Medicine is a farce

[Food]

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The last week has been extremely discouraging. I am now convinced that large tertiary care centers with multidisciplinary teams are detrimental to patient care. The fragmentation of medicine into specialties and subspecialty services that have fantastic tunnel visions, ginormous egos and megalomaniac level self-masturbation is the standard.

When you have an IM team that is managing a patient and they need help from multiple specialties who refuse to acknowledge the veracity or legitimacy of each others claims, the patient is suffering.

When you have attending who pass things on to residents who then spew it at each other, you have a 2 way game of telephone that has 0 science involved and 100% egotistical self suckage. Confidence may be a necessary trait in a doctor but its actually detrimental when you don't know what you're talking about and continue to do it anyway, from your bottom orifice.

If a patient needs an excisional biopsy to properly guide diagnosis and tx for a cutaneous t cell lymphoma you don't argue with the pathologist telling you that this is what would give him adequate sampling to do flow. You don't google papers regarding core needle biopsy sensitivity in this type of lymphoma and tell IM to piss off and ignore path and heme oncs recs. You don't drag on with this wishy washy bull**** for 2 weeks while this patient suffers and develops TEN from his lymphoma which we can't treat because we font have path. What a ****ing joke.

If you are MICU you don't refuse a TEN, septic, lymphoma patient because he isn't unstable and desating YET. Why is modern medicine (in practice) all about treating things once they become completely FUBAR as opposed to actually taking proactive steps to prevent them. Sure you can write upgrade to progressive care and pat yourself on the back for all the good it will do.

Thank god I am not an IM resident and am off service. This isn't aimed at MICu or surgery specifically but at all services who play this stupid ****ing game day after day and call it good medical care. Pathetic.

 

[mercaptovizadeh]

The last week has been extremely discouraging. I am now convinced that large tertiary care centers with multidisciplinary teams are detrimental to patient care. The fragmentation of medicine into specialties and subspecialty services that have fantastic tunnel visions, ginormous egos and megalomaniac level self-masturbation is the standard.

When you have an IM team that is managing a patient and they need help from multiple specialties who refuse to acknowledge the veracity or legitimacy of each others claims, the patient is suffering.

When you have attending who pass things on to residents who then spew it at each other, you have a 2 way game of telephone that has 0 science involved and 100% egotistical self suckage. Confidence may be a necessary trait in a doctor but its actually detrimental when you don't know what you're talking about and continue to do it anyway, from your bottom orifice.

If a patient needs an excisional biopsy to properly guide diagnosis and tx for a cutaneous t cell lymphoma you don't argue with the pathologist telling you that this is what would give him adequate sampling to do flow. You don't google papers regarding core needle biopsy sensitivity in this type of lymphoma and tell IM to piss off and ignore path and heme oncs recs. You don't drag on with this wishy washy bull**** for 2 weeks while this patient suffers and develops TEN from his lymphoma which we can't treat because we font have path. What a ******* joke.

If you are MICU you don't refuse a TEN, septic, lymphoma patient because he isn't unstable and desating YET. Why is modern medicine (in practice) all about treating things once they become completely FUBAR as opposed to actually taking proactive steps to prevent them. Sure you can write upgrade to progressive care and pat yourself on the back for all the good it will do.

Thank god I am not an IM resident and am off service. This isn't aimed at MICu or surgery specifically but at all services who play this stupid ******* game day after day and call it good medical care. Pathetic.

I have seen some equally horrendous stuff on pediatrics, where the situation is even worse because "we need to have XYZ specialty on board" and the culture of "fellow run" and "pan-consultation" some attendings practice. On a simple patient with one issue this is ok (but stupid for the residents, because all you do is write notes and putting in orders per "recommendations" (i.e. commands) from the specialties). For a complex patient where the treatment for condition X is causing alarming new condition Q, it's a recipe for disaster. The specialties have blinders on and are egomaniacs who cannot accept that you can't trash the rest of the body to treat the random condition that they are "experts" on.

 

[Food]

Yeah. I know what you mean. I always had this hope as a medical student that despite all the drama and interpersonal squabbles, whatever is right for the patient ends up being done. That hope is rapidly evaporating.

 

[NotAProgDirector]

Not all academic medicine is this way. All of the institutions I have worked at (which I realize is exactly 2) had great working relationships between specialists, residents and teams. There's always a chance of disagreement -- ID and Surgery consult on a patient, ID states patient needs to go to the OR for debridement, GS says that no surgical treatment is needed. We just get both sides together and try to work it out.

