Not meant to impress you, just to point out that underneath all the bells and whistles, theres a primary care physician just like yourself.
cheers.
Not meant to impress you, just to point out that underneath all the bells and whistles, theres a primary care physician just like yourself.
cheers.
D
deleted87716
No. Specialists aren't generalists, despite the IM background. You are what you practice, and most specialists (particularly those who work in the ICU) aren't practicing primary care.
As for the "BC" part, most specialists don't bother to maintain their IM board certification once they're boarded in their specialty.
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Does the medical world know that Superman posts in here? 
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This in itself ends the argument. When one service has been effectively shown to reduce the two most important endpoints (in my mind) in any study, that service is deemed superior. The fact that you are comfortable taking care of your ICU patients is irrelevant. The data doesnt lie.
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....
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Obviously you don't know much about research where studies choked full of confounding variables/research biases/conflicting interests are pretty much the rule rather than the exception with your "the data doesn't lie" but hey points to you for making it sound like a line out of a B sci fi flick.
Over two thirds of ICUs are "open" by the way and it's far from established that patients do better in closed ICUs. Also with the hospitalist movement nonintensivist who spend all their time in the hospital deal with critical care and codes on a daily basis. It's not as if they are a fish out of water.
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True. So, what's the problem? If an individual doctor can demonstrate those endpoints superiorly in an open ICU in their community, why would anyone have anything to say?
MedDoc's point is well taken that these NEJM studies paint in broad strokes and make very big generalizations that may not pertain to the resources and capabilities of an individual community.
If you really wanted to shut MedDoc down, you should pull his hospital data and compare them to others in MedDoc's hospital and to national data. Quoting a health care systems article and trying to make it a universal truth is weak argumentation. It doesn't take into account individual variations.
When I was a resident, some of the private community attendings (with financial problems) started to talk a bunch of crap about our residency program. When the hospital busted out those above data points, the residents did better than the attendings when judged by the same parameters. The attendings then tried to say that the residents had less severe patients. But when the hospital analyzed the data, they found that the residents were managing higher acuity of patients than the private attendings. The private attendings still ran their mouths, except after all that analysis, no one was listening.
2 out of 5 of our ICU's are closed. Intensivists do not "run" the neuro ICU (neurologists do) and intensivists do not "run" the cardiothoracic ICU (CT surgeons do). It's not always true that closed ICU's do better and it's not true that everyone agrees with it.
And, yes, our Pulm/CC intensivists do consult Pulmonary when patients are in our closed ICU's. The reason why is because they want to make it very clear that the intensivists are working as primary when they are in the ICU and are not there to monopolize the bronchoscopies as a politicoeconomic matter. And, having a non-intensivist pulmonologist on board on a case helps the IM/FM primary when that patient steps down into an intermediate unit. That being said, if the patient has no insurance, no one wants to help. That is a universal fact at my hospital. LOL.
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lol your a funny guy. The animosity you constantly portray in all of your posts tells me you are an unhappy resident. I'm not quite sure why that is but I hope a time comes when you don't feel you need to constantly talk yourself up as if people around your are questioning your abilities. A bit of humility goes along way in our profession bud.
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All of our third year residents are comfortable in the ICU. Now you are claiming clairavoyeance. Your scientfic prowess is disconcertingly keen. Again, 2/3 rds of ICUs nationwide are open. Where is "your dog in this anyway"? You peolple are coming out of nowhere with ridiculous assertions.
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I fail to see any ridiculous assertions. I'm planning a CC fellowship so I guess that's my dog though I hardly consider this a fight. And anyone who reads this thread and sees the continuous animosity and hostility you portray in everyone of your posts would assume the same things about you that I had previously posted. You need to chill out bud your getting awfully worked up and defensive in what should be an easy going conversation
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I tell you what bugs me although there is no real animosity. What bugs me aside from the above ill informed posts and ridiculous claims is the continual erosion of the medical profession toward specialist technician and away from actual doctor. I chose general practice because that's what I enjoy. If every specialty with a vested interest in claiming a certain type of patient was successful there would be no general practice and you would need a left and a right big toe doctor if you hurt both toes and they wouldn't know what to do if it extended to the toenail. Intensivists don't own the icu although that is their goal. In fact only 1/3 of ICUs have intensivists. You aren't an expert and have no special knowledge on the subject. You do however appear to like "the sound of your own voice" as well as your ad hominem arguments and I'm done wasting my time bantering back and forth with you.
