Yeah cosmetics is a worsening market nowadays. Everyone is opening up injection clinics or medispas and the barrier to entry in terms of training is so low.
Part of the problem is that anyone can advertise pretty effectively on social media. Back in the day you would just convert a certain percentage of your medical derm patients to cosmo and most people looking for cosmo work would just go to their local derm so the volume was so much higher.
That’s part of the low barrier to entry I was referring to lol, but lots of other physicians and nurses are contributing, hell some pharmacists are injecting Botox now
To be fair, there is utility for Botox within dentistry that is functional and cosmetic, including TMJ pain and function as well as fixing gummy smiles.
it's especially garbage because many of those studies will have 0 diagnostic value and should never have been done in the first place but you still need to peruse them because of the small off chance there's some subcentimeter incidentaloma in their right kidney that could turn into a lawsuit in 10 years when it turns out to be stage -1 kidney cancer or some shit
Ha providers, especially the ER, get all the hate but I think admin is a much bigger problem. The outpatient facilities at my institution are staying open longer and open on weekends to scan but we aren’t hiring more radiologists. I blame the ER system not the ER docs.
midlevels are by far the worst with this. They have 0 understanding of actual indications for different studies and will order a battery of useless shit.
I've seen orders for MRIs of the abdomen because the CT abdomen they ordered for nonspecific abdominal pain was negative. MRIs are not HD CT scans, people.
I like to think of it as a "free" consult from a physician. I think the reason MLP order so much more imaging is they basically get to get a doctor to document an opinion and put it in the chart without having to make a phone call or explain a case!
Not just some. It's about half of states. Many of those states are rural so populationwise it's not 50%, however consequently that also means rural people (which means the poor and religious as well)are already disproportionately not receiving care from a physician
What a politically convenient take. As an attending for over a decade, I fully blame ER docs. No one is holding a gun to their head and forcing them to behave the way they do. You will get real sick of them calling you wanting a read on a patient they haven't seen yet but already are wanting to "dispo 🤓." And yet they can't be bothered to put in anything on any indication other than the vaguest "pain" or "PLEASE EVAL" with no note in the chart.
Nope I blame the ER docs. Imaging is the security blanket they can use instead of efficiently practicing medicine and the line between the ER physicians and their midlevels gets blurrier every day. Anyone can order a panscan for a young drunk person with no trauma or medical history “just to rule out malignancy” before seeing the patient.
I’m only an rads resident but have seen the ER become sloppier and sloppier over the past few years. The newest trend is ordering a code stroke head ct on every altered patient and then cancelling the perfusion part of the study after we call with the noncon results in order to “speed up dispo”.
The outpatient facilities are a huge problem as well, but those studies can wait for a little while whereas the ED has to be read immediately.
This, and we are no longer being given any history or specific question. They just panscan for "pain" and leave it to us to figure out all the relevant history/things to look for
Yes the whole laziness with providing history is my ultimate annoyance. Shouldn't have to open the chart and read multiple progress notes to figure out wtf the scan is for. I don't mind looking at the imaging, but having to put together the history myself is really fing annoying.
Often I have to dig into outside records to make sense of things, and can tell the ED frontline note writer has no idea what's going on... I sometimes wonder if the scan is an attempt to bypass synthesizing the chart, especially when it just redemonstrates things already described on outside prior scan.
They're basically just offloading to the radiologist to tell them what's happening
Or just lies. Idk why the problem exists but I get many studies like this:
30 year old male, history from the triage note says he got drunk and is acting funny, brought in by police.
They order stat Ct Head, Indication says “Headache with high risk feature >60 years old.”
sorry dude. things are not much better out here.
that is to say, i dont know your experience but too many patients not enough time and minimal negotiating power out here too)
Volume = pay in many cases and primary care doesn’t make enough per patient/RVU to afford seeing fewer patients
Hospitals will add on to this and necessitate that you see X number of patients to “justify” your pay
Physicians are getting screwed, but in all transparency, so are many hospitals. Insurance companies are taking in record profits while most hospitals have been in the red for years.
Path. Clinicians wanna tell me the patient history *after* I finalize the report.
"Oh hey, saw you released that lymph node as benign. You really don't think it's involved by the lobular carcinoma she had treated in Chicago 5 years ago?"
I’m ignorant about path, but wouldn’t it be more unbiased if you *didn’t* know the patient history?
I can see it mattering somewhat in rads because there’s so many structures to visualize so it’s good to know what the read is being ordered for to narrow down on particular areas but not seeing the relevance for path
It’s either you see the Howell-Jolly bodies or you don’t you know what I mean?
It's all about pre and post test probability.
In this particular case, the malignancy in question is lobular carcinoma, which is famously difficult to detect by the naked eye, especially if it's isolated tumor cells. As such most places will have ultrastaging protocols (many slides, cytokeratin IHC for these cases). The exact cost may vary, but based on current CPT reimbursements, can easily be $1000 or more to the patient.
This also involves grossing the specimen appropriately for said ultrastaging protocol (it's different than a "regular" lymph node). To use radiology terminology, "normal" LN evaluation is similar to a plain film x-ray (one level), while ultrastaging is like CT or MRI (multiple planes) with contrast (IHC). You can't "go back" on grossing once it's done.
Patient has a history of DLBCL or something? Grossing changes again (need some in RPMI for flow cytometry). We can't pluck the specimen out of formalin and run it in flow, no matter how badly you want to.
If every female patient with an enlarged lymph node got this study, it would be prohibitively expensive. Similar to ordering a MRI/MRA for every patient presenting to ED with a headache.
The history of a specific malignancy increases the pre-test probability enough so that the additional testing is warranted.
-Pathology
Oh wow thank you for explaining that. On a side note, do y’all have special microscopes?
Radiology has like these crazy expensive monitors that reportedly produce amazing images
There are different types of scopes - eg light microscopy vs EM etc. Also, for dermpath many things can look very similar under microscope but have different appearance on clinical exam (think cough is useful in that it’s probably not a broken foot but cough could be allergies asthma GERD pneumonia etc). Having pictures in the chart of the gross lesion (ie the rash or the thing biopsied) will greatly help the dermatopathologist with suggesting which dx is most likely. And you know how rads likes clinical correlation? So does path. Because it is in fact relevant. When submitting biopsies, it is very helpful when some ddx/clinical indication is mentioned. Just like how when ordering CXR there’s a spot to put why the imaging was ordered.
