology makes some diagnoses missed by others - that's why they do a residency. Pathology - sure, they get tissue and can make a definitive diagnosis based on microscopic evidence. I love you guys. Seriously, Path comes through and helps people out when the rest of us are confused by the clinical picture. ID/Heme-Onc/IM/Derm/Rheum. All great choices. For the all time detective, I would go with IM and if I had to specialize, nephrology. Kidney docs are pretty damn smart

We're not idiots in the ED either. We control the diagnostic hub of the hospital. We're not always right, sometimes we miss, but as mentioned, we are tasked with stabilization of unstable patients, recognizing emergency medical and surgical conditions and appropriating resources to the benefit of our patients.

Let's be honest. We can't be complete diagnosticians in 2-3 hours. I'd love to diagnose complex medical problems in the ED, but I don't have time. I have VOLUME to deal with. I have 15-30 patients in a shift who need medical attention, 5 of which usually need my skillset. I am a resuscitationist. I am not an IM doctor who can explore various reasons why a patient is sick. I don't have time. I treat and modify treatment on patient response. IM doc's in the hospital don't have time either! They do what they can, but refer back to primary care once a patient is stable.

So. If you want to dig, really dig into a patient's history, AND if you have no objection to the amount of time it will take, consults it will muster, then go IM and go academic. The EDP is a great diagnostician, but we can't figure everything out in 2-3 hours.

The great "diggers" in my medical upbringing were medicine docs. And they rocked it.

 

[barsoum.michael]

I think it might be a House joke.

The first thing I thought of when reading the title was House. Great minds think alike

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[gwjib04]

This has been a spirited debate! I see lots of residents, attendings and medical students adding points. So, to the OP, to the reason we are typing pages and pages... I agree that radiology makes some diagnoses missed by others - that's why they do a residency. Pathology - sure, they get tissue and can make a definitive diagnosis based on microscopic evidence. I love you guys. Seriously, Path comes through and helps people out when the rest of us are confused by the clinical picture. ID/Heme-Onc/IM/Derm/Rheum. All great choices. For the all time detective, I would go with IM and if I had to specialize, nephrology. Kidney docs are pretty damn smart

We're not idiots in the ED either. We control the diagnostic hub of the hospital. We're not always right, sometimes we miss, but as mentioned, we are tasked with stabilization of unstable patients, recognizing emergency medical and surgical conditions and appropriating resources to the benefit of our patients.

Let's be honest. We can't be complete diagnosticians in 2-3 hours. I'd love to diagnose complex medical problems in the ED, but I don't have time. I have VOLUME to deal with. I have 15-30 patients in a shift who need medical attention, 5 of which usually need my skillset. I am a resuscitationist. I am not an IM doctor who can explore various reasons why a patient is sick. I don't have time. I treat and modify treatment on patient response. IM doc's in the hospital don't have time either! They do what they can, but refer back to primary care once a patient is stable.

So. If you want to dig, really dig into a patient's history, AND if you have no objection to the amount of time it will take, consults it will muster, then go IM and go academic. The EDP is a great diagnostician, but we can't figure everything out in 2-3 hours.

The great "diggers" in my medical upbringing were medicine docs. And they rocked it.

Thanks a lot for your post LabMonster. Super helpful and candid description of EM from somebody who obviously knows it well.

"stabilization, recognition of emergency and surgical conditions, appropriating resources, VOLUME, resuscitation, treatment and modification on patient response"

 

[Shipping News]

Thanks a lot for your post LabMonster. Super helpful and candid description of EM from somebody who obviously knows it well.

"stabilization, recognition of emergency and surgical conditions, appropriating resources, VOLUME, resuscitation, treatment and modification on patient response"

"...and read the radiology report to find out what the diagnosis is"

I jest, I jest.

Sort of.

 

[LabMonster]

"...and read the radiology report to find out what the diagnosis is"

I jest, I jest.

Sort of.

You know, not enough grads read radiology studies... I work only at night, I don't have radiology back-up. I get outside reads from a radiologist I don't know, and usually don't trust. This week, I have had 2 reads which missed critical detail. I caught one, the other was caught by a rad colleague on over-read, and the patient wasn't harmed.

