I love this. I have a saying I love in the ER, it has a similar vibe to what you say and it goes “Everyone’s story is true, and some of them actually happened”
@@itspresro They need to include this ideology (and phrase) more often out-the-gate in med school - empathy seems to be one of the first fires, for many, that burns out.
"The first pulse to check is your own." In EM, quite literal. In psych, I might say the first vibe to check is your own, or for the older docs, the first mood to assess. We can't care for others if we don't care for ourselves, and we can't assess others accurately if we are ourselves in a disrupted state.
Room on this ride for two makes me think of Hickam’s dictum. “A man can have as many diseases as he damn well pleases”. The more I move through medicine, the more this is my most used diagnostic principle. Loving this insightful series, best of luck in your training!
I really appreciate this sort of thinking as a patient. I had anemia caused by both not enough vitamin C and my body not producing methylated folate. Solving both of those problems took a long time since the second issue isn't that common, and afterwards I still had some symotoms like exhaustion, indicating a third issue. Blood tests found an autoimmune disorder, and we still don't really have enough information to treat it properly but at least I know there's something else to chase up on. If we had stopped at "you're taking iron so your anemia should be gone" not even one of my issues would've been solved.
The first razor can also extend to the idea that it’s more likely to have an atypical presentation of a common disease than to have a typical presentation of a rare disease. The medical TV show “Scrubs” have touched on this idea in one of their episodes quoting this razor.
- if you hear hooves, think horses not zebras - occam’s razor - every dog has ticks and fleas - hanlon’s razor - hickam’s dictum - sound vs valid arguments
I think it's also important to note that it's important to still skillfully think through the zebras even if you're 99.9% sure it's a horse! Great video -- the "fleas and ticks" one is something I'm definitely going to keep in mind! ALSO -- can you give more advice on navigating medical environments where people can be mean/rude/etc -- i try not to take it personally, but it can be emotionally draining nonetheless. THANK YOU! Keep being you! :) love the content! (I'm in nursing school!)
I'm a systems engineer in the software industry, which basically means I'm a server doctor, and the number of parallels between the principles and ideas used in diagnostic medicine and what I do never ceases to amaze me. The only difference is that computers only do what they're told - which is a mixed blessing, in that i know my patient isn't lying or leaving something out, but if something is wrong/off it's almost always ultimately the fault of my own or one of my colleague's actions or lack thereof. 😂
Love this direction you're going with your videos! Taking your presenting skills and combining it with humor and critical thinking skills is so helpful! Can't wait to take these insights into psych intern year!
Hey I really appreciate everything you do. I liked how you mentioned how you process when people are yelling at you. I have been in practice for 8.5 years. I just had the opportunity to approach the situation this way and it was very helpful. Hang in there! Residency does get better!
We got cat and free feet at the end of the video 😂 I love your content! It is good to hear about these things from a doctors perspective. Psychiatry gets a bad wrap for not being medical enough. I do wonder how we hear horror stories of people getting misdiagnosed or told they are fine when they are suffering from whatever aliment. I had to be locked in 3 different psych wards before I got labeled as BPD and told I can't really be treated. I'm glad we are advancing the field enough to find different modalities to treat stuff like that. Combining philosophy and medical training seems to be a good thing, but it feels invalidating when you feel like there's something wrong and no one can give you answers that make sense.
Could you do a video about how you felt before starting residency? I was expecting to feel blissful after match day but I've been surprised by how much anxiety I've felt honestly. Sincerely, a matched and grateful but terrified M4 ✨
Yeah man, I have a whole video diary of residency up to this point on tik tok, I have been putting off compiling it to throw it on RU-vid but this comment gave me the push
I love this content!!! I’m applying to med school and am super interested in psychiatry/neurology, and feel like these videos help me think like the doctor I want to be someday 🥹 ur super inspiring. Also, cute cat!!!
I think the Occam's and hoofbeats principles can apply to some of the most wrongly diagnosed conditions. For example, almost anytime you are thinking of diagnosing bilateral lower limbs cellulitis, you're venturing into wildly unlikely territory (separate disease processes really) where a diagnosis of stasis dermatitis would be an absolutely reasonable explanation of the symptoms.