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I was just wondering, since EM residents now have the opportunity to do critical care fellowships
...and seeing as how EM and FP have the same scope of practice (in terms of being trained to see all types of patients--IM,Peds,OBGYN--although one would argue FP is trained more thoroughly in those fields)...it's a valid point for FP to have the opportunity to do ICU training
additionally on a unrelated point, I think FP should also be eligible to get training in Allergy & Immunology
...and seeing as how EM and FP have the same scope of practice (in terms of being trained to see all types of patients--IM,Peds,OBGYN--although one would argue FP is trained more thoroughly in those fields)...it's a valid point for FP to have the opportunity to do ICU training
additionally on a unrelated point, I think FP should also be eligible to get training in Allergy & Immunology
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I totally agree.
Their patients are of the same age groups, and they both deal with OB/gyn issues. This doesn't mean that they have the same "scope of care", nor does it mean that one is trained more "thoroughly" than the other. Over the last 40 years FP is evolving from "jack of all trades" to a focus on primary care. FP residency is <50% inpatient medicine, let alone ICU. FPs often staff ERs, and moreso in the past. But that's because EM has only been around since the 70s. The first residency in EM was established in 1970, so until there were enough EM docs to staff all the ERs, almost any specialty could practice in the ER.
A residency in EM requires rotations in many critical care related specialties. A typical EM resident has the following rotations (besides the many months of EM) - Trauma surgery, Surgical-ICU, Medical-ICU, Neonatal-ICU, Pediatric-ICU, Anesthesiology.... and its not just a month of each. A typical FP resident would have a lot of difficulty scheduling that many electives.
Also, as I had alluded to before, Fellowships from Family Med are not always the same as with other specialties like IM, Peds, and Surgery. EM/P/GS, etc. generally do ACGME Fellowships, esp. for any specialty with Board certification. FPs do such fellowships in Sports, Geriatrics... but many FP "fellowships" are more like Family Practice regulated Certificates of Added Qualification - in things like Addiction, pediatrics, obstetrics... You can do an Addiction fellowship if you first do Psychiatry, but can also do an Addiction "fellowship" after FP. They aren't actually the same thing. Point being, you dont go into FP if you want to cherry-pick your fellowship later on.
Allergy/Immunology is a different ball of wax entirely... and thats not happening. AI is not just skin testing for allergens... If you're suggesting having training in that, then I think thats reasonable. But thats about it. Allergy is probably the easy part. Immunology, not so much. Selective immunoglobulin deficiencies,Hyper-IgE, Chediak-Higashi, Ataxia-telangectasia, SCID, Wiskott-Aldrich..... are immunologic disorders that every FP or internist learns about in their first year of med school, but most never see.... ever. Its not something you'll fall into as an FP.
In sum - No
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Anybody else getting tired of these posts by self appointed non FP/FP experts? I have job offers for both ER and hospitalist positions. Our residents moonlight in both urgent care and ER (without backup). We discharge patients directly from the ER as ER consults if they are particularly bad admit calls by the ER Docs. We see patients admitted directly to the ICU by ER docs who have been known to, at times, do minimal to no real workup. On the flip side there are patients Who are admitted to our hospital by ER docs with benign paroxysmal vertigo after getting both a CT and an MRI of the brain because they apparently have trouble differentiating bppv from a stroke. Your downplaying of the value of broad based knowledge is nothing but an ill informed opinion.
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Nope, but we are getting tired of your anecdotal FP-uberdoc experiences.
