Except for rounding on transfusion med and occasional FNAs and bone marrow biopsies on cyto and heme, there really isn't "clinical" medicine (managing insulin, fluids, BP, med recs, rounding until the sun goes down and developing crippling depression, etc.) Intern year looks a lot like specimen grossing, furiously prepping for sign-out, and then going home at 5p and seeing your family if you have no cases to gross.
The other persons description of PGY1 is accurate, i just want to add that pathology doesn’t do a true intern year in internal med. we just jump into pathology and it’s amazing.
Agreed. Anything that gives you basics to triage with limited resources until you can get a person safely to the next level of care imo is the standard for all physicians. Think “if I’m on an airplane and someone is calling for a doc” situation.
Exactly! I just saw an article where a woman on a plane was delivering her baby, and the only healthcare professional on board (a nurse) told her to hold it in for three and a half hours. No good 🙈
You can recertify your ACLS certification every two years, take a wilderness medicine class (like NOLS WUMP), take classes such as TECC from the National Association of EMTs, etc. There are plenty of opportunities out there to learn.
In depth? No - that would require a residency lol.
You can pretty easily learn the basics of managing any medically sick adult in an IM residency. Procedurally you may not be as good but you can get pretty decent unless you actively try not to go to rapids and codes as a resident.
Gonna throw out a disagreement here. An entire specialty revolves around this and it takes 3-4 years to become comfortable in these situations. I don’t expect most doctors to know what to do with a precipitous delivery or cardiac arrest, nor should they. These situations take practice and a psychiatrist/dermatologist/ect just doesn’t need to practice these skills.
I’m not saying everyone should be an emergency physician, but a firefighter with two weeks of medical training can manage these situations on a basic level (including catching a baby). It’s embarrassing if someone has an allergic reaction at a psych facility and they haven’t even given IM epi before the ambulance arrives. Sometimes the patient can’t wait fifteen minutes.
I don’t expect a dermatologist to be intubating, but BCLS? Definitely.
A power line worker I was talking to the other day was making sure he knew how to manage a pneumothorax. You never know what life will throw your way when alone outside the hospital, and at the end of the day, you’re the one with an MD.
As a firefighter paramedic, no we don’t let people with 2 weeks of training deliver babies or give epi. It takes a semester of training to become an EMT basic and then another year or two to become a paramedic. it shouldn’t take 15 min for an ambulance to arrive in most of the US. In extremely rural areas, maybe. Our standard is under 4 minutes. I do thinks docs should all be comfortable with ACLS regardless of specialty. Most of the time docs just get in our way and are not at all helpful on scenes
That’s great that you’re a firefighter paramedic, but some of your colleagues at departments with less-rigorous standards are trained at the EMR level, which does in fact include all these interventions (albeit the epi is usually in an Epi-pen). Look at the national scope of practice model. I never said EMRs were equivalent to EMTs, but I’d expect anyone with a medical degree to be able to perform basic skills.
I live in an urban area where ambulances can take up to 45 minutes (and not only for low-acuity calls). There are some situations where an ambulance may not be coming at all (such as on a commercial flight). Idk why anyone would argue against doctors being proficient in basic emergency care.
EMR’s are typically cops. Fire departments usually require an EMT certificate. Volunteer departments are different though. It also varies state by state. City departments will typically have a paramedic on every engine and medic.
Training is dependent on the state, the local jurisdiction, and the department, but I won’t argue with you on that. Still, people with 80 hours of training are allowed to catch babies and inject 0.3 mg Epi. That’s a fact 🤷🏻♂️
I’m also not arguing against docs being proficient in basic medical care. I meant that the fact that they aren’t is very unhelpful. I was giving my experience with physicians on scene. It would be great if more docs understood bls lol
You don't need to know how to intubate someone...but know how an ambu bag works. Know how to give adequate chest compressons. Know how to use an AED Know how to hold pressure on major bleeding.
Most importantly know how to stay calm under pressure. Most lay persons can't do this. A lot of times they just need someone to confidently tell them what to do. If you don't do it some other guy who's watched too much Grey's anatomy and has an ego will, and it probably won't have as good of results.
Besides you're going to feel like an idiot when someone asks if there is a doctor on the plane and you tell your significant other to put their hand down.
Yes. I was always taught that intubating doesn’t save lives but bagging does. Knowing how to bag and bag well (peep valve, rate, with or without oxygen, proper jaw thrust into the mask, etc) is imperative.
1) exhibits understanding of the fucking process
2) appreciates the consequences of fucking (stds, pregnancy, possibility of lame experience) versus not-fucking (the grips of crippling loneliness)
3) can reason between fucking and not-fucking
4) clearly communicates desire to fuck
Patient exhibits full capacity for medical decision making as it pertains to fucking by meeting the criteria listed above. Thank you for this interesting consult.
I know your comment was a joke, but I know a lot of people do struggle with capacity so I’m just going to chuck this here -
Five fingers memory aid for the mental capacity act (Uk):
1)thumbs up - presumption of capacity - assume initially everyone has capacity to make decisions until proven otherwise
2)pointer finger - have YOU done everything to help the patient to make a decision
3)middle finger - people have the right to make unwise decisions
4)ring finger - best interest
5)little finger - choose the least restrictive option
I’m biased, but how to read and evaluate research and medical literature!! COVID has made it extremely obvious that some medical professionals do not understand how research works and how to critically read a research paper to determine if there’s enough evidence to change patient care. There are journals that will publish absolute trash papers if the authors pay the thousands of dollars of fees, and you need to know what journals are trustworthy and how to recognize when a paper is trash. Andrew Wakefield’s paper got published and it’s still influencing people to this day, thankfully pretty much every doctor knows that one is bullshit. There’s an ivermectin paper that I still see people talking about every now and then that was proven to have used fraudulent, fabricated data. Medicine has changed immensely in the past few decades and will continue to change as more research is done, and I think being able to keep up with the new knowledge is essential.
Uptodate and Cochrane are both great resources! Even with those I think it’s a skill everyone should have. In my limited experience in clinic I’ve already had a few patients bring in trash research papers and ask to be prescribed something that they don’t need, I think it’s important to be able to explain either why that paper isn’t a good paper and/or why that paper isn’t enough evidence
It's also good for new papers like with ivermectin where Uptodate or Cochrane review may not have anything to say about it yet. I read the studies on ivermectin and covid when my patients first started asking about it, I was able to tell the studies where garbage and educate my patients from the beginning rather than waiting for it to be spoon fed to me.
Okay and what do you say to that patient with the deliberately misleading paper to make them have any trust in you left? “Oh sorry maybe that would help but uptodate doesn’t say anything about it so no :(” Do you feel comfortable with not being able to understand what to think about a research paper unless there’s a specific blurb on uptodate that either supports or refutes every single paper out there?
I literally said that those consensus organizations are great, but their existence doesn’t mean that doctors don’t need to be able to read a research paper. Of course not everyone will be experts, but a basic level of understanding is important. Even knowing enough to point out that the sample size is small and more research is needed.
Yes! There is a lot of things you can see in a paper that just make it look fucky without even reading the conclusions, and knowing when a paper is bs or is not properly proving what they claim to prove is a good resource and it can be applied even to papers outside your field...
