Equal work for equal pay

[DermViser]

Ok man you obviously have some weird bone to pick with EM. I'm not going to argue with you since you're obviously very passionate, though quite mistaken, about this specialty. I don't know what your experience was when you rotated.

Just to clarify about the specialty - emergency medicine became a specialty because of how terrible and inefficient the care was when other specialties staffed the department. There were no rules - they would have GI docs and derm's and cardiologists each take a few shifts at the hospital they worked at, and people were having terrible outcomes (no surprise).

http://vimeo.com/m/99666716

Check that video out for origins on EM, pretty interesting. Sorry about the derm comments in that video - you'd have to agree that rash doctors aren't really ideal to take care of MI's or really anything.

You need to get rid of your preconceptions. Yeah maybe we do send rashes or basal cells to you guys to take care of - but you know what, we didn't want that patient coming to the ED for a non-emergency either, because we're training to take care of emergencies, not cosmetics. So if you want us to take off that suspected basal cell instead of "triage"ing that patient to you, sorry.

Yes I heard several of the cracks on Dermatology (10:40) in that video. Maybe you guys should actually learn to actually be able to recognize a BCC first (it's taught in med school)? What about eye injuries? Those can be dangerous. You guys treat those? Of course, not. It's a call to Ophtho.

Trained to take care of emergencies? Oh you mean, when you have a patient with an acute abdomen, a surgical emergency, (and not a "suspected" one) you're going to be doing the surgery yourself? This is news to me and probably to @DarknightX.

Consulting specialists or turfing admissions to specialties who actually solve the problem isn't medicine. Sorry.

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[DermViser]

If you didn't have keratoses to remove, you'd only work 3 hrs a day instead of 6. I think you can handle it.

Says the specialty that works a max of 15 shifts a month so work nearly half the year.

 

[freemontie]

Nobody mentioned that Seattle already established a $15 minimum wage. But t-shirt folding at the Gap is obv dead end so I don't think any resident physicians should be too jealous.

 

[KnuxNole]

Regardless, everyone knows that EM and Derm doc practice a LOT of medicine, and do a lot of good. After all, ED docs are extremely helpful, if they were incompetent...holy crap would things be bad. It's a bit too far to say they are "triage nurses" since they do so much.

 

[DermViser]

Regardless, everyone knows that EM and Derm doc practice a LOT of medicine, and do a lot of good. After all, ED docs are extremely helpful, if they were incompetent...holy crap would things be bad. It's a bit too far to say they are "triage nurses" since they do so much.

Even if they are incompetent, it doesn't really matter since the person they admit to will be taking the patient on anyways.

 

[username456789]

If you didn't have keratoses to remove, you'd only work 3 hrs a day instead of 6. I think you can handle it.

It's cute when you try to hang with the big boys.

And just in case anybody who isnt a troll is reading, we generally don't remove seborrheic keratoses, they're harmless. And they're certainly not moles. The number of people with SKs I get sent to me with "referral for melanoma" attached is mind boggling. I don't expect PCPs to be experts and everything, but I expect a minimal level of competence.

 

[swamprat]

All this hate on EM, I just have to

Dermatologists..What do you guys really do? You look at a skin lesion, come up with a ridiculous differential which all comes down to putting the same cream on it anyway and then because your never sure you biopsy it and have a pathologist make your diagnosis for you and then..oh no, wrong cream: you prescribe a different one.

 

[e30ftw]

As an emergency physician I consult many specialists at inconvenient times to take care of patients. The vast majority are helpful, pleasant, and professional.

It is almost comically humorous that several people claiming to be dermatology residents in this thread have some sort of vendetta against the ED. Do you even rotate with us during derm residency? Do you even take ED call? Have you ever worked a shift in the Emergency Department in derm residency?

I'm just having a hard time understanding why it is even worth it for you to be irritated at emergency physicians when out of all specialties in the house of medicine, we probably bother you the least. I routinely call anesthesia (for blood patch, have never called for airway), radiology, ophtho for f/u, ENT, etc and have spoken with pathologists and radiation oncologists in the middle of night but have never paged a dermatologist.. However I am happy to refer patients to several local dermatologists for further evaluation of their chronic rashes since they are better able to follow the patient.

I respect our consultants and am always grateful for help taking care of patients; we see sick, undifferentiated patients and sometimes after an appropriate work up and resuscitation I haven't figured it out yet and am grateful for someone to continue the work up as an inpatient.

I completely understand the sometimes complex relationship between ED/IM/surgery since we interact so much but to hear this kind of thing from derm just really makes me wonder why it's even worth your time to think like this, especially when you really know nothing about our specialty and would **** your pants the first time you had to take care of multiple undifferentiated critically ill patients.

