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Hi,

I’ve been struggling for some time now. I’m finishing my second year of IM residency, and don’t feel that I’m performing at the level of other residents. My clinical reasoning is terrible (I’ll be thinking of PE when ACS is top differential). My exam skills have not improved. My evaluations at putting me at the level of a late intern, or early PGY2, and comments reflect that I’m performing below average. Now an attending has voiced concerns to leadership that I am not responding to a rapid response situation appropriately (my lack of confidence in my abilities may me stand back and let them take over when a patient was unresponsive—had they not been there I would have taken over and done the same things they did). Going to work has become hell for me—not only is my reasoning poor, but I’m extremely inefficient, which means I get to work at 5:30 and leave at 9:30almost every day. I sleep 4-5 hours a night. I know I have no chance at fellowship anymore with all of these bad evils, even for something non competitive.
I’ve tried changing my techniques for prerounding, reading more, MKSAP questions, nothing has helped with poor clinical reasoning. I’ve went to counselor for anxiety/depression-they basically told me I was exaggerating my symptoms.

I feel like I‘m just too poor a resident to continue at this point, but have no idea how to pay back loan debt. I feel that at some pointI will be fired.Just need some advice.
 

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Hi,

I’ve been struggling for some time now. I’m finishing my second year of IM residency, and don’t feel that I’m performing at the level of other residents. My clinical reasoning is terrible (I’ll be thinking of PE when ACS is top differential). My exam skills have not improved. My evaluations at putting me at the level of a late intern, or early PGY2, and comments reflect that I’m performing below average. Now an attending has voiced concerns to leadership that I am not responding to a rapid response situation appropriately (my lack of confidence in my abilities may me stand back and let them take over when a patient was unresponsive—had they not been there I would have taken over and done the same things they did). Going to work has become hell for me—not only is my reasoning poor, but I’m extremely inefficient, which means I get to work at 5:30 and leave at 9:30almost every day. I sleep 4-5 hours a night. I know I have no chance at fellowship anymore with all of these bad evils, even for something non competitive.
I’ve tried changing my techniques for prerounding, reading more, MKSAP questions, nothing has helped with poor clinical reasoning. I’ve went to counselor for anxiety/depression-they basically told me I was exaggerating my symptoms.

I feel like I‘m just too poor a resident to continue at this point, but have no idea how to pay back loan debt. I feel that at some pointI will be fired.Just need some advice.

Is there talk of not promoting you to PGY-3 year? It sounds like you don't feel comfortable being a 3rd year IM resident.

Is there another specialty that you're interested in? Why did you choose IM to begin with?
 

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Hi,

I’ve been struggling for some time now. I’m finishing my second year of IM residency, and don’t feel that I’m performing at the level of other residents. My clinical reasoning is terrible (I’ll be thinking of PE when ACS is top differential). My exam skills have not improved. My evaluations at putting me at the level of a late intern, or early PGY2, and comments reflect that I’m performing below average. Now an attending has voiced concerns to leadership that I am not responding to a rapid response situation appropriately (my lack of confidence in my abilities may me stand back and let them take over when a patient was unresponsive—had they not been there I would have taken over and done the same things they did). Going to work has become hell for me—not only is my reasoning poor, but I’m extremely inefficient, which means I get to work at 5:30 and leave at 9:30almost every day. I sleep 4-5 hours a night. I know I have no chance at fellowship anymore with all of these bad evils, even for something non competitive.
I’ve tried changing my techniques for prerounding, reading more, MKSAP questions, nothing has helped with poor clinical reasoning. I’ve went to counselor for anxiety/depression-they basically told me I was exaggerating my symptoms.

I feel like I‘m just too poor a resident to continue at this point, but have no idea how to pay back loan debt. I feel that at some pointI will be fired.Just need some advice.

Stay the course, finish. You only have a year to go. You can certainly be a general internist, and you can certainly become an outpatient physician (sounds like you're struggling with inpatient). Moreover, it's good to be residency trained. You're dead in the water without a residency.