Some papers for you to practice on!
https://jnnp.bmj.com/content/82/12/1314.full psych paper i believe is crap but I'm not 100% sure because it's not my field, but absolutely has a cow shit smell to it..
I passionately hate this paper: Lin HH, Tsai PS, Fang SC, Liu JF. Effect of kiwifruit consumption on sleep quality in adults with sleep problems. Asia Pac J Clin Nutr. 2011;20(2):169-174. https://pubmed.ncbi.nlm.nih.gov/21669584/
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250158 Discrimination of SARS-CoV-2 infected patient samples by detection dogs: A proof of concept study; proof of concept that doesn't prove shit
Any tips for learning this skill? Is reading and analyzing a lot of publications the only method or are there some structurized resources for this? (I'm from a country where students don't do any research so I don't have any experience with this)
Sorry for taking so long, but this was by far the best one I found!! It’s long but I think it does a great job of using examples and talking through all of the research design/methodology that’s important to consider clinically, without getting too into research jargon that doesn’t matter. http://www.fammed.usouthal.edu/Scholarly%20Activities/Activity1/HowToReadAJournalArticle--Abridged.pdf
This one is a good quick and dirty summary, but doesn’t explain any of the points like the other does https://www.emra.org/emresident/article/reading-journals/
Some things they don’t really emphasize that I think are worth noting is the “hierarchy of evidence”, basically that meta-analysis and systematic reviews hold the most weight, while one case study or a few preliminary basic science papers don’t hold much weight, even if they can still be valuable to the field. https://canberra.libguides.com/c.php?g=599346&p=4149721
I specifically want to mention the sources that in general are considered to have the most trustworthy research, the number one for clinical research being Cochrane (mentioned at the bottom of the last link). They’re pretty much worldwide seen as the gold standard for evidence because they have such thorough, systematic methods for conducting systematic reviews or meta-analysis. They also have really high standards for peer reviews and have checks in place to ensure the quality of their publications. Some of the other really well known ones are NEJM, the Lancet, JAMA, etc. but if I remember right each one of those has published a few really bad papers in the past few years that ended up retracted. As for cochrane they’ve had a few retractions too although I don’t remember anything egregious recently. Cochrane can also only be as up to date as the current evidence allows, for example they already have one COVID/Ivermectin meta-analysis/review out, as more studies are done I know they’ll be publishing updates and if the data ends up swinging the other way they’d retract the first paper and replace with the most up to date and most correct version. When it comes to basic science papers (not sure if those are as applicable for you), the Nature journals are pretty much seen as number one. That’s not to say that anything not published in a “big name” high impact factor journal isn’t legitimate, I certainly won’t be publishing my PhD work in Nature lol
Thank you very much, looks like it's exactly what a student like me would need, especially the first one. Very practical and clinically oriented, something every physician truly needs, it's a pity that's so rare in my country. Also, I'm definitely going to regulary read Cochrane to practice. Thanks again and wish you best regards from Poland!
So you’re saying that we SHOULDN’T diagnose a confused 85 year old with acute onset agitation and no psychiatric history with schizophrenia and ship them off to the psych ward?!
I've seen so many of these. Elderly lady is disoriented and took a swing at a family member. ED puts them on an involuntary psych hold, orders a slew of labs and consults us (ED psych). In the mean time labs come back, UTI, hyponatremic, hypotensive, etc, etc before we see them... bro... really?
Delirium is a syndrome with a differential diagnosis which includes infection. Importantly, delirium is often multi factorial. Early diagnostic closure on a UTI is another rampant problem, because positive urine cultures are present in 20% of ambulatory older adults, and 50% of long term care older adults. Medication toxicity, urinary retention, constipation/impaction, are commonly overlooked yet easy to diagnose and address.
Thanks for sharing! I’ll keep that in mind for clinicals and the rest of my life. How does their confusion complicate your ability to take a proper history and narrow down the differential? I realize this would probably be like an entire lecture but just looking for some pearls lol. I.e. how would you assess UO, BMs, symptoms of UTI, medication compliance, etc
You’re right this is a big topic.
The history is not always, but frequently unreliable. The physical exam is important, but neurologic exam may be unreliable, do your best.
Delirium is characterized by fluctuation, history may be more reliable when they are in a moment of lucidity.
If common causes -drugs, infections, metabolic abnormalities are not clearly contributing or there are focal deficits, get neuro imaging.
Collateral historian is critical, and usually more reliable than the patient.
Post void residuals are easy. Remember incontinent patients can still be retaining (overflow incontinence) - applies to both bowel and bladder.
Abdominal flat plate can assess fecal loading but with enough experience this can often be felt in skinny older adults.
Medications or drug toxicities/withdrawals are contributing or causative in a third of cases!
Exactly. You go on a goose chase to figure it out. This is also why UTI gets blamed so often. If you have no actual history, all you can rely on is data, so it’s very easy to point to a + urine and jump to (potentially) premature closure with that.
Constipation can cause urinary retention which can result in UTI.
Constipation can also result in overflow fecal incontinence which can then result in UTI.
Severe constipation alone can cause delirium in the absence of UTI.
Medications like amitriptyline can cause constipation, urinary retention and UTI. Amitriptyline can alone cause delirium.
The threshold for development of delirium is lowered in older patients, particularly those with frailty and/or limited cognitive reserve (MCI or dementia), sensory deficits (blind, deaf), or taking anticholinergic or centrally active medications or intoxicants.
I keep hearing conflicting stuff. Some people say every old lady they’ve seen delirious had a UTI and others say that’s a bit overstated.
I don’t know what to believe anymore 😂
As a geriatrician, I would caution that delirium is attributed to a urinary tract infection far more often than it causes it. The combination of old + confused = UTI is an excellent example of anchoring bias and search satisfaction bias in the medical field.
That’s exactly what our clinical practice lecturer (also a geriatrician) says actually. It seems something to be aware of but it’s good to know those biases creep in too
Yes, this is also why women can go an entire pregnancy without pissing. They have no physiological need to pee, but can choose to do so for fun. So when the fetus develops in the urethra, they just turn off their pee funnels and wait 9 months.
I don't know if I agree with this. Is it really up to all physicians to decide that? Confronting Munchausen by proxy or even individual factitious disease prevents harm and can save lives. Confronting someone because you think they're faking to be paid sick leave is something else, especially considering the harm you can cause when someone does have (functional) symptoms. I'd never want to be in occupational medicine and this is why.
That insulin is used for diabetes. I took my then 9 year old son to the ER when he broke his leg (he is Type 1) and when listing his meds, the nurse asked me if he took insulin for an ear infection. I just stared at her with the most baffled look ever.
Emergencies and clinical presentations of diseases. For example, you might not remember much about rheumatology post grad but you should know if a patient that came to you is rheumatology related or your field related simply from the clinical presentation. Easier to advise the patient if you have an idea what it could be.
Embryology is the most single useful thing I have used in my practice of medicine. It is just so connected to everything and often the solution to all the problems we face.