 

[DermViser]

All this hate on EM, I just have to

Dermatologists..What do you guys really do? You look at a skin lesion, come up with a ridiculous differential which all comes down to putting the same cream on it anyway and then because your never sure you biopsy it and have a pathologist make your diagnosis for you and then..oh no, wrong cream: you prescribe a different one.

Really? That's what you think actual dermatologists do? Have you EVER even done a dermatology rotation at an academic medical center with a dermatology dept.? I expect a med student to say what you just said, but you're an EM resident. Probably not, as that would explain the pseudo-melanomas that are actually just darkly pigmented SKs or stasis dermatitis patients that you guys are 100% sure was cellulitis. If derm is that easy, and not a big deal, you should at least be able to easily recognize what it is, right? Or did you not read Section 20 of Tintinalli's?

Same for other specialties -- you guys aren't treating endocrine emergencies like DKAs - IM does that, you aren't treating Heme/Onc emergencies, the Heme/Onc docs take them onto their service. You aren't identifying and treating acute abdomens - you page General Surgery. Same for nearly every other organ system.

EM residents all the time whine about their off-service rotations when they rotate with Medicine, Surgery, OB-Gyn, etc. God forbid, they would actually have to see what admitting services have to deal with and actually work up patients and come up with an actual differential diagnosis after an H&P, and order labs, imaging, etc. and see things to the end.

Are you actually saying that EM residents are all the time doing actual emergencies in their ERs? Seems like the longest differential for EM docs is admit or not admit, and even then it's deciding which extension to call as to what service you can easily turf it off to before your shift is over.

 

[deleted128562]

Really? That's what you think actual dermatologists do? Have you EVER even done a dermatology rotation at an academic medical center with a dermatology dept.? I expect a med student to say what you just said, but you're an EM resident. Probably not, as that would explain the pseudo-melanomas that are actually just darkly pigmented SKs or stasis dermatitis patients that you guys are 100% sure was cellulitis. If derm is that easy, and not a big deal, you should at least be able to easily recognize what it is, right? Or did you not read Section 20 of Tintinalli's?

Same for other specialties -- you guys aren't treating endocrine emergencies like DKAs - IM does that, you aren't treating Heme/Onc emergencies, the Heme/Onc docs take them onto their service. You aren't identifying and treating acute abdomens - you page General Surgery. Same for nearly every other organ system.

EM residents all the time whine about their off-service rotations when they rotate with Medicine, Surgery, OB-Gyn, etc. God forbid, they would actually have to see what admitting services have to deal with and actually work up patients and come up with an actual differential diagnosis after an H&P, and order labs, imaging, etc. and see things to the end.

Are you actually saying that EM residents are all the time doing actual emergencies in their ERs? Seems like the longest differential for EM docs is admit or not admit, and even then it's deciding which extension to call as to what service you can easily turf it off to before your shift is over.

Wow. I used to have some respect for you and the stuff you posted, but it's gone now. I don't pretend to know what a day in your life is like, and conversely you can't imagine what I actually do in the ED. If you have to stoop to bashing other specialities to make yourself feel important, then you've come to a pretty sad place.

Disappointing, man.

 

[DermViser]

As an emergency physician I consult many specialists at inconvenient times to take care of patients. The vast majority are helpful, pleasant, and professional.

It is almost comically humorous that several people claiming to be dermatology residents in this thread have some sort of vendetta against the ED. Do you even rotate with us during derm residency? Do you even take ED call? Have you ever worked a shift in the Emergency Department in derm residency?

I'm just having a hard time understanding why it is even worth it for you to be irritated at emergency physicians when out of all specialties in the house of medicine, we probably bother you the least. I routinely call anesthesia (for blood patch, have never called for airway), radiology, ophtho for f/u, ENT, etc and have spoken with pathologists and radiation oncologists in the middle of night but have never paged a dermatologist.. However I am happy to refer patients to several local dermatologists for further evaluation of their chronic rashes since they are better able to follow the patient.

I respect our consultants and am always grateful for help taking care of patients; we see sick, undifferentiated patients and sometimes after an appropriate work up and resuscitation I haven't figured it out yet and am grateful for someone to continue the work up as an inpatient.

I completely understand the sometimes complex relationship between ED/IM/surgery since we interact so much but to hear this kind of thing from derm just really makes me wonder why it's even worth your time to think like this, especially when you really know nothing about our specialty and would **** your pants the first time you had to take care of multiple undifferentiated critically ill patients.

