Anyone else exhausted by managing midlevel screw-ups?

[RustedFox]

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?

So that I can give you a legit answer (I'm not being snarky): what situation are you asking me about?

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[thegenius]

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.)

Yea i misspelled and wrote "IC" .... what I meant was I don't CT CSpine all of these minor head traumas. That is..if I can get a coherent story it is highly unlikely they broke their neck.

Would love to see the paper or research indicating 5-10% with ICH for those who fell, GCS 15 not on AC. I am aware that all of clinical decision rules exclude people > 65

yes there are tiny bleeds that are OK to miss...we have had this discussion on a prior thread. Even the CT Canadian Head rules exclude tiny ditzel bleeds. But we won't rehash these same arguments again...someone can just go back in time to look them up.

 

[GonnaBeADoc2222]

Can we just avoid the same old PLP arguing ad nauseum? Why not make this a physician only forum? Engaging with them is like an adult talking to a teenager.

 

[Fox800]

Last shift: be me, working as the only physician in a busy, overloaded level 2 trauma center. With an NP that just decided to change from inpatient internal medicine to emergency medicine.

30 something guy with end-stage liver disease, bilirubin has been 30-40+ for the past six months. Triage note: fluctuating confusion (delirium). Anasarca. NP's plan: get a CT, to "see how much fluid there is" (pt obviously has anasarca on exam with abdominal wall and pitting LE edema). NP planned to send patient home with furosemide, asks me if that is OK

Labs: creatinine 0.5 -> 2.5 in the past 9 days. Bilirubin 31->41. Hepatorenal syndrome. Tachycardia, WBC 19k. Worsening abdominal pain with delirium.

Yeah that DC plan's gonna be a no for me, dawg. Albumin, paracentesis, GI consult, admit.
This person could be working solo in a rural ED somewhere.

 

[RustedFox]

Can we just avoid the same old PLP arguing ad nauseum? Why not make this a physician only forum? Engaging with them is like an adult talking to a teenager.

No.

 

[RustedFox]

Last shift: be me, working as the only physician in a busy, overloaded level 2 trauma center. With an NP that just decided to change from inpatient internal medicine to emergency medicine.

30 something guy with end-stage liver disease, bilirubin has been 30-40+ for the past six months. Triage note: fluctuating confusion (delirium). Anasarca. NP's plan: get a CT, to "see how much fluid there is" (pt obviously has anasarca on exam with abdominal wall and pitting LE edema). NP planned to send patient home with furosemide, asks me if that is OK

Labs: creatinine 0.5 -> 2.5 in the past 9 days. Bilirubin 31->41. Hepatorenal syndrome. Tachycardia, WBC 19k. Worsening abdominal pain with delirium.

Yeah that DC plan's gonna be a no for me, dawg. Albumin, paracentesis, GI consult, admit.
This person could be working solo in a rural ED somewhere.

Hospice consult.

 

[rickylafleur]

So that I can give you a legit answer (I'm not being snarky): what situation are you asking me about?

I struggled to properly frame my question but hopefully hit my mark.

In a nutshell, how would you direct the PA profession in the future knowing the NP side has both weakened their education/training standards AND have moved into independent practice

We unfortunately are intertwined to some degree and seen as one in the same. Clearly it triggers me when our abilities and missteps are assumed to be equal.
The concern being an unsure future if we are out maneuvered in practice rights but on the flip side alienated from our physician allies if we keep up with the Jones’s

 

[rickylafleur]

Last shift: be me, working as the only physician in a busy, overloaded level 2 trauma center. With an NP that just decided to change from inpatient internal medicine to emergency medicine.

30 something guy with end-stage liver disease, bilirubin has been 30-40+ for the past six months. Triage note: fluctuating confusion (delirium). Anasarca. NP's plan: get a CT, to "see how much fluid there is" (pt obviously has anasarca on exam with abdominal wall and pitting LE edema). NP planned to send patient home with furosemide, asks me if that is OK

Labs: creatinine 0.5 -> 2.5 in the past 9 days. Bilirubin 31->41. Hepatorenal syndrome. Tachycardia, WBC 19k. Worsening abdominal pain with delirium.

Yeah that DC plan's gonna be a no for me, dawg. Albumin, paracentesis, GI consult, admit.
This person could be working solo in a rural ED somewhere.

Plus antibiotics? SBP is a high concern here as well

 

[Fox800]

Plus antibiotics? SBP is a high concern here as well

Para was negative.

 

[RustedFox]

I struggled to properly frame my question but hopefully hit my mark.

In a nutshell, how would you direct the PA profession in the future knowing the NP side has both weakened their education/training standards AND have moved into independent practice

We unfortunately are intertwined to some degree and seen as one in the same. Clearly it triggers me when our abilities and missteps are assumed to be equal.
The concern being an unsure future if we are out maneuvered in practice rights but on the flip side alienated from our physician allies if we keep up with the Jones’s

Answer is: Just because they suck and do things that they shouldn't doesn't mean that you should also do the things that you shouldn't.
I'll try my best to give you a better answer later. I just finished a 12-hour overnight, and popped COVID+ here at home.

See you all in a few days.

 

[rickylafleur]

Answer is: Just because they suck and do things that they shouldn't doesn't mean that you should also do the things that you shouldn't.
I'll try my best to give you a better answer later. I just finished a 12-hour overnight, and popped COVID+ here at home.

See you all in a few days.

No good. Get rest and feel better

 

[Old_Mil]

Had a NP order a d-dimer for "medical clearance" on a 70 yo pt getting ready for a laminectomy "because he had a DVT 10 years ago". Pt was asymptomatic and sent to the ED.