 

[Raryn]

It really is institution dependent. Most of our consultants play nice with each other (and with the primary team). They do generally put in only recommendations regarding their primary system, but that's why you called them. As the primary team, we are the ones who balance the different concerns.

The only people who come to mind as really disagreeing with each other are the neurosurgeons vs ID. They get into arguments all the time regarding appropriate treatment, usually with ID wanting the neurosurgeons to do something that they don't want to do.

 

[nlax30]

I don't think the problem is as much with different specialists making differing recommendations, but rather the lack of communication or discuss among them about what may be the best approach for the patient.

Obviously each specialist is going to have some sort of bias for their organ/system and this is where medicine gets hard and why we are physicians who can think through a problem analytically and tailor decisions based on other factors. If it was easy and just flowchart based then hell, just have midlevels follow guidelines in everyone.

But in a way I agree with you, I just get frustrauted with the lack of communication at times, not just at different specialists making recs that may be at odds with each other. Actually that's when I actually get to be a real doctor and discuss the options with the patient and other docs and come up with a solution.

 

[PistolPete]

OP's post has a lot of truth to it. When I was on medicine I felt like a social worker/chimp, simply putting in recs from other specialties. Later, as the one receiving the consult, when I asked the resident why they were putting in the consult, half the time it was "I dunno, my attending wants it." Pan-consulting has become the norm. The level of ego in medicine in general is out of control, especially between certain services that I won't name.

 

[DarknightX]

Not all academic medicine is this way. All of the institutions I have worked at (which I realize is exactly 2) had great working relationships between specialists, residents and teams. There's always a chance of disagreement -- ID and Surgery consult on a patient, ID states patient needs to go to the OR for debridement, GS says that no surgical treatment is needed. We just get both sides together and try to work it out.

Ha. It always makes me laugh when ID tells us that we have to debride something that we don't feel needs to be debrided.

You know, with all their extensive experience of wound debridement.

 

[username456789]

Ha. It always makes me laugh when ID tells us that we have to debride something that we don't feel needs to be debrided.

You know, with all their extensive experience of wound debridement.

A few months ago, I had to deal with general surgery aggressively debriding pyoderma gangrenosum in two different patients. Despite me explaining very clearly that their direct actions were making things so so much worse.

Now the pendulum has swung the other way, and we get consulted in almost every possible ulcer/nec fasc/similar because "maybe this is also that PG thing you guys mentioned before."

 

[DarknightX]

A few months ago, I had to deal with general surgery aggressively debriding pyoderma gangrenosum in two different patients. Despite me explaining very clearly that their direct actions were making things so so much worse.

Now the pendulum has swung the other way, and we get consulted in almost every possible ulcer/nec fasc/similar because "maybe this is also that PG thing you guys mentioned before."

Ha, you'd think they'd know better, especially with the IBD patients we see.

It goes both ways, for sure.

 

[username456789]

Ha, you'd think they'd know better, especially with the IBD patients we see.

It goes both ways, for sure.

Oh sure. I don't profess to be an expert in all things, and everyone makes mistakes. This was just a particular incident (well, incidents) that really left an impression on me.

 

[nlax30]

Recently I witnessed an awkward phone call between an ID docs and a radiologists regarding a possibly infected PICC and whether it should come out or not. Both were quoting literature, stats and guidelines from their respective fields and it got kind of heated. Almost humorous.

 

[Kahreek]

somethings you said are right.
but as i grow up i learn to try to ditch the ever so easily grown cynical side of me, because it hurts me at professionally and socially too much.

 

[DermViser]

Yeah. I know what you mean. I always had this hope as a medical student that despite all the drama and interpersonal squabbles, whatever is right for the patient ends up being done. That hope is rapidly evaporating.

😆😆

 

[DermViser]

OP's post has a lot of truth to it. When I was on medicine I felt like a social worker/chimp, simply putting in recs from other specialties. Later, as the one receiving the consult, when I asked the resident why they were putting in the consult, half the time it was "I dunno, my attending wants it." Pan-consulting has become the norm. The level of ego in medicine in general is out of control, especially between certain services that I won't name.

👍👍👍👍

 

[Arcan57]

OP's post has a lot of truth to it. When I was on medicine I felt like a social worker/chimp, simply putting in recs from other specialties. Later, as the one receiving the consult, when I asked the resident why they were putting in the consult, half the time it was "I dunno, my attending wants it." Pan-consulting has become the norm. The level of ego in medicine in general is out of control, especially between certain services that I won't name.

