Do Surgeons have the diagnostic skills/capabilities of IM physicians?

[Archdelux]

Just looking for opinions from physicians across the board.. (ie this is in reference to skills/capabilities acquired through residency training / med school; not skills inherent to the individuals).

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[Winged Scapula]

Just looking for opinions from physicians across the board.. (ie this is in reference to skills/capabilities acquired through residency training / med school; not skills inherent to the individuals).

Surgeons are better at diagnosing surgical diseases and internists are better at diagnosing medical diseases, for the most part and especially true when the disease is an unusual one.

But surgeons do not lose their ability to diagnose common medical illnesses anymore than an internist forgets the basics of diagnosing common surgical diseases.

 

[Archdelux]

Thanks for your response. Diagnosing common medical illnesses are a result of surgical/IM residency training or medical school? In other words, would surgeons have as much (or more or less) ability as, say, a neurologist to diagnose common medical illnesses? Does this also hold true for the immediate specialties in surgery (urology, nerosurg, oto, ortho, etc.)?

 

[Blade28]

A very diplomatic answer!

Edit: to the OP, are all these questions a way for you to decide what specialty to go into?

Because the best advice to that end is, do well on your MCAT, keep an open mind in med school, and see what rotations you like.

 

[Archdelux]

No, they are not really designed to help me or anyone decide on a specialty--I'm just curious as to what the consensus is. I'd like to get a better idea of the types of skills learned/retained at various points along different specialty paths. I'm using IM as a standard, as IM seems to be the traditional medical doctor with the training to diagnose and treat many illnesses across the board. ... Thoughts?

 

[docB]

I'm always up for a good discussion but this isn't it. Doctors train to be the best in their area. That training also should teach them when to defer to someone who is better at another area. To start throwing around the gross generalizations that would be the only responses to this question would be pointless.

 

[Archdelux]

Yes you are right--However, I merely wanted to start a discussion on the extent to which doctors in certain specialties are capable (given their training) to practice 'general' medicine. For example, I get the feeling that in Optho, one is extremely specialized and say, 5 years into the specialty, it is often difficult to practice 'generally' (ie as a hospatilist/IM doc). Similarly, I was wondering which specialties have sufficient general training such that it is within their capabilities to diagnose/treat general medical cases.

Another way to put it is--which specialties take you furthest away from general medicine?

 

[gutonc]

Another way to put it is--which specialties take you furthest away from general medicine?

Everything that's not general medicine, including many medicine subspecialties. It's just the nature of the beast these days. There's too much to know in any one specialty to be good at more than one of them.

 

[Gfunk6]

Another way to put it is--which specialties take you furthest away from general medicine?

Sub-specialties w/ one or zero years of general medicine.

1. Pathology (0 years gen med)
2. Radiology (1 year gen med)
3. Psychiatry (~0.3 years gen med)

These are probably the big three residencies that are furthest removed from general medicine. There are other specialities of course, with similarly limited gen med exposure (Dermatology, Radiation Oncology, Orthopaedic Surgery, Ophthalmology, Physical Medicine and Rehabilitiation, etc).

The best "general practioners" (e.g. who can do many things, jack-of-all-trades), would probably include:

1. Family Medicine (possibly w/ an OB fellowship)
2. Internal Medicine
3. General Surgery (particularly in rural/underserved areas)

Ultimately, the bottom line is this. Nobody should practice general medicine who has not explicitly trained to do so. In other words, I would not want my surgeon tinkering with my outpatient medications for hypertension and diabetes any more than I would want an Internist removing my inflamed appendix.

 

[MacGyver]

Surgeons are fond of the following quote (which I think is total bull**** by the way):


"A surgeon is an internist who has completed his training"

 

[Bertelman]

Sub-specialties w/ one or zero years of general medicine.

1. Pathology (0 years gen med)
2. Radiology (1 year gen med)
3. Psychiatry (~0.3 years gen med)

This is the best way to consider your question. Realize that a few of the subspecialties wil be introduced to NO general medicine beyond medical school, and many subspecialties will only have a few months. So asking a pathologist to see your general medical complaint is like asking an MS3 at best.