This is what is causing me burn out. This is my most hated part of the job. Dealing with these midlevel *****s. Still enjoy taking care of the pts. But man, seeing these people get such garbage care is soul crushing.

Relax. That one order is what will prevent you from being included in the lawsuit when that 70 year olds post operative course includes a DVT, PE, and Death. Remember, defensive medicine is the standard of care.

In all seriousness, the veteran ED PAs that I've worked with are pretty good. NPs on the other hand, not so much. They continually outkick their coverage.

 

[RustedFox]

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.

Quoted for truth.
Masterfully spoken.

 

[Dred Pirate]

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”

I am curious as to why a PA in primary care would join this site and so far every single one of their posts has been on an emergency medicine forum? Forgive me for being snarky, but it sounds like a troll account, or a second account that you don’t want to link to your primary account where you post about primary medicine things

And yea, spend a week in the ED and you will see people coming in wanting their chronic illness/injury/pain fixed instantly at 3 in the morning. All the time.

 

[RustedFox]

And yea, spend a week in the ED and you will see people coming in wanting their chronic illness/injury/pain fixed instantly at 3 in the morning. All the time.

and remarkably, they never supply you with any history that their complaint had been evaluated before, in any capacity, by anyone, ever. Amen.

 

[Zebra Hunter]

and remarkably, they never supply you with any history that their complaint had been evaluated before, in any capacity, by anyone, ever. Amen.

&%#* I hate when I let a patient know that their 3 days of abdominal pain is not an emergency after a $10k workup including CT and lab work, narcotics, etc. for them to say, “Ugh, y’all always tell me there is nothing wrong.”

“…I thought this was going on for only 3 days?”

“Well off and on for 5 years, but y’all never take me seriously!”

 

[RustedFox]

&%#* I hate when I let a patient know that their 3 days of abdominal pain is not an emergency after a $10k workup including CT and lab work, narcotics, etc. for them to say, “Ugh, y’all always tell me there is nothing wrong.”

“…I thought this was going on for only 3 days?”

“Well off and on for 5 years, but y’all never take me seriously!”

Related:

I actually said this out loud the other day.

"They didn't tell me nothin' when I went to the (other hospital, subspecialty clinic, etc)."

Well, why should they? You won't listen to anything that they say. They probably did their absolute best to explain it to you, only for you to completely ignore them.

I have actually done this to a patient or two:

Me: "In plain and simple terms, the problem is that (X) interferes with (Y), and causes (Z). It's as simple as that." (Pause) "So, what is the problem; what is causing (Z)?"

Patient: "I dunno."

Me: "I just explained it to you. I just explained it to you."

Patient: "Ohh."

Seriously, why do I waste my time with these cretins?


Just last shift, I explained to mom/dad that a virus was causing the fever in their 2-year old - only for them to immediately say - "So, its bacteria."

Honestly, that people graduate from middle school and don't know what a bacteria/virus is...

 

[CoolDoc1729]

Related:

I actually said this out loud the other day.

"They didn't tell me nothin' when I went to the (other hospital, subspecialty clinic, etc)."

Well, why should they? You won't listen to anything that they say. They probably did their absolute best to explain it to you, only for you to completely ignore them.

I have actually done this to a patient or two:

Me: "In plain and simple terms, the problem is that (X) interferes with (Y), and causes (Z). It's as simple as that." (Pause) "So, what is the problem; what is causing (Z)?"

Patient: "I dunno."

Me: "I just explained it to you. I just explained it to you."

Patient: "Ohh."

Seriously, why do I waste my time with these cretins?


Just last shift, I explained to mom/dad that a virus was causing the fever in their 2-year old - only for them to immediately say - "So, its bacteria."

Honestly, that people graduate from middle school and don't know what a bacteria/virus is...

You explained it plain and simple, but still not plain and simple enough. 🤦🏻‍♀️

 

[rickylafleur]

I am curious as to why a PA in primary care would join this site and so far every single one of their posts has been on an emergency medicine forum? Forgive me for being snarky, but it sounds like a troll account, or a second account that you don’t want to link to your primary account where you post about primary medicine things

And yea, spend a week in the ED and you will see people coming in wanting their chronic illness/injury/pain fixed instantly at 3 in the morning. All the time.

I have been a lurker in SDN for years. Opened an account without any real thought of posting initially.
I enjoy reading many of the areas here. I have gleaned some things I feel are valuable over my time here.

But when you comment on your eavesdropping in conversations in which 2 individuals are examining and treating pts and somehow draw conclusions that one is a tool for not recognizing some medication names I call it out.

 

[rickylafleur]

I have been a lurker in SDN for years. Opened an account without any real thought of posting initially.
I enjoy reading many of the areas here. I have gleaned some things I feel are valuable over my time here.

But when you comment on your eavesdropping in conversations in which 2 individuals are examining and treating pts and somehow draw conclusions that one is a tool for not recognizing some medication names I

I have been a lurker in SDN for years. Opened an account without any real thought of posting initially.
I enjoy reading many of the areas here. I have gleaned some things I feel are valuable over my time here.

But when you comment on your eavesdropping in conversations in which 2 individuals are examining and treating pts and somehow draw conclusions that one is a tool for not recognizing some medication names I call it out.

Ok so I looked back. You were in a joint discussion.
So what though? You initially make inferences, then give some “pass” to them on not knowing this medicine.
It’s just weak.

When you pile on an anti PA thread I respond.

In this actual scenario it sounds like someone inquired with colleagues on the management of a case and received some valuable feedback,
How is that deserving of your ridicule?

