It's OFFICIAL....Most Competitive Specialties by Step 1 and Step 2 Scores...

[colbgw02]

Sorry you get clinicians like that, then... all the ones I rotate with are cost-obsessed and are loathe to order so much as an LP on a febrile patient with neck stiffness, photophobia and hx of syncope. (<-- true story)

Yeah, me too. But that's only the tip of the iceberg, sadly.

---

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[herpmed]

I would love to find physicians that are able to diagnose PE, DVT, Aortic Dissection, Hemmoragic stroke of the brain "clinically".

As Kent W correctly indicated above, these are commonly diagnosed clinically. In addition, one could argue that one of the significant contributing influences for the disproportional compensation for diagnostic radiologists is the unfortunate trend of practicing "defensive" medicine. As threats of litigation and insurers combine to force the practicing clinician to reinforce medical decisions with many supplementary (and often, unnecessary) imaging studies, many such studies are performed routinely. This is one of the reasons why the American medical system exhibits a poor yield for the amount of funds expended. Note, this does not mean that confirmatory studies are unnecessary. However, the medical need for some confirmatory imaging has been partially replaced by a perceived need to LEGALLY prove a condition, as opposed to clinically support the same. I agree that the comment quoted above suggests that you have not practiced medicine for any substantial period of time.
Having said that, it is noteworthy that the discussion has wandered from the main theme of this thread (ie the role of USMLE scores in determination of indices of competitiveness among residency positions in various specialties).
For what it is worth, I fully agree with some of the contributors above who stated that the individual's credentials in total weigh to a greater extent. Also, there is no question that having "connections" (specifically, knowing someone in the faculty/having a family member as a previous graduate, having performed well in a rotation in the program of interest, etc) can often overcome a less than "competitive" exam score.
One last point, there are a fair number of PhDs (myself included) that earned a medical education after functioning as a biomedical researcher/faculty member for a number of years (as opposed to completing a combined MD/PhD program). Thus, a significant number of PhD/MDs enter residency with very different presupposed interests in various specialties. Interestingly, I always wanted to pursue either FM or primary care IM (I CHOSE family medicine) due to my perceptions that in clinical medicine, there is increasing simplicity with sub-specialization (meaning, a much reduced focus). The job of a primary care physician is extremely broad and quite complex. Of the admittedly very small sampling (about 11 individuals including myself) of my colleagues holding the PhD prior to medical school, none entered radiation oncology. Most entered neurology, IM/FP or psychiatry.

 

[Apollyon]

Boring?

Radiology is the most cerebral subspecialty in medicine. Most subspecialties rely heavily on preset protocols or algorithym.

In medicine, intellectual fulfillment resides in diagnosing diseases. No other specialty gives you as many opportunities to diagnose diseases than in radiology. As a radiologist you will see the most interesting cases in the hospital.

I daresay that pathology goes head to head with rads for diagnosis. As for "most cerebral", heme/onc also I believe is competitive.

At the same time, I am loathe to have ANYTHING to do with you, having gone through multiple distasteful encounters in the past.

 

[edinOH]

This thread has sure gone into the crapper in a hurry. Just as some predicted it would earlier in the thread. This **** is so childish. But amusing.

 

[Winged Scapula]

I would love to find physicians that are able to diagnose PE, DVT, Aortic Dissection, Hemmoragic stroke of the brain "clinically".

I heard the Homan's Sign, and asymmetric pulses are very reliable for diagnosis. Also, since ischemic strokes are so easy to distinguish from hemmoragic strokes clinically, is it really cost effective to get a CT?

Why stop there? Let's use jaundice, fever, ruq pain to diagnose cholangitis.
Why get an Ultrasound?

While we are at it. Let's diagnose osteomyelitis clinically by tapping the bone.

Lastly, I'm sure Hammond's crunch is very effective at diagnosing booerhave's syndrome. What's the point of getting a X-ray to look for pneumomediastinum or air under the diaphragm.

You're getting a bit carried away here. No one said we didn't use radiological tests to CONFIRM what we already believe. Radiology is a very important part of our armamentarium, just as are our colleagues in other fields.

And yes, surgeons besides me often do diagnose patients although you are right in that some may come "pre packaged" by the internists, et al. However, obviously you have not been privy to the common diagnostic category of those specialists you name: abdominal pain. Hardly a diagnosis IMHO but I guess despite this being a daily occurence for surgeons the world around, we aren't diagnosticians, simply cutters who run to the operating room without figuring out what is going on with these patients.

But since you are talking about Booerhave's and I like to toot my own horn, shall we talk about the 13 yo that I clinically diagnosed with Booerhave's last month based on history and clinical examination which was verified by the CT the ED ordered before asking me to see him (but done after I arrived) because "something is wrong, we don't know what it is"? Obviously the CT scan gave us a lot of information but it didn't diagnose the kid, nor did the results of pneumomediastinum suprise me.

I could come up with other examples to prove my point, but I suspect you have a deficit when it comes to understanding other fields and some sort of axe to grind. Everyone has something to offer and it doesn't help to stereotype each other nor denigrate fields about which you have limited knowledge. ..

 

[deleted87716]

WTF is "Virginia State"?

http://www.vsu.edu/pages/1.asp

But since you're at UVA, I'm sure you knew that already.