But to get back on the original topic 
When I went on my interviews for residency -
One FP program in particular mentioned that during their ICU month, residents only follow 2 patients at a time. Faculty mentioned that it is enough exposure for typical Family Practice in the area. However, if I wanted to manage ICU patients regularly, I can do an ICU fellowship. They also said the same if I wanted to do full-spectrum OB. I asked a current FP resident in the program about this, and he said that the ICU month "wasn't much different than medical school". He also said that there were ICU fellowships for FP trained docs.
Take home points.
1. There are differences among regions and programs
2. There are critical care fellowships for FPs out there
Try as one might, nobody will convince me I didn't have the above experience. Also, having had applied to both IM and FP, at one point it was my responsibility to know what the minimum educational requirements for each specialty were, and what the similarities and differences were. So, if an IM program boasted that they offer "three whole months of ICU!!!!" to those interested; I knew that they were just blowing smoke since three months is the bare minimum for any accredited IM residency.
When I went on my interviews for residency -
One FP program in particular mentioned that during their ICU month, residents only follow 2 patients at a time. Faculty mentioned that it is enough exposure for typical Family Practice in the area. However, if I wanted to manage ICU patients regularly, I can do an ICU fellowship. They also said the same if I wanted to do full-spectrum OB. I asked a current FP resident in the program about this, and he said that the ICU month "wasn't much different than medical school". He also said that there were ICU fellowships for FP trained docs.
Take home points.
1. There are differences among regions and programs
2. There are critical care fellowships for FPs out there
Try as one might, nobody will convince me I didn't have the above experience. Also, having had applied to both IM and FP, at one point it was my responsibility to know what the minimum educational requirements for each specialty were, and what the similarities and differences were. So, if an IM program boasted that they offer "three whole months of ICU!!!!" to those interested; I knew that they were just blowing smoke since three months is the bare minimum for any accredited IM residency.
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Hold on. If you knew up front you wanted to do critical care regularly, you wouldn't have done FM. You would/should have done IM-Pulm-CC. That is why ABMS doesn't allow you to duplicate residencies and fellowships.
Minimum standards for FM is hard to define because of regional and community variations in needs. So, like you said, you can just as well have 1 program with a low budget critical care rotation like the one you interviewed at and another where critical care experience is more robust. That's the breadth and variation that FM has and students and residents should know that up front before they pick their specialty AND before they pick their program.
That being said, you can't look the RRC minimum standards for accreditation and then cast this overarching judgement on all family doctors as a whole. There are many programs that go above and way beyond the minimum requirements for any given bullet point in the RRC minimum standards. AND, there are a lot of residents who go above and beyond what their programs or RRC requires even if the program or RRC requirement isn't all that robust. So, the position of AAFP as well as ACP and AAP is that hospital privileging and competency should be determined on an individual basis, based on experience and supported by credentialing.
There are plenty of IM-Pulm-CC doctors who can't practice general IM if their lives depended on it. It's no big deal, it's simply because their practice environment doesn't call for them to keep up with that experience, and so it atrophies. Conversely, if an FM doctor does a lot of hospital medicine, it's natural to believe that their competency towards hospital medicine and critical care would be better than those who simply do outpatient medicine. Again, it depends on the individual.
Both the internal medicine and family medicine boards recognize that this idea of competency depends on the individual (and not whether you are an FP or not) that IM & FM jointly participate in certifying individuals with particular interest in Hospital Medicine with the RFP-Hospital Medicine (Recognition of Focused Practice in Hospital Medicine). It's like a CAQ, but different. You need to have practiced Hospital Medicine and have the patient encounters before you can go for the RFP.
The RFP is one example that you can't look at the specialty or the RRC requirements to determine who should and shouldn't be considered competent to practice in a particular field. Instead, it's an attempt at credentialing competence based on individual practice and if someone is interested in hospital medicine, they should go for it.
