How worthless has Neurology become?

[Splenda88]

Awww c'mon, what fun would SDN be then? It's fun ragging on my 2 most hated specialties (Neuro and Emergency medicine)

Here's the thing: we all know Neurology is not an effective in-patient service, really. We also know this about Rheum and Endocrine, hence most community hospitals don't have a staff endocrine or rheum for inpatient consults (academic ones do). Which is fine most times, we get a patient through their DKA or Lupus flare, they follow up with their outpatient Rheum or Endocrine, and this is where they get helped the most by those specialists (in the outpatient setting).

Rheum and Endocrine will admit that much. And the hospital doesn't have a mando rule to consult Endocrine on every DKA, or Rheum for every lupus flare admission.

But for some reasons, Neurologist wont admit how useless they are in the inpatient setting, and hospitals continue to require neuro consults for every weak TIA admission. Go figure.

If your place is a "stroke center" (whatever that means), that is probably the reason.

If you don't use the stroke order set where I am, you will get a text message from our CMO...

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[gutonc]

If your place is a "stroke center" (whatever that means), that is probably the reason.

If you don't use the stroke oder set where I am, you will get a text message from our CMO...

 

[dozitgetchahi]

Awww c'mon, what fun would SDN be then? It's fun ragging on my 2 most hated specialties (Neuro and Emergency medicine)

Here's the thing: we all know Neurology is not an effective in-patient service, really. We also know this about Rheum and Endocrine, hence most community hospitals don't have a staff endocrine or rheum for inpatient consults (academic ones do). Which is fine most times, we get a patient through their DKA or Lupus flare, they follow up with their outpatient Rheum or Endocrine, and this is where they get helped the most by those specialists (in the outpatient setting).

Rheum and Endocrine will admit that much. And the hospital doesn't have a mando rule to consult Endocrine on every DKA, or Rheum for every lupus flare admission.

But for some reasons, Neurologist wont admit how useless they are in the inpatient setting, and hospitals continue to require neuro consults for every weak TIA admission. Go figure.

Oh, good rheumatologists can be very effective on an inpatient service. (Cue me running around like a madman on my very busy hospital rotations as a rheum fellow, helping to manage super sick cases of lupus, vasculitis, etc).

It’s not that we aren’t effective. It’s that most of us ****ing hate going to the hospital to round, and have zero desire to do so. I’d kick ass on a rheumatology consultation service as an attending - I was trained with massive consult volumes as a fellow. It’s just that you’d have to drag me kicking and screaming into the hospital to do it.

 

[NewYorkDoctors]

Oh, good rheumatologists can be very effective on an inpatient service. (Cue me running around like a madman on my very busy hospital rotations as a rheum fellow, helping to manage super sick cases of lupus, vasculitis, etc).

It’s not that we aren’t effective. It’s that most of us ****ing hate going to the hospital to round, and have zero desire to do so. I’d kick ass on a rheumatology consultation service as an attending - I was trained with massive consult volumes as a fellow. It’s just that you’d have to drag me kicking and screaming into the hospital to do it.

I have a patient with Anti MDA5 anti synthetase syndrome. rapidly progressive ILD indeed. despite rapid outpatient efforts for pred 1mg/kg, MMF, and IVIG (the IVIG arranged by academic rheumatologist) the patient still rapidly progressed to acute hypoxic respiratory failure and now is in MICU intubated on high PEEP and FiO2
pulse steroids calmed things down a bit.
thank goodness for the rheumatologist doing all of the heavy lifting with getting rituxan, looking out for hepatitis B reactivation , getting tofacitinib coordinated with pharmacy overnight express, and now getting plasmapheresis on board

I just have to manage the MRSA seen on BAL, the sugars, the anemia, the low tidal volume ventilation, the urine output.

thank goodness for strong inpatient rheumatology or else this patient might be dead already.

 

[DrMetal]

Oh, good rheumatologists can be very effective on an inpatient service.

thank goodness for the rheumatologist

Well, if you have inpatient rheum, then by all means use it. It's certainly not a service I expect in every hospital (like Cards/GI/Pulm). Most of these hard inpatient rheum NOS cases are fluids-->solumedrol-->ICU, ritux, plasmapheresis. Done by hospitalists/nephro/Intensivists. Would love to have rheum if its there.

I appreciate that Rheum and Endo do not fancy themselves as huge inpatient services, forcing themselves into orders sets and hospital protocols. That's the unfortunate case for Neuro.

A mild RA flare can be dispo'd out of the ER (even out of an Urgent Care) with PO steroids for 5 days. No hospital protocol requires a stat Rheum consult.

A simple TIA or small lacunar infarct (with a normal neuro exam) can/should be dispo'd out of the ER (you can get a stat partial MRI done, start ASA/Statin, send them home). But no, we have to admit for 2 nights to let Neuro see them, to do what? And then we get pounced on for BS admits and LOS.

