Dumbest things taught

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jbar

jbar

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Found this in my liver notes, feel free to put up the dumbest things you've been taught.

"Most patients with viral hepatitis exhibit typical patterns of illness. Atypical patterns are seen in a small proportion."


Glad I'm paying for the meanings of typical and atypical. Yay med school.
 
Not exactly in line with jbar's OP but here's something that kills me. In our physical exam classes I heard this probably a dozen times.

After teaching us some nonsense physical exam step like skin turgor or tactile fremitus the old prof would say something like, "you need to learn this for when you are in Guatemala and don't have a CT scanner."

I always wanted to reply, "uhh if I'm in Guatemala I hope I'm not running around making confident diagnoses based on archaic, largely useless physical exam steps."
 
AmoryBlaine said:
I always wanted to reply, "uhh if I'm in Guatemala I hope I'm not running around making confident diagnoses based on archaic, largely useless physical exam steps."
Click to expand...

"What if I don't want to go to Guatemala or some other 3rd world country?" That question was always met with blank stares from the professor.
 
GeneralVeers said:
"What if I don't want to go to Guatemala or some other 3rd world country?" That question was always met with blank stares from the professor.
Click to expand...

haha..I completely agree. I've heard them say all that too.
 
GeneralVeers said:
"What if I don't want to go to Guatemala or some other 3rd world country?" That question was always met with blank stares from the professor.
Click to expand...

I had a professor who kept asking me what I'd do if I was in the middle of Alaska and didn't have a CT scanner/x-ray/anything with me. He did the whole blank stare thing when I looked at him and said, "Why would I be in the middle of Alaska?"
 
easily the dumbest thing i've been taught besides algebra and 1st semester physics: cranial. i'm middle of the road osteopathically and i just wouldn't drink the kool-aid.
 
In the right, oldschool, 50 years of experience hands, Im sure lots of those physexam components/findings are quite useful. I think everyone had those profs in school. What I think they meant was when THEY are in honduras without modern technology, that stuff works great. Physical exam is certainly not worthless, but there is no getting around our reliance on technology, which isnt a bad thing - it is probably more accurate albeit more expensive and more often potentially dangerous to the patient.

What interests me is the question of to what degree does our medicolegal climate guide our reliance on technology? If we had a reasonably acceptable miss rate, how differently would we practice given our current technology?

I digress from the original topic, pardon.
 
Dumbest thing taught:

technology eliminates the need for old-school skills.

😎
 
The dumbest thing that I was "taught" in med school was in 3rd year. We had admitted a guy with neutrapenic fever who was on chemo for widely metestatic colon CA. As I'm presenting the patient on morning rounds and I mention that he has colon cancer the attending stops me and asks if I had assessed his risk factors for colon cancer. 😕 I thought she was kidding at first and I chuckled and said "No." Turns out she was serious and she launched into a seminar on colon cancer risk factors. To this day I'm convinced she wanted me to ask this poor dying patient if he had eaten lots of fiber in his life so I could tell him that he either was or was not at high risk for the disease that he undeniably had which was killing him. In retrospect I'd say he was "high risk" for colon cancer.🙄
 
The number one risk factor for colon cancer is the diagnosis of colon cancer.
 
I'm not justifying bugging your patients about risks for diseases they already have, but in some cases knowing the risk factors might change prognosis, like spontaneous lung CA v smoking/asbestos related. (Don't know if there is a difference in survival, just an example) Also I guess if there are no risk factors whatsoever for some diseases you might start thinking genetic causes and thinking about family screening.
 
Danbo1957 said:
Dumbest thing taught:

technology eliminates the need for old-school skills.

😎
Click to expand...

I got served! Now it's on!

I'll brace for flames but I think in many cases, in the united states, it absolutely does. Especially when those "skills" cannot lead to definitive dx but instead are more like party tricks.

I will rescind that statement if someone can tell me a situation in which a physical exam finding or lack thereof (excluding vital signs) "rules out" a dangerous condition so as to preclude imaging.

Example: 72 y/o with fevers, chills, productive cough etc etc. You can't find any focal crackles on pulm exam or any whispered pectoriloquy - do you skip the CXR?
 
Tension pneumothorax is a clinical diagnosis, and you absolutely do NOT wait for imaging 😉

AmoryBlaine said:
I got served! Now it's on!

I'll brace for flames but I think in many cases, in the united states, it absolutely does. Especially when those "skills" cannot lead to definitive dx but instead are more like party tricks.

I will rescind that statement if someone can tell me a situation in which a physical exam finding or lack thereof (excluding vital signs) "rules out" a dangerous condition so as to preclude imaging.

