Is IM really like this?

[padastra]

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By the way, Dermpath reports don't have treatment/management recommendations. They do however, describe the histology. Hope you like basic science.

There's always going to be "stupid" consults which are a product of being overworked or having a dozen other issues to take care of (just like when we complain about the ED and we don't see the 99 patients they didn't admit). That being said, I readily admit that the vast majority of IM physicians are horrible at derm, MSK, and eye. Keep in mind that 99.99% of patients aren't hospitalized for dermatology issues, and most of us don't remember the stuff we don't use, just like most dermatologists would have a hard time adjusting sliding scale insulin.

If it gets you off, that's great. But let's not bloviate at length about how magical Dermatology is when the vast majority of the field follows this simple algorithm (mohs and dermpath excepted): 1) Biopsy 2) Ignore results 3) Prescribe steroids

 

[alpinism]

Someone once told me about why they went into hematology/oncology instead of cardiology. He said something along the lines of, "Your patients in cardiology are usually there because of their own bad decisions. Your patients in hematology/oncology are usually just unlucky." I've liked every single heme/onc attending that I've worked with. They're just a higher class of people in my experience.

While that might have been true 20yrs ago, much of adult heme/onc nowadays deals with CA related to bad decisions i.e. smoking (lung CA), drinking (HCC), and obesity (esophageal CA, breast CA, colorectal CA).

While its certainly not as bad as in IM, it still represents a significant percentage of patients.

Peds heme/onc is a different story however.

 

[Anastomoses]

While that might have been true 20yrs ago, much of adult heme/onc nowadays deals with CA related to bad decisions i.e. smoking (lung CA), drinking (HCC), and obesity (esophageal CA, breast CA, colorectal CA).

While its certainly not as bad as in IM, it still represents a significant percentage of patients.

Peds heme/onc is a different story however.

The arrogance is astounding. I don't care if it's the patient's fault or it's the chemicals in the air or the coal in a mining station. I don't even care if it's the same patient that won't stop boozing with his cirrhosis. Maybe med school needs to incorporate a class on "**** you, stop judging choices and do your job".

That said, I definitely find it absurd that doctors would be held responsible for any patient non-compliance. Why aren't the lobbyists making this clear to the government?

Furthermore, I'd have no problem videotaping any interaction/consult with a non-compliant patient. I would have them sign that they understand all the risks they are putting themselves at by continuing to ignore medical advice.

And call me an icicle or what you want, but I doubt I'd get burned out by this. I've seen myself in similar situations in which others act as if the world is such a heavy burden when in reality, it's not your drama so chill out. Maybe I have left over energy from when I'm not busy judging the patient's choices. I'm not trying to get philosophical here, but how do you know the will power your patient is born with...or whether his or her life sucks so bad that eating another croissant with cherry coke isn't the only solace in life. Either way, I don't care. I will avoid making rash judgments. Of course, I shouldn't be surprised...doctors are just humans too. They don't all necessarily have particularly far-reaching insight into humanity beyond medical care. So frustrate yourself away.

Side note: I've also observed an attending physician in IM who was nothing but polite and a raised eyebrow when patients confessed non-compliance shyly. He was generally upbeat after work and never heard him complain about the patients...but that's private practice, so...I don't know.

 

[Anastomoses]

Except now they are trying to tie things related to compliance like A1c and readmission rates for CHF to payments.

This part, I entirely agree...is not okay.

 

[DermViser]

There's always going to be "stupid" consults which are a product of being overworked or having a dozen other issues to take care of (just like when we complain about the ED and we don't see the 99 patients they didn't admit). That being said, I readily admit that the vast majority of IM physicians are horrible at derm, MSK, and eye. Keep in mind that 99.99% of patients aren't hospitalized for dermatology issues, and most of us don't remember the stuff we don't use, just like most dermatologists would have a hard time adjusting sliding scale insulin.