Don't take things personally. The way we teach in medicine is actually very inefficient and douchy in my opinion. We love to pick on people for what they don't know, we love to make absolute statements in a very non-exact science. You're not wrong for thinking about a PE and ACS in a patient presenting with chest pain. Which goes higher on your differential? In real life, who cares? You're going to work up both. You'll get the D-Dimer and troponins. If the former is positive, go for the CTA, if the latter, call Cards for a likely stress modality or cath. Now an a$$hole attending will try to make you rank one ahead of the other for academic purposes, but again in real life, you better rule out both.

In medical school and residency, we still try to teach this bllsht utopian, 'bed-side' rounding form of medicine, that's always cost-conscious.

Real life is quite a different story. We blast patients with all sorts of labs/rads because we don't want to be the attending on the chart if something is missed. We don't really care about the history and physical exam, because these can be very subjective things that often lead you astray. We do care about vitals+labs/rads (ie solid objective evidence). We should just teach what we do in real life.
 
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On behalf of decent mental health providers, I'm sorry your counselor made you feel that you were exaggerating your symptoms. Do you have another mental health provider you can turn to?

Has there been talk of holding you back and if not, would you prefer to complete PGY 2 year again? Or do you just not want to do IM at all?
 

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Per my advisor, no talk so far, but I imaging it will come up at some point. I want to do infectious disease and research in the long run, but I also have evalsfrom my ID rotation saying I’m inefficient at chart review, and specifically, that this is an essential tool in ID fellowship (basically saying I’mmot cut out for it). I’m honestly not a fan of inpatient or outpatient primary care, and feel most miserable on the wards. Not only do I feel like I’m terrible at what I do, I also feel like I’m dumped on—dealing with placement patients with difficult families, admitting the pre-op patient without active medical issues because the surgeons don’t want to deal with them. Dealing with all the scut of hospitalist work—social stuff, mainly—is frustrating. I got yelled by three patients in one day for peridischarge stuff that wasn’t my fault. I’m sorry to complain, but it’s to the point where I’m just angry and irritable all the time. And now this slew of poor evals (some of which are from rotations I did months ago but attending a just now getting to them) and this new complaint make me feel like I should just leave before I’m fired.
 
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You need to have a long talk with your PD before you do anything rash. I know we all hate the word, but you're burned out and symptoms of that include critical self-evaluation. Not saying you're exaggerating the evals or how poorly you're doing, but I wonder if you're thinking of this situation as hopeless when it's not. I'd hate for you to throw away your career in this frame of mind.

Please set up a meeting with your PD (and advisor to join you if you like) and come up with a game plan to turn things around. That might involve remediation, but at this point, it's better than quitting or being fired.
 
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DrMetal

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Per my advisor, no talk so far, but I imaging it will come up at some point. I want to do infectious disease and research in the long run, but I also have evalsfrom my ID rotation saying I’m inefficient at chart review, and specifically, that this is an essential tool in ID fellowship (basically saying I’mmot cut out for it).

Ouch! For what it's worth, sometimes you can do research (you can do an academic fellowship, or a post-doc) in a field, without necessarily doing the fellowship. You certainly need the fellowship and BC if you want to touch a patient in that sub-specialty, but if all you want to do is research in a particular topic, go nuts. Maybe an MPH is up your alley?

I’m honestly not a fan of inpatient or outpatient primary care, and feel most miserable on the wards. Not only do I feel like I’m terrible at what I do, I also feel like I’m dumped on—dealing with placement patients with difficult families, admitting the pre-op patient without active medical issues because the surgeons don’t want to deal with them. Dealing with all the scut of hospitalist work—social stuff, mainly—is frustrating. I got yelled by three patients in one day for peridischarge stuff that wasn’t my fault. I’m sorry to complain, but it’s to the point where I’m just angry and irritable all the time. And now this slew of poor evals (some of which are from rotations I did months ago but attending a just now getting to them) and this new complaint make me feel like I should just leave before I’m fired.

So, this part of your post is a little more concerning, a little more telling that you don't want to be an internist. You basically just described what an internist does. If your really feel this way, then I'd understand your decision to quit. But only if you really feel this way, not because you're having a stress reaction.

