Anyone else exhausted by managing midlevel screw-ups?

[calvnandhobbs68]

Another recent example that had me absolutely livid. Elderly african american gentleman sees the noctor for fatigue. Says he has been experiencing some fatigue recently as well as weight loss, increasing abdominal distension, abdominal pain, urinary retention, and constipation. Has never had nor been offered a colonoscopy by pcp noctor. She started him empirically on vitamin d. Had a cbc that showed microcytic anemia, gave some iron tabs. No GI referral, no imaging despite 2-3 visits over 6 months for this. Comes to me in the ER with melena. CT shows 10 cm colonic mass and mets to the liver. This one I actually spoke to the physician who oversaw them at the clinic. I told him on the phone "I don't think I've met a single med student that would miss that many red flags. She has no business treating patients"

Good lord, just randomly lurking but this is like a freaking USMLE question. Another great example of why primary care is exactly the worst place for noctors.

---

Members don't see this ad.

 

[thegenius]

Had a lady sent in yesterday for "cold foot". She'd had classical claudication for 2-3 mo now, had an US last week was back in clinic today for scheduled followup. Shocking twist--foot wasn't cold.

Even the good ones are annoying. I was working w/ our best PA tonight. Lady checks in w/ 5 days of constipation, I order a KUB while she's waiting in triage so that she'll think we did something. He picks her up, adds labs (that come back normal) and then a CT and signs it out. Shockingly, her abd is benign, she's just constipated and CT shows nothing.

Yea I find that numerous midlevels and even some ER doctors use advanced imaging to "know what's going on" rather than to rule out emergency medical conditions.

I've been an attending for 8 years now. In the beginning I used to CT a lot of abdominal pain for that reason above...and I'm slowly learning that it simply isn't necessary. I'm more than happy discharging a < 65 year old patient who comes in with constipation for 5 days with meds and that's it (provided their vitals and exam are benign). If their vitals and abd exam are OK....and the patient is reliable and can reliably tell you a history, then if they say their constipated then I believe them. I'm +/-KUB although I agree if you are sitting around waiting for 3 hours to get a room, just get an XRAY.

There are a lot of abdominal pathologies that don't have to be diagnosed right now. You gotta know your **** in order not to work it up though. But diagnoses like diverticulitis, renal colic, epiplic appendigitis, pSBO or incomplete SBO, ileus, all varieties of enteritis and colitis, and others don't have to be diagnosed right at that time. They can be missed. Especially if vitals, exam, and labs are OK. The constipated person could have an ileus or intestinal colic, but that's OK. As long as there are no red flags...they can just go home.

 

[wholeheartedly]

Good lord, just randomly lurking but this is like a freaking USMLE question. Another great example of why primary care is exactly the worst place for noctors.

Hell, I’m trained as a clinical lab scientist and epidemiologist and even I knew that was full of red flags

 

[RustedFox]

Even the good ones are annoying. I was working w/ our best PA tonight. Lady checks in w/ 5 days of constipation, I order a KUB while she's waiting in triage so that she'll think we did something. He picks her up, adds labs (that come back normal) and then a CT and signs it out. Shockingly, her abd is benign, she's just constipated and CT shows nothing.

"Even the good ones are annoying."

Yep. So true.

NO, don't pick up that 66 year old syncope. YES; go suture this laceration and deal with the 3 year old with fever thats not a a fever. You're here to see simple things quickly - not to argue with me about why you want to work this patient up THIS way.

 

[Dred Pirate]

I feel odd piling on here considering I am not a doc, but I sit right in the PITT with y'all and I can't believe some of the conversations I hear between the docs and mid-levels. Like the other night the doc basically teaching extremely basic thought processes to a PA that has been a PA for 15 years. Like, stuff that are basic things an average medical student would know. When to do urine cultures (don't on simple cystitis) and very basic abx selection, how to administer rabies IVIG, on and on.

The other night said PA ordered three drugs they have never heard of before the night (after joint conversation with me and the attending) - fosfomycin, regitine, and tranexamic acid

 

[wholeheartedly]

I feel odd piling on here considering I am not a doc, but I sit right in the PITT with y'all and I can't believe some of the conversations I hear between the docs and mid-levels. Like the other night the doc basically teaching extremely basic thought processes to a PA that has been a PA for 15 years. Like, stuff that are basic things an average medical student would know. When to do urine cultures (don't on simple cystitis) and very basic abx selection, how to administer rabies IVIG, on and on.

