Specialty Stereotypes

[salmonella]

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At my hospital there are always complaints about ortho dumping patients on medicine using reasons such as "pain control" or "uncontrolled diabetes" or even "medication management". That certainly pissed off a lot of medicine attendings/residents. Just out of curiosity, why can't ortho admit and manage their own patients? Is this how it's done in other hospitals? May be ortho guys are too busy in the OR to manage patients on the floor? I mean, other surgical services (especially general surgery) take pretty good care of their own patients' medical problems and only consult medicine for the most complicated issues.

 

[DOtobe]

The only patients ortho will admit to their own service at my hospital are those who are young (i.e. less than 50 y/o) with NO medical problems. As soon as they see any PMHx at all, they admit to the primary doc. It gets really annoying when winter comes and we're stuck admitting a ton of hip fractures from the patients slipping and falling on the ice...

 

[cardiologydude]

The same happens in my hospital. Ortho people are notorius for dumping their patients on medicine for BP control (yes their BP is elevated because they are in pain due to fracture), diabetes management, even plain old sinus tachycardia.

As far as the ER goes, they are obviously smart bunch but as their training progresses something happens to them. Some decisions made in ER are not easy to explain.

 

[Mumpu]

Ortho surgeons are not trained in medical management of their patients, therefore it makes perfect sense for them to do what they are good at (surgery) and not meddle in things they have no training in. IMHO this makes orthopods far smarter than, say, general surgeons who also receive no training in medical management of patients but insist on doing it anyway (ever seen a gen surgeon manage HTN and DM? sca-ry!)

 

[8744]

The same happens in my hospital. Ortho people are notorius for dumping their patients on medicine for BP control (yes their BP is elevated because they are in pain due to fracture), diabetes management, even plain old sinus tachycardia.

As far as the ER goes, they are obviously smart bunch but as their training progresses something happens to them. Some decisions made in ER are not easy to explain.

Hindsight is twenty-twenty. That's the explanation.

 

[Winged Scapula]

...general surgeons who also receive no training in medical management of patients

This is absolutely incorrect, at least IMHO. I spent a great deal of time doing just that - ie, medically managing patients who either:

a) didn't need an operation, but we had operated on them in the past, so they were "our" patient, even if the problem was medical

b) didn't need an operation, and we had never operated on them, but because they had a potential "surgical" problem (ie, trauma, diverticulitis, UC exacerbation, etc.) they came to a surgical service.


Besides, if your surgeons didn't learn how to manage HTN or DM at least by watching the internists do it after 5+ years, then they should be ashamed of themselves.

 

[Apollyon]

This is absolutely incorrect, at least IMHO. I spent a great deal of time doing just that - ie, medically managing patients who either:

a) didn't need an operation, but we had operated on them in the past, so they were "our" patient, even if the problem was medical

b) didn't need an operation, and we had never operated on them, but because they had a potential "surgical" problem (ie, trauma, diverticulitis, UC exacerbation, etc.) they came to a surgical service.

Besides, if your surgeons didn't learn how to manage HTN or DM at least by watching the internists do it after 5+ years, then they should be ashamed of themselves.

At Duke (which may be classified in the higher tiers of residency programs), there was a continuing atmosphere of the patients in (a) and (b) NOT going to the surgical services (and, VERY often, going to the service only after the attending verbally lashed the resident for not taking the patient).

And, as far as the DM and HTN management, it was a "if all you have is a hammer, everything looks like a nail" mentality.

 

[toofache32]

At Duke (which may be classified in the higher tiers of residency programs), there was a continuing atmosphere of the patients in (a) and (b) NOT going to the surgical services (and, VERY often, going to the service only after the attending verbally lashed the resident for not taking the patient).

And, as far as the DM and HTN management, it was a "if all you have is a hammer, everything looks like a nail" mentality.

I always laughed when many of the general surgeons around here would say, "a general surgeon is an internist who can operate." Just because you manage the medical issues doesn't mean you're giving patients the best management.