Example: 72 y/o with fevers, chills, productive cough etc etc. You can't find any focal crackles on pulm exam or any whispered pectoriloquy - do you skip the CXR?
Click to expand...
 
Danbo1957 said:
Dumbest thing taught:

technology eliminates the need for old-school skills.

😎
Click to expand...

👍 I'm actually surprised and a little scared that people are refering to those simple signs as "archaic." I sure wouldn't want some PGY1 missing my grandmother's poor skin turgor and not giving IV fluids so that she goes into renal failure and then the subsequent other failures.... what, are you going to wait for an ultrasound or renogram then?
 
Our evidenced-based medicine attending admitted that to date no study has proved the usefulness of EBM medicine
 
sleepymed said:
Tension pneumothorax is a clinical diagnosis, and you absolutely do NOT wait for imaging 😉
Click to expand...

If you THINK the patient has a tension pneumo, certainly needle them. I personally have diagnosed tension pneumo twice by XR and once by CT😳

Does that mean that I am a bad diagnostician? I hope to god not. But, if the patient is stable, and there are no OBVIOUS signs of a tension pneumo, it is okay to get the study (usually CXR) first. After all, tracheal deviation is the classic book teaching (trying to stay on-topic), but is not SENSITIVE [reason for edit--oops, wrong stats word] when absent. Good luck finding JVD and hyperresonance in the trauma bay... (see? I AM staying on topic!!!!)
 
sleepymed said:
Tension pneumothorax is a clinical diagnosis, and you absolutely do NOT wait for imaging 😉
Click to expand...
Quite true but there's a big difference between that and tactile fremitus. So many things on physical exam have been either discredited or are at best just a justification for the eventual work up. Examples include Homan's sign for the former and Murphy's sign for the latter.

I have to agree with Amory on this one. As much as it pains us that PE skills have taken a back seat to high tech, high cost diagnostics they have. Defensive medicine called shotgun.
 
I disagree with the tenets of this thread. Everything I was taught in medical school was absolutely necessary. I am a much better ER doctor because I was able to reconstruct the hexose-monophosphate shunt for 30 minutes before a biochem test and 60 minutes before step 1. 😉

I use physical exam skills mainly to impress the patient and make them think I care how big their spleen is. When I actually want to know if they have splenomegaly, I get an ultrasound. If I am getting pimped, or answering a test question, I say that I would measure pulsus paradoxis. If I really care if someone has a significant pericardial effusion, I get an ultrasound. If I don't want to get a chest x-ray to rule out pneumonia, I do a little more thourough exam, maybe throwing in egophany or tactile fremitus, so that I can document that it wasn't present. I have never, in 2 years shadowing doctors, 4 years of med school, and 3 years of residency, seen an attending do anything other than listen to lungs on a real patient. If I want to know if someone has pneumonia, I get a chest x-ray.
 
chuck deli said:
Our evidenced-based medicine attending admitted that to date no study has proved the usefulness of EBM medicine
Click to expand...


Nor would you find an RCT to support the use of a parachute when jumping out of a plane...some things just make sense. :idea:
 
jbar said:
Found this in my liver notes, feel free to put up the dumbest things you've been taught.

"Most patients with viral hepatitis exhibit typical patterns of illness. Atypical patterns are seen in a small proportion."


Glad I'm paying for the meanings of typical and atypical. Yay med school.
Click to expand...

That gave me a good laugh, thanks for sharing that one. I'm making a list as we speak of my share of stupidity.

Will be back shortly:scared:
 
sleepymed said:
Tension pneumothorax is a clinical diagnosis, and you absolutely do NOT wait for imaging 😉
Click to expand...

Traumatic amputation is a "clinical diagnosis" as well. What I am asking for is a PE finding that would rule-out a dangerous diagnosis in the setting of a dangerous history.
 
leorl said:
👍 I'm actually surprised and a little scared that people are refering to those simple signs as "archaic." I sure wouldn't want some PGY1 missing my grandmother's poor skin turgor and not giving IV fluids so that she goes into renal failure and then the subsequent other failures.... what, are you going to wait for an ultrasound or renogram then?
Click to expand...

a) there are many reasons to be scared of me as a clinician beyond me view of the PE. 😀

b) hopefully the old bag would be giving me some other signs of dehydration (tachycardia, mental status, anuria, etc, etc) other than the speed with which her pinched skin returns to it's original position.

c) what is a renogram?
 
One of my favorite medical school mentors often tells the story of how he was disgusted and thought that learning about parasites, mosquitoes ,malaria and worms was absolutely useless. After all he was going to practice internal medicine in the affluent suburbs of New York City.