 

[Splenda88]

How worthless has Neurology become

I mean, come on. Can we please just accept that Neurology, as a clinical service, is essentially useless? Can we stop the charade?

There is a lot charade in medicine.

Somewhere I believe you mentioned ED shouldn't (did not) have to be a specialty. I kind of agree with you on that,

Let me vent about the other charades.

Let's pretend that an 8-yr degree is necessary to become a doctor. At best, that thing should be 2 yrs prereqs after HS and 3-yr med school (at worst, maybe 6 yrs total)

First, let's stop pretending that IM docs are well trained to be outpatient PCP when there are IM programs out there w/ primary care tract.

Let's pretend that CCM is not IM+procedures

Let's not pretend that 2-yr of endocrinology fellowship is not a charade when 75%-85% of their panel are patients w/ DM2, hypo/hyperthyroidism.

 

[DrMetal]

Let's pretend that an 8-yr degree is necessary to become a doctor. At best, that thing should be 2 yrs prereqs after HS and 3-yr med school (at worst, maybe 6 yrs total)

Quite true. I consult Cardiology and get an NP who's had 6 years of education (4 yrs BSN + 2 year cracker-jack MS degree), vs a Cardiologist who has who has 14 years of education and training. Crazy thing is, the NP does a great job.

 

[greatnt249]

Quite true. I consult Cardiology and get an NP who's had 6 years of education (4 yrs BSN + 2 year cracker-jack MS degree), vs a Cardiologist who has who has 14 years of education and training. Crazy thing is, the NP does a great job.

Probably because when you narrow the scope of an NP for what they need to focus on, it's easier to implement management for things you tend to see on a recurrent basis. If the NP sticks with any relatively narrow-focused specialty long enough, they're probably going to get the hang of what most of their department deals with routinely. Where the problems become exposed is when what appears to be routine is, in fact, not routine and requires a more nuanced approach than "guideline" therapy; at that point, do you trust that they will run the patient's case by you (even if they don't "have" to) or stumble along blindly due to failure of recognition?

 

[dozitgetchahi]

Probably because when you narrow the scope of an NP for what they need to focus on, it's easier to implement management for things you tend to see on a recurrent basis. If the NP sticks with any relatively narrow-focused specialty long enough, they're probably going to get the hang of what most of their department deals with routinely. Where the problems become exposed is when what appears to be routine is, in fact, not routine and requires a more nuanced approach than "guideline" therapy; at that point, do you trust that they will run the patient's case by you (even if they don't "have" to) or stumble along blindly due to failure of recognition?

Also, NPs are very “monkey see, monkey do”.

They may do OK in narrow situations within an algorithmic specialty like cardiology. They do not tend to perform well if left to their own devices in, say, rheumatology.

 

[greatnt249]

Also, NPs are very “monkey see, monkey do”.

They may do OK in narrow situations within an algorithmic specialty like cardiology. They do not tend to perform well if left to their own devices in, say, rheumatology.

Right, that was my point. That being said, there are facets of my specialty that are not well-suited to have the nurse practitioner follow routinely unless there's tight supervision. I would argue that family medicine, general internal medicine, and emergency medicine are too broad in scope to have them practice effectively in either, yet it seems to attract a decent number of them out of "necessity of access." My observations of why it seems like they can perform equivocally to physicians in these specialties are 1) many patients are going to do "well" whether you observe the condition or "treat" the condition (emergency medicine excluded) or even get seen for the condition at all in the office and 2) many clinical problems being surveilled in the outpatient FM/IM office don't manifest as larger problems until a relatively long period of time has passed, so it becomes difficult for an outside observer to ascertain whether the condition was mismanaged or if the outcome was otherwise inevitable.

 

[dozitgetchahi]

Right, that was my point. That being said, there are facets of my specialty that are not well-suited to have the nurse practitioner follow routinely unless there's tight supervision. I would argue that family medicine, general internal medicine, and emergency medicine are too broad in scope to have them practice effectively in either, yet it seems to attract a decent number of them out of "necessity of access." My observations of why it seems like they can perform equivocally to physicians in these specialties are 1) many patients are going to do "well" whether you observe the condition or "treat" the condition (emergency medicine excluded) or even get seen for the condition at all in the office and 2) many clinical problems being surveilled in the outpatient FM/IM office don't manifest as larger problems until a relatively long period of time has passed, so it becomes difficult for an outside observer to ascertain whether the condition was mismanaged or if the outcome was otherwise inevitable.

Agree. To your points I’d add 3) many patients don’t know if they’re actually receiving quality care or not, especially in a specialty like rheumatology that tends to be somewhat obscure, so some people are “really happy” with their midlevel just because they’re “nice” etc, even when the care is horrible.