While attempted healthcare payment reform may change things, the culture of pan-consulting is not just adaptive but highly beneficial to many physicians in private practice. It generates tons of revenue both for the consultants as well allowing a higher patient census and kickbacks from the specialist using the doctor for admission for single system problems within their specialty. It keeps some lower volume specialties available for complex cases where the economics otherwise wouldn't justify it (ID comes to mind). It's perceived as decreasing medicolegal risk and definitely decreases peer-review actions. Until incentives change from adding on to splitting the pie, I think it's a trend that's going to continue unabated.

 

[Food]

While attempted healthcare payment reform may change things, the culture of pan-consulting is not just adaptive but highly beneficial to many physicians in private practice. It generates tons of revenue both for the consultants as well allowing a higher patient census and kickbacks from the specialist using the doctor for admission for single system problems within their specialty. It keeps some lower volume specialties available for complex cases where the economics otherwise wouldn't justify it (ID comes to mind). It's perceived as decreasing medicolegal risk and definitely decreases peer-review actions. Until incentives change from adding on to splitting the pie, I think it's a trend that's going to continue unabated.

I get it, that there are external pressures guiding a lot of the problematic trends. But when did doctors stop being doctors and become playground bullies? For all the talk of professionalism we get in medical school, the collective culture seems to me anything but. Individual doctors are professional and have their strengths and weaknesses. You put them in a group though and it seems to blow up.

The most alarming thing I see though is how overconfident everyone seems to be. Attending overconfident in their own experience, senior residents confident in their attending and their specialty koolaid. Who is keeping them in check? Its taking everything not to call out people on their bull**** sometimes.

 

[nlax30]

I have to remind myself that physicians are regular old humans with the same strengths, weaknesses and selfish motivations as anyone else out there.... we happen to have trained in a specific and demanding career.

But it's really the same in any other field...business, finance, law, etc. People are out for their own good and there is always going to be "office politics" and individuals who don't play well with others.

 

[Arcan57]

I get it, that there are external pressures guiding a lot of the problematic trends. But when did doctors stop being doctors and become playground bullies? For all the talk of professionalism we get in medical school, the collective culture seems to me anything but. Individual doctors are professional and have their strengths and weaknesses. You put them in a group though and it seems to blow up.

The most alarming thing I see though is how overconfident everyone seems to be. Attending overconfident in their own experience, senior residents confident in their attending and their specialty koolaid. Who is keeping them in check? Its taking everything not to call out people on their bull**** sometimes.

Taking things in order:

1) Doctors are still doctors and playground bullies sometimes grow up into doctors. Medical training is hierarchical and most hierarchies are designed to be self-perpetuating. This is as much a feature as it is a bug. The same process that's used to differentiate out intern and resident responsibilities is going to perpetuate power differentials and people are going to exploit those power differentials when faced with competition for resources.

2) Social skills are one of the first things to go when people are stressed. Many residents spend their entire residency in that condition. You're seeing it more in medicine because you have more interactions with medical personnel. If you took the average person off the street, kept them at work for 16 hours, and then started questioning how they're doing their job you'd see a range of responses with most people choosing to avoid confrontation. If you remove evasion as an option, things would get hostile really quickly.

3) Confidence is an important part of practicing medicine since often we are forced to act on incomplete information with unclear risks/benefits. Showing a lack of confidence when suggesting high-risk interventions may be honest, but it also is viewed unfavorably by everyone (patient, family, colleagues, trainees). As a result we're conditioned to show confidence.

Some of that confidence may be coming from experience that you just don't learn in the textbooks. Most attending level surgeons are really good at determining who's going to potentially benefit from an operation. Those of us who haven't dealt with the aftermath of Hail Mary operations tend to be blasé about the complications. When faced with a problem outside of our scope of practice, the temptation is to engage in magical thinking that if the consulting service would just do procedure x than patient would do just fine. The reality is that for a lot of patients that are critically ill there's no happy ending to their story. Since they're our patients, that's tough to accept and it's easy to displace blame from an uncaring universe onto a (perceived) uncaring colleague.

4) In academic centers, M&M tends to be what keeps people in check from a medical management standpoint. The departments tend to be silo'd so allowances for interpersonal friction tend to be dependent on department chairs. Many of the chairs did not become chairs due to a profound understanding of employee management.
In the community, these issues tend to be dealt with by a multi-disciplinary peer review committee that is probably more effective when multiple doctors are available for the same specialty and less effective if you only have one doctor for that service.

5) Calling people on BS is tricky. You have to be sure you're right (which being in training you may or may not be) and you have to have a reason beyond settling a personal vendetta. Nobody wants to deal with someone else's interpersonal mess so you have to come off as somewhere between Gandhi and Mother Theresa to not get some degree of blowback from whoever has to arbitrate. It's much easier (and usually also the right move) to run it up the chain and let the attending to attending conversation happen. You'd be surprised how many PGY-2s get their god-complexes beaten out of them due to this sequence.

