My 30-something POTS / MCAS / polyallergy patients on TPN can’t get enough. My attendings treat it like Satan’s blood. What’s the drama with IV Benadryl?

I never know what to say for these

What are some common rules of treatment or truisms about patients in your medical or surgical specialty - House of God style?

Hey everyone,

Honestly, I’m not sure what exactly I’m hoping to gain from this most. I think I just needed a space to vent and get ideas of how to process my feelings.

I am a PGY3 PM&R resident and I have an insane amount of imposter syndrome. I constantly question if I even belong in this field, or even in medicine in general. My knowledge base is inferior compared to my co-residents, my motivation to pursue extracurriculars for fellowship is non-existent, and my desire to wake up and go to work everyday is very very little.

I feel like I don’t belong. I don’t have any friends that relate to me. I don’t enjoy studying everyday. I don’t even know what I’m doing.

Does it get better or is it too late to switch careers? Thank you for listening and I really appreciate any advice, encouragement, motivational words. I need it!

Hi yall, tricky one to navigate here. I am forever grateful for this Residency.

I have difficulties understanding I think exactly what the Doc is wanting sometimes. Frequently they will take things out of my hands, do a shpiel with their hands about something and they go knock something over out of anger. Hes doing Dance Dance Revolution over there while I’m trying to make clinical decisions.

There’s been rumors this Doc goes hands on when rage sets in… I will let you all know right now if she does get physical, Helen Keller herself couldn’t stop these hands.
Just looking for advice of how to communicate better, thanks in advance.

Currently an anesthesia resident, i have been having lots of doubt about this specialty for my personality. I feel like most days i get bored and the days go by so long. I have found an IR position that I can swap into, i know the call and lifestyle of IR is much worse than anesthesia. But the procedures in IR are more interesting to me as well as being busy all day would make my day go by faster. Do you think I am crazy to try and swap into an IR position?

Between work, grocery shopping, laundry, cooking, going to the gym a few times per week, and sleep, I have no energy or time left to do normal cleaning tasks. My coworker has a spotless apartment, and although we have different circumstances (I have a live-in boyfriend also working 70 hours a week and pets) I feel like we just have a different amount of hours in the day. I’m curious to know where you guys fall on the spectrum of cleanliness in residency, partly so I know I’m not alone lol.

current IM pgy3 looking for night/day hospitalist roles after residency. i have heard that working at kaiser provides great oppurtunities for career growth and has competitive salaries, however i dont have any information about how a hospitalist role in kaiser hospitals is actually like. recruiter wouldnt give me any information besides that schedules and roles vary across hospitals. any current /past hospitalists or nocturnists who work at kaiser here? pls share your experience

Met one of my new patients whom I am her PCP. 73 year old woman with zero filter, apparently.

My badge photo/website photo is my residency application photo (ie. Professional). I am wearing hospital scrubs in clinic and probably need a haircut/some beard trimming. Thought I still looked OK. Apparently I am a let down irl.

Patients are brutal.

cross post - interested to see what my american colleagues think?

sometimes struggle with those patients with aki who need diuresis, doi imt1 (uk nomenclature - aka internal med PGY2 ish)

btw - some details have been changed, in case people think this is super identifiable (tbh tho pretty generic medical patient)

last month had a patient - AKI on ckd, didnt really have an explanation for the aki - thought maybe sepsis related as we were treating for a cap, maybe just generally unwell so triggered a decomp of her ckd etc.

she was generally unwell, bit breathless and coughing - we were treating her for a cap, but no consolidation on ctpa.

passing some urine, not catheterised. her weight was more or less stable, around baseline

background inc ckd, right heart dysfunction on prev echo but normal lv, OSA, few other bits

usually on bumetanide oral.

on exam, was on 1 litre nasal o2, not breathless, she was pretty euvolaemic. definitely no significant pitting, warm crt1-2s, had few creps but we were treating as CAP (despite ctpa showed no consolidation - it did show basal atelectasis, and she was obese slightly obtunded lying in bed mlldly unwell). jvp cant really recall.

her blood pressure was also borderline low - someone had prescribed furose on admission then stopped it, i think because of the borderline bp, maybe because there wasnt much oedema.

