Is IM really like this?

[Arkangeloid]

I'd fire them anyway. Screw pay for performance. I didn't go into medicine to bang my head against a wall. Find it on your heart to follow my recommendations or find another cardiologist

Heh

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[Instatewaiter]

This is a very tricky subject, but definitely pay is an important factor. I've had GI rotation and to be honest is was more painful than IM.

Yeah GI is pretty crappy

 

[DermViser]

This is very hospital culture dependent. Where I trained we would rarely consult.

In private practice you won't be complaining about those consults because it will be your lifeblood. I complain about the stupid consult for a mildly elevated troponin but that would be 200 dollars in my pocket for 30 minutes of work.

Also get off your high horse about derm. If it didn't pay so well, no one would go into derm. Essentially every derm guy is a sellout.

Bull**** Lets not front like there is some massive toolbox of meds you give. You and I both know it's a lie

Hypocritical coming from you, Mr. Cards. If Derm paid as much as primary care IM, I would still do it - without a doubt. I'm going into Pedi Derm - so the amount of procedures (i.e. skin biopsies, etc.) is much lower.

See my posts above - we have many more available modalities than just steroids, noob. Compare that to your cardiologist - pills and stents.

 

[Kahreek]

Yeah GI is pretty crappy

coincidently I've done more crap work when working in gen surg or IM, GI doesn't touch a bum unless they've got a scope.

 

[Instatewaiter]

Hypocritical coming from you, Mr. Cards. If Derm paid as much as primary care IM, I would still do it - without a doubt. I'm going into Pedi Derm - so the amount of procedures (i.e. skin biopsies, etc.) is much lower.

See my posts above - we have many more available modalities than just steroids.

Many more modalities? Like steroid creams and steroid injections and steroid ointments. Low potency steroids and medium potency steroids and high potency steroids?

Oh and topical antibiotics? I forgot about those.

Also yes cards makes money but at least you're doctoring. Quite frankly you don't really need to go to med school to be a derm; you could easily get the training you need in a derm apprenticeship without med school.

 

[Instatewaiter]

.

Also yes cards makes money but at least you're doctoring. Quite frankly you don't really need to go to med school to be a derm; you could easily get the training you need in a derm apprenticeship without med school.

When someone on an airplane stands up and says is there a doctor on the plane, what is the dermatologist going to stand up and say damn his rash is really bad. I don't know what to do about his chest pain but let's give him some topical steroids

 

[SouthernSurgeon]

When someone on an airplane stands up and says is there a doctor on the plane, what is the dermatologist going to stand up and say damn his rash is really bad. I don't know what to do about his chest pain but let's give him some topical steroids

I don't know about you, but I definitely picked my career based around a theoretical once in a lifetime emergent situation.

 

[The kitchen sink]

I don't know about you, but I definitely picked my career based around a theoretical once in a lifetime emergent situation.

Well thank god. I thought I was the only one.



/sarcasm

 

[Instatewaiter]

I don't know about you, but I definitely picked my career based around a theoretical once in a lifetime emergent situation.

You know I'm in cards right? I picked it because of the crazy emergent situations.

 

[DermViser]

Many more modalities? Like steroid creams and steroid injections and steroid ointments. Low potency steroids and medium potency steroids and high potency steroids?

Oh and topical antibiotics? I forgot about those.

Also yes cards makes money but at least you're doctoring. Quite frankly you don't really need to go to med school to be a derm; you could easily get the training you need in a derm apprenticeship without med school.

Like I said in my previous post to another noob, "No, try the many immunomodulators (that aren't steroids), phototherapy (UV light and lasers), biologics, retinoids, antibacterial/antifungal/antivirals, chemotherapeutic agents, etc. that come in oral/topical/injectable form." But please, continue to show your vast ignorance.

I understand those CMS reimbursement cuts make you a little angry, but get over it. It's not my problem you entered a specialty in which you can't actually SOLVE the patient's problem, just pill titration or curing a patient's stent deficiency.

 

[username456789]

Many more modalities? Like steroid creams and steroid injections and steroid ointments. Low potency steroids and medium potency steroids and high potency steroids?

Oh and topical antibiotics? I forgot about those.

Also yes cards makes money but at least you're doctoring. Quite frankly you don't really need to go to med school to be a derm; you could easily get the training you need in a derm apprenticeship without med school.

While DermViser is obviously being overly argumentative on several points, you're just intentionally being a *****. Unless you actually believe what you're saying, in which case you're just horribly naïve. I'm honestly not sure which one I prefer at this point.