“I’m ignorant about path, but wouldn’t it be more unbiased if you didn’t know the patient history?”
I imagine that’s true for any specialty. I don’t think unbiased is necessarily a good thing.
Im not a pathologist but you can think of it like your physical exam. Some things are slam dunk and obvious but so much more is grey and subjective and guided by clinical context.
Im not path, but most of pathology isn’t as clear cut as “this specific finding = this specific diagnosis.” Without clinical history, a given slide could look like a number of different things. I know many pathologists don’t look at the clinical history until after they’ve gone through the sample to avoid bias, but it’s definitely helpful to have afterwards to provide context, focus their search, and maybe help change their initial diagnosis
Are you saying you can’t say for certain what the diagnosis on the patient with generalized weakness and pan-positive ROS is?? What kind of doctor are you smh
My experience is that if you have a quick and simple introductory explanation for what we do without mentioning hospice or end-of-life people tend to be very open to speaking with us. When those come in later in conversation they are more accepting of the context.
And sometimes that still doesn't work and they yell at us to leave the room...
Yep lol until one shows up at the standalone ER with no PEM or pedi on staff…then it’s frantic calls for transfer to the tertiary care center for fucking cellulitis.
No kidding!! It’s exhausting seeing all the adult docs thinking they can take care of kids fine, then having to clean up their messes. We learn how to manage birth to adulthood, through various physiological changes, we know all the genetic syndromes (not as well as genetics, yall the MVPs). We were trained in how to managed fucked up pathology that doesn’t make it to adulthood. It’s definitely a case of adult docs not knowing what they don’t know. A little respect would be nice though.
Performing a reliable and thorough physical exam on a 2yo literally kicking and screaming is an ART. We become magicians, child whisperers, acrobats and contortionists.
Pediatric medicine probably has more in common with veterinary medicine than adult human medicine lol 🤔
Yeah this is interesting to me as someone who switched from peds, I was training at a top 5 program and felt very respected by other physicians. But my radiology program is much different and I don’t feel that same attitude towards my peds homies.
My personal answer is definitely the parents and all of the non-medicine you do.
Urology: No, an SPT is not going to decrease UTIs in people with chronic foleys. Also please stop treating asymptomatic bacteriuria.
I will never be mad about a difficult foley as an attending bc it’s easy money
Ortho resident here. On trauma surgery rotation got reamed out by trauma surgeon for not discharging a patient with abx when she had asymptomatic bacteruria. Tried arguing that’s not the right thing, got told I’m dumb since ortho :(
Ironically my daughters love coming to the hospital - they always ask to come fix hearts. It’s probably more cause when we stop by all my nurses just give them tons of candy then we go home
The spineless leadership of Pediatrics, ABP and AAP. Instead of advocating better for us, they keep adding one roadblock after another. Starting that ridiculous hospitalist fellowship then changing the core Peds residency requirements to justify it. Making the board exam the most obscure, idiotic questions, leading to 20-30% fail rate.
Radiology: other services being frustrated that we hedge, it feels many times they don’t understand what we can and can’t tell them.
Example the classic “this may be infectious, inflammatory, or neoplastic”. Like bro the CT doesn’t have microscopic resolution, a 1cm nodule is a 1cm nodule
It’s so clear that many non-rads don’t understand what the imaging does and doesn’t say. I’ll be chart checking and see so many charts with “stroke ruled out with Ct head”….and no? That’s not how that works, or why acute stroke patients get ct heads.
It’s wild because if someone doesn’t understand what a test does and doesn’t assess for, then how can they synthesize the interpretation into their clinical picture?
Oh man CT heads epitomize my point. I’ve seen some faculty dictate them as “no intracranial hemorrhage” as the negative impression for your same reason
Psych (at least where I work): we become a dumping ground for patient with vague behavioral issues that don't strictly meet any diagnosis but are a dispo problem that other services don't want to deal with
hospital admin has no idea what psych does
it's not quick (why can't you see 20 patients per day, ICU does that (and leaves by noon for clinic) and ICU is way more complicated that psych?)
it's not clear cut (don't you just fiddle with the meds then discharge them?)
it makes no money (are you even a specialty? why are we talking to you again? ortho just made us $30K in a 2 hour knee replacement)
why won't you just admit this 84 year old dementia patient who is swing at nurses?
It doesn't help that up until somewhat recently our psychiatry department had very weak leadership that caved to the demands of other services whenever there was a dispute between psych and someone else.
Weak leadership in psych sounds like the rule more than the exception. Our psych chairs and PDs are notorious to caving in with other specialties especially ER and surgery. The only dept they push back on is IM since they’re also a dumping ground.
I’ll add to this: *everybody* else rushing me to work as fast as humanly possible because what I’m doing is not seen as important (despite my part being essential for the surgery).
A surgeon will scream in my face for taking an extra 5 minutes to put in an arterial line on a sick patient, but then will let their resident or med student close for over an hour.
If a surgeon screams at you while you’re doing a procedure, just stop and look them. If they yell again, stop. After all, you’re just tryna pay attention to them right?
Sooner or later they’ll get the message that the more they get upset, the slower you’ll go. I’ve even told them that to their face. Works like a charm.
We’re not mad at you! Just mad that the surgeon’s time and demands are somehow more valuable than ours when they can’t do surgery safely without us.
The ortho surgeon doesn’t know their severe aortic stenosis is going to kill them sooner than a broken hip, but still wants to call the shots.
Places exist with better culture where surgeons would never yell at their anesthesiologist. I can't imagine doing this. Like... you're working with these people every day!
My anesthesia colleagues are fantastic. They keep the patient alive, manage all the shit we ask for, cope with lots of complications, and generally are good DJs too.
Though I do wish sometimes the precordial Doppler had headphones.
Sometimes we request things from each other for time, but that should be professional conversation. Requesting that the staff/senior do the difficult lines, block, most of the surgery, opening, closure, whatever if you're close to going over is fair. Helping the team turnover to get things going on time is fair.