If it gets you off, that's great. But let's not bloviate at length about how magical Dermatology is when the vast majority of the field follows this simple algorithm (mohs and dermpath excepted): 1) Biopsy 2) Ignore results 3) Prescribe steroids

Your being "overworked" is not another specialty's problem, just bc you choose (and yes it's a choice) to not even take the minimum effort to work up something. Also the "stuff we don't use" excuse doesn't start at the attending level. It starts at the beginning from the intern level. Maybe if you guys actually read up on things with foundational knowledge, instead of using UpToDate as a crutch, your diagnostic and physical exam skills would be better.

It's not the "stupid consults" only. It's the almost REFLEXIVE need to consult by General IM to any specialty, bc they don't do anything. Then they wonder why the get laughed at and crapped on by other specialties - i.e. Surgery, EM, etc. There is almost never an admission in which General IM doesn't consult a subspecialty. Patient has kidney failure -- consult Nephrology. Patient has CHF -- consult Cardiology. Patient has Diabetes and I'm not getting his sugars under control -- consult Endocrine. God forbid a General IM team actually THINK about what to do without automatically consulting a specialist. This is another reason why third party payers are now clamping down as the bills are getting too high esp. due to the constant running of generalists to specialists for help.

If you truly think that general Dermatology is "1) Biopsy 2) Ignore results 3) Prescribe steroids" it shows you know absolutely NOTHING, as steroids are a small speck in the gamut of medications both oral, topical, and injectible that are used in the armamentarium of dermatologic practice. For those who think that Derm is just "1) Biopsy 2) Ignore results 3) Prescribe steroids", it's amazing how again and again IM is forced to consult Dermatology, considering how "easy" it is.

 

[Anastomoses]

Unless you have literally zero emotional investment in your work, it will bother you eventually.

Is it possible my emotional investment is just quite different than yours? I'm invested in quality of life...not merely the prolongation of it. If this person is having trouble sticking to a regimen, I will offer everything my brain can think of...but exasperation? Probably not.

You should see how I deal with religious people. 🙂

 

[DermViser]

The arrogance is astounding. I don't care if it's the patient's fault or it's the chemicals in the air or the coal in a mining station. I don't even care if it's the same patient that won't stop boozing with his cirrhosis. Maybe med school needs to incorporate a class on "**** you, stop judging choices and do your job".

That said, I definitely find it absurd that doctors would be held responsible for any patient non-compliance. Why aren't the lobbyists making this clear to the government?

Furthermore, I'd have no problem videotaping any interaction/consult with a non-compliant patient. I would have them sign that they understand all the risks they are putting themselves at by continuing to ignore medical advice.

And call me an icicle or what you want, but I doubt I'd get burned out by this. I've seen myself in similar situations in which others act as if the world is such a heavy burden when in reality, it's not your drama so chill out. Maybe I have left over energy from when I'm not busy judging the patient's choices. I'm not trying to get philosophical here, but how do you know the will power your patient is born with...or whether his or her life sucks so bad that eating another croissant with cherry coke isn't the only solace in life. Either way, I don't care. I will avoid making rash judgments. Of course, I shouldn't be surprised...doctors are just humans too. They don't all necessarily have particularly far-reaching insight into humanity beyond medical care. So frustrate yourself away.

Side note: I've also observed an attending physician in IM who was nothing but polite and a raised eyebrow when patients confessed non-compliance shyly. He was generally upbeat after work and never heard him complain about the patients...but that's private practice, so...I don't know.

You deserve an Emmy for this performance. I am thoroughly convinced you are either about to start med school or are an MS-1. Get back to reading, Clinically Oriented Anatomy by Moore and Dalley, noob.

 

[Anastomoses]

You deserve an Emmy for this performance. I am thoroughly convinced you are either about to start med school or are an MS-1. Get back to reading, Clinically Oriented Anatomy by Moore and Dalley, noob.

Are you on crack? Because aside from your unnatural level of aggression on these boards, you seem like you might be insane. Videotaping patient encounter is completely valid.

 

[SouthernSurgeon]

Is it possible my emotional investment is just quite different than yours? I'm invested in quality of life...not merely the prolongation of it. If this person is having trouble sticking to a regimen, I will offer everything my brain can think of...but exasperation? Probably not.

You should see how I deal with religious people. 🙂

Frustration with other peoples' limitations is a reality in any job. To not experience some degree of emotional reaction to being let down by someone else is inhuman.

