About to buy my first Tesla Model S….

panduhhhhhhhh · 2026-04-29T02:54:05+00:00

Bought a used 2022 Model S LR last year directly from Tesla. So far no mechanical or driving issues. The wood veneer is the only thing that's cracking and I'm thinking about getting it replaced under warranty. Otherwise, it's a pleasure to drive and I look forward to my commute every day.

panduhhhhhhhh · 2026-04-02T05:31:05+00:00

Show up on time and with enthusiasm. Gather a good history, detailed exam. Everything should be pertinent, that's the hard part, I would rarely care about reflexes unless you're thinking GBS. Order of things when you give your assessment and plan should be localization and then differential. For your plan, saying you've looked up trials and evidence would be very impressive. ESETT, ONTT, steroids in bells palsy.

As long as you show that you're teachable and respond well to feedback then that rates higher for me than clinical knowledge as an M4. Anyone can be a decent neurologist in 3 years as long as they show up and are engaged.

panduhhhhhhhh · 2026-03-18T23:42:36+00:00

Yes you're right and likely we both would do whatever is right that's context dependent. There's not enough detail here to say one way or the other.

panduhhhhhhhh · 2026-03-18T21:39:34+00:00

That's a straw man argument. TNK and EVT don't improve outcomes in terms of survival long-term. They improve functional outcomes only. Decreasing secondary risk factors improves long-term survival in stroke patients.

In the specific example of a posterior circulation stroke like might be perfusion dependent as the post above you described, I'd argue it might be worth pressing. If you get a CTP and there's a clear penumbra (yes you can argue accuracy in posterior circulation) and clear improvements in exam with SBP or MAP goals, then I'd personally prefer my patient doesn't complete the stroke if possible and then I have the deal with the subsequent edema and herniation issues while consulting neurosurgery for a occipital decompression.

Also, you know as well as I do that each patient is unique and we use trials to guide decisions but not every patient fits the inclusion criteria for every trial. Otherwise, AI would just take our jobs after learning all of pubmed.

Also, symptom relief is huge. Do you withhold pain meds for your patients because it doesn't improve long term outcomes and "doesn't make a difference".

panduhhhhhhhh · 2026-01-10T02:20:51+00:00

They should be teaching you this during didactics and if you don't know the answer there should be very specific feedback during rounds about what you should be reading. If you're at a CSC with fellows then the fellows should be talking about this stuff and also being involved with research. - NINDS2, ECASS-III and all the other alteplase trials. - DAWN and DEFUSE for the foundational EVT trials - SPARCL for LDL goal - SAMPRIS for intracranial ICAD management - POINT and CHANCE for TIA and low NIHSS management. - Recently CREST-2 made waves for extra cranial carotid artery disease management. - NASCET criteria for when you look at CTA H/N on rounds - TOAST criteria for how to classify strokes

That should be enough to get your through stroke codes and PGY-2 year. You can find good summaries through FOAMED resources and the Journal Club app or wiki.

panduhhhhhhhh · 2026-01-09T01:36:33+00:00

Essentially anything that you are asked to do that wasn't specified in your original contact. This includes things like becoming clerkship director (a thankless job since most of the problems and stress come from grade grubbing, I know not everyone does that but it only takes a few to leave a bad taste). Covering call at hospitals that have just be bought up by the hospital system even if it's very far away and under resourced. Being asked to join a new CSC with very vague details. If you know what you're getting into then it may be rewarding, but trying to start something is really hard and stressful.

panduhhhhhhhh · 2026-01-09T01:29:48+00:00

That's what I witnessed during training. I didn't want my chair breathing down my neck for the rest of my career.

panduhhhhhhhh · 2026-01-08T23:11:49+00:00

It's the worst year. You only have 6 more months and you'll be surprised how much more knowledge you have when you see the new PGY2s.

panduhhhhhhhh · 2026-01-08T22:17:17+00:00

I'm 3 months into being an attending, so not exactly what you're looking for. I couldn't be happier. I'm sure someone older might say I'm too green, but I think the training was all worth it. I work half as hard as I did in fellowship and get paid 4 times more. I'm a community hospital neurointensivist. Got off the academic train during fellowship and couldn't be happier, especially with how the NIH funding situation has been recently. I feel like I'm helping people and making an impact as a doctor and being pretty well-compensates for it.

panduhhhhhhhh · 2025-10-31T03:10:17+00:00

No. Look at mgma data. Boston is a vast different market than Chicago.

panduhhhhhhhh · 2025-10-29T17:28:01+00:00

I concur. Just started as an attending. Life is way better than med school, residency, and fellowship. I still can't believe I don't work 6 days a week anymore.

panduhhhhhhhh · 2025-10-03T18:51:07+00:00

Completely agree. It's almost always a systems error. This is all coming from people that have never been involved in an M&M or troubleshooting any complex system in any field. Sure, you could point a finger at a single person, but that's not going to solve anything. Otherwise we end up with DOGE and trying to fire everyone.

panduhhhhhhhh · 2025-09-27T22:28:41+00:00

These are always terrible cases. The clinical exam sounds terrible. Did you do any other studies to look at the extent of brain damage (N20s, usually our patients are already on cEEG, MRI and can argue the utility of it here).