The other night said PA ordered three drugs they have never heard of before the night (after joint conversation with me and the attending) - fosfomycin, regitine, and tranexamic acid

Yeah, my two faves so far were when we had a paramedic get a needle stick. Baseline testing comes back positive for Hep C.

PA goes: wow, that infection was fast! never seen anyone get infected from a needle stick before

Me: No, baseline testing checks to see what you already had. Hep C has a much longer incubation period than a few hours.

PA: how do you know all this stuff

Me: i read a lot, it’s my job to know this

Me (in my head): how do you NOT know this?

next day, talked to NP on duty to try again to get in touch with the paramedic again. He also thought positive baseline testing meant she got it from the needle stick in a matter of a couple hours



The other fun one was the DNP who ordered UA and chlamydia and gon. testing in every 20 something dude with burning on urination, penile pain, discharge etc. UA comes back pos for leuk esterase and WBCs on microscopy, maybe bacteria. Gon. comes back pos. Patients get rx’d azithromycin, ceftriaxone for the STI and then bactrim for the “UTI” which unsurprisingly never grew anything,

 

[thegenius]

The other night said PA ordered three drugs they have never heard of before the night (after joint conversation with me and the attending) - fosfomycin, regitine, and tranexamic acid

I have never given regitine in my life. I had to look it up, but I know what they are used for. That's some heavy duty shiiit right there.

 

[Mount Asclepius]

I wasn’t familiar with the brand name of Phentolamine either and had to look up Regitine when mentioned. I’ve injected Phentolamine a few times for Levo infiltration, but pretty rarely. Not sure how much it actually ever helped. Can’t say I’d blame a midlevel for not being familiar with it.

Part of the skill of any physician though is to know how to fix complications. I could maybe wing taking out an appendix, but it would be a mangled job and I’d get myself in trouble pretty quick. I don’t have the training for it, and I know that. I also wouldn’t work in the ED if I wasn’t an EP.

It’s the crux of the argument against midlevel utilization in independent practice. People don’t know what they don’t know. Non-physicians don’t have a strong base of extensive training to pick up rarer pathology or keep the train from completely coming off the rails when something unforeseen inevitably happens.

 

[Dred Pirate]

I have never given regitine in my life. I had to look it up, but I know what they are used for. That's some heavy duty shiiit right there.

That one I completely give a pass on - but the other two, not so much. We do use regitine a decent amount in the hospital as a whole for vassopressor infilatation. That does bring up a question - if a patient is sick enough to require norepi drip, should of a mid-level signed up for them in the first place? (obviously we all know initial presentation sometimes doesn't always predict dispo)

 

[rickylafleur]

That one I completely give a pass on - but the other two, not so much. We do use regitine a decent amount in the hospital as a whole for vassopressor infilatation. That does bring up a question - if a patient is sick enough to require norepi drip, should of a mid-level signed up for them in the first place? (obviously we all know initial presentation sometimes doesn't always predict dispo)

Feels “odd” piling on but proceeds hoping for the usual anti mid level pile on…
Lists drugs with astonishment that a mid level doesn’t recognize again hoping for that pile on….opposite received….”I give a pass on that one”
Seems disingenuous to make a statement like that then “give a pass”
Buy typical and follows tracks with the usual narrative here.

 

[Dred Pirate]

Feels “odd” piling on but proceeds hoping for the usual anti mid level pile on…
Lists drugs with astonishment that a mid level doesn’t recognize again hoping for that pile on….opposite received….”I give a pass on that one”
Seems disingenuous to make a statement like that then “give a pass”
Buy typical and follows tracks with the usual narrative here.

Opened a new account with three posts and proceeds to be confrontational on all of them.

that being said I work with some very good mid levels - and some not so great - it is all about knowing your proper role in the healthcare system.

 

[Tiger26]

I’m still searching for the mythical “very good mid level.” I’ve only ever encountered a range from horrendous to god awful.

