Mr Paul Lewis’s elbow had been swollen for the past month when he fell backward and landed on it while walking his dog. Multiple joint aspirations hadn’t shown any evidence of infection or any crystals to suggest he had gout. What they did show was blood. He had lots of blood in that joint and a subsequent MRI showing what the radiologist called “extensively destructive arthropathy,” which means that he had all kinds of badness going on inside that elbow. As part of the work-up, our attending suggested we get a rheumatoid factor.
Seriously? A rheumatoid factor? In a patient with an acute problem in a single joint following a traumatic event? And if the rheumatoid factor is positive, we’re going to do what exactly – start him on some NSAID’s and possibly methotrexate and hope he gets better?
The doctor in the example above is double boarded in internal medicine and neurology and was covering our inpatient service for the week. He really is quite knowledgeable. He’s the guy that you want taking care of you if you have diabetes concurrent with poorly controlled seizure disorder. Bone and joint issues…not so much his thing.
I struggle on a daily basis to delineate those facts that I should absolutely know in order to consider myself a competent family physician from those facts which I absolutely do not need to know – to figure out during which lectures I need to perk up and during which lectures I can plug my ears and yell, “la la la la la.” This is quite a bit more difficult than one would think. Nearly everything written in every medical textbook or journal from any specialty is potentially relevant to family medicine. But, even the very best family docs are only familiar with a small portion of this information. In fact, those in our field who have attained the highest levels of prestige and stature (program directors, department chairs, etc) often are the most actively involved in research and therefore have only mastered a relatively smaller portion of medicine as they’ve had to devote more time to learning fewer topics, albeit in greater detail.
So, is the guy who thinks you need to get a rheumatoid factor on someone with an obvious hemarthrosis competent? Every physician has gaps in his or her knowledge. If I graduate from residency with as much knowledge of psychiatry as our obstetrically trained faculty and as much knowledge OB as our sports medicine faculty and as much knowledge pediatrics as the guy who only does adult inpatient medicine, will I be competent? I certainly hope so, because there isn’t a doctor alive who knows as much OB as an OBGYN and as much psych as a psychiatrist and as much peds as a pediatrician and as much about your teeth as a dentist etc. Yet, in family medicen, we’re supposed to know about all of these things. The question is, how much? Where can we stop? Since the very start of my medical career I have been searching for this minimum standard for what it means to be competent. Does passing your boards make you competent? Nah, I think there are plenty of incompetent physicians who’ve managed to pass their boards. The only standard I’ve found so far is that you are competent until you start doing too many things that embarrass your colleagues. And that’s no kind of standard.
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