Something else to consider is the breadth of patients seen by the practitioner. A general surgeon will not just see surgical cases. He/she will see patients with possible surgical issues, but will be able to rule them out, thus being exosed to a much wider variety of patient population than even a cardiothoracic surgeon or neurosurgeon.

And as bright as any of these folks may have been during their internship, the reality of medicine these days is that treatments change often enough, with new drugs or new studies, such that by probably ten yars out of medical school, if you haven't seen enough of asthma, CHF or the like, you may be able to diagnose it, but your treatment plan will be outdated.

 

[doc02]

Surgeons are fond of the following quote (which I think is total bull**** by the way):


"A surgeon is an internist who has completed his training"

Yeah, I'm a surgical intern and I hate it when colleagues say this. It usually makes me spray them in the face with coffee. We have equivalent diagnostic skills with SURGICAL ENTITIES. Medical residents don't know jack about surgery and I don't expect them to. I know very basic medicine that applies to surgical patients, but nothing more.

I don't know why people feel the need to pretend that they are what they are not.

(Cheap shot at EM withheld since I'm in a good mood today.)

 

[Blade28]

I'm always up for a good discussion but this isn't it. Doctors train to be the best in their area. That training also should teach them when to defer to someone who is better at another area. To start throwing around the gross generalizations that would be the only responses to this question would be pointless.

Well said.

 

[Llenroc]

Everything that's not general medicine, including many medicine subspecialties. It's just the nature of the beast these days. There's too much to know in any one specialty to be good at more than one of them.

Some doctors always remain very good at all the "basic" Internal Medicine stuff, which includes Cardiologists, Nephrologists, and cancer doctors.

 

[elwademd]

Some doctors always remain very good at all the "basic" Internal Medicine stuff, which includes Cardiologists, Nephrologists, and cancer doctors.

considering that cardiologists, nephrologists, and hematologists/oncologists (cancer doctors) have to complete an internal medicine residency before going on to their respective specialties, i would hope that they remain good at the "basic" internal medicine stuff!

 

[doc02]

Some doctors always remain very good at all the "basic" Internal Medicine stuff, which includes Cardiologists, Nephrologists, and cancer doctors.

Um, this is actually incorrect. Cardiologists, for example, are of course very good at anything dealing with their field (which is, admittedly, very broad). They'd probably faint if you asked them something about lupus, however.

As a medical student, I was on a team with the hospital's head of the GI department. One day, she told me, off the top of her head, the entire synthetic pathway for bilirubin. But a few minutes later on a different patient, when we were going through his med list, she didn't know what an ARB was. (She asked the fellow what cozaar was and I told her it was an ARB and she was like, "what's that?" I thought she was pimping me until she started to look it up on the computer.)

Specialists are fantastic in their field. Not so much outside of it, however.

 

[doc02]

By the way, one story about Cardiology I have to share. One Cardiologist I worked with as a medical student was fantastic at EKGs. It was literally astounding watching him. He could actually put together all the vectors of all the waveforms to tell you not just WHAT abnormality the patient had, but he localized it fairly well, too. (We subsequently verified it with further testing.) I was always in awe of him. That guy could have told me that he didn't know what the colon was and I'd still respect him.

 

[AmoryBlaine]

Yes you are right--However, I merely wanted to start a discussion on the extent to which doctors in certain specialties are capable (given their training) to practice 'general' medicine. For example, I get the feeling that in Optho, one is extremely specialized and say, 5 years into the specialty, it is often difficult to practice 'generally' (ie as a hospatilist/IM doc). Similarly, I was wondering which specialties have sufficient general training such that it is within their capabilities to diagnose/treat general medical cases.

Another way to put it is--which specialties take you furthest away from general medicine?

It's not a bad question you're asking, but you should understand that the only people who practice "general medicine" are family physicians and general internists.

I know that in medical school there is a great fear among some students of "forgetting" general medicine - this seems to be one of the reasons alot of people chose things like IM, FM, and EM. Keep in mind that while you will probably "forget" alot of gen med as an ophthalmologist or pathologist, you are going to replace it with an intricate and impressive expertise.