I missed, contract rads missed a small amount of pelvic fluid in a male involved in a serious mvc. He was admitted for CT findings and my assessment.

Second case, fall in elderly with broken ribs and pelvis, missed by outside Rads Service, I identified the injuries I suspected and treated appropriately.

There are problems with medicine, but there are also problems with the profession.

I interpret a history and physical exam, read my own scans, interpret my own labs, basically old school MD. I Make Decisions. I don't wait for a non clinical colleague to tell me what the diagnosis is on video. A radiologist is always better at reading imaging studies than I. A cardiologist is better at EKGS, Orthpods are better at reducing fractures. But no one is better at resuscitating the dead, handling actual emergencies or managing other specialties complications.

Respect your colleagues, learn with them and teach. "and read the radiology report to find out what the diagnosis is," is absolutely insulting and asinine. Do not generalize, and no, I don't take it as a joke.

And btw - when someone codes in the scanner, or you poke a hole in something vital by accident, who do you call? Who comes running?

We are a team. It's time for docs to stop being bitches related to their specialties. It's not about us.

 

[DRsmartypants]

^For the record, as someone who has done a few rads rotations. I agree everyone should stick to their respective specialties, but not reading reports of someone, who is an expert, is asinine. Imaging is far too complex for a non-radiologist to be a master. I have seen radiologists do simple-moderately complex clinical diagnoses, just like how I have seen clinicians do simple-moderately complex reads, but the minute it becomes the management of multiple comorbidities which multiple medications, the radiologist is out of his depth, just like when a scan involves multiple subtle changes from prior to current scans, and very difficult differentials, and a great understanding of medical phyiscs to truly get the image, there should be deference to the radiologist. I agree we are a team, but it becomes an issue when we don't trust each other. What I will say is that cherry picking times when radiologists have failed is easy, every clinician makes mistakes. If a radiologist had the PE findings, Hx, Labs, and had the time to go over it once purely radiologically, and a second time including findings from the clinician(that way you get an objective and "non-objective" viewpoint), radiology reports would be great. Due to our litigious society, some radiologists hedge. There is wayyy, wayyyyy more volume in radiology then any other specialty besides maybe pathology. A radiologist for all intents and purposes isn't allowed to "go back" because of time constraints. If a clinician decides to change medications, that is possible. I have seen clinicians kill patients before, just like I have seen radiologists miss lethal diagnoses, people make mistakes. I also think part of the issue with pathology and radiology is that people do not treat them like consults. They treat them like a service, much akin to calling a phlembotomist to take blood. If non-clinicians were viewed and respected in the same light as clinicians, I could guarantee the whole of medicine would work a lot more smoothly for it. My point is don't diss other people without knowing how they work. Last point I want to make, the way a radiologist views an image is very, very different form a clinician. A radiologist scans every cm of that image, every slice to make sure everything is working and in order or to find pathology, a clinician will usually look for diagnosis that confirms or denies his/her suspicion.

P.S. If someone codes in the scanner, you'd be damned to find a good radiologist who wouldn't start ACLS and start figuring it out. Radiologist are diagnosticians, very good ones generally.

 

[medic86]

lol.

 

[LabMonster]

