Do you allways "know" what to do, or do you have to "ponder options"?

[surftheiop]

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Sorry if this is a dumb question, but was curious about the thought process of physiatrists (and physicians in general really) once your an attending.

When confronted with a patient/symptoms, have you been trained so much and learned so much that you pretty much instantly know how to interpret the symptoms/tests/labs?

And given what you know about the patient, do you pretty much know the best treatment option right away?

How often do you have to "think hard" to figure out a diagnosis or treatment?

 

[RUOkie]

Sorry if this is a dumb question, but was curious about the thought process of physiatrists (and physicians in general really) once your an attending.

When confronted with a patient/symptoms, have you been trained so much and learned so much that you pretty much instantly know how to interpret the symptoms/tests/labs?
often but not always
And given what you know about the patient, do you pretty much know the best treatment option right away?
often but not always
How often do you have to "think hard" to figure out a diagnosis or treatment? At least weekly

I have found that medicine never gets old. And that is after 15 years. Every time you think you have seen it all, you find that something comes along that either baffles you or you need to ask for help figuring out. This week I saw a guy with complete ossification of the ligamentum flavum with cervicothoracic myelopathy. He is 33. He had a C7-T8, T10-L1 laminectomy 2 days ago.😱 a 12 hour case with two spine surgeons. None of us have found a reported case of that before (it looked like OPLL, but of the ligamentum flavum).

 

[SSdoc33]

thats a good question. quite frankly you start to be able to see how things unfold pretty quickly once you've seen enough patients. most often you run thru your treatment algorithm pretyt quickly in your head and know what to do. but ruokie is right. every now and then you get a case that makes you stop and think. for me, this is probably less than once a week. invariably, ill be thinking about it for a while, do some research, and sometimes talk to colleagues about it.

i find that this happens a lot with EMGs. they really make you think, and provide a nice break from your typical clinic/inpatient/injection day.

 

[Ludicolo]

I think hard almost every day. The way I’ve always viewed the practice of academic medicine is that I'm getting paid to think. I'm thinking about my patients, as well as about the education of students/residents/fellows training under me. I am thinking about my differential diagnosis/workup/first line treatment options as I’m talking to the patient or as I’m reviewing records or as someone is presenting to me. Yes, I still ponder. Some days though, I need to ponder harder than others.

I believe that, after developing the art and skill of pattern recognition that only comes with experience, it does get quicker and easier as an attending. I wish though I could say I’m so brilliant and knowledgeable that I know every time what a patient has and what the ideal treatment plan is before I walk into the room. With bread and butter cases, sometimes I honestly do. But funny things sometimes happen after you talk to and examine patients. Things don’t always present according to textbook. And one size does not always fit all when it comes to treatment options. And every now and then you run into a zebra. Or even a unicorn. Part of the fun of being a physician is learning and adjusting on the fly.

 

[PMR 4 MSK]

For new patients, I usually have the history already in the chart (we have people to do that), labs and MRIs, etc, along with a pain diagram, so I have a pretty good idea of what the pain generator is, what has been done and what the next steps are likely to be. Sometimes things change while in the exam room and we take a different route.

For follow-ups, it's basically are they better enough to stop treatment or keep going with the current plan of care, or do we need to change course and if so, what's the next step.

Physiatrists tend to see a lot of neck and back pain patients. There is so little really known about these, that it is almost all anecdotal experience and heuristics. What I do is probably different than what the guy down the street does, but we probably end up at the same place most of the time.

I would say 75% of the time, my assessment and plan are confirmed in the exam room and 25% take me in a different direction.

It's not unusual to be stumped and need someone else's opinion. I have a coccydynia pt today that I've tried everything I know and suggested she see an pain anesthesiologist to see if they have any better ideas. Yesterday I sent a patient to neurology after repeat EMG showed a rapidly-progressing PPN of the BUE w/o LE symptoms. I often send patients to orthopedic and neurosurgeons when I can't resolve their symptoms.

And for most of what we do, there is no "best" treatment option. There is so little research to guide us for most of what we do, it's mostly what you have learned through clinical practice.

I can interpret most labs, x-rays, spine MRIs and EMGs. If I do the EMG, I can usuaklly give a concrete dx, but some are confusing and need more thought, maybe more testing. probably 90% of spine MRI's are interpreted the same by the radiologist as how I see them, 10% of the time they see something I miss (and probably 5% of the time I see something they miss...).

I could not interpret a hip or shoulder MRI to save my soul. I've missed subtle fxs on xrays. I've seen weird stuff on MRI's and xrays, called the radiologist and s/he says "Bah, it's nothing."

If it got to the point where nothing surprised me, I'd lose my interest in medicine. But I am far enough along that my guesses are right more than they are wrong.

 

[nleeds24]

For new patients, I usually have the history already in the chart (we have people to do that), labs and MRIs, etc, along with a pain diagram, so I have a pretty good idea of what the pain generator is, what has been done and what the next steps are likely to be. Sometimes things change while in the exam room and we take a different route.

For follow-ups, it's basically are they better enough to stop treatment or keep going with the current plan of care, or do we need to change course and if so, what's the next step.

Physiatrists tend to see a lot of neck and back pain patients. There is so little really known about these, that it is almost all anecdotal experience and heuristics. What I do is probably different than what the guy down the street does, but we probably end up at the same place most of the time.

I would say 75% of the time, my assessment and plan are confirmed in the exam room and 25% take me in a different direction.

It's not unusual to be stumped and need someone else's opinion. I have a coccydynia pt today that I've tried everything I know and suggested she see an pain anesthesiologist to see if they have any better ideas. Yesterday I sent a patient to neurology after repeat EMG showed a rapidly-progressing PPN of the BUE w/o LE symptoms. I often send patients to orthopedic and neurosurgeons when I can't resolve their symptoms.

And for most of what we do, there is no "best" treatment option. There is so little research to guide us for most of what we do, it's mostly what you have learned through clinical practice.

I can interpret most labs, x-rays, spine MRIs and EMGs. If I do the EMG, I can usuaklly give a concrete dx, but some are confusing and need more thought, maybe more testing. probably 90% of spine MRI's are interpreted the same by the radiologist as how I see them, 10% of the time they see something I miss (and probably 5% of the time I see something they miss...).

I could not interpret a hip or shoulder MRI to save my soul. I've missed subtle fxs on xrays. I've seen weird stuff on MRI's and xrays, called the radiologist and s/he says "Bah, it's nothing."

If it got to the point where nothing surprised me, I'd lose my interest in medicine. But I am far enough along that my guesses are right more than they are wrong.

One of the best posts I've seen. Thank you.

 

[surftheiop]

Thanks for the responses everyone!