"helpful, pleasant, and professional." -- in other words, other services gladly taking your admit or seeing your consult. And if they aren't, then they are "unprofessional"?

You realize that people in Rads, Derm, Anesthesia, Ophtho do prelim internship years right? Most prelim years incorporate an EM month where we do shifts, so we're quite well aware on what happens in the ED, as well as getting your admits the rest of the year.

Yes, I agree you see sick, undifferentiated patients, but please don't make it seem like you guys try to actually solve and figure out what is going on in order to manage/treat. Pretty much if you can't figure it out within 15-20 minutes, it's a push for admission to an admitting service, hopefully before your shift is over. The first question you guys ask yourself is admit or not admit, not actually figure out what it is. Remember, every service in the hospital interacts with the ER - Surgery and all its subspecialties, IM and all its subspecialties, Neurology, OB-Gyn, Psych, etc. so pretty sure they would disagree on what you guys ACTUALLY do.

I'm sure you are grateful, "for someone to continue the work up as an inpatient", long after you have clocked out when your shift is over.

 

[ChiDO]

ortho works harder and longer hours than all of you.

 

[DermViser]

Wow. I used to have some respect for you and the stuff you posted, but it's gone now. I don't pretend to know what a day in your life is like, and conversely you can't imagine what I actually do in the ED. If you have to stoop to bashing other specialities to make yourself feel important, then you've come to a pretty sad place.

Disappointing, man.

What part of what I said that you quoted was incorrect? Am I mistaken? Do you guys actually do a full H&P, come up with a full differential diagnosis, order labs, imaging, etc. and see things to the end without calling IM or Surgery?

You forget, prelim and transitional residents rotate in the ED for at least 1 month, so we actually can imagine what you actually do in the ED. I have yet to see an EM resident actually rotate on the floor wards with IM or General Surgery (although they do ICU months).

 

[DermViser]

ortho works harder and longer hours than all of you.

Yes, they do and they solve the actual problem. No one disagrees with you.

 

[swamprat]

What part of what I said that you quoted was incorrect? Am I mistaken? Do you guys actually do a full H&P, come up with a full differential diagnosis, order labs, imaging, etc. and see things to the end without calling IM or Surgery?

You forget, prelim and transitional residents rotate in the ED for at least 1 month, so we actually can imagine what you actually do in the ED. I have yet to see an EM resident actually rotate on the floor wards with IM or General Surgery (although they do ICU months).

Dude you obviously have never done a real ED rotation then. It's not IM where its what is the most likely Dx, its what will kill this patient and how can I rule that out? That is how it works down here. If we figure out the actual diagnosis (of a non-emergent condition), that is great, but that is not the job of the ED.

 

[DermViser]

Dude you obviously have never done a real ED rotation then. It's not IM where its what is the most likely Dx, its what will kill this patient and how can I rule that out? That is how it works down here. If we figure out the actual diagnosis (of a non-emergent condition), that is great, but that is not the job of the ED.

Yes, I'm well aware that actually figuring out what the diagnosis is, is not your job in the ED (that's obvi). As far as figuring out what will kill the patient, IM and Surgery just as easily could do the job (as they did before EM became it's own specialty).

EM essentially takes the differential diagnosis ordered by likely possibility and flips it on its head to figure out what is the most life-threatening and what could possibly kill the patient - something IM and it's subspecialties and Surgery and its subspecialties could do and did for the longest time and ran the nation's EDs. Once life-threatening things have been "ruled-out" by EM, they're turfed to an admitting service.

 

[deleted128562]

What part of what I said that you quoted was incorrect? Am I mistaken? Do you guys actually do a full H&P, come up with a full differential diagnosis, order labs, imaging, etc. and see things to the end without calling IM or Surgery?

You forget, prelim and transitional residents rotate in the ED for at least 1 month, so we actually can imagine what you actually do in the ED. I have yet to see an EM resident actually rotate on the floor wards with IM or General Surgery (although they do ICU months).

Yes. I do a full H&P on every patient. Most of my charts include a broad differential. I do labs and/ or imaging on most patients. And about 70% of my patients get discharged home with a diagnosis made by me. Well over half of my patients have a diagnosis made at time of admission. For every abdominal pain I consult surgery for I've seen 10 others, worked them up, and sent them home.

Of course I could ask you.... Have you ever intubated a comatose patient with a heart rate of 20 and put a transvenous pacer in them? I have. Have you ever delivered a baby in the middle of a parking lot? I have. Have you ever been handed a seizing 28 day old? I have. Have you ever reduced a dislocated joint and then sent the patient home? I have. Many times.

