Is it typical to have preceptors in M3 and M4 who are NPs and PAs at your school?

[Matthew9Thirtyfive]

Let’s keep it professional, everyone. Personal attacks and insults are not necessary or allowed.

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[Lawpy]

I agree but that would be prohibitively expensive.

Maybe but i think it can be worked out. That depends on the overall finances for every school and program though to decide what needs to be cut or removed so too much variability

 

[Redpancreas]

The attendings who don't bother to teach should be reported and permanently removed from clinical teaching service

LOL. @Lawpy if this were the case...

 

[Redpancreas]

I think attendings should be paid a lot more to teach and the med education pathway should be made more popular across all schools to incentivize future educators

Dude, look at how much thought was put into your preclinical education and extrapolate that to clinical education.

 

[Lawpy]

Dude, look at how much thought was put into your preclinical education and extrapolate that to clinical education.

I know but i'm hoping for some reform instead of just letting the status quo get worse and worse

 

[Redpancreas]

I know but i'm hoping for some reform instead of just letting the status quo get worse and worse

Residents are not innocent bystanders in this. One of the top reasons interns/residents rate their seniors and attendings high is because they get out on time.

 

[xtangk]

I agree, medicine is a team sport
But the physician drives the critical facets of the patient's care and therefore, in order to be the physician, a significant part (>80%) of your education ought to come from the physician.
PAs/NPs/Techs/RTs/RNs often are delegated tasks driven by the diagnosis/treatment plan from the physician. The medical student will spend time with these other members of the team and learn how these tasks are performed. Tasks like putting in orders, med recs, removing JP drains, progress notes, H/Ps etc etc.
Oftentimes, PA/NPs have seen enough through experience in performing their respective tasks; experience does not translate into knowledge gained in medical school. In these cases, they can be allowed to see consults and begin preliminary work-up based on their experiences. The medical student can learn these tasks however, your knowledge base has to be expanded by the critical thinking that the physician brings to the equation. As a third year medical student, you definitely know way more medicine that the PA/NPs, however, the clinical application is what the NP/PAs will have more experience than you. Hence, they can teach you a thing or two. The problem is, some PA/NPs take this as an opportunity to claim that they know enough medicine that they actually train physicians, hence they are technically physicians without the formal medical training. Do not let this claim derail you from your quest for knowledge and clinical experience.

 

[The Knife & Gun Club]

Just to counter everyone here - when I did FM I did 4days/week with a FM doc, and on fridays I was with an NP who was based out of a local middle school.

Initially I was livid. Then I actually enjoyed it. The Np didn’t know her head from her a**, so if an actual medical problem came up, I could talk it out with her and it really illustrated - to both of us - the knowledge gaps in NP training. By the end I had an appreciation for what NPs can do (follow directives and protocols from MDs, perform routine monitoring, address social issues quite well) and also what their limitations are.

From me she learned gynecomastia is a side effect of risperidone, and that whatever “pharmacology” she had learned was the tip of a gigantic, titanic grade iceberg that she needs to talk with a doc about when she has questions.

A few shifts with an NPp can be helpful, a lot can be harmful.

 

[calivianya]

My personal opinion is that we do most of our learning from UWorld. Rotating with a preceptor, MD, DO, NP, whatever - you’re going to see the most common things in the specialty over and over again, and very rarely or maybe never see the unicorns depending on the acuity of your hospital. What’s getting tested on our COMATs/NBMEs/boards? The unicorns, at a much higher rate than we’re seeing them in real life.

I had a metric ton of heme/onc questions on my IM COMAT. I think I had one cancer patient my entire second IM rotation, and he had some kind of indolent lymphoma that we weren’t even treating. If I had based my learning off just what I learned from my clinical experience and/or my preceptor, I would have failed that COMAT because the material we are being tested on is NOT the material we are seeing in our rotations... or at least that has been my experience.

The only things actual clinical experience is good for in med school IMO are getting patient contact experience if you didn’t already have it, learning what it’s like to work with other people if you never held a job before, and getting better/faster at writing notes, and I think a MD, DO, or NP can probably teach us all of that equally well.

Maybe I’ve just had crappy preceptors, I don’t know, but I haven’t learned much from any of them, so this is an academic discussion to me. I don’t care who I ”learn” from since the learning I’m getting out of my rotation experiences is minimal compared to the amount I’m learning at home on my own.