 

[jocg27]

Sub-specialties w/ one or zero years of general medicine.

1. Pathology (0 years gen med)
2. Radiology (1 year gen med)
3. Psychiatry (~0.3 years gen med)

These are probably the big three residencies that are furthest removed from general medicine. There are other specialities of course, with similarly limited gen med exposure (Dermatology, Radiation Oncology, Orthopaedic Surgery, Ophthalmology, Physical Medicine and Rehabilitiation, etc).

.

This is the best way to consider your question. Realize that a few of the subspecialties wil be introduced to NO general medicine beyond medical school, and many subspecialties will only have a few months. So asking a pathologist to see your general medical complaint is like asking an MS3 at best.

Something else to consider is the breadth of patients seen by the practitioner. A general surgeon will not just see surgical cases. He/she will see patients with possible surgical issues, but will be able to rule them out, thus being exosed to a much wider variety of patient population than even a cardiothoracic surgeon or neurosurgeon.

And as bright as any of these folks may have been during their internship, the reality of medicine these days is that treatments change often enough, with new drugs or new studies, such that by probably ten yars out of medical school, if you haven't seen enough of asthma, CHF or the like, you may be able to diagnose it, but your treatment plan will be outdated.

you guys really don't think a pathologist could handle "general" medical problems?

An experienced pathologist would be just as useless as an m3 in handling general medical problems? This sounds absurd to me...I don't know, maybe I am overestimating pathologists? Do you really think they just throw their diagnoses out there with a medical student's level of understanding of how they're managed?

 

[skypilot]

you guys really don't think a pathologist could handle "general" medical problems?

An experienced pathologist would be just as useless as an m3 in handling general medical problems? This sounds absurd to me...I don't know, maybe I am overestimating pathologists? Do you really think they just throw their diagnoses out there with a medical student's level of understanding of how they're managed?

When do you think the last time the pathologist 10 years out of medical school touched a stethoscope?

 

[Misterioso]

"A surgeon is an internist who has completed his training"

Yup. A fully trained general surgeon can do anything a general internist can do, plus they can also operate. I mean how difficult is it to manage the stuff internists deal with (HTN, diabetes, asthma, etc)? I'm a 4th year and I can already manage that stuff now.

 

[Top Gun]

Yup. A fully trained general surgeon can do anything a general internist can do, plus they can also operate. I mean how difficult is it to manage the stuff internists deal with (HTN, diabetes, asthma, etc)? I'm a 4th year and I can already manage that stuff now.

Okay. So does that mean when you become a surgical resident you won't call us IM residents with all kinds of consults?

 

[doc02]

The most fun I had was when my friend was on consult service for IM. I'd always call him and he'd bust on me for calling such stupid consults. Then a few hours later he'd call me with an equally stupid one. This would go on for weeks. It was pretty hilarious because we ended up trying to call the most lame consults on each other to aggravate each other (in a friendly manner). That's called good times in the hospital.

P.S. This doesn't apply to anyone in the ER, for reasons that everyone should understand. (But which I can explain if anyone really needs.)

 

[Misterioso]

Okay. So does that mean when you become a surgical resident you won't call us IM residents with all kinds of consults?

No, not "all kinds". The general stuff that a general internist can handle I will be able to handle too. But the medical subspecialty stuff that requires fellowship training, that I may have to call a consult on.

 

[Blade28]

Okay. So does that mean when you become a surgical resident you won't call us IM residents with all kinds of consults?

Well technically we only consult IM subspecialties - Renal for HD, Cards for AFib, ID for Candida glabrata, Endocrine for refractory DM, etc.

I've never heard of consulting straight IM (at least at my program).

 

[Misterioso]

Well technically we only consult IM subspecialties - Renal for HD, Cards for AFib, ID for Candida glabrata, Endocrine for refractory DM, etc.

I've never heard of consulting straight IM (at least at my program).

And there you have it.