One month after he finished his internship. He found himself practicing Army medicine from a firebase in Vietnam up to his *** in parasites, mosquitoes malaria and worms.
 
docB said:
I have to agree with Amory on this one. As much as it pains us that PE skills have taken a back seat to high tech, high cost diagnostics they have. Defensive medicine called shotgun.
Click to expand...

As much as I would like to say it, the only tension PTX (or more likely just total collapse, as there were not other sx) I have seen are diagnosed by x-ray. Why? Because the triage nurses check that box off when the cc at triage is "SOB". So usually I see the film before I see the patient.
The only time I have seen a radiologist come out of his cave was to come over, get the attention of an attending, take her to the PACS viewer, and show her the pneumo. Instant up-triage.
 
Jarabacoa said:
If I want to know if someone has pneumonia, I get a chest x-ray.
Click to expand...

If I even remotely entertain the possibility of pneumonia, regardless of exam findings, I get a chest X-ray. If someone's complaining of cough for greater than a week I get a chest X-ray.

The vast majority of patients I can appropriately diagnose and treat them just be looking at the nurses' triage note, and getting a history from the patient. The whole listening to lungs/heart and pressing on the abdomen bit is purely so the patient thinks I did something.

Exception: Appendicitis.
 
Wouldn't you also be able to hear the absence of breath sounds with the stethoscope for the pneumothorax case? Of course, then XR or XR before listening as said before..
 
you know, I know some Indian FMG's that say you can't graduate med school over there without being able to percuss a pleural effusion to the exact level.

fact is, american grads suck at some physical exam findings.
 
Greenbbs said:
you know, I know some Indian FMG's that say you can't graduate med school over there without being able to percuss a pleural effusion to the exact level.

fact is, american grads suck at some physical exam findings.
Click to expand...

I agree that we are worse off at actually touching patients and figuring out what is wrong. Truth be told, SO WHAT?????? With the med mal climate being what it is, you better order that test before you send a patient home or upstairs. Or be prepared to get reamed out by the admitting docs (who always want one more test), or get reamed out by the lawyer because that patient had highly resistant TB, and a run of the mill strep pneumonia...

How does knowing the exact level of the effusion help? It doesn't. You are still going to get some sort of imaging test before you tap it anyway (at least you better)...
 
ineedsleep said:
I had a professor who kept asking me what I'd do if I was in the middle of Alaska and didn't have a CT scanner/x-ray/anything with me. He did the whole blank stare thing when I looked at him and said, "Why would I be in the middle of Alaska?"
Click to expand...

I always replied, call 911 and schedule transport to higher level of care.
 
Greenbbs said:
you know, I know some Indian FMG's that say you can't graduate med school over there without being able to percuss a pleural effusion to the exact level.

fact is, american grads suck at some physical exam findings.
Click to expand...

I don't think I suck at the physical exam, and I don't think that most of my colleagues do either. I don't equate a healthy skepticism for the utility of certain PE findings with not being "good" at them.

Your first comment prompts this question: Would you want one of those Indian docs putting a needle into your pleural space based on their percussive findings? If the answer is no then you seem to be lamenting American unfamiliarity with a parlor trick.
 
EM2BE said:
Wouldn't you also be able to hear the absence of breath sounds with the stethoscope for the pneumothorax case?
Click to expand...

When you hear (or don't hear, as it may be) this as a third year medical student I can pretty much guarantee that you will pull your stethoscope off the patient's chest and tap it to make sure it's working.

I mean...not that I would know from personal experience or anything...
 
SoCuteMD said:
When you hear (or don't hear, as it may be) this as a third year medical student I can pretty much guarantee that you will pull your stethoscope off the patient's chest and tap it to make sure it's working.

I mean...not that I would know from personal experience or anything...
Click to expand...

Not that I almost did this tonight when listening to an obese person's heart...heard almost nothing at LLSB. Then just assumed I needed better ears and/or a better stethoscope. Thanks for the answer!
 
Greenbbs said:
you know, I know some Indian FMG's that say you can't graduate med school over there without being able to percuss a pleural effusion to the exact level.

fact is, american grads suck at some physical exam findings.
Click to expand...

I was told that the indian residents kicked *** in physical exam, so I stuck by them in medicine.. for them, it was important because they didn't have CTs to make diagnoses ... (or that pts couldnt afford them) i figure another thing in my toolbox can never hurt
 
The one PE skill I've never seemed to understand is b/l symmetric chest expansion on the respiratory exam. I have never seen one patient that this was positive in.
 
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