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I think this attitude is what is wrong with medical education. We b!tch about our debt and the time we put into training, and yet when it's time to learn and train, we procrastinate, saying that if you're "interested" you can do it in fellowship. Otherwise known as "kicking the can down the street".
No. You're in residency. The time to learn is now. Not later. It really bugs me when I hear that people are having watered down training experiences during residency simply because a fellowship exists. Fellowship is time for advanced learning. Not remediation. OB fellowship should be about learning OB at a higher level. Not getting your 1st C-section.
You see this problem everywhere and it's one reason why general medicine in all specialties suffer and why there's fragmentation in care. You see it in PM&R. You see it in Radiology. You're starting to see it in Orthopedics. But the worst specialty to see it is Pathology. In all of these fields, you water down residency because that experience will be picked up in fellowship.
Is there such a thing anymore as a general physiatrist, or a general radiologist, or a general pathologist? No. You can't get a job unless you are fellowship trained.
We can't do that in Family Medicine. The time to learn a skill is now, while you are in residency. I think students interested in family medicine should demand a robust experience from their residency programs, or else don't go. You can't be perfect and super-uber in everything. But at the same time, don't tolerate it when people are wasting your time and money.
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True to form more ass umptions
I don't get your logic here... Sure immunology is complex. Are you suggesting that internists just "fall into", but FP's would not. Allergy is an outpatient focused specialty that sees lots of kids. By your description of residency, that seems closer to FM than IM.
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I simply have a hard time believing that anyone can come out of 3 years of FP, while trying to cram the essentials of 3 specialities +/- surgery, with 2-3 half days of clinic a week, and boast they are just as good at critical care as someone who dedicated an entire 1-2 years to the sub-speciality AFTER finishing a 3-5 year residency in either IM, gas, surgery, or EM, to do nothing but critical care. That sounds like arrogance to me. I'm not personally convinced ICUs need to necessarily all be closed, but I think any doc not using an intensivist when one is available is simply playing with fire for most ICU care.
I dont think anyone really "falls into" it... It seems to be more of a decision from day-1. Neither IM nor FP sees patients with serious immunopathology in their daily practice, and thus develops an interest in AI (thats what I mean by falling into).
AI is heavily academic and research oriented, and very competitive for IM or Peds residents. Yes, AI sees adults and kids, and is mostly outpatient, but thats just a superficial appearance of the setting... not whats going on in the mind of the clinician. Immunology deals with rare diseases that are seen mostly in tertiary care centers, and tertiary care isn't a big part of FP.
It also the difference in the way of thinking between FP and IM... Im sure this point will be argued ad nauseum. But here goes anyway. FP's think "what is the most likely diagnosis for my patient....", while internists think "what zebra could this be, which would kill the patient if not found". The latter lends itself to fields like AI and Medical Genetics, even though they deal with adults and peds in the outpatient setting.
My views arent totally thought out... but the basic gist of my comment is in the first paragraph. As others have stated, you dont go into FP if you start out with an ultimate interest in CCM, AI, tertiary care.... And while i agree with FPs having more training in CCM, I don't hold the same with AI, because Immunological disorders arent commonly seen in community medicine, whereas CC can be.
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This isn't a great reason why FP can't do AI. as an IM resident, I never had a case of COP/RBILD/EG/sarcoid, that's why I'm in fellowship, to see those rarer cases. Personally I find it funny that it's ok for an IM base trained person to see kids with an AI fellowship, but an FP doc can't see rarer immunologic problems because they "don't see rare" crap in their FP training?
I was thinking about that.... especially in terms of Medical Genetics....
EDIT: ok, its not a question of rarity, or agegroups.... To me, the main issue is "utility in primary care or community medicine"
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D
deleted87716
It's called "differential diagnosis," and yes...FPs are generally more cost-effective in their approach.
http://www.aafp.org/online/en/home/...the-public/20090407grhm-cntr-usualsource.html
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What does that prove? FP's spend less money? That means nothing unless you're measuring the quality of care.