 

[DrMetal]

We're preaching to the choir here about NPs.

The medical industrial complex doesn't care. Even if you could undeniably prove that the usage of mid-levels resulted in a decrease in the quality of care by a factor of 'X', if it means the hospital budget is reduced by a factory of 'Y', the latter wins.

Patients don't care any more either. They just want a diagnosis, a treatment plan, and to go home. If they can get that much from a doctor, an NP, or chatGPT, it's all good.

The job physician is coming to an end.

 

[rokshana]

There is a lot charade in medicine.

Somewhere I believe you mentioned ED shouldn't (did not) have to be a specialty. I kind of agree with you on that,

Let me vent about the other charades.

Let's pretend that an 8-yr degree is necessary to become a doctor. At best, that thing should be 2 yrs prereqs after HS and 3-yr med school (at worst, maybe 6 yrs total)

First, let's stop pretending that IM docs are well trained to be outpatient PCP when there are IM programs out there w/ primary care tract.

Let's pretend that CCM is not IM+procedures

Let's not pretend that 2-yr of endocrinology fellowship is not a charade when 75%-85% of their panel are patients w/ DM2, hypo/hyperthyroidism.

Again… you comment on things you have no experience in… you are a hospitalist straight out of residency and have done nothing else.

I have done your job… you have not done mine.

And you yourself say you really don’t do that much when you are at work and watch tv and okay video games.

Unless you have actually done a subspecialty fellowship, you don’t know what you are talking about.

And, no, as an actual endocrinologist, my panel is not made up of just diabetes… majority of that can be ( and should be) managed by a PCP… generally I see less than 20% dm both as inpt and clinic … because a hospitalist should be able to manage diabetes inpt and not call an endo consult for them. But of course that is not always the case… but hey! As an attending, it’s an easy consult( though I still roll my eyes a bit)…

 

[Splenda88]

Again… you comment on things you have no experience in… you are a hospitalist straight out of residency and have done nothing else.

I have done your job… you have not done mine.

And you yourself say you really don’t do that much when you are at work and watch tv and okay video games.

Unless you have actually done a subspecialty fellowship, you don’t know what you are talking about.

And, no, as an actual endocrinologist, my panel is not made up of just diabetes… majority of that can be ( and should be) managed by a PCP… generally I see less than 20% dm both as inpt and clinic … because a hospitalist should be able to manage diabetes inpt and not call an endo consult for them. But of course that is not always the case… but hey! As an attending, it’s an easy consult( though I still roll my eyes a bit)…

You did not address my point

I said DM, hypo/hyperthyroidism. I know I am not an endocrinologist, but I rotated for 1 month in endo as a PGY3.

I commented on that to the attending I was working with, and he did agree with me. He had few osteoporosis patients as well. That was academia. Maybe things are different in the community, but I doubt it.

Unless the month that I rotated was an atypical month. I stand by what I said.

Even IM should not be a 3-year residency. Let's stop that charade about trying to make IM docs outpatient PCP. Continuity clinic in IM is just BS. Cut that nonsense and make the program 2-yr. Even with the nonsense, IM should be 2-yr.

People in medicine should stop lying to themselves.

What percentage of your patient panel is DM/hypo/hyperthyroidism?

Nothing against these specialties by the way, but as @DrMetal said, we need to stop the charade.

 

[Splenda88]

Again… you comment on things you have no experience in… you are a hospitalist straight out of residency and have done nothing else.

I have done your job… you have not done mine.

And you yourself say you really don’t do that much when you are at work and watch tv and okay video games.

Unless you have actually done a subspecialty fellowship, you don’t know what you are talking about.

And, no, as an actual endocrinologist, my panel is not made up of just diabetes… majority of that can be ( and should be) managed by a PCP… generally I see less than 20% dm both as inpt and clinic … because a hospitalist should be able to manage diabetes inpt and not call an endo consult for them. But of course that is not always the case… but hey! As an attending, it’s an easy consult( though I still roll my eyes a bit)…

Is that supposed to be an attack?

I would be even happier if they were paying me that 350k to stay at home and spend more time with my family.

 

[rokshana]

You did not address my point

I said DM, hypo/hyperthyroidism. I know I am not an endocrinologist, but I rotated for 1 month in endo as a PGY3.

I commented on that to the attending I was working with, and he did agree with me. He had few osteoporosis patients as well. That was academia. Maybe things are different in the community, but I doubt it.

Unless the month that I rotated was an atypical month. I stand by what I said.

Even IM should not be a 3-year residency. Let's stop that charade about trying to make IM docs outpatient PCP. Continuity clinic in IM is just BS. Cut that nonsense and make the program 2-yr. Even with the nonsense, IM should be 2-yr.

People in medicine should stop lying to themselves.

What percentage of your patient panel is DM/hypo/hyperthyroidism?

