jack of all master of none

I pose this post as a question to readers of this blog or those who stumble across it by accident. Please feel free to comment and add your thoughts or opinions.

As I finish up medical school and get ready to start residency I have found myself in many conversations with friends, family and others where medical topics are discussed. Often a question will be directed at me directly. Sometimes it is a group discussion and I may give an opinion or a thought regarding a medical topic within the conversation.

I am a little sensitive to the idea that I amy come across as pretentious "know it all" large ego pride filled "doctor" when discussing medical topics. Sometime I have caught myself starting a comment with the words "I tell patients......." or "Often I explain ..... to my patients ......" For example, the other day a group of my friends and some family members where sitting around the table and discussing life when one friend brought up the subject of headaches. Everyone was talking about different things they have heard or have read about different types of headaches. Some shared their own experiences with their headaches and everyone was casually discussing the topic.

In this particular group I was the only person who works in the healthcare field. At some point in the conversation I made a comment that started with "I like to tell my patients, ....... about their headache and ..... about their treatment options." I was asked a couple of medical questions about headaches and the conversation continued with others sharing their knowledge or comments about headaches. Eventually we moved onto a different non-medical discussion about something else.

Ok, so where am I going with this and what am I babbling about, what is my point? I do not want to come across to people as a pretentious egomaniac. I was not making comments out of turn or interrupting the discussion or correcting anyone and maybe I am worrying too much about it but this is my question.

Do you think it sounds pretentious to start a comment or statement when discussing a medical topic or even a medical question directed to me by non-medical people if I start the comment or response with "I tell my patients......"?

I have not had any bad reactions from anyone or looks from people that would suggest that they think I am acting high and mighty but I want to avoid sounding like a egotistical know it all. On one hand I think when I start a statement with "I tell patients ......" it may sound like or come across like I am saying I have treated thousands of patients with (fill in the blank), when in fact I am trying to say "with the patients I have seen or treated with (fill in the blank), I have found..." In some cases it may have been several patients, in other cases it may have been only a small number of patients that I have seen thus far in my training.

Feel free to share your thoughts and comments and suggestions. I have been seeing and treating (under supervision) patients on some level / degree for the past 2.5 years across nearly every field of medicine in 2 week to 8 week blocks and have directly or indirectly worked with 1000's of patients on some level with lots of different diseases. For example when I did my neurology rotation I worked with at least 100 patients on some level with headaches.

You kind of get to see a little bit of everything on some level during your rotations but are not an "expert" on any of it. It is like being a jack of all trades and master of none as you wrap up your medical school training and get ready for residency.

I am "wet behind the ears" and I am very young in my career / life long training. I have a long way to go and I am certainly not an "expert" on headaches or any other illnesses at this point. The nice part about medical school is that during your clinical training year you get to see a little of everything as you rotate through all the different specialties but you really start honing in on your "expert" level training during residency which I will begin shortly.

I do not want people thinking "he thinks he is hot stuff and is in the beginning of his training and talks like he has seen thousands of patients with (fill in the blank)." I never want to be one of those doctors that thinks he / she is a god and then end all be all expert. I certainly do not want to come across as a pretentious, pompous "know it all" either.

Let me have it and give me your thoughts. Should I stop saying "I tell patients ......" or am I overly sensitive? If you think I should avoid saying, "I tell patients ......" what would be a better way to convey a response or comment regarding a given medical topic?

Thanks.

Research and Waiting

Currently I am doing 2 week elective and senior independent research paper. In other words I have 2 weeks to write a paper on a topic of my choice that will be a learning experience for me and possibly a document that my school could use to help medical students as they start their clinical rotations.

My topic = The most common chief complaints (CC) at emergency departments and the differential diagnosis (DDx) for these ailments. While researching this topic it was easy to see what I already knew that if you approach it from the "most common" you quickly see that the most common are not necessarily what an Emergency Physician needs to master. Many of the most common complaints / presenting patients to the ED are not true emergencies but rather primary care type chief complaints and they seem to always occur at 3:00 am.

For example. At 3:00 am on one shift a patient comes in and says hey I am constipated. After examine the patient and doing a thorough physical exam and realize that this is not an emergency. He had been battling with the constipation on and off for 6 months but for some reason at 3:00 am on this thursday night he decided it had become an emergency. He did have a good case of constipation but no primary care physician and did not have insurance. He was intoxicated and rather belligerent. So I decided that I take care of the patient. Ultimately after some enemas I digitally disimpacted the harden fecal mater in his bowel and this relieved his issues. I started him on a regimen and treatment plan to improve his diet and cut back on the drinking and smoking and sent the happy patient on his way. Not really an emergency. It could have possibly developed into an emergency but when I saw him at 3:00 am it was not an emergency.

I decided to change the topic of my paper the 10 most important chief complaints in the emergency department and the to DDx for each. One would be a chief complaint of chest pain and I wrote out in detail all the possible different diagnosis that it could be and how you would narrow it down to make an accurate diagnosis. Just to name a few it could be a myocardial infarction, pneumothorax, pneumonia, fractured rib / flail chest, mallory-weis tear, pancreatitis and etc, etc the list goes on and on. No need to bore you here.