 

[yaah]

This thread has sure gone into the crapper in a hurry. Just as some predicted it would earlier in the thread. This **** is so childish. But amusing.

Indeed it has! Medicine is a competitive field, and there will always be a sizeable proportion of its inhabitants with superiority (or inferiority) complexes who think they are doing everyone a favor by being in the same realm. It's as if somehow you get more respect, money, sex, whatever by proving that you are more competitive. It's too bad people can't just do what they enjoy doing and be done with it, and let others do the same.

Most people think that their specialty of choice is "the best" or "more challenging" or whatever. It's second nature. If you spend all your time in one field, you will see the subtleties and challenges inherent to it, whereas if you only look at it peripherally (like the radiologist above who only sees the peripheral parts of surgery and medicine) it will be an easy specialty which you have to "bail out" frequently because they need you more than you need them.

I think everyone needs to take a step back more often and realize that medicine is a huge field, that every field is important and unique and challenging in its own way. No one is better. No one is more important overall. Personally, I can name people in almost every field (including my own) who I think are crappy doctors and fit all stereotypes of the "bad" example of a practitioner within their field to a T. But I also see the opposite. When you realize people are individuals and don't need to be defined by their CV you relax a bit.

 

[Winged Scapula]

Thank you.

 

[SLUser11]

Can we please not let one little guy get everyone's panties in a bunch?

p53's statements are purposefully inflammatory, obviously biased and inaccurate, and yet everyone is freaking out and coming to the rescue of their beloved specialty.

Please just ignore him, and he will slowly retreat into a dark room and start reading chest x-rays.

Still, just to be a little inflammatory myself, I think it's important that we differentiate between the utility of radiologic tests and radiologist interpretation. I find CTs, x-rays, and ultrasound to be crucial to my diagnosis. However, I don't know how how much "Clinical correlation recommended" aids in my diagnosis.


Despite my own beliefs that a chance to cut truly is a chance to cure, the specialties that makes the largest difference in society are probably Family Medicine and primary care IM. It's ironic that the biggest heroes in medicine are non-competitive and insignificant by p53's standards....

 

[EC3]

p53 might be teh best troll that SDN has ever seen. You guys are doing exactly what he expected you all to. The second post of this thread should've been something to the tone of "Yes, you are correct." If someone did that, I could see him in his little dark room somewhere growing hot with rage like a pissed off fisherman.

He's probably a little scrawny guy that got picked on all throughout his life and during school the only thing he really had going for him was his ability to spend all of his time studying; now that he's made it into a competitive specialty (and after listening to all the gawking med students), he thinks he has some status and he's making up for all those years of nobody taking him seriously.

 

[mgdsh]

...he thinks he has some status and he's making up for all those years of nobody taking him seriously.

And yet he still isn't being taken seriously.

 

[Winged Scapula]

You're right...I was feeling a little moody these past few days (I'm bored out of my mind) and took the bait.

mea culpa

 

[Old_Mil]

Six blind men of Hindustan, we are told, once went in search of that wonderful creature, the elephant. Or, perhaps there were only three blind men, in Han China. Yet again, there were anywhere between three and eight, somewhere in the Middle East. In the Buddhist original (?) the number is unspecified.

From there, however, the stories are similar. Each man encountered a different aspect of the elephant and drew a different inference as to its essential nature. One walked into its side, concluding that an elephant is like a wall. Another, prodded by the tusk, declared that an elephant is like a spear. The chap hanging onto the tail was convinced that he had found a sort of rope. And so on.

Asked for a description of the elephant, each firmly and confidently gave his opinion, solidly grounded in empirical experience and all radically different. In the Buddha's tale:

Then they began to quarrel, shouting, "Yes, it is!" "No, it is not!" "An elephant is not that!" "Yes, it's like that!" and so on, till they came to blows over the matter.
Brethren, the raja [who in this version had presented the elephant] was delighted with the scene.

Just so are these scholars holding various views blind and unseeing. … In their ignorance they are by nature quarrelsome, wrangling and disputatious, each maintaining reality is thus and thus.

Then the Exalted One rendered this meaning by uttering this verse of uplift:

"O how they cling and wrangle, some who claim
For preacher and monk the honoured name!
For, quarrelling, each to his view they cling.
Such folk see only one side of a thing."
(Udana 68-69)

 

[Blade28]

Reminds me of a good (related joke)...

What did the Zen Buddhist say to the hot dog vendor?
Make me one with everything.

 

[Reaganite]

He's probably a little scrawny guy that got picked on all throughout his life and during school the only thing he really had going for him was his ability to spend all of his time studying; now that he's made it into a competitive specialty (and after listening to all the gawking med students), he thinks he has some status and he's making up for all those years of nobody taking him seriously.

actually, that is exactly what he looks like. Somebody posted his pic, residency location, and other info a few months back.

 

[McLovin]

bully for their step scores, but the baddest ass docs in the hospital are the GOOD critical care guys.

"no change......stable film......unchanged" : thats the mantra of a radiologist.

 

[kito]

Okay rad onc has more PhDs, but I say derm has the hottest female residents out of all specialties.

ophtho gives you a run for your money.

 

[funkless]

Are you serious? Every one of those is commonly diagnosed clinically.