If given a choice I’d take a senior medical student over a mid level 100% of the time

I'd take a great paramedic before both of them any time (we have some amazing ones in our department that just do everything well that you ask).

 

[rickylafleur]

Opened a new account with three posts and proceeds to be confrontational on all of them.

that being said I work with some very good mid levels - and some not so great - it is all about knowing your proper role in the healthcare system

 

[rickylafleur]

My initial post was not confrontational. It simply pointed out that a PA was called a “noctor” which was absolutely untrue.

 

[rickylafleur]

Opened a new account with three posts and proceeds to be confrontational on all of them.

that being said I work with some very good mid levels - and some not so great - it is all about knowing your proper role in the healthcare system.

Clearly I am new to posting on here as my response ended in the wrong place. However my statement stands.

 

[Dred Pirate]

Clearly I am new to posting on here as my response ended in the wrong place. However my statement stands.

My initial post was not confrontational. It simply pointed out that a PA was called a “noctor” which was absolutely untrue.

https://www.reddit.com/r/Noctor/.

. Many physicians consider PA’s noctors

 

[Kryptocoin]

We can list all the midlevel mishaps, but the problem is that the system doesn't even hold them accountable. Instead, state after state is giving them independent practice rights. Their insurance premium is still very low. Local nursing boards don't even know what the word 'discipline' is.

I applied for a private malpractice insurance. I was quoted $7k for me and $1k for a midlevel. This is an independent practice state. There is a medspa boom in my city because every midlevel has a low barrier to entry.

 

[rickylafleur]

I’m still searching for the mythical “very good mid level.” I’ve only ever encountered a range from horrendous to god awful.

If given a choice I’d take a senior medical student over a mid level 100% of the time

https://www.reddit.com/r/Noctor/.

. Many physicians consider PA’s noctors

We’ll they are wrong. Don’t be like them. The term comes from nurse + doctor. The man these guys were making fun of claimed to be neither.

 

[rickylafleur]

We can list all the midlevel mishaps, but the problem is that the system doesn't even hold them accountable. Instead, state after state is giving them independent practice rights. Their insurance premium is still very low. Local nursing boards don't even know what the word 'discipline' is.

I applied for a private malpractice insurance. I was quoted $7k for me and $1k for a midlevel. This is an independent practice state. There is a medspa boom in my city because every midlevel has a low barrier to entry.

I don’t disagree. I am a Physician Assistant. I am a dependent practitioner and practice as such. When all mid levels are lumped together and ridiculed it serves no purpose and is inaccurate

 

[BoardingDoc]

We’ll they are wrong. Don’t be like them. The term comes from nurse + doctor. The man these guys were making fun of claimed to be neither.

The term may have originated that way. It is generally used nowadays to mean "not a doctor" which itself carries the explicit connotation that "doctor" means "physician."

There is also the general connotation that a noctor is someone practicing independently (or under dubious oversight).

I would agree that using "noctor" interchangeably with "midlevel" is not generally correct.

 

[Rekt]

Feels “odd” piling on but proceeds hoping for the usual anti mid level pile on…
Lists drugs with astonishment that a mid level doesn’t recognize again hoping for that pile on….opposite received….”I give a pass on that one”
Seems disingenuous to make a statement like that then “give a pass”
Buy typical and follows tracks with the usual narrative here.

If he said phentolamine every med student and physician would know what it is without any hesitation. I've used it a few times. Never in my life heard it by the brand name.

Probably less than 1% of mid levels even know what the generic is or what it's used for. Or other uses besides pressor extrav.

 

[rickylafleur]

If he said phentolamine every med student and physician would know what it is without any hesitation. I've used it a few times. Never in my life heard it by the brand name.

Probably less than 1% of mid levels even know what the generic is or what it's used for. Or other uses besides pressor extrav.

You have no foundation for that statement. I know very well what it is as do the people I consider my colleagues, PAs who completed a rigorous training and not only that yearned and actively sought medical knowledge at every step.

And yes I knew it by both brand and generic.

You can’t pigeon hole my knowledge by your mixed experience with NP and PA alike. Just like I can’t know your knowledge based on the physicians I have worked with.

 

[JAFERD_MD]

You have no foundation for that statement. I know very well what it is as do the people I consider my colleagues, PAs who completed a rigorous training and not only that yearned and actively sought medical knowledge at every step.