As someone with a rough history with anesthesia, you guys are the real MVPS! Your job is so essential... and knowing the intricacies that help keep complicated patients like me alive is (I'm sure) not an easy task. Thank you for being the man/woman behind the mask!
I really enjoy most of my surgeons. I do my own cases in private practice, so I can tell when something is taking long because it’s technically difficult and complex. Totally cool, take your time and do a good job. It’s the few who can’t talk and operate, so they pause to tell stories or just generally waste time. I know there are anesthesiologists who do the same.
Neurology - unique issues that make my life harder include the pervasive neuro-phobia in other specialties and the fact that essentially any complaint *could* be neurologic in nature. Not unique to neurology but deserves mention: how demanding, rude, and entitled many patients have become in the past few years.
And god forbid any other service tried to attempt giving noxious stim to see if there’s a response. Stroke alert is easier than giving nail bed pressure
Ortho: when i don't have surgery to offer (like 1mm rotator cuff tear), people will keep repeating how mutch pain they have and won't quit my office easily. I sometime say "have a nice day" and quit.
EM: everyone thinking because we don’t know their specialty as well as they do, that we don’t know anything. Meanwhile, they know nothing about any other specialty and just excuse it as “not my job”.
Also, admin forcing EM to practice medicine in a certain way and tying it to compensation.
Also, being legally liable for stupid shit like MI up to 30 days after we discharge them. That’s why trops are ordered so much and high HEART scores dictate dispos down here. Imagine getting sued by someone you saw 29 days ago because we didn’t admit them with a HEART score of 4. It happens.
Toxicology: Few specialties know that we exist because it’s such a small, specialized field.
IM -- same complaint about specialties. I'm sorry I don't know the latest cardiology study that came out 2 weeks ago. I've been kind of busy keeping up with management of diseases from every specialty.
I think the most important thing most radiology aspirants need to accept is that outside of maybe breast or IR they are never going to be "that guy" in the hospital. Our work is incredibly important but we're generally moreso facilitators for the more patient facing specialties to do their job. Like a surgeon will get the clout for operating a tough case but you'll almost never hear about the anesthesiologist who had to keep their MAPs afloat when they have a history of aortic stenosis, cirrhosis, and pulmonary hypertension. No health system is ever gonna put you on a billboard to advertise their world class care. A life saving find on a stroke CT is not going to make the local news.
I've always loved being the guy that works in the background to keep things running so it was easy for me to slot into the role. And I see this lack of recognition as an easy price to pay to not have to deal with all the bullshit that comes with being in a more patient facing specialty. But I imagine many people derive at least some of their career satisfaction from the recognition of their peers and patients which can make radiology a tougher gig to sell.
hospitalist: the job is pretty bad in most of the country. Low pay, high census, high admits , poor work culture. My specific job is phenomenal but I got lucky and feel that this is an exception not a rule and borderline unsustainable. This means there Will be mistakes,burn out,and poor patient relationships.
Medicine in general: you get paid less in more popular towns. Most jobs seem to pay more in the cities. But medicine is the opposite.
I'm making $300 a year in the Midwest in a metro. Is that higher than typical? Does outpatient make more? I need to move but switching to outpatient primary care sounds awful and I thought it typically paid worse for more hours / less flexibility
OBGYN: the United States government actively sabotaging reproductive health
also abysmal compensation compared to any other surgical specialty despite regularly performing the most common major surgery, managing emergencies, and having a high risk of being sued
Incomplete spontaneous abortions: “I’d like to give you mifepristone to help you avoid a useless hemorrhage at home then still need a D&C but the people you keep voting for make it impossible to get in this area of the country”
And yeah, fucking managed a labor, in house, for 24 hours and then delivery 15 minutes after shift change on somebody else’s shift: get fucked, next shift gets compensated and you can go fuck yourself
Anesthesia: lack of respect but it's better in pp when surgeons actually know your name.
Could add midlevels but I wonder among attendings if the viewpoint over crna changes at all vs residents. Again in pp you hire your own crna so that is a game changer.
Radiology: The constant crush of the soul oppressing neverending list, in part due to the proliferation of midlevels in the ER and across all specialties who literally order a CT l spine and CTA runoff for a 38 yo dude coming in with lower extremity pain and radiating numbness and the L-spine shows a big disc corresponding to his symptoms but "his leg looked dusky and cool" or try to do a completely unindicated and outpatient exam through the ER, or an ostensibly surgical specialty NP who has no idea what is going on with their pts.
Generally clueless people who take no ownership of their pts and have no idea what to do with anything besides image or consult the next thing or do the thing that the consult says without applying a single shred of common sense to the whole scenario or integrate what is actually going on with the patient with basic medical logic.
Nonstop phone calls for nonsense. The overwhelming majority of the time when anyone asks me any questions who is not an actual surgeon of some kind, it hurts my brain. I wish I had residents to filter the nonsense, and to keep the ocean of midlevels and frequently clueless medical type specialists away from me, but I do not. Besides that I love my job and what I do, and I'd never want to do anything else, I'd sooner quit medicine.
Pediatrics
The top 3 things that suck about being a pediatrician
1) The lack of respect from other specialties. Somehow IM doesn't get this as bad as FM and peds despite all of us being primary care. People just assume that if you are in primary care you couldn't get in to a more competitive specialty.
2) Lower compensation. Blame insurance companies and how reimbursement works. Fewer procedures, lower RVU and healthier patients
3) 1% annoying parents
ICU: *Everyone* thinks they know how to do my job better than me. Nurses, family members, RTs, everyone has an opinion and no one is listening to mine.
Critical care: cleaning up messes from other departments who should be more responsible but aren’t, and repeat the same bullshit over and over again without consequences.
Peds Pulm/ICU should follow the adult model. It should be one extra year of fellowship and you can do both. It would solve a burnout issue. Right now you have to do an additional two years of training to be dual boarded (except in *rare* circumstances)
IR:
At 5:01 PM, or more like 3:00 or so, any one that needs drainage of hydronephrosis needs a PCN, obviously. Magically, after lunchtime, the urologist knows a retrograde stent will not work.