Suspected, yes. Diagnosed, no. Without visualization (surgical or radiological) or a path report, it's hard to claim a definitive diagnosis.

 

[Llenroc]

Was p53 born a jackass, or did the mind numbing tedium of radiology make him such a social ******?

 

[deleted87716]

Suspected, yes. Diagnosed, no. Without visualization (surgical or radiological) or a path report, it's hard to claim a definitive diagnosis.

Nonsense.

If I see a patient in my office who has RLQ pain, fever, an elevated WBC count, and tenderness over McBurney's point, I'm going to diagnose them with acute appendicitis and send them to a surgeon.

The surgeon will examine the patient and order a CT (most likely), which will be read by a radiologist, who will issue a report which will (hopefully) describe inflammation in the area of the appendix.

The surgeon will then operate, and remove the appendix, which he'll send to a pathologist.

The pathologist will examine the specimen grossly and microscopically, and issue a report, which will (hopefully) confirm appendicitis.

Looking back at all of this, who do you really think diagnosed acute appendicitis? Ask the patient.

 

[Reaganite]

ophtho gives you a run for your money.

I'm not going into derm, so don't think I'm a homer, but the hottest girls are in dermatology, and it's not even close.

 

[p53]

The fact is that anyone that diagnoses PE or DVT clinically is the dumbest physician on the planet. NO ONE IS THAT STUPID.

What is the sensitivitiy of the Homan's Sign? What is the sensitivity of pleuritic chest pain?

Let's not BS the medical students on here.

PE and DVT is a radiological diagnosis. Hemmoragic Strokes are also a radiological diagnosis. There is no way you can suspect hemmoragic vs ischemic stroke upon physical diagnosis and/or history. Feed me some more lies guyes.

You may not like me, or my style. However, the fact is that medical imaging DIAGNOSES diseases. You may have a clinical suspicion of a certain disease but please don't try to dupe people on here by saying that you already know when someone has a PE by physical diagnosis. You are full of Shizznit.

 

[Tired]

I'm not going into derm, so don't think I'm a homer, but the hottest girls are in dermatology, and it's not even close.

If you're still looking to date chicks in med school or residency, then you're not smart enough to get into Derm anyway.

 

[p53]

Pediatrics has the best looking women....BAR NONE....

 

[funkless]

Nonsense.

If I see a patient in my office who has RLQ pain, fever, an elevated WBC count, and tenderness over McBurney's point, I'm going to diagnose them with acute appendicitis and send them to a surgeon.

The surgeon will examine the patient and order a CT (most likely), which will be read by a radiologist, who will issue a report which will (hopefully) describe inflammation in the area of the appendix.

The surgeon will then operate, and remove the appendix, which he'll send to a pathologist.

The pathologist will examine the specimen grossly and microscopically, and issue a report, which will (hopefully) confirm appendicitis.

Looking back at all of this, who do you really think diagnosed acute appendicitis? Ask the patient.

Brilliant example; it proves my point. The conventional wisdom--and maybe Dr. Cox can help substantiate this--seems to be that if a general surgeon isn't removing at least 15% normal appendices, then his/her threshhold for operating is too high. In other words, a good surgeon often will perform an appendectomy based on his/her clinical suspicions, but really won't know until the specimen is actually visualized. (Now, if you call 85% "definitive specificity," then I think we're going to have a hard time finding any common ground here.)

As I was saying before, you can operate on clinical suspicion all day long, but without something more concrete, it's difficult to claim a definitive diagnosis.


EDIT: Indeed. Consult the patients all you want, but bear in mind that, as laymen, they typically won't know the difference between an educated guess and a confirmed diagnosis.

 

[colbgw02]

that if a given general surgeon isn't removing at least 15% normal appendices, then his (or her) threshhold for operating is too low.

do you mean too high?

 

[Reaganite]

If you're still looking to date chicks in med school or residency, then you're not smart enough to get into Derm anyway.

LOL. Yeah, who in their right mind would want to date a hot chick making 300k working 40hrs a week?

 

[colbgw02]

Looking back at all of this, who do you really think diagnosed acute appendicitis? Ask the patient.

Ask the patient? You know better than that.

 

[DireWolf]

Regarding competitiveness, I think RadOnc, Derm, and plastics are the most competitive specialties without question. Radiology, while also competitive, just isn't in the same tier as these 3. It may have the same board score average as RadOnc, for example, but you can't just look at board scores when you are comparing the competitiveness of specialties, especially RadOnc. It has been suggested that the Step1 average for RadOnc may be diluted by all of the PhDers. This is certainly not a knock against people with combined degrees, but the informal consensus on our board seems to be that the average board score of those with combined degrees is significantly lower than the MD-only average scores. These people still match, however, because extensive research experience/publications are highly valued in the field. It is often said that to match in RadOnc, you either need a PhD or an absolutely outstanding academic record.

I agree. Derm/Plastics/Rad Onc are in the top tier when it comes to competitiveness.

ENT/Ortho/Uro/Rads/Neurosurgery/Ophtho probably make up the second tier.

 

[funkless]

do you mean too high?

I certainly did mean "too high." Nice catch. Editing the original.

