Is IM really like this?

[DermViser]

So your point is "close enough"?

No my point is classifying a scorpion as a bug is a HUGE understatement.

vs.

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[Winged Scapula]

Gotta step in for a moment to defend my ortho brethren.

Its undeniable that ortho consults/turfs to IM with an almost embarrassing frequency, but it's not because orthopaedist immediately become mouth-breathers once they start PGY2. Unlike gen surg, ortho doesn't mess with any vital organs and therefore a lot of the IM-type floor work that gen surg retains competency in dealing with is lost early in ortho residency.

Another thing to consider is that, on average, orthopaedic residents deal with a far larger operative volume than gen surg residents. Because there's such a large volume to be dealt with in the OR, the field has essentially given up everything outside of their immediate scope of practice to ensure all the work gets done and residents are appropriately trained by the end of residency. It's not at all uncommon to see stand-alone orthopaedic hospitals at large academic institutions where there are dedicated IM hospitalists to manage things like HTN, DM, AKI, etc...

Just look at the median operative case numbers from the ACGME for residents graduating in 2013:
Ortho: 2223
G Surg: 971

Don't get me wrong, G Surg is indeed a badass field that can handle the sickest patients in the hospital, but their ability to handle IM issues is largely due to the goals of their training and their frequent need to tinker with vital organs.

Just curious: does your board come down on you for doing *too many* cases?

Back in the day we had to <ahem> "adjust" our case logs if they were too high so I always take average numbers with a grain of salt.

 

[DermViser]

Gotta step in for a moment to defend my ortho brethren.

Its undeniable that ortho consults/turfs to IM with an almost embarrassing frequency, but it's not because orthopaedist immediately become mouth-breathers once they start PGY2. Unlike gen surg, ortho doesn't mess with any vital organs and therefore a lot of the IM-type floor work that gen surg retains competency in dealing with is lost early in ortho residency.

Another thing to consider is that, on average, orthopaedic residents deal with a far larger operative volume than gen surg residents. Because there's such a large volume to be dealt with in the OR, the field has essentially given up everything outside of their immediate scope of practice to ensure all the work gets done and residents are appropriately trained by the end of residency. It's not at all uncommon to see stand-alone orthopaedic hospitals at large academic institutions where there are dedicated IM hospitalists to manage things like HTN, DM, AKI, etc...

Very surprised that Ortho hasn't always been a competitive specialty, just based on the sheer volume of cases they do, esp. if you can build a standalone orthopedic hospital. In this scenario, I think it works very well as far as what ortho surgeons do and what hospitalists do.

 

[WhippleWhileWeWork]

So, it's not just pre-allo...

 

[Priapism4tooLong]

At my institution DKA's don't get endocrinology consults, otherwise our endocrinologist would be doing nothing else. Not even the complicated cases like DKA in the setting of ESRD. It's a pretty protocoled admission that is bread and butter medicine, and any of our residents should be able to handle it. After taking care of a half dozen of them in my first few months of intern year (none of which we even considered an endocrine consult for), I can probably write admission orders for DKA in my sleep. Hell, we admit most DKA straight to the floor on an insulin drip. Not to the stepdown unit (or the ICU) unless they have some funny comorbidites (like the ESRD).

Thyroid storm is a legitimate reason to consult endocrine though. For sure.

Regarding the AKI, it depends. If they don't meet criteria for emergent dialysis, we don't usually consult nephro unless we're really stumped. Like, we've done the full workup with blood and urine labs+imaging that we can think of and it's all a mixed picture and we're wondering if we should get a renal biopsy stumped. That or if they simply aren't getting better after several days of appropriate treatment for whatever etiology we've figured it out to be. Obviously, if we think they meet criteria for inpatient dialysis, we consult nephro right away, simply because we can't order that.

Lol, endocrinologists would not be happy people if they got a consult for every DKA.

 

[DermViser]

Lol, endocrinologists would not be happy people if they got a consult for every DKA.