And yes I knew it by both brand and generic.

You can’t pigeon hole my knowledge by your mixed experience with NP and PA alike. Just like I can’t know your knowledge based on the physicians I have worked with.

Continues to be confrontational and defensive because of the "I'm not the screwup, everyone else is" mentality. "I'm part of the <1% who knows what is phentolamine."

No one is personally attacking you.

Everyone is attacking a system that allows for inappropriate independent practice granted by legislation, lax educational standards and a lack of accountability.

Your comment on not judging an entire profession's average base of knowledge is hilarious. That's like saying I should be ok with a paralegal or a dental hygienist doing my legal work or dental work because how am I to judge their knowledge base against a lawyer or dentist? How about a teaching assistant? Architectural assistant?

This feeds into the whole new worldview of political correctness, not offending anyone's life story or learned experiences, etc.

You betcha when I go to the dentist I let the hygienist do their work, within their scope of practice, and have the dentist take over. When I went to college, I had TAs (who were mostly PhD students or PhDs already) and went to their sessions. But ultimately, my professor directed the coursework, wrote all the tests and gave us grades.

The average board certified, specialized physician has a greater knowledge base, has had more rigorous training and also continues to "yearn and actively seek medical knowledge at every step" (i.e. CME) than the average physician assistant or nurse practitioner practicing "healthcare."

The only reason PAs and NPs are allowed to get away with not having a similar structure as dentists, lawyers and teachers is because physicians have a weak lobbying group, PAs/NPs have a strong lobbying group and the corporate takeover of medicine has allowed this nonsense to proliferate. Dentists and lawyers have fought against practice creep from those who say "I've watched them do dental/legal work, I can do it just as well as them and get paid as much too with half the education!"

Hilarious that many of those in Congress are lawyers and don't see the irony with healthcare scope creep after actively fighting against paralegals working as lawyers.

 

[rickylafleur]

Again

Continues to be confrontational and defensive because of the "I'm not the screwup, everyone else is" mentality. "I'm part of the <1% who knows what is phentolamine."

No one is personally attacking you.

Everyone is attacking a system that allows for inappropriate independent practice granted by legislation, lax educational standards and a lack of accountability.

No actually this thread is attacking the knowledge of all midlevels. It gets to me when blanket statements are made that are patently false.
Like less than 1% know what phentolamine is or that EVERY physician or med student does. Those are both ridiculous statements and in my mind demonstrate ignorance.

Now if this thread had the theme as you described above I would agree.

 

[JAFERD_MD]

Again

No actually this thread is attacking the knowledge of all midlevels. It gets to me when blanket statements are made that are patently false.
Like less than 1% know what phentolamine is or that EVERY physician or med student does. Those are both ridiculous statements and in my mind demonstrate ignorance.

Now if this thread had the theme as you described above I would agree.

Actually, yes. Every medical student who has finished MS1 knows what phentolamine is. The number of times I had to answer a USMLE question on the mechanism, indications, etc. for phentolamine is f*ng astounding. For the record, I have never used it in practice.

Fine, not every physician does. But if you give them some hints, they'll come up with the right answer. Why would a pathologist or orthopedist need to know this?

Oh, I'm sorry. You may still remember how to do integrals and derivatives in your daily practice as a healthcare professional...my b, my b.

Which brings up one of my underlying points: medical education is standardized and heavily scrutinized, such that the average physician is more knowledgeable and competent than the average non-physician. The same cannot be said about other educational systems. ...Like online NP schools.

Note that I said average. So stop with your 1% comments.

 

[rickylafleur]

Actually, yes. Every medical student who has finished MS1 knows what phentolamine is. The number of times I had to answer a USMLE question on the mechanism, indications, etc. for phentolamine is f*ng astounding. For the record, I have never used it in practice.

Fine, not every physician does. But if you give them some hints, they'll come up with the right answer. Why would a pathologist or orthopedist need to know this?

Oh, I'm sorry. You may still remember how to do integrals and derivatives in your daily practice as a healthcare professional...my b, my b.