^For the record, as someone who has done a few rads rotations. I agree everyone should stick to their respective specialties, but not reading reports of someone, who is an expert, is asinine. Imaging is far too complex for a non-radiologist to be a master. I have seen radiologists do simple-moderately complex clinical diagnoses, just like how I have seen clinicians do simple-moderately complex reads, but the minute it becomes the management of multiple comorbidities which multiple medications, the radiologist is out of his depth, just like when a scan involves multiple subtle changes from prior to current scans, and very difficult differentials, and a great understanding of medical phyiscs to truly get the image, there should be deference to the radiologist. I agree we are a team, but it becomes an issue when we don't trust each other. What I will say is that cherry picking times when radiologists have failed is easy, every clinician makes mistakes. If a radiologist had the PE findings, Hx, Labs, and had the time to go over it once purely radiologically, and a second time including findings from the clinician(that way you get an objective and "non-objective" viewpoint), radiology reports would be great. Due to our litigious society, some radiologists hedge. There is wayyy, wayyyyy more volume in radiology then any other specialty besides maybe pathology. A radiologist for all intents and purposes isn't allowed to "go back" because of time constraints. If a clinician decides to change medications, that is possible. I have seen clinicians kill patients before, just like I have seen radiologists miss lethal diagnoses, people make mistakes. I also think part of the issue with pathology and radiology is that people do not treat them like consults. They treat them like a service, much akin to calling a phlembotomist to take blood. If non-clinicians were viewed and respected in the same light as clinicians, I could guarantee the whole of medicine would work a lot more smoothly for it. My point is don't diss other people without knowing how they work. Last point I want to make, the way a radiologist views an image is very, very different form a clinician. A radiologist scans every cm of that image, every slice to make sure everything is working and in order or to find pathology, a clinician will usually look for diagnosis that confirms or denies his/her suspicion.

P.S. If someone codes in the scanner, you'd be damned to find a good radiologist who wouldn't start ACLS and start figuring it out. Radiologist are diagnosticians, very good ones generally.

I love the radiologists I work with, don't get me wrong, and I trust them implicitly. You're correct in that they are masterful diagnosticians based on little clinical data (especially given my most clinicians - not a sterotype if it's true) and excellent at differential diagnoses. I shared a code blue situation with one of my radiologists about a year ago who had a patient with anaphylactoid reaction to dye - he was great, a little jacked up, but he's not used to that crap (nor should he be.) We got the Pt over to the ED, I took over and the patient did fine.

Don't misunderstand, I don't think I said I don't read the radiology reports of the outside service - I do, but I also read them as carefully as I can. Trust but verify. I'm glad you've done a few rotations in rads - hope you've gleaned a fraction of what they can pick up. I'm not actually cherry picking, we are on our third outside night-read radiology service because of missed items over-read. These are tallied, kept track of by the radiology department and brought to administration. I'm not picking on the guys I work with. I'm not picking on the radiology specialty. I'm not dissing them, and I DO KNOW how they work.

I had two points really, so I'll say them bluntly. You're right, we need to trust each other, and the bull**** between specialties needs to end. There is a culture of ****ting on other services in medical school and in training. The younger generations of docs can make that happen. I'm not going to get anywhere with the 65 yo surgeon or orthopod or internist. Med studs, residents, yes, understand that we all need to embrace the suck, band together to take good care of patients and defend our profession from outside influence.

The second point is simply that all clinicians at the point of care should not absolutely rely on the radiology read - as you noted, we all screw up, we make errors affecting patient care, but it's worse in radiology when you don't have a great history and the patient isn't in front of you. We all need to be able to read, yes, complex studies, and we all need to train in order to pick up EVERYTHING the radiology doc does. That means we are learning and protecting our patients and our colleagues. We won't, they will always see more, always offer more - thats why they did their residency, but as you also mentioned, they can code a patient too.

I'm an ER doc. I work in an isolated, critical access hospital with limited resources. I am the only doc, beside the hospitalist, on at night. Other docs are 30 min away. I see very sick people, with crappy access to care, who don't take care of themselves and use drugs. I am the second damned best radiologist,neurologist, internist, oncologist, ophthalmologist, cardiologist, intensivist and surgeon that I have. I will never be as good as the primaries, but I am a skilled ED resuscitationist, and I can fix dead people, near dead people, and people "fixin' to die."

Remember that the place where you learn, and the place where you train is not necessarily the place you will practice (or want to practice.) Good work on the Rads rotations, sounds like you may want to go that route - we're on the same team. If not, learn your reads, talk to your colleagues (even the ER docs.)

 

[bashwell]

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

Hey OP, if you're inspired by Faith Fitzgerald, she's an academic internist (IM). Academic IM is a good way to go for what you're talking about. That may be what you're looking for.

However, keep in mind as an M1, you will likely change your mind about what you want out of medicine as you progress through med school.

