Disrespecting other specialties

[pags]

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It's been an interesting 4th year in many ways. I've found many attendings, especially in medicine, have respect for some fields and little respect for others. In my travels, it seems to me that ER docs and radiologists get disrespected most often in the hospital. Reasons I've heard are that ER docs are glorfied triage nurses and are weak physical examiners, and radiologists know nothing about real medicine and can be socially inept. I was told by a friend of mine that her PM&R uncle feels that radiology is the least respected medical field out there. I never heard of that before.

Any thoughts, comments, or concerns?

 

[neutropeniaboy]

I've heard the same things about ER physicians and radiologists. The same bit about ER docs being primary care guys who take care of people with the flu or take 6 hours to finally treat someone with meningitis.

I kind of feel the same way about the newer ER physicians. Older ER physicians were internists or surgeons -- physicians who actually knew a thing or two about medicine and long term patient management. Now, I can't tell you how many young adults with a low grade fever, mild cough, and small patch of hazy lung are admitted with pneumonia; honestly, the patient can't understand and neither can I why they are admitted. Looking at the ER notes for a patient is a disaster. The histories are poor and so are the exams. Maybe it's because they're so busy or are truly becoming a triage service for medicine or surgery.

Regarding radiology, I used to think that way about the doctors reading films, but then I got a bit of insight during my radiology rotation: they get handed a patient and a history that says something like "Hx of cough" and everyone expects a radiologist to make a diagnosis based on a ****ty history. Garbage in, garbage out.

I also hear a lot of bad things about family docs, but I have a lot of respect for them since their scope of knowledge has to be huge, and I can completely understand why it isn't very deep sometimes.

And, of course, surgeons are pretty much hated by everyone, including surgeons... 🙄

•••quote:•••Originally posted by pags:
•It's been an interesting 4th year in many ways. I've found many attendings, especially in medicine, have respect for some fields and little respect for others. In my travels, it seems to me that ER docs and radiologists get disrespected most often in the hospital. Reasons I've heard are that ER docs are glorfied triage nurses and are weak physical examiners, and radiologists know nothing about real medicine and can be socially inept. I was told by a friend of mine that her PM&R uncle feels that radiology is the least respected medical field out there. I never heard of that before.

Any thoughts, comments, or concerns?•••••

 

[Voxel]

Weak physicians get disrespected no matter what their specialty. This is hardly a problem for people who are PGY-3-4 in their field and beyond, although it does happen.

I think a big problem is that docs should understand other doctors' role in medicine. Once that happens, there should not be disrespect, if the physician is competent in their area of expertise. This also means that they can be less knowledgable in other fields, without being disrespected.

Here's some reasons why ER physicians have it tough.
1)First, ER physicians consult every sub-specialist who knows more than the ER doc in their area of expertise. So if an ER doc does not know something or did not think of something, some sub-specialist look down on ER or any other physician they come across. Pure Ego.
2) Hindsight is always 20/20. Much harder to do when you are in the trenches with a noisy ER juggling multiple patients simultaneously. Sub-specialist have it easier if the diagnosis was made or some diagnoses were ruled out and more information is available now than when the patient arrived in the ER.
3) The ER physician is under tremendous pressure to get people admitted or discharged. If they spent as much time as 3rd year medical students with their patients, the waiting time for ER visits would go through the roof. There is also pressure to admit soft conditions so the hospitals fill their beds, that why someone with quasi-pneumonia can be admitted. This usually comes from hospital administrators.
4) The ER physician is under a lot stress from malpractice lawyers if they miss anything that could have possibly been missed, even though the odds were low. That's why we have "abdominal pain r/o everything" on the CT request by ER physicians or their nurses. Granted ER docs should do a physical exam, but thinking goes, why not put the patient in the CT and if there's nothing there or the radiologist misses it, then I am off the hook and the patient can get some maalox and go home, assuming all other tests came back negative. This is also a reason why many specialist get consults from other specialists for relatively simple things. Hand it over to someone else and let them take care of problem X and let them worry about getting sued for X. There is also something known as a referral economy as well.

Lastly, if there was a true emergency such as a running a code or stablizing a patient, I'd want the ER doc to do it or someone from the ICU. As a diagnostic radiologist, I'm not as good as the ER physician, because they do this on a daily basis. They are well trained and use those skills often.

 

[Freeeedom!]

Yep everyone is stupid and everybody hates each other.

The End.

