complex or interesting cases

[wonderer]

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Something an attending in another specialty said recently has been bugging me, and I was hoping someone on here could respond in a way that would put my mind at ease.

attending: "The trouble with FM is that if the patient has a complex, rare, or interesting disease, then they don't belong in your office."

I do want to see interesting pathology.

Please help.

 

[thethom]

When you are 50 years old are you still gonna want to see the complex pathologies or are you going to want to go to the office, finish your work, and then go home so you can play golf and see your family. You will get to manage plenty of interesting pathology in residency. A common misconception is that all the "cool cases" go to IM, however most hospitals have a system where unassigned admissions in the ER alternate between FM and IM, so both specialties have equal dibs on the "interesting pathology." FM however gets to see interesting cases in kids unlike IM. Interestingly, most IM graduates that go on to practice will also have a predominantly outpatient practice, which means they will be managing the EXACT same things you will as an FM. Those that go into hospitalist practice will also be managing exactly the same things an FM does in a hospitalist setting.

You make the decision, I think FM is the perfect mix of routine stuff and occasional complex cases.

-T

 

[lowbudget]

attending: "The trouble with FM is that if the patient has a complex, rare, or interesting disease, then they don't belong in your office."

Fact or opinion?

As a free thinking medical student, you need to be asking this on a regular basis whenever you talk to your patients, residents, and attendings.

1. What's complex, rare, or interesting for some is straightforward, commonplace, and downright boring for others. There's no universal definition for what consitutes "interesting pathology". It's up to the individual.. and therefore, his statement is an opinion.

2. How can your attending know so much about something he doesn't do? Unless your attending shadows your FM attending on a daily basis, your attending has no basis in making that assumption. Many FM docs only refer out after they've maxed out. So... if I successfully manage a "complex" case, do we automatically reclassify it as "simple" just because I'm an FP?

I don't think so. Unless your attending rotates through my clinic, he has no clue what I am managing on a daily basis.

If your attending is an FP, well... that's just the sort of practice your attending chose to have. Ain't no problem with that. I just find it real hard to believe that you can generalize across the specialty like that based on 1 person's practice...

3. Boundaries of medicine is fluid and ever changing. That's what makes it fun. FP's were the first to discover/diagnose and manage AIDS. And as it got more "complex", ID did more of it. But now, the management of HIV/AIDS is going back to the hands of primary care (with/without ID co-management). There's no such thing as "belong" per se with all these nice little boxes to pigeon-hole things.

4. I have 2 observations. 1) Doctors & medical students are whiners/complainers, and 2) Doctors & medical students always act like they know more than they really do. That's why we hide behind the degrees on our walls... so that we can use brute force to put someone into intellectual submission.

If 1 doctor could do everything, why do we have 500 different doctors and specialties? The answer is because there's no way anyone can know everything. And if your attending doesn't refer out when he or she is maxed out, your attending is an idiot.

A better way to say it is: "If your patient becomes too complex... *for you*..., they don't belong in your office."

You see, medicine ain't about you (the doctor). It's about your patients. Therefore, I have no shame asking for a little help or another opinion when it's the best thing for my patient.

"The beauty of FM is that I get to deem what is complex, rare, or interesting... and where it belongs."

 

[cali-ob]

well said LB👍

 

[Drawing Dead]

attending: "The trouble with FM is that if the patient has a complex, rare, or interesting disease, then they don't belong in your office." quote]


You could have easily turned it around on him as well. What specialty was he in?

For arguement's sake, let's say he was a surgeon. You easily could have said "I think diabetes is interesting, do they belong in your office instead?"

 

[wonderer]

attending: "The trouble with FM is that if the patient has a complex, rare, or interesting disease, then they don't belong in your office." quote]


You could have easily turned it around on him as well. What specialty was he in?

For arguement's sake, let's say he was a surgeon. You easily could have said "I think diabetes is interesting, do they belong in your office instead?"

Thanks for the replies, everyone, I'm feeling better again.

He's uber sub-specialized, so he doesn't refer out for anything in his area, because he is the end of the line. He refers out only for things that aren't in his domain, and should have been sent elsewhere.

But yes, there are plenty of cases that I would consider interesting that don't belong anywhere near his office.

I think he was saying that he enjoys the intellectual stimulation of solving the very hardest, no-one-else-can-solve-them cases, and being on the cutting edge of his uber-sub-specialized field.

He's afraid that FM won't provide intellectual stimulation for me, and I'll be bored.

 

[lowbudget]

I think he was saying that he enjoys the intellectual stimulation of solving the very hardest, no-one-else-can-solve-them cases, and being on the cutting edge of his uber-sub-specialized field.

He's afraid that FM won't provide intellectual stimulation for me, and I'll be bored.

Again, very black & white thinking.

You'd be surprised at how many cases FP's solve after patients have bounced from specialists to specialists, $80k of medical costs later... putting their families closer to bankruptcy.

You don't have to be uber-sub-specialized to have a job that's intellectually stimulating. Having an intellectually stimulating job depends on YOU, not the specialty you chose. If you're the type that accepts dogma, jumps to conclusion, never question authority... then no matter what job you take, it'll likely be intellectually dormant.

If you have the guts to ask "why", or "what if", or "how about", or take a medical problem X and add to the end "in the primary care setting", then your job starts to become more interesting. And what appeared on first blush "simple" becomes more complex.

Have some beers with techies and business-y types. They do this all the time. They talk about doing things better, faster, cheaper. It's how things advance and innovate. That's what we need to do.

If you want to be intellectually stimulated, keep an open mind; and dare yourself to challenge, seek certain truths, and find a faculty who'll support you and mentor you through it. And when you find your answers, talk about it, teach it, publish it.

Before you know it, you're doing research! And some medical student will think that YOU're on the cutting edge! And patients, students, and residents will be banging down the door to be near you. Creating your own destiny, and inspiring others to do the same.

I find it very hard to believe that a field so broad, affecting so many people, every day, in every manner... can be so boring (according to your attending). Medicine and the health care system is so jacked up that there's opportunities everywhere to make things better, faster, and cheaper.

Maybe that was the case back in the day when your attending was going through training. But Barack is president now. And like he said, "time has come to set aside childish things... Starting today, we must pick ourselves up, dust ourselves off, and begin again the work of remaking America."

 

[iswitched]

The trouble with specialists is that if the patient has simple, common, and boring disease, then they don't belong in the specialist's office.

Our healthcare system is being bankrupted by ENTs treating common thyroid disease, orthopedists being referred shoulder bursitis, pulmonologists treating asthma, cardiologists treating hyperlipidemia, GI guys treating IBS etc etc etc (often being referred by PCPs!).

I see my job in FP as one of separating the wheat from the chaff. The wheat is there if you're smart enough/take the time to look. The vast majority of wheat can be treated by the PCP. I think the quoted specialist was right: if the disease is rare and complicated, a specialist should manage the condition. That's why they're "specialists." But such conditions are rare (and complicated 🙂).

Finding "interesting" cases is simply a function of statistics...prevalence of disease vs number of patients you are seeing. If you are 50 years old and are not catching "interesting" cases then you need to find some other career that you are good at. Same applies if you're 30.

Frankly, I find the "hunt" to be one of the aspects of medicine that is most intellectually satisfying. Even more satisfying is catching things without wasting a bunch of money (i.e. using your brain, recollection of medical facts, and using history/exam findings instead of a bunch of labs/radiology). When it comes to managing the finer points of scleroderma, well, I have no interest in such. Again, that's why god made specialists.