 

[DermViser]

When someone on an airplane stands up and says is there a doctor on the plane, what is the dermatologist going to stand up and say damn his rash is really bad. I don't know what to do about his chest pain but let's give him some topical steroids

We get it, every specialist sucks except yours. Funny you could say the exact same thing about Radiology, PM&R, Pathology, Psychiatry, Radiation Oncology, etc. We get it, you guys are gods at "chest pain". It's any wonder Cardiology is hated by the rest of the IM dept. Unlike other divisions (maybe GI being the other - but even they aren't nearly as pompous as Cards), they think they own the dept.

 

[Priapism4tooLong]

Lol, this argument is funny. But lets all get serious, the only real speciality is Orthopedic Surgery, everything else is wanna-be orthos.

 

[DermViser]

Many more modalities? Like steroid creams and steroid injections and steroid ointments. Low potency steroids and medium potency steroids and high potency steroids?

Oh and topical antibiotics? I forgot about those.

Also yes cards makes money but at least you're doctoring. Quite frankly you don't really need to go to med school to be a derm; you could easily get the training you need in a derm apprenticeship without med school.

Doctoring = Pill titration and doing unnecessary procedures (even with no comparable decrease in mortality) http://www.kevinmd.com/blog/2010/07/mark-midei-failure-peer-review.html ----> hence why CMS is instituting huge cuts to Cardiology.

 

[GadRads]

DermViser, the IM docs are you hospital sound like *****s. I think they embody the worst of the IM stereotype which is basically a care coordinator who is the gatekeeper to specialists. This certainly is not how it's supposed to be and I think the trainees at your institution are really having a disservice done to them.

A competent IM doc should be able to handle most firstline diagnosis and treatment of many common conditions, derm included. If this isn't happening, I think it is largely institution/provider dependent

I wonder how much of this is due to the IM physician practicing defensive medicine, you know, "just to make sure I am not missing anything that could get me sued" aka failure to diagnose.

 

[DermViser]

I wonder how much of this is due to the IM physician practicing defensive medicine, you know, "just to make sure I am not missing anything that could get me sued" aka failure to diagnose.

You don't see General Surgeons at academic medical centers do this. They take FULL responsibility for the patient, and feel that they've let themselves down for consulting another service (i.e. Surgery consulting IM). They don't turf their management for another specialty to complete.

 

[VisionaryTics]

We get it, every specialist sucks except yours.

This is basically your entire SDN posting history. "Every specialty sucks but derm".

 

[Priapism4tooLong]

You guys are hating on derm so much its ridiculous, some of my friends are dermatologists and if it wasn't for them a lot of teenage girls would be really upset about their face. I give them props for helping them. Because remember, when you look bad on the outside, you feel bad on the inside.

 

[KnuxNole]

If I were to consult cardiology for CHF (in situations other than ones where I think they need a cath) or consult nephrology for an AKI (in situations other than where I think they need dialysis), they would laugh at me. I can't think of *any* situation in which case I'd consult endocrinology for diabetes on an inpatient basis. Inpatient endocrine consults are for things like panhypopituitarism or really really funny thyroid panels (i.e. not your typical hypo-/hyper-/sick eu-thyroid)

There are a few hospitalists at my institution who do act like that (consulting subspecialists at the smallest opportunity), but even they don't do something as ridiculous as consulting endocrine for inpatient diabetes management. I don't know where you trained, but you must have some crappy internists.

Really? It seems endo gets diabetic consults(mainly DKA) as the most common ones. I'm sure thyroid storms are legit though...had a cool case with that not too long ago. Same with nephro....AKI that doesn't get better after a day or so gets a demanded consult or get yelled at. For endo, I think at some places, they might be begging for work D:

 

[DermViser]

This is basically your entire SDN posting history. "Every specialty sucks but derm".

That may be your interpretation but, no, not really. See my comments on Radiology and Anesthesiology.

 

[Substance]

I admit I laughed. Mainly bc it's always funny to me how Internal Medicine believes it's still somehow revered and on the pedestal of the House of Medicine. I admit it gives me quite the high that no matter how smart IM docs are (and putting down Dermatology), when they see a skin condition on the wards in which they have not even the most basic clue about (even though there is a whole section in Harrisons - Ch. 51-56) , they always end up consulting Dermatology. Actions speak much louder than words.

By the way, Dermpath reports don't have treatment/management recommendations. They do however, describe the histology. Hope you like basic science.

To be fair to the IM docs, consulting other services acts as more of a hedge against future malpractice claims rather than, or in combination with, a true lack of understanding of simple conditions.