You're getting emotionally affected by patients yelling at you, because (as a resident) you have to show that you care. In real life, we semi-care, or don't care at all. When the alcoholic that I've admitted 3 times this week yells at me/nursing staff, as a resident I was forced to show BS compassion that we all know is fake. As an attending I walk out of the room and call security. Then I don't think twice about that piece of @#$% and move on to a nice patient who actually wants my help.

All things said, still, you're close enough that I'd advise finishing. Try the job as an attending for a few years, see if you like it. It really is different being an attending. It's nice! you call your own shots, don't have to answer to anyone (well, except hospital admin, but you know what i mean), you're time is your, don't have to fake compassion, spend maximal time with the patients that really need you, less time with others.
 
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Splenda88

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Stay the course, finish. You only have a year to go. You can certainly be a general internist, and you can certainly become an outpatient physician (sounds like you're struggling with inpatient). Moreover, it's good to be residency trained. You're dead in the water without a residency.

Don't take things personally. The way we teach in medicine is actually very inefficient and douchy in my opinion. We love to pick on people for what they don't know, we love to make absolute statements in a very non-exact science. You're not wrong for thinking about a PE and ACS in a patient presenting with chest pain. Which goes higher on your differential? In real life, who cares? You're going to work up both. You'll get the D-Dimer and troponins. If the former is positive, go for the CTA, if the latter, call Cards for a likely stress modality or cath. Now an a$$hole attending will try to make you rank one ahead of the other for academic purposes, but again in real life, you better rule out both.

In medical school and residency, we still try to teach this bllsht utopian, 'bed-side' rounding form of medicine, that's always cost-conscious.

Real life is quite a different story. We blast patients with all sorts of labs/rads because we don't want to be the attending on the chart if something is missed. We don't really care about the history and physical exam, because these can be very subjective things that often lead you astray. We do care about vitals+labs/rads (ie solid objective evidence). We should just teach what we do in real life.

That was brutal, but true...

Everyone in IM pretends they are **t when in reality we are blasting patients with imaging and labs...
 

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That was brutal, but true...

Everyone in IM pretends they are **t when in reality we are blasting patients with imaging and labs...

I used to argue this point as a resident (I had some nads on me!)

My favorite was the TIA workup.

Me: So if the patient's symptoms have completely resolved, and her neuro exam is completely normal (CN2-12 intact, no weakness, all reflexes good.....and the neurologists neuro exam is normal as well), then why do we need to get the MRI?

Attending: so we can be sure she didn't have a stroke.

Me: so why bother with the physical exam? If we don't trust it, and if we're going to get the MRI anyway, why bother?

Attending: just get the MRI

LOL!
 
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OP, do everything in your power to finish your residency. Even if you decide to leave clinical medicine altogether, being board certified in anything will open significantly more doors to you.
 
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BoardingDoc

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I used to argue this point as a resident (I had some nads on me!)

My favorite was the TIA workup.

Me: So if the patient's symptoms have completely resolved, and her neuro exam is completely normal (CN2-12 intact, no weakness, all reflexes good.....and the neurologists neuro exam is normal as well), then why do we need to get the MRI?

Attending: so we can be sure she didn't have a stroke.

Me: so why bother with the physical exam? If we don't trust it, and if we're going to get the MRI anyway, why bother?

Attending: just get the MRI

LOL!
Because MRI findings of reversible ischemia confirms your diagnosis? Because you can have symptom resolution and still have abnormal DWI which generally indicates a massively increased chance of future stroke?

I'm all for arguing against the use of pointless tests (e.g. your comment earlier about getting both trops and a dimer on chest pain patients. I seriously hope chest pain != dimer + trops unless you have a significant suspicion for a PE), however, I don't think I'd rally behind the flag of "we don't need to do an MRI as part of a TIA workup."
 
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Because MRI findings of reversible ischemia confirms your diagnosis? Because you can have symptom resolution and still have abnormal DWI which generally indicates a massively increased chance of future stroke?

I'm all for arguing against the use of pointless tests (e.g. your comment earlier about getting both trops and a dimer on chest pain patients. I seriously hope chest pain != dimer + trops unless you have a significant suspicion for a PE), however, I don't think I'd rally behind the flag of "we don't need to do an MRI as part of a TIA workup."
But how does it change management? Whether the patient had a non-large vessel obstruction stroke that has now resolved clinically or a TIA, you are going to work up and treat the patient the exact same way (carotid dopplers, 2DEcho, telemetry, appropriate antiplatelet or anticoagulant). The presence or not of a small DWI abnormality makes no difference here other than academic (unless you suspect a functional presentation, but that should be based on your exam).
 
