unsung

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Which specialty has the most challenging diagnoses? I'm finding out that this is a BIG component of what I enjoy about medicine.

Just starting to dip my toes into clinical rotations, and I found myself insanely bored with outpatient peds. Don't get me wrong, I've learned a lot. Occasionally, there will be an interesting ADHD kid or something. But overall, it just has not been intellectually challenging at all. Look in everyone's ears, steroids for eczema, etc. etc.

And the frenetic pacing of it all: one patient after the next. It makes me wonder why we had to go through years and years of schooling just to make snap decisions about patients based on a few symptoms.

I guess I'm looking for a specialty with "mystery" cases that are difficult to solve, take extended thought (more than the "5 minute judgment call" that seems to comprise most visits).

So which specialty/what kind of practice would offer that?

In terms of patient population, I like psych patients the most. They are unpredictable, full of interesting back stories, and makes for an interesting history. Yet psych diagnoses don't seem that difficult either. But the interesting patients almost make up for that... except the one big problem I have with psych: medications. I just don't think I'd feel that comfortable prescribing many of the psychotropic drugs, especially to kids. This stuff has so many side effects, and I'm not sure the data is really there regarding long-term effects... or even efficacy above placebo, in general.
I know in our society it's pretty popular to take these drugs for granted as part of life. But I just am not quite convinced by the data that these psychotropic meds are all that great. Certainly anti-psychotics for the acutely psychotic schizophrenic patient are essential... but the less acute the condition, the more uncomfortable I am with the med...

I'd be the psychiatrist "prescribing" exercise for mild dysthymia over pills... and I don't think that would work out very well. :rolleyes:

I also am fascinated by obscure brain disorders (think Oliver Sacks' "Man who Mistook his Wife for a Hat"). Neuro certainly does offer a level of diagnostic intrigue. Main prob with neuro is that I'm fairly bored by muscular disorders (i.e. pretty much the peripheral nervous system). Plus, I like to spend more time with the history, and apparently it isn't hugely important for neuro.

So... does that mean the specialty that I'm looking for doesn't exist?

I'm kind of terrified that the type of medical practice I'm looking for really doesn't exist.

Anyone else with similar worries over choosing a specialty?
 

Isoprop

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inpatient ID?
 

DrBowtie

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I'd say an academic neurologist. You can let the other docs do EMG and NM disorders.
 

ztaw15

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How did you come to the conclusion that history isn't big in neuro? All day long I here the neuro docs say that if you aren't 90% sure what's going on after the history then you need to take the history again.
 

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[Insert obligatory reference to "House, MD"]
 

45408

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I think pathologists and radiologists often see oddball diagnoses, since they get a sampling from a wide variety of specialists. They also frequently have "Unknown" conferences where they look at the latest and greatest zebra, or at least they always did on my radiology and pathology rotations.
 

2012mdc

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inpatient ID?
I've never done an ID rotation but at the hospital where I'm doing medicine ID gets consulted A LOT and none of it seems to be zebras, then again I'm only in my 3rd week so maybe the sample size is too small.

I agree with the poster who said academic neurology. As an attending your residents will take the horses for you and leave the zebras
 

VA Hopeful Dr

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Get as subspecialized as you can, and neuro does seem to offer the greatest potential for this sort of stuff.

As for this gem...

And the frenetic pacing of it all: one patient after the next. It makes me wonder why we had to go through years and years of schooling just to make snap decisions about patients based on a few symptoms.
This is exactly WHY we go through so much training, so we can know what something is as soon as we see it. If I say "45 yo overweight female with post-prandial abd pain, eats a very unhealthy diet of fast food" your mind should have gone to gallbladder before you even finish this sentence. Likewise "fever, sore throat, lymphadenopathy, no cough" should scream strep to you. The more you learn, the more obscure diagnoses you'll be able to identify in such a manner. That's what the education is for.
 

BigRedder

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Just about everything is more mysterious than outpatient peds. Kids just aren't that complicated by years of wear and tear, so they tend to have one problem at a time. Adult medicine is more likely to blindside you with problems you weren't even thinking of. Rheumatologic diseases have a tendency to look similar, so you might get some zebras. ID sees some random tropical diseases and such, but mostly they manage antibiotic resistant organisms. Then again, you could get lucky and a new disease like HIV will come out and you can reminisce about how exciting it was for the rest of your professional career.