Good luck with whatever you end up choosing!

 

[673441]

I am certainly biased but...without a doubt....Neurology!

I was told by a neurology resident that its an abundance of Parkinson's, Huntington's, TIA's and thats about it... Seems pretty mundane if thats what its really like.

 

[barsoum.michael]

Can't you just be a diagnostician?

The first thing I thought of was House.

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[gwjib04]

Blog post by a rural family medicine doc that's very relevant to this thread
https://acountrydoctorwrites.wordpress.com/2016/01/04/specialists-in-diagnostics/

 

[Neuro Storm]

I was told by a neurology resident that its an abundance of Parkinson's, Huntington's, TIA's and thats about it... Seems pretty mundane if thats what its really like.

Not sure who you spoke to but that is not the case. Wrong on many levels. TIAs? Stroke was the third leading cause of death in the US for a long time..I wish they all turned out to be TIAs. There is no such thing as an "abundance of huntingtons" as it is not a common disorder and, unless you are in a movement d/o clinic will not encounter this disease on a daily basis. I think when you make comments like that you have to ask yourself..."I am oversimplifying this just a bit?" We are one of the oldest and most established fields of medicine, we have our own ICU and again hospital CEOs and academic centers worldwide are dumping, sometimes, hundreds of millions of dollars into their neuroscience centers/research. This speaks to the variety of things we do. Usually we get called in a pinch when people don't know what's going on and need CSF/EEG/Angiogram/autonomic studies/Emg Ncs/ to save the day and figure it out. This is why I posted that we are baller diagnosticians...because I spend a large part of my day figuring out what multiple docs before me from multiple specialties didn't. Go Neuro.

 

[Cognovi]

We are one of the oldest and most established fields of medicine

"even as specialization became more commonplace by the end of World War I, American physicians never wholeheartedly or enthusiastically accepted the separation of neurology from what had come to be known, under the influence of Sir William Osler with formation of the Association of Physicians of Great Britain and Ireland in 1906, as ‘internal medicine’... The American Board of Psychiatry and Neurology, established in 1935, did not begin giving separate designations in the two fields until 1948." http://brain.oxfordjournals.org/content/133/2/638

 

[673441]

Not sure who you spoke to but that is not the case. Wrong on many levels. TIAs? Stroke was the third leading cause of death in the US for a long time..I wish they all turned out to be TIAs. There is no such thing as an "abundance of huntingtons" as it is not a common disorder and, unless you are in a movement d/o clinic will not encounter this disease on a daily basis. I think when you make comments like that you have to ask yourself..."I am oversimplifying this just a bit?" We are one of the oldest and most established fields of medicine, we have our own ICU and again hospital CEOs and academic centers worldwide are dumping, sometimes, hundreds of millions of dollars into their neuroscience centers/research. This speaks to the variety of things we do. Usually we get called in a pinch when people don't know what's going on and need CSF/EEG/Angiogram/autonomic studies/Emg Ncs/ to save the day and figure it out. This is why I posted that we are baller diagnosticians...because I spend a large part of my day figuring out what multiple docs before me from multiple specialties didn't. Go Neuro.

Thanks for clearing up that misconception I had. Again it was just something I was told by a resident. I guess he was mistaken. Sounds like a pretty cool field.


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[Neuro Storm]

"even as specialization became more commonplace by the end of World War I, American physicians never wholeheartedly or enthusiastically accepted the separation of neurology from what had come to be known, under the influence of Sir William Osler with formation of the Association of Physicians of Great Britain and Ireland in 1906, as ‘internal medicine’... The American Board of Psychiatry and Neurology, established in 1935, did not begin giving separate designations in the two fields until 1948." http://brain.oxfordjournals.org/content/133/2/638

I'm talking Charcot homie...the field of Neurology predates the USA by a long time.

 

[mTORC]

Just follow the footsteps of real life House, Dr. Gahl head of the Undiagnosed Diseases Program at the NIH: https://www.genome.gov/10005723/gahl--group/


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[gwjib04]

Recently began out 8 week neuro class and I'm starting to see why so many people mentioned neurology in response to this thread.