Nothing against these specialties by the way, but as @DrMetal said, we need to stop the charade.

Yeah… that “month” really was 2-3 weeks since all the residents take their vacation time on electives and are generally on jeopardy/ back up call and get called in … that’s like the commercial for staying at a holiday inn giving you expertise…

not an attack… just tired of your Dunning Kruger showing… you don’t know what you are talking about yet you constantly pipe up…you’re been like this since you first started posting as a noob hospitalist fresh out of residency… thought you would mature as you gained experience…🤷🏽‍♀️…you’re kinda like a mid level with this…and you know how annoying and tiring that is…

 

[sloh]

Is that supposed to be an attack?

I would be even happier if they were paying me that 350k to stay at home and spend more time with my family.

Based.

 

[DrMetal]

Nothing against these specialties by the way, but as @DrMetal said, we need to stop the charade.

Guys guys, let's not fight. Let's get back to bashing the real charlatans, Neurologists.

 

[Drrrrrr. Celty]

Awww c'mon, what fun would SDN be then? It's fun ragging on my 2 most hated specialties (Neuro and Emergency medicine)

Here's the thing: we all know Neurology is not an effective in-patient service, really. We also know this about Rheum and Endocrine, hence most community hospitals don't have a staff endocrine or rheum for inpatient consults (academic ones do). Which is fine most times, we get a patient through their DKA or Lupus flare, they follow up with their outpatient Rheum or Endocrine, and this is where they get helped the most by those specialists (in the outpatient setting).

Rheum and Endocrine will admit that much. And the hospital doesn't have a mando rule to consult Endocrine on every DKA, or Rheum for every lupus flare admission.

But for some reasons, Neurologist wont admit how useless they are in the inpatient setting, and hospitals continue to require neuro consults for every weak TIA admission. Go figure.

As someone who hates inpatient endocrinology. It's not all DKA and DM. And I think most hospitals need a phone line to an affiliated endocrinology service that can review labs and notes.

Most medicine trained folks don't know how to prescribe methimazole, dose iv levothyroxine, taper steroids, or interpret endocrinological labs. Also pumps.

Rheum stuff is a bit more rare. But a lot of endocrinology is common bread and butter stuff that occurs often even in community hospitals and are mismanaged. Endocrinology is pretty often a dark zone for a lot of doctors and they aren't good at it.

 

[Drrrrrr. Celty]

There is a lot charade in medicine.

Somewhere I believe you mentioned ED shouldn't (did not) have to be a specialty. I kind of agree with you on that,

Let me vent about the other charades.

Let's pretend that an 8-yr degree is necessary to become a doctor. At best, that thing should be 2 yrs prereqs after HS and 3-yr med school (at worst, maybe 6 yrs total)

First, let's stop pretending that IM docs are well trained to be outpatient PCP when there are IM programs out there w/ primary care tract.

Let's pretend that CCM is not IM+procedures

Let's not pretend that 2-yr of endocrinology fellowship is not a charade when 75%-85% of their panel are patients w/ DM2, hypo/hyperthyroidism.

I suspect if you saw a stable patient with PCOS or someone who is currently pregnant you would actively have palpitations, inpatient boy.

Endocrinology is incredibly complicated. And yes, common things are common. Cardiology is the same it's 80% heart failure, benign arrhythmia, and hypertension. Pulm is 80% asthma and copd. etc. What's the rest of the 20%? The stuff you spend 2 years of fellowship learning how to do well because it honestly is really hard. Like I'm in my second year of fellowship and I can tell you that I still get plenty of complicated patient that don't respond to first line medications, complicated adrenal imaging, pituitary patients, and syndromic patients that honestly I've seen once in all of training.

 

[Drrrrrr. Celty]

Yeah… that “month” really was 2-3 weeks since all the residents take their vacation time on electives and are generally on jeopardy/ back up call and get called in … that’s like the commercial for staying at a holiday inn giving you expertise…

not an attack… just tired of your Dunning Kruger showing… you don’t know what you are talking about yet you constantly pipe up…you’re been like this since you first started posting as a noob hospitalist fresh out of residency… thought you would mature as you gained experience…🤷🏽‍♀️…you’re kinda like a mid level with this…and you know how annoying and tiring that is…

This is the guy who will miss 10 primary hyperpara pts because who cares about a calcium of 10.4, follow up outpatient. Not currently fractured.

 

[NewYorkDoctors]

lost in all this is that it's probably not appropriate to bash an entire specialty / subspecialty due to poor experiences with a few other physicians of the respective specialties / subspecialties.

there are plenty of ****tty doctors out there regardless of specialty/subspecialty.

I have found that the "most helpful" ones are the ones who "take ownership of their disease process no matter how silly, annoying, or tedious said case is."