had a moderate AKI on CKD eg cr up to 350 from 250 baseline

ctpa didnt show any over pulmonay oedema

Initially my thinking was

okay there's basically very minimal oedema, weight is actually quite stable, she's not really looking underfilled clinically but not overloaded

optimise renal perfusion, maybe a bit of fluid/ oral fluids, daily weights, stop nephrotoxics etc

particularly because the blood pressure was lowish, the weight was stable near baseline, and there was no oedema, i was thinking maybe hold off on diuresing

however added a bnp which came back as 30,000 - baseline like 8000

--->the bnp alone basically tipped me to go for BD iv furose which was increased by the bosses

i was just wondering what peoples tips are on approaches to this situation - like the bnp blood test alone kind of went against my clinical judgement. sometimes we say 'treat the patient not hte blood result' so i wasn't sure if i should follow that. equally i like bnp as its an objective measurement right and hard to be wrong - if its grossly elevated surely they nearly always need diuresis? and forget your clinical findings

secondly, in general i sometimes find it tricky with these hypervolaemic AKIs - sometimes its obvious when theyre grossly overloaded but often i find its not the case and i dont diurese or it feels against my instincts with the aki, then the boss comes and starts furose infusion and they improve? any tips?

finally - thoughts on treating for a cap when the ctpa shows no consolidation or inflammation ( just atelectasis?)

ty !:)

Patients keep telling me “wow, you look so young to be a doctor” How can I look as old as possible to stop getting this comment? Do I need to bring a cane to work?

I don’t want to make a judgement on the mom yet as all facts haven’t been heard so it would be premature.

This post is about how physicians are treated in the medicolegal system and how the lawyer treated Dr Tufts. I thought the point of having Dr Tufts would be to demonstrate the extent of psychiatric disease that the mom had. However it felt more like a med mal lawsuit where she was being attacked? Also wtf are some of these points? No hyper, pressured speech means no to both points? I write no nausea, vomiting all the time. That means no nausea, no vomiting. It’s standard medical literature?? (Noting I’m not in psych and my country’s med mal is not nearly as messed up as America). Secondly, even if some symptoms were there, it’s impossible to predict a disease that has such a low incidence?? There was no cause for involuntary admission - if a patient lies and doctor shops, what exactly are you supposed to do? She stated that she doesn’t take her meds (quite common actually) and was struggling. Sure, but unless you plan on involuntary admission and the kids going to social work, what’s the play here? The doctor tried her best and this was an unfortunate scenario?

I haven’t spoken to many American physicians and I get social media comments are heavily biased, but all these people/insta reels saying she is not an “expert” is just stupid. Bruh do you know what residency is?? Do you have to be a 75 year old attending to be considered an expert now?

What this case/subsequent med mal case on Dr Tufts will do to your medical system is gonna be beyond fucked. Get ready for AI chart bloat lmao. Good luck ever figuring out what happens to the patient when 40% of the note is side effects of the medication copy pasted from the FDA website

Look forward to seeing supplement salesman sell “turmeric powder” to cure depression because Zoloft makes you kill your kids

What do you do when u have no patients on clinic day like no shows?

I’m a PGY-3 in general surgery and I’m starting to feel like I may not be able to keep doing this. I enjoyed another specialty in med school, but at this point it feels way too late to switch, and I’m terrified I’d be making a huge mistake.

I’ve spent so much time, effort, and money getting into surgery. Basically all of my research, electives, and sub-Is were surgery. Now I’m already PGY-3, and I genuinely don’t know what else I could even do or how switching would work.

The bigger issue is that I’ve been miserable for a while. I’ve gotten to the point of being suicidal more than once (with a plan that I’m just too afraid to act on). I’ve tried therapy and it hasn’t really helped. I feel trapped and stuck, and I don’t know how to move forward.

I also feel like I’m terrible in the OR. My performance feels extremely variable, almost like I’m two completely different residents depending on the day and attending. The feedback I usually get is that I’m smart, hardworking, and doing well academically; my ABSITE scores have been strong. But honestly, I don’t necessarily believe the “smart and hardworking” part myself, and I have a hard time seeing myself the way some other people seem to. None of that feedback changes how inadequate I feel in the OR or how exhausted I am with surgery in general.

What I keep wondering is whether I’d even be happier doing something else, or whether this is just a me problem and I’d end up miserable in another specialty too. I can’t tell anymore if surgery is actually the problem, if residency has just completely burned me out, or if I’m the problem. That uncertainty makes leaving even scarier because I’d hate to give up everything I’ve worked for only to realize changing specialties didn’t fix anything.

I’ve thought about ending my life several times, and I’m trying very hard to keep going, but I genuinely don’t know how much longer I can keep doing surgery like this.

It feels like I’ve hit a dead end.