No matter what specialty you like, the nature of zebras is that they are rare, and thus not going to pay the bills. You have to do "mundane" stuff if you want to make any money. That said, if you want to see "zebras", go to "Africa". Work at an academic center that has a large patient population that doesn't take care of itself. You will see crazy diseases that have been brewing for years and you'll be the first to see them.
 

cpants

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ID is your best chance to see some crazy weird stuff. The key is to work in an urban environment with a large and diverse immigrant population and a high incidence of HIV. That's when you see the crazy opportunistic infections and tropical diseases. ID in a more private, suburban environment will be spent treating resistant organisms ad nauseum.
 

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If you see enough of it (those crazy cases that get pushed to big academic centers) then they don't really seem like zebras anymore. Those cases usually come from SOMEWHERE. I was in an internist in a very rural area over the summer and saw tons of very rare things. Just because some are 1 in xxx,xxx people rare doesn't mean you have to see that many people.

Living in a rural or poor area really does let you see more crazy stuff though, simply because they don't like to go to doctors until it is the absolute worst it can be.


That being said, my dad has been a radiologist for nearly 40 years and still encounters things he has to look up because he has never seen or has read once in a journal.
 
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unsung

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Get as subspecialized as you can, and neuro does seem to offer the greatest potential for this sort of stuff.

As for this gem...



This is exactly WHY we go through so much training, so we can know what something is as soon as we see it. If I say "45 yo overweight female with post-prandial abd pain, eats a very unhealthy diet of fast food" your mind should have gone to gallbladder before you even finish this sentence. Likewise "fever, sore throat, lymphadenopathy, no cough" should scream strep to you. The more you learn, the more obscure diagnoses you'll be able to identify in such a manner. That's what the education is for.
Well, you're going to hate me for making this point. ;) But I think *experience* is what gives someone the ability to do those things, not education. That is, a nurse practitioner with enough experience will be able to draw those same connections. It's pattern recognition at work. And we don't learn pattern recognition in pathophys or biochem, really.

This is what I meant by "years of education" being distilled into snap judgments. If the majority of daily medicine is based on experience-driven pattern recognition, why did we need 4 yrs of undergrad + 4 yrs of med school? :confused:

I agree with you though re: specializing... I think I'd get a lot more enjoyment out of delving into something in-depth rather than doing some form of primary care.
 
OP
unsung

unsung

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If you see enough of it (those crazy cases that get pushed to big academic centers) then they don't really seem like zebras anymore. Those cases usually come from SOMEWHERE. I was in an internist in a very rural area over the summer and saw tons of very rare things. Just because some are 1 in xxx,xxx people rare doesn't mean you have to see that many people.

Living in a rural or poor area really does let you see more crazy stuff though, simply because they don't like to go to doctors until it is the absolute worst it can be.


That being said, my dad has been a radiologist for nearly 40 years and still encounters things he has to look up because he has never seen or has read once in a journal.
I think you make a good point. Paradoxically, rural family med has a certain appeal! In the same way that psych has great appeal: It's the people. Their back stories and unpredictability, which makes for such interesting encounters.

I was actually hoping someone would stick up for psych and rebut my arguments against psychotropic meds :D... thing is, I really do like psych pts. I enjoy dealing with the psychosocial factors impacting illness. Another poster asked about history-taking and neuro. Well... I was really referring to the length of the interview, and the importance of social/environmental contributions to illness. History is certainly important in neuro... but what kind of a history?

Thing is, how important is a person's upbringing in ALS? How important is a person's environment/family/relationships in addiction to meth? Psych has a certain amount of complexity too, which I enjoy...

It's just that the treatments psychiatrists offer (i.e. psychotropic meds) tend to go only so far toward helping the person. If I were in the field, I think I'd actually prefer to be the psychologist offering psychotherapy....

Also, I don't get why people like to bash FM for not being "intellectual", whereas IM (which deals with the same diseases basically... minus kid stuff) is considered a more cerebral field.

But yeah, that's neither here nor there. ;) I think rural FM (or for me, probably more inner city FM) has a certain appeal... which would also seem to contradict my last post. lol
 
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VA Hopeful Dr

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Well, you're going to hate me for making this point. ;) But I think *experience* is what gives someone the ability to do those things, not education. That is, a nurse practitioner with enough experience will be able to draw those same connections. It's pattern recognition at work. And we don't learn pattern recognition in pathophys or biochem, really.