 

[dozitgetchahi]

lost in all this is that it's probably not appropriate to bash an entire specialty / subspecialty due to poor experiences with a few other physicians of the respective specialties / subspecialties.

there are plenty of ****tty doctors out there regardless of specialty/subspecialty.

I have found that the "most helpful" ones are the ones who "take ownership of their disease process no matter how silly, annoying, or tedious said case is."

This is true.

However, I have noticed this issue with neurology across 4 different states, urban/rural settings, academia and community practices (although academics seem to be slightly better). When you see this happen over and over again, you start asking questions. I’m not sure if it’s a culture issue, a training issue or whatever, but it’s there.

 

[Drrrrrr. Celty]

This is true.

However, I have noticed this issue with neurology across 4 different states, urban/rural settings, academia and community practices (although academics seem to be slightly better). When you see this happen over and over again, you start asking questions. I’m not sure if it’s a culture issue, a training issue or whatever, but it’s there.

I can't say I've run into too much of a major problem with my neurologists. They seem to be willing to worth with me on what I need.

I will say that at least in my experience Psychiatry is essentially useless in the hospital. Very little help. And I have never seen the value in a CL psych consult other than to have a formal blessing of what we all already know or for medicolegal reasons.

 

[NewYorkDoctors]

This is true.

However, I have noticed this issue with neurology across 4 different states, urban/rural settings, academia and community practices (although academics seem to be slightly better). When you see this happen over and over again, you start asking questions. I’m not sure if it’s a culture issue, a training issue or whatever, but it’s there.

im playing devils advocate here (I do not know any neurologists personally)

maybe it's because they hate delirium/dementia as much as we Internal Medicine trained physicians do?
or if its not something with defined treatments like MS, cerebral aneurysm, myelitis/myelopathy, brachial plexus lesions, etc whatever then they are as lost as we are?

I remember doing that rotation with the private practice neurology group (many of which graduated from top neurology residencies like columbia mt sinai etc) in IM residency that a common chief complaint was "numbness." the neurology attending would say "nope your neurological exam, MRI and EMG are fine. I cannot do anything for numbness for you. Would you like some Vitamin B complex?"


"yes I would like some placebo. thanks."



anyway in my residency training years ago, house neurology was so bad (mainly slow, unresponsive and "unhelpful" to move the patient along the admission) that aforementioned private group would be consulted all the time. They appreciated the business. They also asked me "why do you all consult us all the time?" "because you are faster, more receptive, and more helpful even with the 'crap neuro cases'." (in retrospect it's because it's an easy consult that pays them)

 

[greatnt249]

I honestly probably wouldn't mind the "routine" consults I get where I know the management is tested for on general IM boards if the referring party at least acknowledged "yeah I know it seems like a silly consult." At least then I know where the expectations lie with the referring personnel and helps me have a more productive discussion with the patient. Instead, many times I wonder if I'm in some Twilight Zone episode where I feel like I'm being "sold" a patient for an urgent evaluation for a condition that is neither urgent nor complicated to manage as a generalist (at least not on chart review) because my specialty's organ is "scary" to deal with, and I'm left with trying to figure out how to satisfy both the referring doc/NP's expectations as well as tamper down the patient's resultant anxiety as a result without seeming dismissive.

 

[Splenda88]

Yeah… that “month” really was 2-3 weeks since all the residents take their vacation time on electives and are generally on jeopardy/ back up call and get called in … that’s like the commercial for staying at a holiday inn giving you expertise…

not an attack… just tired of your Dunning Kruger showing… you don’t know what you are talking about yet you constantly pipe up…you’re been like this since you first started posting as a noob hospitalist fresh out of residency… thought you would mature as you gained experience…🤷🏽‍♀️…you’re kinda like a mid level with this…and you know how annoying and tiring that is…

You still have not answered the question.

What percentage of your panel is DM/hypo/hyperthyroidism?

Nothing against your specialty. I like calling a spade a spade.

 

[Splenda88]

Guys guys, let's not fight. Let's get back to bashing the real charlatans, Neurologists.

Why such contempt toward neurologists?

 

[Splenda88]

I suspect if you saw a stable patient with PCOS or someone who is currently pregnant you would actively have palpitations, inpatient boy.

Endocrinology is incredibly complicated. And yes, common things are common. Cardiology is the same it's 80% heart failure, benign arrhythmia, and hypertension. Pulm is 80% asthma and copd. etc. What's the rest of the 20%? The stuff you spend 2 years of fellowship learning how to do well because it honestly is really hard. Like I'm in my second year of fellowship and I can tell you that I still get plenty of complicated patient that don't respond to first line medications, complicated adrenal imaging, pituitary patients, and syndromic patients that honestly I've seen once in all of training.

I beg to differ on your comparison of endo with cardio/GI/pulm

I guess endo is as complex as nephrology for both of them to require the same # of years. By the way, there are a couple 3-yr endo programs in the country. Seriously!