The clinical exams are super interesting for a neuro workup. Seems like a lot can be deduced from the eyes, then you have all of the reflexes, not to mention the electrophysiology which is appealing too.

Plus you must be a useful consultant for everyone else in the hospital since these symptoms and conditions don't overlap with any other specialty.

 

[Kazaki]

Love this thread! Here's my 2 cents from what I've seen in medicine so far. Keep in mind this is coming from someone who was torn between rads and neuro.

Neurologists are some of the smartest doctors I've ever seen. Some are scary smart. Like you wonder if they killed someone and somehow incorporated their brains into their own bodies. They often make the diagnosis when everyone in medicine is running around like a chicken with its head cut off. The syndromes you read about in neurology are very interesting (how often you actually see these rare conditions is something I can't answer).

Like every speciality, there's the bread-and-butter cases you see in neuro, which are headache, stroke, epilepsy, dementia. Here's my beef with neuro, stroke patient rushes in, you hand in him over to rads for interventional work (true story: neurologists aren't the top choice for interventional fellowships or jobs at hospitals since rads and NSG have a tremendous advantage over them in this field), moving on. You just figured out what type of epilepsy this patient has, great! Start him on meds to manage their condition. Oh you want to be treated? Let me refer you to NSG. You suspect Alzheimer's, do a full exam (something that I think only a neurologist can master after considerable experience), order scans, start meds, confirm on autopsy. Oh wait, you don't confirm the diagnosis, the pathologist does. So yeah you can localise the lesion and make the diagnosis, but what can you do about it as a neurologist? Not much really. Infact, almost nothing.
That's brain pathology. We can come up with all the fancy equipment to diagnose diseases, but unless we can remove the tumour, bleed or epileptic focus, there really isn't much we can do. Peripheral neuropathies are a bit better, but still.
Neurologists make some of the most accurate diagnoses based on physical exam findings, but in the era of evidence-based medicine, your diagnosis is worth piss all without some evidence to back it up, and most often than not, that evidence comes from rads.
@Neuro Storm though, I honestly doubt that a neurologist or any non-rads doc can out-read a radiologist. If that were true, someone would've figured it out by now, and radiology as a speciality would be obsolete.

Rads on the other hand is much more focused. An attending once told me that a good radiologist figures out what the attending is looking for from the history/PA and tries to answer that question first in their report, they then list all the positives/negative and stuff.

Now. Let me get back to first aid....

 

[sloop]

Here's my beef with neuro, stroke patient rushes in, you hand in him over to rads for interventional work (true story: neurologists aren't the top choice for interventional fellowships or jobs at hospitals since rads and NSG have a tremendous advantage over them in this field), moving on. You just figured out what type of epilepsy this patient has, great! Start him on meds to manage their condition. Oh you want to be treated? Let me refer you to NSG. You suspect Alzheimer's, do a full exam (something that I think only a neurologist can master after considerable experience), order scans, start meds, confirm on autopsy. Oh wait, you don't confirm the diagnosis, the pathologist does. So yeah you can localise the lesion and make the diagnosis, but what can you do about it as a neurologist? Not much really. Infant, almost nothing.

I don't really get why people get wrapped up in the "definitive diagnosis" thing. If something walks like a duck, talks like a duck, and responds like a duck when you treat it like a duck, are you really that bothered by some existential claim that the duck might just be an illusion?

Call me crazy, but I kind of feel like if the diagnosis seems to work to make the patient better, it's not that important whether the diagnosis is "definitive." Of course if you need definitive diagnosis as part of your job (don't really know why one would, but whatever) you should go into path.

This is all speaking as someone whose chosen field is psychiatry, however, so that's my perspective.

 

[Zebra Hunter]

I don't really get why people get wrapped up in the "definitive diagnosis" thing. If something walks like a duck, talks like a duck, and responds like a duck when you treat it like a duck, are you really that bothered by some existential claim that the duck might just be an illusion?