For some hospitals it's part of policy, to consult Endocrinology, esp. when you're starting and continuing insulin drips.

 

[Priapism4tooLong]

For some hospitals it's part of policy, to consult Endocrinology, esp. when you're starting and continuing insulin drips.

Interesting, didn't know that

Edit: My institution seems the same as raryn, we rarely consult for DKA

 

[Priapism4tooLong]

For some hospitals it's part of policy, to consult Endocrinology, esp. when you're starting and continuing insulin drips.

You sure they just aren't telling the derm guys that to make them feel better?

 

[DermViser]

You sure they just aren't telling the derm guys that to make them feel better?

Yeah, that must be it.

 

[Anastomoses]

You sure they just aren't telling the derm guys that to make them feel better?

You're cheeky.

 

[DermViser]

You're cheeky.

Or more ballsy, since he has priapism4tooLong.

 

[evilbooyaa]

What a (terrible) thread.

As a real response to the OP - Reimbursement will hinge on patient compliance if you are an IM doc. That is the future and something you have to deal with. Re-admissions within a certain time period will be penalized by the ACA. Unless something changes in the ACA, this will be something you have to deal with. You can't fire every non-compliant patient you have. Unfortunately a large portion of IM is 'delaying the inevitable', especially in non-compliant patients who will continue to flare their CHF from a cheeseburger or go into DKA from skipping their insulin dose.

On a side note (and a rant) -

In this thread we have an IM who thinks Derm does literally nothing beyond steroids and antibiotics/fungals (when they deal with more serious conditions using varying treatments on a somewhat regular basis, although not as often as more basic rashes), and a Derm who thinks IM cannot work up a basic patient without consulting the specialty or specialties that are having issues, and thinks Cards does nothing besides pills and stents. Both of these thought processes are incorrect, but neither one will admit as such (or at least admit that it MAY be unique to their shop and not how things work across the entire nation).

DermViser - Derm patients will generally be happier, because they are generally LESS ill (since most Derm is outpatient), and you can fix their conditions more often than IM (who will slowly die from their non-compliance after getting DM2, HTN, CAD, CHF, etc.) or Cards (who will get a stent and then go back to eating cheeseburgers).

^^Wishful thinking I'm sure.

Honestly, this bickering between various specialties (in this thread, IM/Cards vs Derm between ) is part of the reason physicians as a whole are getting their asses handed to them on the political end. We cannot band together as physicians who take care of all the patients in the US, across a wide spectrum of overall healthiness. Instead, each specialty tries to show it's superiority by belittling other specialties, even when the scope of practice between the two specialties (like between IM and Derm) is so wildly different.

/soapbox

All I can say is that I'm glad I'm going into oncology. While there are cancers that are self-inflicted, I will have to deal with less (obviously still >0%) non-compliance, while at the same time being able to respect the decisions of a patient if they refuse treatment.

Inb4 attack on how oncology is a terrible field. 3.... 2.... 1.

 

[DermViser]

What a (terrible) thread.

As a real response to the OP - Reimbursement will hinge on patient compliance if you are an IM doc. That is the future and something you have to deal with. Re-admissions within a certain time period will be penalized by the ACA. Unless something changes in the ACA, this will be something you have to deal with. You can't fire every non-compliant patient you have. Unfortunately a large portion of IM is 'delaying the inevitable', especially in non-compliant patients who will continue to flare their CHF from a cheeseburger or go into DKA from skipping their insulin dose.

On a side note (and a rant) -

In this thread we have an IM who thinks Derm does literally nothing beyond steroids and antibiotics/fungals (when they deal with more serious conditions using varying treatments on a somewhat regular basis, although not as often as more basic rashes), and a Derm who thinks IM cannot work up a basic patient without consulting the specialty or specialties that are having issues, and thinks Cards does nothing besides pills and stents. Both of these thought processes are incorrect, but neither one will admit as such (or at least admit that it MAY be unique to their shop and not how things work across the entire nation).