I would also, although I hate to pull out the old trope, suggest that your abstract thoughts on this may change once you get some real patient care experience.

 

[Anastomoses]

Frustration with other peoples' limitations is a reality in any job. To not experience some degree of emotional reaction to being let down by someone else is inhuman.

I would also, although I hate to pull out the old trope, suggest that your abstract thoughts on this may change once you get some real patient care experience.

Fair enough. I'll keep you apprised.

 

[boogaloo]

While that might have been true 20yrs ago, much of adult heme/onc nowadays deals with CA related to bad decisions i.e. smoking (lung CA), drinking (HCC), and obesity (esophageal CA, breast CA, colorectal CA).

While its certainly not as bad as in IM, it still represents a significant percentage of patients.

Peds heme/onc is a different story however.

I had the peds heme/onc attendings in mind when I said that, albeit the adult heme/onc guys are great too. They've been in practice for >20 years, so I guess it did hold true for them at some point.

 

[CassieBagley]

The alternative to all this non-sense is to become an orthopedic surgeon and just turf all your non-ortho complaints to medicine, deal with mostly healthy patients who want to get better, and make a ton of money for a relatively relaxed lifestyle (especially if sports or joints). But then again, you'd be stuck in the OR for 10-12 hrs 3-4 days per week.

 

[padastra]

It's not the "stupid consults" only. It's the almost REFLEXIVE need to consult by General IM to any specialty, bc they don't do anything.

If you truly think that general Dermatology is "1) Biopsy 2) Ignore results 3) Prescribe steroids" it shows you know absolutely NOTHING, as steroids are a small speck in the gamut of medications both oral, topical, and injectible that are used in the armamentarium of dermatologic practice. For those who think that Derm is just "1) Biopsy 2) Ignore results 3) Prescribe steroids", it's amazing how again and again IM is forced to consult Dermatology, considering how "easy" it is.

I don't know what ****ty hospital you work at but that's not the way it works for us.

And I'm real impressed at the "armamentarium" of dermatologic medications which are given to patients by not one--not two--but THREE different routes: oral, topical, ***AND*** injectable (1)! WOW!


(1) Oral steroids, topical steroids, injectable steroids.

 

[username456789]

(1) Oral steroids, topical steroids, injectable steroids.

Pretty sure he was talking about biotin (for shiny healthy hair), hydroquinone (for melasma), and botox. I mean that's really all I do, at least.

 

[DermViser]

I don't know what ****** hospital you work at but that's not the way it works for us.

And I'm real impressed at the "armamentarium" of dermatologic medications which are given to patients by not one--not two--but THREE different routes: oral, topical, ***AND*** injectable (1)! WOW!


(1) Oral steroids, topical steroids, injectable steroids.

Pretty sure he was talking about biotin (for shiny healthy hair), hydroquinone (for melasma), and botox. At least, that's all I do.

Yeah, General IM attendings, esp. hospitalists, rarely consult other specialties and services, on their patients. They're the go-get-em, solve it on our own types. 🙄

No, try the many immunomodulators (that aren't steroids), phototherapy (UV light and lasers), biologics, retinoids, antibacterial/antifungal/antivirals, chemotherapeutic agents, etc. that come in oral/topical/injectable form. But please, continue to show your vast ignorance.

 

[DermViser]

Are you on crack? Because aside from your unnatural level of aggression on these boards, you seem like you might be insane. Videotaping patient encounter is completely valid.

Yes, if it's anything a patient loves it's an antagonistic doctor who uses videotape to document his non-compliance with the purpose of avoiding malpractice lawsuits. That will really help the patient-physician relationship. Your patient satisfaction survey scores will go through the floor to Hades.

 

[username456789]

No, try the many immunomodulators (that aren't steroids), phototherapy (UV light and lasers), biologics, retinoids, antibacterial/antifungal/antivirals, chemotherapeutic agents, etc. that come in oral/topical/injectable form. But please, continue to show your vast ignorance.

Topical nitrogen mustard is icky. Why can't those gross patients with CTCL just put Mirvaso on themselves to get rid of the redness. It works for all the WASPy 50 year old women.