Sorry I can't tell the difference between a vague rash and another vague rash.... guess I got other stuff to worry about.

 

[DermViser]

Yes. I do a full H&P on every patient. Most of my charts include a broad differential. I do labs and/ or imaging on most patients. And about 70% of my patients get discharged home with a diagnosis made by me. Well over half of my patients have a diagnosis made at time of admission. For every abdominal pain I consult surgery for I've seen 10 others, worked them up, and sent them home.

Of course I could ask you.... Have you ever intubated a comatose patient with a heart rate of 20 and put a transvenous pacer in them? I have. Have you ever delivered a baby in the middle of a parking lot? I have. Have you ever been handed a seizing 28 day old? I have. Have you ever reduced a dislocated joint and then sent the patient home? I have. Many times.

Sorry I can't tell the difference between a vague rash and another vague rash.... guess I got other stuff to worry about.

Doing something on a once-in-a-lifetime occurence (delivering a baby in a parking lot) or bc you can't turn to a specialist that you have in-house, doesn't a specialty make.
Being the one left over bc there is no specialist to actually accomplish the job, doesn't mean the ABMS should recognize your specialty.

The difference is that my job is set and I don't get to turf and nor am I dependent on other physicians or specialists.

"ever intubated a comatose patient with a heart rate of 20 and put a transvenous pacer in them?" -- Anesthesiology could do that

"Have you ever delivered a baby in the middle of a parking lot?" -- OB-Gyn could do that

"Have you ever been handed a seizing 28 day old?" -- Neonatologist/Child Neurology could do that

"Have you ever reduced a dislocated joint and then sent the patient home?" -- Ortho could do that.

And yes, I would say recognizing melanoma vs. an SK (when it comes to a patient having to pay more just to find out it's an SK) is pretty darn important. It's not surprising that EM docs increases the tab of medical services both inside and outside the hospital.

 

[deleted128562]

Doing something on a once-in-a-lifetime occurence (delivering a baby in a parking lot) or bc you can't turn to a specialist that you have in-house, doesn't a specialty make.
Being the one left over bc there is no specialist to actually accomplish the job, doesn't mean the ABMS should recognize your specialty.

The difference is that my job is set and I don't get to turf and nor am I dependent on other physicians or specialists.

"ever intubated a comatose patient with a heart rate of 20 and put a transvenous pacer in them?" -- Anesthesiology could do that

"Have you ever delivered a baby in the middle of a parking lot?" -- OB-Gyn could do that

"Have you ever been handed a seizing 28 day old?" -- Neonatologist/Child Neurology could do that

"Have you ever reduced a dislocated joint and then sent the patient home?" -- Ortho could do that.

And yes, I would say recognizing melanoma vs. an SK (when it comes to a patient having to pay more just to find out it's an SK) is pretty darn important. It's not surprising that EM docs increases the tab of medical services both inside and outside the hospital.

OK. Well haters gonna hate. If you show up in my ED apneic, I'll be sure to page anesthesia and not bother you with my pathetic triage nurse skills in the mean time. And don't worry, the CRNA generally only takes 15-20 minutes to show up.

 

[DermViser]

OK. Well haters gonna hate. If you show up in my ED apneic, I'll be sure to page anesthesia and not bother you with my pathetic triage nurse skills in the mean time.

I'm pretty sure an Anesthesiologist or a Pulm/Crit Care doc can do better intubations than you can, as that is well within their expertise. Just bc you are first on the scene, just by matter of logistics doesn't make you the superior provider. How that makes me a hater is beyond me.

For the longest time, ERs were run without actual EM docs, so I'm pretty sure we could have lasted a few more decades without another ABMS official specialty.

 

[alpinism]

What part of what I said that you quoted was incorrect? Am I mistaken? Do you guys actually do a full H&P, come up with a full differential diagnosis, order labs, imaging, etc. and see things to the end without calling IM or Surgery?

You forget, prelim and transitional residents rotate in the ED for at least 1 month, so we actually can imagine what you actually do in the ED. I have yet to see an EM resident actually rotate on the floor wards with IM or General Surgery (although they do ICU months).

Hmmm well I did 1 month on derm as a med student. I must know everything about derm right?

Also did 2 months on surgery, I must know everything about performing operations as well?

Yes, I'm well aware that actually figuring out what the diagnosis is, is not your job in the ED (that's obvi). As far as figuring out what will kill the patient, IM and Surgery just as easily could do the job (as they did before EM became it's own specialty).