 

[gutonc]

Arcan nailed it up there. Hoping he doesn't Birdstrike it.

In the immortal words of Dan Savage - it gets better.

 

[BlondeDocteur]

One of the worst parts is that something positive-- resident camaraderie and pride in their specialty-- often devolves into tribalism, with the same blind, reflexive defensiveness. You consult a service specifically to play a expert role, and you're not allowed to expose any chinks in their armor.

I am loooooovvvving pathology thus far in large part because you get to play the expert role to just about everybody else, all the time, with almost no blowback.

#PeaceintheMiddleEast

 

[Arcan57]

Arcan nailed it up there. Hoping he doesn't Birdstrike it.

In the immortal words of Dan Savage - it gets better.

While the phenomena is well understood, I believe you're the first person to use him as a verb 🙂

 

[greg1184]

Taking things in order:

1) Doctors are still doctors and playground bullies sometimes grow up into doctors. Medical training is hierarchical and most hierarchies are designed to be self-perpetuating. This is as much a feature as it is a bug. The same process that's used to differentiate out intern and resident responsibilities is going to perpetuate power differentials and people are going to exploit those power differentials when faced with competition for resources.

Medicine is very hierarchical in many levels, despite the desire of being a collegial field that "everything is for the patient." This hierarchical attitude is ingrained very early in medicial education, eg. Quartiles in medical school, step 1 score/residency applications, ignorant, schadenfreude potshots about certain specialties about another specialty. I once read an article talking about negative perceptions about physicians perceived by laypeople, yet in the same article it makes some smartass remarks about certain fields like radiology. Ultimate hypocrisy. This is I believe an issue in the medical field.

My goal as a budding radiologist is to be as collegial as possible with my colleagues, knowing that not everyone will be the same way.

 

[evilbooyaa]

Taking things in order:

1) Doctors are still doctors and playground bullies sometimes grow up into doctors. Medical training is hierarchical and most hierarchies are designed to be self-perpetuating. This is as much a feature as it is a bug. The same process that's used to differentiate out intern and resident responsibilities is going to perpetuate power differentials and people are going to exploit those power differentials when faced with competition for resources.

2) Social skills are one of the first things to go when people are stressed. Many residents spend their entire residency in that condition. You're seeing it more in medicine because you have more interactions with medical personnel. If you took the average person off the street, kept them at work for 16 hours, and then started questioning how they're doing their job you'd see a range of responses with most people choosing to avoid confrontation. If you remove evasion as an option, things would get hostile really quickly.

3) Confidence is an important part of practicing medicine since often we are forced to act on incomplete information with unclear risks/benefits. Showing a lack of confidence when suggesting high-risk interventions may be honest, but it also is viewed unfavorably by everyone (patient, family, colleagues, trainees). As a result we're conditioned to show confidence.

Some of that confidence may be coming from experience that you just don't learn in the textbooks. Most attending level surgeons are really good at determining who's going to potentially benefit from an operation. Those of us who haven't dealt with the aftermath of Hail Mary operations tend to be blasé about the complications. When faced with a problem outside of our scope of practice, the temptation is to engage in magical thinking that if the consulting service would just do procedure x than patient would do just fine. The reality is that for a lot of patients that are critically ill there's no happy ending to their story. Since they're our patients, that's tough to accept and it's easy to displace blame from an uncaring universe onto a (perceived) uncaring colleague.

4) In academic centers, M&M tends to be what keeps people in check from a medical management standpoint. The departments tend to be silo'd so allowances for interpersonal friction tend to be dependent on department chairs. Many of the chairs did not become chairs due to a profound understanding of employee management.
In the community, these issues tend to be dealt with by a multi-disciplinary peer review committee that is probably more effective when multiple doctors are available for the same specialty and less effective if you only have one doctor for that service.

5) Calling people on BS is tricky. You have to be sure you're right (which being in training you may or may not be) and you have to have a reason beyond settling a personal vendetta. Nobody wants to deal with someone else's interpersonal mess so you have to come off as somewhere between Gandhi and Mother Theresa to not get some degree of blowback from whoever has to arbitrate. It's much easier (and usually also the right move) to run it up the chain and let the attending to attending conversation happen. You'd be surprised how many PGY-2s get their god-complexes beaten out of them due to this sequence.

Quoting for posterity, on the offchance that the post gets Birdstrike'd.

 

[Food]

Thanks for adding perspective, people. Thank god for M&M. Just wish it didn't come to that and the patient didn't need to be the subject of one.