 

[Voxel]

Part 2.
I think a big problem is that docs should understand other doctors' role in medicine. Once that happens, there should not be disrespect, if the physician is competent in their area of expertise. This also means that they can be less knowledgable in other fields, without being disrespected.

Radiologists getting disrespected.
1) Diagnostic radiologists have little patient contact, so some physicians think that if you do not have patient contact that you should not be respected. Also, you are not in the trenches dealing with some really nasty people/patients. Pathologists sometimes get lumped in as well.

2) Diagnostic studies have overlap of findings. Most physicians when ordering a imaging scan want a definitive diagnosis and think that imaging modalities always give clear cut answers, even though there is overlap in pathology. So radiologists tend to hedge (the national plant of the radiologist). Mostly it is a CYA just like the ER physicians. However, sometimes the overlap is so significant that things need to be followed clinically or by other means over time. Radiology is not perfect. The problem comes when weak radiologists use the hedge as a crutch all the time; this is unacceptable. You are paid to give your impression and in your impression one should give the most/more likely diagnosis if at all possible.
3) Diagnostic radiologist rarely treat disease and mostly just diagnose. Some docs think that only people who give treatment are real doctors. Again not understanding people's role in medicine.

4) There is still a prevailing myth that most radiologist are 9-5 and never take call and never get woken up from their nice cosy bed. Maybe 20 years ago, but not today. This is especially untrue for partners in a practice that covers the hospital(s)' ER. Call can be brutal (without residents like in academia) and then you have to work the next day if it's the weekday or your turn to be on weekend.

I've found that really intelligent and understanding clinicians find us to be useful consultants.

As a consultant, radiologists should try to understand things from the referring physician's side and provide great service to the referring physician. Then the level of disrespect can decrease.

 

[dr.evil]

•••quote:••• And, of course, surgeons are pretty much hated by everyone, including surgeons... ••••<img border="0" alt="[Pity]" title="" src="graemlins/pity.gif" />
Ah, neutropeniaboy, why did you have to go and say something like that. Out of the middle of nowhere you have to bust on surgeons. I'm feeling no love. maybe people don't hate surgeons, maybe they're envious of surgeons. :wink: or maybe not but I'll let my ego believe it's envy.

Anyway, it seems every specialty is disrespected by some other specialty or group. Surgeons don't like internal med guys and vice versa. heck, I don't know if internal meds like anyone who's not internal med. This is one of the reasons I really didn't like my medicine rotation. I felt that they always felt superior but somehow had to prove that they were. but anyway. i could go on and on about which specialties ridicule other specialties (and of course this is not universal) but it's not worth the time.

Every specialty has its value and no one specialty is more respected than another (actually, that's not true. All surgical specialties are the most respected fields in medicine but I may be biased 😀 ).

I agree that it has been interesting over the past 2 clinical years to see each specialty's view of other specialties. Pretty interesting. Just goes to show that we're all a bunch of egomaniacs. <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />

 

[wandering_scholar]

All bad physicians have a tendency to disrespect other specialties. Good physicians see the necessity of the strengths and weaknesses of each specialty.

Internists think surgeons are mechanics. Surgeons think internists are geeks that are afraid to look under a bandage. Everyone thinks radiologists are little hermits that hang out in dark rooms. Anesthesiologists are technicians. Orthopedists are dumb jocks. ER docs are triage nurses. Neurologists are great diagnosticians but don't cure anyone. Plastic surgeons are money grubbers. etc, etc, etc

In more support of ER docs (go Voxel!) I will quote a very wise physician.

"The last doctor to see a patient is the smartest one"

ER docs see the patient first with nothing to go on. (frequently) Many times a patient will be seen by ten docs, from primary care to ER to consultants to whatnot, and the last doc will look at all of the notes of previous ones and say "ah-ha!" not because he is smarter but because he has a better perspective.

They don't see it as their job to work up a patient, merely stabilize and TURF (a la House of God). Better ER docs will actually do a good Hx and PE, but they're not really trained to diagnose or treat anything other than emergencies or very minor problems.

 

[Goofy]

Voxel,

I largely agree with your comments about ER physicians. I emphatically disagree with your comments about ER physicians running codes. Certainly they are a viable option, but any half decent internist should be able to handle this rather 'bread and butter' emergency with ease. Patients on the floors code far more often than they do in the emergency room. There is a lot of great emergency medicine being practiced way above the ER. Anyone who has gone through surgical training has at least as much, if not more experience running codes. Certainly any physician who has trained in critical care has ample training to 'run a code.'