EM essentially takes the differential diagnosis ordered by likely possibility and flips it on its head to figure out what is the most life-threatening and what could possibly kill the patient - something IM and it's subspecialties and Surgery and its subspecialties could do and did for the longest time and ran the nation's EDs. Once life-threatening things have been "ruled-out" by EM, they're turfed to an admitting service.

You do realize that the only reason why EM became a specialty was because medicine/surgery/dermatology docs were so incompetent at taking care of ER patients that they letting them die left and right in the hallways?

Ive also diagnosed everything from GBM to TB to Tamponade to Meningitis to Melanoma in the ED.

True story.

 

[deleted128562]

I'm pretty sure an Anesthesiologist or a Pulm/Crit Care doc can do better intubations than you can, as that is well within their expertise. Just bc you are first on the scene, just by matter of logistics doesn't make you the superior provider. How that makes me a hater is beyond me.

For the longest time, ERs were run without actual EM docs, so I'm pretty sure we could have lasted a few more decades without another ABMS official specialty.

Ok. Well one question then. Do you read all your own path slides? Because if not it seems to me that the pathologist is the one actually making your diagnoses, and you're just a punch biopsy tech. Very much like I'm just a glorified triage nurse.

 

[DermViser]

Hmmm well I did 1 month on derm as a med student. I must know everything about derm right?

Also did 2 months on surgery, I must know everything about performing operations as well?

I was talking about rotating as an intern, once one has graduated from medical school.

You do realize that the only reason why EM became a specialty was because medicine/surgery/dermatology docs were so incompetent at taking care of ER patients that they letting them die left and right in the hallways?

Ive also diagnosed everything from GBM to TB to Tamponade to Meningitis to Melanoma in the ED.

True story.

Did the Heme-Oncs/Infectious Disease/Cardiologists/Dermatologists let you shadow? Or was this the diagnosis you gave them when you were admitting/consulting them on the phone? You must have been really proud of your accomplishment when when your shift ended.

 

[DermViser]

Ok. Well one question then. Do you read all your own path slides? Because if not it seems to me that the pathologist is the one actually making your diagnoses, and you're just a punch biopsy tech. Very much like I'm just a glorified triage nurse.

Yeah, actually we do. A sizable part of Dermatology training and Derm boards is learning Dermatopathology where we do read our own histopath slides. Why would I send a derm histopath slide to a AP/CP pathologist when I can read it myself?

 

[username456789]

All this hate on EM, I just have to

Dermatologists..What do you guys really do? You look at a skin lesion, come up with a ridiculous differential which all comes down to putting the same cream on it anyway and then because your never sure you biopsy it and have a pathologist make your diagnosis for you and then..oh no, wrong cream: you prescribe a different one.

This is strangely hilarious coming from a guy named doxycycline.

 

[DermViser]

Ok. Well one question then. Do you read all your own path slides? Because if not it seems to me that the pathologist is the one actually making your diagnoses, and you're just a punch biopsy tech. Very much like I'm just a glorified triage nurse.

Just admit it - your specialty of Emergency Medicine wouldn't work without having every other specialist in house. You guys have chapters in Tintinalli on Ophtho Emergencies, but in real life it's not like you guys are actually going in and fixing the problem - unless you're in a rural area with no specialists, and thus have no choice. What do you do at most places, esp AMCs? You consult Ophtho to come see the patient and work them up and fix them. Am I wrong?

I realize you were called out earlier in this thread by Raryn on the inaccuracy of your post:

EM resident here. I would be THRILLED if I only did 40-50 hours a week. In just a bit I'll be heading in for my 7th shift in 8 days, shifts which average 12 hours of nonstop pandemonium, and which occur at various times throughout the day. ICU months with their regular predictable hours and the occasional call, feel like a break. Seriously.

 

[DermViser]

This is strangely hilarious coming from a guy named doxycycline.

Thought I was the only one that noticed that. It's the antibiotic he most writes for in the ER on discharge (which the ID docs laugh about later on the choice of coverage).

 

[username456789]

It is almost comically humorous that several people claiming to be dermatology residents in this thread have some sort of vendetta against the ED.

Name two.

DV and I are, to my knowledge, the only derm residents on here. I have not denigrated the ED once here (although I have mentioned my disdain for some PCPs' ridiculous referrals . . . if that other poster to whom I replied earlier happened to be an ED resident and not some primary care specialty, so be it.

I respect the hell out of all specialties, because I know we all play a role in this f*cked up system of healthcare. We all occasionally joke about other specialties, but most of what I observe tends to be in good fun. Some of it goes beyond that.

Don't lump me in with other people attacking specialties, please.