 

[LunaOri]

I think attendings should be paid a lot more to teach and the med education pathway should be made more popular across all schools to incentivize future educators

That would be excellent! We currently get paid $0 for the privilege of teaching all of you.

 

[amali]

I did both dental school and med school...
I was honestly shocked at the amount of times I was under direct supervision of an NP/PA as a med student. I also didnt appreciate that the midlevels would get to scrub in over me while I sat on a stool in the OR. It would be blasphemy in dental school to be directed by a hygienist or a non DDS/DMD during clinical rotations. Im obviously not comparing midlevels to dental hygienists/assistants by any means. I just think there is a movement towards diminishing medical school experience because of all this.

 

[Ho0v-man]

My personal opinion is that we do most of our learning from UWorld. Rotating with a preceptor, MD, DO, NP, whatever - you’re going to see the most common things in the specialty over and over again, and very rarely or maybe never see the unicorns depending on the acuity of your hospital. What’s getting tested on our COMATs/NBMEs/boards? The unicorns, at a much higher rate than we’re seeing them in real life.

I had a metric ton of heme/onc questions on my IM COMAT. I think I had one cancer patient my entire second IM rotation, and he had some kind of indolent lymphoma that we weren’t even treating. If I had based my learning off just what I learned from my clinical experience and/or my preceptor, I would have failed that COMAT because the material we are being tested on is NOT the material we are seeing in our rotations... or at least that has been my experience.

The only things actual clinical experience is good for in med school IMO are getting patient contact experience if you didn’t already have it, learning what it’s like to work with other people if you never held a job before, and getting better/faster at writing notes, and I think a MD, DO, or NP can probably teach us all of that equally well.

Maybe I’ve just had crappy preceptors, I don’t know, but I haven’t learned much from any of them, so this is an academic discussion to me. I don’t care who I ”learn” from since the learning I’m getting out of my rotation experiences is minimal compared to the amount I’m learning at home on my own.

I hear your frustrations. Maybe you have had crappy preceptors. Or maybe in person instruction doesn’t work for you until you’ve studied on your own first.

But if we’re using heme onc as an example, I was recently on a heme onc rotation. ICU called for DIC vs TTP. Now we typically learn that as arrow questions for step exams and not much else, but there’s a lot more nuance to it than that. Doc sent over his NP. She ordered coags and iron studies and straight up said later she had no idea what any of us were talking about. These aren’t the people you should be learning from.

 

[YCAGA]

At my school, no, at least not in a “this NP will teach you for the next 2 weeks and then evaluate you.”

It would just be awkward and embarrassing for midlevels if they tried to do this. M4’s on their EM sub-I’s routinely run circles around “experienced” mid-levels in terms of clinical knowledge and understanding of the most basic medicine. Not complex stuff, literally stuff like where is the aorta on a CT Chest w/ contrast.

 

[calivianya]

I hear your frustrations. Maybe you have had crappy preceptors. Or maybe in person instruction doesn’t work for you until you’ve studied on your own first.

But if we’re using heme onc as an example, I was recently on a heme onc rotation. ICU called for DIC vs TTP. Now we typically learn that as arrow questions for step exams and not much else, but there’s a lot more nuance to it than that. Doc sent over his NP. She ordered coags and iron studies and straight up said later she had no idea what any of us were talking about. These aren’t the people you should be learning from.

Well, it’s more just that I‘ve had to teach myself everything on my own. Most of the people I’ve worked with have wanted the notes written on all their patients before they get there, and I’m a little bit of a perfectionist (I imagine most of us are), so I want to get it right.

I’ve spent forever on diagnoses I’ve never seen before, found the up to date recommendations, dug through the chart to see if we’ve done all the previous workup, blah blah blah, put in the assessment and plan based on what up to date says. The feedback I usually get is “this is good,” and my preceptor adds “agree with med student’s note as above” and signs my note.

They don’t have anything left to teach me if I have to have looked up how to diagnose, work up, and treat the disease before they even get in the door - you know? Occasionally I have questions if there are multiple different options about how to treat something and I wasn’t sure which one to put, but otherwise, I don’t have any questions left to ask.

 

[Steve_Zissou]

I had a buddy who got pushed off by the pediatrician at a rural clinic that was supposed to be his preceptor. Ended up having to rotate with their PA. He noted that the PA lacked a lot of basic clinical knowledge, almost missing a textbook classic T1DM until my buddy brought it up as a differential.