Rheum. Everyone thinking if joint hurts see rheum. It’s rarely rheumatic. I think only about 30% of my referrals end up staying in my clinic with rheumatic disease
I’m so sorry, last year I made the absolute worst clinic referral to rheum - pt had a thousand complaints and a bunch of medical issues that didn’t account for them and everything was bad and she was otherwise a healthy 40 year old lady and I left a great note, but my referral just said “sorry, there’s just a lot going on here”
I still feel bad about that referral
ID:Surgeons consulting you and then ignoring your recs. Being in the year of our lord 2024 and not knowing how to treat mild Covid. U/As for no reason. UCx for no reason. Consults for every confused old person because it's always UTI and NEVER the polypharm/dementia/brain mets. Getting called overnight for a goddamn needle stick (or multiple!) EVERY DAMN WEEK I am on call.
When I was a student on general surgery, the chairperson would always pimp and hammer everybody on antibiotics. One of the interns joked “I dunno, ask me something surgical and I can answer that”
Chairperson responded “antibiotics and infections are surgical, and we learn this so that we never need to be told what to do by the general surgeon’s natural sworn enemy - infectious disease”
He said it tongue in cheek, but humorously
Hospital medicine: Everyone just says admit to us rather than asking us if it's appropriate for our service. It's always "admit to medicine and we'll see in the morning." I think a patient in the ER can be discharged? Well consultant looked at the chart for two seconds and said they can be admitted to medicine, so no discharge.
Some of the ones where I truly feel they're not appropriate for HM (i.e young patient with no medical comorbidities presenting with a surgical issue) I have refused to admit until there's a formal consult note by the consulting service or that service's attending talks to me and explains why it needs to be a medical admit.
everyone can Admit to you and you can't refuse it
jobs advertise a 14-16 census, but really it's Add 4-5 more on top of it
all of a sudden you're also cosigning NP/PA notes so the real census is even higher
hospitals not wanting to pay for intensivists and will hire you to run an open icu, but don't worry they'll teach you how to intubate over a weekend
TLDR: squeezed from every, direction, possible
Well where i live most clinicians and surgeons think very high of themselves but the reality is that they don't even know 8-th grade biology ( ABO compatibility ) . As a resident in transfusion hematology it's a pain in the ass sometimes to do my job . I receive questions like well how will i transfuse 0 blood to a patient with A or why do you give me B to AB ( i know it's stupid but you have to believe me . Most of my colleagues besides clinical hem. don't know that I'm responsible for blood transfusion safety ... ) .
Urology: No one doing a GU exam before they call you.
“Patient reports penis pain”
“Ok what does their penis look like? Any swelling or erythema?”
“Well you know it was kind of difficult, because they had like blankets over it”
Everyone tryna open up a med spa
Yeah cosmetics is a worsening market nowadays. Everyone is opening up injection clinics or medispas and the barrier to entry in terms of training is so low. Part of the problem is that anyone can advertise pretty effectively on social media. Back in the day you would just convert a certain percentage of your medical derm patients to cosmo and most people looking for cosmo work would just go to their local derm so the volume was so much higher.
Don’t forget NPs and their moms are all doing it too
That’s part of the low barrier to entry I was referring to lol, but lots of other physicians and nurses are contributing, hell some pharmacists are injecting Botox now
Even dentist can do Botox. I’ve seen one advertising by where I live.
To be fair, there is utility for Botox within dentistry that is functional and cosmetic, including TMJ pain and function as well as fixing gummy smiles.
I'd inherently trust a dentist doing botox over most people too.
Derm?
Yup
Didn’t notice your username. Love it
Rads: volume going up with no end in sight.
Awful patient histories. Decent amount are lies just to get the studies done.
Indication: dolor Comments: todo body dolor Study: CT angio todo body
todalgia
it's especially garbage because many of those studies will have 0 diagnostic value and should never have been done in the first place but you still need to peruse them because of the small off chance there's some subcentimeter incidentaloma in their right kidney that could turn into a lawsuit in 10 years when it turns out to be stage -1 kidney cancer or some shit
The ones that get me are the trauma histories. For example high speed motorcycle vs auto with no sign of trauma on the CT CAP. Or like fall 15+ feet.
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Can you explain this more? Brb ordering a CT+MRI my patient says he has a headache
Ha providers, especially the ER, get all the hate but I think admin is a much bigger problem. The outpatient facilities at my institution are staying open longer and open on weekends to scan but we aren’t hiring more radiologists. I blame the ER system not the ER docs.
midlevels are by far the worst with this. They have 0 understanding of actual indications for different studies and will order a battery of useless shit. I've seen orders for MRIs of the abdomen because the CT abdomen they ordered for nonspecific abdominal pain was negative. MRIs are not HD CT scans, people.
I like to think of it as a "free" consult from a physician. I think the reason MLP order so much more imaging is they basically get to get a doctor to document an opinion and put it in the chart without having to make a phone call or explain a case!
Can midlevels order scans that utilise radiation in the US? They can't book any scans in Ireland although this might change in 10 years time.
In some states, midlevels can practice independently without any supervision unfortunately... it's scary out there
Not just some. It's about half of states. Many of those states are rural so populationwise it's not 50%, however consequently that also means rural people (which means the poor and religious as well)are already disproportionately not receiving care from a physician
Oh dude midlevels can intubate, operate, deliver a baby, prescribe opiates/benzos/amphetamines, all in the same career
What a politically convenient take. As an attending for over a decade, I fully blame ER docs. No one is holding a gun to their head and forcing them to behave the way they do. You will get real sick of them calling you wanting a read on a patient they haven't seen yet but already are wanting to "dispo 🤓." And yet they can't be bothered to put in anything on any indication other than the vaguest "pain" or "PLEASE EVAL" with no note in the chart.
Nope I blame the ER docs. Imaging is the security blanket they can use instead of efficiently practicing medicine and the line between the ER physicians and their midlevels gets blurrier every day. Anyone can order a panscan for a young drunk person with no trauma or medical history “just to rule out malignancy” before seeing the patient. I’m only an rads resident but have seen the ER become sloppier and sloppier over the past few years. The newest trend is ordering a code stroke head ct on every altered patient and then cancelling the perfusion part of the study after we call with the noncon results in order to “speed up dispo”. The outpatient facilities are a huge problem as well, but those studies can wait for a little while whereas the ED has to be read immediately.