 

[username456789]

Ok. Well one question then. Do you read all your own path slides? Because if not it seems to me that the pathologist is the one actually making your diagnoses, and you're just a punch biopsy tech. Very much like I'm just a glorified triage nurse.

A large portion of dermatology training is dermatopathology. Most graduating dermatology residents are superior to non-dermatopathology-fellowship-trained pathologist attendings in reading dermatopathology slides. One of the biggest hurdles if you're out in the community practicing and are not planning on being the person to read all your own slides is finding a competent dermatopathologist whose judgement you trust. Conversely, some dermatologists cherry-pick what slides they choose to read (easy lay-ups with low potential for bad stuffy happening if the diagnosis is wrong) and send the rest to an actual boarded dermatopathologist.

Either way, I know you're just giving DV a taste of his own medicine. But I find that one of the best parts of dermatology is being able to diagnose and treat a patient without ever having to do a biopsy.

 

[VisionaryTics]

Jesus Christ, DV, half the reason the board craps on derm is because you muck up every thread with this stupid crap. You don't know what the life of an EM resident is like. He doesn't know what the life of a dermatology resident is like. You both have important positions in the medical system. Shut the hell up and stop trying to come up with reasons why every specialty is **** other than derm.

 

[DermViser]

Either way, I know you're just giving DV a taste of his own medicine. But I find that one of the best parts of dermatology is being able to diagnose and treat a patient without ever having to do a biopsy.

Yeah, except he utterly failed in that regard. No dermatologist sends their slides to a pathologist (who has only done AP/CP training) to read it and "make" the diagnosis for them. Dermatologists read their own slides many of whom have gone on and done even further fellowship training. Emergency Medicine doctors by the very nature of their specialty depend and rely on OTHER doctors to take care of their patients. How this is such a controversial opinion is beyond me.

 

[DermViser]

Jesus Christ, DV, half the reason the board craps on derm is because you muck up every thread with this stupid crap. You don't know what the life of an EM resident is like. He doesn't know what the life of a dermatology resident is like. You both have important positions in the medical system. Shut the hell up and stop trying to come up with reasons why every specialty is **** other than derm.

I've never said that. I agree every specialty has it's space within the system (deserved or otherwise). My point is that EM as a specialty is highly dependent on other players within the system, unlike the others who take care of the patient as a whole from start to finish. ENT (and Surgeons in general) do the same thing - they take care of the patient from start to finish.

 

[PL198]

Yeah, except he utterly failed in that regard. No dermatologist sends their slides to a pathologist (who has only done AP/CP training) to read it and "make" the diagnosis for them. Dermatologists read their own slides many of whom have gone on and done even further fellowship training. Emergency Medicine doctors by the very nature of their specialty depend and rely on OTHER doctors to take care of their patients. How this is such a controversial opinion is beyond me.

why are you so mad about this? you could argue then that specialists depend on PCPs to get referrals. EM clearly serves a purpose or it would be rid of.

 

[DrBowtie]

Yes. I do a full H&P on every patient. Most of my charts include a broad differential. I do labs and/ or imaging on most patients. And about 70% of my patients get discharged home with a diagnosis made by me. Well over half of my patients have a diagnosis made at time of admission. For every abdominal pain I consult surgery for I've seen 10 others, worked them up, and sent them home.

Of course I could ask you.... Have you ever intubated a comatose patient with a heart rate of 20 and put a transvenous pacer in them? I have. Have you ever delivered a baby in the middle of a parking lot? I have. Have you ever been handed a seizing 28 day old? I have. Have you ever reduced a dislocated joint and then sent the patient home? I have. Many times.

Sorry I can't tell the difference between a vague rash and another vague rash.... guess I got other stuff to worry about.

I think the bolded neglects a certain consultant used on nearly every patient in the ED.

 

[DermViser]

why are you so mad about this? you could argue then that specialists depend on PCPs to get referrals. EM clearly serves a purpose or it would be rid of.

Depends on your health insurance. Specialists are not "dependent" on PCPs. If your insurance has a gatekeeper function to where to see any specialist/subspecialist requires a PCP referral, then yes I guess in that scenario a specialist would need them. Although how a specialist would know when there are so many different insurances out there, I wouldn't know. PCPs serving as "gatekeepers" more derives out of the HMO model in an attempt to restrain costs in the 1990s. Patients rebelled bc they felt in the HMO model, PCPs were purposefully not referring them to specialists due to a bottom line for the company.

If you look at the list of actual ABMS specialties, the creation of board certified specialties and fellowships isn't always bc it actually serves a purpose. EM became an official ABMS specialty in 1979, one of the latest. Which is why the many, many docs who worked in ERs before then, were grandfathered in and became EM docs without having to do a 3 year EM residency.