Which brings up one of my underlying points: medical education is standardized and heavily scrutinized, such that the average physician is more knowledgeable and competent than the average non-physician. The same cannot be said about other educational systems. ...Like online NP schools.

Note that I said average. So stop with your 1% comments.

Dude I didn’t start with the 1% crap. The guy above did.
And I agree with all you said above. But words matter and when HE stated 1% midlevels don’t know the drug and that EVERY physician and med student wouldn’t hesitate to answer what it is is untrue.

And I’m not going to let it just ride

 

[JAFERD_MD]

Dude I didn’t start with the 1% crap. The guy above did.
And I agree with all you said above. But words matter and when HE stated 1% midlevels don’t know the drug and that EVERY physician and med student wouldn’t hesitate to answer what it is is untrue.

And I’m not going to let it just ride

So you're not ok with people painting broad strokes about a profession (e.g. that most midlevels do not know what phentolamine is) and you're also not ok with people pointing out specific midlevel screw-ups they've personally witnessed because it doesn't tell the whole story of their "rigorous training" and active seeking of continuous medical education (despite some on this thread even giving praise to some midlevels).

I really don't know what you want.

The whole point of this thread is that because we are individuals, we ONLY have our anecdotal experiences working with midlevels to even discuss these complaints. If you can look past these individual complaints, they paint themes of undereducation, poor supervision, inappropriate legislation for medical practice and exploitative capitalism.

Shall we all just have a book club discussion on Patients at Risk then?

 

[southerndoc]

STOP

Everyone take a breather because it's getting a little uncivil here and I would rather not have to enforce ToS through moderation.

 

[RustedFox]

Even signing their charts is friggin' annoying.
The ones at my new site simply can't be bothered to take an extra minute to make sure that their charts are coherent.
M-modal isn't the best at capturing speech, but if I have to read your chart, and I have no idea what it was that you were trying to say, then we have a problem.

Also; they never clear C-spines in the elderly and/or demented. Distracting injuries all over.
Head CT only. No C-spine CT. Not even x-rays (not that THAT would be right, either).

 

[turkeyjerky]

Even signing their charts is friggin' annoying.
The ones at my new site simply can't be bothered to take an extra minute to make sure that their charts are coherent.
M-modal isn't the best at capturing speech, but if I have to read your chart, and I have no idea what it was that you were trying to say, then we have a problem.

Also; they never clear C-spines in the elderly and/or demented. Distracting injuries all over.
Head CT only. No C-spine CT. Not even x-rays (not that THAT would be right, either).

But atraumatic neck pain in a 40 year old? CTs all around.

 

[RustedFox]

But atraumatic neck pain in a 40 year old? CTs all around.

Had an NP ask me about a case yesterday.
Nontraumatic knew pain x 15 years.
Knows that he needs a TKR.

"Would you get an x-ray? Because he fails the Ottawa knee rule, but I don't know..."

 

[rickylafleur]

Actually, yes. Every medical student who has finished MS1 knows what phentolamine is. The number of times I had to answer a USMLE question on the mechanism, indications, etc. for phentolamine is f*ng astounding. For the record, I have never used it in practice.

Fine, not every physician does. But if you give them some hints, they'll come up with the right answer. Why would a pathologist or orthopedist need to know this?

Oh, I'm sorry. You may still remember how to do integrals and derivatives in your daily practice as a healthcare professional...my b, my b.

Which brings up one of my underlying points: medical education is standardized and heavily scrutinized, such that the average physician is more knowledgeable and competent than the average non-physician. The same cannot be said about other educational systems. ...Like online NP schools.

Note that I said average. So stop with your 1%

So you're not ok with people painting broad strokes about a profession (e.g. that most midlevels do not know what phentolamine is) and you're also not ok with people pointing out specific midlevel screw-ups they've personally witnessed because it doesn't tell the whole story of their "rigorous training" and active seeking of continuous medical education (despite some on this thread even giving praise to some midlevels).

I really don't know what you want.

The whole point of this thread is that because we are individuals, we ONLY have our anecdotal experiences working with midlevels to even discuss these complaints. If you can look past these individual complaints, they paint themes of undereducation, poor supervision, inappropriate legislation for medical practice and exploitative capitalism.