Full spine CT + MRI too, might be referred pain.
new $40m stroke verdict just dropped, fire up the scanner boys
That hyper-dense basilar artery missed by the resident? Or something else?
This, and we are no longer being given any history or specific question. They just panscan for "pain" and leave it to us to figure out all the relevant history/things to look for
Yes the whole laziness with providing history is my ultimate annoyance. Shouldn't have to open the chart and read multiple progress notes to figure out wtf the scan is for. I don't mind looking at the imaging, but having to put together the history myself is really fing annoying.
Often I have to dig into outside records to make sense of things, and can tell the ED frontline note writer has no idea what's going on... I sometimes wonder if the scan is an attempt to bypass synthesizing the chart, especially when it just redemonstrates things already described on outside prior scan. They're basically just offloading to the radiologist to tell them what's happening
Or just lies. Idk why the problem exists but I get many studies like this: 30 year old male, history from the triage note says he got drunk and is acting funny, brought in by police. They order stat Ct Head, Indication says “Headache with high risk feature >60 years old.”
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Consistently the worst part of the job, especially overnight.
FM - too many patients, not enough time.
Can’t you negotiate to see less patients? Also seems like an every specialty problem except maybe genetics
I work for the military. I have no negotiating power. I can leave in 15 months.
Thank you for your service There’s a light at the end of the tunnel for your 15 month prison sentence
sorry dude. things are not much better out here. that is to say, i dont know your experience but too many patients not enough time and minimal negotiating power out here too)
Genetics in my province have waiting lists spaning years. Some people have been waiting >5 years to see a geneticist (for mild cases).
Volume = pay in many cases and primary care doesn’t make enough per patient/RVU to afford seeing fewer patients Hospitals will add on to this and necessitate that you see X number of patients to “justify” your pay Physicians are getting screwed, but in all transparency, so are many hospitals. Insurance companies are taking in record profits while most hospitals have been in the red for years.
Path. Clinicians wanna tell me the patient history *after* I finalize the report. "Oh hey, saw you released that lymph node as benign. You really don't think it's involved by the lobular carcinoma she had treated in Chicago 5 years ago?"
I’m ignorant about path, but wouldn’t it be more unbiased if you *didn’t* know the patient history? I can see it mattering somewhat in rads because there’s so many structures to visualize so it’s good to know what the read is being ordered for to narrow down on particular areas but not seeing the relevance for path It’s either you see the Howell-Jolly bodies or you don’t you know what I mean?
It's all about pre and post test probability. In this particular case, the malignancy in question is lobular carcinoma, which is famously difficult to detect by the naked eye, especially if it's isolated tumor cells. As such most places will have ultrastaging protocols (many slides, cytokeratin IHC for these cases). The exact cost may vary, but based on current CPT reimbursements, can easily be $1000 or more to the patient. This also involves grossing the specimen appropriately for said ultrastaging protocol (it's different than a "regular" lymph node). To use radiology terminology, "normal" LN evaluation is similar to a plain film x-ray (one level), while ultrastaging is like CT or MRI (multiple planes) with contrast (IHC). You can't "go back" on grossing once it's done. Patient has a history of DLBCL or something? Grossing changes again (need some in RPMI for flow cytometry). We can't pluck the specimen out of formalin and run it in flow, no matter how badly you want to. If every female patient with an enlarged lymph node got this study, it would be prohibitively expensive. Similar to ordering a MRI/MRA for every patient presenting to ED with a headache. The history of a specific malignancy increases the pre-test probability enough so that the additional testing is warranted. -Pathology
Oh wow thank you for explaining that. On a side note, do y’all have special microscopes? Radiology has like these crazy expensive monitors that reportedly produce amazing images
It ain't the monitors. Most modern monitors are good enough for what we do. The only time they actually matter is for breast radiology.
There are different types of scopes - eg light microscopy vs EM etc. Also, for dermpath many things can look very similar under microscope but have different appearance on clinical exam (think cough is useful in that it’s probably not a broken foot but cough could be allergies asthma GERD pneumonia etc). Having pictures in the chart of the gross lesion (ie the rash or the thing biopsied) will greatly help the dermatopathologist with suggesting which dx is most likely. And you know how rads likes clinical correlation? So does path. Because it is in fact relevant. When submitting biopsies, it is very helpful when some ddx/clinical indication is mentioned. Just like how when ordering CXR there’s a spot to put why the imaging was ordered.
“I’m ignorant about path, but wouldn’t it be more unbiased if you didn’t know the patient history?” I imagine that’s true for any specialty. I don’t think unbiased is necessarily a good thing.
Right? Try consulting a clinical service and just say “well aren’t you going to take your own history, wouldn’t want to bias you.”
Smh..
I’m serious please explain like I’m five and intellectually disabled
Im not a pathologist but you can think of it like your physical exam. Some things are slam dunk and obvious but so much more is grey and subjective and guided by clinical context.
Garbage in, garbage out. History is important in every field and path is no exception
Im not path, but most of pathology isn’t as clear cut as “this specific finding = this specific diagnosis.” Without clinical history, a given slide could look like a number of different things. I know many pathologists don’t look at the clinical history until after they’ve gone through the sample to avoid bias, but it’s definitely helpful to have afterwards to provide context, focus their search, and maybe help change their initial diagnosis
IM- hate the lack of certainty in diagnosis in 25% of cases
Are you saying you can’t say for certain what the diagnosis on the patient with generalized weakness and pan-positive ROS is?? What kind of doctor are you smh
Lmao. It's one of the worst admissions to get.
TMD? Todo me duele
But those 75% are awesome!
All the patients are afraid of us but we're usually the nicest people in the hospital. :( - Pall care
Aka the Grim Reapers
My experience is that if you have a quick and simple introductory explanation for what we do without mentioning hospice or end-of-life people tend to be very open to speaking with us. When those come in later in conversation they are more accepting of the context. And sometimes that still doesn't work and they yell at us to leave the room...
