Does anyone ever miss research?

[MarsRover]

Now I know this may be not a popular opinion because a lot of med students saw research as a necessary premed evil. 

But now that I am in clerkship, sometimes I definitely miss research. I find in medicine sometimes the focus is on just recognizing symptoms and medications to give - which granted yes that is what you should know. But I guess as a premed/preclerk it was easy to romanticize medicine as like being on the front line of not knowing most modern treatments and trying new things. That was the fun thing of research totally understanding some metabolic pathway and hypothesizing ways that things could change it and ways this could benefit us. 

But it seems a lot of medicine isn't really about knowing those fine details and hypothesizing treatments based on physiology- and also for good reason lots of chance to be wrong. But sometimes say when dealing with DM2 which actually has amazingly interesting physiology - I can miss it when the actual care itself can be a little less cool. You just have a flow chart of what meds to try after metformin based on their pre-existing conditions and lifestyle.

Medicine seems to focus more on knowing the known physiology, and keeping up to date with new advancements made by others. A lot of attendings do find great satisfaction in just knowing the physiology and changes others make, and not hypothesizing the mechanisms and tweaking them themselves. 

 

Basically, I do love medicine. Just does anyone ever miss that problem solving and intense knowledge of physiology that biochemical/biomedical research has? I'm sure a big part of this is being a clerk, but I am focusing specifically on what attendings do/think.. also in a community centre. 

[Edict]

On 10/24/2018 at 2:40 PM, MarsRover said:

Now I know this may be not a popular opinion because a lot of med students saw research as a necessary premed evil. 

But now that I am in clerkship, sometimes I definitely miss research. I find in medicine sometimes the focus is on just recognizing symptoms and medications to give - which granted yes that is what you should know. But I guess as a premed/preclerk it was easy to romanticize medicine as like being on the front line of not knowing most modern treatments and trying new things. That was the fun thing of research totally understanding some metabolic pathway and hypothesizing ways that things could change it and ways this could benefit us. 

But it seems a lot of medicine isn't really about knowing those fine details and hypothesizing treatments based on physiology- and also for good reason lots of chance to be wrong. But sometimes say when dealing with DM2 which actually has amazingly interesting physiology - I can miss it when the actual care itself can be a little less cool. You just have a flow chart of what meds to try after metformin based on their pre-existing conditions and lifestyle.

Medicine seems to focus more on knowing the known physiology, and keeping up to date with new advancements made by others. A lot of attendings do find great satisfaction in just knowing the physiology and changes others make, and not hypothesizing the mechanisms and tweaking them themselves. 

 

Basically, I do love medicine. Just does anyone ever miss that problem solving and intense knowledge of physiology that biochemical/biomedical research has? I'm sure a big part of this is being a clerk, but I am focusing specifically on what attendings do/think.. also in a community centre. 

I totally get what you are saying, i personally don't but then again is because I tend to like keeping things practical. I just want to know what to do at the end of the day. 

But yeah, this is one of those things that differentiates clerks from pre-clerks. The theory is so different from the reality it is shocking at times. In theory, you need to know all the conditions in Step 1, a little bit about everything. In reality, 99% of your cases are probably related to 1 of 25 or so conditions. For the other 1%, you look it up. The other nasty thing about reality is that oftentimes you treat without knowing the cause due to time constraints, diagnostic tests not being accurate or being too time consuming or expensive, or the need to treat now due to financial constraints or patient safety. I find a lot of what researchers discuss isn't always practical. They may spend hours debating between 3 drugs of the same class, but in reality, you don't have the time or energy to care, you just prescribe whatever drug is commonly used in your department. 

 

 

 

 

[MarsRover]

5 hours ago, Edict said:

I totally get what you are saying, i personally don't but then again is because I tend to like keeping things practical. I just want to know what to do at the end of the day. 

But yeah, this is one of those things that differentiates clerks from pre-clerks. The theory is so different from the reality it is shocking at times. In theory, you need to know all the conditions in Step 1, a little bit about everything. In reality, 99% of your cases are probably related to 1 of 25 or so conditions. For the other 1%, you look it up. The other nasty thing about reality is that oftentimes you treat without knowing the cause due to time constraints, diagnostic tests not being accurate or being too time consuming or expensive, or the need to treat now due to financial constraints or patient safety. I find a lot of what researchers discuss isn't always practical. They may spend hours debating between 3 drugs of the same class, but in reality, you don't have the time or energy to care, you just prescribe whatever drug is commonly used in your department. 

 

 

 

 

Yea for sure. To be honest I prefer practicality too when I am actually in medicine. I like in my surgery rotations so far its like you have this issue. we can do these surgeries and approaches and they are tangibly different ways to try to solve this. ER is practical as well. can i help this now? does this need urgent assessment? yes/no

 

I am mainly still just getting over the surprise that I don't enjoy internal or largely outpatient clinics. I just imagined trialing meds to help patients with symptoms finding what works, but definitely more like ok we have this option up to this dose then this one if those dont work well sorry.. in internal thinking over lab work imagining what it could be and such. But as you said most times apples are apples not zebras. And most the time you are going to check if its an apple anyway. so i find the discussion around what it could or could not be no the wards when you know your going to order the tests to see if its an apple anyway kind of pointless until you see if its an apple or not. 