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BoardingDoc

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But how does it change management? Whether the patient had a non-large vessel obstruction stroke that has now resolved clinically or a TIA, you are going to work up and treat the patient the exact same way (carotid dopplers, 2DEcho, telemetry, appropriate antiplatelet or anticoagulant). The presence or not of a small DWI abnormality makes no difference here other than academic (unless you suspect a functional presentation, but that should be based on your exam).
This is precisely what I was getting at. If you feel that your clinical examination skills are good enough to definitively say that a persons seemingly neurological presentation is somatization/functional/psychiatric/etc then by all means.

Is it pretty obvious in some cases and you can probably skip the MRI? Sure. Would I make using my clinical gestalt the definitive test? I personally wouldn't. I'm also not a neurologist, so I don't purport to be an expert.
 
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This is precisely what I was getting at. If you feel that your clinical examination skills are good enough to definitively say that a persons seemingly neurological presentation is somatization/functional/psychiatric/etc then by all means.

Is it pretty obvious in some cases and you can probably skip the MRI? Sure. Would I make using my clinical gestalt the definitive test? I personally wouldn't. I'm also not a neurologist, so I don't purport to be an expert.
I would point out that in his original post, the consulting neurologist reported everything was normal on exam.
 

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Unless your neurologists are significantly different than mine, I would also imagine that same neurologist wanted the MRI.
Hey, I don’t have enough experience to be arguing for or against your thought process. But since you said “I'm also not a neurologist, so I don't purport to be an expert”, I assumed you would defer this judgement to a neurologist and follow on their recommendation to get or not get an MRI. I am also assuming that the neurologist didn’t believe an MRI would be necessary as he didn’t order it; I don’t think consulting a neurologist only for them to tell you that getting an MRI “is up to the primary care team” would be particularly helpful of them.
 

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Hey, I don’t have enough experience to be arguing for or against your thought process. But since you said “I'm also not a neurologist, so I don't purport to be an expert”, I assumed you would defer this judgement to a neurologist and follow on their recommendation to get or not get an MRI. I am also assuming that the neurologist didn’t believe an MRI would be necessary as he didn’t order it; I don’t think consulting a neurologist only for them to tell you that getting an MRI “is up to the primary care team” would be particularly helpful of them.
Totally reasonable. If a neurologist consulted on a patient with a TIA presentation and they stated that it was clearly X and didn't need an MRI, I'd be completely fine with not getting one unless I had a really damn good reason otherwise. All I took from the original post was that neuro said the patient had a normal exam, which simply brings me back to my original comment about there still being the possibility of an abnormal MRI which would cinch the neuro diagnosis as opposed to an alternate etiology. If they said that the patient has a normal exam and they don't need an MRI, that's something I didn't read into the comment.
 
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Totally reasonable. If a neurologist consulted on a patient with a TIA presentation and they stated that it was clearly X and didn't need an MRI, I'd be completely fine with not getting one unless I had a really damn good reason otherwise. All I took from the original post was that neuro said the patient had a normal exam, which simply brings me back to my original comment about there still being the possibility of an abnormal MRI which would cinch the neuro diagnosis as opposed to an alternate etiology. If they said that the patient has a normal exam and they don't need an MRI, that's something I didn't read into the comment.
I guess that’s possible, but then my question would be why didn’t they order an MRI?

I would probably reach out and clarify with the neuro team first, personally.
 
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I guess that’s possible, but then my question would be why didn’t they order an MRI?

I would probably reach out and clarify with the neuro team first, personally.
Your consultants place orders on your patients? I've never seen that. Agree about clarifying with neuro.
 
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Your consultants place orders on your patients? I've never seen that. Agree about clarifying with neuro.
Generally imaging and labs should be no problems, right? Not the same as meds or interventions, but I guess this can be institution dependent.
 