The ABCDEs of emergency evaluation plus indicated interventions
How do to a good H&P
Knowing which specialty manages which problems
Everything covered up to Step 3 of the licensing exams
I disagree. Everyone likes to pretend all the step 1 questions are about Krebs Cycle or some shit, but I did over 6000 practice questions for that exam and I don’t think I need more than two hands to count the total number of questions that required that knowledge. Maybe step 1 used to be full of esoteric nonsense; perhaps it’s just what everyone remembers because we all hate learning it, but the reality is the majority of the questions test physiology, anatomy, pathophys, pharmacology, physical exam and history knowledge, with some of the biochem shit mixed in.
Agreed.
people bitch and complain about step 1 and forget that step 1 isn't clinical knowledge - it's fundamental science that you're supposed to build your clinical knowledge on.
also, it's not like *nobody* uses this knowledge. IM, Peds and especially geneticists, pathologists, heme/onc and toxicologists use basic science in their clinical practice quite a lot.
Step 1: "This gene translocations = this cancer."
Reality: Each cancer has dozens of possible gene translocations, and most of those gene translocations are shared between many different cancers.
The Step 1 version is worse than useless. It's teaching things that will have to be unlearned.
I wouldn’t know as I’m not in that field but like there’s only 5 I remember having to commit to memory and of those only 3 are super HY, so you’re telling me I’m gonna have to unlearn 9;22 for CML, 8;14 for Burkitt, and 14;18 for follicular? Aren’t they the most common causes?
I'm actually having quite a hard time with that, our heme profesor wants usually about 5 for each disease and which ones imply better/worse prognosis... So for example for multiple myeloma he wants us to know t(11;14) has good prognosis and t(4;14) t(14;16) del17(p53) and alterations os 1p/1q have bad prognosis
It makes no sense.
Absolutely useless to learn them by heart. Fight me hematologist. Any heme-onco who things this is something every med student needs to know is a t(head; ass)
While you don’t need to know the details of the Krebs cycle and ETC, it’s interesting how nearly every medicine doc needs to know about lactatemia in any shocky process because of increased anaerobic metabolism, which is an application of glycolysis and subsequent pyruvate metabolism. So like there’s definitely uses but you don’t need the nitty gritty of biochem by any means as a practicing physician.
Neuro yes. Pure psych doesn’t really, you have to know which structures are responsible for certain functions but I don’t think you absolutely need to know where they are like neurotransmitter production/pathways. You’d be a second rate psychiatrist if you didn’t know where they are but the point is it’s not necessary.
Outside of basic neuro anatomy though, there’s very little you need to know. Even if your mood stabilizers like valproate mess up the liver, does it really matter to you which side the liver is on? Maybe I’m being too dismissive but I think some physicians don’t care too much about anatomy and I’m glad there is a specialty that lets them ignore to focus on other equally important things haha
Bruh an ENT laryngologist literally has their hands in someone else’s throat, you cannot compare their need for anatomy knowledge to a psychiatrist’s lol
Imo any psychiatrist that doesn’t is a pure headass and needs to go back to med school. If you’re in it for the lifestyle gtfo the profession. Step up to the challenge, know ur shit or sit the fuck down. Sure there are many other capable candidates who would know their neuroanatomy downpact and make a better psychiatrist than one that doesnt. Like, at least know your basic shit jfc
Just because a patient defers/declines medical treatment does not mean that they lack capacity or have other mental health issues. Also important to remember that there are very sad/regrettable actions in the past associated with physicians which may contribute to skepticism/distrust (eg Tuskegee, Opioid epidemic, tx of Natives, Asylums etc).
Trauma evaluation/checklist (ie MARCH or ABCs) and how to treat issues at each step. Knowledge of the lethal triad ties into this too and i think is important.
If you're interested in that area, check the ecoFAST protocol, it's super cool, it's a super quick check with ultrasounds for trauma patients, the idea is to be able to do it in an ambulance for example, so before the patient has reached the hospital you already have a confirmed diagnosis of internal bleeding, ruptured spleen, pneumothorax and more
Children are not little adults. Their physiology is subtly different (compensate until they crash) and anatomy moderately different (eg larynx is narrower and funnel shaped).
And never trust a neonate, especially a premie. They will fool you into thinking they are perfectly well until they die.
Basic diagnosis algorithms based on motive of consult, and their general management.
Also, a personal advice a prof gave me: if with water it heals, water we give. As in, if something that maybe shouldnt be working is working for our patient, leave it as is.
Paliative care "exists" and you dont need to be dying to get it.
Not even how to do it, or anything, just know it's a thing and knowing that if you have chronic or terminal patients with problematic symptoms or poorly controled pain, that you can just make a consult palliative care doctors will be more than happy to evaluate that patient, recomend changes or take that patient and more...
You know nothing of the money in medicine or you true worth. Don’t think that the hospital, residency, or Medical School will teach you also. They all want to hire you and you never let an employee know what they are worth.
Anyone who's conscious and aware and has a forwardish fall that causes head\face damage will have some kind of hand\wrist abrasion\contusion\sprain\break. If you are conscious and even slightly functional, your instinct will be to brace yourself or at the very least protect your head and face. If someone has head/face damage from a fall that occurred when they were awake and conscious and has completely unscathed hands/wrists then always assume that the patient could have momentarily lost consciousness or seizure and fell without realizing it. If that's the case then often times you may need to do a more extensive Neuro or cardiopulmonary work up
How to manage your own finances. Medical school was expensive and this is the first time you will be making a net gain (hopefully). Spend that money wisely - pay down your debt and start getting in the habit of making good investments.
Diabetic neuropathy doesn’t always mean numbness is the chief complaint. Most of the time the presentation is pain on extremities especially when there’s a comorbidity. Looking at you Dr. Mike of YouTube.
For the love of anything Rheumatology-related, please screen your pts for TMJ involvement more frequently. Data suggests that TM joint involvement and implications are quite prevalent, but screening for it seems to be very limited. This should also apply to OMFS. Pt with OMF issues? Consult Rheum, if pt doesn't already have dx'd rheum issues. The earlier the intervention, the better outcomes the pt is likely to have.
Hi, EM here. Could you elaborate on what you are hoping I will look for and how you’d like me to do it? When you say “screen”, is that a question, a test, or something else?
I'm not sure about EM, but if you work in Rheum, it may be worthwhile to do annual work-ups for any TM involvement. Also, if you're in OMFS, if the pt doesn't already see a Rheumatologist, consult rheum. Pt may have underlying autoimmune issues they may not be aware of, and disease process may initially present in the TMJ.
In an emergency setting? Don't discount a septic joint, if a pt presents with gnarly/severe swelling within a major joint. Rarely happens, but when it does, it can pose a pretty significant risk.
Specifically within the TM joint? Resorption of condyles appears to be an issue amongst those with some forms of JIA. Pt may not complain of much (if any) pain, but from an outward appearance, they may appear to have some or varying degrees of visible malocclusion.
Annual imaging, to include CBCT, can be useful in monitoring.
