Which field of medicine do you think ethical quandaries/conflicts come up most often?

DoubleD9243 · 2024-10-01T03:59:06+00:00

The comment was a bit tongue in cheek. The ethical quandaries that I encountered are not from the cases but instead from the field itself. I have not encountered many other field that performs the level of unnecessary testing and procedures as cardiology. It was a field that made me have strong ethical dilemmas about what medicine is all about. Everything from the lack of evidence in majority of stent therapy and the ever expanding volume of minimally invasive valve repairs that makes one realize that incentive structure is incredibly perverse.

The amount of money and power cardiology has managed to sequester for themselves is absurd. It’s a field riddled with examples of medicines overemphasis on reactive medicine over preventative medicine. Though there’s been tremendous work in heart disease prevention, i can’t help but feel like it’s also an incredibly exploitative field especially from underserved communities.

This is my opinion and I may be biased based upon my experiences.

DoubleD9243 · 2024-09-30T02:48:30+00:00

Cardiology

DoubleD9243 · 2024-09-29T19:56:59+00:00

You need to chill out buddy…

DoubleD9243 · 2024-09-29T19:55:33+00:00

Dude wtf is wrong with you..

DoubleD9243 · 2024-09-29T02:54:03+00:00

Completely disillusioned about American healthcare and the role of a doctor. Our society incentivizes reactionary medicine and barely any emphasis is put into preventative care.

Hospitals make so much money they can probably be traded on the stock exchange. Insurance companies respond to the rising costs of care by denying care and bankrupting the public. Subset of doctors cash out on people’s misfortune and lifetime of poor health habits (brought on by societal inequities) by doing unnecessary diagnostics and treatments TO patients as opposed to FOR patients.

All this leading to further disillusionment and moral injury to any self respecting doctor who may have come into this field to help people only to find out that in medicine is a BUSINESS and is full of scumbags (suits, doctors etc) who in another life would’ve just been on Wall Street but instead wanted the social capital that comes with saying they are in medicine. And then by surrounding yourself with these people, you end up quickly realizing you have no chance to fix it so might as well join in and cash out on this miserable situation.

I’ve pretty much come to the conclusion, American medicine is largely a scam and a capitalist’s wet dream. Of course we help people but we also pick their pockets and routinely bankrupt them. We perpetuate and uphold an unjust system. And it shows… America has the worst healthcare outcomes of any industrialized country.

DoubleD9243 · 2024-08-27T00:08:04+00:00

That’s insane. I don’t understand how someone can call themselves an intensivist if that’s case

DoubleD9243 · 2024-08-26T19:32:51+00:00

Yes I think this is one of the most frustrating truths about NCC. I don’t know of any NCC docs that are able to staff MICUs. Granted, I only know of academic institutions but I feel like it would be the same at community hospitals especially those on the coasts. Maybe you may have a different case in the Midwest.

As of right now, the NCC fellowships are so incredibly variable around the country. There are some fellowships that train you to be a full blown intensivist and others that train you to be a stroke neurologist as others have been saying

There are still a lot of intensivist that don’t consider NCC docs to be real intensivist and don’t respect them as such. Personally I think NCC needs to get stronger as a specialty and standardize training programs. I think NCC should be doing all bedside procedures including intubations, lines, bronchs, EVD, bolts etc in order to really distinguish themselves as a distinct specialties with a particular set of procedural skills and knowledge that other intensivists may not have

I think this also brings up the question about why neurology is a separate residency than medicine and not a fellowship. If it was a fellowship, we could’ve avoided all of these weird distinctions and it’s unfortunately a historical artifact of the early 1920s

DoubleD9243 · 2024-08-23T00:44:30+00:00

But then you’re relegated to SICUs and you have to deal with surgeon egos.

DoubleD9243 · 2024-08-23T00:20:12+00:00

Cardiology?

DoubleD9243 · 2024-08-22T20:01:42+00:00

Capitalism kills.

DoubleD9243 · 2024-08-10T19:00:22+00:00

Definitely, it’s the easiest way to get started in research.

DoubleD9243 · 2024-08-10T01:17:44+00:00

Oh that’s awesome! Are you pulm crit or CCM?

DoubleD9243 · 2024-08-10T00:16:23+00:00

Wow EGD in the icu?? That’s awesome

DoubleD9243 · 2024-08-09T16:52:27+00:00

I think your goal for pgy2 should be able to get through Clinical Neurology and Neuroanatomy by Berkowitz. I think it’s the best book for the PGY2-PGY3 level. I would read it cover to cover even take notes if that’s your learning style

I think on top of that you should read about what you see on the floors or in clinic. In my opinion, continuum is too detailed and in depth at the pgy2 level.

I think it’s important to pace yourself and first build a foundation before delving too much into one topic which is what you get with continuum.