There are fields that aren't exposed to this type of emergency as completely, for example radiology, pathology, dermatology etc... But ER phsyicians don't have the market cornered on 'running codes.' In fact other disciplines have more experience.

ER physicians are great because they function best in this high pressure and disorganized environment, but while they are experts in running codes, they are not THE only experts.

 

[Freeeedom!]

K, you have to be friggin KIDDING ME!!! An internist running a code??? HAHAHAHAHAHA IM guys are funny!
Yeah, I've seen a few internists running codes and I have seen EM docs running codes. Big difference, sorta like triple A and major league players...both are good but which one do you want on your office softball team!?
I have seen IM docs move out of the way when an EM doc walks in the room or when an EM resident is on the service for the month...the EM guy is in charge of all codes. Happens everywhere!
IM guys are funny!

 

[rastelli]

As young docs/soon-to-be-docs, it would be fantastic and in all of our best interest to remember these observations later in life. I've never understood the rivalry between various specialists. The warm-fuzzy notion that we need all specialists for adequate patient care is completely appropriate.

 

[navs]

There are some great points that have been made.

I just wanted to make the comment doctors no matter what specialty have one thing in common, they are all members of the human race. And being "human" means having flaws as: jealousy and arrogancy.

Many specialties that don't get "respect" are fields that are either envied by other fields, due to whatever reason, either they are: "cushy" or are viewed to being payed more then they deserve.

Then comes arrogance. Every doc due to spending so many yrs. learning his field (3+yrs) obviously is very biased in thinking their field is the hardest.

In the end, no matter what others say about a particular field u should go into it or not go into it due to what YOU feel about the field, not what others will think of u in the future.

And love the comment about it should start with us to realize and start respecting each field has their own difficulties, so we can change some of these stereotypes in the future!!

Good luck.

 

[Arch Guillotti]

An internist running a code as well as an ER doc. Now that's a laugh. <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />

 

[Voxel]

About running codes, notice I said ER or ICU doctor. I think that general internists practice in the outpatient setting for the most part. While they do have training running codes, for most of them it's been a long time since they have run a code. For the ER physician, codes are run probably atleast once per day if not much more than that. For the ICU physician probably with close to the same frequency, but maybe less or more. I think people who are good at doing something and do it day in and day out are better than someone who has not run a code in 1-10 years. Most private general medicine attendings do not run codes daily or monthly for that matter. So while I believe that an private general internal medicine physician could run a code better than I diagnostic radiologist, I think those that do it more frequently should be the ones to do it. This is not a knock on general internists, but just a fact of life.

 

[A little elf]

As a fourth year hopefully matching in EM in 2 weeks, I really can't see why people like to come down on EM docs so much. Like radiology, extremely good med students are going into EM. An EM doc is NOT a glorified triage nurse, I highly doubt any of those who say they are have ever rotated in an ER with a large volume. I've got nothing but love for the other professions...it's only a matter of time before people start giving EM the respect it deserves.

 

[Goofy]

•••quote:•••Originally posted by Voxel:
•About running codes, notice I said ER or ICU doctor. I think that general internists practice in the outpatient setting for the most part. While they do have training running codes, for most of them it's been a long time since they have run a code. For the ER physician, codes are run probably atleast once per day if not much more than that. For the ICU physician probably with close to the same frequency, but maybe less or more. I think people who are good at doing something and do it day in and day out are better than someone who has not run a code in 1-10 years. Most private general medicine attendings do not run codes daily or monthly for that matter. So while I believe that an private general internal medicine physician could run a code better than I diagnostic radiologist, I think those that do it more frequently should be the ones to do it. This is not a knock on general internists, but just a fact of life.•••••Voxel,
My point was that by the end of an internal medicine residency, internists are fully trained to run codes. The ICU provides MORE exposure to this sort of thing than the ER.

Another point, running a code isn't anything particularly challenging. It's algorithmic medicine at it's best and most patients, over 99% wont make it no matter what you pump in. Treating diabetes offers more in the way of intellectual challenge in my opinion (not that I enjoy treating diabetes, but I have run over 30 codes and treated diabetes even more often than that).

I have worked in several different ER's and I can tell you that Codes aren't nearly as common as one might think, at least in my experience. We had far more gunshot, stab wounds than actual codes. Even on the codes, most of the resuciation has already been done in the field. Not much glamour in my opinion.

In the ICU, you have the opportunity to act immediately as patients are wired every which way but loose. Granted there is a high mortality rate here, but my only saves came in this setting.