Who’s to say they have never heard of these drugs? We all have recall issues. Our education has presented this to us I can assure you.
There is always a first time to use a medication no matter when we had first learned of the drug and as some have posted they have not used it either.
When we have questions we present them to our colleagues to provide the best care to the pt,

 

[Mount Asclepius]

In a nutshell, how would you direct the PA profession in the future knowing the NP side has both weakened their education/training standards AND have moved into independent practice

We unfortunately are intertwined to some degree and seen as one in the same. Clearly it triggers me when our abilities and missteps are assumed to be equal.
The concern being an unsure future if we are out maneuvered in practice rights but on the flip side alienated from our physician allies if we keep up with the Jones’s

Medical school. The answer is adequate training to practice medicine. PAs and NPs are more comparable than they are not. Experience is the only differentiator, not whether you are a NP or a PA.

When you pile on an anti PA thread I respond.

You do have some valid points. However, you are on a physician forum. Respectfully, you don’t need to respond.

 

[Mount Asclepius]

Related:

I actually said this out loud the other day.

"They didn't tell me nothin' when I went to the (other hospital, subspecialty clinic, etc)."

Well, why should they? You won't listen to anything that they say. They probably did their absolute best to explain it to you, only for you to completely ignore them.

I have actually done this to a patient or two:

Me: "In plain and simple terms, the problem is that (X) interferes with (Y), and causes (Z). It's as simple as that." (Pause) "So, what is the problem; what is causing (Z)?"

Patient: "I dunno."

Me: "I just explained it to you. I just explained it to you."

Patient: "Ohh."

Seriously, why do I waste my time with these cretins?


Just last shift, I explained to mom/dad that a virus was causing the fever in their 2-year old - only for them to immediately say - "So, its bacteria."

Honestly, that people graduate from middle school and don't know what a bacteria/virus is...

I feel your pain. I think we all get this completely and have been in the same situation countless times.

I do think though that there is a real skill in relaying information to people with an average health literacy of less than a 6th grade level. I thought I knew this, but it took longer than I thought to really fully understand what this truly means.

I’ve learned that really simplifying information to the most basic, basic of levels helps me accomplish the objective of patients feeling like they understand what’s going in a more satisfied way for both me and them. We all leave the encounter better off than if I’d tried to spend time trying to provide a semi-decent scientific explanation.

Saying something like, “Good news! (Excitedness feigned - actually only slightly as glad for the easy disposition, but do not enjoy taking care of non-emergencies). You tested negative for COVID and the flu, but were positive for Rhinovirus (substitute whatever viral infection they tested positive for) which causes the common common cold. This is causing everything that is making you not feel well. Your lungs sound normal, your ears don’t show signs of an ear infection and I don’t see any signs of strep throat. Your worst symptoms will probably be for the next couple days, but then you should start feeling better even if you still have some symptoms for the next couple of weeks…”

Overall, works better than saying anything more in depth. You and most physicians inherently know this, but it really does take dumbing it down as far as you possibly can. I’m not saying it’s a good thing. America is ignorant. I just have less difficult interactions at work and feel that both patients and I go home less annoyed.

Sometimes the more annoyed though, the better the story I can relay to my wife regarding the absurdity of American humanity.

 

[rickylafleur]

Medical school. The answer is adequate training to practice medicine. PAs and NPs are more comparable than they are not. Experience is the only differentiator, not whether you are a NP or a PA.

You do have some valid points. However, you are on a physician forum. Respectfully, you don’t need to respond.

So is that the consensus of the leadership of this site?
A PA should not and is not welcome to respond?
Isn’t dred a Pharmacist?
But if he continues with the general anti midkevel dump he is given “a pass?”

Like I have said I get physician frustration however to lump groups together and comment unilaterally without being open to retort again seems weak

But ok. I’ll bow out if the pharmacist does as well

 

[RustedFox]

Dred isn't trying to manage patients and make some vague claims of equivalence like the PLP crowd often does.

 

[rickylafleur]

Dred isn't trying to manage patients and make some vague claims of equivalence like the PLP crowd often does.

Dred mentioned specifically a PA in that comment. A PA by nature of training and licensure does not claim equivalence to a physician

 

[rickylafleur]

Dred mentioned specifically a PA in that comment. A PA by nature of training and licensure does not claim equivalence to a physician

And for that matter sounds like A PA who conferred with physician on duty on management of a patient and received an answer.
Doesn’t sound like someone who needed to be ridiculed by the pharmacist later.
Sounds like they were following their role
Regardless if they didn’t recall the specific medications.

 

[RustedFox]

Anybody else want to let him know of the big piece that he's missing before I do?

 

[RustedFox]

Dred mentioned specifically a PA in that comment. A PA by nature of training and licensure does not claim equivalence to a physician

Okay, fine. I will. I waited long enough.

Amigo, I highlighted it. You said: "A PA by nature of training and licensure does not claim equivalence to a physician."

But, they do stake that claim.
They do it all the time.
They do it when they don't know what they don't know.
They do it on dayshift.
They do it on nighshift (lol, they don't work nightshifts, that's too icky).
They do it to the Fox.
They do it on a box.
They do it all the time.
They do it in rhyme.
They do it 'til it hurts.
They do it and it's the worst (that's called "bending a rhyme").

They want to do the things, with the stuff, and manage the crashing patients, and tube and line, and sedate and reduce, and they want to get paaaid, and they want to run departments, and they want to be admins, and they want to do all the things.

But they don't know the medicine. Hence, the title of this thread:

Anyone else exhausted by managing midlevel screw-ups?​

They eff up the things because they don't know the sciences, or how to think thru a situation, or even how to apply the guidelines in the correct situation. They want to run before they can crawl (too often, they don't even want to learn to crawl); AND they get really mouthy and insolent when you tell them: "Hey, listen to me; don't do that."

