Consults/division of labor destroy the fun of internal medicine?

[Spetzler-Martin]

Know that I'll probably get flamed for this post but here it goes... Currently on internal medicine as my last rotation. I was under the impression that in internal medicine we would be doing the vast majority of critical thinking when it comes to creating differentials. Rather, what I've been experiencing is that the majority of the workup is done in the emergency department and by the time they come to us, nearly everything pertinent is already ordered. Additionally, it seems like the specialists come in whenever they feel like it when the cases are interesting. Case in point, we had a patient with potential signs of a cocciodomycoses infection come in this week. ED does a good chunk of the workup and then consults IM and infectious diseases. Infectious diseases then orders anything else they see fit. So why even consult medicine at that point? If you get the fun of diagnosing, then you should maintain said patient on your panel?

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[seeinghowitgoes]

So much to be said. Many things could be better in medicine, but not related to these things. I’ll just hit some highlights.

1) Doing consults is a small part of medicine’s job. Usually when you’re an attending you run a service, and then you decide if you want a consult.

2) there is so much nuance in every decision - just because ID makes abx decisions doesn’t mean they’re going to manage the 10 other complex problems a patient has- and I promise as an attending you have so much on your plate and so many decisions to make you don’t ever feel bored because a consultant is involved.

3) huge inter-hospital variation in how much work up is done before pts come to you and how involved consultants are. At my hospital we do most the work ups.

I mean no disrespect with this, but the above comment sounds like it is coming from a med student following one patient with all the time in the world. This isn’t a perfect analogy but would be somewhat like saying to an attending surgeon “don’t you miss getting to close” rather than seeing they’re so busy thinking deeply about other parts of the case that the help they receive is usually always appreciated.

If the pathology medicine deals with isn’t interesting to you, if you don’t like rounding, etc, then by all means don’t go into it. But consults/teamwork is definitely not killing medicine - on the contrary I’m so thankful to have thoughtful consultants so I only have to jog around all day to implement my plans rather than sprint.

I’d go as far as to say it is rare medicine can’t offer something to a patient’s care - people who think they have no role because a consultant is “driving the bus” is not thinking enough about the patient.

 

[operaman]

Yeah I think you’re getting a skewed view of things. Though the fundamental issue is one you haven’t raised: 98% of the time the diagnosis is ridiculously obvious. Not a lot of head scratching most days. Even aside from consultants, zebras are called such for a reason. There are still a lot of them, but they are not the bulk of your day in any field.

What I find most interesting is the actual management part. Diagnosing an unusual fungal infection is not nearly as interesting as managing it, dealing with possible complications, side effects of treatment, comorbidities, patient factors — those are the true challenging and interesting parts in my mind.

If working up I differentiated patients is truly your jam, then you may want to consider EM or something like that. You give up the management fun part but you do get to do the workup and diagnosis much of the time.

 

[Spetzler-Martin]

Yeah I think you’re getting a skewed view of things. Though the fundamental issue is one you haven’t raised: 98% of the time the diagnosis is ridiculously obvious. Not a lot of head scratching most days. Even aside from consultants, zebras are called such for a reason. There are still a lot of them, but they are not the bulk of your day in any field.

What I find most interesting is the actual management part. Diagnosing an unusual fungal infection is not nearly as interesting as managing it, dealing with possible complications, side effects of treatment, comorbidities, patient factors — those are the true challenging and interesting parts in my mind.

If working up I differentiated patients is truly your jam, then you may want to consider EM or something like that. You give up the management fun part but you do get to do the workup and diagnosis much of the time.

Really good points. I also concede that what's "fun" is purely subjective. I think a part of me was expecting internal medicine to be like an episode of House MD, thus the ultimate letdown. lol

 

[deleted1079620]

Really good points. I also concede that what's "fun" is purely subjective. I think a part of me was expecting internal medicine to be like an episode of House MD, thus the ultimate letdown. lol

I think you should do an elective in ID if you want an experience like that.

