Idk if it's an academics thing or these stories are embellished, but as a neuro resident reading these feels like stepping into a completely different reality.
The vast majority of our stroke codes that get called aren't real strokes. Of the ones that are or could be, most of them don't get TNK anyway. Either the deficits aren't severe enough to outweigh bleeding risk, they're out of the intervention window, on blood thinners, or something else comes up. TNK can be great for specific situations, but it's often not the best next step. I don't see it given that often.
You nailed it with your first phrase. Youre in academics.
Here's the reality. when you become an attending, ESPECIALLY, if you go into a community hospital, a bunch of factors occur at the same time to rapidly degrade the quality of medicine massively.
1. some people you will interact with were just not great evidence based practitioners even in residency and they went to the community exactly so they dont have to be bound by that so tightly. They're going to do what feels right to them rather than what the data actually suggests. As an extra annoyance, everyone will love them for some reason. That's just how the world works.
2. lots of physicians are 30+ years into practice and 30+ years since they ever seriously refreshed themselves on CME and practice patterns. So they're out there just practicing the way they thought was cutting edge in 1995 or 2000. You know how you are tempted to just phone it in on some of those modules/journal clubs/lectures in residency? That desire to just phone it in and just get the certificate rather than actually learning is 50-100x higher once you're out of residency. If you try to educate these people on being out of date they will let you know that theyve been doing it this way for three decades and they havent killed anyone yet (as a point of fact: yes they have, but its impossible for them to see how many individual bad outcomes were preventable, because no one has that ability to view their practice patterns objectively across time and without ego so all bad outcomes were unavoidable in their mind).
3. In the community lots of things happen just for customer service. Lots of people (especially specialists, but I'm not excluding EM) will happily ignore good medical practice because they feel that keeping the patient alive is the #1 priority, keeping them happy is #2, and actually doing whats *best* for them is #3 or lower. If the dumb thing the patient wants is not likely to kill them but is very likely to make them think you're a great doctor - you do it even if you know better.
4. You no longer have a layer of program leadership to be a heat shield for you against the never ending supply of nurse and MBA administrators who are constantly trying to find a way to quantify, gamify, or both, every element of the medical process. And them being fully and completely wrong about stuff can still make your life a living hell because they get paid to send you emails that you don't get paid to respond to (but you have to), so for them emailing you is a fulfilling experience but its a one-way street for sure. And if they don't like your answer or you ignore them, the annoyances will go from annoying emails, to uncomfortable in person talks, to slaps on the wrist, to formal discipline in a relatively steady manner. And again - often they will be fully incorrect, but since its their job to nitpick everything you do but they don't have the knowledge to understand immediately why you didn't do what they expected you to do, their constant emails will wear down your patience to not just do the thing that leads to the least emails even when it questionable or not indicated at all.