DermViser - Derm patients will generally be happier, because they are generally LESS ill (since most Derm is outpatient), and you can fix their conditions more often than IM (who will slowly die from their non-compliance after getting DM2, HTN, CAD, CHF, etc.) or Cards (who will get a stent and then go back to eating cheeseburgers).

^^Wishful thinking I'm sure.

Honestly, this bickering between various specialties (in this thread, IM/Cards vs Derm between ) is part of the reason physicians as a whole are getting their asses handed to them on the political end. We cannot band together as physicians who take care of all the patients in the US, across a wide spectrum of overall healthiness. Instead, each specialty tries to show it's superiority by belittling other specialties, even when the scope of practice between the two specialties (like between IM and Derm) is so wildly different.

/soapbox

All I can say is that I'm glad I'm going into oncology. While there are cancers that are self-inflicted, I will have to deal with less (obviously still >0%) non-compliance, while at the same time being able to respect the decisions of a patient if they refuse treatment.

Inb4 attack on how oncology is a terrible field. 3.... 2.... 1.

Just to be clear I obviously know why Derm patients are generally happier. My only point in bringing that up is that:
1) It contributes a great deal to physician satisfaction of which Dermatologists are one of the most satisfied and
2) P4P is coming in like a freight train to reimbursement models.

Emergency Medicine doctors already have Press-Ganey surveys they have to deal with from ER patients: http://www.pressganey.com/Documents...estudies/cs_oregonHealthScienceUniversity.pdf
Which, as an aside, I can't believe that any EM physician PD would actually be touting this for his residency program His quote of "service excellence" sounds like a hotel or car dealership.

 

[Priapism4tooLong]

What a (terrible) thread.

As a real response to the OP - Reimbursement will hinge on patient compliance if you are an IM doc. That is the future and something you have to deal with. Re-admissions within a certain time period will be penalized by the ACA. Unless something changes in the ACA, this will be something you have to deal with. You can't fire every non-compliant patient you have. Unfortunately a large portion of IM is 'delaying the inevitable', especially in non-compliant patients who will continue to flare their CHF from a cheeseburger or go into DKA from skipping their insulin dose.

On a side note (and a rant) -

In this thread we have an IM who thinks Derm does literally nothing beyond steroids and antibiotics/fungals (when they deal with more serious conditions using varying treatments on a somewhat regular basis, although not as often as more basic rashes), and a Derm who thinks IM cannot work up a basic patient without consulting the specialty or specialties that are having issues, and thinks Cards does nothing besides pills and stents. Both of these thought processes are incorrect, but neither one will admit as such (or at least admit that it MAY be unique to their shop and not how things work across the entire nation).

DermViser - Derm patients will generally be happier, because they are generally LESS ill (since most Derm is outpatient), and you can fix their conditions more often than IM (who will slowly die from their non-compliance after getting DM2, HTN, CAD, CHF, etc.) or Cards (who will get a stent and then go back to eating cheeseburgers).

^^Wishful thinking I'm sure.

Honestly, this bickering between various specialties (in this thread, IM/Cards vs Derm between ) is part of the reason physicians as a whole are getting their asses handed to them on the political end. We cannot band together as physicians who take care of all the patients in the US, across a wide spectrum of overall healthiness. Instead, each specialty tries to show it's superiority by belittling other specialties, even when the scope of practice between the two specialties (like between IM and Derm) is so wildly different.

/soapbox

All I can say is that I'm glad I'm going into oncology. While there are cancers that are self-inflicted, I will have to deal with less (obviously still >0%) non-compliance, while at the same time being able to respect the decisions of a patient if they refuse treatment.

Inb4 attack on how oncology is a terrible field. 3.... 2.... 1.

Lmao oncology really?? More like conversational therapist who administers a few drugs

 

[evilbooyaa]

Just to be clear I obviously know why Derm patients are generally happier. My only point in bringing that up is that:
1) It contributes a great deal to physician satisfaction of which Dermatologists are one of the most satisfied and
2) P4P is coming in like a freight train to reimbursement models.