We all know how piss-poor derm tutelage is in medical school (its one of the secret back-room specialties, like ophtho and uro, so they don't really teach you anything about it other than it exists and that they can be consulted), and this probably extends into IM residency as well. Now, if I was some hospitalist whose life revolved around social-work, paper-work, and other types of non-value-added-"work" with the occasional med titration for CHF thrown in, I'd be pretty reluctant to make a call on even the most basic of conditions outside of the CHF/Afib/angina/dehydration/diabetes pentafecta lest that one thing I miss be transformed into a lawyer's new SLS.

The whole stress of hospitalist work has to do with an overeducated person doing menial work. Derm, rads, ophtho etc tend to avoid the majority of the paperwork and are paid well to do so. Paperwork is not reimbursed, so the fields that do the most of it are spending time doing things that add no value, relative to other specialties.

 

[DermViser]

You guys are hating on derm so much its ridiculous, some of my friends are dermatologists and if it wasn't for them a lot of teenage girls would be really upset about their face. I give them props for helping them. Because remember, when you look bad on the outside, you feel bad on the inside.

Coming from someone, such as yourself, who needs to see a urologist urgently.

And yet dermatology patients are one of THE MOST SATISFIED, when it comes to their dermatologists. But I guess this doesn't compare to the hordes of cardiology patients who verbally thank their Cardiologists, for helping them, oh wait...

 

[KnuxNole]

The thing about consults too, is the HUGE fear of things being way advanced beyond your scope of practice. it's a challenge to balance "Hmmm should I consult...?" vs. "Why didn't you call EARLIER? Generalists aren't meant to handle THIS!"

 

[DermViser]

To be fair to the IM docs, consulting other services acts as more of a hedge against future malpractice claims rather than, or in combination with, a true lack of understanding of simple conditions.

We all know how piss-poor derm tutelage is in medical school (its one of the secret back-room specialties, like ophtho and uro, so they don't really teach you anything about it other than it exists and that they can be consulted), and this probably extends into IM residency as well. Now, if I was some hospitalist whose life revolved around social-work, paper-work, and other types of non-value-added-"work" with the occasional med titration for CHF thrown in, I'd be pretty reluctant to make a call on even the most basic of conditions outside of the CHF/Afib/angina/dehydration/diabetes pentafecta lest that one thing I miss be transformed into a lawyer's new SLS.

The whole stress of hospitalist work has to do with an overeducated person doing menial work. Derm, rads, ophtho etc tend to avoid the majority of the paperwork and are paid well to do so. Paperwork is not reimbursed, so the fields that do the most of it are spending time doing things that add no value, relative to other specialties.

Yes, but then if that was the case, you don't see General Surgeons do they same thing that General IM does (to hedge against future malpractice claims), but they don't. Not nearly to the same extent that General IM does.

 

[Instatewaiter]

. It's not my problem you entered a specialty in which you can't actually SOLVE the patient's problem, just pill titration or curing a patient's stent deficiency.

STEMI. Cath lab. Problem fixed.

Arrhythmia. Ablation. Fixed

Severe AS. TAVR. Fixed

Heart block. Pacemaker. Fixed

 

[DermViser]

Really? It seems endo gets diabetic consults(mainly DKA) as the most common ones. I'm sure thyroid storms are legit though...had a cool case with that not too long ago. Same with nephro....AKI that doesn't get better after a day or so gets a demanded consult or get yelled at. For endo, I think at some places, they might be begging for work D:

Exactly.

 

[Siggy]

You don't see General Surgeons at academic medical centers do this. They take FULL responsibility for the patient, and feel that they've let themselves down for consulting another service (i.e. Surgery consulting IM). They don't turf their management for another specialty to complete.

Gen surg? Yes.

Ortho and neuro sx? The only good admit is the one they can turf to medicine.

 

[DermViser]

Gen surg? Yes.

Ortho and neuro sx? The only good admit is the one they can turf to medicine.

Maybe at a community hospital, but definitely not at a university academic program. That's why I'm comparing apples to apples, when it comes to reflexively getting consults: General IM vs. General Surgery.

 

[Substance]

Yes, but then if that was the case, you don't see General Surgeons do they same thing that General IM does (to hedge against future malpractice claims), but they don't. Not nearly to the same extent that General IM does.

I think they would if they didn't have gen IM to which they could turf patients.

 

[Priapism4tooLong]

Coming from someone, such as yourself, who needs to see a urologist urgently.

And yet dermatology patients are one of THE MOST SATISFIED, when it comes to their dermatologists. But I guess this doesn't compare to the hordes of cardiology patients who verbally thank their Cardiologists, for helping them, oh wait...

Lol how can you compare a derm patient with a cardio patient?. I have no hate on derm at all either. I do think it's important and that you need a medical education for it unlike the other guy who posted lol.