This is what I meant by "years of education" being distilled into snap judgments. If the majority of daily medicine is based on experience-driven pattern recognition, why did we need 4 yrs of undergrad + 4 yrs of med school? :confused:

I agree with you though re: specializing... I think I'd get a lot more enjoyment out of delving into something in-depth rather than doing some form of primary care.
You make a fair point, and there is much to be said for experience. However, this could be just me, but I find that having the knowledge there before you see the zebra makes it more likely you'll remember the encounter. If you know that disease X causes symptoms/lab values A, B, and C then, when a patient comes in with disease X and you see those symptoms, I would think you'd remember it better the next time you saw it.
 

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I'm the same way as you, OP (get easily bored with the mundane stuff), and I'd look into critical care/intensive care. I did an ICU experience my first year and found my calling. I got to see a lethal subarchnoid hemorrhage, guillian barre syndrome, and a mysterious Jane Doe diagnosis in action (all in a small hospital in a rural-ish Midwestern college town). You can enter ICU from several fields, including anesthesiology, IM (by far the most common), general surgery, and neurology, since you seem interested in that (though I've heard Neuro CC is an exceedingly tiny field, there's only a handful of practitioners nationwide). ICU is also more academic, which appeals to me because I really want to stay in the ivory tower.

And since you mention psych, you can make a psychiatry practice where you do predominantly psychotherapy if you wanted to.
 
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boaz

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Inpatient at a cancer hospital. You'll see the most f'ed up cases, each one is a phenomenon on its own.
 

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Genetics (particularly pediatrics) - you'd probably see some very rare/unique metabolic conditions.
 

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In terms of patient population, I like psych patients the most. They are unpredictable, full of interesting back stories, and makes for an interesting history. Yet psych diagnoses don't seem that difficult either. But the interesting patients almost make up for that... except the one big problem I have with psych: medications. I just don't think I'd feel that comfortable prescribing many of the psychotropic drugs, especially to kids. This stuff has so many side effects, and I'm not sure the data is really there regarding long-term effects... or even efficacy above placebo, in general.
I know in our society it's pretty popular to take these drugs for granted as part of life. But I just am not quite convinced by the data that these psychotropic meds are all that great. Certainly anti-psychotics for the acutely psychotic schizophrenic patient are essential... but the less acute the condition, the more uncomfortable I am with the med...
Psychosomatic Medicine/Consult-liaison psychiatry at a major academic center would likely allow you to see some weird stuff. Come over to the psych forum and investigate it. :)

I think many psychiatrists would agree that psychotropic meds are frequently misused - a big part of psych training is learning when it's appropriate or not to prescribe a psychotropic! My experience has been that often the best psychiatrists try to simplify their patient's medication regimen by taking them off drugs that they were put on by practitioners who didn't know what they were doing.
 

Mr hawkings

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ID in DC, NY or FL.
Or any other large city in a state with a large influx of imigrants from tropical countries.

BTW i'm in a similar boat. I cant seem to break out of the habit ofthinking of the zebras first. I hear rash, and the first thing to pop in my mind is RMSF. I really need to get myself used to thinking of the "most likely" causes first before i get to third year or i'm screwed. I'd hate to be "that guy" on rounds
 

Knicks

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No matter what specialty you like, the nature of zebras is that they are rare, and thus not going to pay the bills. You have to do "mundane" stuff if you want to make any money.
Truth!



Well, you're going to hate me for making this point. ;) But I think *experience* is what gives someone the ability to do those things, not education. That is, a nurse practitioner with enough experience will be able to draw those same connections. It's pattern recognition at work. And we don't learn pattern recognition in pathophys or biochem, really.

This is what I meant by "years of education" being distilled into snap judgments. If the majority of daily medicine is based on experience-driven pattern recognition, why did we need 4 yrs of undergrad + 4 yrs of med school? :confused:
More truth!
 

DoctwoB

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OP, what you need to understand is that no matter what specialty you're in, even if every single one of your patients is a "zebra," there will still be zebras that are far more common than others and become mundane to you.

For example:
-someone brought up medical genetics, where you encounter tons of rare genetic disorders. However, the vast majority of your time will be spent with the "common" rare genetic disorders, which you will see on many many occasions and thus feel mundane, even though by medical standards they are still zebras.
-Critical care sees some rare cases, but you have to treat all the other terminal multi-system failure patients who want every inhumane action done or whose families essentially want you to medically torture them until their death. I don't think I could handle that, but you do get to make some great saves as well.