 

[operaman]

Really good points. I also concede that what's "fun" is purely subjective. I think a part of me was expecting internal medicine to be like an episode of House MD, thus the ultimate letdown. lol

Yeah I’ve been a bit disappointed too - not once have I had to go break into some patient’s house!

I do think you can get some aspects of the House experience in most any field. Even in ent I get to make some occasional zebra diagnoses. I remember as a resident on consults diagnosing Kawasaki’s disease at least twice when consulted for excisional lymph node biopsy. In both cases primary team just never really did a good thorough exam because they didn’t want To upset the child. Nowadays I’m mostly adults so fewer of those, but plenty of rare neuro diseases, autoimmune, infectious, cardiac, etc.

The point is - there’s plenty of diagnostic mystery to be had if you’re thorough and look for it. A good habit to start now is to do your own workup for every patient. Don’t just take what you’re told at face value; do the workup and think it through yourself. Even now I get sent patients from my partners with one diagnosis and when I do my own eval I come up with something totally different ( I sure hope other docs are doing the same with patients I send to them). So even if the ED or consultants tell you one thing, take a fresh look at everything yourself and make sure you agree. There’s zero chance that every patient on your service has a completely accurate diagnosis and treatment plan, so I’m sure there’s some diagnostic work to be done somewhere.

 

[Ho0v-man]

I felt similarly to OP as a med student. You were either following an already worked up patient and management was following the up to date algorithm or just letting the consultant deal with it. I felt like my entire education boiled down to:

“ - Etiology is likely multi factorial.
- Dispo is complicated as patient is medically complex, actively psychotic, and homeless.
- Appreciate specialist recs.
- Avoid nephrotoxic medications.”

But they’re not letting the third year med student manage the patient who’s starting to crash and needs the right calls made now to stay off the vent.

Furthermore, as you go you’ll realize how much you can’t always rely on the ED to work up a patient. This isn’t a bash on the ED. But if they find any reason to admit and the patient won’t die between now and the time you see the patient, then they’re done. That’s their job. You’ll find many other things need worked up and managed. Patients usually have more than one problem and as the primary, your job is to deal with all of them. You should trust but verify the ED and consultants plans. You’ll get burned if you think the ED wraps up everything with a bow or you.



But I did like the idea of making a diagnosis much more than management. If you feel the same, you might enjoy something like rads or path more.

 

[TelemarketingEnigma]

I doubt the specialists are just signing themselves up for random patients - someone had to call them, maybe your team isn’t doing a great job of sharing their consult thought process? It also sounds like the EM folks are more proactive at your institution than many others. For example, I’ve never had a patient where EM consulted ID for us, that’s almost always a consult placed by the primary team as part of their own work up. Not a knock on EM - their job is to stabilize, diagnose what they can, and consult the right people to keep the patient alive. Most ID consults are sick but not actively crashing (if they’re crashing, EM/critical care is gonna be managing that part) so they can wait until a patient gets to the floor. Exceptions being stuff like mucor or nec fasc, but even then the emergent consult is going to be ENT/surgery before ID

ID is a GREAT service to rotate on though if you like big long discussions of wide differentials for unexplained fever/lymphadenopathy/“weird symptoms”. I find that super fun and house like. But you’ll also have lots of “MRSA bacteremia, please give antibiotic recs and tell us if we need an echo” consults too

 

[throwaway123342]

I agree. EM does not get enough credit for what they do. In order to admit a patient you need an admitting diagnosis. 99% of the time this diagnosis is the same as the discharge diagnosis. Internal Medicine usually just deals with management and intra-admission complications. If those complications or management questions are too difficult, they just consult.

I will say that the fun of IM depends on culture. At my institution the culture is to let the intern run the show and the senior advises them. The attending sits in the background. When we consult, we truly are asking for recommendations. We don't just automatically follow what they suggest if we disagree. etc.