 

[Winged Scapula]

Brilliant example; it proves my point. The conventional wisdom--and maybe Dr. Cox can help substantiate this--seems to be that if a general surgeon isn't removing at least 15% normal appendices, then his/her threshhold for operating is too low. In other words, a good surgeon often will perform an appendectomy based on his/her clinical suspicions, but really won't know until the specimen is actually visualized. (Now, if you call 85% "definitive specificity," then I think we're going to have a hard time finding any common ground here.)

That would be about right...generally, if you don't remove 15-20% normal appys, you aren't operating enough.

 

[funkless]

Thanks for the input.

 

[AlternateSome1]

http://www.vsu.edu/pages/1.asp

But since you're at UVA, I'm sure you knew that already.

I was hinting at the fact that there is no such medical school as "Virginia State". To call UVA "Virginia State", would be akin to calling the University of Florida "Florida State". Furthermore, MCV is connected to VCU, not VSU.

 

[McLovin]

The fact is that anyone that diagnoses PE or DVT clinically is the dumbest physician on the planet. NO ONE IS THAT STUPID.

What is the sensitivitiy of the Homan's Sign? What is the sensitivity of pleuritic chest pain?

Let's not BS the medical students on here.

PE and DVT is a radiological diagnosis. Hemmoragic Strokes are also a radiological diagnosis. There is no way you can suspect hemmoragic vs ischemic stroke upon physical diagnosis and/or history. Feed me some more lies guyes.

You may not like me, or my style. However, the fact is that medical imaging DIAGNOSES diseases. You may have a clinical suspicion of a certain disease but please don't try to dupe people on here by saying that you already know when someone has a PE by physical diagnosis. You are full of Shizznit.

Medical imaging diagnosis SOME disease. Most of the time you get "consistent with" or "reccomend further imaging in order to pad my wallet"

 

[rccool111]

This may be slightly off topic, but I was looking at this chart
http://www.nrmp.org/data/chartingoutcomes2007.pdf
for the 2007 match outcomes and was looking at match data for step 1. It seems that independent applicants fit into one of the following six categories have lower USMLE Step 1 AND Step 2 scores on average than those who matched.
1)Previous graduate of a U.S. medical school (someone who graduated earlier than September 1 in the year before the match)
2)Student/graduate of a U.S. osteopathic medical school
3)Student/graduate of a Canadian medical schooll
4)Student/graduate of a Fifth Pathway program
5)U.S. citizen student/graduate of an international medical school
6)Non-U.S. citizen (including permanent residents) student/graduate of an international medical school.

So this data seems to indicate that it would be better to go to a DO/Caribbean/Foreign Medical school. What do you guys think about this and can anyone offer anymore insight into these numbers (about why they are lower for independents)

* I know that some people take a year off to do research to show they are really interested in a specific specialty, which often compansates for poorer grades, but I'm pretty sure that this care A) doesn't apply to everyone and B) even if it did, wouldn't lower the average scores to what the chart above indicates. (Because of the presence of FMG's who wouldn't get visa/green cards to stay and have enough time to do research in the US for a year and many other factors...
Sorry for the really long post

 

[herpmed]

Hemmoragic Strokes are also a radiological diagnosis. There is no way you can suspect hemmoragic vs ischemic stroke upon physical diagnosis and/or history. Feed me some more lies guyes.

Although this string has wandered far away from the initial discussion and is increasingly inflammatory, one should not make unsupported statements such as that quoted. There are several grading systems that are used for supporting a clinical diagnosis of ischemic vs hemorrhagic stroke (see below for an example). In the US and other western countries with huge expenditure in medical care, it is EXPECTED that a confirmatory imaging diagnosis is performed. In the case of hemorrhagic vs ischemic infarcts, I certainly support stat use of a CT w/o contrast. However, clinical diagnostic criteria can certainly be used in considering (or, even simpler as you stated, "suspecting") the diagnosis. Also, in many poorer countries these criteria are used often w/o any confirmatory imaging. I have worked in several Third World countries and was impressed with the diagnostic acumen of experienced clinicians without the immediate luxury of expensive imaging modalities.
I will not add to any personal attacks here. However, the overabundance of imaging studies due to understandable concerns regarding potential litigation has led to a mis-perception of the role of radiologists and diagnostic radiology. These will always have an important role in medical practice, but should not be construed as a means of substituting for clinical diagnosis of a large variety of clinical presentations.

Clinical Diagnosis of Ischemic versus Hemorrhagic Stroke: Applicability of Existing Scores in the Emergency Situation and Proposal of a New Score
Til St&#252;rmera,b, Gregor Schlindweinb, Bernhard Kleiserc, Achim Roemppd, Hermann Brennera,b

aDepartment of Epidemiology, German Centre for Research on Ageing, Heidelberg, Departments of
bEpidemiology,
cNeurology and
dInternal Medicine I, University of Ulm, Germany

Address of Corresponding Author
Neuroepidemiology 2002;21:8-17 (DOI: 10.1159/000048608)
Key Words

• Stroke, ischemic
• Stroke, hemorrhagic
• Diagnosis
• Score
• Receiver operating characteristic