Can't disagree with those points.

Emergency Medicine doctors already have Press-Ganey surveys they have to deal with from ER patients: http://www.pressganey.com/Documents...estudies/cs_oregonHealthScienceUniversity.pdf
Which, as an aside, I can't believe that any EM physician PD would actually be touting this for his residency program His quote of "service excellence" sounds like a hotel or car dealership.

I've been on the EM forums enough to know about the bane of Press-Ganey scores. I don't believe that those who pay nothing for their healthcare should be able to dictate how their healthcare is done by the emergency physician.

Priapism - I said inb4, so it doesn't count!

 

[DermViser]

Can't disagree with those points.

I've been on the EM forums enough to know about the bane of Press-Ganey scores. I don't believe that those who pay nothing for their healthcare should be able to dictate how their healthcare is done by the emergency physician.

Priapism - I said inb4, so it doesn't count!

His username is Priapism4tooLong, hence why I keep mentioning it. I don't know if he actually has it. Patients are pretty thankful when you put their cancer into remission or fully cure them of it. Hence if you look at the chart - Oncologists are quite high on the physician satisfaction scale.

 

[Priapism4tooLong]

Priapism - I said inb4, so it doesn't count!

Damnit, you win this time.

 

[SouthernSurgeon]

For some hospitals it's part of policy, to consult Endocrinology, esp. when you're starting and continuing insulin drips.

Our hospital started a hyperglycemia management team (consisting of what seems like a small army of mid-levels who staff with an endocrinologist). It is now policy to consult them for all kinda nonsense that everyone was fine managing themselves previously. I'm assuming it's a money maker for the hospital.

 

[Brain Bucket]

Just to be clear I obviously know why Derm patients are generally happier. My only point in bringing that up is that:
1) It contributes a great deal to physician satisfaction of which Dermatologists are one of the most satisfied and
2) P4P is coming in like a freight train to reimbursement models.

Emergency Medicine doctors already have Press-Ganey surveys they have to deal with from ER patients: http://www.pressganey.com/Documents...estudies/cs_oregonHealthScienceUniversity.pdf
Which, as an aside, I can't believe that any EM physician PD would actually be touting this for his residency program His quote of "service excellence" sounds like a hotel or car dealership.

Why are Urologists so low?

 

[DermViser]

Why are Urologists so low?

A complete guess on my part, but possibly reimbursement cuts. On a completely unrelated note, I know they've gotten reamed in the media regarding Davinci robotic surgery.

 

[evilbooyaa]

A complete guess on my part, but possibly reimbursement cuts. On a completely unrelated note, I know they've gotten reamed in the media regarding Davinci robotic surgery.

Also getting reamed in the media for urorads and the associated reimbursement cuts.

Also, they have to do a lot of rectals. No bueno.

 

[Brain Bucket]

Also getting reamed in the media for urorads and the associated reimbursement cuts.

Also, they have to do a lot of rectals. No bueno.

Dunno man, at 300 median, I'd be ok with doing a few rectals, although I haven't heard anything of the sort from the urologists I know. They seem a perfectly content bunch.

 

[KinasePro]

Just curious: does your board come down on you for doing *too many* cases?

Back in the day we had to <ahem> "adjust" our case logs if they were too high so I always take average numbers with a grain of salt.

Good question, but I'm just an ortho hopeful at this point so I can't say for sure. Though I'd wager that there is no pressure to deflate caseloads, because programs are generally pretty boastful about those numbers. There's a community program in PA that brags about chiefs graduating with ~3000 cases, which would put them over 90th percentile per ACGME. Sounds a bit much to me tbh.

Very surprised that Ortho hasn't always been a competitive specialty, just based on the sheer volume of cases they do, esp. if you can build a standalone orthopedic hospital. In this scenario, I think it works very well as far as what ortho surgeons do and what hospitalists do.

