JFarnsworth Posted September 12, 2014 Share Posted September 12, 2014 So my new Derm SP chastised me for not having Lichen Planopilaris in my differential for a patient who was diagnosed with cicatricial alopecia x several months. How many derm PAs have seen LPP? From what I understand, this is pretty rare with a different presentation than that of cicatrical alopecia . She also was miffed that I didn't think a patient with alopecia areata in his beard had Mojocchi Granuloma (he was also diagnosed several months ago with alopecia areata, that was responding to K10 injections). I tend to not look for zebras in every patient, but now I am feeling like I am falling short. Thoughts? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 12, 2014 Moderator Share Posted September 12, 2014 there is constructive criticism (hey did you think about this? let me tell you about it) then there is being a douche because you got beat up on the playground everyday and have to belittle everyone else. you decide..... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted September 12, 2014 Share Posted September 12, 2014 Heck, I don't even know what it is, much less what it would look like. The second one sounds like something you would find in a native from the Mojave desert. Tell them to get a life and live a little and to get their noses out of the d*** journals. No wonder these yahoos didn't have a life in med school. They probably still walk around with pocket protectors and calculators on their belts (ok, so I'm dating myself again). Heck, they might even date back to slide rules days. Link to comment Share on other sites More sharing options...
JFarnsworth Posted September 12, 2014 Author Share Posted September 12, 2014 God I love you guys. I was feeling like sh*t for not knowing all the rare-see-it-once-in-10-years diagnoses. It wasn't even presented as, "think about this" but more, "WHY didn't you consider this as a viable diagnosis"? Um, cause I didn't do a Derm residency and because it is so rare that if I worked every one up for this kind of sh*t then it starts to get costly, and let's not get crazy? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 12, 2014 Moderator Share Posted September 12, 2014 everyone misses something every now and then. Billy(F-bomb)Mallon, one of the best em guys out there on the lecture circuit talks about circles of probability. it's like the reverse of a regular dart board. the center is common stuff appearing the way it normally does. your mom should get this stuff. weight loss, always hungry and thirsty, peeing all the time, duh they are diabetic. the next circle is common things with less common presentations like diagnosing dm based on wide spread tinea and a good level of clinical suspicion. maybe 50% of clinicians get this. the next level is uncommon things in common presentations like lupus with a butterfly rash for those of us not working in derm. maybe 25% of nonderm folks get this. the final narrow circle is uncommon things presenting uncommonly like lupus based on a chest pain pattern, most folks miss these. Link to comment Share on other sites More sharing options...
PACdan Posted September 12, 2014 Share Posted September 12, 2014 ^^^ As one professor just said to us: "Uncommon presentations of common diseases occur more commonly than common presentations of uncommon diseases." 3x fast :) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 12, 2014 Moderator Share Posted September 12, 2014 ^^^ As one professor just said to us: "Uncommon presentations of common diseases occur more commonly than common presentations of uncommon diseases." 3x fast :) yup, exactly. Link to comment Share on other sites More sharing options...
JFarnsworth Posted September 12, 2014 Author Share Posted September 12, 2014 ^^^ As one professor just said to us: "Uncommon presentations of common diseases occur more commonly than common presentations of uncommon diseases." 3x fast :) Oooh, I like this. Could you call my SP please, and tell her this? She keeps saying that all itchy rashes should be considered scabies until proven otherwise. I was like, "what?" Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 12, 2014 Moderator Share Posted September 12, 2014 Oooh, I like this. Could you call my SP please, and tell her this? She keeps saying that all itchy rashes should be considered scabies until proven otherwise. I was like, "what? how about all itchy rashes affecting extremities>torso and web spaces on the hands....I see a lot of scabies working in an inner city urban e.d. and in Haiti It's not a terribly difficult diagnosis most of the time. 1. see the rash 2. check the distribution 3. take a social hx: anyone else with this?boyfriend/girlfriend/spouse/ just get out of jail/homeless/etc 4. bingo. permetherin or ivermectin, pick your poison. repeat tx in 1 week. http://www.healthline.com/health-slideshow/scabies-bites#1 always also think about secondary infection with scabies. looks like scabies with pus coming from some lesions? bingo. ivermectin + clinda. Link to comment Share on other sites More sharing options...