I literally had one of the PLPs at OldJob say: "You're not the boss of me."

- and we're getting fugging sick of it.

 

[rickylafleur]

Okay, fine. I will. I waited long enough.

Amigo, I highlighted it. You said: "A PA by nature of training and licensure does not claim equivalence to a physician."

But, they do stake that claim.
They do it all the time.
They do it when they don't know what they don't know.
They do it on dayshift.
They do it on nighshift (lol, they don't work nightshifts, that's too icky).
They do it to the Fox.
They do it on a box.
They do it all the time.
They do it in rhyme.
They do it 'til it hurts.
They do it and it's the worst (that's called "bending a rhyme").

They want to do the things, with the stuff, and manage the crashing patients, and tube and line, and sedate and reduce, and they want to get paaaid, and they want to run departments, and they want to be admins, and they want to do all the things.

But they don't know the medicine. Hence, the title of this thread:

Anyone else exhausted by managing midlevel screw-ups?​

They eff up the things because they don't know the sciences, or how to think thru a situation, or even how to apply the guidelines in the correct situation. They want to run before they can crawl (too often, they don't even want to learn to crawl); AND they get really mouthy and insolent when you tell them: "Hey, listen to me; don't do that."

I literally had one of the PLPs at OldJob say: "You're not the boss of me."

- and we're getting fugging sick of it.

You have a way with words on here. Very eloquent and actually enjoyable..seriously but a PA IS dependent.
PAs do all of the clinical tasks you describe above but do it under the direction of the physician…if they have the training and credentials to do so. Not as a replacement or equivalent.
And again I would argue they have been taught the medicine. No one knows it all or recalls it all but they have been taught. The gold standard is medical school/residency but PA educated well and trained well with experience and under the direction of a physician is not dangerous or bravado as you try to make it seem.
All fine and good then even when they do that the pharmacist ridicules them for the clinical discussion and you guys love it.

You are very outspoken here. How are you at work?
“You’re not the boss of me?” Well they are dependent to you, what did you do to correct them? Oh boo-hoo I get into trouble if I complain.
Maybe your complaints don’t hold water in the way you think they do.
Do you need more training in how to direct/manage those extenders of your care?
Do you talk with them with the bravado you have here? Or do you try to direct them in the way you want pt care to go?
Much less some pill counter making his inferences based on “listening in”
I guess at some point I get sick of the whining and say do something about it

Don’t disparage anonymously on a website,

But the norm seems to be on here to just bitch and moan, if it wasn’t “PLPs” it would go back to the whining about FM working in ER or then MD greater than DO etc
I’ve seen plenty of those threads too. Bitching about improper management and ER referrals by primary care etc (usually followed by said primary care blaming their midlevels)
Move some goal posts, straw man and follow some tangents with a pointed finger.
It’s so typical on here.

 

[rickylafleur]

You have a way with words on here. Very eloquent and actually enjoyable..seriously but a PA IS dependent.
PAs do all of the clinical tasks you describe above but do it under the direction of the physician…if they have the training and credentials to do so. Not as a replacement or equivalent.
And again I would argue they have been taught the medicine. No one knows it all or recalls it all but they have been taught. The gold standard is medical school/residency but PA educated well and trained well with experience and under the direction of a physician is not dangerous or bravado as you try to make it seem.
All fine and good then even when they do that the pharmacist ridicules them for the clinical discussion and you guys love it.

You are very outspoken here. How are you at work?
“You’re not the boss of me?” Well they are dependent to you, what did you do to correct them? Oh boo-hoo I get into trouble if I complain.
Maybe your complaints don’t hold water in the way you think they do.
Do you need more training in how to direct/manage those extenders of your care?
Do you talk with them with the bravado you have here? Or do you try to direct them in the way you want pt care to go?
Much less some pill counter making his inferences based on “listening in”
I guess at some point I get sick of the whining and say do something about it

Don’t disparage anonymously on a website,

But the norm seems to be on here to just bitch and moan, if it wasn’t “PLPs” it would go back to the whining about FM working in ER or then MD greater than DO etc
I’ve seen plenty of those threads too. Bitching about improper management and ER referrals by primary care etc (usually followed by said primary care blaming their midlevels)
Move some goal posts, straw man and follow some tangents with a pointed finger.
It’s so typical on here.

I’m sure pill counter will be seen as a violation here but “PLP” has become the norm without comment
How fast would we get a mod involved if I used a similar term for a physician?

 

[wholeheartedly]

So is that the consensus of the leadership of this site?
A PA should not and is not welcome to respond?
Isn’t dred a Pharmacist?
But if he continues with the general anti midkevel dump he is given “a pass?”

Like I have said I get physician frustration however to lump groups together and comment unilaterally without being open to retort again seems weak

But ok. I’ll bow out if the pharmacist does as well

I won’t presume to speak for the rest of the moderation team on this issue, but here’s how I view threads like this.

SDN is open to very wide array of healthcare professionals and people are free to post wherever, but we do give each group their own space and expect people to respect the spaces of the other groups when visiting them.

This section of SDN is for emergency medicine physicians, residents in training, and folks who are interested in these things. This is their space to support each other working through the challenges of the training in and practice of emergency medicine. The title of the thread is

“Anyone else exhausted by managing midlevel screw-ups?”​

It’s clearly a venting thread. Venting is a healthy outlet for coping with frustrations and stressors. Physicians are increasingly being asked to supervise and sign off on the work of PAs and NPs that they often have no input in hiring or vetting, no input in training, no input in evaluating, and no input in terminating, but full liability if they make mistakes or cause harm. This is a perfectly reasonable thing to be frustrated and want to vent about.