I'd say neuro is your best bet. Its all about using deductive reasoning based on physical and exam to diagnose things you can't see (at least until the CT or MRI comes back). Plus you can incorporate a more neuro-psych pathway, which i find much more interesting than traditional psych
 

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The problem with neuro is that there are a lot of 'unknowns' that they can't figure out what the cause is in order to be able to treat (i.e. un-fixable). Rare pathologies are one thing, but untreatable rare pathologies are different. Everyone loves figuring out a mystery diagnosis and telling a patient and their family that all they need is x and it will get better. Telling a patient and family that they have an unknown neuro disorder that is not understood with no treatment and that it's likely permanent and progressive does not feel good in the least.
 

loveoforganic

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Psychosomatic Medicine/Consult-liaison psychiatry at a major academic center would likely allow you to see some weird stuff. Come over to the psych forum and investigate it. :)

I think many psychiatrists would agree that psychotropic meds are frequently misused - a big part of psych training is learning when it's appropriate or not to prescribe a psychotropic! My experience has been that often the best psychiatrists try to simplify their patient's medication regimen by taking them off drugs that they were put on by practitioners who didn't know what they were doing.
That's what I was going to suggest, just based on what I've read from the psych forum. Kugel is the C&L guy there I believe, if you want to get his insight.
 

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Based on my experience (n of 1, take with grain of salt), look into the fields of medicine that are 'less' physiology based (physiology based being cards, pulm, nephro, etc) and look into things like ID (as someone else mentioned), allergy/immuno, rheum. Every specialty will have unavoidable B&B but those latter fields have a lot of 'mystery' cases. I found rheum to have a lot of cool mystery cases, but for every mystery case, there are five fibromyalgia women in the clinic.
 
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The problem with neuro is that there are a lot of 'unknowns' that they can't figure out what the cause is in order to be able to treat (i.e. un-fixable).
I agree.
Unfortunately, this also goes for a lot of the non-rare cases that neuro practitioners see.

I.e.: Alzheimer's, Multiple Sclerosis, ALS, Parkinson's, stroke.

I work in a neuro department right now, and it's fairly depressing.

All these progressive and uncurable/manageable diseases make happy bear sad. :thumbdown:
 

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I think people bash FM a little bit too much without really experiencing what FM is like in a rural setting. I have been working in such a setting for almost a year now and while my #1 diagnosis in order of occurrence is healthy individuals getting their weight, height and blood pressure checked followed closely by common colds, I see strange stuff.

The problem I have is that I lack a lot of meds and lack the materials to perform quickly most lab tests and all radiologic studies. I'm lucky I even have glucose sticks and a machine that checks capilar lipids and glycosilated Hb. I even have instant HIV tests though they are supposed to be only for pregnant women. I only have access to a list of about 200 common use meds and can't request anything out of that list. I get oddball meds I rarely if ever use like Tadafil and don't have meds I commonly use like Ketorolac IV. Heck, what I'd do to get some Trimebutine, not having that drug on the 200 drug list really hurts me every month.

I can suspect a disease, but if the patient never performs the test for whatever reason you can imagine, even a common horse can still seem like a zebra case. I seriously suspect I have a patient with hypothyroidism but every attempt to convince her to perform that test has been kind of futile (old lady, lives alone, poor background, lives in the boonies, doesn't know how to read, etc..). I gave her the lab request again a few days ago crossing my fingers she will give the paper to her daughter who is hopefully going to show up to visit her for XMAS and will take her. If the test comes out positive I'm going to refer her to an internist in a zip (hoping she'll actually even bother to go because I don't have thyroid meds).

Exotic diseases in some regions are common in others. Chagas is an exotic disease in Mexico City and probably nearly unheard of in the US, but it's common in the region I live in. The problem is that the mexican government has given little, if any importance to treat the problem because most people that have heart failure are old folks and most doctors just think their heart failure is because of their diabetes or some other common cause. Most people find out they have Chagas when they donate blood because the disease is screened with every donation by federal law, other than that they'll probably never find out they have it. I have a patient with severe heart failure I've been unable to convince the caretakers to take to an internist (guess they don't care too much about the poor man), I wouldn't be surprised he has Chagas because clinically his heart is enlarged and he's lived in the region his entire life. He doesn't have diabetes, doesn't smoke, doesn't drink alcohol, isn't overweight or has HP and he's not even 50 years old. His main problem is that he's paralyzed from the waist down from a fall a few years ago.

I have a patient that I'm pretty sure has cisticercosis and an unusual presentation of the disease as well which is uncommon in Mexico but it still occurs. Most cisticercosis cases present with neurologic symptoms so this case even for me is unusual. Luckily I referred her to an internist and I'm waiting to find out the confirmed diagnosis by a CAT scan. Her lab tests only reveal slight ferropenic anemia.