 

[ESPNdeportes]

In my experience (almost halfway through third year), every service I've rotated through think they get dumped on by other services.

In general, it is the goal of most residents is to reduce their amount of work as much as possible.

 

[toofache32]

In my experience (almost halfway through third year), every service I've rotated through think they get dumped on by other services.

This is not true for specialists....they are the ones who do the dumping. 👍

 

[tega]

Ortho surgeons are not trained in medical management of their patients, therefore it makes perfect sense for them to do what they are good at (surgery) and not meddle in things they have no training in. IMHO this makes orthopods far smarter than, say, general surgeons who also receive no training in medical management of patients but insist on doing it anyway (ever seen a gen surgeon manage HTN and DM? sca-ry!)

Concur!
Medicine residents have alot more time-emphasis on time- and expertise to manage the multiple medical issues-stable or not- many ortho pts present with. It's good pt care.
That said, who the heck wants to answer pages about "doc the pt does not have (insert random medication) ordered" at 2am in the morning. So i do my absolute best to admit any pt to any service other than ortho when I can. Let the medicine intern do the bitch work. 🙂

 

[salmonella]

Many surgeons seem to have the attitude that they are all ABLE to handle complex medical issues, but because of "time constraint" or "we have better things to do than ordering Tylenol" or "medicine is just too easy for us", they feel that they have the right (or privilege?) to dump patients on other services. Isn't it more fun to be the primary team and take care of the patients' problems from admission to discharge?

 

[SLUser11]

Ortho surgeons are not trained in medical management of their patients, therefore it makes perfect sense for them to do what they are good at (surgery) and not meddle in things they have no training in. IMHO this makes orthopods far smarter than, say, general surgeons who also receive no training in medical management of patients but insist on doing it anyway (ever seen a gen surgeon manage HTN and DM? sca-ry!)

It sounds like you know alot about general surgery.👍

Seriously, this thread is generally unfunny, and it sounds like everyone is getting their panties in a bunch trying to defend their specialty while simultaneously bashing every other specialty.

This antagonistic relationship between the ER and all the other specialties is one that I've found to be universal. I can't remember how many times in med school I heard IM/surg/psych/neuro residents complaining about the stupid ER docs. The accepted thing to do was to agree, and eventually I would then be the resident regurgitating the ER hate that I learned in school.

However, I did a month of ER during my fourth year, which I recommend to all med students, and it gave me some needed perspective. I found the ER docs to be very intelligent and rational with their decisions to admit, and I very rarely saw a super-weak admit. What I DID see alot though were the mid-level IM residents (budding know-it-alls) whining and crying about admits that really couldn't be avoided. It seemed like the less-knowledgable residents generally whined the loudest.......In the end, it's the ER doc's butt if they send home a sick patient.........

In my awesome opinion.

 

[tega]

. Isn't it more fun to be the primary team and take care of the patients' problems from admission to discharge?

Of course it is. But why have all the fun, when there is a medicine resident sleeping through 6hours of morning rounds.
Again, and as mentioned above, most pods do not hesistate defering medical management to those BETTER at it. And admitting pts with multiple medical issues into an ortho service increases their risk of of unecessary complications. We simply do not pay attention to some details medicine folks may appreciate in these pts.

And dude....sleeping, or flirting with the ICU nurse on a call night is alwys better than ordering tylenol.

 

[u_r_my_serenity]

Internal medicine and general surgery fundamentally are the cornerstones of medicine in its entirety. Virtually every specialty that exists today stemmed from these areas, and many specialties have a complement in the other: cardiothoracic surgery vs cardiology/pulmonology, neurosurgery vs neurology, colorectal surgery/hepatobiliary surgery vs gastroenterology/hepatology, etc. The exceptions are the specilaties that incorporate some degree of both internal medicine and general surgery.

