Specialty with the most problem solving

[azygous84]

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Hey guys - your opinion - which medical specialty has the most problem solving in it?

 

[Atlas]

Hey guys - your opinion - which medical specialty has the most problem solving in it?

For me it's a tie: Nephro or critical care

 

[Phlegm]

Critical care would be at the top of the list, followed by nephrology, heme-onc and pulmonary.

 

[Adcadet]

Critical care sure does involve many fast decisions, but I get the impression that you're rarely 100% sure of anything (like "is this patient truly septic") because your patients are too sick to tolerate treatment delays. Some people like this, some people hate it. The neph people tend to be the most cerebral, IMO. And general IM still has many decisions and problems to solve, even if they're sometimes not life or death decisions. But hey, if you're talking about IM, every internist is a problem solver.

 

[salmonella]

I would rank it as: (for internal medicine specialties)

pulmonary/critical care
hem/onc
nephrology
Infectious disease
general internal medicine/primary care
geriatric medicine
rheumatology
endocrinology
GI
cardiology
sports medicine
allergy/immunology

 

[Rocky2007]

Here's what I think:

Nephrology
ID
Critical Care
Heme/Onc
Rheum
Cards
GI

I didn't include general IM...I think in many ways gen med can be the most challenging.

Also - Do you notice how the pay scale goes inversely proportional to this list (more or less). That is truly a sad state of affairs.

 

[gwen]

i'd say rheum involves a lot of problem solving. now i'm not saying that its life-saving or requires a super genious. but its pretty tedious work to deal with a fibromyalgia patient who is ANA+, has slightly high ESR, blah, blah blah. Do we do a cardiac biopsy? Do we try this? its a looot of, pardon my french, mental masturbation.

 

[Adcadet]

I really think it depends on what you mean by "problem solving." A general internist who's practice is largely composed of the socioeconomically disadvantaged may need to do considerable problem solving just to get his/her patients basic medical care and treatment. Meanwhile, each and every procedure is essentially one bit of problem solving after another (how should I position the patient? how do I sterilize this field? how do I drape this field? What kind of stitch should I use? How do I expose this cirrhotic liver during a liver transplant - OK, maybe that last one isn't usually an IM issue).

 

[carrigallen]

I think I could answer which field might have the least problem solving: general pediatrics.
After all, it seems most stuff beyond vaccinations and routine infections get referred to specialists for care. I guess the hard part is knowing which specialist.

 

[TommyGunn04]

Also - Do you notice how the pay scale goes inversely proportional to this list (more or less). That is truly a sad state of affairs.

Sad, but true. It's because our system reimburses people for "doing" rather than "thinking" or "problem-solving." It seems as if the only incentives for non-proceduralists to solve medical problems are internally-imposed ones, such as the joy of making a patient better, the responsibility we feel towards helping others, and the pleasure of knowing you solved a difficult puzzle.

It really bothers me that cardiologists get paid absurd amounts to stent people with CAD, but internists are poorly reimbursed even if they do a great job of keeping people from needing these procedures in the first place!

I wonder if we'll ever see a system where good internists are paid more for keeping their patients healthier? (adhering to recommended screenings, better controlling patients' blood pressures, getting A1c's and lipids to goal, etc.)

 

[carrigallen]

I wonder if we'll ever see a system where good internists are paid more for keeping their patients healthier? (adhering to recommended screenings, better controlling patients' blood pressures, getting A1c's and lipids to goal, etc.)

Yes, this is already happening. But the system is that you are paid normal amounts for keeping patients healthy, and deducted reimbursements for not having patients at goal.

So you are penalized for doing a bad job, not rewarded for doing a good one.

 

[TommyGunn04]

Yes, this is already happening. But the system is that you are paid normal amounts for keeping patients healthy, and deducted reimbursements for not having patients at goal.

So you are penalized for doing a bad job, not rewarded for doing a good one.

This seems like a bad idea for a few reasons. First, it's not necessarily the doctor's fault if a patient isn't at goal. I have a number of diabetic patients with A1c's in the 9-11% range who simply refuse to change their diet and are not willing to take insulin, and I've gotten them as low as they'll go with just oral medications. Should physicians really be penalized for these patients?? A consequence of this will be a "cherry picking" phenomenon, whereby some docs will fire patients who refuse to help themselves, and only keep the well-managed ones. While there are many things we can to do help improve adherence to a medical regimen for diabetes, hypertension, etc., I don't think it's fair to penalize physicians for patients who won't take the meds as prescribed. But how would insurers ever account for the non-adherence issue?? It's well known that patients lie about how often they miss their meds because they want to please their doctor, so I imagine they'd lie to insurance companies too, and then the physician would get dinged!

 

[jiggabot]

We seems to have some consensus of the most "problem solving" specialties within internal medicine. Let's cross-compare the specialties between surgery and medicine.