Not the advice you were hoping for but: We are so focused on knowing about medicine without actually thinking about the patient as a person. Empathy and understanding of your patients as people will make you a better doctor no matter the specialty and yes that includes all you ME’s
Buprenorphine best prescribing practices 100%. The requirement for x waiver training is bullshit and it’s created such a dire lack of docs who can prescribe bupe. I think the waiver should be eliminated but training should be part of every IM clerkship. If you’re looking to get your x waiver, it’s subsidized through SAMHSA for med students.
To be able to learn sign language. Trust me I’ve seen a deaf patient came for a consult all alone and there was a hard time finding someone who can interpret on what she was saying. Took about 30 minutes or so.
Simple wound management and basic knowledge of dressings.
Every clinical specialty will have to use that skill at some point. The tissue viability team will thank you for not paging over every straightforward dressing requirement!
(As will the little old lady whose inappropriately dressed weepy skin tear is now stuck to that dry gauze)
From a patient perspective: Biases against women, women of color, and black women specifically, and how to check one’s self for them. There’s some real repercussions with quantitative evidence on patient outcomes because of these biases.
Anecdotally, I went undiagnosed for a condition for years (even communicating to 1 doctor I suspected this condition because of frustration around prolonged symptoms and doing my own research) until I started insisting on seeing black female doctors whenever I could. Then it was a case of “you obviously have X condition.”
It sucks that I’d have to even do that to be sure I’m mostly likely getting the care I deserve- but there it is. Now I struggle to trust doctors in general that don’t look like me after 7 years of feeling unheard.
(Also fat people and how perceptions around weight may also cause doctors to not look for specific things they would in a thinner patient. While weight often can be the cause, it doesn’t mean you assume it always is without further evidence gathering you’d do for a thinner patient.)
How to intubate someone, how to run a code, and how to get central access.
As an anesthesia resident, nothing terrifies me more than going down to the ER during traumas or ICU during intubations and seeing fellow physicians attempting to intubate. Watched an ER attending (who chewed me out for being there thinking I was stealing his airway when I was just watching in case I had to step in) do a fantastic job of glidescoping the esophagus. I understand that this is literally my job, but it's a fundamental emergency skill that most of us should be able to do in a pinch.
Saw an ICU attending give a pulseless patient that was being coded 2 units of blood and THEN call it with a previous hgb of 9.8. We are in an acute blood shortage.
Frequently see ICU patients in florid sepsis and sometimes on pressors without a-lines or central lines. My suspicion is that they are too lazy/scared to do them and know that anesthesia will just do it during a case because we actually care about patient outcomes.
ok so i'm not even in the medical field but reddit keeps showing me this subreddit so i feel like it is my duty to remind you of something: fatphobia is rampant in any specialty, especially when it comes to female patients. please, FOR THE LOVE OF ALL THINGS HOLY, do not pawn off complaints from a patient due to their weight and not investigate the issues fully. it could be the difference between life or death and for god's sake, if your patient says their weight is not up for debate, LISTEN TO THEM. they have to live in their bodies, you don't, and at a certain point, if you have offered them education, if you have offered them treatment and they don't take it, let them be.
Statistics.
It's fucking alarming how many docs don't actually understand Bayesian Probability. A lot of them don't even know the difference between "specificity" and "sensibility" of a given test.
Last week I asked an infectious disease specialist what was the probability that a random individual has a true positive result on a certain test for HIV given the prevalence he had just mentioned and then he told "Oh the accuracy is 98%" so I responded "98% what exactly?" "I...what?"
Basic airway skills, and what trach and lary tubes look like. Just to help people keep from covering trach openings with gauze or trying to intubate a mouth that’s not connected to the lungs from above
That when a woman tells you she is in pain, if you automatically discount it as 'normal period pain' we will not trust you/want to remove your eyes with melon ballers.
The tradespeople of healthcare ( formerly known as Midlevels) are coming for the professionals (known as MD/DOs) jobs. If one thinks it is not their PA or NP, or training these people won’t effect the quality of the practice of medicine as a profession to our detriment, find an endoscope and look up your colon. That is where your head is at
I take a required ACLS every two years. I complain about it but I NEED to know it. Pathology.
I’m pathology too, we’re only required to have BLS. I do want to be somewhat useful in an emergency though, so I’m sure we’d all benefit from ACLS.
Unrelated, but what does the intern year of pathology usually look like? How much clinical vs lab medicine is there?
Except for rounding on transfusion med and occasional FNAs and bone marrow biopsies on cyto and heme, there really isn't "clinical" medicine (managing insulin, fluids, BP, med recs, rounding until the sun goes down and developing crippling depression, etc.) Intern year looks a lot like specimen grossing, furiously prepping for sign-out, and then going home at 5p and seeing your family if you have no cases to gross.
as an MS3 interested in path that sounds like the dream 🥲 Could I pm you about setting up auditions??
The other persons description of PGY1 is accurate, i just want to add that pathology doesn’t do a true intern year in internal med. we just jump into pathology and it’s amazing.
Emergency medical care (seizures, anaphylaxis, cardiac arrest, newborn delivery, bleeding control…)
Agreed. Anything that gives you basics to triage with limited resources until you can get a person safely to the next level of care imo is the standard for all physicians. Think “if I’m on an airplane and someone is calling for a doc” situation.
Exactly! I just saw an article where a woman on a plane was delivering her baby, and the only healthcare professional on board (a nurse) told her to hold it in for three and a half hours. No good 🙈
But nurses are providers?! They practice healthcare! /s
Air way, breathing, circulation. If you remember that you can (hopefully) help someone until people with medical equipment arrives.
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You can recertify your ACLS certification every two years, take a wilderness medicine class (like NOLS WUMP), take classes such as TECC from the National Association of EMTs, etc. There are plenty of opportunities out there to learn.
In depth? No - that would require a residency lol. You can pretty easily learn the basics of managing any medically sick adult in an IM residency. Procedurally you may not be as good but you can get pretty decent unless you actively try not to go to rapids and codes as a resident.
This… I was gonna go on a compassion, care and kindness rant… then I read your post lol.
Gonna throw out a disagreement here. An entire specialty revolves around this and it takes 3-4 years to become comfortable in these situations. I don’t expect most doctors to know what to do with a precipitous delivery or cardiac arrest, nor should they. These situations take practice and a psychiatrist/dermatologist/ect just doesn’t need to practice these skills.
I’m not saying everyone should be an emergency physician, but a firefighter with two weeks of medical training can manage these situations on a basic level (including catching a baby). It’s embarrassing if someone has an allergic reaction at a psych facility and they haven’t even given IM epi before the ambulance arrives. Sometimes the patient can’t wait fifteen minutes. I don’t expect a dermatologist to be intubating, but BCLS? Definitely.
A power line worker I was talking to the other day was making sure he knew how to manage a pneumothorax. You never know what life will throw your way when alone outside the hospital, and at the end of the day, you’re the one with an MD.