[Edict]

6 minutes ago, MarsRover said:

Yea for sure. To be honest I prefer practicality too when I am actually in medicine. I like in my surgery rotations so far its like you have this issue. we can do these surgeries and approaches and they are tangibly different ways to try to solve this. ER is practical as well. can i help this now? does this need urgent assessment? yes/no

 

I am mainly still just getting over the surprise that I don't enjoy internal or largely outpatient clinics. I just imagined trialing meds to help patients with symptoms finding what works, but definitely more like ok we have this option up to this dose then this one if those dont work well sorry.. in internal thinking over lab work imagining what it could be and such. But as you said most times apples are apples not zebras. And most the time you are going to check if its an apple anyway. so i find the discussion around what it could or could not be no the wards when you know your going to order the tests to see if its an apple anyway kind of pointless until you see if its an apple or not. 

Yeah, the reality of CTU is essentially: go through your list of common diagnoses to answer the problem. Order all the common tests, shotgun approach. Treat anything that sounds potentially life threatening prophylactically: favourite example is the "septic workup", temp of 38.3? sounds potentially septic, pip-tazo, BC x 2, UC, CXR, CBC, Lytes, Cr, re-evaluate? They look sicker? lactate. Even sicker? send em to ICU. If they don't fit those common diagnoses, treat the symptoms, think about less common causes, do this by consulting various services. Meanwhile, fix em up, and start the dispo planning. 

A lot of people who end up getting discharged on CTU don't have a real diagnosis, they just have their acute issue managed, some generic catch all diagnosis that sounds reasonable (CXR looked hazy? pneumonia), they were sick, vitals unstable, had a temp? (septic (insert source as urine, lines, resp etc.)) and followup with a specialist somewhere.

The thing is, its easier to criticize this approach, but it actually works. It's basically cover your ass medicine, but if you did try to play House M.D. and look for that elusive zebra diagnosis (to impress your attending), you probably won't find it most of the time, and guess what, when you do find it, it is probably entirely academic anyways, since the treatment is probably the same. Derm, Rheum, Nephro use 12 different types of steroids, NSAIDs or immunosuppresants. Cardio uses the same 5 classes of meds. ICU puts everyone on one of a couple pressors. Thrombo's entire specialty is debating warfarin vs heparin vs NOACs. 

 

 

[NLengr]

Medicine is much closer to engineering than science and I don't think 99% of the people in pre-med or pre clerkship understand this. 

You take a system (the patient) with a bunch of unknowns. Then you try to apply what you have avaliable to gather information (history, PE, labs and imaging) to guess what the problem may be. You make educated assumptiins about what you don't know. You create a plan based on what you know about the system and what you know about your potential solutions (aka treatments like drugs or surgery). You then implement those solutions and see if they work. The entire process is fraught with uncertainty and assumptions. 

I think most science background people have a huge issue trying to wrap their heads around this whole concept at first. It's just so different from the precise and methodical nature of lab science. 

I did an engineering background and I grasped the entire idea from day one luckily. I think most engineers in medicine did. 

[MarsRover]

4 hours ago, NLengr said:

Medicine is much closer to engineering than science and I don't think 99% of the people in pre-med or pre clerkship understand this. 

You take a system (the patient) with a bunch of unknowns. Then you try to apply what you have avaliable to gather information (history, PE, labs and imaging) to guess what the problem may be. You make educated assumptiins about what you don't know. You create a plan based on what you know about the system and what you know about your potential solutions (aka treatments like drugs or surgery). You then implement those solutions and see if they work. The entire process is fraught with uncertainty and assumptions. 

I think most science background people have a huge issue trying to wrap their heads around this whole concept at first. It's just so different from the precise and methodical nature of lab science. 

I did an engineering background and I grasped the entire idea from day one luckily. I think most engineers in medicine did. 

Yea that makes a lot of sense. Each condition has a variety of symptoms and findings necessary to satisfy its criteria. So then a lot of it is uncovering knowns like you said and putting it into the best fit based on them. These are the available treatments for this. The key is just committing them all to memory, and obviously because medicine is so wide its not possible hence subspecializing. 

Definitely most premeds do not realize this I agree 100%. 

[NeuroD]

4 hours ago, NLengr said:

Medicine is much closer to engineering than science and I don't think 99% of the people in pre-med or pre clerkship understand this. 

You take a system (the patient) with a bunch of unknowns. Then you try to apply what you have avaliable to gather information (history, PE, labs and imaging) to guess what the problem may be. You make educated assumptiins about what you don't know. You create a plan based on what you know about the system and what you know about your potential solutions (aka treatments like drugs or surgery). You then implement those solutions and see if they work. The entire process is fraught with uncertainty and assumptions. 

I think most science background people have a huge issue trying to wrap their heads around this whole concept at first. It's just so different from the precise and methodical nature of lab science. 

I did an engineering background and I grasped the entire idea from day one luckily. I think most engineers in medicine did. 

Yea, whenever I hear my uncle talk about his approach fixing a car I can't help but see the similarities.