 

[MacGyver]

Yup. A fully trained general surgeon can do anything a general internist can do, plus they can also operate. I mean how difficult is it to manage the stuff internists deal with (HTN, diabetes, asthma, etc)? I'm a 4th year and I can already manage that stuff now.

So you are equally as good at managing IM issues as someone who has completed a 3 year IM residency?

I'm calling a big fat BULL**** on that.

What you are saying is that you learn absolutely ZERO by doing an IM residency that a 4th year med student doesnt already know. I'm not going into IM, but my guess is that you are the only person on this board who feels this way.

 

[SLUser11]

So you are equally as good at managing IM issues as someone who has completed a 3 year IM residency?

I'm calling a big fat BULL**** on that.

What you are saying is that you learn absolutely ZERO by doing an IM residency that a 4th year med student doesnt already know. I'm not going into IM, but my guess is that you are the only person on this board who feels this way.

Troll feeding a troll.....

 

[danielmd06]

Yup. A fully trained general surgeon can do anything a general internist can do, plus they can also operate.

!!!!!

 

[fang]

An IM service can manage afib without a cardiology consult, renal failure without nephrology on board (until they need dialysis) and take care of a patient with IBD without GI. Surgery calls subspecialists for these things, which is entirely appropriate because presumably the pt is on the surgical service for a surgical problem, not these other issues.

 

[PeepshowJohnny]

Um, this is actually incorrect. Cardiologists, for example, are of course very good at anything dealing with their field (which is, admittedly, very broad). They'd probably faint if you asked them something about lupus, however.

Cardiology at my institution is always trying to weasel their way out of managing ANYTHING but a direct heart problem. They always try to get Medicine to be the primary service and themselves called as consult. It's kind of sad to watch former IM doctors trying to avoid managing simple problems like Diabetes in a chest pain patient. I think it's more to do with making the most money for the least effort rather than lack of knowledge though.

This hospital DOES have a general medicine consult service, however it's more for training of residents than an actual functioning service. It mainly seems to cover ortho patients (no surprise there) and those on the rehab floors.

 

[Hernandez]

Um, this is actually incorrect. Cardiologists, for example, are of course very good at anything dealing with their field (which is, admittedly, very broad). They'd probably faint if you asked them something about lupus, however.

This is specialist dependent. Many are quite smart and do remember much of their medicine training, but rightfully so they stick to their area for the most part. It makes complete sense in the areas I've rotated at as the subspecialties stay swamped with only their little area. not to mention it'd look bad to have a cardiologist on the stand before a jury defending why he's taking care of problems which he hasn't handled more than a handful of since his IM residency.

Yup. A fully trained general surgeon can do anything a general internist can do, plus they can also operate. I mean how difficult is it to manage the stuff internists deal with (HTN, diabetes, asthma, etc)? I'm a 4th year and I can already manage that stuff now.

I will say there are some very damn good surgeons out there who do actually manage basic medicine problems, but as I look at my list at 4 in the morning, I can't help but notice that in this hospital at least, there is a nice section of medical consults for medical management with many patients having HTN requiring a single antihypertensive medicine. This approach by surgery is not uncommon at all, and at some institutions can border on abuse of the medicine service.

No, not "all kinds". The general stuff that a general internist can handle I will be able to handle too. But the medical subspecialty stuff that requires fellowship training, that I may have to call a consult on.

If ya say so.

Well technically we only consult IM subspecialties - Renal for HD, Cards for AFib, ID for Candida glabrata, Endocrine for refractory DM, etc.

I've never heard of consulting straight IM (at least at my program).

I hope your training does provide you with the opportunity to learn to manage these conditions to a basic level. It would be nice if we all worked together a bit better and didn't try to dump on our fellow services so much.

 

[OTD]

I can count on one hand the number of times I have consulted IM for anything at our Surgical program. (General IM).

If we have DM refactory to our treatment, or severe HTN with multiple medications and we have trouble controling it then we will (those are the two that I consulted them on). About two other times we have consulted them for general medical management when someone had multiple problems in several systems, CHF/HTN/Renal/ etc.