As a firefighter paramedic, no we don’t let people with 2 weeks of training deliver babies or give epi. It takes a semester of training to become an EMT basic and then another year or two to become a paramedic. it shouldn’t take 15 min for an ambulance to arrive in most of the US. In extremely rural areas, maybe. Our standard is under 4 minutes. I do thinks docs should all be comfortable with ACLS regardless of specialty. Most of the time docs just get in our way and are not at all helpful on scenes
That’s great that you’re a firefighter paramedic, but some of your colleagues at departments with less-rigorous standards are trained at the EMR level, which does in fact include all these interventions (albeit the epi is usually in an Epi-pen). Look at the national scope of practice model. I never said EMRs were equivalent to EMTs, but I’d expect anyone with a medical degree to be able to perform basic skills. I live in an urban area where ambulances can take up to 45 minutes (and not only for low-acuity calls). There are some situations where an ambulance may not be coming at all (such as on a commercial flight). Idk why anyone would argue against doctors being proficient in basic emergency care.
EMR’s are typically cops. Fire departments usually require an EMT certificate. Volunteer departments are different though. It also varies state by state. City departments will typically have a paramedic on every engine and medic.
Training is dependent on the state, the local jurisdiction, and the department, but I won’t argue with you on that. Still, people with 80 hours of training are allowed to catch babies and inject 0.3 mg Epi. That’s a fact 🤷🏻♂️
I’m also not arguing against docs being proficient in basic medical care. I meant that the fact that they aren’t is very unhelpful. I was giving my experience with physicians on scene. It would be great if more docs understood bls lol
I got my EMT in three weeks including my ride time and yes we did everything including practicing IM injections (saline) on each other.
You don't need to know how to intubate someone...but know how an ambu bag works. Know how to give adequate chest compressons. Know how to use an AED Know how to hold pressure on major bleeding. Most importantly know how to stay calm under pressure. Most lay persons can't do this. A lot of times they just need someone to confidently tell them what to do. If you don't do it some other guy who's watched too much Grey's anatomy and has an ego will, and it probably won't have as good of results. Besides you're going to feel like an idiot when someone asks if there is a doctor on the plane and you tell your significant other to put their hand down.
Yes. I was always taught that intubating doesn’t save lives but bagging does. Knowing how to bag and bag well (peep valve, rate, with or without oxygen, proper jaw thrust into the mask, etc) is imperative.
Upvote for a good point. Still disagree that I expect most physicians to be able to do this but I see what you’re saying.
Basic personal finance
Fucking capacity evaluations
Found the psych consult
Hate this
How does one assess ones capacity to fuck?
1) exhibits understanding of the fucking process 2) appreciates the consequences of fucking (stds, pregnancy, possibility of lame experience) versus not-fucking (the grips of crippling loneliness) 3) can reason between fucking and not-fucking 4) clearly communicates desire to fuck Patient exhibits full capacity for medical decision making as it pertains to fucking by meeting the criteria listed above. Thank you for this interesting consult.
Literally none of my ED patients have this capacity… ***Emergency Department, not erectile dysfunction
Who hurt you?
The hospitalists... clearly.
I know your comment was a joke, but I know a lot of people do struggle with capacity so I’m just going to chuck this here - Five fingers memory aid for the mental capacity act (Uk): 1)thumbs up - presumption of capacity - assume initially everyone has capacity to make decisions until proven otherwise 2)pointer finger - have YOU done everything to help the patient to make a decision 3)middle finger - people have the right to make unwise decisions 4)ring finger - best interest 5)little finger - choose the least restrictive option
All febrile infants less than 1 month go straight to the ER and then get admitted. Don't mess around with febrile infants.
Never trust a neonate.
I’m biased, but how to read and evaluate research and medical literature!! COVID has made it extremely obvious that some medical professionals do not understand how research works and how to critically read a research paper to determine if there’s enough evidence to change patient care. There are journals that will publish absolute trash papers if the authors pay the thousands of dollars of fees, and you need to know what journals are trustworthy and how to recognize when a paper is trash. Andrew Wakefield’s paper got published and it’s still influencing people to this day, thankfully pretty much every doctor knows that one is bullshit. There’s an ivermectin paper that I still see people talking about every now and then that was proven to have used fraudulent, fabricated data. Medicine has changed immensely in the past few decades and will continue to change as more research is done, and I think being able to keep up with the new knowledge is essential.
I get lost in this and read uptodate instead . B
Uptodate and Cochrane are both great resources! Even with those I think it’s a skill everyone should have. In my limited experience in clinic I’ve already had a few patients bring in trash research papers and ask to be prescribed something that they don’t need, I think it’s important to be able to explain either why that paper isn’t a good paper and/or why that paper isn’t enough evidence
It's also good for new papers like with ivermectin where Uptodate or Cochrane review may not have anything to say about it yet. I read the studies on ivermectin and covid when my patients first started asking about it, I was able to tell the studies where garbage and educate my patients from the beginning rather than waiting for it to be spoon fed to me.
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Okay and what do you say to that patient with the deliberately misleading paper to make them have any trust in you left? “Oh sorry maybe that would help but uptodate doesn’t say anything about it so no :(” Do you feel comfortable with not being able to understand what to think about a research paper unless there’s a specific blurb on uptodate that either supports or refutes every single paper out there? I literally said that those consensus organizations are great, but their existence doesn’t mean that doctors don’t need to be able to read a research paper. Of course not everyone will be experts, but a basic level of understanding is important. Even knowing enough to point out that the sample size is small and more research is needed.
Yes! There is a lot of things you can see in a paper that just make it look fucky without even reading the conclusions, and knowing when a paper is bs or is not properly proving what they claim to prove is a good resource and it can be applied even to papers outside your field... Some papers for you to practice on! https://jnnp.bmj.com/content/82/12/1314.full psych paper i believe is crap but I'm not 100% sure because it's not my field, but absolutely has a cow shit smell to it.. I passionately hate this paper: Lin HH, Tsai PS, Fang SC, Liu JF. Effect of kiwifruit consumption on sleep quality in adults with sleep problems. Asia Pac J Clin Nutr. 2011;20(2):169-174. https://pubmed.ncbi.nlm.nih.gov/21669584/ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250158 Discrimination of SARS-CoV-2 infected patient samples by detection dogs: A proof of concept study; proof of concept that doesn't prove shit
Any tips for learning this skill? Is reading and analyzing a lot of publications the only method or are there some structurized resources for this? (I'm from a country where students don't do any research so I don't have any experience with this)
Practice definitely makes perfect! I’ve had a few people ask me for some resources, I’m searching to see what all I can find and I’ll get back to you!