How much problem solving are there in more clinical surgeries such as ENT and Urology compared to specialties like Heme/Onc and Cardiology?

How about specialties like Dermatology, Radiology, Psychiatry, or Rad Onc compared to Internal Medicine?

I want to know because I am definitely someone who gravitates towards the problem solving ones, but I have not had the chance to assess all of these other subspecialties. Compare as many as you feel comfortable comparing in the above mentioned specialties...thanks!

 

[tartesos]

Here's what I think:

Nephrology
ID
Critical Care
Heme/Onc
Rheum
Cards
GI

I didn't include general IM...I think in many ways gen med can be the most challenging.

Also - Do you notice how the pay scale goes inversely proportional to this list (more or less). That is truly a sad state of affairs.

agree with you!! id place id and cc tie at second though!!
and GI makes a ridiculous amount of money!!! if you take endoscopies out of GI, what do you have? an IM doc!!! pure and simple!😀

 

[dragonfly99]

If you don't think cards has to do any problem solving, try being in the cath lab with a STEMI that is crashing and in cardiogenic shock and coding...

 

[dragonfly99]

But I agree w/nephro (and a difficult general IM case) being @the top of the "cerbrality" contest. Critical care you could definitely put up there, except I agree w/one of the above comments...those MICU players are so f-ing sick, it's kind of like trauma surgery..the MICU fellows and attendings just do sh-t and they don't really have a great evidence base to back some of it up...

 

[jdh71]

If you don't think cards has to do any problem solving, try being in the cath lab with a STEMI that is crashing and in cardiogenic shock and coding...

I'd be guessing, but I think it's . . . the heart . . .

 

[Micah6:8]

I think the answers here, as to any question, may also be influenced by areas of interest.
Rheumatology definitely requires a lot of problem-solving. Considered the 'detectives' of medicine, they are often the last resort referral when trying to figure out a case. I am not talking about the classic presentations of RA, fibro, etc, but some of the vasculitis, others require a lot of thought. Can be very cerebral as well. Also, overlaps a lot with nephro and heme.

 

[sunset823]

I like this thread - CC, heme/onc, and ID are in my 'short list' (and I enjoyed my renal organ segment, though I'm not really considering nephro), and I never thought that might be because they are the most problem-solving specialties. But it makes sense, I like to solve problems. Definitely more a thinker than a doer. $$ be damned.

 

[jiggabot]

We seems to have some consensus of the most "problem solving" specialties within internal medicine. Let's cross-compare the specialties between surgery and medicine.

How much problem solving are there in more clinical surgeries such as ENT and Urology compared to specialties like Heme/Onc and Cardiology?

How about specialties like Dermatology, Radiology, Psychiatry, or Rad Onc compared to Internal Medicine?

I want to know because I am definitely someone who gravitates towards the problem solving ones, but I have not had the chance to assess all of these other subspecialties. Compare as many as you feel comfortable comparing in the above mentioned specialties...thanks!

We seem to be back to talking about internal medicine subspecialties. Any insight into the surgical and other specialties I mentioned above?

 

[gutonc]

We seem to be back to talking about internal medicine subspecialties. Any insight into the surgical and other specialties I mentioned above?

Wait...talking about IM subspecialties? In the IM forum? What's wrong with us?

Oh...right...it's you.

 

[jiggabot]

Wait...talking about IM subspecialties? In the IM forum? What's wrong with us?

Oh...right...it's you.

That statement achieved just about nothing. You must not be too bright.

My point was that we have already reached some consensus as to which IM specialties are the most problem solving oriented, that has been established 4 years ago when this thread was started. I just want to know how these IM subspecialties compared to surgical ones and other ones such as urology, ENT, derm, and psych for example.

 

[goldengate98]

To those who suggest that Cardiology does not require problem solving skills, I suggest actually observing what a cardiologist does in practice. Doing a rotation in the CCU or working in an outpatient clinic does not give a complete, or even partially complete picture of the myriad of skills required to be a competent cardiologist.