If you go to nursing boards, they have venting threads about docs. I’m a former clinical lab scientist, former infection preventionist/hospital epidemiologist. We have venting threads or posts in those groups about frustrations with other members of the healthcare teams. People need a space to vent.

As someone in those other roles who is not a doctor, but who is interested in topics here, my fields above are sometimes the subject of this kind of venting and while my first instinct might be to defend my colleagues, I rarely do. There’s a time and place for those discussions and it’s not in a venting thread. We have other spaces where people can and do discuss the plusses and minus, benefits and risks about all manner of midlevel practice. That would be the space for you to bring up those points. In this thread it is essentially derailing the topic of the thread. Likewise if a doc goes into the space we have for PAs and NPs and starts criticizing them, we would shut that down, because that’s their space for their professions.

 

[RustedFox]

You have a way with words on here. Very eloquent and actually enjoyable..seriously but a PA IS dependent.
PAs do all of the clinical tasks you describe above but (1) do it under the direction of the physician…if they have the training and credentials to do so. Not as a replacement or equivalent.
And again (2) I would argue they have been taught the medicine. No one knows it all or recalls it all but they have been taught. The gold standard is medical school/residency but PA educated well and trained well with experience and under the direction of a physician is not dangerous or bravado as you try to make it seem.
All fine and good then even when they do that the pharmacist ridicules them for the clinical discussion and you guys love it.

(3) You are very outspoken here. How are you at work?
“You’re not the boss of me?” Well they are dependent to you, what did you do to correct them? Oh boo-hoo I get into trouble if I complain.
(4) Maybe your complaints don’t hold water in the way you think they do.
Do you need more training in how to direct/manage those extenders of your care?
Do you talk with them with the bravado you have here? Or do you try to direct them in the way you want pt care to go?
Much less some pill counter making his inferences based on “listening in”
I guess at some point I get sick of the whining and say do something about it

(5) Don’t disparage anonymously on a website,

But the norm seems to be on here to just bitch and moan, if it wasn’t “PLPs” it would go back to the whining about FM working in ER or then MD greater than DO etc
I’ve seen plenty of those threads too. Bitching about improper management and ER referrals by primary care etc (usually followed by said primary care blaming their midlevels)
(6) Move some goal posts, straw man and follow some tangents with a pointed finger.
It’s so typical on here.

(1) "They do it under the direction of the physician"

Then do as I say, how I say it. But they don't; they want to do it how they want to do it, which is too often flatly incorrect. Hence, this thread.

(2) "I would argue that they have been taught the medicine"

If they were taught it, they sure as hell can't demonstrate it. Hence, this thread.

(3) "You are very outspoken here. How are you at work?"

Colorful. Thanks. Some on here know me in real-life. I bring some levity to the process.

(4) Maybe your complaints don’t hold water in the way you think they do.
Do you need more training in how to direct/manage those extenders of your care?
Do you talk with them with the bravado you have here? Or do you try to direct them in the way you want pt care to go?

After so many instances of trying for "collaborative practice" or "optimal team practice" or whatever the buzzword is, I've run into too many PLPs that just either can't take direction, or refuse to take direction. They stomp their feet and say things like "you're not the boss of me". I'm surprised one hasn't held their breath like a child does when it doesn't get its way. Let me just say this and save you some energy: "Bro, I've heard this precise argument ("maybe the problem is you") on here from PLPs in the past. Remember that."

(5) Don’t disparage anonymously on a website,

That's what websites are for. Welcome to teh internet, I'll be your guide (insert your own meme here).

(6) Move some goal posts, straw man and follow some tangents with a pointed finger.

I love pointing out logical fallacies, too. However, I've committed none of those foibles. I'm engaging you, directly, in a pointed discussion - which I think is what you want. You're pretty good at debate, and you have a point that can be defended. You wanna wrestle? Lets hit the mat.

Listen to me when I say this: You don't work in the ER. You also seem like you're a pretty new PA. Your arguments (while sound in theory) don't pan out in the real-world like you hope they would. Just like medicine... is different on the textbook page than it is in real life.

Wholeheartedly beat me to the punch when he said:

Physicians are increasingly being asked to supervise and sign off on the work of PAs and NPs that they often have no input in hiring or vetting, no input in training, no input in evaluating, and no input in terminating, but full liability if they make mistakes or cause harm. This is a perfectly reasonable thing to be frustrated and want to vent about.

I strongly suspect that this is the *big thing* that you're unaware of.

 

[rickylafleur]

I won’t presume to speak for the rest of the moderation team on this issue, but here’s how I view threads like this.

SDN is open to very wide array of healthcare professionals and people are free to post wherever, but we do give each group their own space and expect people to respect the spaces of the other groups when visiting them.

This section of SDN is for emergency medicine physicians, residents in training, and folks who are interested in these things. This is their space to support each other working through the challenges of the training in and practice of emergency medicine. The title of the thread is

“Anyone else exhausted by managing midlevel screw-ups?”​

It’s clearly a venting thread. Venting is a healthy outlet for coping with frustrations and stressors. Physicians are increasingly being asked to supervise and sign off on the work of PAs and NPs that they often have no input in hiring or vetting, no input in training, no input in evaluating, and no input in terminating, but full liability if they make mistakes or cause harm. This is a perfectly reasonable thing to be frustrated and want to vent about.

If you go to nursing boards, they have venting threads about docs. I’m a former clinical lab scientist, former infection preventionist/hospital epidemiologist. We have venting threads or posts in those groups about frustrations with other members of the healthcare teams. People need a space to vent.