Greater than 90% of the time we manage the surgical and medical problems on our patients during their hospital stay.

Cardiology after MI or Nephrology with dialysis patients etc those things are automatic consults but otherwise we handle it ourselves.

 

[Winged Scapula]

I hope your training does provide you with the opportunity to learn to manage these conditions to a basic level. It would be nice if we all worked together a bit better and didn't try to dump on our fellow services so much.

I cannot speak for Blade, but it appears to me that his service consults appropriately.

He is not talking about consulting Renal for oliguria, but rather for patients that are likely to need dialysis. Would you want a non critical care trained surgeon writing your HD orders?

Same for Endo. I'm sure he and his team are perfectly comfortable managing DM, even placing patients on insulin drips. However, as he noted, some patients are refractory and its a good physician who recognizes that he needs additional help from a specialist and in those cases, warrants an Endo consult.

Finally, again I am fairly sure he is comfortable managing A-Fib. However, new onset A-Fib may require a Cards consult depending on hospital policy and given that the patient may very well need a cardiologist after discharge, it seems not an unwise consult to ask for. Does he know what the cards guys will recommend? I'll bet he does.

At any rate, as noted above, most of us are trained to manage these things on our own. I don't ever recall consulting medicine while at the academic hospital. We rotated one place (a local catholic hospital run by private practice surgeons) where it was standard practice to consult the patient's medical doctor or one of the local groups for "med management" or in the ICU, "vent management". I hated doing that because I could do the work in most cases, but it was sort of a "I'll scratch your back, you scratch mine" relationship between the surgeons, hospitalists, CC guys and IM groups there. IMHO it was ridiculous to charge for consults when the work could have easily been handled by the surgeons.

 

[Hernandez]

I cannot speak for Blade, but it appears to me that his service consults appropriately.

He is not talking about consulting Renal for oliguria, but rather for patients that are likely to need dialysis. Would you want a non critical care trained surgeon writing your HD orders?.

I'm not saying that it's never appropriate to consult medicine, I'm saying at institutions I've been in, medicine would be consulted if they came in with a mildly elevated bp. and oddly enough at night all questions seem to get punted to medicine. nor am I accusing people of doing that, I know there are institution's where the services get along very well, but this isn't a universal truth.

Surgery is definitely not the only service who does this and this isn't everywhere. it's only been my experience in my hospitals that it works this way. But when I was on surgery we got so many bull**** consults from medicine that even I as a medicine intern knew were crap it wasn't funny. There was one medicine doc in particular who would reflexively consult surgery for "abd pain" if they even remotely complained of it and she'd consult before she ever saw the pts. There were 3 times in particular that I was the first one to see the pt and the abdominal pain was DKA (twice) and then another time it was C-diff. you don't need surgery for those.

The places I've rotated at, the surgeons are the prototypical jocks who only feel like cutting and if that's not the solution, then it's medicine's problem.

 

[yaah]

When do you think the last time the pathologist 10 years out of medical school touched a stethoscope?

Personally, I keep my diagnostic skills up by just having family members and friends who are not in the medical field asking me what I think about various symptoms.

Pathologists know more about medicine than you think. I know an awful lot about cancer presentation, diagnosis, assessment, disease pathology and complications, and even some treatment. Probably more in some areas than many internists. I certainly know more about interpreting diagnostic tests. Of course, much of this knowledge wouldn't really translate well to a patient setting. But does it necessarily matter? I don't treat patients. I don't manage patients. I need to know things in order to be able to interpret tests and biopsies appropriately. But other things I don't need to know.

Can I manage patients better than a med student? I have no idea. I don't care. It's irrelevant. I actually had to touch a stethoscope a couple of times last year when I was on blood bank, for what it's worth. But when I was a med student I encountered senior medical residents who had no idea how to auscultate a heart (as auscultation consists of more then listening for a few seconds, not hearing an obvious murmur, and writing "RRR S1S1 no m/r/g.") So lack of usefulness with a stethoscope is certainly not limited to pathologists!