A few examples of the problem solving skills required are:
1) Actually knowing how to read an ECG correctly. The absolute lack of this skill in the general medical community is astounding, as should be expected, given the lack of training.
2) Learning to perform and interpret transthoracic echocardiography to evaluate complex valve disease, LV and RV function, the significance of LV hypertrophy, identify intracardiac masses, detect intra-cardiac shunts, non-invasively assess cardiac hemodynamics (LA,RA pressure, Pulmonary pressures, valvular gradients, shunt significance, identify coarctation, the list goes on and on...
3) Learning when and how to perform trans-esophageal echocardiography for the evaluation of valvular heart disease and to locate intracardiac shunts. Identify thrombus/tumors, help surgeons identify the particular scallop of the mitral valve that is perforated, identify acute aortic dissection, help the interventionalists decide the appropriateness for percutaneous septal occluder device ASD closure, the list goes on and on...
4) perform exercise and pharmacologic stress echocardiography to identify ischemia, hibernating/stunned myocardium, the significance of borderline positive resting pulmonary hypertension, help differentiate between true aortic stenosis or pseudostenosis in the setting of poor stroke volume and low gradients with a reduced aortic valve area,....the list goes on and on
5) perform and interpret myocardial perfusion imaging for the assessment of ischemia and viability that will ultimately guide management
6) perform and interpret complex electrophysiologic testing to differentiate between a nodal dependent and a bypass dependent supraventricular tachycardia.
7) ablate SVTs, VTs, Atrial fibrillation, and atrial flutter using a combination of fluoroscopy, pace-mapping and complex intracardiac mapping
8) perform and interpret a complex invasive hemodynamic study, using simultaneous right and left heart catheterization to help differentiate restrictive cardiomyopathy and constrictive pericarditis. Use invasive testing to evaluate the significance of pulmonary hypertension; namely helping to differentiate between a primary and secondary cause.
9) Use ECG and or intracardiac electrograms, in a patient with a dual chamber ICD, to differentiate between VT or SVT in the ED.
10) place and follow over time permanent pacemakers and ICDs
11) perform and interpret coronary angiography, bypass graft angiography, LV angiography, Aortography, to decide if complex coronary intervention vs bypass surgery is the best approach
12) Interpret cardiac CTA in the ED in the evaluation of chest pain
13) perform and interpret cardiac MRI to help with congenital cardiac disease, myopathic diseases, myocardial viability, shunt assessment, diagnosis of infiltrative diseases.

The list goes on and on. The field of cardiology is very unique and challenging. I suggest anyone who thinks otherwise, come follow me along in a given day/night.

In my opinion, Cardiology requires the ultimate combination of mental grunt-work, tactile skill, decision making, and equanimity. UNFORTUNATELY, we as the trainees of future physicians in Internal Medicine-and hopefully cardiology, don't always do a good job of demonstrating these points. While medical students get to scrub into surgery, they never get to scrub into a complex valve assessment in the cath lab, or a complex percutaneous intervention. They rarely sit and read echos, read nucs/CTs/MRIs. They are lucky if someone shows them the films. Perhaps this should change.

Cardiologist

 

[Instatewaiter]

I was gonna suggest Cards but someone beat me to it. Personally I think the physiology of Cards is more complex than pulm/cc. Granted in the MICU you see a wider breadth of cases but for me the hemodynamics of cards (not to mention basically everything goldengate said) makes it the problem solving more complex. A sick guy comes to the MICU you intubate 'em and stick 'em on levophed. However a sick guy comes into the CCU you really have to think about what intubating them is going to do to the hemodynamics and the choice of pressors is a much more complex one.

I think everyone though, thinks that their specialty of choice is one of the most complex just because they get to see the intricacies of the specialty.

So for me I'd say:
Renal/Cards
Rheum
Pulm/CC
Heme/onc
Infectious disease
endocrinology
GI
sports medicine
allergy/immunology

 

[jdh71]

Uhhhhh . . . picking pressors is not some kind of complex thought process. I really can't believe I just read that.

Every specialty has it's own little ins and outs that others don't realize or often appreciate, while generally at the same time enjoying mother****ing everyone else who doesn't understand or know the very same area. But that's the biggest problem - every specialty doc soon becomes only really good at their specialty, or even sub-sub-specialty . . . there are very complex expert decisions made in all the consult only level areas of IM (or even the surgical sub-specialties). If we all could truly do it all, then there wouldn't be specialties.

With that said the guy that need to know the most complex things about the most stuff is the critical care doc - he needs to know cards, pulm, renal, endo, ID, etc. and all of it at the extreme edges of the physiology. One system docs, get to be kind of like ortho . . . forget there is anything else in the body except their one organ of choice.

Let me put it this way: Who is the consultant of last resort? 'Nuff said.

Also, if you can't be bothered to do anything about your "complex issue" after 5PM M-F, on weekends, or holidays - you're NOT complex, you're simply overly specialized. It's NOT the same thing.

 

[ineed2stpsmurfn]

That statement achieved just about nothing. You must not be too bright. yada yada yada nonsense... etc

LOL so somehow you must be really smart calling an attending 'not too bright' ?? LOL this guy is clowning..

 

[Gastrapathy]

The best part of gastroenterology is that we never feel the need to compete in these junk size contests. We know we're hung.

 

[halogen]

the CLINICAL cardiologist (whose priority is seeing complex cardiology patients not placing stents in 70% lesions) is at the top, as described nicely by goldengate98.

