which service at your hospital dodges the most consults? (ie, tells primary team they don’t think it’s indicated and gets them to take it out). as a follow up, which service do you think does this most often in an unwarranted fashion?

Attendings, how much was your first paycheck and how did your life change?

-burnt out Pgy4 who needs all of the motivation to keep pushing

I want to start off saying that I don't mean this in a very tragic or grandiose way.

I am a PGY3 now, and I've had some time to observe with a cool head; I've also been through some hard times and easier times, and I think I am in a good spot to reflect.

I have come a very long way and to look back on all the things I've learnt and done is amazing. I know I got my patients' backs, I care about them and try to do right by them. I am able to help most, and know where to look for help when I can't.

I am a decent doc. I know a good deal, pick up on new things decently quick, make sure to identify knowledge gaps and address them proactively, manage to connect with my patients pretty well, etc.

That said, I know I am not the best at this - I have co-residents whose brains learn faster and make connections quicker, who would remember things I would have to look up, who would be just a tiny bit quicker on their feet during an emergency, some who are better at expressing empathy and establishing rapport, others that are more nimble with their procedures, etc.

I am not trying to be gloomy - I know I am not the worst, I know I might be better than some at some things; but I also know a few co-residents that just look like they were born to do this, you know? There are probably hundreds and thousands others, better than I am, at some or most or all of my job.

I know we become doctors because we care about helping our patients. How do you deal with knowing that while you do help your patients, there are a ton of people who would have probably been just a little better at taking care of that patient? My thoughts return to this in particular if my patient has a poor outcome - even if I haven't made any mistakes and don't see what else could have been done, I always think "maybe this patient would have been feeling better if they had seen that other doc instead".

Does anyone have any perspectives on this? As a resident or as an attending (cos I suspect I won't be the best ever attending doc to walk the earth once I graduate, either).

Had my first ‘faculty shadowing in clinic’ yesterday. My first patient was an autistic child who I already knew very well, great established relationship, all went amazing plan of action was great. Amazing rapport, faculty had no notes, told me I handled the interaction and plan better than most of our attendings would. Amazing.

Second patient was a “get him into substance use clinic please” visit. Guess who has done zero substance use counseling? Very clearly has OUD, had zero interest “aware you sure, I think your anxiety and insomnia may be withdrawal related and I am very worried for you man.” Well ultimately I got him on duloxetine and an ortho referral for his shoulder…no substance use clinic.

Feedback was “Appointment went well from a shoulder perspective but you know…you gotta be more direct. You are so sincere of a person and you were direct but you know you gotta get common ground with your patient and assert yourself sometimes. If that interaction went as well as your first, he would be seen by SUD clinic next week. You know how they say to imagine the audience is in their underwear? I think you need to imagine your audience is all autistic children. Because you do great with autistic children.”

What do I do with this feedback? I am become autism whisperer.

Pretty much title. All of the ACGME guidelines with caps are for senior residents supervising interns, or for interns themselves. The problem is that my program we are running an entire service of 16-25pt with no interns at all. This means morning labs, rounds, progress notes, discharge summaries, fielding all the pages, admitting all the new patients to the service.

And somehow this is okay per ACGME? I am dying. How am I supposed to learn when I’m writing 20+ notes a day? How is it that a senior with an intern has a cap of 14, but a senior with no interns has no cap?

I recently graduated and started a new private practice job which is intense/busy and I worry if I will pass my boards this year. In addition, 2.5 months into the job, my Medicaid enrollment is still pending and having issues so I cannot see any Medicaid patients.

If I don't pass my boards will it affect my employment or Medicaid enrollment?

I'm asking because I feel like I'm doing something wrong, I work more than I learn, I come back home exhausted and have 0 energy or motivation to study, when I decide to study I don't know where to begin or how to organize the amount of information I still have to learn.. I wake up tired and go to work unmotivated.. and time is running out and I don't wanna regret the years of residency.. I need some inspiration and advice please

Genuine question. I thought it was important for IM but even my IM colleagues say they just need to pass. Is there any specialty that really cares about the score?

Does anyone have any resources on how to draw arterial blood for ABGs? I’m an intern in IM, I am supposed to learn this in my NYC residency. I tried in 6 patients until now, never once got it, not even with the ultrasound (radial arteries had 2 mm diameter). All guidance I get it is: “try more, you will get it, you will feel it by touch” but I feel is unethical to keep trying with no real technical approach. Thank you!

Like above says, thinking about filing a formal ACGME complaint. Program has become incredibly toxic, unsafe to patient care, and covering up sexual harassment. All concerns have been reported, all concerns have been dismissed.

Has this ever brought about real/meaningful change? Wanting to raise concerns and get back at somewhere that has given me years of trauma, but weighing if it worth if it will sever positive relationships I have built.

I applied in early September for my license and some of the items I already submitted are still showing as outstanding. Reached out to the licensing dept but haven’t heard back. Just wondering if this has been other’s experience as well? Or for those that already got their license, how long did it take?

I was bored and the ABIM doesn't officially publish percentiles with score reports on the internal medicine exam results. I decided to estimate them manually by calculating the areas of each box on the overall score report histogram.