I guess hospice/palliative medicine will soon be a 2-yr program as well.

Will we ever start questioning the system?

Why restricting FM residents to get into these fellowship? Are they telling me an FM doc can not become a good cardiologist/endocrinolist etc.

3-yr EM vs. 4-yr EM. Lol

Should we spend 10+ yrs in residency/fellowship to see all pathologies there is in our respective specialty?

 

[Drrrrrr. Celty]

I beg to differ on your comparison of endo with cardio/GI/pulm

I guess endo is as complex as nephrology for both of them to require the same # of years. By the way, there are a couple 3-yr endo programs in the country. Seriously!

I guess hospice/palliative medicine will soon be a 2-yr program as well.

Will we ever start questioning the system?

3 year endo programs are research based. Ex. NIH. They spend that time essentially earning a PhD.

Oh I did a rotation in all of those for one month in residency. So I absolutely know what I'm talking about .

I am finishing Endocrinology fellowship and I can tell you that I'll be learning easily for the next 5 years after fellowship on a lot of topics that I am not entirely prepared to deal with. Endocrinology is not some weird diabetology fellowship with thyroid sprinkled in. Endocrinological diseases are incredibly diverse and complicated.

As a hospitalist you're not going to be involved in the care of most endocrine patients and as such your entire perspective is skewed. You're not involved in pituitary service patients, you don't see apoplexies, you don't see macroprolactinomas that are not responsive to therapy or surgery, thyroid cancers that spread to lungs, brain, bone, you don't see cushings patients who have break through PCP pneumonia despite bactrim prophylaxis, you don't see amiodarone induced thyrotoxicosis that require plasmapharesis as they aren't responding to 2nd and 3rd line agents, and you're not making the decision on interpreting laboratories based on complex drug/binding globulins/ etc.

Just because I'm not sticking a scope up someone's ass doesn't make my field any less important.

 

[Drrrrrr. Celty]

You still have not answered the question.

What percentage of your panel is DM/hypo/hyperthyroidism?

Nothing against your specialty. I like calling a spade a spade.

Most general outpatient endocrinology is 50% DM. 50% parathyroid, osteoporosis, adrenal nodules/ adrenal neoplasia, hyperaldosteronism, thyroid cancer, hypogonadism, lipid disorders, genetic syndromes, pcos/fertility, and pituitary diseases, thyroid and thyroid cancers. Thyroid likely occupies around 20% of that second half.

 

[Drrrrrr. Celty]

I beg to differ on your comparison of endo with cardio/GI/pulm

I guess endo is as complex as nephrology for both of them to require the same # of years. By the way, there are a couple 3-yr endo programs in the country. Seriously!

I guess hospice/palliative medicine will soon be a 2-yr program as well.

Will we ever start questioning the system?

Why restricting FM residents to get into these fellowship? Are they telling me an FM doc can not become a good cardiologist/endocrinolist etc.

3-yr EM vs. 4-yr EM. Lol

Should we spend 10+ yrs in residency/fellowship to see all pathologies there is in our respective specialty?

FM into IM subspecialties is a different topic entirely. That has a lot to do with ABIM more likely than anything. You can't do Endocrinology without being ABIM or AOBIM certified for example.

Do I think we should? Sure. I can't see the harm, especially on a case by case basis.

EM probably needs to go 4 years to save itself from oversaturation. I don't know how EM is supposed to be done in 3 years. You're spread thin, far more than any other specialty.

And no. We don't. It's impossible to see everything. But knowing a framework of how to approach it reasonable? That's your bang for the buck.

 

[Splenda88]

3 year endo programs are research based. Ex. NIH. They spend that time essentially earning a PhD.

As a hospitalist you're not going to be involved in the care of most endocrine patients and as such your entire perspective is skewed. You're not involved in pituitary service patients, you don't see apoplexies, you don't see macroprolactinomas that are not responsive to therapy or surgery, thyroid cancers that spread to lungs, brain, bone, you don't see cushings patients who have break through PCP pneumonia despite bactrim prophylaxis, you don't see amiodarone induced thyrotoxicosis that require plasmapharesis as they aren't responding to 2nd and 3rd line agents, and you're not making the decision on interpreting laboratories based on complex drug/binding globulins/ etc.

Just because I'm not sticking a scope up someone's ass doesn't make my field any less important.

Seen those highlighted in residency.

I did not say your speciality is NOT important, but I question why one needs 2-yr fellowship to become an endocrinologist when you admit close to 90% of what you see can be managed by a good FM doc (not IM).

 

[Splenda88]

FM into IM subspecialties is a different topic entirely. That has a lot to do with ABIM more likely than anything. You can't do Endocrinology without being ABIM or AOBIM certified for example.