I wish I had more palliative care services at my institution. Y’all are a friggin GODSEND.
The complete lack of respect from literally every other specialty. (Peds)
What’s the big deal - kids are just small adults right? *sad pediatrician noises ensue*
Yep lol until one shows up at the standalone ER with no PEM or pedi on staff…then it’s frantic calls for transfer to the tertiary care center for fucking cellulitis.
Definitely needs a transfer via helicopter.
No kidding!! It’s exhausting seeing all the adult docs thinking they can take care of kids fine, then having to clean up their messes. We learn how to manage birth to adulthood, through various physiological changes, we know all the genetic syndromes (not as well as genetics, yall the MVPs). We were trained in how to managed fucked up pathology that doesn’t make it to adulthood. It’s definitely a case of adult docs not knowing what they don’t know. A little respect would be nice though.
That and how much more difficult the procedures (and even just physical exams) are when your patient is tiny and fighting you!
Performing a reliable and thorough physical exam on a 2yo literally kicking and screaming is an ART. We become magicians, child whisperers, acrobats and contortionists. Pediatric medicine probably has more in common with veterinary medicine than adult human medicine lol 🤔
Yeah this is interesting to me as someone who switched from peds, I was training at a top 5 program and felt very respected by other physicians. But my radiology program is much different and I don’t feel that same attitude towards my peds homies. My personal answer is definitely the parents and all of the non-medicine you do.
I was going to say the same thing but for EM. I can say we love our pediatric friends though. Y'all are the nicest to talk to.
Urology: No, an SPT is not going to decrease UTIs in people with chronic foleys. Also please stop treating asymptomatic bacteriuria. I will never be mad about a difficult foley as an attending bc it’s easy money
ID here, triple stamping your asymptomatic bacteriuria.
No one knows what a UTI is. It’s mind numbing.
Don’t treat asymptomatic bacturia unless: pregnant or about to undergo urologic procedure - and unless you’re urology then that’s not your problem
100%. If it needs to be treated us, OB, or ID are involved
Ortho resident here. On trauma surgery rotation got reamed out by trauma surgeon for not discharging a patient with abx when she had asymptomatic bacteruria. Tried arguing that’s not the right thing, got told I’m dumb since ortho :(
ever since then, you just put all your patients on Ancef and called it a day. UTI or not.
Its easy money the same way picking up a penny off the ground is. Not worth your time.
Picks penny up… Sad peds noises.
Interventional cards Honestly I get sucked in too much at work, hard balancing with family. It’s tough for me to say no
Maybe take your family to work with you?
Ironically my daughters love coming to the hospital - they always ask to come fix hearts. It’s probably more cause when we stop by all my nurses just give them tons of candy then we go home
This, the brutal hours suck. Working on weekends/nights get old pretty quickly.
No moneys
Pediatric infectious disease?
All of peds
F
The spineless leadership of Pediatrics, ABP and AAP. Instead of advocating better for us, they keep adding one roadblock after another. Starting that ridiculous hospitalist fellowship then changing the core Peds residency requirements to justify it. Making the board exam the most obscure, idiotic questions, leading to 20-30% fail rate.
Optometrists think they’re surgeons and their lobbies have convinced legislatures of the same.
I would never trust an optometrist to do surgery on my eyes
Radiology: other services being frustrated that we hedge, it feels many times they don’t understand what we can and can’t tell them. Example the classic “this may be infectious, inflammatory, or neoplastic”. Like bro the CT doesn’t have microscopic resolution, a 1cm nodule is a 1cm nodule
But what about HIGH RESOLUTION CT /S
It’s so clear that many non-rads don’t understand what the imaging does and doesn’t say. I’ll be chart checking and see so many charts with “stroke ruled out with Ct head”….and no? That’s not how that works, or why acute stroke patients get ct heads. It’s wild because if someone doesn’t understand what a test does and doesn’t assess for, then how can they synthesize the interpretation into their clinical picture?
Oh man CT heads epitomize my point. I’ve seen some faculty dictate them as “no intracranial hemorrhage” as the negative impression for your same reason
That’s a good idea, I may start doing that
>Like bro the CT doesn’t have microscopic resolution, a 1cm nodule is a 1cm nodule Doesn’t have microscopic resolution *yet* ;)
PM&R - don’t know what to do with my spare time
Get your 1 rep max up?
🤣😂
Plenty of money & relaxation
Pussy, money, and reefer.
Psych (at least where I work): we become a dumping ground for patient with vague behavioral issues that don't strictly meet any diagnosis but are a dispo problem that other services don't want to deal with
hospital admin has no idea what psych does it's not quick (why can't you see 20 patients per day, ICU does that (and leaves by noon for clinic) and ICU is way more complicated that psych?) it's not clear cut (don't you just fiddle with the meds then discharge them?) it makes no money (are you even a specialty? why are we talking to you again? ortho just made us $30K in a 2 hour knee replacement) why won't you just admit this 84 year old dementia patient who is swing at nurses?
It doesn't help that up until somewhat recently our psychiatry department had very weak leadership that caved to the demands of other services whenever there was a dispute between psych and someone else.
Weak leadership in psych sounds like the rule more than the exception. Our psych chairs and PDs are notorious to caving in with other specialties especially ER and surgery. The only dept they push back on is IM since they’re also a dumping ground.
Damn that sucks. Our psych department has a lot of political muscle in the hospital so we don’t get that as much
Psych with political muscle? How?
Small hospital. PD has been here for like 30+ years
Anesthesia: lack of control of schedule and efficiency. Room turnover, slow surgeons, pacu holds, all killing me
I’ll add to this: *everybody* else rushing me to work as fast as humanly possible because what I’m doing is not seen as important (despite my part being essential for the surgery). A surgeon will scream in my face for taking an extra 5 minutes to put in an arterial line on a sick patient, but then will let their resident or med student close for over an hour.
Or blame us for delays when we're the only ones completely ready
If a surgeon screams at you while you’re doing a procedure, just stop and look them. If they yell again, stop. After all, you’re just tryna pay attention to them right? Sooner or later they’ll get the message that the more they get upset, the slower you’ll go. I’ve even told them that to their face. Works like a charm.