 

[Winged Scapula]

I'm not saying that it's never appropriate to consult medicine, I'm saying at institutions I've been in, medicine would be consulted if they came in with a mildly elevated bp. and oddly enough at night all questions seem to get punted to medicine. nor am I accusing people of doing that, I know there are institution's where the services get along very well, but this isn't a universal truth.

Surgery is definitely not the only service who does this and this isn't everywhere. it's only been my experience in my hospitals that it works this way. But when I was on surgery we got so many bull**** consults from medicine that even I as a medicine intern knew were crap it wasn't funny. There was one medicine doc in particular who would reflexively consult surgery for "abd pain" if they even remotely complained of it and she'd consult before she ever saw the pts. There were 3 times in particular that I was the first one to see the pt and the abdominal pain was DKA (twice) and then another time it was C-diff. you don't need surgery for those.

The places I've rotated at, the surgeons are the prototypical jocks who only feel like cutting and if that's not the solution, then it's medicine's problem.

Gotcha...that does sound like a royal pain and that you need to rotate at some different hospitals where the surgeons are more interested in managing the entire patient. I frequently see Orthopods do the above (which reminds me of a story of an inappropriate consult to gen surg, but I'll leave that for another time in favor of...)

Reminds me of an "abd pain" consult I got recently on an obese woman in the vent unit of a local Rehab Hospital. Both the hospitalist and (I think) the Nephrologist had examined her abdomen and decided that she needed a surgical consult for pain (she was sedated and unable to communicate but apparently had winced when examined).

I examined her and found her abdomen totally benign. Another surgical attending did the same. All labs were normal. Vitals were normal. The hospitalist had ordered a CT scan before consulting us. It was normal.

I came back later in the day to reexamine her and her talkative husband was in the room. I again examined her, this time in front of him, and found her examine to be benign. He apparently was there when both the hospitalist and nephrologist examined her and demonstrated to me that I was "doing it wrong". He proceeded to show me the pointy hand, stabbing motion in an upwards fashion below both rib cages that the specialists had used to show her "pain". I reasoned that anyone, even he and I, would grimace if someone had assaulted us in similar fashion.

At any rate, all specialties have their complaints about bogus consults. And I can understand when you have an intubated sedated obese patinet on TPN, HD and steroids that it can be a difficult assessment. But please do not assault the patient on routine exam and then call it abd pain worthy of a consult.

Blade and I have trained in similar fashion where medicine or its subspecialty consults are rarely done except for critically ill patients, new diagnoses or major multi-system failure (which is generally covered in the critically ill category).

Its a "Sign of Weakness" to consult Medicine!

 

[Hernandez]

Oh I've got another crap surgical consult from medicine. "consult dr cut-em re: elevated lactic acid, r/o colonic ischemia" oh by the way, she was status post a 30 minute code.

 

[Winged Scapula]

Oh I've got another crap surgical consult from medicine. "consult dr cut-em re: elevated lactic acid, r/o colonic ischemia" oh by the way, she was status post a 30 minute code.

Hmmm...perhaps "whole body ischemia"? Better consult Neuro too for that brain ischemia and renal for kidney ischemia and...

 

[Blade28]

I hope your training does provide you with the opportunity to learn to manage these conditions to a basic level. It would be nice if we all worked together a bit better and didn't try to dump on our fellow services so much.

I'd like to think so. We can certainly place VasCaths and prepare patients for HD - heck, if we're using CVVHD we don't even need a Renal consult. Traditional HD, yes.

New-onset AFib mandates a Cards consult, I believe. Chronic rate-controlled AFib, obviously not.

And we have to consult ID for some weird bugs because we need their approval for the "big gun" ABX such as Zyvox, ampho, Tygacil, etc.

We can manage insulin drips just fine - it's just these super-refractory patients (e.g. the liver transplant patient on super-high doses of prednisone for acute rejection) where we need help titrating insulin regimens in preparation for discharging the patient home.

 

[OTD]

"sign of weakness". LOL

That's kinda how it is here too, a consult is a last resort thing and only for something that is very complicated/unusual that we don't take care of every day.