 

[DermViser]

The alternative to all this non-sense is to become an orthopedic surgeon and just turf all your non-ortho complaints to medicine, deal with mostly healthy patients who want to get better, and make a ton of money for a relatively relaxed lifestyle (especially if sports or joints). But then again, you'd be stuck in the OR for 10-12 hrs 3-4 days per week.

They do. They consult Internal Medicine for the inane things they don't want and have no desire to deal with and they just do the operating, which they love.

 

[padastra]

Yeah, General IM attendings, esp. hospitalists, rarely consult other specialties and services, on their patients. They're the go-get-em, solve it on our own types. 🙄

No, try the many immunomodulators (that aren't steroids), phototherapy (UV light and lasers), biologics, retinoids, antibacterial/antifungal/antivirals, chemotherapeutic agents, etc. that come in oral/topical/injectable form. But please, continue to show your vast ignorance.

We obviously consult other specialists, but sure, a dermatologist who barely remembers how to manage hypertension should be the one complaining about our fund of knowledge.

Are you getting some sort of bonus RVU for replying to every single post in this thread by the way?

 

[DermViser]

We obviously consult other specialists, but sure, a dermatologist who barely remembers how to manage hypertension should be the one complaining about our fund of knowledge.

Are you getting some sort of bonus RVU for replying to every single post in this thread by the way?

Most of our derm residents remember hypertension and JNC-VII (or now JNC-VIII), quite well from medical school. We just don't care to become experts in an inane condition, which can't be cured, which the patient doesn't care about (as demonstrated by their compliance), and relies in real clinical practice largely on pill titration and polypharmacy.

 

[padastra]

Most of our derm residents remember hypertension and JNC-VII (or now JNC-VIII), quite well from medical school. We just don't care to become experts in an inane condition, which can't be cured, which the patient doesn't care about (as demonstrated by their compliance), and relies in real clinical practice largely on pill titration and polypharmacy.

Let me clarify:
- Morning rounds: **** this patient has HTN, I barely remember what that stands for, oh well my residents can manage it.
- SDN forums: ****ing Internal Medicine doctors consulting me about skin related issues. What am I a ****ing Dermatologist?

 

[DermViser]

Topical nitrogen mustard is icky. Why can't those gross patients with CTCL just put Mirvaso on themselves to get rid of the redness. It works for all the WASPy 50 year old women.

Meanwhile, their underlying patch or plaque progresses into a giant tumor. LOL. I hear you on the difficulty of treating CTCL patients. If there is one section I want to rip out of Bolognia it's that one with all its treatments, WHO classifications, staging, etc.

 

[DermViser]

Let me clarify:
- Morning rounds: **** this patient has HTN, I barely remember what that stands for, oh well my residents can manage it.
- SDN forums: ******* Internal Medicine doctors consulting me about skin related issues. What am I a ******* Dermatologist?

Yes, bc it's a perfectly good use of hospital inpatient resources that Internal Medicine consults Dermatology for eczema. God forbid, that smart, theoretically intelligent General IM doctors learn the skin manifestations of common Internal Medicine diseases or general/primary care derm. No, that's asking way too much. Let's just turf them to specialists and run up the patient's bill even higher. While you guys are consulting ID for a patient's cellulitis, why not consult Derm too, since they have a skin thing? You know more cooks improving the broth, and all. It's all covered by a patient's insurance anyway (at least for now).

 

[DermViser]

Let me clarify:
- Morning rounds: **** this patient has HTN, I barely remember what that stands for, oh well my residents can manage it.
- SDN forums: ******* Internal Medicine doctors consulting me about skin related issues. What am I a ******* Dermatologist?

Here let's try baby steps. Open up Harrison's Principles of Internal Medicine and open up to Section 9 and start reading.