Shall we all just have a book club discussion on Patients

Bro. pa training isn’t “rigorous.” Is it better than nps? You bet. But to call it rigorous is laughable.

Had an NP ask me about a case yesterday.
Nontraumatic knew pain x 15 years.
Knows that he needs a TKR.

"Would you get an x-ray? Because he fails the Ottawa knee rule, but I don't know..."

So there is a post by cajunmedic on the thread about “the crap we have to deal with” with a pt with “knee pain since 1994” and a knee X-ray was done to “make sure there was nothing acute”

You replied to the post but…no mention of the X-ray as being inappropriate or even remotely questionable.

“PLP” needs ridicule but physician gets the amigo treatment.

 

[rickylafleur]

So there is a post by cajunmedic on the thread about “the crap we have to deal with” with a pt with “knee pain since 1994” and a knee X-ray was done to “make sure there was nothing acute”

You replied to the post but…no mention of the X-ray as being inappropriate or even remotely questionable.

“PLP” needs ridicule but physician gets the amigo treatment.

I only meant to reply to rustedfox but I’m new to this and made a mistake
The message still stands though

 

[RustedFox]

So there is a post by cajunmedic on the thread about “the crap we have to deal with” with a pt with “knee pain since 1994” and a knee X-ray was done to “make sure there was nothing acute”

You replied to the post but…no mention of the X-ray as being inappropriate or even remotely questionable.

“PLP” needs ridicule but physician gets the amigo treatment.

Physician understands that the Ottawa Knee rule is for traumatic injury. PLP had no idea what he was even using the rule for.

That you didn't understand the difference is... telling.

If Aqualung (in CajunMedic's story) there just up and showed up in my ER and complained of knee pain, with nothing reliable about his person, story, or anything else, then yeah - you can have an x-ray and wonder just what the hell you'll find.

In the case I'm referring to, the patient says: "Its been that way for decades and I've been to Dr. Chesty McBenchPress, Orthopedics and he says I need a TKR", then there's no point in x-raying the knee.

 

[rickylafleur]

Physician understands that the Ottawa Knee rule is for traumatic injury. PLP had no idea what he was even using the rule for.

That you didn't understand the difference is... telling.

If Aqualung (in CajunMedic's story) there just up and showed up in my ER and complained of knee pain, with nothing reliable about his person, story, or anything else, then yeah - you can have an x-ray and wonder just what the hell you'll find.

In the case I'm referring to, the patient says: "Its been that way for decades and I've been to Dr. Chesty McBenchPress, Orthopedics and he says I need a TKR", then there's no point in x-raying the knee.

So this patient just showed up to the ER with that complaint? “I need a TKR”
I would imagine there is more to them presenting to the ER but that wouldn’t fit the narrative

 

[RustedFox]

So this patient just showed up to the ER with that complaint? “I need a TKR”
I would imagine there is more to them presenting to the ER but that wouldn’t fit the narrative

No, the complaint was chronic knee pain x15 years. The rest of the HPI followed.

You even quoted this in your argument.

Like I said, the PLP saw the patient and tried to use a clinical decision rule meant for traumatic knee pain for nontraumatic knee pain.

I haven't changed any of that to fit a narrative. My criticism of the PLP failing to apply the CDM correctly is independent of any other case.

Keep it up, though. I love people like you on here.

 

[rickylafleur]

No, the complaint was chronic knee pain x15 years. The rest of the HPI followed.

You even quoted this in your argument.

Like I said, the PLP saw the patient and tried to use a clinical decision rule meant for traumatic knee pain for nontraumatic knee pain.

I haven't changed any of that to fit a narrative. My criticism of the PLP failing to apply the CDM correctly is independent of any other case.

Keep it up, though. I love people like you on here.

Ok. I’m not being confrontational just for the kicks.
I guess I would expect there to be more to the presentation to an ER than just woke up today with nothing different about the pain but decided to come in. But anything is possible.
And trying to use Ottawa rules without trauma makes even less sense. However take that statement out of the equation.

Pt presents with chronic knee pain to ER
How many (physician or midlevel) would get the X-ray? That’s my point.
The theme on SDN seems to be just by virtue of it being a midlevel ordering it becomes ludicrous.