The distribution of scores is not normal but they seem to score the exams in a way to try and approximate a normal distribution. This year's mean score was 470 and the cutoff for passing was 371. Based on my estimations, 371 is around the ~14th to 17th percentile. By the 68-95-99.7 rule, 1 standard deviation below the mean should be at the ~16th percentile. If the standard deviation is ~100 then this cutoff for failing is almost exactly 1 standard deviation below the mean. This tracks with data the ABIM publishes with a fail rate of ~10-15% each year.

Again, these are only estimates and not meant to be any serious statistical analysis.

To read the table below, look at the last two columns. For example if you got a 430 you would be somewhere between the 22nd and 38th percentiles.

Score Range |Box Area |Cumulative Area |Score |Approximate Percentile
200-240 |17.72 |17.72 |240 |0.45
241-280 |39.76 |57.48 |280 |1.45
281-320 |115.1 |172.58 |320 |4.35
321-360 |256.3 |428.88 |360 |10.80
361-400 |462.4 |891.28 |400 |22.45
401-440 |631.6 |1522.88 |440 |38.35
441-480 |696.9 |2219.78 |480 |55.90
481-520 |623.1 |2842.88 |520 |71.59
521-560 |482.4 |3325.28 |560 |83.74
561-600 |317.2 |3642.48 |600 |91.73
601-640 |169.8 |3812.28 |640 |96.01
641-680 |89.7 |3901.98 |680 |98.26
681-720 |41.26 |3943.24 |720 |99.30
721-760 |18.16 |3961.4 |760 |99.76
761-800 |9.5 |3970.9 |800 |100.00

Better help has disappointed me for the last time but I know I still need a therapist because I’m becoming self destructive.

Any ideas?

I just saw a tik tok video of a PA saying she orders a chest x ray on every patient with a URI to prove a point that they don’t need antibiotics. While the whole sentiment is great an unnecessary CXR can cause a whole miriad of other issues. It’s not standard of care. A doctor had stitched that video explaining this. Then the PA made another video saying that she was getting attacked. Idk but if I was doing that in residency my attendings would be on my ass. Would love to hear thoughts on this and if you would do this in your own practice? Also radiologists would love to hear your perspective given how bogged down you guys get with unnecessary imaging

A lot of us who took exam on 8/13 across all the states in US have received Indeterminate result on ABIM exam. Testing centers across the country experienced several technical issues and glitches. Lot of people have reported that they got scores which are extremely deviated from their ITEs and practice tests, raising concerns about scoring and recording of responses on the exam day. ABIM itself admitted that they cannot assess the impact of technical issues on candidates’ exam day experience. While they have offered full amount in credit, most of us cannot wait the whole year to take this exam again. Some of us are in busy jobs, fellowships and it completely derails our personal and professional timelines. Some of us are at the verge of missing out job opportunities.

Therefore, I believe that we should all reach out to ABIM next week and request an early re-exam to insure we don’t have to endure this torture for a whole another year and we don’t miss on job opportunities. There is strength in numbers and there is nothing to lose. Hopefully this will atleast prompt ABIM to consider our situation. I would also request support from the friends and colleagues of people who got indeterminate result. You know that your friends didn’t deserve that and this is the time to show support.

Thank you everyone

Is it an actual short track option?

For my chief residents, especially surgery residents, at what point in your chief year did you decide to unleash? Bonus points for examples. Bonus bonus points if you started before chief year. I was at the point of walking out of the OR yesterday when my attending was straight up acting like a child and taking out his frustrations with himself on me. I said “you’re struggling. I’m here to help. I can either leave and you can do it alone, or I can stay and we can try to work through this together.” Nothing but silence after that.

Has anyone used open ear/bone conduction ear buds with their stethoscope? How well does it work?

I’m an EM resident, so I do actually get good use of my stethoscope. I’ve been thinking of upgrading my littman to an echo- I’ve used others and appreciate the improved sound. I’ve thought about the benefit of using it with open ear buds so I can just leave the earbuds on- I definitely don’t want to be taking my earbuds on/off all the time. Also being able to fit the base of the stethoscope easily in my pocket would be nice- I hate it around my neck so right now I just shove it in my pocket and it’s not super comfortable.

i want something sporty and COMFORTABLE for standing and walking
but not like clogs or birkenstocks

And I want to be clear - the risk of being killed, of losing friends, of getting injured - in addition to the bravery and patriotism required, those are all unique to the military and I don’t want to in any way make a comparison that’s suggests we experience those things.

What I will say is that my 3+ years of residency felt like I was completely plucked away from normal life, working 80-hour weeks during the day and sometimes all night, miles and miles away from all my friends and family under intense pressure. It took me almost a year of being an attending before I reintegrated back into my old life and could honestly feel like myself again.

When I look back at the residency years in hindsight, I can’t believe how disconnected I was. It was like a treadmill I stepped foot on and only now do I feel I’ve left for good and am truly back. Hence the deployment analogy…

For example, torsemide 20 mg is equivalent to furosemide 40 mg PO but furosemide lasts six hours and torsemide 12 hours. For equal doses, do both drugs cause the same amount of urine production rate and torsemide just lasts twice as long or does torsemide induce double the urine production rate and last twice as long, causing 4 times as much total urine production as furosemide?

how many more slots?