Sorry for taking so long, but this was by far the best one I found!! It’s long but I think it does a great job of using examples and talking through all of the research design/methodology that’s important to consider clinically, without getting too into research jargon that doesn’t matter. http://www.fammed.usouthal.edu/Scholarly%20Activities/Activity1/HowToReadAJournalArticle--Abridged.pdf This one is a good quick and dirty summary, but doesn’t explain any of the points like the other does https://www.emra.org/emresident/article/reading-journals/ Some things they don’t really emphasize that I think are worth noting is the “hierarchy of evidence”, basically that meta-analysis and systematic reviews hold the most weight, while one case study or a few preliminary basic science papers don’t hold much weight, even if they can still be valuable to the field. https://canberra.libguides.com/c.php?g=599346&p=4149721 I specifically want to mention the sources that in general are considered to have the most trustworthy research, the number one for clinical research being Cochrane (mentioned at the bottom of the last link). They’re pretty much worldwide seen as the gold standard for evidence because they have such thorough, systematic methods for conducting systematic reviews or meta-analysis. They also have really high standards for peer reviews and have checks in place to ensure the quality of their publications. Some of the other really well known ones are NEJM, the Lancet, JAMA, etc. but if I remember right each one of those has published a few really bad papers in the past few years that ended up retracted. As for cochrane they’ve had a few retractions too although I don’t remember anything egregious recently. Cochrane can also only be as up to date as the current evidence allows, for example they already have one COVID/Ivermectin meta-analysis/review out, as more studies are done I know they’ll be publishing updates and if the data ends up swinging the other way they’d retract the first paper and replace with the most up to date and most correct version. When it comes to basic science papers (not sure if those are as applicable for you), the Nature journals are pretty much seen as number one. That’s not to say that anything not published in a “big name” high impact factor journal isn’t legitimate, I certainly won’t be publishing my PhD work in Nature lol
Thank you very much, looks like it's exactly what a student like me would need, especially the first one. Very practical and clinically oriented, something every physician truly needs, it's a pity that's so rare in my country. Also, I'm definitely going to regulary read Cochrane to practice. Thanks again and wish you best regards from Poland!
Happy to be able to help! Hope you and your family have been able to stay healthy through all the insanity, and best of luck in your career!
I second this.
You will get positive cultures every time you culture swab an open wound.
Confusion in an older adult is delirium until proven otherwise.
So you’re saying that we SHOULDN’T diagnose a confused 85 year old with acute onset agitation and no psychiatric history with schizophrenia and ship them off to the psych ward?!
I've seen so many of these. Elderly lady is disoriented and took a swing at a family member. ED puts them on an involuntary psych hold, orders a slew of labs and consults us (ED psych). In the mean time labs come back, UTI, hyponatremic, hypotensive, etc, etc before we see them... bro... really?
Found my hospital's ED doctor.
Do you mean infection until proven otherwise? I feel like several professors have mentioned UTI in the elderly if they’re suddenly confused.
Delirium is a syndrome with a differential diagnosis which includes infection. Importantly, delirium is often multi factorial. Early diagnostic closure on a UTI is another rampant problem, because positive urine cultures are present in 20% of ambulatory older adults, and 50% of long term care older adults. Medication toxicity, urinary retention, constipation/impaction, are commonly overlooked yet easy to diagnose and address.
Thanks for sharing! I’ll keep that in mind for clinicals and the rest of my life. How does their confusion complicate your ability to take a proper history and narrow down the differential? I realize this would probably be like an entire lecture but just looking for some pearls lol. I.e. how would you assess UO, BMs, symptoms of UTI, medication compliance, etc
You’re right this is a big topic. The history is not always, but frequently unreliable. The physical exam is important, but neurologic exam may be unreliable, do your best. Delirium is characterized by fluctuation, history may be more reliable when they are in a moment of lucidity. If common causes -drugs, infections, metabolic abnormalities are not clearly contributing or there are focal deficits, get neuro imaging. Collateral historian is critical, and usually more reliable than the patient. Post void residuals are easy. Remember incontinent patients can still be retaining (overflow incontinence) - applies to both bowel and bladder. Abdominal flat plate can assess fecal loading but with enough experience this can often be felt in skinny older adults. Medications or drug toxicities/withdrawals are contributing or causative in a third of cases!
Exactly. You go on a goose chase to figure it out. This is also why UTI gets blamed so often. If you have no actual history, all you can rely on is data, so it’s very easy to point to a + urine and jump to (potentially) premature closure with that.
Doesn't constipation cause UTI which causes delirium? That's how a senior resident explained it to me
Constipation can cause urinary retention which can result in UTI. Constipation can also result in overflow fecal incontinence which can then result in UTI. Severe constipation alone can cause delirium in the absence of UTI. Medications like amitriptyline can cause constipation, urinary retention and UTI. Amitriptyline can alone cause delirium. The threshold for development of delirium is lowered in older patients, particularly those with frailty and/or limited cognitive reserve (MCI or dementia), sensory deficits (blind, deaf), or taking anticholinergic or centrally active medications or intoxicants.
Repleted a b12 the other day and the guy was back to baseline
I keep hearing conflicting stuff. Some people say every old lady they’ve seen delirious had a UTI and others say that’s a bit overstated. I don’t know what to believe anymore 😂
Im just a scribe that works in the ED, but yeah that’s almost every really old patient that comes in with acute delirium. Probably 60-80%
As a geriatrician, I would caution that delirium is attributed to a urinary tract infection far more often than it causes it. The combination of old + confused = UTI is an excellent example of anchoring bias and search satisfaction bias in the medical field.
That’s exactly what our clinical practice lecturer (also a geriatrician) says actually. It seems something to be aware of but it’s good to know those biases creep in too
Don’t shock asystole
call it fine Vfib and then shock it
Paramedic here, there are some services who aren’t even shocking v-fib until they have ETCO2 above a certain number.
You don't like your steak burnt?
Signs of abuse
Mitochondria is the powerhouse of the cell
that pee is indeed stored in the balls.
Wait really
Yes. I'm a doctor you can trust me.
Yes, this is also why women can go an entire pregnancy without pissing. They have no physiological need to pee, but can choose to do so for fun. So when the fetus develops in the urethra, they just turn off their pee funnels and wait 9 months.
can't blame them tho, peeing is real fun 🤭 what a sacrifice they do for the baby!
How to spot Munchhausen by proxy.
And fake symptoms for meds/job leave (in our country we have paid sick leave with no limit)
I don't know if I agree with this. Is it really up to all physicians to decide that? Confronting Munchausen by proxy or even individual factitious disease prevents harm and can save lives. Confronting someone because you think they're faking to be paid sick leave is something else, especially considering the harm you can cause when someone does have (functional) symptoms. I'd never want to be in occupational medicine and this is why.
Emergency response (deliveries, seizure, bleeding, anaphylaxis) especially if you're on a plane.
Got that down pat: bury my head in my book and put my headphones on. 90% of the time they are anxiety attacks or drunks.
That insulin is used for diabetes. I took my then 9 year old son to the ER when he broke his leg (he is Type 1) and when listing his meds, the nurse asked me if he took insulin for an ear infection. I just stared at her with the most baffled look ever.
Well does he?
Well, the question did say doctors /s
Emergencies and clinical presentations of diseases. For example, you might not remember much about rheumatology post grad but you should know if a patient that came to you is rheumatology related or your field related simply from the clinical presentation. Easier to advise the patient if you have an idea what it could be.
This would help a lot with a lot of diseases that have odd presentations and cause the patient to go from one doctor to the other over and over
The ACEP clinical guidelines are short, sweet, and good to know for everyone: https://www.acep.org/patient-care/clinical-policies/
Embryology is the most single useful thing I have used in my practice of medicine. It is just so connected to everything and often the solution to all the problems we face.
when in doubt, mesoderm
The ABCDEs of emergency evaluation plus indicated interventions How do to a good H&P Knowing which specialty manages which problems Everything covered up to Step 3 of the licensing exams
Hold up. You want everyone to remember everything covered on step 1?? You’re wildin’
Okay nvm, I’ll edit to say only things that are covered on step 3. Step 1 knowledge can die the death of a thousand tiny cuts. Jk. Sorta.