You won't see a lot of unusual stuff in peds because most of the bad genetic diseases are diagnosed almost immediately after birth. I diagnosed a newborn baby I received with severe cleft plate and a baby that lacked an ear out of over 200 babies. Both were quickly referred to a specialist hospital. The oddball peds cases you'll see in FP will be either kids that have already been diagnosed and are in treatment for random problems that arose at birth or in a rare shot that hasn't happened to me previously healthy kids that are now manifesting severe and incurable diseases. The first person that will probably see a kid with Duchenne syndrome will be a FP who will probably refer to a specialist.

Most doctors don't handle zebra cases often, only if you work in a specialty hospital. The major drawback in those hospitals however is that, okay you diagnosed someone with random x disease, unless the patient pertains to your specialty, you refer the patient to a subspecialist in the hospital and don't become their primary physician anymore. Some doctors prefer to work in a community hospital that has less stuff but at least keep up with the odd cases to see how it evolves.

I myself prefer seeing the more common stuff just having one oddball case show up every now and then to open up my books and run out the door to talk to a more experienced doctor about the case, but everyone is different I guess.
 
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Which specialty has the most challenging diagnoses? I'm finding out that this is a BIG component of what I enjoy about medicine.

Just starting to dip my toes into clinical rotations, and I found myself insanely bored with outpatient peds. Don't get me wrong, I've learned a lot. Occasionally, there will be an interesting ADHD kid or something. But overall, it just has not been intellectually challenging at all. Look in everyone's ears, steroids for eczema, etc. etc.

And the frenetic pacing of it all: one patient after the next. It makes me wonder why we had to go through years and years of schooling just to make snap decisions about patients based on a few symptoms.

I guess I'm looking for a specialty with "mystery" cases that are difficult to solve, take extended thought (more than the "5 minute judgment call" that seems to comprise most visits).

So which specialty/what kind of practice would offer that?

In terms of patient population, I like psych patients the most. They are unpredictable, full of interesting back stories, and makes for an interesting history. Yet psych diagnoses don't seem that difficult either. But the interesting patients almost make up for that... except the one big problem I have with psych: medications. I just don't think I'd feel that comfortable prescribing many of the psychotropic drugs, especially to kids. This stuff has so many side effects, and I'm not sure the data is really there regarding long-term effects... or even efficacy above placebo, in general.
I know in our society it's pretty popular to take these drugs for granted as part of life. But I just am not quite convinced by the data that these psychotropic meds are all that great. Certainly anti-psychotics for the acutely psychotic schizophrenic patient are essential... but the less acute the condition, the more uncomfortable I am with the med...

I'd be the psychiatrist "prescribing" exercise for mild dysthymia over pills... and I don't think that would work out very well. :rolleyes:

I also am fascinated by obscure brain disorders (think Oliver Sacks' "Man who Mistook his Wife for a Hat"). Neuro certainly does offer a level of diagnostic intrigue. Main prob with neuro is that I'm fairly bored by muscular disorders (i.e. pretty much the peripheral nervous system). Plus, I like to spend more time with the history, and apparently it isn't hugely important for neuro.

So... does that mean the specialty that I'm looking for doesn't exist?

I'm kind of terrified that the type of medical practice I'm looking for really doesn't exist.

Anyone else with similar worries over choosing a specialty?
Academic neurology. Especially at Mayo. Zebras depend on the zoo you frequent. Mayo has a " Zebra only" zoo.
 

surftheiop

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That's what I was going to suggest, just based on what I've read from the psych forum. Kugel is the C&L guy there I believe, if you want to get his insight.
I think DocSamson is C&L also, and I'm pretty sure he has straight up mentioned "zebra hunting" as a common part of his role.
 

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FM was brought up jokingly but it's really the generalists who have the biggest challenge. The more subspecialized you become the fewer zebras you're going to see, since the zebras aren't zebras anymore if you see them every day. A general IM or peds doc for example gets first crack at tons of different kinds of rare disorders. What's more impressive, the super-subspecialist consultant who is able to confirm the zebra that the primary team suspects? OR the FP who sees the feverish immigrant in his 1/2 day free clinic and correctly diagnoses malaria?
 

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4 words -- genetic and metabolic diseases
 
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Try pediatric metabolic diseases. You'll get all the Tay-Sachs, Nieman Pick's, congenital hypothyroidism, glycogen storage disease, Lesch-Nyhan, and Gaucher's Disease you can handle, with a few ornithine transcarbamylase deficiencies thrown in just to keep you on your toes.