 

[VA Hopeful Dr]

I agree. EM does not get enough credit for what they do. In order to admit a patient you need an admitting diagnosis. 99% of the time this diagnosis is the same as the discharge diagnosis. Internal Medicine usually just deals with management and intra-admission complications. If those complications or management questions are too difficult, they just consult.

I will say that the fun of IM depends on culture. At my institution the culture is to let the intern run the show and the senior advises them. The attending sits in the background. When we consult, we truly are asking for recommendations. We don't just automatically follow what they suggest if we disagree. etc.

That's how it was on the IM service when I was in medical school.

 

[GoSpursGo]

Beyond even the school, I think the rotation site plays heavily into how you experience IM. For example, the medicine team did a lot of the management at the county and VA hospital, but at our private hospital everyone got a consult for everything

 

[Spetzler-Martin]

I agree. EM does not get enough credit for what they do. In order to admit a patient you need an admitting diagnosis. 99% of the time this diagnosis is the same as the discharge diagnosis. Internal Medicine usually just deals with management and intra-admission complications. If those complications or management questions are too difficult, they just consult.

I will say that the fun of IM depends on culture. At my institution the culture is to let the intern run the show and the senior advises them. The attending sits in the background. When we consult, we truly are asking for recommendations. We don't just automatically follow what they suggest if we disagree. etc.

I remember an attending telling me that the best place to do your training is in the midwest (assuming they mean close proximity to rural locations). Apparently, residents get to do more specialist type work in those locations.

 

[Mad Jack]

Really good points. I also concede that what's "fun" is purely subjective. I think a part of me was expecting internal medicine to be like an episode of House MD, thus the ultimate letdown. lol

Most of medicine is routine. Even with that being said though, there are fields where you get sent the weird stuff. Child neurology comes to mind as such a field, I've done some rotations and just about every day there's something interesting no one else could figure out on the schedule. Adult neurology is a bit different and tends to be more routine overall, but diagnosing those lesions would probably stay fun until it became routine. Infectious disease and rheumatology have their challenging cases as well, but again, even in these three fields 90% of the work is routine and 10% is zebras. Psychiatry actually appealed to me because of the diagnostic and treatment challenges, as hearts are hearts and kidneys are kidneys but every mind is very different. Our answers, however, are often not as concrete as some doctors would like.

 

[guytakingboards]

I remember an attending telling me that the best place to do your training is in the midwest (assuming they mean close proximity to rural locations). Apparently, residents get to do more specialist type work in those locations.

Yeah, any more resource limited place like a rural location, county hospital, or VA is typically going to be a better training environment. Flip side it can also blow to have to deal with everything yourself.

 

[Redpancreas]

I doubt the specialists are just signing themselves up for random patients - someone had to call them, maybe your team isn’t doing a great job of sharing their consult thought process? It also sounds like the EM folks are more proactive at your institution than many others. For example, I’ve never had a patient where EM consulted ID for us, that’s almost always a consult placed by the primary team as part of their own work up. Not a knock on EM - their job is to stabilize, diagnose what they can, and consult the right people to keep the patient alive. Most ID consults are sick but not actively crashing (if they’re crashing, EM/critical care is gonna be managing that part) so they can wait until a patient gets to the floor. Exceptions being stuff like mucor or nec fasc, but even then the emergent consult is going to be ENT/surgery before ID

ID is a GREAT service to rotate on though if you like big long discussions of wide differentials for unexplained fever/lymphadenopathy/“weird symptoms”. I find that super fun and house like. But you’ll also have lots of “MRSA bacteremia, please give antibiotic recs and tell us if we need an echo” consults too

This stuff varies across hospitals and different institutions. At one program I was at EM consulted everyone from Surgery to Endocrinology. At another place it was left to the primary team and the triaging attending’s roles differ across institutions. There’s different reasons for why these decisions are made and one way isn’t particularly better than another.