Strides made in joint arthroplasty and sports med probably have a lot to do with the high volume and competitiveness of ortho these days. Back in 50's and 60's before arthroplasty and minimally invasive knee/shoulder surgery were common place, ortho was largely a trauma specialty. If ortho was still mostly trauma work, I imagine it would be less competitive. Still today, ortho trauma is one of the less desirable sub-specialties. Per doc wiki, around 773,000 total joints are performed in US annually, which is approx twice the number of appendectomies performed. And that number continues to climb as we're getting fatter and older.

Why are Urologists so low?

Check out my sig re: burnout among urologists. Definitely a great field, but some of their bread and butter procedures carry morbidity that is probably tough to deal with in clinic all the time (impotence, incontinence, ball pain, etc...).

 

[Winged Scapula]

Good question, but I'm just an ortho hopeful at this point so I can't say for sure. Though I'd wager that there is no pressure to deflate caseloads, because programs are generally pretty boastful about those numbers. There's a community program in PA that brags about chiefs graduating with ~3000 cases, which would put them over 90th percentile per ACGME. Sounds a bit much to me tbh.

Interesting; I had wondered if there was a specialty difference. Thanks for that.

Being that GS also has non-surgical management to master, the fear "back in the day" was that people who were logging 2000+ cases were 1) not ever leaving the hospital and 2) not spending enough time in the ICU and doing non-operative management. I think during my Chief year we actually had to start logging ICU cases.

Since there is no pressure to reduce the number of cases, its probably not very meaningful to compare Ortho case logs to GS (and as it is, I have to wonder if that GS number is still somewhat artificially deflated. Less than 1000 cases by the end of Chief year is pretty low AFAIC).

 

[alpinism]

Just to be clear I obviously know why Derm patients are generally happier. My only point in bringing that up is that:
1) It contributes a great deal to physician satisfaction of which Dermatologists are one of the most satisfied and
2) P4P is coming in like a freight train to reimbursement models.

Emergency Medicine doctors already have Press-Ganey surveys they have to deal with from ER patients: http://www.pressganey.com/Documents...estudies/cs_oregonHealthScienceUniversity.pdf
Which, as an aside, I can't believe that any EM physician PD would actually be touting this for his residency program His quote of "service excellence" sounds like a hotel or car dealership.

As much as I'd love to live in Portland, there's no way on god's green earth I'd ever apply to OHSU for residency.

Here's that JAMA article on patient satisfaction and higher mortality out of UC Davis:

http://www.ucdmc.ucdavis.edu/publish/news/newsroom/6223

 

[ChrisGriffen]

DermViser, you need a hobby outside of posting on SDN. Every other post in this thread is from you.

 

[DermViser]

DermViser, you need a hobby outside of posting on SDN. Every other post in this thread is from you.

I suggest you get off of probationary status first, Chris Griffen.

 

[Winged Scapula]

Dunno man, at 300 median, I'd be ok with doing a few rectals, although I haven't heard anything of the sort from the urologists I know. They seem a perfectly content bunch.

You don't need to do rectal exams to make over 3ooK.

 

[Anastomoses]

You don't need to do rectal exams to make over 3ooK.

Rectal schmectal. It's all good.

The only thing I find a bit off-putting is freaky skin stuff.

 

[DermViser]

Rectal schmectal. It's all good.

The only thing I find a bit off-putting is freaky skin stuff.

Have you actually done a rectal? On a real patient, not a standardized patient.

 

[Winged Scapula]

Rectal schmectal. It's all good.

The only thing I find a bit off-putting is freaky skin stuff.

Eh…I don't mind them either; very little grosses me out. Maybe scorpions.

I was just using that as a comeback to those who state that rectal exams are one of the drawbacks of Urology (or General Surgery for that mater)

 

[Winged Scapula]

Have you actually done a rectal? On a real patient, not a standardized patient.

And "dates" don't count.

 

[DermViser]

Eh…I don't mind them either; very little grosses me out. Maybe scorpions.