Abstract
Several scores exist to clinically differentiate between ischemic and hemorrhagic stroke, but none has been developed in the emergency situation in which transient ischemic attack (TIA) and cerebral infarction might not yet be clearly distinguished. Information on 540 patients with ischemia (including TIA) or hemorrhage was abstracted from medical charts. Of 540 patients hospitalized with stroke, 98 had a hemorrhage. Age, obesity, anamnestic stroke/TIA, peripheral arterial disease, onset during physical activity, headache, impaired consciousness, hemisyndrome, meningismus and systolic blood pressure contributed to the differential diagnosis and were included in our proposed score. The score performed well in comparison with existing scores. The inclusion of TIA and the explicit incorporation of incomplete information may enhance the applicability of differential diagnostic scores in the prehospital emergency situation.
Copyright &#169; 2002 S. Karger AG, Basel

 

[herpmed]

I have had to add a bit more as some of the addendum to my last post did not attach. I intended to include several papers that argue both sides of the discussion re dx of ischemic and hemorrhagic strokes (even though this is more than beating the hell out of an expired equine life form). As a summary, several indices (such as that of Siriraj and Allen) have reported PPVs ranging from the high 70s to the low 90s. The main point is that these indices have general utility for rapid diagnostic screening and provide a means of establishing "suspicion" (as stated above). Certainly, no one is "lying" regarding utilization of clinical diagnostic criteria in assessing etiology of a given stroke. One obviously will perform a CT or MRI if it is available (again, in many countries it is NOT). In addition, I recalled an interesting paper from a couple of years ago that MAY hold promise for expanding and boosting the sensitivity and PPV of such diagnostic criteria (see below; only have the abstract. The full citation is available for anyone so interested).
One good result of this largely ridiculous discussion is consideration of the updated literature re evaluations of some clinical scoring scales.

Research Article
ApoC-I and ApoC-III as potential plasmatic markers to distinguish between ischemic and hemorrhagic stroke

Laure Allard[SIZE=-1] 1[/SIZE][SIZE=-1] *[/SIZE], Pierre Lescuyer[SIZE=-1] 1[/SIZE], Jennifer Burgess[SIZE=-1] 1[/SIZE], Kit-Yi Leung[SIZE=-1] 2[/SIZE], Malcolm Ward[SIZE=-1] 2[/SIZE], Nadia Walter[SIZE=-1] 1[/SIZE], Pierre R. Burkhard[SIZE=-1] 3[/SIZE], Garry Corthals[SIZE=-1] 1[/SIZE], Denis F. Hochstrasser[SIZE=-1] 1[/SIZE], Jean-Charles Sanchez[SIZE=-1] 1[/SIZE][SIZE=-1]1[/SIZE]Biomedical Proteomics Research Group, Central Clinical Chemistry Laboratory, Geneva University Hospital, Geneva, Switzerland
[SIZE=-1]2[/SIZE]Proteome Sciences plc, South Wing Laboratory, Institute of Psychiatry, King's College London, London, UK
[SIZE=-1]3[/SIZE]Neurology Department, Geneva University Hospital, Geneva, Switzerland
email: Laure Allard ([email protected])
[SIZE=-1]*[/SIZE]Correspondence to Laure Allard, Biomedical Proteomics Research Group, Central Clinical Chemistry Laboratory, Geneva University Hospital, CH-1211 Geneva 14, Switzerland Fax: +41-22-372-73-99
setDOI("ADOI=10.1002/pmic.200300809")
KeywordsApolipoprotein • Hemorrhagic stroke • Ischemic stroke • Plasmatic diagnostic marker
AbstractEarly diagnosis and immediate therapeutic interventions are crucial factors to reduce the damage extent and the risk of death. Currently, the diagnosis of stroke relies on neurological assessment of the patient and neuro-imaging techniques including computed tomography and/or magnetic resonance imaging scan. An early diagnostic marker of stroke, ideally capable to discriminate ischemic from hemorrhagic stroke would considerably improve patient acute management. Using surface-enhanced laser desorption/ionization (SELDI) technology, we aimed at finding new early diagnostic plasmatic markers of stroke. Strong anionic exchange (SAX) SELDI profiles of plasma samples from 21 stroke patients were compared to 21 samples from healthy controls. Seven peaks appeared to be differentially expressed with significant p values (p < 0.05). Proteins were stripped from the SAX chips, separated on a one-dimensional electrophoresis (1-DE) gel and stained using mass spectrometry (MS)-compatible silver staining. Following in-gel tryptic digestion, the peptides were analyzed by MS. Four candidate proteins were identified as apolipoprotein CI (ApoC-I), apolipoprotein CIII (ApoC-III), serum amyloid A (SAA), and antithrombin-III fragment (AT-III fragment). Assessment of ApoC-I and ApoC-III levels in plasma samples using a sandwich enzyme-linked immunosorbent assay (ELISA) allowed to distinguish between hemorrhagic (n = 15) and ischemic (n = 16) stroke (p < 0.001). To the best of our knowledge, ApoC-I and ApoC-III are the first reported plasmatic biomarkers capable to accurately distinguish between ischemic and hemorrhagic stroke in a small number of patients. It requires further investigation in a large cohort of patients.

 

[blz]

I'm not going into derm, so don't think I'm a homer, but the hottest girls are in dermatology, and it's not even close.

I've noticed that there are two types of residents in derm: hot blond chicks and skinny asian dudes.