 

[DermViser]

Well I think your point was that EM physicians are comparable to triage nurses? Which isn't as bad as it seems because our triage nurses are awesome. But the offense is still taken.

It's fine man. You can hate on us all you like, we will still save your life when you come in with your MI/car wreck/etcetc. Then yes, after you are stable we will triage you appropriately for the real doctors to do their work.

I don't think I ever said that an EM physician is comparable to a triage nurse. If so, I was mistaken and I apologize. I'm just saying that an EM as a specialty could just as easily by having IM w/subspecialties, Surgery w/subspecialties, OB-GYN, Psych, Anesthesia, etc. running the ED.

When I have my MI -- my cardiologist will save my life.
When I'm in a car wreck -- my trauma surgeon/Ortho will take care of me.

Just bc the patient changes rooms doesn't mean a patient can't destabilize when they're not in the ER. Pretty sure even then, the non-ED docs can handle it.

 

[DermViser]

You just aren't making sense. Yeah, it became a specialty in the 70's. Emergency departments didn't even begin until what, the 50's? Somewhere around then. And typically they were anywhere from 1-5 rooms, staffed by someone who didn't know what they were talking about. Several people took it upon themselves to figure out a better more consistent way to practice medicine in the emergency setting. They were the ones grandfathered in - they built the specialty. How is that a negative thing? How does that mean they don't serve a purpose? What in the world are you talking about at all?

1979 (so about 1980). It only became an official specialty bc of the push for specialization in the 60s and 70s, as more and more doctors wanted to become specialists vs. generalists. It was more due to wanting to be recognized by organized medicine not be an actual "Emergency Medicine" doctor was needed. The founders weren't the only ones grandfathered in to become EM board certified, as you well know. You'll see quite a few, even FM docs, who are listed as being EM board certified bc they were grandfathered in.

 

[DermViser]

This is ridiculous man. EM became a specialty so that physicians could have an avenue to collaborate, improve care, and begin to standardize care throughout the country. Of course some fm docs were grandfathered in - any docs who were regularly staffing the ED's before 1979 were given an opportunity. Why does it matter that they were FM? Some were internists, some were trained as surgeons, etc. there needed to be a specialty in order to continue training physicians specializing in emergency care. Most surgeons did not want to staff the ED - they wanted to operate, but were forced to do a certain number of shifts per month if they wanted to stay at that hospital. Same with all specialties. I can't see how this wasn't "necessary." Sure - surgeons and internists could see every single patient in the ED and hate their lives. Does that seem like a good idea? Or does that seem insane?

Or we can make a new specialty to see all patients, appropriately disposition them while treating both minor and major illnesses, especially life-threatening ones. God, how ridiculous right.

Sigh. That's my point. FM, IM, Surgery, etc. all could become grandfathered in and become EM board certified just bc their practice environment occurred in an ED. A residency requires a a unique set of skills and training not found in another specialty's residency. Someone doing IM, can't do a residency, and then start doing Surgery. The 2 residencies are separate in terms of skills and training.

Emergency Medicine is a practice environment not a specialty. Should we have Urgent Care residency as well?

 

[DermViser]

Every single specialty began this way. Do you think neurologists popped out of thin air? Or do you think just maybe internists took an interest in neurology and eventually started the specialty? Do you think there were dermatologists since the world began?

Did you work with a terrible ED attending? A few terrible shifts? There has to be something..

Actually yes, since the ABMS was created.

• Allergy and Immunology (1971)
• Anesthesiology (1941)
• Colon and Rectal Surgery (1949)
• Dermatology (ABMS Founding Member, 1932)
• Emergency Medicine (1979)
• Family Medicine (1969)
• Internal Medicine (1936)
• Medical Genetics and Genomics (1991)
• Neurological Surgery (1940)
• Nuclear Medicine (1971)
• Obstetrics and Gynecology (ABMS Founding Member, 1930)
• Ophthalmology (ABMS Founding Member, 1917)
• Orthopaedic Surgery (1935)
• Otolaryngology (ABMS Founding Member, 1924)
• Pathology (1936)
• Pediatrics (1935)
• Physical Medicine and Rehabilitation (1947)
• Plastic Surgery (1941)
• Preventive Medicine (1949)
• Psychiatry and Neurology (1935)
• Radiology (1935)
• Surgery (1937)
• Thoracic Surgery (1971)
• Urology (1935)

I also doubt your scenario as Neurology was an official ABMS specialty BEFORE IM was.

 

[DermViser]

Ha ok man. This is ridiculous. There were doctors before the all/powerful abms.