 

[EidolonSix]

ACLS certification is a requirement for most practicing physicians, although, for the most part, a majority of physicians will not run a code routinely, unless they have a significant Hospital/ER/ICU practice. The ACLS guidelines are just that....guidelines, which, unlike standards are care, have a degree of flexibility within them. The ability of a physician to dabble with this "cookbook" and be successful is really dependent on experience, much like the rest of medicine. However, the fact remains that the overall success rate of ACLS (including in hospital and community codes) is still only 5-6%, except in Seattle, where, with a more advanced EMS response system, has been reported percentages as high as 20%. In nursing homes, the success of getting patients back w/ ACLS, etc. approaches 0%.
What does this mean....well it just confirms what we already know, no matter what kind of physician you are....the odds are against you, and a dead patient has a good likelihood of staying dead. However, obvious things can be pointed out. ER physicians/ traumatologists function in an environment of acuity....and in a code situation in an ER, would probably have statistically higher chance of doing a successful code....given the understanding of the protocols in that setting. Similarly, an intensivist in the ICU might have better luck in his/her own setting. A general internist who functions as a hospitalist or has a significant hospital practice may also have success w/ the code. Ultimately, experience is a guide. If I coded on the table for an interventional radiology procedure, I'd expect my radiologist to understand and use ACLS guidelines in my care....not to say that he should fly solo, but at least know the cookbook. Fortunately, there is one set of ACLS protocols and one set of ATLS protocols, as to avoid this argument of who has the best way.

I have in the past, I have approached my defense of medicine rather childishly. Ultimately, I believe the facts help decide. Most specialties have their place in the great scheme of medicine, and although they have a great variety of knowledge bases, they arise from a common medical language, grounded in the sciences. Members of this forum are quick to belittle anyone with a generalist title or is undertaking the broad diagnostic and therapeutic challenges that face ER physicians, FP, and internists. As practicing professionals, we have all witnessed bad doctors. I have personally seen orthopaedists misdiagnose and mis-treat a massive stroke in a patient, general surgeons flood a CHF with fluids, internists delay action on a septic picture, ER physicians misdiagnose obvious lobar pneumonia. This alone.....in 2 years of clinical experience. To "disrespect" (not a verb) other specialties does more to fracture the entire profession of medicine, in a time when solidarity may be our only saving grace, in the face of oppressive insurance premiums, an enormous population of uninsured patients, and a glut of lawyers scouring public records for clients and cases. I guess what I really mean to say is....don't forget who your friends are. At the end of the day....be glad the ER physician is seeing your patient acutely, be glad an intensivist is around to optimize the vent on your ARDS patient, be glad a surgeon is around to remove a pesky gall bladder, and be glad a radiologist will have depth of knowledge to see the less obvious, but no less important abnormalities on a film. :wink:

 

[Billie]

•••quote:•••Originally posted by Klebsiella:
•Voxel,

I largely agree with your comments about ER physicians. I emphatically disagree with your comments about ER physicians running codes. Certainly they are a viable option, but any half decent internist should be able to handle this rather 'bread and butter' emergency with ease. Patients on the floors code far more often than they do in the emergency room. There is a lot of great emergency medicine being practiced way above the ER. Anyone who has gone through surgical training has at least as much, if not more experience running codes. Certainly any physician who has trained in critical care has ample training to 'run a code.'

There are fields that aren't exposed to this type of emergency as completely, for example radiology, pathology, dermatology etc... But ER phsyicians don't have the market cornered on 'running codes.' In fact other disciplines have more experience.

ER physicians are great because they function best in this high pressure and disorganized environment, but while they are experts in running codes, they are not THE only experts.•••••In the small rural hospital that I have done most of my rotations in, the ER physician is the one called when a code on the floor come up. The internal med docs run around and panic and rant and rave, and the ER doc is the one that has to come up and intubate and run the code. I realize that probably doesn't happen in larger centers, but just wanted to give another perspective. In my hospital, it is the ER that runs ALL the codes. I would be petrified of one of the IM docs in my hospital would try to run a code on me or a family member. God help me!

 

[Billie]

•••quote:•••Originally posted by EidolonSix:
•... I guess what I really mean to say is....don't forget who your friends are. At the end of the day....be glad the ER physician is seeing your patient acutely, be glad an intensivist is around to optimize the vent on your ARDS patient, be glad a surgeon is around to remove a pesky gall bladder, and be glad a radiologist will have depth of knowledge to see the less obvious, but no less important abnormalities on a film. :wink: •••••VERY well said! AMEN 🙂

 

[Goofy]

Billie said:

"I would be petrified of one of the IM docs in my hospital would try to run a code on me or a family member. God help me! "

Sir, you have much bigger things to worry about than who runs your code if god forbid you or a loved one is in this situation. Running a code is really very simple stuff, even for brainless IM guys. It's coming through it with your life that is the hard part.