 

[p53]

Responses to some of the comments above

1. To get a proper answer you have to ask the proper question. IF YOU WEREN'T LAZY ENOUGH TO GIVE US CLINICAL DATA we would not ask for clinical correlation or further tests. Most of the time we are given an IMAGE WITH ZERO INFORMATION. If you are going to point a finger point the finger at yourself and your colleagues for not giving the radiologists the information needed to DIAGNOSE.

2. As for the assertion across the country that surgeons can read images just as well as radiologists. That is BS. Radiology is a 4 year residency. A surgery resident does not have the time to read and see as many images as a radiology resident. PERIOD. So for the Surgeons out there that think they can manage patients medically just as well as a medicine resident, or interpret an image just as well as a radiology resident. GET OFF YOUR HIGH HORSE. You are the hardest working resident in the hospital PHYSICALLY but that doesn't mean that you do EVERYTHING.

3. Once again. Any practicing physician in this country that gives antiplatelets based on clinical information SHOULD have his/her license suspended for being a complete DUMB ARSE. History and Physical Exam does not distinguish the two strokes. As for the assertion that APO C can diagnose strokes that is BS. Imaging is faster than lab results and the sensititity and specificity is much higher. FOR THE POSTER THAT POSTED THAT CRAP, your response is clinically known as INTELLECTUALIZATION in psychiatric circles. Bottomline: you want to be right but you are wrong. Getting labs precludes it from being a "clinical" diagnosis. If you read my post carefully (verbal reasoning was likely your worst score on the MCAT) it says HX and Physical exam only.

4. As for the skinny asians and hot blondes in Derm. The skinny asians have a Step 1 score in the 250's and the hot blondes Step 1 average is in the 220-230's. That is why the Step 1 average is so high.

 

[Winged Scapula]

2. As for the assertion across the country that surgeons can read images just as well as radiologists. That is BS. Radiology is a 4 year residency. A surgery resident does not have the time to read and see as many images as a radiology resident. PERIOD. So for the Surgeons out there that think they can manage patients medically just as well as a medicine resident, or interpret an image just as well as a radiology resident. GET OFF YOUR HIGH HORSE. You are the hardest working resident in the hospital PHYSICALLY but that doesn't mean that you do EVERYTHING.

Who made that assertion? I personally would never claim that I can read any imaging study better than a senior resident or attending radiologist who has full clinical information and I have yet to see anyone here claim otherwise.

 

[p53]

Every specialty plays a role in medicine. However, if you want to talk about the most tangible difference in society it is the SURGEONS and the OB/GYN physicians. Family Medicine and Internal Medicine docs manage chronic disease without doing much. Surgeons and Ob/Gyn physicians have tangible results. Although I tease the comments about "a chance to cut is a chance to cure". Surgeons make a profound difference. As do OB docs with surgeries, and delievering babies.

So before you go off on some BS about how medicine and family docs are underappreciated, actually think about what TANGIBLE results different specialties make in people's lives.

Can we please not let one little guy get everyone's panties in a bunch?

p53's statements are purposefully inflammatory, obviously biased and inaccurate, and yet everyone is freaking out and coming to the rescue of their beloved specialty.

Please just ignore him, and he will slowly retreat into a dark room and start reading chest x-rays.

Still, just to be a little inflammatory myself, I think it's important that we differentiate between the utility of radiologic tests and radiologist interpretation. I find CTs, x-rays, and ultrasound to be crucial to my diagnosis. However, I don't know how how much "Clinical correlation recommended" aids in my diagnosis.


Despite my own beliefs that a chance to cut truly is a chance to cure, the specialties that makes the largest difference in society are probably Family Medicine and primary care IM. It's ironic that the biggest heroes in medicine are non-competitive and insignificant by p53's standards....

 

[colbgw02]

IF YOU WEREN'T LAZY ENOUGH TO GIVE US CLINICAL DATA

I'm not really trying to defend p53 here, and I don't know what this "us" stuff is (see above). As I recall, he just started his internship, so no one is giving him any clinical data. But at least one point he makes isn't all together without merit...

The vast majority of clinical histories provided leave something to be desired. Some are woefully inadequate, like "follow-up", "pain", or "needs head CT". Garbage in, garbage out.

 

[herpmed]

Responses to some of the comments above

1. To get a proper answer you have to ask the proper question. IF YOU WEREN'T LAZY ENOUGH TO GIVE US CLINICAL DATA we would not ask for clinical correlation or further tests. Most of the time we are given an IMAGE WITH ZERO INFORMATION. If you are going to point a finger point the finger at yourself and your colleagues for not giving the radiologists the information needed to DIAGNOSE.

2. As for the assertion across the country that surgeons can read images just as well as radiologists. That is BS. Radiology is a 4 year residency. A surgery resident does not have the time to read and see as many images as a radiology resident. PERIOD. So for the Surgeons out there that think they can manage patients medically just as well as a medicine resident, or interpret an image just as well as a radiology resident. GET OFF YOUR HIGH HORSE. You are the hardest working resident in the hospital PHYSICALLY but that doesn't mean that you do EVERYTHING.

3. Once again. Any practicing physician in this country that gives antiplatelets based on clinical information SHOULD have his/her license suspended for being a complete DUMB ARSE. History and Physical Exam does not distinguish the two strokes. As for the assertion that APO C can diagnose strokes that is BS. Imaging is faster than lab results and the sensititity and specificity is much higher. FOR THE POSTER THAT POSTED THAT CRAP, your response is clinically known as INTELLECTUALIZATION in psychiatric circles. Bottomline: you want to be right but you are wrong. Getting labs precludes it from being a "clinical" diagnosis. If you read my post carefully (verbal reasoning was likely your worst score on the MCAT) it says HX and Physical exam only.

