I recently received a comment that I, as a PGY3 in my last year, was in the "third year phase where no one is sick" which makes me wonder.. is this a recognized thing? I can see why it happens especially in my program but it makes me wonder if it would be helpful for those of us beginning our careers if those 'in the know' can let us know what these phases may be? I realize there may not be a universal thing, but I wonder if some general truths may be reached. I think the comments are a correct assessment of myself and I've taken them to heart, just wondering what's next as I get closer to being the guy-in-charge.
Phases of Learning
- Thread starter migm
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No one is sick should be more of a second year issue, but yeah it's a thing. You've gotten comfortable identifying normal and the declared sick but haven't seen enough subtle presentations of common diseases or common presentations of rare diseases to develop a strong sense of intuition. The next step is usually getting blindsided by a case you (or one of your colleagues if you're lucky) blew off and going back to working up everyone. This usually lasts through early attending hood and is a pretty adaptive response to the risks inherent to what we do. Some to most attendings eventually back off from testing on certain disease conditions as their clinical gestalt improves. You can still get hit by the thunderbolt (see thread on testing and medicolegal risk) but the ancillary benefits of not testing start to outweigh perception of risk for most docs. Specifically, less utilization of lab and nursing resources on the not sick tend to be rewarded with higher pph (if you're in a volume based system), esteem from nursing staff, and with less time spent determining diagnosis you have more time to educate patient on disease course and treatment.
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As someone who's supervised 7 classes of EM residents, I don't get annoyed when senior residents don't want to do a big workup. I get annoyed when PGY-3's just can't be bothered to explain to me how they know patients with concerning triage notes are fine. You've got gestalt, I get it, but you need to be able to articulate your rationale in the chart.
If you assume that every patient's complaint is a genuine and true expression of present pathology until you can rule it out, then we're fine. One can rule out badness with a detailed history, a careful physical exam (cough-cough, consistently reproducible chest wall tenderness) or a reasonably thorough ED work up- preferably all 3.