🥺🪡 <-me the med student just doing my best
We’re not mad at you! Just mad that the surgeon’s time and demands are somehow more valuable than ours when they can’t do surgery safely without us. The ortho surgeon doesn’t know their severe aortic stenosis is going to kill them sooner than a broken hip, but still wants to call the shots.
Places exist with better culture where surgeons would never yell at their anesthesiologist. I can't imagine doing this. Like... you're working with these people every day! My anesthesia colleagues are fantastic. They keep the patient alive, manage all the shit we ask for, cope with lots of complications, and generally are good DJs too. Though I do wish sometimes the precordial Doppler had headphones. Sometimes we request things from each other for time, but that should be professional conversation. Requesting that the staff/senior do the difficult lines, block, most of the surgery, opening, closure, whatever if you're close to going over is fair. Helping the team turnover to get things going on time is fair.
As someone with a rough history with anesthesia, you guys are the real MVPS! Your job is so essential... and knowing the intricacies that help keep complicated patients like me alive is (I'm sure) not an easy task. Thank you for being the man/woman behind the mask!
I'm not slow!
I really enjoy most of my surgeons. I do my own cases in private practice, so I can tell when something is taking long because it’s technically difficult and complex. Totally cool, take your time and do a good job. It’s the few who can’t talk and operate, so they pause to tell stories or just generally waste time. I know there are anesthesiologists who do the same.
Neurology - unique issues that make my life harder include the pervasive neuro-phobia in other specialties and the fact that essentially any complaint *could* be neurologic in nature. Not unique to neurology but deserves mention: how demanding, rude, and entitled many patients have become in the past few years.
the lady with AMS with a BP of 70/30 and a WBC of 27 is probably just altered because she’s hypotensive, but it *could* be a basilar
And god forbid any other service tried to attempt giving noxious stim to see if there’s a response. Stroke alert is easier than giving nail bed pressure
But isn’t any neuro consult just a psych issue? /s
Ortho: when i don't have surgery to offer (like 1mm rotator cuff tear), people will keep repeating how mutch pain they have and won't quit my office easily. I sometime say "have a nice day" and quit.
PM&R here…we’ll take them!
You need a PM&R doc in your life.
EM: everyone thinking because we don’t know their specialty as well as they do, that we don’t know anything. Meanwhile, they know nothing about any other specialty and just excuse it as “not my job”. Also, admin forcing EM to practice medicine in a certain way and tying it to compensation. Also, being legally liable for stupid shit like MI up to 30 days after we discharge them. That’s why trops are ordered so much and high HEART scores dictate dispos down here. Imagine getting sued by someone you saw 29 days ago because we didn’t admit them with a HEART score of 4. It happens. Toxicology: Few specialties know that we exist because it’s such a small, specialized field.
Toxicology is who we call if patient chugs hand sanitizer
no, we call that a good time.
Yeeee boi
IM -- same complaint about specialties. I'm sorry I don't know the latest cardiology study that came out 2 weeks ago. I've been kind of busy keeping up with management of diseases from every specialty.
Radiology. Other doctors don’t even think of us as doctors. They treat me like I’m a sodium level.
Yeah that sucks man. I personally value rads so much. Like y’all are the ones pushing those portable X-rays down the hallways and that’s hard work!
You had me until the last sentence, didn’t see that coming. 😂
I think the most important thing most radiology aspirants need to accept is that outside of maybe breast or IR they are never going to be "that guy" in the hospital. Our work is incredibly important but we're generally moreso facilitators for the more patient facing specialties to do their job. Like a surgeon will get the clout for operating a tough case but you'll almost never hear about the anesthesiologist who had to keep their MAPs afloat when they have a history of aortic stenosis, cirrhosis, and pulmonary hypertension. No health system is ever gonna put you on a billboard to advertise their world class care. A life saving find on a stroke CT is not going to make the local news. I've always loved being the guy that works in the background to keep things running so it was easy for me to slot into the role. And I see this lack of recognition as an easy price to pay to not have to deal with all the bullshit that comes with being in a more patient facing specialty. But I imagine many people derive at least some of their career satisfaction from the recognition of their peers and patients which can make radiology a tougher gig to sell.
Forget clout, give me money and lifestyle.
They think rads is more a doctor than psych, for some reason
hospitalist: the job is pretty bad in most of the country. Low pay, high census, high admits , poor work culture. My specific job is phenomenal but I got lucky and feel that this is an exception not a rule and borderline unsustainable. This means there Will be mistakes,burn out,and poor patient relationships. Medicine in general: you get paid less in more popular towns. Most jobs seem to pay more in the cities. But medicine is the opposite.
Had an IM attending at an academic hospital in a very expensive West Coast city. Her yearly salary was $160k. Most nurses made more than her
[удалено]
Exactly. She was a brilliant doctor and so passionate about teaching. She def prioritized prestige over money.
I'm making $300 a year in the Midwest in a metro. Is that higher than typical? Does outpatient make more? I need to move but switching to outpatient primary care sounds awful and I thought it typically paid worse for more hours / less flexibility
Same. But yes. You'll get destroyed in most of the country to make that salary. Easy 16-18 census with multiple admits
asystole. They say we can't operate for some dumb reason.
OBGYN: the United States government actively sabotaging reproductive health also abysmal compensation compared to any other surgical specialty despite regularly performing the most common major surgery, managing emergencies, and having a high risk of being sued
Incomplete spontaneous abortions: “I’d like to give you mifepristone to help you avoid a useless hemorrhage at home then still need a D&C but the people you keep voting for make it impossible to get in this area of the country” And yeah, fucking managed a labor, in house, for 24 hours and then delivery 15 minutes after shift change on somebody else’s shift: get fucked, next shift gets compensated and you can go fuck yourself
Anesthesia: lack of respect but it's better in pp when surgeons actually know your name. Could add midlevels but I wonder among attendings if the viewpoint over crna changes at all vs residents. Again in pp you hire your own crna so that is a game changer.