4. As for the skinny asians and hot blondes in Derm. The skinny asians have a Step 1 score in the 250's and the hot blondes Step 1 average is in the 220-230's. That is why the Step 1 average is so high.

Although my verbal reasoning is far more than sound, yours is painfully lacking. Your post was read carefully, however, you should read carefully those you criticize. The previous posting pondered diagnostic criteria and consideration of those who must make dx W/O the luxury of imaging (as stated, many physicians in the world must rely on PE and Hx ALONE as imaging is not readily available. Conditions such as these impact an enormous number of people). The Apo C potential for testing could (above I said in upper case MAY) aid these criteria. If a test were available that would add to those assessments, it would greatly help those who DO NOT have access to rapid imaging studies. I also stated that OBVIOUSLY if one has imaging capacity, one would unquestionably use CT or MRI. As I am an MD/PhD working in proteomics as well as medicine, it is clear you have no clue re the current efforts to improve a number of diagnostic criteria for those who CANNOT AFFORD to run CTs on the MAJORITY of patients who present with PE/Hx resulting in "SUSPICION" of hemorrhagic (yes, that is how it is spelled) vs ischemic infarct.
As was suggested by contributors in this string, you are simply spewing in an effort to "stir a pot".
Your efforts at psychiatric analysis are as pitiful as your replys (as are your criticisms re the ubiquitous, "clincial correlation recommended". This statement has little to do with a "lazy" paucity of data from the requesting physician, and everything to do with a radiologist sending the legal ramifications of a reading back to those making the DECISIONS re clinical management-the TREATING PHYSICIAN. Also, I have worked with a number of surgeons and general physicians who read CTs and MRIs with impressive expertise). I am done with this "discussion" as I will not continue any personal criticism (I have been trying to avoid this). This will be inevitable with any further reply as you seem incapable of intelligent discourse.
Obviously, the this string has gone totally off of the original track and has little utility.

 

[Llenroc]

Every specialty plays a role in medicine. However, if you want to talk about the most tangible difference in society it is the SURGEONS and the OB/GYN physicians. Family Medicine and Internal Medicine docs manage chronic disease without doing much. Surgeons and Ob/Gyn physicians have tangible results. Although I tease the comments about "a chance to cut is a chance to cure". Surgeons make a profound difference. As do OB docs with surgeries, and delievering babies.

So before you go off on some BS about how medicine and family docs are underappreciated, actually think about what TANGIBLE results different specialties make in people's lives.

Actually you're about 100% wrong about that. The biggest difference in healthcare comes from managing people's chronic conditions *medically*. An even bigger difference comes from things like vaccinations to keep them from getting sick in the first place, or health care checkups to catch disease processes early.

That's why in a lot of countries where they may not have expensive operating theaters and lots of highly specialized surgeries available, but where they do have good, accessible primary care, people tend to live as long or longer than here in the U.S.

 

[ForbiddenComma]

Actually you're about 100% wrong about that. The biggest difference in healthcare comes from managing people's chronic conditions *medically*. An even bigger difference comes from things like vaccinations to keep them from getting sick in the first place, or health care checkups to catch disease processes early.

That's why in a lot of countries where they may not have expensive operating theaters and lots of highly specialized surgeries available, but where they do have good, accessible primary care, people tend to live as long or longer than here in the U.S.

Right... and when people talk about "healthcare provider shortages" in this country, they're talking about primary care. Why else are all these in-store NP clinics sprouting up so fast?

In addition, it's up to the primary care doc to catch the problem to begin with to refer to surgery. (not counting the lazy diagnosis of "surgical abdomen" anyway )

 

[TheFlash]

Actually you're about 100% wrong about that. The biggest difference in healthcare comes from managing people's chronic conditions *medically*. An even bigger difference comes from things like vaccinations to keep them from getting sick in the first place, or health care checkups to catch disease processes early.

That's why in a lot of countries where they may not have expensive operating theaters and lots of highly specialized surgeries available, but where they do have good, accessible primary care, people tend to live as long or longer than here in the U.S.

Nailed it. The difference is made before the patient ever lands him/herself in the OR. If you can manage a patient's DM well, you'll save that patient from a trip to the vascular surgeon later down the road. Having versus not having a foot is a pretty tangible difference, IMO.

 

[borgon]

.

 

[NHL Fever]

Actually you're about 100% wrong about that. The biggest difference in healthcare comes from managing people's chronic conditions *medically*. An even bigger difference comes from things like vaccinations to keep them from getting sick in the first place, or health care checkups to catch disease processes early.

That's why in a lot of countries where they may not have expensive operating theaters and lots of highly specialized surgeries available, but where they do have good, accessible primary care, people tend to live as long or longer than here in the U.S.

Great point. I think this post and part of p53's post are right.