SECTION 9: ALTERATIONS IN THE SKIN
52 - Approach to the Patient with a Skin Disorder. Thomas J. Lawley / Kim B. Yancey
53 - Eczema, Psoriasis, Cutaneous Infections, Acne, and Other Common Skin Disorders Calvin O. McCall / Thomas J. Lawley
54 - Skin Manifestations of Internal Disease. Jean L. Bolognia / Irwin M. Braverman
55 - Immunologically Mediated Skin Diseases. Kim B. Yancey / Thomas J. Lawley
56 - Cutaneous Drug Reactions. Jean-Claude Roujeau / Robert S. Stern / Bruce C. Wintroub
57 - Photosensitivity and Other Reactions to Light. David R. Bickers
e10 - Atlas of Skin Manifestations of Internal Disease. Thomas J. Lawley / Stephen Templeton

You know with medicine being a life-long learning profession and all.

 

[padastra]

Yes, bc it's a perfectly good use of hospital inpatient resources that Internal Medicine consults Dermatology for eczema. God forbid, that smart, theoretically intelligent General IM doctors learn the skin manifestations of common Internal Medicine diseases or general/primary care derm. No, that's asking way too much. Let's just turf them to specialists and run up the patient's bill even higher. While you guys are consulting ID for a patient's cellulitis, why not consult Derm too, since they have a skin thing? You know more cooks improving the broth, and all. It's all covered by a patient's insurance anyway (at least for now).

Again, I don't know what the **** kind of hospital you're working at if the general IM team is consulting for eczema and cellulitis.

 

[username456789]

Again, I don't know what the **** kind of hospital you're working at if the general IM team is consulting for eczema and cellulitis.

I'd like to remain out of this quarrel, but I will say that I have been consulted for "bilateral lower extremity cellulitis" 3 times now this year by the IM team.

I just wish people understood stasis dermatitis better, that's all.

 

[DermViser]

Again, I don't know what the **** kind of hospital you're working at if the general IM team is consulting for eczema and cellulitis.

I didn't say that IM consults us for cellulitis (read again). Based on your logic of a patient having "skin-related issues" so consult Derm, why not consult Dermatology for any skin manifestation? Do the same with any CHFer admitted --> stat consult Cardiology.

 

[DermViser]

I'd like to remain out of this quarrel, but I will say that I have been consulted for "bilateral lower extremity cellulitis" 3 times now this year by the IM team.

I just wish people understood stasis dermatitis better, that's all.

Just direct them in your consult note to p. 398 in Harrison's Principles of Internal Medicine
http://books.google.com/books?ei=ig9CU6O7M8Oo2AXK1YGwAQ&id=9uffAgpvgmEC&dq=harrison's principles of internal medicine stasis dermatitis&focus=searchwithinvolume&q=stasis dermatitis
that might help them.

 

[padastra]

I didn't say that IM consults us for cellulitis (read again). Based on your logic of a patient having "skin-related issues" so consult Derm, why not consult Dermatology for any skin manifestation? Do the same with any CHFer admitted --> stat consult Cardiology.

Seriously, you're representing Cardiology (a medicine fellowship) in this argument now? You probably think the C in CHF stands for cutaneous.

Where I work we do not consult Cardiology for e.g. uncomplicated CHF, ID for cellulitis, or Derm for eczema. I'm sure there's been a couple cases historically where it's been done, but you're ignoring the thousands of cases where it wasn't done. That's what I'm talking about when we get a "stupid" admit from the ED: we didn't see the 100 cases that they didn't admit, and maybe something about this made them uncomfortable. The accepting service should remember that what they get is fundamentally biased by selection.

In your hospital, maybe the IM docs get made fun of by everyone because they truly are incompetent. If true, sorry you have to deal with that. The last "stupid" consult I made was to ophthalmology because I thought a patient might have Wilson's disease without neuropsych manifestations. They told me: nope, stupid consult, because people with Wilson's but without neuropsych manifestations don't have KF rings. Now maybe this is discussed in Harrison's chapter whatever, but I think us GIM people should get a bit of a break sometimes for having to read the entire ****ing book.

EDIT: I just looked it the **** up and KF rings can be an early indicator of Wilson's in otherwise asymptomatic people (0-60% depending on the study), so it wasn't even a stupid consult.

 

[DermViser]

Seriously, you're representing Cardiology (a medicine fellowship) in this argument now? You probably think the C in CHF stands for cutaneous.