Do I think we should? Sure. I can't see the harm, especially on a case by case basis.

EM probably needs to go 4 years to save itself from oversaturation. I don't know how EM is supposed to be done in 3 years. You're spread thin, far more than any other specialty.

And no. We don't. It's impossible to see everything. But knowing a framework of how to approach it reasonable? That's your bang for the buck.

Lol... EM should have never been a specialty. Even EM docs in the EM forum agree.

EM is FM + procedures

 

[The kitchen sink]

This thread is incredibly entertaining…

I don’t have anything useful to add except that medicine is its own worst enemy and theres no stopping the greed

 

[The kitchen sink]

Lol... EM should have never been a specialty. Even EM docs in the EM forum agree.

what is the alternative that is proposed for pts in the acute setting?

Internists, peds, surgeons and obgyn all rotating thru ERs and triaging their own cases?

 

[Splenda88]

what is the alternative that is proposed for pts in the acute setting?

Internists, peds, surgeons and obgyn all rotating thru ERs and triaging their own cases?

You create a 1-yr fellowship for FM docs.

It would be nice to see mortality stats due to urgent medical issues when EM was not a speciality 30+ yrs ago.

 

[Drrrrrr. Celty]

Seen those highlighted in residency.

I did not say your speciality is NOT important, but I question why one needs 2-yr fellowship to become an endocrinologist when you admit close to 90% of what you see can be managed by a good FM doc (not IM).

Because a good IM trained physician and FM trained physician cannot do what I do well.

Most docs cannot even manage basic DM well. This not to mention that most docs cannot grasp how to manage a lot of endo dz because they lack experience in it.


The short answer is nothing is stopping you from doing most endocrinology as a medicine only trained person. Nothing stopping you from doing 90% of pulmonology as a medicine trained person either. You do fellowship so you can only deal with it, and deal with it well.

 

[Splenda88]

Because a good IM trained physician and FM trained physician cannot do what I do well.

Hence 1-yr fellowship.

I remember what our GME president who is a med-peds doc said.

She said if after 2 yrs of residency IM/FM residency that you are not competent, she has hard time believing a 3-yr will make you competent and she said that is based on her experience.

She went even further by saying if she were the one designing residency, she would structure IM/FM/Peds to be 2 yrs because she believe after 2-yrs you are competent to practice and know when "you are in over your head". She said people learn a lot more in their 1st year of attending-hood than what they learned in their 3rd yr of residency.

I guess some people in academia get it.

 

[Splenda88]

Mod should close this thread. I am done venting

 

[Drrrrrr. Celty]

Hence 1-yr fellowship.

I remember what our GME president who is a med-peds doc said.

She said if after 2 yrs of residency IM/FM residency that you are not competent, she has hard time believing a 3-yr will make you competent and she said that is based on her experience.

She went even further by saying if she were the one designing residency, she would structure IM/FM/Peds to be 2 yrs because she believe after 2-yrs you are competent to practice and know when "you are in over your head". She said people learn a lot more in their 1st year of attending-hood than what they learned in their 3rd yr of residency.

I guess some people in academia get it.

I think 2 years of residency in IM if you intend to do fellowship as a fast tracking is probably entirely fine.
I would not be okay with my fellowship being 1 year. When I started this year I was not comfortable with a lot of complicated and even basic endocrine conditions.

 

[NewYorkDoctors]

Seen those highlighted in residency.

I did not say your speciality is NOT important, but I question why one needs 2-yr fellowship to become an endocrinologist when you admit close to 90% of what you see can be managed by a good FM doc (not IM).

im not taking anyone's sides here

but as someone who does PCP (admittedly not by myself anymore. I oversee an NP for most cases. though I will still see the more complex IM cases as well), MICU (far less than I use to), primarily outpatient and inpatient pulmonary (thankfully most of my patients dont get admitted so I avoid the hospital as much as possible), and some nephrology (i am very selective with my cases. I do not see noncompliant DM/HTN/CKD5. I have a small panel of lupus nephritis, membranous, ADPKD, FSGS, IgA, etc) ... I have to say that I feel totally confident handling most things that come my way. If it is in MKSAP, im handling it myself. I know the local GI hates IBS anyway and the local neuro (see what I did there) never really takes ownership of the migraine patient I send over there anyway.

but what I will say is it is ****ing exhausting doing it all myself. from all the talking and explaining, talking to families, getting prior authorizations, pursuing followups, etc... but hey I try to "do it all myself" as much as possible as I know I can rely on myself.
but it's diminishing returns as billing a higher level does not pay as much as just seeing another 99213.

the true value of having a team based approach is to dissipate the workload so one can focus on another patient who needs you as well.


the role of the internist / hospitalist is not to fix everyone's problems single handedly. it's to see as many people who need you as you can possibly get to and treat their primary/acute and "low hanging fruit issues" while reaching as many of them as possible. however some individuals take this to the extreme and just do the same level of work as a midlevel and panconsult for MKSAP level stuff. well hey I like an easy referral as much as the next doc. so thanks for the softball down the middle of the plate.