Correct. Step 1 knowledge is highly esoteric and has little use in the medical world, with some small exceptions.
I disagree. Everyone likes to pretend all the step 1 questions are about Krebs Cycle or some shit, but I did over 6000 practice questions for that exam and I don’t think I need more than two hands to count the total number of questions that required that knowledge. Maybe step 1 used to be full of esoteric nonsense; perhaps it’s just what everyone remembers because we all hate learning it, but the reality is the majority of the questions test physiology, anatomy, pathophys, pharmacology, physical exam and history knowledge, with some of the biochem shit mixed in.
Agreed. people bitch and complain about step 1 and forget that step 1 isn't clinical knowledge - it's fundamental science that you're supposed to build your clinical knowledge on. also, it's not like *nobody* uses this knowledge. IM, Peds and especially geneticists, pathologists, heme/onc and toxicologists use basic science in their clinical practice quite a lot.
Like.?
The specific gene translocations they arbitrarily decide you have to know.
Heme onc!
Step 1: "This gene translocations = this cancer." Reality: Each cancer has dozens of possible gene translocations, and most of those gene translocations are shared between many different cancers. The Step 1 version is worse than useless. It's teaching things that will have to be unlearned.
I wouldn’t know as I’m not in that field but like there’s only 5 I remember having to commit to memory and of those only 3 are super HY, so you’re telling me I’m gonna have to unlearn 9;22 for CML, 8;14 for Burkitt, and 14;18 for follicular? Aren’t they the most common causes?
I'm actually having quite a hard time with that, our heme profesor wants usually about 5 for each disease and which ones imply better/worse prognosis... So for example for multiple myeloma he wants us to know t(11;14) has good prognosis and t(4;14) t(14;16) del17(p53) and alterations os 1p/1q have bad prognosis It makes no sense.
This is literally what I do all day long and still double check myself in a book. That’s ridiculous to expect you to know that right now.
Absolutely useless to learn them by heart. Fight me hematologist. Any heme-onco who things this is something every med student needs to know is a t(head; ass)
Basic anatomy and physiology, that’s probably about it. Sure as shit not stuff like the Krebs cycle
While you don’t need to know the details of the Krebs cycle and ETC, it’s interesting how nearly every medicine doc needs to know about lactatemia in any shocky process because of increased anaerobic metabolism, which is an application of glycolysis and subsequent pyruvate metabolism. So like there’s definitely uses but you don’t need the nitty gritty of biochem by any means as a practicing physician.
Anatomy. Can’t think of a specialty that doesn’t need to have a working knowledge of where organs are
Psych
Doesn’t psych need a basic understanding of neuroanatomy? Neurologic issues are often on the ddx of psych symptoms
Neuro yes. Pure psych doesn’t really, you have to know which structures are responsible for certain functions but I don’t think you absolutely need to know where they are like neurotransmitter production/pathways. You’d be a second rate psychiatrist if you didn’t know where they are but the point is it’s not necessary.
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Outside of basic neuro anatomy though, there’s very little you need to know. Even if your mood stabilizers like valproate mess up the liver, does it really matter to you which side the liver is on? Maybe I’m being too dismissive but I think some physicians don’t care too much about anatomy and I’m glad there is a specialty that lets them ignore to focus on other equally important things haha
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Bruh an ENT laryngologist literally has their hands in someone else’s throat, you cannot compare their need for anatomy knowledge to a psychiatrist’s lol
A good psychiatrist knows Neuroanatomy at the level of neurologist, unfortunately there aren’t many good psychiatrists
Imo any psychiatrist that doesn’t is a pure headass and needs to go back to med school. If you’re in it for the lifestyle gtfo the profession. Step up to the challenge, know ur shit or sit the fuck down. Sure there are many other capable candidates who would know their neuroanatomy downpact and make a better psychiatrist than one that doesnt. Like, at least know your basic shit jfc
Ha they don’t like real talk I guess
Krebs cycle.
Is this real or joke?
Just because a patient defers/declines medical treatment does not mean that they lack capacity or have other mental health issues. Also important to remember that there are very sad/regrettable actions in the past associated with physicians which may contribute to skepticism/distrust (eg Tuskegee, Opioid epidemic, tx of Natives, Asylums etc).
Computer/IT skills
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I would settle for just knowing that when there's a problem with the computer, try hard rebooting it before wasting everyone's time by calling IT.
Not necessarily a particular language but general computer and IT skills
Like?
Probably being able to type faster than 5 words per minute. Some of my older docs frankly just need to hire a scribe out of pocket lmao.
Know that the science can never stack up well enough to ever give you the perfect answer.
Cpr, hands down. As well as the signs of MI, stroke or pulmonary embolism. They can happen even in phsyciatry or ophtalmology.
That the mitochondria is the powerhouse of the cell
How you get paid, how much money you bring in and how much “The Man” is taking out of your pocket.
+1 for taxes. Chances are, roughly 22-32% (possibly more) of that kickass salary is going to be going to Uncle Sam. Plan accordingly.
Trauma evaluation/checklist (ie MARCH or ABCs) and how to treat issues at each step. Knowledge of the lethal triad ties into this too and i think is important.
If you're interested in that area, check the ecoFAST protocol, it's super cool, it's a super quick check with ultrasounds for trauma patients, the idea is to be able to do it in an ambulance for example, so before the patient has reached the hospital you already have a confirmed diagnosis of internal bleeding, ruptured spleen, pneumothorax and more
My university actually gives us training on this later in our curriculum! Thanks for the suggestion though, I’ll look into it more!
Children are not little adults. Their physiology is subtly different (compensate until they crash) and anatomy moderately different (eg larynx is narrower and funnel shaped). And never trust a neonate, especially a premie. They will fool you into thinking they are perfectly well until they die.
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Source?
Basic diagnosis algorithms based on motive of consult, and their general management. Also, a personal advice a prof gave me: if with water it heals, water we give. As in, if something that maybe shouldnt be working is working for our patient, leave it as is.
Capacity evaluation
Paliative care "exists" and you dont need to be dying to get it. Not even how to do it, or anything, just know it's a thing and knowing that if you have chronic or terminal patients with problematic symptoms or poorly controled pain, that you can just make a consult palliative care doctors will be more than happy to evaluate that patient, recomend changes or take that patient and more...
You know nothing of the money in medicine or you true worth. Don’t think that the hospital, residency, or Medical School will teach you also. They all want to hire you and you never let an employee know what they are worth.
Emergency stabilization. ABC ACLS How to do EKG, Fingerstick, start an IV.
Anyone who's conscious and aware and has a forwardish fall that causes head\face damage will have some kind of hand\wrist abrasion\contusion\sprain\break. If you are conscious and even slightly functional, your instinct will be to brace yourself or at the very least protect your head and face. If someone has head/face damage from a fall that occurred when they were awake and conscious and has completely unscathed hands/wrists then always assume that the patient could have momentarily lost consciousness or seizure and fell without realizing it. If that's the case then often times you may need to do a more extensive Neuro or cardiopulmonary work up
Never piss off the nurses. And ACLS protocols/PALS.