Where I work we do not consult Cardiology for e.g. uncomplicated CHF, ID for cellulitis, or Derm for eczema. I'm sure there's been a couple cases historically where it's been done, but you're ignoring the thousands of cases where it wasn't done. That's what I'm talking about when we get a "stupid" admit from the ED: we didn't see the 100 cases that they didn't admit, and maybe something about this made them uncomfortable. The accepting service should remember that what they get is fundamentally biased by selection.

In your hospital, maybe the IM docs get made fun of by everyone because they truly are incompetent. If true, sorry you have to deal with that. The last "stupid" consult I made was to ophthalmology because I thought a patient might have Wilson's disease without neuropsych manifestations. They told me: nope, stupid consult, because people with Wilson's but without neuropsych manifestations don't have KF rings. Now maybe this is discussed in Harrison's chapter whatever, but I think us GIM people should get a bit of a break sometimes for having to read the entire ******* book.

The size of the textbook is comparable to Sabiston's (Surgery), Nelson's/Rudolph's Pediatrics, etc. Specialties (Derm, Rads, Ophtho) have even huger texts as well. IM is hardly special in that regard. Consults were originally supposed to be used for very complicated cases that the General IM doctor needed further help from a specialist. It's now morphed into "do the work" that a GIM is supposed to do, or a "while we're here, we might as well get a consult from ______" or "just so we aren't missing anything, let's consult ______", etc.

 

[padastra]

I'd like to remain out of this quarrel, but I will say that I have been consulted for "bilateral lower extremity cellulitis" 3 times now this year by the IM team.

I just wish people understood stasis dermatitis better, that's all.

Since we're on the allopathic forum, I will say this: one thing every medical student should do, while on rotations, is to ask what consults happen that shouldn't happen (e.g. Urology for basic foley issues).

 

[padastra]

It's now morphed into "do the work" that a GIM is supposed to do, or a "while we're here, we might as well get a consult from ______" or "just so we aren't missing anything, let's consult ______", etc.

Well, I have to go, so let's end on agreement:

If what you write is an accurate representation of your hospital environment, I agree your GIM team needs improvement. I think it's also fair to say that, from an accepting or consulting service standpoint, keep in mind that you get to look at something in isolation with fresh eyes and (sometimes) more time.

 

[DermViser]

Well, I have to go, so let's end on agreement:

If what you write is an accurate representation of your hospital environment, I agree your GIM team needs improvement.

This is at a university, academic hospital (where "learning"/"education" takes priority) not a community-based hospital.

 

[padastra]

Well, I have to go, so let's end on agreement:

If what you write is an accurate representation of your hospital environment, I agree your GIM team needs improvement.

This is at a university, academic hospital (where "learning"/"education" takes priority) not a community-based hospital.

Well, I tried.

 

[D elegans]

DermViser, the IM docs are you hospital sound like *****s. I think they embody the worst of the IM stereotype which is basically a care coordinator who is the gatekeeper to specialists. This certainly is not how it's supposed to be and I think the trainees at your institution are really having a disservice done to them.

A competent IM doc should be able to handle most firstline diagnosis and treatment of many common conditions, derm included. If this isn't happening, I think it is largely institution/provider dependent

 

[SLC]

Cardiology and GI are one of the most competitive fellowships. You're not going to meet those (or at least those who will admit) who pursued a Cards/GI fellowship and failed to match to it. You'll only be exposed to the success stories, hence the selection bias.

Cardiology and GI are two of the most competitive fellowships. And still the match rates for applicants are in the 75% range for GI, and north of 80% for Cardiology.

It takes a special kind of person to go through 3 years of IM residency, and still have the energy to pursue 3+ more years of training. Many people just decide to call it a day and become a hospitalist after the 3 years of IM are over.

 

[DermViser]

Cardiology and GI are two of the most competitive fellowships. And still the match rates for applicants are in the 75% range for GI, and north of 80% for Cardiology.

It takes a special kind of person to go through 3 years of IM residency, and still have the energy to pursue 3+ more years of training. Many people just decide to call it a day and become a hospitalist after the 3 years of IM are over.

Exactly. That was the point I was getting at. Even with the high self-selection (usually those at the top of the residency class) of those who apply to GI and Cardiology only 75% actually get GI, and 80% for Cardiology. All this after a grueling and taxing IM residency.