 

[DrMetal]

what is the alternative that is proposed for pts in the acute setting?

Internists, peds, surgeons and obgyn all rotating thru ERs and triaging their own cases?

This was exactly the case pre-1985. Someone felt the need to create EM, a specialty loosely based on an acuity level ('emergency'), instead of a specific pathology or age-group. It was a bad idea, as we can see now (nobody's applying to it, and its getting flooded by mid-levels).

 

[DrMetal]

Did not mean this to become a Rheum vs Endocrine vs GIM fight.

I think everyone would agree that Rheum and Endocrine are primarily outpatient services. Bless them, they're worth their weight in gold if they can keep patients out of the hospital.

I appreciate that they DO NOT tout themselves as an essential inpatient service, requiring they be consulted on every DKA, every lupus flare, thus increase hospital costs and increasing length of stay.

Neurologists don't have this insight. They honestly think they're valuable in the inpatient setting, everyone knows they're not. Yet, they've built themselves into every jackss TIA/stroke protocol, and we have to call them, and can't discharge until 3 days later when they finally see the patient via their BS tele-neurology service.

Why such contempt toward neurologists?

Because I have anger issues.

 

[NewYorkDoctors]

This was exactly the case pre-1985. Someone felt the need to create EM, a specialty loosely based on an acuity level ('emergency'), instead of a specific pathology or age-group. It was a bad idea, as we can see now (nobody's applying to it, and its getting flooded by mid-levels).

thsi got me interested and I pubmed' a nice historical review about EM

The modern history of emergency medicine essentially began in the 1960s. In 1960, there was no emergency medicine as a defined academic specialty. Typical hospital emergency rooms staffing patterns used resident, intern, other hospital staff physicians, or rotating on-call duty of all specialties including those such as psychiatry and even pathology. There was neither coordination of hospital care nor organized pre-hospital care. At least half of all ambulance services run by morticians or funeral directors because they had vehicles that could transport people horizontally, often using untrained staff. There were no national coordinating organizations.

nice I'd like to see that

Emergency medicine in the United States: a systemic review

Fifty years of our history in developing and advancing emergency medicine into an independent medical specialty will surely provide emergency medicine colleagues from all over the world with valuable suggestions and guidance.DATA SOURCES: This systemic ...

www.ncbi.nlm.nih.gov

Did not mean this to become a Rheum vs Endocrine vs GIM fight.

I think everyone would agree that Rheum and Endocrine are primarily outpatient services. Bless them, they're worth their weight in gold if they can keep patients out of the hospital.

I appreciate that they DO NOT tout themselves as an essential inpatient service, requiring they be consulted on every DKA, every lupus flare, thus increase hospital costs and increasing length of stay.

Neurologists don't have this insight. They honestly think they're valuable in the inpatient setting, everyone knows they're not. Yet, they've built themselves into every jackss TIA/stroke protocol, and we have to call them, and can't discharge until 3 days later when they finally see the patient via their BS tele-neurology service.



Because I have anger issues.

but isnt this some "core measure" dictated by CMS and joint commission?
wouldn't this be a case of "don't hate the player, hate the game?"

 

[DrMetal]

Emergency medicine in the United States: a systemic review

Fifty years of our history in developing and advancing emergency medicine into an independent medical specialty will surely provide emergency medicine colleagues from all over the world with valuable suggestions and guidance.DATA SOURCES: This systemic ...

www.ncbi.nlm.nih.gov

A great article written by emergency physicians. This is like me, touting myself as the next Eddie Van Halen on my YouTube music channel.

I don't care about pre-hospital logistics (ambulance traffic, coordination, comms, etc). Physicians don't have to be involved in that, per se.

The old timers I talk to said everything worked out fine. Everyone spent their 1-2 weeks/year in the ER, they got it done.

Whatever the case, there's evidently a lot of problems in EM. You know that's true when they can't fill their residency spots.

Unfilled in emergency medicine: An analysis of the 2022 and 2023 Match by program accreditation, ownership, and geography - PubMed

EM residency programs accredited within the past 5 years or those with a primary clinical site under for-profit ownership had a greater risk of not filling all positions within the past two Match cycles.

pubmed.ncbi.nlm.nih.gov

but isnt this some "core measure" dictated by CMS and joint commission?
wouldn't this be a case of "don't hate the player, hate the game?"

You're probably right. No, I prefer to hate the player. I'm the Draymond Green of medicine.

 

[gutonc]

Mod should close this thread. I am done venting

We should, and will. In fact, I probably should have closed it much earlier.