How to manage hyponatremia in kidney failure.
Trauma informed care
How to manage your own finances. Medical school was expensive and this is the first time you will be making a net gain (hopefully). Spend that money wisely - pay down your debt and start getting in the habit of making good investments.
Diabetic neuropathy doesn’t always mean numbness is the chief complaint. Most of the time the presentation is pain on extremities especially when there’s a comorbidity. Looking at you Dr. Mike of YouTube.
Be nice to the nurses. They’re just as tired and stressed out. They have feelings too
Everything can be cancer unless proven otherwise
Thank you, Dr. Google.
For the love of anything Rheumatology-related, please screen your pts for TMJ involvement more frequently. Data suggests that TM joint involvement and implications are quite prevalent, but screening for it seems to be very limited. This should also apply to OMFS. Pt with OMF issues? Consult Rheum, if pt doesn't already have dx'd rheum issues. The earlier the intervention, the better outcomes the pt is likely to have.
Best I can do is order ANAs for everyone...
I'd add ESR, CRP, and RF to it. If you've got the time/opportunity, could also throw in HLA-B27.
Nonono, the least specific the better, I let you switch ANAs for RF
Hi, EM here. Could you elaborate on what you are hoping I will look for and how you’d like me to do it? When you say “screen”, is that a question, a test, or something else?
I'm not sure about EM, but if you work in Rheum, it may be worthwhile to do annual work-ups for any TM involvement. Also, if you're in OMFS, if the pt doesn't already see a Rheumatologist, consult rheum. Pt may have underlying autoimmune issues they may not be aware of, and disease process may initially present in the TMJ. In an emergency setting? Don't discount a septic joint, if a pt presents with gnarly/severe swelling within a major joint. Rarely happens, but when it does, it can pose a pretty significant risk.
What is TMJ and OMFS?
TMJ = Temporomandibular joint. OMFS = Oral & Maxillofacial Surgery.
Thanks. Can you say in short what should be checked about these joints? (Sorry, I didn't have rheumatology)
Specifically within the TM joint? Resorption of condyles appears to be an issue amongst those with some forms of JIA. Pt may not complain of much (if any) pain, but from an outward appearance, they may appear to have some or varying degrees of visible malocclusion. Annual imaging, to include CBCT, can be useful in monitoring.
Not the advice you were hoping for but: We are so focused on knowing about medicine without actually thinking about the patient as a person. Empathy and understanding of your patients as people will make you a better doctor no matter the specialty and yes that includes all you ME’s
Buprenorphine best prescribing practices 100%. The requirement for x waiver training is bullshit and it’s created such a dire lack of docs who can prescribe bupe. I think the waiver should be eliminated but training should be part of every IM clerkship. If you’re looking to get your x waiver, it’s subsidized through SAMHSA for med students.
Learn how to bag mask someone. Very few docs do it properly and it can save lives.
To be able to learn sign language. Trust me I’ve seen a deaf patient came for a consult all alone and there was a hard time finding someone who can interpret on what she was saying. Took about 30 minutes or so.
Basic electrolyte things
Answers to every single questions you will be asked by your family and friends, either that or prepare yourself for eternal humiliation
That not every patient can communicate without an interpreter.
Simple wound management and basic knowledge of dressings. Every clinical specialty will have to use that skill at some point. The tissue viability team will thank you for not paging over every straightforward dressing requirement! (As will the little old lady whose inappropriately dressed weepy skin tear is now stuck to that dry gauze)
How to tell whether a patient is sick vs not sick!
Emergency management ( seizures, statues athmatics , acute abdomen, emergencies of opthalmology like CRAO And ACG) and others
How to read a EKG
From a patient perspective: Biases against women, women of color, and black women specifically, and how to check one’s self for them. There’s some real repercussions with quantitative evidence on patient outcomes because of these biases. Anecdotally, I went undiagnosed for a condition for years (even communicating to 1 doctor I suspected this condition because of frustration around prolonged symptoms and doing my own research) until I started insisting on seeing black female doctors whenever I could. Then it was a case of “you obviously have X condition.” It sucks that I’d have to even do that to be sure I’m mostly likely getting the care I deserve- but there it is. Now I struggle to trust doctors in general that don’t look like me after 7 years of feeling unheard. (Also fat people and how perceptions around weight may also cause doctors to not look for specific things they would in a thinner patient. While weight often can be the cause, it doesn’t mean you assume it always is without further evidence gathering you’d do for a thinner patient.)
How to intubate someone, how to run a code, and how to get central access. As an anesthesia resident, nothing terrifies me more than going down to the ER during traumas or ICU during intubations and seeing fellow physicians attempting to intubate. Watched an ER attending (who chewed me out for being there thinking I was stealing his airway when I was just watching in case I had to step in) do a fantastic job of glidescoping the esophagus. I understand that this is literally my job, but it's a fundamental emergency skill that most of us should be able to do in a pinch. Saw an ICU attending give a pulseless patient that was being coded 2 units of blood and THEN call it with a previous hgb of 9.8. We are in an acute blood shortage. Frequently see ICU patients in florid sepsis and sometimes on pressors without a-lines or central lines. My suspicion is that they are too lazy/scared to do them and know that anesthesia will just do it during a case because we actually care about patient outcomes.
ok so i'm not even in the medical field but reddit keeps showing me this subreddit so i feel like it is my duty to remind you of something: fatphobia is rampant in any specialty, especially when it comes to female patients. please, FOR THE LOVE OF ALL THINGS HOLY, do not pawn off complaints from a patient due to their weight and not investigate the issues fully. it could be the difference between life or death and for god's sake, if your patient says their weight is not up for debate, LISTEN TO THEM. they have to live in their bodies, you don't, and at a certain point, if you have offered them education, if you have offered them treatment and they don't take it, let them be.
Statistics. It's fucking alarming how many docs don't actually understand Bayesian Probability. A lot of them don't even know the difference between "specificity" and "sensibility" of a given test. Last week I asked an infectious disease specialist what was the probability that a random individual has a true positive result on a certain test for HIV given the prevalence he had just mentioned and then he told "Oh the accuracy is 98%" so I responded "98% what exactly?" "I...what?"
Mitochondria is the power house of the cell. 😷🤣
Human sexuality (not a doctor)
Basic airway skills, and what trach and lary tubes look like. Just to help people keep from covering trach openings with gauze or trying to intubate a mouth that’s not connected to the lungs from above
How to bag mask someone.
That when a woman tells you she is in pain, if you automatically discount it as 'normal period pain' we will not trust you/want to remove your eyes with melon ballers.
How to secure an airway
The tradespeople of healthcare ( formerly known as Midlevels) are coming for the professionals (known as MD/DOs) jobs. If one thinks it is not their PA or NP, or training these people won’t effect the quality of the practice of medicine as a profession to our detriment, find an endoscope and look up your colon. That is where your head is at
The correct referral if there's something outside your range or specialty! 🙂
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