 

[RustedFox]

Ok. I’m not being confrontational just for the kicks.
I guess I would expect there to be more to the presentation to an ER than just woke up today with nothing different about the pain but decided to come in. But anything is possible.
And trying to use Ottawa rules without trauma makes even less sense. However take that statement out of the equation.

Pt presents with chronic knee pain to ER
How many (physician or midlevel) would get the X-ray? That’s my point.
The theme on SDN seems to be just by virtue of it being a midlevel ordering it becomes ludicrous.

This is our world, amigo. The bolded happens every damn day to us.

And to answer your question: many on here (including myself at times) simply order the useless study reflexively because "it stops the clock". That's different than trying to think your way thru a CDM rule that doesn't apply to the situation.

 

[rickylafleur]

This is our world, amigo. The bolded happens every damn day to us.

And to answer your question: many on here (including myself at times) simply order the useless study reflexively because "it stops the clock". That's different than trying to think your way thru a CDM rule that doesn't apply to the situation.

Yep. On this one I have to be honest and concede. I didn’t initially see your focus was on their attempt to use trauma inclusion criteria for a atraumatic pain and more thought this was about decision to X-ray.

 

[RustedFox]

Yep. On this one I have to be honest and concede. I didn’t initially see your focus was on their attempt to use trauma inclusion criteria for a atraumatic pain and more thought this was about decision to X-ray.

For the record, this same NP admitted a patient "who needs transfusion" without ordering a BMP last shift.

I got a call from a pissed off hospitalist when the K was 8.5.

NP admitting to NP, then it came to the attention of the MD.

 

[rickylafleur]

For the record, this same NP admitted a patient "who needs transfusion" without ordering a BMP last shift.

I got a call from a pissed off hospitalist when the K was 8.5.

NP admitting to NP, then it came to the attention of the MD.

Sigh. Man I just don’t know what to say

I get it. I get why physicians are upset by so much of this.
I wholeheartedly agree that online programs and BS clinical experience following other clueless practitioners is not only inadequate it’s dangerous

This is not the standard for PA education.
I can’t listen to people taking swipes at education/training and medical knowledge particularly of PAs because I know the education process and training. I am a PA. I am speaking for PAs.

I read the anecdotes of what this person and that person didn’t know and the common theme that we don’t know what we haven’t been taught…well we were taught these things.
Just because someone couldn’t recall the names of certain drugs, conditions etc doesn’t mean they were not exposed to it in training. For the most part yes they were.

Just because a PA made a mistake is not inherently because they are “just a PA.”
Mistakes are made my all levels. Recall isn’t always on point or perfect. Outcomes are not always optimal.

 

[RustedFox]

Sigh. Man I just don’t know what to say

I get it. I get why physicians are upset by so much of this.
I wholeheartedly agree that online programs and BS clinical experience following other clueless practitioners is not only inadequate it’s dangerous

This is not the standard for PA education.
I can’t listen to people taking swipes at education/training and medical knowledge particularly of PAs because I know the education process and training. I am a PA. I am speaking for PAs.

I read the anecdotes of what this person and that person didn’t know and the common theme that we don’t know what we haven’t been taught…well we were taught these things.
Just because someone couldn’t recall the names of certain drugs, conditions etc doesn’t mean they were not exposed to it in training. For the most part yes they were.

Just because a PA made a mistake is not inherently because they are “just a PA.”
Mistakes are made my all levels. Recall isn’t always on point or perfect. Outcomes are not always optimal.

So, your point is well-received. I'll point out that it's anecdotes like these (considering how amazingly commonly they occur) is why independent practice for any of the PLPs is just a hard stop for us.

Add on to that that there's no residency training, and they flit between subspecialties at will, AND they have the illusion of adequacy in each discipline, and you see how you have a perfect storm for "knowing just enough to be dangerous".

 

[Boatswain2PA]

For the record, this same NP admitted a patient "who needs transfusion" without ordering a BMP last shift.

I got a call from a pissed off hospitalist when the K was 8.5.

NP admitting to NP, then it came to the attention of the MD.

Comparing PAs to NPs is like comparing BC EPs to chiropractors.

You can call us all PLPs, and we can call you and chiropractors both "doctor".

Or we can understand the vast differences between the education between them.