PA offered him a letter of recommendation. He did not take them up on the offer.

 

[YCAGA]

I had a buddy who got pushed off by the pediatrician at a rural clinic that was supposed to be his preceptor. Ended up having to rotate with their PA. He noted that the PA lacked a lot of basic clinical knowledge, almost missing a textbook classic T1DM until my buddy brought it up as a differential.

PA offered him a letter of recommendation. He did not take them up on the offer.

Modern medicine, folks

 

[Chads2]

Well, it’s more just that I‘ve had to teach myself everything on my own.

The feedback I usually get is “this is good,” and my preceptor adds “agree with med student’s note as above” and signs my note.

They don’t have anything left to teach me if I have to have looked up how to diagnose, work up, and treat the disease before they even get in the door - you know?

Well, you’re obviously self-motivated, in part through your own personality and in part due to some of the unfortunate realities of DO school clinical rotations. Believe me, I’ve been there.

By the way, CMS does not allow “agree with student’s note” as proper attending documentation. Sounds as if you’ve had less than stellar faculty preceptors.

 

[Redpancreas]

Well, you’re obviously self-motivated, in part through your own personality and in part due to some of the unfortunate realities of DO school clinical rotations. Believe me, I’ve been there.

By the way, CMS does not allow “agree with student’s note” as proper attending documentation. Sounds as if you’ve had less than stellar faculty preceptors.

In medical school, there was talk about making med student notes billable. I think it was supposed to happen sometime in 2020.

That said, I still think it’s inappropriate. I could not imagine any medical student’s note being so perfect that the attending has no modifications and after the plan is made on rounds, even half the intern’s note is wrong. The attending should always be writing an addendum.

 

[Redpancreas]

Well, it’s more just that I‘ve had to teach myself everything on my own. Most of the people I’ve worked with have wanted the notes written on all their patients before they get there, and I’m a little bit of a perfectionist (I imagine most of us are), so I want to get it right.

I’ve spent forever on diagnoses I’ve never seen before, found the up to date recommendations, dug through the chart to see if we’ve done all the previous workup, blah blah blah, put in the assessment and plan based on what up to date says. The feedback I usually get is “this is good,” and my preceptor adds “agree with med student’s note as above” and signs my note.

They don’t have anything left to teach me if I have to have looked up how to diagnose, work up, and treat the disease before they even get in the door - you know? Occasionally I have questions if there are multiple different options about how to treat something and I wasn’t sure which one to put, but otherwise, I don’t have any questions left to ask.

You may be extremely self motivated and really good but I doubt the bolded is the case. This is more a product of a complicit attending and is especially annoying to the resident/attending team trying to understand why XYZ was done.

In some cases it may be appropriate like a skilled nursing facility bound patient waiting for insurance approval for the attending to glaze over the note likely copied forward from a more heavily scrutinized H&P. On the other hand, it’s completely inappropriate for a consult note on a medically complicated patient where the primary team’s waiting on this one note to determine management. Even if the attending’s communicated the plan exactly to the medical student I still want to see writing in print from the attending because things get misphrased and then there’s the classic attending who changes their mind at 9-10 pm and puts in an order without telling primary.

 

[Aheadbyacentury]

Given that this is SDN, I should have expected the complaining, the wailing and gnashing of teeth, the bitterness, and, of course, the elitism.

We now return you to your usual SDN dumpster fire

Spoken like a true administrator!!
I think the outrage is completely warranted. If you are training to be a physician you should be proctored and mentored by PHYSICIANS period. Anything less is un acceptable..
Can the LPN help you turn on the computer, OF COURSE.. you should learn from him/her
Can the RT show you the on/off switch on the ventilator. Of course
BUt those are limited to logistics and not the incredible nuances of medicine that is necessary to practice at a high level.. NPs should not be teaching anything about medicine to medical students.

 

[Aheadbyacentury]

I did both dental school and med school...
I was honestly shocked at the amount of times I was under direct supervision of an NP/PA as a med student. I also didnt appreciate that the midlevels would get to scrub in over me while I sat on a stool in the OR. It would be blasphemy in dental school to be directed by a hygienist or a non DDS/DMD during clinical rotations. Im obviously not comparing midlevels to dental hygienists/assistants by any means. I just think there is a movement towards diminishing medical school experience because of all this.