Internal medicine is the prevention, diagnosis, and treatment of disease. Today we should add "in adults" to the end of that definiton, but this was not always the case. My point is that it is largely a waste of time to bash an area so important as internal medicine because to some degree virtually every physician is an internist (or at least should be), including the anesthesiologist or otolaryngologist. I challenge any of you to name great physicians, even some of the great surgeons (of which there are many), who did not value the principles of internal medicine.

As for the stereotypes, yes internists are "fleas" in the sense that they are usually present around the patients who die. The reason for this is simple: complicated patients (usually patients with two or more medical problems) are transferred to internal medicine. This is because a physician who will see the patient as a whole is required to balance the complex medical problems as well as the risk versus benefit of the different recommendations of different specialty services. What should be done when a patient with a mechanical heart valve in atrial fibrillation who needs to be anticoagulated presents with a severe upper GI bleed? Depending on the time of surgery, the particular hospital, or even something as simple as where there was an open bed, this patient could end up in a medical ICU staffed by a pulmonolgist or a surgical ICU staffed by an anesthesiologist. In some hospitals the patient may not even go to the ICU. Regardless of where the patient ends up, hopefully the care will be based on evidence and the principles of internal medicine.

It is also true that internists tend to formulate a differential diagnosis and conduct more workups than the other services. Although many diagnoses are rare, they do occur, and they are presenting at your medical center right now if it is of any significant size. Even if the chance is 1 out of 10,000, how long do you think it will take before a patient with new onset blurry vision actually has neurocystercircosis? Or a patient has sterile pyruia as the only presenting sign of tuberculosis?

By the way, all three patients I described (sterile pyruia --> TB, blurry vision --> neurocystercircosis, and MVR/a.fib with UGIB) are patients I have had this month.

 

[toxic-megacolon]

I always laughed when many of the general surgeons around here would say, "a general surgeon is an internist who can operate." Just because you manage the medical issues doesn't mean you're giving patients the best management.

If General Surgeons don't get any training in medicine, why is only one year required to do an ICU fellowship (vs. 3 for internal medicine). And yes, surgical intensivists routinely deal with medically complicated patients (CVA, DKA, Severe Sepsis, ARDS, etc)...

Not arguing which one is better but to say general surgeons aren't trained in medicine (or putting them on the same level of internal medicine training as ENT or Ortho) is just wrong.

 

[8744]

I think if I could only take one doctor on my space ark and had to pick from a general surgeon and an internist I'd take the general surgeon. The general surgeon knows enough medicine to make a pretty good showing at it plus he can operate.

 

[Mumpu]

With all due respect, unless you rotate through internal medicine, you do not receive training in internal medicine. Surgeons learning medicine from other surgeons who learned it from other surgeons does not count as internal medicine training (I bet there are very few, if any, surgeons who routinely follow IM literature, and therefore the training is by definition not up-to-date and the care is substandard). There are a few programs in the nation that make their interns do several months of IM. Everyone else is not providing IM training. Unless you are willing to state that an internist who visits the OR a couple of times a week is well trained in general surgery (sounds ridiculous, doesn't it?)

As for the intensivist comment, you forgot that all IM fellowships include one-two years of research. The clinical training is the same one year. And there is a reason why you do not see surgery/anesthesia-trained intensivists in medical ICUs.

 

[cchoukal]

If General Surgeons don't get any training in medicine, why is only one year required to do an ICU fellowship (vs. 3 for internal medicine). And yes, surgical intensivists routinely deal with medically complicated patients (CVA, DKA, Severe Sepsis, ARDS, etc)...

Not arguing which one is better but to say general surgeons aren't trained in medicine (or putting them on the same level of internal medicine training as ENT or Ortho) is just wrong.

My understanding is that, although pulm/CC fellowships for medicine are 3 (sometimes 4) years, straight critical care fellowships for IM are one year, just like for surgeons, anesthesiologists, and, ultimately, ER physicians.