As someone in those other roles who is not a doctor, but who is interested in topics here, my fields above are sometimes the subject of this kind of venting and while my first instinct might be to defend my colleagues, I rarely do. There’s a time and place for those discussions and it’s not in a venting thread. We have other spaces where people can and do discuss the plusses and minus, benefits and risks about all manner of midlevel practice. That would be the space for you to bring up those points. In this thread it is essentially derailing the topic of the thread. Likewise if a doc goes into the space we have for PAs and NPs and starts criticizing them, we would shut that down, because that’s their space for their professions.

Ok point taken. I was done honestly until dred poked me again
No more from me on here

 

[Ho0v-man]

This thread is like a bunch of adults trying to vent to each other about how hard it is to raise obstinate children. Then a first grader shows up and decides to argue that he doesn’t need a bedtime and is more than capable of eating ice cream and Doritos for dinner. Of course the argumentative child never figures out their opinion doesn’t mean anything.

Sadly, corporate medicine seems to be on the side of the first grader.

 

[GonnaBeADoc2222]

Imagine wanting to do a job (medicine) but then choosing the backdoor pathway (PLP school) because it's faster and easier.

Let's apply the concept to other fields and see how it flies:
-Nursing: 1 year crash course
-Teacher: Associates degree
-Lawyer: Bachelors in History
-Police officer: 2 weeks of "how to use a gun"

 

[GonnaBeADoc2222]

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

This thread is like a bunch of adults trying to vent to each other about how hard it is to raise obstinate children. Then a first grader shows up and decides to argue that he doesn’t need a bedtime and is more than capable of eating ice cream and Doritos for dinner. Of course the argumentative child never figures out their opinion doesn’t mean anything.

Sadly, corporate medicine seems to be on the side of the first grader.

Similar to with my 3 year old, this is the point where the adults say "it's bed time."

 

[CoolDoc1729]

This thread is like a bunch of adults trying to vent to each other about how hard it is to raise obstinate children. Then a first grader shows up and decides to argue that he doesn’t need a bedtime and is more than capable of eating ice cream and Doritos for dinner. Of course the argumentative child never figures out their opinion doesn’t mean anything.

Sadly, corporate medicine seems to be on the side of the first grader.

Well, the lemonade IS cheaper at the kiddie lemonade stand so …

 

[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.

2 shifts ago:

82 year old man fell from the roof of his shed. Estimated height, 6-7 feet. His only complaint is the laceration on his leg. No pain anywhere else. No thinners. Guy is totally with it, was fixing the roof of the shed because I'm pretty sure he traveled the Oregon Trail and fixed everything himself from Fort Kearney to the Willamette Valley, forded 7 rivers on the way there, traded with the Indians, and died of dysentery once.

I tell the PA: "NO! You need to scan him".


L1-L4 compression fractures. T8 CHANCE FRACTURE and epidural hematoma. C7 transvere process fracture.

So, what the PA was going to repair and send home became an unstable fracture, neurosurgery consultation, admission, and critical care time.

Thankyoupleasedrivethru.

 

[Dred Pirate]

@rickylafleur A lot to unpack here.
1. Why do you feel the need to come at me so specifically? I never called you out specifically (other than asking why you started a new account to just comment on this one specific thread that is outside of your practice area?). And to call me a pill counter - shows maturity when one resorts to calling someone else a name. (PS, I don't even know what a PLP means, but you weren't called one, directly)

2. I post on this this forum because I have worked in the ED for 18 years - I enjoy contributing to the threads and I learn things that I find interesting, or that actually sometimes help me in my job.

3. If you go on to another professions thread and bash them, you are gonna get it right back - usually in spades. Go to any thread, my forum will harp on bad prescribing habits, but a physician who comes and asks legit questions, and is respectful, often will get their questions answered professionally. When I have started threads on another professions forum, I have often asked what I can do in my profession to help the care of a patient, or to make everyone's lives better/easier.

4. This thread was about frustrations with mid-levels, I added some anecdotes to it. In 18 years I have seen a lot, I also know physicians often probably have stories of idiot pharmacists who made their life harder/annoying. I would not come in here and instantly defend them simply because I share initials after my name with them if it was a legit complaint.

5. I said I have seen a lot of good PA's and NP's (honestly more PA's than NP's) who know their roll and are valuable to the care team. A couple of case stories.
A. PA 1 comes in after seeing a patient for a facial lac that fell off their motorcycle. Comes out to the room and instantly says to the MD and myself (again, literally sitting shoulder to shoulder) - I am going to need both of your help - pt has Hemophilia A and last time we had to "helicopter the drug in from a neighboring hospital", and he admitting does't know what to give, and what to do. The three of us work as a team, I describe the dosing strategies and options for factor VIII treatment.
B. PA literally deals with all of the homeless frequent fliers at 3 in the morning that have no legit complaints and frees up the doc's time. This guy is actually a good friend of mine.

6. But this thread isn't about #5 - it is about the annoying, frustrating things that happen from those that don't know their limits. That is why I contributed. Other examples:
A. PA #3 - he tells me in convo studies show that PA's perform as high or a higher level than MD's in treating patients at a reduced cost and in the future a ED will be staffed completely by PAs with one MD just to "sign off on them". Ironically 2 months later this same PA was fired for mismanagement of a pt that I ironically said "I think you need to do X right?" He said "No, it is not necessary" - well, it was necessary and returned before the end of my shift (I am leaving out the specifics because it did cost someone their job. (I kept to myself the convo I had about my suggestion because it wasn’t a pharmacy thing, and I could tell the attending was furious and I wouldn’t add anything to the situation)

7. PS - I wasn't "easedropping" or "listening in" I was actually part of the conversations I listed. Trying to explain why you generally can't treat a male UTI with the same short term abx that you use in a woman with cystitis. The attending MD overheard the convo and stepped in to correct the PA. (now I know there is some evidence that might state differently, but as far as I know, I believe it is not standard of care to do 3-5 days of abx in these pts)

8. Ultiamtely we all have a role in the mess that is the healthcare machine - I feel like you are trying to pull rank or something with the comments directly specifically at me. I just don't get why - Is it because you know you don't "outrank" the physicians in the hierarchy, and thus are trying to direct down on me? Someone that is likely fairly lateral with you in said hierarchy? (yes there are some things you can do that I can't and vice versa - but if we all do our role, life is a heck of a lot easier)

I have more I could add, but I was complaining about a new one at work that I would never let a friend or family member see as a patient. This is the internet, getting so upset over a random anonymous guy or gal - just crack a beer and laugh or scroll on - life will be a lot easier.