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Because MRI findings of reversible ischemia confirms your diagnosis? Because you can have symptom resolution and still have abnormal DWI which generally indicates a massively increased chance of future stroke?

I love the MRI. (I think it's the greatest invention of all time) . My point was that the physical exam (especially the neuro exam) is useless (if it's negative, we get the MRI, if it's positive, we get the MRI, so why bother with it). We love to teach the neuro exam, but we don't actually use it. This is true of many things in medicine. When's the last time you diagnosed a heart condition via auscultation, without getting an EKG, without getting an ECHO? I just wish in medicine we'd actually just teach how we practice.

I seriously hope chest pain != dimer + trops unless

It absolutely does, in every ER in America. And I'm ok with it. They're simple labs with good negative predictive values (in the right patient population). If it were my loved one in the ER, I'd want you to check it. I don't care about your physical exam capabilities. Let's just be honest . . .
 

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I agree with you about the physical exam being given far more weight in a teaching setting than it is in clinical practice.

It absolutely does, in every ER in America. And I'm ok with it. They're simple labs with good negative predictive values (in the right patient population). If it were my loved one in the ER, I'd want you to check it. I don't care about your physical exam capabilities. Let's just be honest . . .
This is categorically false. ER attending here. The number of chest pain patients who get a d-dimer is maybe 20% at most. This isn't limited to my practice, this is how ED's actually work. I'm honestly shocked that you would even suggest otherwise. If you don't suspect a PE, there is no reason to do one. Moreover, if you are doing a dimer on everyone with chest pain, you are going to be doing a significant number of unnecessary CTAs on people because of all the false positives that you're going to get.

To "be honest" as you said, I absolutely would NOT want my loved one getting an unnecessary D-dimer, and getting one on every chest pain patient in the ED is demonstrably bad medicine.
 

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I agree with you about the physical exam being given far more weight in a teaching setting than it is in clinical practice.


This is categorically false. ER attending here. The number of chest pain patients who get a d-dimer is maybe 20% at most. This isn't limited to my practice, this is how ED's actually work. I'm honestly shocked that you would even suggest otherwise. If you don't suspect a PE, there is no reason to do one. Moreover, if you are doing a dimer on everyone with chest pain, you are going to be doing a significant number of unnecessary CTAs on people because of all the false positives that you're going to get.

To "be honest" as you said, I absolutely would NOT want my loved one getting an unnecessary D-dimer, and getting one on every chest pain patient in the ED is demonstrably bad medicine.

What defines 'bad medicine' in 2020? A negative D-dimer and/or a negative trop in the young population with no other risk factors quickly stops the crazy train. No further CTA, no need for emergent stress modality. (these tests may be falsely reassuring if negative in the elderly crowd with co-morbidities. So for the elderly with previous conditions, you might have to go to CTA anyway). Ok, but your point is well taken. Lets say 'chest pain+some other concerning symptom (dyspnea, exertion)' may buy you a D-Dimer/trop.

I'm honestly shocked

No you're not, cmon. You've seen worse. A serum D-Dimer/trop shocks you? I've seen ER physicians order these with patients still in triage.
 

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What defines 'bad medicine' in 2020? A negative D-dimer and/or a negative trop in the young population with no other risk factors quickly stops the crazy train. No further CTA, no need for emergent stress modality. (these tests may be falsely reassuring if negative in the elderly crowd with co-morbidities. So for the elderly with previous conditions, you might have to go to CTA anyway). Ok, but your point is well taken. Lets say 'chest pain+some other concerning symptom (dyspnea, exertion)' may buy you a D-Dimer/trop.



No you're not, cmon. You've seen worse. A serum D-Dimer/trop shocks you? I've seen ER physicians order these with patients still in triage.
Chest pain that's pleuritic? Chest pain and associated leg swelling, etc etc? Yeah, agree. I don't care if you dimer those people on top of your trop. That makes sense. I was, however, honestly shocked at the idea of every chest pain getting a dimer. Maybe I work in a fairy tale ED, but all of my colleagues are well trained and none of them would do that ****. I also haven't seen any of my colleagues ever order a d-dimer on a patient that was still in triage. I certainly haven't.