 

[jdh71]

the CLINICAL cardiologist (whose priority is seeing complex cardiology patients not placing stents in 70% lesions) is at the top, as described nicely by goldengate98.

bull****

those guys just blame the lungs and move on

 

[sacrament]

I think everyone though, thinks that their specialty of choice is one of the most complex just because they get to see the intricacies of the specialty.

This is exactly true. It's very easy to stand on the outside and say things like: "Rheum is easy, you just put everybody on steroids" or "cards is easy, you just throw stents in everybody." But that's just because you are largely shielded from the high-level decision-making and thought processes that occur in every specialty. I just finished a case in the cath lab where we paused for awhile after shooting the coronaries to pull up the echo, the stress test and the previous RHC numbers, to try to sort out whether an intervention would be worthwhile for this particular patient. But all the referring physician will know is that either a stent was deployed or not.

 

[Gastrapathy]

This is exactly true. It's very easy to stand on the outside and say things like: "Rheum is easy, you just put everybody on steroids" or "cards is easy, you just throw stents in everybody." But that's just because you are largely shielded from the high-level decision-making and thought processes that occur in every specialty. I just finished a case in the cath lab where we paused for awhile after shooting the coronaries to pull up the echo, the stress test and the previous RHC numbers, to try to sort out whether an intervention would be worthwhile for this particular patient. But all the referring physician will know is that either a stent was deployed or not.

Let me guess...the stent was deployed.

 

[sacrament]

Let me guess...the stent was deployed.

It was not. But that attitude basically makes my point.

 

[jdh71]

It was not. But that attitude basically makes my point.

How did you guys feel about that? Sounds like tough stuff. Did anyone need extra counseling?

And how much longer before you guys were blaming the dyspnea on the lungs?

 

[sacrament]

How did you guys feel about that? Sounds like tough stuff. Did anyone need extra counseling?

And how much longer before you guys were blaming the dyspnea on the lungs?

Believe me, I wish we still lived in an era where there was a substantial financial incentive to drop stents. I'd gladly wrestle with my conscience on a daily basis.

 

[tco]

Having everyone rank endocrinology so low is shocking the heck out of me.

 

[pntgrd]

Pulmonology/Critical Care is being way overrated on this thread. Just because the pts in the MICU are closer to death doesn't mean the problem solving is more complex. In fact, in some ways it is simpler and more algorithm driven.

 

[jdh71]

Pulmonology/Critical Care is being way overrated on this thread. Just because the pts in the MICU are closer to death doesn't mean the problem solving is more complex. In fact, in some ways it is simpler and more algorithm driven.

says the medical student

 

[mercaptovizadeh]

Having everyone rank endocrinology so low is shocking the heck out of me.

Probably also why they rank rheum low. Lower $.

 

[Trifling Jester]

This is exactly true. It's very easy to stand on the outside and say things like: "Rheum is easy, you just put everybody on steroids" or "cards is easy, you just throw stents in everybody." But that's just because you are largely shielded from the high-level decision-making and thought processes that occur in every specialty. I just finished a case in the cath lab where we paused for awhile after shooting the coronaries to pull up the echo, the stress test and the previous RHC numbers, to try to sort out whether an intervention would be worthwhile for this particular patient. But all the referring physician will know is that either a stent was deployed or not.

Rhc numbers affected your decision on stent placement? How?

 

[sacrament]

Rhc numbers affected your decision on stent placement? How?

There was a notion that his dyspnea was an anginal equivalent. Whether or not he had other good reasons for dyspnea was therefore relevant.

 

[tco]

Probably also why they rank rheum low. Lower $.

I mean on the list of problem solving specialties...

 

[boanssi]

Why would you guys say that GI has a significant amount of problem solving?

 

[surge55]

nephro is about even with critical care. for #1.

it's why I want to do both... a PD I met on the interview trail has both certifications. is it possible still? I think it is if you do nephro then do one year of CC.

 

[jdh71]

nephro is about even with critical care. for #1.

it's why I want to do both... a PD I met on the interview trail has both certifications. is it possible still? I think it is if you do nephro then do one year of CC.

Yes. Very possible. Two years nephro + 1 critical care afterwards

 

[gutonc]

Yes. Very possible. Two years nephro + 1 critical care afterwards

Very possible, but you'll have to find the right CCM program. Not all of them are down with the 1 year clinical fellows.

But, with work hour changes and CCM fellows often having to cover the ICU while their interns take their Q45min naps, many places will look to fill the gaps with more CCM fellows while not having to dilute the bronch pool.

 

[surge55]

Very possible, but you'll have to find the right CCM program. Not all of them are down with the 1 year clinical fellows.

But, with work hour changes and CCM fellows often having to cover the ICU while their interns take their Q45min naps, many places will look to fill the gaps with more CCM fellows while not having to dilute the bronch pool.

cool; I'm definitely thinking about it. maybe some ER moonlighting too. the ER at my program is losing some physicians and wants more senior IM residents to work there.