Look, the GME system, and the generalist-specialist-subspecialist system is man-made and imperfect. There will be problems as times change, and we're changing to a fragmented niche specialist clinician system which wasn't as prominent in the 60's and 70's. What worked in the 70's may not work now, but getting all bent out of shape over what is an arbitrary imperfect system isn't constructive.
(enjoy the creative prose)
In '60s, the various surgeons, dermatologists, internists and psychiatrists who had been working in Emergency Rooms banded together and petitioned to designate Emergency Medicine as a bona fide specialty. In classic greek tragedy style, they vowed to never enter a fellowship within the American Board of Internal Medicine. In return, they were granted the American College of Emergency Physicians. While they had their own fellowships in Toxicology and Sports, they recently began to pine for Critical Care. Critical Care Fellowships for surgeons and Anesthesiologists welcomed the young EPs, but the EPs couldn't set foot in IM's CCM fellowships. The young EM docs didnt know the deal that their predecessors had to cut in order to become EPs... Yet, after much negotiation and gnashing of teeth, EPs became eligible to do CCM fellowships
In 1969, GPs banded together and created the specialty of Family Medicine. What normally could have been done with a single year of internship plus passage of the USMLE Step3 (Wonder why Path and Neuro residents take Step3, which is really a FM test...? ), now required a 3year residency plus Boards. . And so it was, that the GPs were now dubbed Board Certified Family Physicians. Unfortunately in doing so, each FP had imbibed their only vial of Gee-Ehm Elxir. This had not posed any difficulties for Forty and Two years thereafter, as FPs were happy and rejoiced in their niche as Primary Care providers. Until it came to pass that some young FPs wished to depart from the Isle of Primary Care. Alas, they discovered that indeed, they each had only one vial of Gee-Ehm Elixir, and it was already partaken of.
With great sadness, the FPs inscribed messages on the SDN.... "Surely, there must be a way that we can depart from the Isle of Primary", they said. But they had forgotten the pact that was swore upon in the Year of Our Lord, Nineteen Hundred and Sixty Nine - that in order to practice Family Medicine as a primary care Specialist, one must consume their only vial of Gee-Ehm Elixir... never could they leave the Isle of Primary. For only those Practioners of the Medical Arts who had taken their Gee-Ehm Elixir for the purposes of anything other than Family Medicine, were given another vial of Gee-Ehm Elixir to drink of. Those in Medicine, Surgery, Peds, and all the others were free to drink of their second vial of Gee-Ehm Elixir, and enter the Fellowship.
"This is unjust!", the FPs cried. But they had forgotten what their elders had sacrificed in return for their own, and their disciples' respect, prestige, and honor as members of the American Academy of Family Physicians. And now, as internists, pediatricians, radiologists, surgeons, pathologists, OB/Gyns, psychiatrists, and even ophthalmologists have all left the Isle of Primary, and the Kingdom of General Practice..... the FPs are left with the burden of sustaining the Isle of Primary. A burden that was bestowed upon them with the honor of the American Academy of Family Physicians
(enjoy the creative prose)
In '60s, the various surgeons, dermatologists, internists and psychiatrists who had been working in Emergency Rooms banded together and petitioned to designate Emergency Medicine as a bona fide specialty. In classic greek tragedy style, they vowed to never enter a fellowship within the American Board of Internal Medicine. In return, they were granted the American College of Emergency Physicians. While they had their own fellowships in Toxicology and Sports, they recently began to pine for Critical Care. Critical Care Fellowships for surgeons and Anesthesiologists welcomed the young EPs, but the EPs couldn't set foot in IM's CCM fellowships. The young EM docs didnt know the deal that their predecessors had to cut in order to become EPs... Yet, after much negotiation and gnashing of teeth, EPs became eligible to do CCM fellowships
In 1969, GPs banded together and created the specialty of Family Medicine. What normally could have been done with a single year of internship plus passage of the USMLE Step3 (Wonder why Path and Neuro residents take Step3, which is really a FM test...? ), now required a 3year residency plus Boards. . And so it was, that the GPs were now dubbed Board Certified Family Physicians. Unfortunately in doing so, each FP had imbibed their only vial of Gee-Ehm Elxir. This had not posed any difficulties for Forty and Two years thereafter, as FPs were happy and rejoiced in their niche as Primary Care providers. Until it came to pass that some young FPs wished to depart from the Isle of Primary Care. Alas, they discovered that indeed, they each had only one vial of Gee-Ehm Elixir, and it was already partaken of.