I can try to give one. Basically the difference is just that any argument can be valid based on your starting "facts" (we call these "premises"), but only if the starting point is true is it also a sound argument, which also means that your conclusion is in fact true. The point being that if you start from a bad assumption, everything else is nonsensical from there and you need to start again. Let's say, you get an abnormal lab value back which means this patient has a vitamin deficiency. It is valid to say that if this lab is this value, they have the deficiency/diagnosis, and that means that you conclude they have the deficiency. As long as you believe (or hopefully can prove) your initial facts are true, your reasoning is also sound. However, maybe later the lab calls you and says the result was wrong - the sample was mislabeled or the machine was broken or something. That means the premise was wrong, so the reasoning is not sound and the conclusion is not necessarily true... But the reasoning is still valid, in the sense that if the initial premise were true then that would be your conclusion. These are really just technical terms, but nice if you want to be very precise about this kind of thing and/or want to read more on philosophy or logic. They're foundational concepts in that field, which is all about how we reason/determine what's true or not and what is a valid, well-supported, irrefutable argument.
Love the lesson. Preston do you store your dining chairs upside down on the table?? 🤔 Never seen that outside a restaurant, but boy does it look easier to vacuum that way 😮
I’d love to see a video next on how psych, despite being “real medicine” (it is), is sometimes treated as a “diagnosis of exclusion” which seemingly contradicts the first “ “
Yes, there is room on this ride for 2! Yes!! But, please dont miss the zebras... sometimes zebras are long ignored. Like... young onset dementia. It is underdiagnosed and most often assumed to be the horse- depression.
That could be a great and easy way to sus them out! Other options could looking for oligoclonal bands in the CSF. MRI c and t spine to assess for other lesions and a full physical to look for other signs of tertiary syphilis to help push you in either direction
I’m gonna use there is room on this ride for two. The verbal punch ups I have seen between psychiatrists about diagnostic disagreements…honestly, like children….I’m right, you’re wrong, so there!
Valid and I know this is very nitpicky and not relevant to what was being discussed but you can actually have ocular syphilis with negative CSF testing because ocular syphilis can manifest before neurosyphilis develops. In that particular scenario it's valid to try to rule out ocular syphilis before concluding the symptoms are MS related because the consequences of missing ocular syphilis are potentially disastrous! The logic is sound I just wanted to point out it maybe wasn't the best example.
Hahaha this is an ID attending level of knowledge. I think in this scenario we would end up treating for ocular syphilis with 2 weeks of penicillin and run the CSF for oligoclonal bands. The example I gave was meant to encourage not anchoring on just syphilis and include MS on the differential which I honestly did a poor job of setting up the scene for
I will make a counterargument to the room on the ride for 2: catching 2 diseases at the same time seems like it would contradict Occams Razor, as that it would be more less likely/more complex for two completely separate diseases to occur and cause hospitalization at the same time. It’s important because if someone has one condition but is diagnosed with 2 seperate ones, it is most likely going to negatively influence their treatment path. Good video though, love these ones lately!
What do you do when you're a zebra and you've been through several doctors insisting you're a horse? I understand the logic behind this mentality, but there is no reason why easily diagnosed conditions take years to achieve diagnosis just because physicians are refusing to connect the dots in the right order.
I'm sure he'll get to this, but in medicine we also talk about cognitive biases that influence our care. In the case of someone who has a rare diagnosis but is always labeled with a common one, a number of biases may be at work. For example: anchoring bias, which is continuing with your original diagnosis despite new, contradicting evidence; premature closure, or failing to pursue other diagnoses that have not been explored or ruled out after coming to an early conclusion; or diagnostic momentum, where a patient who carries a diagnosis from another provider does not have their history completely evaluated because it's "already been done." There are many others, of course. This video doesn't address those issues, but more some basic philosophical approaches. Like hey, most hoofbeats are horses (common things are common) but simultaneously we have to remember that multiple things can be true at the same time and also there's room for 2 and also and also... He's highlighting really what makes medicine such an art. If you've been labeled a horse but you think something's amiss, it's totally appropriate to cue your providers. Unfortunately, coming in saying, "I think I have X" can make some doctors think you've just been googling too much and become dismissive. Even a simple change of words from "I think I have" to "I've been wondering about X" or "I'm worried my diagnosis may not be right" can neutralize a defensive ego. I'm not defending dismissive doctors, mind you. We simply don't get as much training as we need (read: any) to recognize when our internal protectors turn on and makes us into jackasses.
Hi ID fellow here, love your points and don’t want to undermine them at all - just a small thing to add for everyone’s education about ocular syphilis is that CSF VDRL is about 0% sensitive for it (some people say 50%) but we stopped even asking for LPs and just treat it now. Non med people- please just use protection, there’s so much more syphilis now 🥲 If it means anything- one of my razors is question everything that doesn’t make sense to you, always ask why. Keep up the good content my friend, have loved seeing your journey through med school to starting residency
That’s a really helpful tip thank you! In this (hypothetical) scenario we treated for neurosyphilis and evaluated for MS rather keeping the possibility of both diagnoses or a unifying diagnosis open