Edit: you know whose patients are the most unhappiest?? FORENSIC PATHOLOGISTS

 

[Siggy]

Maybe at a community hospital, but definitely not at a university academic program. That's why I'm comparing apples to apples, when it comes to reflexively getting consults: General IM vs. General Surgery.

I was on IM at a county academic hospital when we got a consult for a BGL of 160 on a chem 7. Neuro Sx rotation at the same place was, "Well, nothing else we can do... transfer to medicine." Granted, it's going to be different everywhere, but um... yea.

 

[Siggy]

Edit: you know whose patients are the most unhappiest?? FORENSIC PATHOLOGISTS

Have you ever heard of one of their patients complaining?

 

[DermViser]

I think they would if they didn't have gen IM to which they could turf patients.

If a patient has a medical issue and not a surgical issue, it's natural for Surgery to send the patient to IM. Just like if a patient has a surgical issue and not a medical issue, it's natural for IM to send the patient to Surgery. That isn't "turfing".

We're talking about consultation WITHIN a specialty.

 

[Priapism4tooLong]

Have you ever heard of one of their patient's complaining?

Haha good point

 

[DermViser]

I was on IM at a county academic hospital when we got a consult for a BGL of 160 on a chem 7. Neuro Sx rotation at the same place was, "Well, nothing else we can do... transfer to medicine." Granted, it's going to be different everywhere, but um... yea.

What neurosurgical intervention do you expect a neurosurgeon to do for a blood glucose of 160?

 

[DermViser]

Lol how can you compare a derm patient with a cardio patient?. I have no hate on derm at all either. I do think it's important and that you need a medical education for it unlike the other guy who posted lol.

Edit: you know whose patients are the most unhappiest?? FORENSIC PATHOLOGISTS

We're talking about patient satisfaction here, which unless you're an emotionless drone, does contribute to physician satisfaction. This will especially be more the case when doctors' salaries are tied to P4P, as mandated by healthcare reform - i.e. Press-Ganey patient surveys of Emergency Medicine physicians, when it comes to reimbursement.

Forensic Pathologists come in AFTER the patient is already dead, we're talking about living patients here.

 

[Substance]

If a patient has a medical issue and not a surgical issue, it's natural for Surgery to send the patient to IM. Just like if a patient has a surgical issue and not a medical issue, it's natural for IM to send the patient to Surgery. That isn't "turfing".

We're talking about consultation WITHIN a specialty.

Gen surgeons are consultant specialists who operate within a very limited scope, namely abdominal/GI surgery. A few here and there do skins and thyroids but for the most part it's subdiaphragmatic GI tract. If any surgical issue comes up that is outside of their scope, they do the right thing and consult out. I've never seen them consult another surgical service for a GI issue because GI issues are their specialty.

With IM its different. The whole concept of "generalist" is blurry and in my opinion is irrelevant in modern medicine. Where does the line dividing what a specialist must deal with vs what a generalist can manage start and end? Some people, including lawyers, say it starts at the specialist. Some hospitalists are so burned out on the menial garbage they deal with that anything outside of that menial garbage gets consulted out.

This is more of a system problem than a problem between specialties. It is unfortunate that, as a profession, we cannot see beyond our own experiences. This is why things are so backwards and Luddite in medicine and why our reimbursements, public image and autonomy are getting killed. We blame each other for the problems instead of taking control and fixing the system.

 

[Priapism4tooLong]

We're talking about patient satisfaction here, which unless you're an emotionless drone, does contribute to physician satisfaction. This will especially be more the case when doctors' salaries are tied to P4P, as mandated by healthcare reform - i.e. Press-Ganey patient surveys of Emergency Medicine physicians, when it comes to reimbursement.

Forensic Pathologists come in AFTER the patient is already dead, we're talking about living patients here.

Patient satisfaction? Ok let's take a derm patient, usually younger whose dermatological problem (eczema, psoriasis, acne, whatever) normally goes away. Ofcourse they are going to be happy.

Now a cardio patient older grumpier, wayyyy more problems, but you treat him for MI, afib or whatever, they are more annoyed about being in a hospital and normally are recovering from something serious. They aren't going to be as happy.

I just saw a 34 year old female with no prior history with a dissection that went from her carotids down to her femoral. You think she's going to be happy? She was in surgery for near 12 hours I think. But it's ridiculous to compare patient satisfaction when most general people know no medicine.

 

[Instatewaiter]

And yet dermatology patients are one of THE MOST SATISFIED, when it comes to their dermatologists. But I guess this doesn't compare to the hordes of cardiology patients who verbally thank their Cardiologists, for helping them, oh wait...