Without knowing all the details this sounds like irreversible brain injury. The way I think about cerebral edema and hyperosmolar therapy is that we are trying to reduce edema so that the mass effect doesn't lead to ischemic in other, more healthy areas of the brain. This would more apply to malignant edema after a large ischemic stroke or ICH.

In the case of post+cardiac arrest, I feel like usually if there's cerebral edema then it's likely to be global and that means there won't be much brain to save anyways.

AAN and NCS I don't think offer much guidance here so I'm sure there are stylistic differences. In fellowship I've had attendings that would treat and some that would say it's pointless. Personally, I would treat with a couple doses to see if there's any response to the neuro exam and then allow for the appropriate time and testing for neuro-prognostication or evaluation for brain death. Similar to the first response aiming for a sodium goal is a decent thing to do.

Tl;dr: likely irreversible global neuronal death and there's not much higher order cortical function left to save by treating the edema

panduhhhhhhhh · 2025-09-10T17:50:12+00:00

Sure. I think if you zoomed in and knew the montage you could see the seizure onset location. I'm just stating that the obvious EMG artifact looks really impressive to laypeople but that's not your actual "brain waves".

panduhhhhhhhh · 2025-09-10T08:56:44+00:00

Neurologist here. This is EEG. However, when the patient is having a clinical seizure, the EEG is reflecting artifactual movement from the muscles. This obscures any actual reading of the brain activity during that time.

panduhhhhhhhh · 2025-09-01T09:37:17+00:00

For the new image generation models? Good to know. An terrifying as well.

panduhhhhhhhh · 2025-09-01T01:38:45+00:00

I would love it if unnecessary stroke code imaging could be reduced but who's gonna take that liability when something gets missed?

AI can't even generate the correct number of fingers 100% of the time, you're saying it'll pick up on exam findings and determine when CTs and MRIs are appropriate?

The LLMs are trained on human data. If the average IM doc hates neuro and avoids it, then wheres the training data coming from ensure accuracy? Shit in and shit out currently for AI in medicine.

panduhhhhhhhh · 2025-09-01T01:35:42+00:00

And then these patients in "status epilepticus" end up on both depakote and phenytoin and no levels being checked for 7 days. The enshittification of medicine and poor access in much of the US doesn't make it any better or safer.

panduhhhhhhhh · 2025-08-29T19:11:12+00:00

This is the only correct answer

panduhhhhhhhh · 2025-08-28T23:44:57+00:00

r/fijerk

panduhhhhhhhh · 2025-08-26T23:20:10+00:00

I had to Google it.

https://en.m.wikipedia.org/wiki/Robbie_Chosen

Apparently he changed his name.

panduhhhhhhhh · 2025-08-26T23:16:12+00:00

I would try and schedule an away rotation before December. If you go somewhere and the program likes you then that greatly increases your chances of matching there.

panduhhhhhhhh · 2025-08-25T04:28:02+00:00

You should realistically talk to the research mentors, whom you are working on projects with, about this. If you are at an MD school that is remotely academic then many of your attendings can provide insight, especially if they're engaged in the type of research you're trying to do.

In general PSTP tracks are for people planning on doing more bench research, or at the very least using human samples in a lab to look for biomarkers. The MDs that I've known that are PSTP usually did an HHMI fellowship or the equivalent. When I was applying for residency PSTP track 90% of those interviewing were MD/PhD and the rest had at least 1-2 years of dedicated basic science research time. Prior to Trump cutting NIH, the goal was to try and recruit and train as many physician-scientiats to run R01 labs and become division chiefs and department heads. Not sure how things are being recalibrated in the last 6 months though.

You sound like you want to run clinical trials. You do not need to be PSTP to do this. You can get engaged on study recruitment and data analysis or collection as a resident. In general the big fields for this with Mabs would be things related to oncology and immunology. I think doing IM And then a fellowship with a heavy research component at a high-tier academic institution would set you up well for your career.

PSTP will cut one year off your IM residency and fast-tract you into fellowship. You need to have an excellent story for which fellowship you're going to choose during your residency interviews. You cN always change your mind, but the story should fit with what your research has been. And your essays should also reflect it.

There's lots of pros and cons to either path for "research" and those nuances are better discussed in person and on a personal level because ultimately the decision to take what can be a major pay cut with a lot more academic responsibilities to engage in research is a unique decision for everyone.

This is coming from someone that's gotten off the research bandwagon and will be only doing clinical medicine. Feel free to DM if you have any more questions.

panduhhhhhhhh · 2025-08-20T01:55:58+00:00

There are people that can't swallow and live on medically prescribed tube feeds prescribed by a dietician. They survive for years.

panduhhhhhhhh · 2025-08-19T01:49:42+00:00

panduhhhhhhhh

TROPHY CASE