Dueces

DP

 

[HemeOncHopeful19]

5. I said I have seen a lot of good PA's and NP's (honestly more PA's than NP's) who know their roll and are valuable to the care team. A couple of case stories.
A. PA 1 comes in after seeing a patient for a facial lac that fell off their motorcycle. Comes out to the room and instantly says to the MD and myself (again, literally sitting shoulder to shoulder) - I am going to need both of your help - pt has Hemophilia A and last time we had to "helicopter the drug in from a neighboring hospital", and he admitting does't know what to give, and what to do. The three of us work as a team, I describe the dosing strategies and options for factor VIII treatment.
B. PA literally deals with all of the homeless frequent fliers at 3 in the morning that have no legit complaints and frees up the doc's time. This guy is actually a good friend of mine.

I swear there is something about the hemophilia gene where it is coinherited with some “I am going to take risks either riding a motorcycle, rock climbing/skydiving, or getting into bar fights” gene that we just haven’t discovered yet.

Reminds me of that Jerry Seinfeld bit about helmets.

 

[rickylafleur]

@rickylafleur A lot to unpack here.
1. Why do you feel the need to come at me so specifically? I never called you out specifically (other than asking why you started a new account to just comment on this one specific thread that is outside of your practice area?). And to call me a pill counter - shows maturity when one resorts to calling someone else a name. (PS, I don't even know what a PLP means, but you weren't called one, directly)

2. I post on this this forum because I have worked in the ED for 18 years - I enjoy contributing to the threads and I learn things that I find interesting, or that actually sometimes help me in my job.

3. If you go on to another professions thread and bash them, you are gonna get it right back - usually in spades. Go to any thread, my forum will harp on bad prescribing habits, but a physician who comes and asks legit questions, and is respectful, often will get their questions answered professionally. When I have started threads on another professions forum, I have often asked what I can do in my profession to help the care of a patient, or to make everyone's lives better/easier.

4. This thread was about frustrations with mid-levels, I added some anecdotes to it. In 18 years I have seen a lot, I also know physicians often probably have stories of idiot pharmacists who made their life harder/annoying. I would not come in here and instantly defend them simply because I share initials after my name with them if it was a legit complaint.

5. I said I have seen a lot of good PA's and NP's (honestly more PA's than NP's) who know their roll and are valuable to the care team. A couple of case stories.
A. PA 1 comes in after seeing a patient for a facial lac that fell off their motorcycle. Comes out to the room and instantly says to the MD and myself (again, literally sitting shoulder to shoulder) - I am going to need both of your help - pt has Hemophilia A and last time we had to "helicopter the drug in from a neighboring hospital", and he admitting does't know what to give, and what to do. The three of us work as a team, I describe the dosing strategies and options for factor VIII treatment.
B. PA literally deals with all of the homeless frequent fliers at 3 in the morning that have no legit complaints and frees up the doc's time. This guy is actually a good friend of mine.

6. But this thread isn't about #5 - it is about the annoying, frustrating things that happen from those that don't know their limits. That is why I contributed. Other examples:
A. PA #3 - he tells me in convo studies show that PA's perform as high or a higher level than MD's in treating patients at a reduced cost and in the future a ED will be staffed completely by PAs with one MD just to "sign off on them". Ironically 2 months later this same PA was fired for mismanagement of a pt that I ironically said "I think you need to do X right?" He said "No, it is not necessary" - well, it was necessary and returned before the end of my shift (I am leaving out the specifics because it did cost someone their job. (I kept to myself the convo I had about my suggestion because it wasn’t a pharmacy thing, and I could tell the attending was furious and I wouldn’t add anything to the situation)

7. PS - I wasn't "easedropping" or "listening in" I was actually part of the conversations I listed. Trying to explain why you generally can't treat a male UTI with the same short term abx that you use in a woman with cystitis. The attending MD overheard the convo and stepped in to correct the PA. (now I know there is some evidence that might state differently, but as far as I know, I believe it is not standard of care to do 3-5 days of abx in these pts)

8. Ultiamtely we all have a role in the mess that is the healthcare machine - I feel like you are trying to pull rank or something with the comments directly specifically at me. I just don't get why - Is it because you know you don't "outrank" the physicians in the hierarchy, and thus are trying to direct down on me? Someone that is likely fairly lateral with you in said hierarchy? (yes there are some things you can do that I can't and vice versa - but if we all do our role, life is a heck of a lot easier)

I have more I could add, but I was complaining about a new one at work that I would never let a friend or family member see as a patient. This is the internet, getting so upset over a random anonymous guy or gal - just crack a beer and laugh or scroll on - life will be a lot easier.

Dueces

DP

That was well thought and well stated.
Obviously I got “triggered.”
I felt a need to defend my profession and separate from the NP lunacy.
I have since cracked said beer and and am moving on moving on.