If all radiologists disappeared today, and scans were left up to specialties to interpret, there would be a certain decline in overall health care most acutely in the area of of interventional procedures, but the system would still function fairly. If you took away surgeons, or family docs for example the whole system would collapse. A huge proportion (the majority?) of conditions simply would never get diagnosed and treated. There would be very few conditions that would go undiagnosed if there were no radiologists, as long as there were radiologic technicians to run the machines. I can only speak to my own experience which is short, but I have yet to witness or hear about a situation where the the radiologist identifies a problem that was both not already suspected AND the specialist was unable to identify it by looking at the scan/film him/herself. Nevertheless they do exist, and I'm sure every radiologist can vividly recall such a situation if asked, and therefore if the resources are there, they have that value. It could be said that advanced imaging and radiologic consult are part of what define a sophisticated, modern system.

But I echo the others in saying its kinda pointless of try to rank the value in any objective way of any specialty verses another. They all have different value depending on your perspective and situation, and the medico-legal factors have a disproportionate impact on the use of this or that specialist compared to pure value in terms of best interest of the population being served. If I most value being 100% certain of something or maximizing my chances of avoiding legal action, I will value radiologic input more than the person trying to consider maximizing the finite resources of the health district for the whole community, yet both of those positions can be noble in intent. On a personal level my own bias as a resident in the hospital is if I had to choose one area outside my own where I could have the most competent colleague it would be internal medicine. NOBODY can help you as much as an outstanding med consultant IMHO.

I'm not a family doctor, but I happen to think family doctors are the most important line of health care. If I had to pick between having the best family doctor around, vs the best surgeon or OB or ped or internist, I would choose having the best family doc. He/she is going to benefit me far more (assuming I'm the average person) in overall impact during my life than any of the others. In fact I would probably choose to have the best family doctor around, instead of the best surgeon AND OB AND ped AND internist, if for whatever absurd reason I had to make that choice. And if I was forced to choose one major specialty involved in my care where I would receive a poor performer, I would quite honestly choose radiology over those others. My unstoppable family doctor would be good with routine scans to make up for that, and priceless for all the other visits I would make to them over the years. Of course, there will always be people with weird and/or chronic conditions requiring specialization as their primary modality of care, but I'm only talking about myself as the average person. Although I think GP's are the most valuable docs to the community, I didn't become a GP because I simply enjoyed something else which I believe is a better fit for my personality and style. I give the same credence to any specialty for the same reason.

 

[colbgw02]

If all radiologists disappeared today, and scans were left up to specialties to interpret, there would be a certain decline in overall health care most acutely in the area of of interventional procedures, but the system would still function fairly. If you took away surgeons, or family docs for example the whole system would collapse. A huge proportion (the majority?) of conditions simply would never get diagnosed and treated. There would be very few conditions that would go undiagnosed if there were no radiologists, as long as there were radiologic technicians to run the machines. I can only speak to my own experience which is short, but I have yet to witness or hear about a situation where the the radiologist identifies a problem that was both not already suspected AND the specialist was unable to identify it by looking at the scan/film him/herself. Nevertheless they do exist, and I'm sure every radiologist can vividly recall such a situation if asked, and therefore if the resources are there, they have that value. It could be said that advanced imaging and radiologic consult are part of what define a sophisticated, modern system.

I try not to be too much of a specialty homer, and I have a lot of respect for clinicians. But this part of your post is pretty ignorant. I know you tempered your comments somewhat, but still.

The average clinician really has no idea about the nuances and the subtleties that go into interpretting a study. There's a reason why it takes 4 years and 3 board exams to become certified to practice. My own experience is replete with examples where the relevant subspecialist was way, way off. This says nothing of understanding the physics involved, which test to order, how to protocol the examination, or how best to follow it up. That's not a knock; that's how it's supposed to be. That's why we exist. Sure, in theory, you could tack a year or two onto everyone's residency training so that they could be profficient in their commonly ordered studies. But you could also say that we should get rid of urology and add 2 years onto a general surgery residency??

I'm sorry for getting kinda riled up about this, but I think that radiology is incredibly misunderstood. And I think it's silly to think that you could get rid of radiologists and expect the system to function anywhere near it currently does.

 

[Whisker Barrel Cortex]

I apologize that an intern who thinks he is radiologist is causing all of you such grief. p53 is a notorious troll on radiology forums as well.

As a radiologist, I would be the first to agree that we do not make diagnoses in isolation. It is up to the astute clinician to take our interpretation in the context of the patient's situation. Many diagnoses would be made without the radiologst, but much of the subtlety that can affect the treatment of the patient profoundly would not be made. As clinicians who have not been in the role of a radiologist, you do not see how often this really happens. Maybe for each of you it happens once in a while and the remainder of the time you the rad doesn't effect your treatment. Thus you don't perceive the radiologists value. Since we deal with numerous clinicians on a daily basis, we see how often it really happnes.

This is also the difference that a good radiologist can make over a poor one (a response to NHLs post). I see this every day. I've worked with amazing radiologists in residency and relatively poor ones while working out in the real world (and when reading outside film reports). While I could name numerous examples daily where this is a major factor in the care of patients, I'll save you the extra reading and just say that having your study interpreted by a poor radiologist is asking for trouble (and having it read by most clinicians can be just plain dangerous).

A brief note on the original topic of this post. Who gives crap what the most competitive specialty is? Just do what you like (if you can get into it). Focusing on the competitiveness of any specialty as proof of its worth and your own self-worth is pretty pathetic.