With great sadness, the FPs inscribed messages on the SDN.... "Surely, there must be a way that we can depart from the Isle of Primary", they said. But they had forgotten the pact that was swore upon in the Year of Our Lord, Nineteen Hundred and Sixty Nine - that in order to practice Family Medicine as a primary care Specialist, one must consume their only vial of Gee-Ehm Elixir... never could they leave the Isle of Primary. For only those Practioners of the Medical Arts who had taken their Gee-Ehm Elixir for the purposes of anything other than Family Medicine, were given another vial of Gee-Ehm Elixir to drink of. Those in Medicine, Surgery, Peds, and all the others were free to drink of their second vial of Gee-Ehm Elixir, and enter the Fellowship.
"This is unjust!", the FPs cried. But they had forgotten what their elders had sacrificed in return for their own, and their disciples' respect, prestige, and honor as members of the American Academy of Family Physicians. And now, as internists, pediatricians, radiologists, surgeons, pathologists, OB/Gyns, psychiatrists, and even ophthalmologists have all left the Isle of Primary, and the Kingdom of General Practice..... the FPs are left with the burden of sustaining the Isle of Primary. A burden that was bestowed upon them with the honor of the American Academy of Family Physicians
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Yes, I totally agree with you. It is more cost effective, more timely, and better for the patient, to think of what the most likely diagnosis is, based on the patients presentation, personal, medical, and social Hx, environmental and epidemiological factors. FPs are trained to think like that - think of the whole patient.
Internists are trained to think of all the differentials, and rule out out the most dangerous systematically (like Dr House's whiteboard)
Different ways of thinking, thats all. It goes back to the time when FPs were really good at treating patients even if they didnt have a definitive Dx. If the patient wasnt doing well, the GPs would consult the "doctor's doctor"... the Internist. The internist would systematically hunt the zebra.....
Its a historical paradigm that has kinda stuck around.
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deleted87716
If you know of any studies showing that internists provide higher-quality care compared to FPs, feel free to post the links.
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I did a IM prelim year at a big university hospital before switching to FM. At least at that institution, I learned much, much less for the amount of time spent there than what I have learned at my unopposed FM residency. The difference is I rotate with specialists at my current residency and it is one on one with the attending without 8 people following around one attending like a bunch of baby ducks. The attendings in FM were and are much more knowledgeable in just about every category. Encyclopedic knowledge in some cases. I don't know why that is but it is. Whereas the IM attendings would berate interns on how they should carry around 2 weeks worth of old labs whether normal and on presentations my FM attendings spend their time teaching and answering any and all questions. Whereas in my IM prelim year interns weren't allowed to call the specialist because that was the upper levels "job" in my FP residency interns call or curbside any attending they want. Everyone knows everyone else and attendings of any specialty are happy to teach or give opinions when asked. Interns order whatever and see patients in the icu. Not so at the IM university hospital Where I did the IM prelim year. Whereas In my IM prelim year ccu and even general med months were spent putting in orders given by attendings during walking rounds that took all freaking day in my FM residency we had sit down rounds with all orders placed before checking the patient out with changes or even just suggestions by the attending. In my FM rotation I had one on one instructions by nephrologists and endocrinologists who taught the medicine rotations the specialists in my IM prelim year didn't even know my name and were too busy training they're own trainees to mess with an IM resident much less an IM intern. It was night and day in terms of quality of education.
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Its just the culture in IM vs FM. FM is more personal, collegial, and laid back. If you think IM is malignant.... surgery is worse.