Part of being a good / great emergency physician is being able to quickly and accurately diagnose and treat many different life threatening illnesses. However you get your fair share of non-emergant pathologies as well and you have to be able to manage these illnesses and manage all the different colorful personalities that may show up on a given night. No one said it was not interesting and I happen to love the chaos and the never ending unbelievable stories that show up as patients to be treated and helped to heal. There is a saying in medicine that says Emergency Doctors always have the best stories to share at social gatherings.

I have to finish up this project this week and then I start a month long rotation doing internal medicine at a VA hospital. Government medicine at its finest. I will have some great stories for sure so you may want to stay tuned.

Age of the younger Tox Patients

There is a general rule regarding toxicology patients. Generally fro age 0 - 3 we see lots of accidental exposures to toxic substances. This is the toddler that gets his / her hands on mom's or grandpa's medications and gobbles them down or the kid that drinks bleach or some other substance. These are usually accidental exposures.

Children at the ages 4 or 5 - 12 this is a relatively a calm period for accidental exposures or intentional poisonings. Any of exposures in this age group the physician must consider medical conditions that require medications and possible interactions of the medications or too much of a given medication or possibly child abuse, either by neglect or by munchausen by proxy.

Children at ages from 12 or 13 and older and above have toxic exposures by suicide attempts or accidental overdoses in drug abuse. Teens start experimenting with drugs at these ages and also some teens attempt suicide by pills. The physician has to be aware of these trends and make sure to fully investigate all of these possibilities when the patient presents to the emergency department.

This is toxicology!

What is Toxicology?

I completed a 1 month rotation in clinical Toxicology. So what is toxicology? Like everything else in medicine it is a complicated question. A clinical toxicologist usually completes medical school and then completes a residency in emergency medicine (3-4 years) followed by a 2 year fellowship in toxicology.

A clinical toxicologist will usually work as an emergency medicine physician part time and then work as a consultant in toxicology where they get consulted on cases where a patient has overdosed or taken a poison (intentionally or accidentally). The toxicologist will come in and see the patient and make recommendations on how to treat the poisoned patient. These consultations usually come from emergency medicine doctors or the poison control.

The clinical toxicologist will also usually be professor tied to an academic teaching hospital and will spend some of their time teaching about various toxic exposures that occur to patients. Their job includes several different roles which makes it an interesting field.

As one toxicologist told me; "Everything in medicine is tox related"

I matched at my #1 spot

In order to keep some anonymity I will not post my actual place of residency. Those who know me like friends, family and others will already know the location.

However, I am very excited and will say that I did match at my #1 choice. That is great and I feel blessed as there are many this year who did not match and some of the program directors of the residency programs were saying that this was the most competitive year they have seen, meaning that they received many more applications for the spots this year than they had in prior years.

I feel like everything lined up and I was fortunate enough to not only match but get my top choice. Like I said, I was blessed.

I Matched

Today at 10:50 am I received and email stating the following:

Congratulations! You have matched.

This means on Thursday I will get an envelope with a letter in it telling me where I matched. It looks like I will be starting my first job as a doctor in emergency medicine in July. We just need to know where.

I will post.

Where have I been?

No excuses! I have not posted in a while. I will play some catch up. I finished 3 rotations in emergency medicine in very different emergency settings. Inner city, Suburban area , and a Urban area (not inner city but not community or suburban setting). All of them were great and the experiences re-confirmed my choice to pursue emergency medicine for residency.

I interviewed at 14 programs and ended up ranking 12 programs total. If you have read my past threads about the match this will make sense to you. There was a lot of traveling involved in going to each of these residency programs and interviewing and checking out what they had to offer for training. The bottom line in emergency medicine is that most programs if not all of them in the USA will get you trained to run a busy hectic emergency room and handle all the procedures you need to be able to do. There are very strict guidelines and rules that the residency must adhere to in order to stay accredited. Wherever you train you will get the procedures down and the skills it takes or at least be provided the opportunity to gain those skills.

As an applicant it come down to where do I want to go and what will be best for me and my family. I have some highly regarded programs as my top choices and I certainly hope to match at my #1 choice but I would happily go to any of my choices on my list.

Last month I completed a 1 month Radiology rotation and worked with a famous Radiologist who really focused on the important areas of emergency medicine with regards to radiology. I learned a ton of ultrasound and how to maneuver the probe to enhance certain exams and procedures done in the ED. I also got a great amount of CT reading and Xray training in. It was hands on and focused. I felt like I got 4 months crammed into 1 month and it was extremely high yield for me.

Currently I am on a toxicology rotation and I will dedicate some future threads to this rotation as I am only 1/2 way through it. I absolutely love it. It is all about poisonings; intentional, accidental, drugs of abuse, alcohol, drug interactions etc. Very fascinating and a great part of emergency medicine.

Next week is a big week for me. On Monday 3/15 I find out "if" I matched. I will get an email at about 11:00 am saying one of the following:

1. Congratulations, you matched.

2. You did not match.

3. You matched to a PGY1 position only.

4. You matched to a PGY2 position only.

Mine will hopefully be: congratulations, you matched. Options 3. and 4. do not apply to me as I did not apply to any programs that would only accept me for a 1 year position or a year 2 position.

Then on Thursday 3/18 at 11:00 am my entire class will meet and receive our individual envelopes. I will open mine and see "where" I matched. Then the celebrating and panic can begin as I get ready for the next phase, residency.

This is the last summer of my childhood.......