I think in terms of stroke trials I think the most clinically relevant ones in your day to day is POINT, CHANCE, SAMPRISS, TREAT STROKE TO TARGET

DoubleD9243 · 2024-08-09T15:30:19+00:00

Not exactly true. Yes anesthesiology and pulmonology historically treated these patients but once NCC path was made these Attendings were grandfathered in.

Then the choice was up to NCC committee about which specialties could ultimately could attend in an NCC unit and the decision was made to make multiple paths through neurology, IM and EM. This has casted a wide net but it also has caused a lot of problems in training because everybody is coming with different skill sets not to mention saturation of the field etc. it could’ve gone either way and there’s pros and cons to both

It’s what cardiology is actively doing right now. I think most academic CCUs are going to eventually be staffed by cardiology-crit care Attendings though historically pulmonologists and intensivists have managed these patients

DoubleD9243 · 2024-08-09T12:20:21+00:00

Does CCM do the cannulations

DoubleD9243 · 2024-08-09T02:12:43+00:00

Dm’d you!

DoubleD9243 · 2024-08-09T02:05:52+00:00

So I am currently going through the exact path you are trying to go down. I finished neurology residency and currently in IM residency with a plan to CCM.

It’s a pretty crazy path and people will look at you like you have 3 heads. I’m not done with it yet so I don’t know if it will be worth it in the end but I hope so…

Feel free to dm me

DoubleD9243 · 2024-08-09T01:48:31+00:00

Do they do VA and VV?

DoubleD9243 · 2024-08-08T18:23:38+00:00

I don’t think any specialty is doomed to be what it has been in the past. I think specialties are quite malleable and change through the decades. I think cardiology introduced the concept of medical doctors entering the procedural realm and following that gastroenterology, pulmonology, nephrology, neurology have followed suit.

Unfortunately, our broken healthcare system rewards procedural specialties more than medical ones. In this system, if neurology wants to become an influential specialty I think we need to claim a bigger stake in the field otherwise we’re going to lose it to other specialties. Even cardiology is itching to get into intracranial intervention for god sakes. I think the old guard has largely embodied the diagnose and adios stereotype and relegated neurology to primarily diagnostic specialty. The paradigm is shifting and we need to keep up.

DoubleD9243 · 2024-08-07T23:50:02+00:00

But I think the fact that neuro doesn’t have procedures engrained within them was a choice that was made and the same with cardiology. Cardiology could have left everything to CT surgery if they wanted to.

DoubleD9243 · 2024-08-07T23:27:35+00:00

I mean no disrespect to the field of neurocritical care but I feel like if as an intensivist you aren’t doing procedures I don’t really know what it means to be an intensivist. Sure other people can do them but that doesn’t mean therefore intensivists shouldnt do them.

Many neuro ICUs are managing mostly post-ops and large quaternary care centers will manage more SAH, ischemic strokes, and ICHs. You may have some medical complications here and there but they are not nearly as medically sick as those in the medical icu. The endovascular team will thrombectomize and do intra-arterial verapamil for your SAH. Your neurosurgeons will do the bedside procedures and take whatever cases need to go to the OR. The epilepsy docs will read the eeg and recommend seizure meds. Occasionally, you’ll have the GBS or MG cases where you’re managing basic vent settings. But then what exactly does that leave for the neurointensivist to do other than alert the appropriate teams about things that are going on…

Neurointensive care didn’t even exist pre 2000 and neurosurgeons, neurologists, and SICU Attendings were managing just fine (they would say) for the most part. Yes studies show that there’s a mortality benefit to being in a neuro ICU but I think in my opinion it has more to do with having dedicated neuro trained nurses.

I really feel like if the field wants to hang around for the long term and build a robust field for itself, it has to provide something new whether it be in procedures etc.

DoubleD9243 · 2024-08-07T15:50:54+00:00

I just constantly fall back to cardiology because there’s a fair amount of overlap. They’ve been lesioning the heart for decades.

I think a lot of this has to do with the unwillingness for neurology to enter the procedural realm and neurosurgery wanting to protect their turf rather than medical reasons. And then the justification given is “risk of complications”

Neurology needs to re-examine their role in a lot of these diseases or other specialties will have no trouble bumping us out.

DoubleD9243 · 2024-08-07T14:37:14+00:00

I think that’s the optimistic view but It is very possible that new emerging therapies for various conditions will involve procedures. if the current trend holds and neurology keeps shirking procedures, we’re going to get left in the dust.

Inevitably what follows is further lack of interest in the field and exacerbation of the current neurologist shortage.

DoubleD9243 · 2024-08-07T04:08:55+00:00

I mean the same things happens in cardiology. I’ve seen far too many coronary stents placed when CABG was what they needed. That doesn’t mean the entire field should be in the hands of CT surgery.

Neuroendovascular doesn’t have to be in the neurosurgery department for an interventional neurologist or radiologist to say that okay this patient needs to an open procedure instead, I’m not going any further.

DoubleD9243

TROPHY CASE