I was just using that as a comeback to those who state that rectal exams are one of the drawbacks of Urology (or General Surgery for that mater)

Yes, rectals are definitely not limited to just Urology, General Surgery, or IM.

Although med students (the bad ones) seem to think they're "too good" to do them. Of course, not at all shocked anymore by the millenial MS-3 who believes they're too good to do certain things. Have to wonder sometimes, what they thought actual medicine encompassed.

 

[Anastomoses]

Have you actually done a rectal? On a real patient, not a standardized patient.

No, but I've inserted a catheter in an obese woman in a third world country. Can I substitute that on my resume?

 

[Successful BM]

Have you ever heard of one of their patients complaining?

Maybe their patients just don't expect much to begin with.

 

[DermViser]

No, but I've inserted a catheter in an obese woman in a third world country. Can I substitute that on my resume?

Yeah, not quite the same experience.

 

[Dave89]

I suggest you get off of probationary status first, Chris Griffen.

Genuinely curious here - which year of residency are you in? I really don't get how you do have the time for this...

 

[DermViser]

Genuinely curious here - which year of residency are you in? I really don't get how you do have the time for this...

I'm in Derm residency. Time is not exactly a rare commodity.

 

[Dave89]

I'm in Derm residency. Time is not exactly a rare commodity.

Oh, haha. I thought all residencies are hell, regardless of life at the end of the respective tunnels. My mistake.

 

[DermViser]

Oh, haha. I thought all residencies are hell, regardless of life at the end of the tunnel. My mistake.

Some residencies (not just Derm by any means) do allow some semblance of normalcy during residency AND as an attending.

I hear surgical subspecialties (after General Surgery) also allow this, depending on what it is, but 5 years of General Surgery residency to achieve that is an immense sacrifice (IMHO). Hat tip to those who are able to do so and achieve the fellowship they desire.

 

[username456789]

Oh, haha. I thought all residencies are hell, regardless of life at the end of the respective tunnels. My mistake.

The hours spent in the clinic/hospital as a Derm resident are very manageable. The amount of time spent at home reading/studying is pretty enormous at times.

We recently had our mock boards/inservice exam in late February (and just got scores back yesterday, finally), and the national AAD meeting/party was in March, so most Derm residents are probably still coasting a bit.

 

[Winged Scapula]

Yeah, not quite the same experience.

I dunno - I'd rather do 100 rectals for every obese female Foley,

 

[DermViser]

I dunno - I'd rather do 100 rectals for every obese female Foley,

You might change your mind when it's done on an elderly, slightly demented man, who keeps saying, "Quit touching my dingus!" God I hated internship.

 

[Dave89]

You might change your mind when it's done on an elderly, slightly demented man, who keeps saying, "Quit touching my dingus!" God I hated internship.

 

[username456789]

You might change your mind when it's done on an elderly, slightly demented man, who keeps saying, "Quit touching my dingus!" God I hated internship.

In his defense, Old Country Buffet was an odd place for you to practice this.

 

[DermViser]

In his defense, Old Country Buffet was an odd place for you to practice this.

Or I guess I should have at least bought him a dinner entree first.

 

[Winged Scapula]

You might change your mind when it's done on an elderly, slightly demented man, who keeps saying, "Quit touching my dingus!" God I hated internship.

LOL...remember I had 7 years of stuff like that.

 

[Winged Scapula]

Although I might have had it worse based on the number of times the patient acted like they were enjoying the examination.

I hate creepy patients.

 

[DermViser]

Although I might have had it worse based on the number of times the patient acted like they were enjoying the examination. I hate creepy patients.

I'm almost willing to bet it's an elderly VA patient (most likely widowed). I don't know if it's engrained but it seems to me that male, elderly patients think they can get away with things more if the physician is a female (the era of doctor = male, nurse = female thing).

 

[DermViser]

LOL...remember I had 7 years of stuff like that.

So true. Rectal exams on IM where it's done every once in a while, is nothing compared to General Surgery, where it's almost a refrain (besides asking have you passed stool and have you passed gas.)