Moderator ventana Posted September 12, 2014 Moderator Share Posted September 12, 2014 Gotta disagree with the masses on this one you are in a speciality role, and yes those zebra's do need to be on your radar.... that is the exciting stuff with medicine, not just another case of acne.... In all honesty I am not familiar with either one of the things you mention, but I am a PCP and not a Derm person - you as a derm person should have these rare things on your list and be looking for them, even if just to rule them out.... now the bigger issue is how was this presented to you - a polite reminder, or even a little stronger reminder is fine (heck sometimes we all need a little prodding) but outright yelling or putting you down is unacceptable..... This advice applies to ANY specialty, and for PCPs who are getting board one of the best nuggets of advice I every got was this "before you Dx anyone, make sure you can list at least 5 different things it could be, if you can not list 5 things you need to think about it more....." Amazing how this forces you to think with a broader sense!! Either way it was presented it was a valid point out - but if presentation was poor you might need to work on the doc to be nice about it.... Link to comment Share on other sites More sharing options...
JFarnsworth Posted September 14, 2014 Author Share Posted September 14, 2014 ventana, good point and well taken. I guess my beef is that I do consider outlier diagnoses on every patient, but I really don't consider the super rare diagnoses that present differently than my patient does. I'm not going to look for the uncommon presentations of uncommon diseases in every patient. That would be like ruling out a PE for every patient you see who has a cough and no other symptoms. I would have welcomed a presentation that EMEDPA outlined. As in, "there's this rare condition that can sometimes present like this, something to consider" but what I got was, "I was concerned that you didn't think of this condition when seeing the patient. Obviously you will need a lot more training before you can see patients on your own." And we're talking about alopecia that is responding to traditional therapies. I was thinking, why would I suddenly think of an unlikely condition that usually doesn't present this way? And I was venting. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 14, 2014 Moderator Share Posted September 14, 2014 there are both docs and PAs who are good mentors and unfortunately many more who just aren't.... one of the reasons I stay at my current primary job is the ability to interact with students from a quality program. Link to comment Share on other sites More sharing options...
JFarnsworth Posted September 15, 2014 Author Share Posted September 15, 2014 there are both docs and PAs who are good mentors and unfortunately many more who just aren't.... one of the reasons I stay at my current primary job is the ability to interact with students from a quality program. Can I be your student? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 15, 2014 Moderator Share Posted September 15, 2014 Can I be your student? too late, you had to go ahead and graduate already.....:) I have had several members of this forum as students and enjoy teaching a great deal. I like to approach students as future colleagues. They always teach me things throughout their time working with me and help me remember stuff I had previously known but forgotten. Teaching is a two-way street. Link to comment Share on other sites More sharing options...
PACdan Posted September 15, 2014 Share Posted September 15, 2014 too late, you had to go ahead and graduate already.....:) I have had several members of this forum as students and enjoy teaching a great deal. I like to approach students as future colleagues. They always teach me things throughout their time working with me and help me remember stuff I had previously known but forgotten. Teaching is a two-way street. Oh man, I call dibs on a spot in 2 years for one of my elective rotations. I am planning to triple-up on EM rotations. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 15, 2014 Moderator Share Posted September 15, 2014 Oh man, I call dibs on a spot in 2 years for one of my elective rotations. I am planning to triple-up on EM rotations. then plan on going to U.WA/Medex. I did exactly this: required em rotation 5 weeks peds em (counted as peds) 5 weeks 12 week preceptorship in em also got a 5 week/600 hr trauma surgery rotation (for surgery) with an ATLS class the week before the rotation. Link to comment Share on other sites More sharing options...
JFarnsworth Posted September 17, 2014 Author Share Posted September 17, 2014 too late, you had to go ahead and graduate already.....:) I have had several members of this forum as students and enjoy teaching a great deal. I like to approach students as future colleagues. They always teach me things throughout their time working with me and help me remember stuff I had previously known but forgotten. Teaching is a two-way street. Darn it. It seems there is a dearth of good mentors for PA students. Lots of times it seems like a one way street where the PA student is supposed to be in reverant awe of their preceptor and is never allowed to question any thing. I bet your students do well. Maybe I could get a job where you are and you could mentor me? Link to comment Share on other sites More sharing options...
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