Healthcare is a mess all around, and I concur with the vast majority of your postings here.

 

[Boatswain2PA]

why independent practice for any of the PLPs is just a hard stop for us.

While I agree we shouldn't have independent practice, that horse has left the barn. Worse yet, the donkey with the worst training/education was the first one out.

Add on to that that there's no residency training,

There is a growing trend for "residencies" in the PA world. Like most things in the PA world the language ("residency") is off-putting to many, but that's what it is being called.

And, following in the historical footsteps of physicians, the ability to flit between specialties is also going away. (As it should)

 

[thegenius]

Even signing their charts is friggin' annoying.
The ones at my new site simply can't be bothered to take an extra minute to make sure that their charts are coherent.
M-modal isn't the best at capturing speech, but if I have to read your chart, and I have no idea what it was that you were trying to say, then we have a problem.

Also; they never clear C-spines in the elderly and/or demented. Distracting injuries all over.
Head CT only. No C-spine CT. Not even x-rays (not that THAT would be right, either).

I don't ct cspine all of these old people who fall with minor head trauma. if they are demented maybe...but if people can tell me a coherent story and they have a small lac above their left eyebrow...and that's it...I don't c-spine them. Sometimes I don't even CT their head.

The rate of IC injury is so exceedingly low in a population who is acting normally with minor head trauma that it's just not worth it.

Broken necks hurt. Even in demented people.

 

[thegenius]

I guess I would expect there to be more to the presentation to an ER than just woke up today with nothing different about the pain but decided to come in. But anything is possible.

Are you an MD or DO that works in an ER?

We get this all the time. This is what happens when there is a free societal resource offered to the forlorned suffering from a life of ennui.

 

[lucid_leprechaun]

I don't ct cspine all of these old people who fall with minor head trauma. if they are demented maybe...but if people can tell me a coherent story and they have a small lac above their left eyebrow...and that's it...I don't c-spine them. Sometimes I don't even CT their head.

The rate of IC injury is so exceedingly low in a population who is acting normally with minor head trauma that it's just not worth it.

Broken necks hurt. Even in demented people.

I would mention the rate of ICH in elderly patients with fall, GCS 15, not on AC is estimated at 5-10% based on the literature. There are no validated clinical decision tools in this population. The ones that have been attempted perform badly. You could make a case that most of these don’t require intervention but I think the rate of injury is too high to not scan all patients (unless you want to miss tICH.)

 

[rickylafleur]

Are you an MD or DO that works in an ER?

We get this all the time. This is what happens when there is a free societal resource offered to the forlorned suffering from a life of ennui.

No I am not. I am a PA in primary care

I admitted my ignorance in that post. My thought was it had to be the usual presentation where the pt has acute on chronic joint pain
You ask did something happen?…a new injury? The answer…”I don’t know i might have hurt it when I tripped/fell/etc and not the flat “been hurting 15 years and I decided to hit up the ER tonight”

 

[rickylafleur]

So, your point is well-received. I'll point out that it's anecdotes like these (considering how amazingly commonly they occur) is why independent practice for any of the PLPs is just a hard stop for us.

Add on to that that there's no residency training, and they flit between subspecialties at will, AND they have the illusion of adequacy in each discipline, and you see how you have a perfect storm for "knowing just enough to be dangerous".

I do agree independent practice for mid levels should not be and has not ever been for me
I guess my struggle is what would you as a physician advise PAs to do in this situation?

 

[RustedFox]

I don't ct cspine all of these old people who fall with minor head trauma. if they are demented maybe...but if people can tell me a coherent story and they have a small lac above their left eyebrow...and that's it...I don't c-spine them. Sometimes I don't even CT their head.

The rate of IC injury is so exceedingly low in a population who is acting normally with minor head trauma that it's just not worth it.

Broken necks hurt. Even in demented people.

My patient population here in the United States Capital of Old People disagrees.

Old people have a lot of space to bleed into before they start acting wacky.

I play by the Nexus and New Orleans rules.

I find actionable stuff on minor bonks all the time. Old people are frequently

1. Stoic.
2. Neuropathic.
3. Narc'ed up anyways.
4. Drunk (and hiding it).
5. Dumb.
6. Any combination of the above.

It goes on.