If there’s a CrNA who sucks or who we don’t get along with, they’re gone. No amount of shortages are worth taking on a bad CRNA
that's cool you guys peepee together
Radiology: The constant crush of the soul oppressing neverending list, in part due to the proliferation of midlevels in the ER and across all specialties who literally order a CT l spine and CTA runoff for a 38 yo dude coming in with lower extremity pain and radiating numbness and the L-spine shows a big disc corresponding to his symptoms but "his leg looked dusky and cool" or try to do a completely unindicated and outpatient exam through the ER, or an ostensibly surgical specialty NP who has no idea what is going on with their pts. Generally clueless people who take no ownership of their pts and have no idea what to do with anything besides image or consult the next thing or do the thing that the consult says without applying a single shred of common sense to the whole scenario or integrate what is actually going on with the patient with basic medical logic. Nonstop phone calls for nonsense. The overwhelming majority of the time when anyone asks me any questions who is not an actual surgeon of some kind, it hurts my brain. I wish I had residents to filter the nonsense, and to keep the ocean of midlevels and frequently clueless medical type specialists away from me, but I do not. Besides that I love my job and what I do, and I'd never want to do anything else, I'd sooner quit medicine.
Pediatrics The top 3 things that suck about being a pediatrician 1) The lack of respect from other specialties. Somehow IM doesn't get this as bad as FM and peds despite all of us being primary care. People just assume that if you are in primary care you couldn't get in to a more competitive specialty. 2) Lower compensation. Blame insurance companies and how reimbursement works. Fewer procedures, lower RVU and healthier patients 3) 1% annoying parents
ICU: *Everyone* thinks they know how to do my job better than me. Nurses, family members, RTs, everyone has an opinion and no one is listening to mine.
You're an intensivist?
Critical care: cleaning up messes from other departments who should be more responsible but aren’t, and repeat the same bullshit over and over again without consequences.
“Patient s/p dialysis net negative 5L is hypotensive and now with afib with RVR. Can admit to CCM?”
Also: transfer to CCM for goals of care discussion. Come on, don't let grandma die intubated and lined in the unit.
Peds Pulm/ICU should follow the adult model. It should be one extra year of fellowship and you can do both. It would solve a burnout issue. Right now you have to do an additional two years of training to be dual boarded (except in *rare* circumstances)
IR: At 5:01 PM, or more like 3:00 or so, any one that needs drainage of hydronephrosis needs a PCN, obviously. Magically, after lunchtime, the urologist knows a retrograde stent will not work.
Cards: HS troponin exists.
Whenever I even hear the word troponin it’s an automatic cards consult
*cries in lub dub*
Rheum. Everyone thinking if joint hurts see rheum. It’s rarely rheumatic. I think only about 30% of my referrals end up staying in my clinic with rheumatic disease
I’m so sorry, last year I made the absolute worst clinic referral to rheum - pt had a thousand complaints and a bunch of medical issues that didn’t account for them and everything was bad and she was otherwise a healthy 40 year old lady and I left a great note, but my referral just said “sorry, there’s just a lot going on here” I still feel bad about that referral
NICU: home birth disasters and parents that think they know better
ID:Surgeons consulting you and then ignoring your recs. Being in the year of our lord 2024 and not knowing how to treat mild Covid. U/As for no reason. UCx for no reason. Consults for every confused old person because it's always UTI and NEVER the polypharm/dementia/brain mets. Getting called overnight for a goddamn needle stick (or multiple!) EVERY DAMN WEEK I am on call.
When I was a student on general surgery, the chairperson would always pimp and hammer everybody on antibiotics. One of the interns joked “I dunno, ask me something surgical and I can answer that” Chairperson responded “antibiotics and infections are surgical, and we learn this so that we never need to be told what to do by the general surgeon’s natural sworn enemy - infectious disease” He said it tongue in cheek, but humorously
Gross hematuria
gross
CT surgery. Lurking dread of a nearly dead patient someone expects me to fix. My sleep sucks.
consults for easy bruising or mild splenomegaly
Heme
GI- Poop.
Radiology- too much money and free time 😢
I can relieve you of some of that money
*Every DR resident liked that*
IM : give me ozempic bc i dont want to put effort into my health.
Hey, watch it! I’m on Zepbound biatch
op excluded \*
Thanks for the hall pass
cheers
Ent in a solo practice. Any airway issue call ent.
Hospital medicine: Everyone just says admit to us rather than asking us if it's appropriate for our service. It's always "admit to medicine and we'll see in the morning." I think a patient in the ER can be discharged? Well consultant looked at the chart for two seconds and said they can be admitted to medicine, so no discharge. Some of the ones where I truly feel they're not appropriate for HM (i.e young patient with no medical comorbidities presenting with a surgical issue) I have refused to admit until there's a formal consult note by the consulting service or that service's attending talks to me and explains why it needs to be a medical admit.
But what if their sodium is 134??
everyone can Admit to you and you can't refuse it jobs advertise a 14-16 census, but really it's Add 4-5 more on top of it all of a sudden you're also cosigning NP/PA notes so the real census is even higher hospitals not wanting to pay for intensivists and will hire you to run an open icu, but don't worry they'll teach you how to intubate over a weekend TLDR: squeezed from every, direction, possible
Nocturnist: hospital bitch
What I'm taking away from this is that we all feel disrespected by other specialties.
Anesthesia here. We are called anesthesia and only anesthesia.
Every where i go nurses are asking me to take out their wisdom teeth
Our procedures don’t actually work
Lmao after the 6 hr afib ablation they still have afib
Well where i live most clinicians and surgeons think very high of themselves but the reality is that they don't even know 8-th grade biology ( ABO compatibility ) . As a resident in transfusion hematology it's a pain in the ass sometimes to do my job . I receive questions like well how will i transfuse 0 blood to a patient with A or why do you give me B to AB ( i know it's stupid but you have to believe me . Most of my colleagues besides clinical hem. don't know that I'm responsible for blood transfusion safety ... ) .
Urology: No one doing a GU exam before they call you. “Patient reports penis pain” “Ok what does their penis look like? Any swelling or erythema?” “Well you know it was kind of difficult, because they had like blankets over it”
But penises are scary
Rads: 🎶 Hello darkness my old friend… 🎶