But to each his own. As far as quality of education, personally I can use a bit of the added pressure. It helps me stay on top of things and keep my learnin' on.
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This whole thread is just outrageous. I a med student who doesn't know my ass from a hole in the ground, but this one cracked me up. I was working on a research project where part of the project was having all of the physicians in a private group certified in diabetes care (~17 IM docs). All but one of the physicians was following the standard of care, except one guy... who refused to put his diabetics with microalbuminuria on an ACEI. He said that wasn't how he learned to do it and he wasn't going to do it that way on "his patients" as if they were completely unlike anyone else's patients.
Basically, you're saying you don't believe in evidence in the literature unless it's done in "your hospital." So do you put your DM patients on ACEIs/ARBs? Do you give ASA to chest pain patients who are admitted with possible MIs? Hell, do you use Macrobid/Cipro over random_antibiotic_03 for UTIs? All of these decisions are based on medical evidence, but none of them were done at "your hospital" -- so based on your statement, you shouldn't follow any of these guidelines.
You may be a phenomenal FP and a fantastic CC doc -- but I hope neither I nor any of my family get sick under your care, because I'd be afraid that you'd be all-too-willing to throw evidence out the window in favor of whatever you feel like doing.
In addition, you've stated multiple times in the thread that you did not think CCM was "that complicated." I think that is also an incredibly scary statement. Yes, I'm sure a lot of CCM (just like a lot of medicine in ANY specialty) is "routine," -- and honestly, a lot of the routine stuff is not hard to learn. And yet, becoming a physician requires some of the most grueling training of any professional field -- and the reason is because while there may be a lot of routine, there's also some very challenging aspects to medicine, not the least of which being some ICU patients. And while you may be perfectly capable of managing 9/10 or even 99/100 ICU patients (though I think the last is unlikely), if I'm the 1/100, I'd damn well rather have someone who did the fellowship and spends a significant portion of their time each month doing CCM taking care of me.
I've got bad news for you dude -- in spite of the fact that I know next to nothing about practicing medicine, even I know this much: in medicine, arrogance kills people. The fact that you seem to have missed that simple fact in your training scares the **** out of me.
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Lots of Inflammatory rhetoric and no substance. Be our guest and dissect the research and present the results. Again 2/3 of ICUs are open. Just saying the "research says this" Doesnt cut it. There is research stating NP training is better than MD training. If you don't have time to do that, aren't able to do that, or just aren't interested enough to do that then you should stop making bold statements about "the studies show this" if you don't want to sound ignorant.
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Just a few points. In my hospital, cipro has just awful e. coli coverage and so I don't use it for UTIs. What you fail to understand is that guidelines are just that: guidelines. They aren't rules set in stone. They are suggestions based on large volumes of research that may or may not apply to you.
The ACE/aspirin comparisons are not really the same, both of those have been shown to be very effective in the proper settings. If you don't use those in certain patients, you'd better have a damn good reason not to.
I suspect my enthusiastic collegue here doesn't actually do CC that much differently from the fellowship-trained CC people.
And I'd suspect that FPs is rural Texas, or Alaska, who do appendectomies, dont do them much differently than surgeons. That's not the issue.
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I think the distinction here is the acuity of patients. For instance, where I train, DKA almost never comes to the ICU and is taken care of on the floor/step down. At other places it automatically goes to the ICU. At a neighboring hospital, any A-fib with RVR automatically comes to the CCU.
Some ICUs really only take incredibly sick patients and that makes having an open ICU almost impossible because the patients are liable to crash at any moment. This necesitates having the doc in the ICU at all times.
Some ICUs really only take incredibly sick patients and that makes having an open ICU almost impossible because the patients are liable to crash at any moment. This necesitates having the doc in the ICU at all times.
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If the patient has afib with rvr that patient could be on the verge of crashing. I had one last week who took too much of her digoxin and went from a heart rate of 46 asymptomatic to a hr of 155 with flash pulmonary edema. Code was called patient was given 15 mg of cardizem and intubated. she later required amiodarone for runs of vtac. She has since been d/c from hosp. Had a dka several months back with a ph of 7.1 with kusmaul respirations. Both types need close monitoring.
