Maintaining knowldge

[Dr.TurkandJD]

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Hey all,

Ive been out of residency for a year, just working in the community, 15-20shifts a month- never had any issues. I started studying for oral boards and I realized I forgot medicine. I did not remember iron overdose is treated by deferoxamine or indications. Did not remember all the meds needed to be given in acute angle glaucoma...both of those easily looked up and helped with Poison Control/Optho. Am I a bad doctor? I went to a good residency, I feel more than prepared, this is just stuff I do NOT remember. Should I be doing Rosh? I don't have time for EmRap as I don't have a commute. I already passed my written, now freaking out about the knowledge for oral, and just medical knowledge in general.

 

[gro2001]

Hey all,

Ive been out of residency for a year, just working in the community, 15-20shifts a month- never had any issues. I started studying for oral boards and I realized I forgot medicine. I did not remember iron overdose is treated by deferoxamine or indications. Did not remember all the meds needed to be given in acute angle glaucoma...both of those easily looked up and helped with Poison Control/Optho. Am I a bad doctor? I went to a good residency, I feel more than prepared, this is just stuff I do NOT remember. Should I be doing Rosh? I don't have time for EmRap as I don't have a commute. I already passed my written, now freaking out about the knowledge for oral, and just medical knowledge in general.

Don't freak out, you're not a bad doctor. There are lots of things that exist in our corpus of knowledge more because they are testable than because we need to be able to recall them without looking up. Having said that, given the chaotic nature of oral boards, that might be the kind of stuff that could be a hinderance. I would start with the Okuda book. Go through all the cases, ideally with someone being the examiner. Thankfully the format of the book allows it to be even someone without medical knowledge to serve as the examiner. Some of the critical actions are a little iffy, but some of the critical actions on on oral boards are too. I feel if you can get through all the cases in that book, you're probably ok.

 

[RoyBasch]

You should probably study that for boards, but in reality would you ever manage one of those rare but high risk conditions without specialist consultation? The main things to know are that those conditions exist and when to suspect them, how to make the initial dx. Once you do you contact tox or ophtho and go from there. I would never initiate chelation therapy without involvement of a toxicologist, and every case of acute angle closure glaucoma I have managed with an ophthalmologist dictating the meds/drops I should use and next steps.

 

[thegenius]

Hey all,

Ive been out of residency for a year, just working in the community, 15-20shifts a month- never had any issues. I started studying for oral boards and I realized I forgot medicine. I did not remember iron overdose is treated by deferoxamine or indications. Did not remember all the meds needed to be given in acute angle glaucoma...both of those easily looked up and helped with Poison Control/Optho. Am I a bad doctor? I went to a good residency, I feel more than prepared, this is just stuff I do NOT remember. Should I be doing Rosh? I don't have time for EmRap as I don't have a commute. I already passed my written, now freaking out about the knowledge for oral, and just medical knowledge in general.

Haha no. I can't speak for the boards as it's been 8 or 9 years since I took them.

But in real life you have a ton of information in your brain and you will start forgetting little bits and pieces here and there. But that does not mean you are going to fail patients. Let's look at some real life examples from yours above:

1). iron toxicity. In real life that will never be on the top of your differential unless you are given an empty ferrous sulfate pill bottle by the patient or their family member. This is very hard to pick up. If you frankly put it in your differential at all when you admit the patient for an overdose, you are better than most ER docs. What do I remember about iron toxicity? Very little. People vomit and have abdominal pain. And you can give a few different iron binders to chelate it. I can't remember them and I would look them up. I've never seen iron toxicity and I doubt I've even missed it because it's just so rare.

2). acute angle glaucoma. Much easier to consider when you have a patient with a red eye and pain. it's not hard to diagnose. You think the patient has it? get a pressure. If it's elevated you know there are tons of drops to give. Remember 1 or 2 of them, then go look up the rest. Time is eyeball...but it's not like the eyeball is going to die in 2 minutes if you don't get the drops in. I remember timolol and brimonidine. I don't even know the concentrations. I also know that diamox and mannitol can be used...but those are either oral or IV. So in real life (and I've seen acute glaucoma maybe 3-4 times in 9 years)...I would say "Wow OK the pressure is 48". I calmly go to the computer, order timolol/brimonidine, call pharmacy and ask them to expedite approval. I get the meds, put in a drop of each, then I call ophthalmology. Then they help guide me until they come in. Easy. Not much more you need to do besides check the pressure every 10 minutes or so to make sure it's not getting worse.

 

[AlmostAnMD]

Rofl

Manage rare ****

I had my first case of malaria in years. The clue was the patient just came from the heart of a country I'd never heard of and told me, "I think I have malaria."