Have I seen unnecessary dimer/trop combos (or other non-indicated tests which now have downstream consequences) get sent in by Jenny McJennyson NP at the local urgent care? Yeah, more times than I can count. I've frequently told the patient that they received poor care when I go and see them in the ED.
 

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Chest pain that's pleuritic? Chest pain and associated leg swelling, etc etc? Yeah, agree. I don't care if you dimer those people on top of your trop. That makes sense. I was, however, honestly shocked at the idea of every chest pain getting a dimer. Maybe I work in a fairy tale ED, but all of my colleagues are well trained and none of them would do that ****. I also haven't seen any of my colleagues ever order a d-dimer on a patient that was still in triage. I certainly haven't.

Have I seen unnecessary dimer/trop combos (or other non-indicated tests which now have downstream consequences) get sent in by Jenny McJennyson NP at the local urgent care? Yeah, more times than I can count. I've frequently told the patient that they received poor care when I go and see them in the ED.
The ED doc where you work must be different. I don't think there is anyone who c/o chest pain in my ED that does not get the whole shabanmmm
 
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Chest pain that's pleuritic? Chest pain and associated leg swelling, etc etc? Yeah, agree. I don't care if you dimer those people on top of your trop. That makes sense. I was, however, honestly shocked at the idea of every chest pain getting a dimer.

Order sets are probably to blame. They are good tests, have a good negative predictive value in the young and non-comorbids.

Maybe I work in a fairy tale ED
You must. It's probably sparkling clean, blindingly white, everyone's hot and sexy, and you have no drug-seekers.

Hey go nuts man. If you can practice the utopian way of medicine, I commend you. You're the last of the mohicans. Problem is: your hospital admin isn't going to defend you if you miss a PE in a 28-yo F who presented with light symptoms, and you're trying to make the argument that her 'history' wasn't convincing. They'll ask, 'why didn't you just check a D-Dimer, and yeah if positive why not scan her?'.

We've all seen this happen unfortunately, and no one will back you up for trying to be the good doctor that didn't want or an un-necessary blood draw. It's unfortunate, but again, it's 2020, not 1960.
 
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I love the MRI. (I think it's the greatest invention of all time) . My point was that the physical exam (especially the neuro exam) is useless (if it's negative, we get the MRI, if it's positive, we get the MRI, so why bother with it). We love to teach the neuro exam, but we don't actually use it. This is true of many things in medicine. When's the last time you diagnosed a heart condition via auscultation, without getting an EKG, without getting an ECHO? I just wish in medicine we'd actually just teach how we practice.



It absolutely does, in every ER in America. And I'm ok with it. They're simple labs with good negative predictive values (in the right patient population). If it were my loved one in the ER, I'd want you to check it. I don't care about your physical exam capabilities. Let's just be honest . . .
If you’re a neurologist, neurosurgeon, or orthopedic surgeon, I guarantee you the neuro exam changes management and is highly useful information separate from imaging findings. If you’re a service consulting any of these services for a neuro issue, doing a good neuro exam can help them triage, order appropriate tests, and direct efficient work up (and they will of course do their own exam when they see the patient).

OP, other than feeling like you’re treading water or that there may be the threat of dismissal, is there any actual barrier to completing your last year of residency? As others have said, finishing residency regardless of your future plans is likely to be much more beneficial than not, particularly given you only have a year left.
 
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hallowmann

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I'm not an ED resident, but here the ED does not Dimer everyone with chest pain. That would really be ridiculous. For the young people they get an ECG, probably a trop, and 7/10 a GI cocktail that resolves their symptoms. There is a relatively narrow population that we Dimer, usually where the clinical suspicion is low to moderate (basically modified Wells). The high people usually get CT regardless of dimer and the low (i.e. PERC of 0) usually get other management.

For OP, finishing residency is definitely worth it, but I can't say I've never considered quitting early. The burnout is real. For me it helps to make small goals. One week at a time, one block at a time, one year at a time. Its worked pretty well for 3 yrs. Also, to be honest things do get better. I don't know if you just don't worry about things as much, become more comfortable with more, or just realize that there's a lot you don't know and honestly won't know, so just try to be comfortable knowing how to get the info you need.
 
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