By a couple months out, I felt comfortable identifying the existence of murmurs, gallops, a-fib, crackles, and wheezes (as in my call was consistent with multiple other doctors). I won't ever have a cardiologist's precision in characterizing that murmur, but honestly I don't care to either. In practice, it doesn't matter to me exactly how loud or exact location. If I hear a clear ejection quality murmur, I might be a little more alarmed. Still doesn't do much for me in matters of practicality. For something like probable endocardiosis I do keep tabs on how loud they are as it tends to get louder and louder as they progress. Only ones I specifically look for location wise are high axillary region in young pets for potential PDAs (have only heard one of those out of school, but it's not one I want to miss). Otherwise all that matters to me is that it's there or not. Either the owners go for cardio referral or they don't. If they don't, I have them sign a waiver and I use heart friendly drugs for sedation/anesthesia, and possibly advise against elective procedures. If in CHF and they don't go for referral, it still doesn't matter to me what kind of murmur it is. It doesn't really change what I do.
It's amazing how well some of these heart failure dogs do on empiric therapies and going up on dose based on physical exam and auscultations for crackles only. I have one patient who went into acute CHF way back in March, never saw a cardiologist. I'm maxed out on lasix, pimo, enalapril, and getting there on spironoloactone. All med increases just based on PE. I don't think I would ever do anything differently based on other characteristics of a murmur. Dog has been doing clinically so well that the owners think it's a scam I keep telling them to spend so much on meds and rechecks. I don't know how many times I've told the owners we will never go down on meds. He never believes me, but he can't get himself to risk killing his dog by taking her off meds so he begrudgingly complies. Every month or two, I start hearing lung congestion again, and it's not enough. We go up on meds, and the dog does fine and the owner complains. I'm shocked that the dog is still alive.
I never got ophtho all that well during school. Still not so great at it. Early on, I was stubborn with the eye cases that just weren't getting better in the timeframe it should have, and realized in hindsight things would have gone much better had I referred earlier. So I refer many ophtho cases after my first recheck if the results aren't sparkling, or if things regress at subsequent rechecks. I hate check eye appointments.
I also left fairly uncomfortable with ortho. Still not my favorite. Thank goodness we have lots of surgeons in the area, and for rad consults. Cruciates are easy to diagnose, and it comes down to medical management or referral. But the vague lameness that doesn't respond to doxycycline and NSAIDs are awful. I hate those so much. Especially forelimb lamenesses. It does make me feel better when the orthopod then can't figure it out either, but I have neither the confidence or skills to shrug and go, meh without the referral.
Dentistry has a very steep learning curve. Just because you have the pet under anesthesia, and you need to be able to diagnose and treat all the pathology right then and there. It took a year and a half of living and breathing dentistry even when off work, and being persistent about providing the best care I could possibly provide for each patient along the way and not making any excuses to do otherwise, but I'm now pretty confident in it. I think I'm able to provide very high quality dentistry, and at this point I can really stand behind my work and i wouldn't be ashamed if a dentist sees a case I've worked on.
No one will ever be perfect at everything. I have doctors at my practice who have been out 10-25 years, and they still have the same weaknesses they never grew out of. It's fine as long as you find a way to provide adequate care by getting better yourself, complementing your strengths/weaknesses with other doctors in your practice, or referring.
. Plus, with 130 students and like 7 required rotations, some of our rotations are huuuuuge. I had 8 other first years with me on our ER rotation (in addition to 3 4th years), and there were 16 total when I was on farms. The Illinois VTH is old enough that it wasn't built to contain this many students. You can't learn too much via observation if you can't see anything...