I ordered a malaria smear--which I didn't even know we had--and after it was positive just admitted her

Zero effort, zero time in even thinking how to treat this nonsense. Life is not a step 1 exam, getting the answer wrong isn't a point off it's a lawsuit

 

[Groove]

I haven't touched a textbook in years. I almost exclusively read Uptodate and that's just used as a point of reference if I'm curious about a small caveat in management or want to familiarize myself with something in more detail. I probably reference UTD about once a shift or every 2 shifts. It's not that I necessarily have to but I like learning new things and feel that there's always something new on there. It's a great resource. Sometimes it's completely unrelated to emergency medicine such as how to pick the best anti-hypertensive, best mono therapy, vs dual therapy, etc.. Because I feel we do a lot of FM in the ED. Anyway...there's always something new you can learn on there. I have the extra benefit of working with residents and they always have good questions and will keep me on my toes. I like playing tricks with them sometimes... Other day I was working with an intern and memorized an EKG on a pt we were managing. Later on when we were discussing the pt, I asked them about the EKG and they couldn't find it, so I casually rattled off the bpm, PR/QT interval lengths, QRS, etc.. Their eyes widened and they thought I had some kind of super attending photographic memory. I gave them this expression like "what? you can't remember the EKG?" haha. They are good kids but I love messing with them, lol.

I guess the point is....over time, if you just pick a single resources like UTD, WikiEM or whatever... You'd be surprised about the amount of info you'll accumulate. I also read the occasional journal but not regularly. We all forget management on rare cases that we never see, but over time you'll start to remember after you've seen it a few times. That's just normal. I also like querying pubmed to see if there have been any studies on certain topics that I might be interested in researching.

 

[HemeOncHopeful19]

Haha no. I can't speak for the boards as it's been 8 or 9 years since I took them.
1). iron toxicity. In real life that will never be on the top of your differential unless you are given an empty ferrous sulfate pill bottle by the patient or their family member. This is very hard to pick up. If you frankly put it in your differential at all when you admit the patient for an overdose, you are better than most ER docs. What do I remember about iron toxicity? Very little. People vomit and have abdominal pain. And you can give a few different iron binders to chelate it. I can't remember them and I would look them up. I've never seen iron toxicity and I doubt I've even missed it because it's just so rare.

This reminds me of a patient I had in clinic the other day referred for iron deficiency.

Her primary doc had told her to go to pharmacy and take “300mg of iron once a day.” Patient went to Costco and bought an iron supplement that said on the bottle “325mg Ferrous Sulfate (60mg iron)” or something to that effect and promptly start taking 5-6 a day to make it 300 of iron for 2 months while waiting to see me.

Shockingly, she was not constipated. Iron was also fully repleted!

 

[Angry Birds]

Rofl

Manage rare ****

I had my first case of malaria in years. The clue was the patient just came from the heart of a country I'd never heard of and told me, "I think I have malaria."

I ordered a malaria smear--which I didn't even know we had--and after it was positive just admitted her

Zero effort, zero time in even thinking how to treat this nonsense. Life is not a step 1 exam, getting the answer wrong isn't a point off it's a lawsuit

That was a pretty good clue

 

[emergentmd]

20 yrs out and if I walked into an ABEM board recert cold, you would see me fail. I do a 1 week cram before recert, memorize as much detail as possible, pass the test, and then forget it soon after.

What makes a good/great EM doc

1. Calm multitasker who can chart quickly
2. Know who is sick and who is not
3. Know who needs to be admitted and who can be discharged
4. Have good relationship with specialists
5. Come across as caring and attentive to pts concerns


Detailed knowledge is of little importance. I google stuff I am not completely sure of. 99% of your shift is abd pain, chest pain, URI, rashes, minor procedures, vauge complaints. You need to memorize about 15 drugs and you will use it so often that you will eventually know it.

 

[Angry Birds]

20 yrs out and if I walked into an ABEM board recert cold, you would see me fail. I do a 1 week cram before recert, memorize as much detail as possible, pass the test, and then forget it soon after.

What makes a good/great EM doc

1. Calm multitasker who can chart quickly
2. Know who is sick and who is not
3. Know who needs to be admitted and who can be discharged
4. Have good relationship with specialists
5. Come across as caring and attentive to pts concerns


Detailed knowledge is of little importance. I google stuff I am not completely sure of. 99% of your shift is abd pain, chest pain, URI, rashes, minor procedures, vauge complaints. You need to memorize about 15 drugs and you will use it so often that you will eventually know it.

One of my best cases was a woman I saved from a poly medication overdose (suicide attempt). I got tons of praise for the way I treated her and saved her life. Meanwhile, I knew the real hero was the Tox fellow I had phone consulted telling me what to do in a five minute conversation. That along with wikiem.

 

[Dr.TurkandJD]

YOU GUYS ARE AMAZING, I am studying for oral boards, and some of the critical actions are just stupid. I also feel like I have gaps in knowledge without reference... I haven't touched any educational material in 1.5 years ive been out, and it feels like an uphill battle.