Yup my lifesaving care in the CICU could never, ever could compare to your rash treatment. I'm sure the tears just flow after the rash treatment. Im sure it goes something like this, "derviser than you so much for curing my acne. And that rash you cleared up. My god my life would have been over if not for your medium potency steroids. "

What a joke.

 

[DermViser]

Patient satisfaction? Ok let's take a derm patient, usually younger whose dermatological problem (eczema, psoriasis, acne, whatever) normally goes away. Ofcourse they are going to be happy.

Now a cardio patient older grumpier, wayyyy more problems, but you treat him for MI, afib or whatever, they are more annoyed about being in a hospital and normally are recovering from something serious. They aren't going to be as happy.

I just saw a 34 year old female with no prior history with a dissection that went from her carotids down to her femoral. You think she's going to be happy? She was in surgery for near 12 hours I think. But it's ridiculous to compare patient satisfaction when most general people know no medicine.

Tell that to the govt. and third party payers who are instituting this as part of reimbursement schemes in a goal to achieve more "value". I didn't say it's fair. It does however, contribute a great deal to physician satisfaction. Why? Bc most physicians truly do want to help people. Not one doctor doesn't feel good when a patient is thankful to them. We feel great satisfaction when a patient is thankful for our services.

 

[Substance]

Patient satisfaction is a meaningless metric. Why we give it even a smidgen of our attention escapes me.

 

[Priapism4tooLong]

Yup my lifesaving care in the CICU could never, ever could compare to your rash treatment. I'm sure the tears just flow after the rash treatment. Im sure it goes something like this, "derviser than you so much for curing my acne. And that rash you cleared up. My god my life would have been over if not for your medium potency steroids. "

What a joke.

How dare you, dermviser only uses the highest of potencies

 

[Winged Scapula]

The culture of consults varies widely with environment and who's running the ship. In my residency, consults were few and far between; we took pride in not consulting others unless there really was a new problem which we could not handle (e.g., Nephro for dialysis; Ortho for trauma cases, etc).

Now out in PP, I see some of the ridiculous consults going on. A friend, colorectal surgeon taking GS call, was consulted by IM on a 20 year old male they'd admitted with abdo pain (not sure how he got to IM first) who did well after a lap procedure for appendicitis; healthy kid, no co-morbidities. She rounds on him POD #1 to see that IM had consulted ID. Different culture.

 

[Priapism4tooLong]

Tell that to the govt. and third party payers who are instituting this as part of reimbursement schemes in a goal to achieve more "value". I didn't say it's fair. It does however, contribute a great deal to physician satisfaction. Why? Bc most physicians truly do want to help people. Not one doctor doesn't feel good when a patient is thankful to them. We feel great satisfaction when a patient is thankful for our services.

Of course that's true. Everyone feels great full. Derm is a great speciality , good lifestyle and money. And you are right when you say lots of docs don't know basic skin problems. I've witnessed it as well.

 

[DermViser]

Yup my lifesaving care in the CICU could never, ever could compare to your rash treatment. I'm sure the tears just flow after the rash treatment. Im sure it goes something like this, "derviser than you so much for curing my acne. And that rash you cleared up. My god my life would have been over if not for your medium potency steroids. "

What a joke.

Funny how you parse your words carefully. You say, "my lifesaving care in the CICU could never, ever could compare to your rash treatment." Yes, I am sure your CICU patients are always thanking you profusely for saving their life.

You're either completely naive or purposefully obtuse if 1) you believe that the entire extent of the diseases we treat, esp. in an academic medical center, is acne and 2) that the only drug we use is steroids and topical antibiotics (when I listed the many other modalities).

 

[username456789]

There was a great article in JAMA recently about how higher patient satisfaction (in a hospital setting) is associated with worse patient outcomes.

[as it turns out, maybe patients don't actually know what's best for them.]

 

[DermViser]

How dare you, dermviser only uses the highest of potencies

Only if I want their skin to permanently atrophy.

 

[Priapism4tooLong]

Who are you guys gonna call when TEN, SJS, or necrotizing fasciitis comes around?!??

 

[username456789]

Who are you guys gonna call when TEN, SJS, or necrotizing fasciitis comes around?!??

The burn unit/gen surgery.

 

[alpinism]

Many more modalities? Like steroid creams and steroid injections and steroid ointments. Low potency steroids and medium potency steroids and high potency steroids?

Oh and topical antibiotics? I forgot about those.

Also yes cards makes money but at least you're doctoring. Quite frankly you don't really need to go to med school to be a derm; you could easily get the training you need in a derm apprenticeship without med school.

Don't forget ultra high potency steroids.

Also,