 

[Voxel]

ACLS yes, I can memorize an algorithm just like anyone else. I guess radiologists can be known for having good memories. Long term recall should still work well even after 10-20 years. As an interventional radiologist, the odds of encountering a code are much much higher than for a diagnostic radiologist. Anyway, I don't think I've ever seen ECD paddles and/or acrash cart in the the radiology department outside of the interventional radiology suites. I think you're supposed to keep some epi around for the anaphylactic contrast reactions in the CT room. It's best to say that ER/ICU has all the nice tools and could do all the stuff slightly faster than most non-interventional radiologists. Whether this actually makes a difference is debatable.

 

[Billie]

•••quote:•••Originally posted by Klebsiella:
•Billie said:

"I would be petrified of one of the IM docs in my hospital would try to run a code on me or a family member. God help me! "

Sir, you have much bigger things to worry about than who runs your code if god forbid you or a loved one is in this situation. Running a code is really very simple stuff, even for brainless IM guys. It's coming through it with your life that is the hard part.•••••Now I have an even bigger problem, You called me sir, and I am a ma'am! 😀 See, while I was under that code, the IM guy did a sex change on me! Ya just can't trust em!! <img border="0" alt="[Wowie]" title="" src="graemlins/wowie.gif" />

Sorry I couldn't resist. 😀 My point is that at my hospital there are some very poor IM docs, and some very aggressive ER docs. And the ER docs are the ones that have to come up and run the codes. I don't know how it got started that way in my hospital, but that is just the policy now. So simple or not, some of the doctors cannot do it. I have met some great IM docs at other places, so I know that is not the case everywhere.

Billie, back to her female self

 

[Goofy]

My humblest apologies Billie 🙂

 

[task]

Hi folks.

Billie, I have nothing but the utmost respect for all my colleagues -- ER, medicine, surgical, anesthesia, rads, for what their training entails and their hard earned expertise. But at my hospital, the vast majority of ER docs (attendings and residents) are frightening in terms of what they miss and what they let go. But that doesn't mean that there aren't really excellent ones. Some of the better ER attendings are ones who are double boarded or ones who trained in Medicine or Surgery in a previous life, but not all of them. We don't even allow their residents to do their MICU/CCU rotations at our main training site (a county hospital) -- they can only do them at the VA that we rotate thru. Granted, their residency program is rather new and is overshadowed by a top 5 IM program and an extremely strong Surgery program, but still. Where I train, Medicine residents wear the code pagers and the majority of the time our Surgeons defer to us in a code situation on their own patients. Not that they can't do them themselves, but Medicine people by virtue of the time we spend in our Units and what we do on a daily basis tend to have the edge in "what drug should I try next based on the rhythm I'm seeing and what the patient is doing clinically" -- a point Klebsiella addressed very well in a previous post. In the end, I think that EidolonSix's statistical point is very well taken and something that is often overlooked in any code situation.

Klebsiella makes the point that at the END of an IM residency, a well trained IM physician is probably better at coding patients than an ER doc not only because of the depth of their training but because the vast majority of code situations occur on the floors or in Units on inpatients with multiple problems that by virtue of our training we IM people put into perspective more rapidly than our colleagues downstairs -- that's what we IMs do on inpatient services. ER docs train and are much better in the delivery of acute care and in initial stabilization of the patient -- an art unto itself. Seeing a patient for the first time and deciding what their #1 problem is that might earn them a hospital admission or a celestial discharge is not easy, and as an IM trainee working in the ER I've had to fight my IM tendencies more than once to do what I reallly need to be doing as an ER person for that month.

Sure, after 20 years in private practice, a general medicine doc who spends his time running a busy pratice isn't going to be throwing lines in people and isn't going to be the first person who you'd go to in a code situation -- not for lack of training, but for lack of practice. They just haven't done the "all hell is breaking loose" patient care model for a while. My Dad is an internist who has been in private practice for almost 35 years. Does he even want to be put into a situation where he runs a code? Hell no. Can he manage a practice and see 40-50 patients in a day and deliver appropriate care. Yes. That's what happens to people when they're out of training. Nature of the beast -- you become good at what your practice pattern dictates you become good at. And the other stuff you become rusty at. Happens in all fields.