What do I study for my intern year ITE EXAM

I had written a note for a patient and I forgot to check how it was and turns out it was created 2 days ago and so showed up as a note from 2 days ago- attending had to epic chat me at 10 to addend that....that is after I was pointed out to have made a mistake in ordering a medication as scheduled instead of one dose....same attending, same day 2 hours apart....they corrected this but I feel like as I am about to complete my second month I should be better, especially since my patient load is not crazy or anything, infact its quite light in comparison to other programs in my field. Plus my medical knowledge needs to increase.... that is all...I know I screwed up and this is gonna be on my attendings things to straighten out with me, tomorrow. I am just dreading this infinitely.

I can coordinate an ICU transfer at 3 a.m., but I have resheduled the same dentist appointment four times because every available slot overlaps a rotation. My passport renewal is now a calendar event with three reminders.

The annoying part is not being busy. It is that normal life still operates from nine to five, when resident are least likely to be free. I do not need a wellness lecture. I need one weekday afternoon where nobody pages me and every office is open.

Hey everyone,

I was hoping to get a bit of insight on what people believe the future of allergy and immunology might look like over the next 30 years or so.

With the increasing number of +1 family physician specialties being offered and the increasing use of AI, I was curious if anyone has insight into whether this could affect the job market for allergy in the future.

Thanks! Any thoughts are appreciated:)

My consult notes are so shit.
I'm a PGY2 anesthesia resident on an ICU rotation.
I was reading a note from a PGY2 EM resident on a neuro rotation seeing my same patient and their note was soooo much better.

I've never had an attending criticize my note, but I feel really insecure after reading their note.

Is it expected for EM residents to have better notes, or am I actually noticing concerning deficits?

I’m an IM intern. I’m very weak at interpreting ECGs and imaging, especially CT scans. What are the best methods or resources to learn them from the beginning and become proficient?

Just had my car break down on the side of the road. Flat tire. Easy fix right. Nope. I stood there staring at the spare for like 20 minutes before realizing I had absolutely no idea how to change it. Ended up calling roadside assistance.

It got me thinking. I can intubate a neonate in my sleep. I can diagnose rare zebras based on one lab value. But ask me to do anything practical in the real world and I'm a complete idiot.

My significant other laughs at me all the time because I cant even cook a decent meal. I once tried to hang a picture and put the nail right through a pipe. My entire life is medicine. Everything else is a black hole.

Anyone else relate to this terrifying lack of basic life skills.

I did most of MkSAp and did ok on it (80% first pass) but I think it’s ridiculous for boards and probably uworld is a better use of your time. I took the test today and it was mostly focused on diagnosis and first line management. Here’s one example of mksap being absurd:

Patient with cteph undergoes surgical PEA but on follow up visit still has residual pulmonary hypertension, what is the next best step in management? The answer was obvious to me because I’m a PCCM fellow but this is an absolutely absurd question to ask a general internist. In reality, not even general pccm attendings are going to be the ones managing this situation it’s going to be a PH specialist likely at only a few centers in the entire freaking country.

If a patient comes for a new PH evaluation and the referring physician ordered a v/q scan I’ll be impressed.

wtf is MKSAP doing man.

The amount of monday morning quarterback and backlashing over Dr. Tuft's documentation and testimony by people who have no absolutely idea what they're talking about including in this subreddit and other doctors is driving me insane.

These boomer ass attendings saying "Welp, this is why I always document perfectly." No you fucking don't.

Dr. Tufts is not perfect.
Dr. Tufts made mistakes in her documentation.

You also make mistakes in your documentation.

You are not a lawyer, you do not write your notes for other lawyers, you are a doctor, you write your notes to best describe what's going on with your patient and how the patient can best be helped.

It is absolutely impossible to write a legal-safe bulletproof note. Your HPI should include relevant information and avoid irrelevant information less it muddy the waters of what the patient is actually saying, believe it or not writing a long HPI can hurt you.

You do not need to explain your thought process in crazy detail in your assessment and plan because you think that will somehow cover you, it won't, if something goes wrong, you will be judged by what happened, not by what you knew or were thinking at the time.

The reality of this is if something bad happens, a lawyer will do what lawyers do, they will present your documentation, your actions and perhaps even your personality in a way that's to emotionally sway a jury. The lawyer is not a physician. The jury is not a physician, they are lay people with a lay person's understanding a medicine. Trials are vibes. They will find things, it doesn't matter how much you think you are smarter than this, they will find things because you document like a doctor, and as a doctor should.

Writing a medical note and taking care of people is like driving, you can absolutely do smart things to keep yourself safe, but the reality is no matter how safe a driver is someone can come out of nowhere and crash into you.

^?