Call me crazy, but I kind of feel like if the diagnosis seems to work to make the patient better, it's not that important whether the diagnosis is "definitive." Of course if you need definitive diagnosis as part of your job (don't really know why one would, but whatever) you should go into path.

This is all speaking as someone whose chosen field is psychiatry, however, so that's my perspective.

Path frequently does not make definitive diagnoses either.

 

[Crayola227]

general internal medicine

 

[Siggy]

Why so condescending? Just a general question.


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The attendings at my hospital aren't credentialed for lines... and the intensivist leaves at 6pm... so it falls to the ED attending for emergent procedures. Thankfully most of them are comfortable enough with the residents to do distant supervision if the resident if comfortable with the procedure.

 

[HelpPleaseMD]

arent there other residents around signed off on lines? What happens to a floor patient that emergently needs a line and its after 6pm.?

 

[alpinism]

Depends on the hospital. Sometimes there just aren't any experienced residents available. If not they call down to the ED.

 

[Crayola227]

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.

QFT. So I can keep track of this post for so consicisely putting it all together. I want to go plaster this a bit in pre-allo. Here's modern medicine for ya baby. All of the specialties get a little of that stink of processed **** as @Tecmo Bowl put it.

If you are thinking IM or EM, you better read this, and love *this*. If you do, you will go into IM or EM with eyes wide open.

 

[LabMonster]

I don't really get why people get wrapped up in the "definitive diagnosis" thing. If something walks like a duck, talks like a duck, and responds like a duck when you treat it like a duck, are you really that bothered by some existential claim that the duck might just be an illusion?

Call me crazy, but Think if the diagnosis seems to work to make the patient better, it's not that important whether the diagnosis is "definitive." Of course if you need definitive diagnosis as part of your job (don't really know why one would, but whatever) you should go into path.

This is all speaking as someone whose chosen field is psychiatry, however, so that's my perspective.

I use the "duck" talk all the time, but in EM, we work with undifferentiated patients most frequently. I agree, definitive diagnosis is for fools - rarely does a patient present with classic ANYTHING. I explain that treating the symptoms they are complaining about is higher priority, and holds a higher likelihood of success than a "definitive diagnosis." People want a label. They want a brand - and its cultural. The ER does risk stratification and emergent stabilization. We diagnose 50% with what is likely causing their Sx.

So, half the time I can definitely help with their duck, but the other 50% will require more work to define their albatross

 

[delco714]

Depends on the hospital. Sometimes there just aren't any experienced residents available. If not they call down to the ED.

There are plenty of PAs on trauma services or ER that could readily do this as well.

 

[Blackdogue]

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.

Dammit dude, I just accepted a neurology position at a university clinic in Germany and have not been able to sleep at night second guessing my choice, because of my fear of neuro being miserable. Your posts were exactly what I needed to give me some courage and some peace of mind till I start next month. I know I'm resurrecting an ancient thread, but thanks! Hope you're still feeling the same way about your field!

 

[Philosopher Jagger]

Others have said these, but you're looking at things like General IM, Rheum, Infectious Disease (think travel-related zebras), and Pathology

Infectious Disease would be a cool option. Particularly at a big academic center on a coast or located at an international travel hub (think NYU, NY Presbyterian, UCLA, etc.) Or if you could land some place like Mayo, MGH, Brigham, Hopkins...you know those elite joints, you could probably see a large and wide variety of pathogens. Of course this isn't just ID...apply to any of the above options people have mentioned

Edit: don't forget about the ICU (be it adult, peds, or neonates) -- you have TONS of complex patients with advanced pathology. Most if not all incapacitating diagnoses end up there. But keep in mind this is often low volume and not a sit-down-with-the-patient scenario.

Bottom line: more patients & more travelers at a huge referral center = higher chance of obscure zebras = more robust diagnostic challenge

 

[Philosopher Jagger]

I support this post. There is a reason I chose my avatar, name, and signatures as I did

 

[gwjib04]

OP here, I chose Emergency Medicine. I think it was the right choice. Still love the undifferentiated patient and the mystery within. Good luck to everyone, it was an extremely tough decision. You couldn't ask for a better job than medicine imo. Screw the trolls.