You kidding? We IM residents would manage those on the telemetry floors. We don't need no fancy Intensivist for that.
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You have vents on your telemetry floors? The Er doc told me when I was admitting the 18 yr old with a ph of 7.1 that he thought he would die. He didn't but he kept me up all night.
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Sure step downs can handle vented patients, though our step-downs are probably like your ICUs. And if you and your ED doc think a pH of 7.1 in a DKA is impressively low, you've simply not seen enough DKAs.
I think I'm starting to understand your arrogance. You simply don't see enough to know what you don't know.
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No bp. Comatose. Yeah right. Your full of it. That guy would have bern in your icu or someone would have your head on a stick. Jackass.
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This comment doesn't even make sense it light of the conversation.
I never said anything about where a patient would or would not have gone at my shop, I merely corrected your ignorance regarding step downs and vents and a DKA with a pH of 7.1
Humility will take your far grasshopper. You still have much to learn.
EDIT: Also helpful are 1) reading comprehension and 2) a quick reminder that you're =/= your
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Yeah well Im posting from an iPhone and your posts arent worth an apostrophe. Truthfully I don't remember his exact ph. It was probably lower than 7.1 as that would place him just outside the severe category in terms of ph but he would have still made the severe based on dehydration and comatose.
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YES ?!?!!
One of the hospitals I rotated at can handle vents on the general medical floor.You still don't get it, do you? There are regional differences in level of care, and across every hospital in the US, there are differences in what can be handled outside vs. inside the ICU. You simply don't know what you dont know. Like the Allegory of the Cave, you see the shadows of CCM that fall on the your hospital, and think "Thats CCM!". Your arrogance chains you to face the shadows, not the forms behind you that create them.
You haven't the foggiest idea of what would or wouldn't be sent to the ICU at other's hospitals, and what would get our heads on sticks.
What would be sent to ICU at one hospital would be sent to tele at another.
What would be sent to ICU at one hospital would be taken away by LifeFlight from another.
What would have been sent to ICU at one, would be hooked up to eICU apparatus at another.
What would be sent to ICU at one hospital would have died at home in another region.
The simple fact that you and your ER doc can say "so and so would have died" should show you that you have some pre-conceived notion of what is and isn't compatible with life AT YOUR HOSPITAL. What you should realize, is that you don't know the same for anyone else's hospital.
Same goes for other fields of medicine. What's considered High Risk OB in one place is routine at another (thats why High Risk OB is called MFM - they acknowledge regional differences). I bet pediatric critical care is quite regional too, Right?
What it appears like from your words is that what you consider critical care is what some of us consider close monitoring. What some of us consider critical care is what you'd consider dead. Not that theres anything wrong with that - its what our respective communities need in terms of healthcare services. The annoying thing is that your arrogance prevents you from seeing the big picture - and thats part of your job as an FP - understanding the healthcare of your patients in the context of their community.
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No one said anything about a step down unit but you and the other poster. It fits with the whole pattern of this thread. You talk with yourself put words in my mouth and accuse me of being arrogant after you make a bunch of ignorant arrogant statements. This whole thread is a complete waste of time and just represents a couple of immature residents/ barely out of residency critical care fellows who see fm in the icu as stepping on their turf. Dying/coding nonstable patients don't belong in "step down units". It doesn't matter what you define as a step down unit. A septic dying patient is actually more straight forward than a patient with multiple life threatening arrhythmias and if you don't call that critical care you are just a *****.
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Jeebus. Go on vacation for a week, come back to this.
I think that this is an interesting discussion, but it won't be so if people throw around insults like "jackass." Keep it civil and professional, please. Gracias.
As you were.
I think that this is an interesting discussion, but it won't be so if people throw around insults like "jackass." Keep it civil and professional, please. Gracias.
As you were.