A Cardiology or GI fellowship is nowhere close to being assured for anyone. Those who don't match into Cards/GI are essentially "forced" into Hospitalist medicine.

 

[SLC]

Exactly. That was the point I was getting at. Even with the high self-selection (usually those at the top of the residency class) of those who apply to GI and Cardiology only 75% actually get GI, and 80% for Cardiology. All this after a grueling and taxing IM residency.

A Cardiology or GI fellowship is nowhere close to being assured for anyone. Those who don't match into Cards/GI are essentially "forced" into Hospitalist medicine.

And you might be surprised to discover that there are a whole lot of people out there who actually really enjoy hospitalist medicine. It's an up-and-coming field from what I can tell.

Most of the senior IM residents I've met and interacted with are sorta waffling back and forth over whether or not to do fellowship; mainly because most of them are perfectly happy on the wards.

 

[Anastomoses]

Yes, if it's anything a patient loves it's an antagonistic doctor who uses videotape to document his non-compliance with the purpose of avoiding malpractice lawsuits. That will really help the patient-physician relationship. Your patient satisfaction survey scores will go through the floor to Hades.

I know doctors who do this. Plastic surgeons, for one do it...and I don't mean for before and afters. I have seen bonafide "do you understand this is not a guaranteed procedure" type of questions put on video. And if you have a lovely bedside manner, I don't see why a patient would even object. We'll see. I could be wrong. I'll let you know if I am.

 

[DermViser]

I know doctors who do this. Plastic surgeons, for one do it...and I don't mean for before and afters. I have seen bonafide "do you understand this is not a guaranteed procedure" type of questions put on video. And if you have a lovely bedside manner, I don't see why a patient would even object. We'll see. I could be wrong. I'll let you know if I am.

Yes, bc it's not like patients will ever say "No" once you have a great bedside manner. Great bedside manner is a sedative-hypnotic agent that makes the patient automatically do what you tell them to do. 🙄

Don't worry you don't have to let me know. I already know you are wrong, MS-1/MS-2.

 

[HopefulReapp]

Is it possible my emotional investment is just quite different than yours? I'm invested in quality of life...not merely the prolongation of it. If this person is having trouble sticking to a regimen, I will offer everything my brain can think of...but exasperation? Probably not.

You should see how I deal with religious people. 🙂

I understand that you have a year or two in academics ahead of me, but I am fairly sure that I have a few thousand hours of patient experience inside of an inpatient setting more than you. It seems that quality of life comes secondary to the prolongation of it. I can't even count how many 90 something year old LOLs (or BOLs/BOM, I guess) that are full code, regular diet, incontinent of stool and urine. Staying in bed all day and being turned once every two hours isn't a great quality of life, but it makes up for a majority of my patients.

I can't speak for residents or attendings, but from my perspective the American health system is not in line with your career ideals.

 

[DermViser]

And you might be surprised to discover that there are a whole lot of people out there who actually really enjoy hospitalist medicine. It's an up-and-coming field from what I can tell.

Most of the senior IM residents I've met and interacted with are sorta waffling back and forth over whether or not to do fellowship; mainly because most of them are perfectly happy on the wards.

There is also a huge burnout factor to hospitalist medicine. The 5 year retention rate is atrocious. Most can't go at that speed for huge decades of their life.

 

[DermViser]

I understand that you have a year or two in academics ahead of me, but I am fairly sure that I have a few thousand hours of patient experience inside of an inpatient setting more than you. It seems that quality of life comes secondary to the prolongation of it. I can't even count how many 90 something year old LOLs (or BOLs/BOM, I guess) that are full code, regular diet, incontinent of stool and urine. Staying in bed all day and being turned once every two hours isn't a great quality of life, but it makes up for a majority of my patients.

I can't speak for residents or attendings, but from my perspective the American health system is not in line with your career ideals.

Be lucky you figured this out now, rather than at MS-3 when it's too late. Now you know why lifestyle specialties, ROAD or otherwise are so popular.