 

[toofache32]

If General Surgeons don't get any training in medicine, why is only one year required to do an ICU fellowship (vs. 3 for internal medicine). And yes, surgical intensivists routinely deal with medically complicated patients (CVA, DKA, Severe Sepsis, ARDS, etc)...

What's DKA?

 

[salmonella]

In reality, surgical intensivists often consult medicine or medical specialists (especially cardiology, nephrology, ID) for more advanced medical issues. I have also seen MICU team serving as primary on trauma patients that have significant amount of medical history, and trauma surgery just do consults on them.

 

[Blake]

What's DKA?

Diabetic ketoacidosis.

 

[toxic-megacolon]

In reality, surgical intensivists often consult medicine

Surgical intensivists consult general medicine? Never seen that one. If this is your experience with general surgeons, then I see why you would think they don't know much medicine!

 

[edinOH]

Why is it so hard to recognize that different specialties are better at different things? This seems elementary.

Of course surgeons know how to medically manage most patients. Some choose not to or prefer to let an IM expert do it for them. Same with ortho. They have less experience in medical management, and ultimately would prefer and IM expert as well.

On one hand I seem to be reading "surgeons/orthopods are complete idiots, they shouldn't be managing medical issues," while the next sentence states "I really hate how the surgeons/orthopods dump all their patients on the medicine consultant". Which is it?

As for me, I'm in EM so I'm thought equally incompetent by both surgery and medicine. Thankfully that isn't true. Just as the medicine and surgery guys rightfully have pride in their skills and their unique contribution to the practice of medicine, us EM guys are equally proud and confident of what we bring to the table.

I think the one's who look down on the medicine we practice have never really walked a mile in our shoes, nor had their asses saved by us. And I mean that in the most humble way possible. To our detractors, my response would be "if you think you can do a better job, come on down here and do it."

 

[rajvosa]

Surgical intensivists consult general medicine? Never seen that one. If this is your experience with general surgeons, then I see why you would think they don't know much medicine!

At my hospital we receive multipe daily consults from surgical services, including SICU and NICU, for management of common medical problems such as SVTs, A.fluter/A.fib with RVR, uncontrolled DM, HTN crises, post-op MIs, etc.

 

[The_Sensei]

Sure, when you are 78 and suffer MI with EF of 15%, you should ask your anestesiologist friend to implant that stent and defibrilator in your ass.

The last time I checked, being a gastroenterologist, electrophysiologist or interventional cardiologist is far more prestigeous, complicated and sought after than being an anestesiologist. It certainly requires more training.

No thanks, kid. I'll ask the people that you mentioned who spent forever doing a residency and fellowship to do that. Prestige is a state of mind. They can toil away whilst I enjoy my life AND make sick amounts of cash thank you very much!

 

[The_Sensei]

God, if my job for the rest of my life was starting IVs and writing down little numbers on paper while trying not to nod off to sleep, I'd try and leave even earlier!

The CRNAs do that for us, sir. I am too busy drinking coffee and reading the newspaper. C'mon now.....get your facts straight.😡

 

[cardiologydude]

No thanks, kid. I'll ask the people that you mentioned who spent forever doing a residency and fellowship to do that. Prestige is a state of mind. They can toil away whilst I enjoy my life AND make sick amounts of cash thank you very much!

I bet you were talking different crap at you med school admission interview session.

 

[salmonella]

No thanks, kid. I'll ask the people that you mentioned who spent forever doing a residency and fellowship to do that. Prestige is a state of mind. They can toil away whilst I enjoy my life AND make sick amounts of cash thank you very much!

When the CRNAs take over anesthesia in 10-15yrs, they are the ones who will be making "sick amounts of cash."

 

[The_Sensei]

When the CRNAs take over anesthesia in 10-15yrs, they are the ones who will be making "sick amounts of cash."

Won't happen

 

[The_Sensei]

I bet you were talking different crap at you med school admission interview session.

You bet your ass I was. I said I wanted to do family practice in an underserved rural area. Couldn't have ended up farther from that.....😎