 

[thegenius]

2 shifts ago:

82 year old man fell from the roof of his shed. Estimated height, 6-7 feet. His only complaint is the laceration on his leg. No pain anywhere else. No thinners. Guy is totally with it, was fixing the roof of the shed because I'm pretty sure he traveled the Oregon Trail and fixed everything himself from Fort Kearney to the Willamette Valley, forded 7 rivers on the way there, traded with the Indians, and died of dysentery once.

I tell the PA: "NO! You need to scan him".


L1-L4 compression fractures. T8 CHANCE FRACTURE and epidural hematoma. C7 transvere process fracture.

So, what the PA was going to repair and send home became an unstable fracture, neurosurgery consultation, admission, and critical care time.

Thankyoupleasedrivethru.

You're making me look bad homey.

You saying he had no back pain and had a normal back exam and had "L1-L4 compression fractures. T8 CHANCE FRACTURE and epidural hematoma. C7 transvere process fracture."

I find that hard to believe. Seriously. What did he park the car and walk into the ER with a lac?

EDIT: My guess is he wasn't properly examined

 

[Mount Asclepius]

There’s a reason trauma surgeons want pan scans. There are so many injuries not picked up easily by the patient or on exam. The most commonly missed fracture is the second one. I liberally scan trauma anymore. People aren’t reliable. Exams aren’t reliable. We aren’t the docs of last century.

I also agree though that we CT a lot of old peoples necks when they fall down for no reason. The vast majority of C-spine fractures (which aren’t overly common) are managed conservatively, non-operatively, and could be missed without significant bad outcomes.

The competing argument is really related to our medico-legal environment. Is it ok to ever miss any injury, or is it ok to miss clinically insignificant injuries where the management doesn’t really change?

 

[maxxor]

You're making me look bad homey.

You saying he had no back pain and had a normal back exam and had "L1-L4 compression fractures. T8 CHANCE FRACTURE and epidural hematoma. C7 transvere process fracture."

I find that hard to believe. Seriously. What did he park the car and walk into the ER with a lac?

EDIT: My guess is he wasn't properly examined

Trauma / distracting injuries and the need for a tertiary survey a couple days later is there for a reason. Send me all the trauma CTs. I don't mind those; the ER exam that drives me nuts on call is the surprise cancer restaging when you have traumas and strokes on the list...

 

[RustedFox]

You're making me look bad homey.

You saying he had no back pain and had a normal back exam and had "L1-L4 compression fractures. T8 CHANCE FRACTURE and epidural hematoma. C7 transvere process fracture."

I find that hard to believe. Seriously. What did he park the car and walk into the ER with a lac?

EDIT: My guess is he wasn't properly examined

You heard me. Presents via triage with "leg lac".

PA sees patient, gets history.

"Do I really need to sca-.... ?"

YES.

Guy is bitching and moaning that he's fine and wants to be discharged.

Repeat Oregon Trail joke .

 

[CoolDoc1729]

You're making me look bad homey.

You saying he had no back pain and had a normal back exam and had "L1-L4 compression fractures. T8 CHANCE FRACTURE and epidural hematoma. C7 transvere process fracture."

I find that hard to believe. Seriously. What did he park the car and walk into the ER with a lac?

EDIT: My guess is he wasn't properly examined

I’d agree, BUT I think a significant number of us are working at sites right now that have inadequate nursing staffing, etc and are doing some sort of provider in triage process.
I know how this interaction would go at my place:
(Setting: 3x5 room that somehow has 3
Chairs, a computer, a nursing cart, a lac cart and the ENT cart crammed into it )
Patient: OMG IM BLEEDING TO DEATH
Patients wife : OMG HES BLEEDING TO DEATH you have to DO SOMETHING
::brand new PA seeing patient::
Does anything else hurt?
Patient: NO OMG IM BLEEDING TO DEATH
::brand new PA :: there can’t be anything else wrong , I better fix this cut so he doesn’t bleed to death
::no exam whatsoever, documents thorough normal exam including normal fundi and bowel sounds::
At least your PA asked you before they did the wrong thing. I have no confidence that some of mine would have.

 

[BoardingDoc]

Trauma / distracting injuries and the need for a tertiary survey a couple days later is there for a reason. Send me all the trauma CTs. I don't mind those; the ER exam that drives me nuts on call is the surprise cancer restaging when you have traumas and strokes on the list...

Who the hell is ordering cancer scans of any kind in the ED? The only thing remotely close is when I'll sometimes order a CT AP or chest when the person is there for some vague complaint in the area and I suspect I'm going to find nothing, something weird or cancer. I guess that could technically wait for an outpt workup but it isn't like I'm scanning someone with a known malignancy simply to reevaluate said malignancy.

 

[RustedFox]

Who the hell is ordering cancer scans of any kind in the ED? The only thing remotely close is when I'll sometimes order a CT AP or chest when the person is there for some vague complaint in the area and I suspect I'm going to find nothing, something weird or cancer. I guess that could technically wait for an outpt workup but it isn't like I'm scanning someone with a known malignancy simply to reevaluate said malignancy.

Yes.
More politely: I only order malignancy-related imaging if the patient is being admitted and "oncology wants this done".
Keep in mind, that we are the "this patient needs to be admitted" department as much as we are the emergency department.

 

[Boatswain2PA]

Similar to with my 3 year old, this is the point where the adults say "it's bed time."

Are you a doc yet junior?

 

[doctalaughs]

The proliferation of midlevels in American medicine is a tragedy. It’s more than frustrating …. it makes me sad for patients what I’ve seen.

I don’t really fault the midlevels… they have been told they are doing something noble and helping people and “essential team members.”

The truth is most of them are inadequately trained and on average do a lot of harm (that most of them probably are blissfully ignorant of).

It’s sad. And it’s across all specialties. Makes me want to get my healthcare outside of this country when I get old….