 

[DermViser]

DermViser, the IM docs are you hospital sound like *****s. I think they embody the worst of the IM stereotype which is basically a care coordinator who is the gatekeeper to specialists. This certainly is not how it's supposed to be and I think the trainees at your institution are really having a disservice done to them. A competent IM doc should be able to handle most firstline diagnosis and treatment of many common conditions, derm included. If this isn't happening, I think it is largely institution/provider dependent

Sadly this is what General IM is relegated to these days. The "gatekeeper" designation was started by insurance companies. Apparently coordinator is what they want: http://www.ncbi.nlm.nih.gov/pubmed/10359396

 

[rocketbooster]

DermViser, why don't you multi-quote for your responses. Your 10 posts in a row are killing me.

 

[D elegans]

Sadly this is what General IM is relegated to these days. The "gatekeeper" designation was started by insurance companies. Apparently coordinator is what they want: http://www.ncbi.nlm.nih.gov/pubmed/10359396

Maybe I don't think about this "PCP as coordinator" notion because I primarily want to work inpatient, but I think it's crap. A competent PCP who keeps up with medical knowledge should not have to immediately refer patients to X specialist when they are diagnosed with X common specialty diagnosis. Not every RA patient has to see a rheumatologist, not every COPD patient needs a pulmonologist, not every rosacea patient needs a dermatologist, etc. In my admittedly limited experience I have seen PCPs manage at least first line treatment on many of the common conditions that they should be able to handle.

 

[Kahreek]

This is a very tricky subject, but definitely pay is an important factor. I've had GI rotation and to be honest is was more painful than IM.

 

[Raryn]

It's not the "stupid consults" only. It's the almost REFLEXIVE need to consult by General IM to any specialty, bc they don't do anything. Then they wonder why the get laughed at and crapped on by other specialties - i.e. Surgery, EM, etc. There is almost never an admission in which General IM doesn't consult a subspecialty. Patient has kidney failure -- consult Nephrology. Patient has CHF -- consult Cardiology. Patient has Diabetes and I'm not getting his sugars under control -- consult Endocrine. God forbid a General IM team actually THINK about what to do without automatically consulting a specialist. This is another reason why third party payers are now clamping down as the bills are getting too high esp. due to the constant running of generalists to specialists for help.

If I were to consult cardiology for CHF (in situations other than ones where I think they need a cath) or consult nephrology for an AKI (in situations other than where I think they need dialysis), they would laugh at me. I can't think of *any* situation in which case I'd consult endocrinology for diabetes on an inpatient basis. Inpatient endocrine consults are for things like panhypopituitarism or really really funny thyroid panels (i.e. not your typical hypo-/hyper-/sick eu-thyroid)

There are a few hospitalists at my institution who do act like that (consulting subspecialists at the smallest opportunity), but even they don't do something as ridiculous as consulting endocrine for inpatient diabetes management. I don't know where you trained, but you must have some crappy internists.

 

[Instatewaiter]

Exactly. The unintended consequences of doing Pay for Performance on certain measures for patients, esp. with internists, is the firing of those non-compliant patients.

I'd fire them anyway. Screw pay for performance. I didn't go into medicine to bang my head against a wall. Find it on your heart to follow my recommendations or find another cardiologist

 

[Instatewaiter]

There is almost never an admission in which General IM doesn't consult a subspecialty. Patient has kidney failure -- consult Nephrology. Patient has CHF -- consult Cardiology. Patient has Diabetes and I'm not getting his sugars under control -- consult Endocrine.

This is very hospital culture dependent. Where I trained we would rarely consult.

In private practice you won't be complaining about those consults because it will be your lifeblood. I complain about the stupid consult for a mildly elevated troponin but that would be 200 dollars in my pocket for 30 minutes of work.

Also get off your high horse about derm. If it didn't pay so well, no one would go into derm. Essentially every derm guy is a sellout.

If you truly think that general Dermatology is "1) Biopsy 2) Ignore results 3) Prescribe steroids" it shows you know absolutely NOTHING, as steroids are a small speck in the gamut of medications both oral, topical, and injectible that are used in the armamentarium of dermatologic practice.

Bull****. Lets not front like there is some massive toolbox of meds you give. You and I both know it's a lie