I can't believe I chose a useless specialty. Someone must've tricked me. Enjoy the rashes!

It's ok. There is always waste in Medicare dollars in many parts of the healthcare system.

 

[VisionaryTics]

Actually yes, since the ABMS was created.

• Allergy and Immunology (1971)
• Anesthesiology (1941)
• Colon and Rectal Surgery (1949)
• Dermatology (ABMS Founding Member, 1932)
• Emergency Medicine (1979)
• Family Medicine (1969)
• Internal Medicine (1936)
• Medical Genetics and Genomics (1991)
• Neurological Surgery (1940)
• Nuclear Medicine (1971)
• Obstetrics and Gynecology (ABMS Founding Member, 1930)
• Ophthalmology (ABMS Founding Member, 1917)
• Orthopaedic Surgery (1935)
• Otolaryngology (ABMS Founding Member, 1924)
• Pathology (1936)
• Pediatrics (1935)
• Physical Medicine and Rehabilitation (1947)
• Plastic Surgery (1941)
• Preventive Medicine (1949)
• Psychiatry and Neurology (1935)
• Radiology (1935)
• Surgery (1937)
• Thoracic Surgery (1971)
• Urology (1935)

I also doubt your scenario as Neurology was an official ABMS specialty BEFORE IM was.

I will quote you from another thread, in which you, while defending the right for dermatologists to be called surgeons, said that it doesn't matter that Mohs isn't a recognized specialty by the ABMS:

It's bc they don't want to be under a bureaucratic nightmare like the ABMS and its continuing and never ending mandates and the ABMS requires you to institute a formalized exam, and of course politics.

In the words of Mike Ditka, WHO YA CRAPPIN'?

 

[DermViser]

I will quote you from another thread, in which you, while defending the right for dermatologists to be called surgeons, said that it doesn't matter that Mohs isn't a recognized specialty by the ABMS:

In the words of Mike Ditka, WHO YA CRAPPIN'?

I defended the right of Mohs Surgeons to be called...wait for it...Mohs Surgeons.

The list above are all general certificate specialties.

Mohs is a subspecialty UNDER Dermatology. They already have the American College of Mohs Surgery and The American Society for Dermatologic Surgeons.

 

[Mad Jack]

Judging by the fact that you've got like, 9,000 posts in the last year, I'd say there's some validity to derm working less than other specialties in residency.

Wish I could do derm someday, but alas, it ain't in the cards

 

[DermViser]

Judging by the fact that you've got like, 9,000 posts in the last year, I'd say there's some validity to derm working less than other specialties in residency.

 

[DermViser]

But, remember - he's a real specialty and quite necessary. So don't worry. In 5 years he'll be glad to take off you're mole. He'll even look at it himself under the fancy microscope! He told me. Better than a pathologist.

Sigh. Pathologists only boarded in AP/CP don't do Dermpath. Like even GuyWhoDoesStuff told you, Dermatopathology is an integral part of Dermatology residency, as well as on boards. I'll just bc happy if you can tell the difference between melanoma vs. seborrheic keratosis or stasis dermatitis vs. cellulitis. You'll probably find it in Tintinalli's.

 

[Mad Jack]

But, remember - he's a real specialty and quite necessary. So don't worry. In 5 years he'll be glad to take off you're mole. He'll even look at it himself under the fancy microscope! He told me. Better than a pathologist.

Derm's a great field in every way. You shut your mouth.

Path on the other hand...

 

[DermViser]

Derm's a great field in every way. You shut your mouth.

Path on the other hand...

ROFLing!!!! Awesome GIF. Pathology (AP/CP) is also a great field as well. Key is to get into a great program. Just ask BlondeDocteur.

 

[Roxas]

I must have missed something, and @DermViser what is the problem with EM?

 

[DermViser]

I must have missed something, and @DermViser what is the problem with EM?

Oh, no, we aren't starting that merry-go-round again.

 

[Mad Jack]

ROFLing!!!! Awesome GIF. Pathology (AP/CP) is also a great field as well. Key is to get into a great program. Just ask BlondeDocteur.

Isn't she in Canada? Path in America's hat isn't as bad as it is around here due to their much tighter control on the number of residency positions. Other specialists are hurting though, it's crazy.

http://www.royalcollege.ca/portal/p...documents/policy/employment_report_2013_e.pdf

It's a pity, path would be a great field if they weren't so hell-bent on eating their own young in every conceivable way. I could probably match a strong program (even Columbia path takes DOs), but I wouldn't want to enter a market that's that hot with big lab competition and very little opportunity for PP.