This is why I feel dentistry in 2021 is a better investment for those who feel its a good fit.
]

 

[Chads2]

In medical school, there was talk about making med student notes billable. I think it was supposed to happen sometime in 2020.

Med student notes are billable under certain CMS circumstances but never without huge revisions and certainly not without the proper attestation language.

 

[Chads2]

That would be excellent! We currently get paid $0 for the privilege of teaching all of you.

I just tell them, “Someday, and that day may never come, I will call upon you to do a service for me, like a nephrostomy exchange on a Saturday. But until that day, accept this teaching as a gift from internal medicine.”

 

[calivianya]

You may be extremely self motivated and really good but I doubt the bolded is the case. This is more a product of a complicit attending and is especially annoying to the resident/attending team trying to understand why XYZ was done.

In some cases it may be appropriate like a skilled nursing facility bound patient waiting for insurance approval for the attending to glaze over the note likely copied forward from a more heavily scrutinized H&P. On the other hand, it’s completely inappropriate for a consult note on a medically complicated patient where the primary team’s waiting on this one note to determine management. Even if the attending’s communicated the plan exactly to the medical student I still want to see writing in print from the attending because things get misphrased and then there’s the classic attending who changes their mind at 9-10 pm and puts in an order without telling primary.

Oh, these notes weren’t on a team. They were on a preceptor based rotation, and this is exactly how my surgery and OB rotations went. They usually got in at 8 AM and I usually got in around 4-5 AM, because it often took me that long to round on all the patients and get all the notes done, especially if there were diagnoses I wasn’t familiar with in the first place and had no idea what to do with.

I got told I was “expected to get all my work done” when I didn’t completely finish two of the notes because one of the patients had an emergency and I stuck with them instead of documenting... so this was an expectation - to finish all notes, on all patients, before the attending got there. I also had another doc call me unprofessional because I didn’t get around to the last patient of the day when all of the others were complicated.

One of my IM rotations was on a team and the other was preceptor-based, and my preceptor-based IM rotation was close - but at least that attending let us finish our notes up once rounding was over. We were expected to have a draft with an assessment and plan on all of the patients, though.

...I’m not saying I remembered all of it. A lot of it was a complete blur because I was just searching things on up to date as fast as I could to get the notes done, but my preceptors almost never said anything different than I had found on up to date.

 

[Matthew9Thirtyfive]

I also didnt appreciate that the midlevels would get to scrub in over me while I sat on a stool in the OR.

Wtf that is a travesty. That would never happen here.

 

[deleted1066189]

kinda curious on this too...I don't mean to hijack a thread but I have something similar
I'm heading to a DO school but I interviewed this cycle with Geisinger, an MD school whose mission is producing primary care physicians (though their match list says otherwise)...I received a pamphlet in the mail that their second year clinical class is exclusively taught by NPs and PAs. Is this an issue? Seemed kind of oddball...is this common at other schools?

 

[curbsideconsult]

It's funny how anyone shouting from the mountain tops that "medicine is a team sport!!!" conveniently leave out the part that teams have captains and coaches. Also, my "team" is not going to be with me during my board exams or with me when I'm trying to defend a medmal suit so I'd better be getting most of my education from a physician in the relevant field.

 

[Jack Donaghy]

I did both dental school and med school...
I was honestly shocked at the amount of times I was under direct supervision of an NP/PA as a med student. I also didnt appreciate that the midlevels would get to scrub in over me while I sat on a stool in the OR. It would be blasphemy in dental school to be directed by a hygienist or a non DDS/DMD during clinical rotations. Im obviously not comparing midlevels to dental hygienists/assistants by any means. I just think there is a movement towards diminishing medical school experience because of all this.

This is an important anecdote. We are the only profession where this "PC" culture of accept anything and everything may directly affect the education of the future generation.

A law student being instructed by paralegals? Blasphemy.
A dental student being instructed by hygienists? Blasphemy.
A flight student being instructed by a stewardess? Blasphemy.
A pharmacy student being instructed by a pharmacy technician? Blasphemy.

A medical student being instructed by a midlevel? Totally fine, because, you know, mEdIcInE iS a TeAm SpOrT

 

[Steve_Zissou]

This is an important anecdote. We are the only profession where this "PC" culture of accept anything and everything may directly affect the education of the future generation.

A law student being instructed by paralegals? Blasphemy.
A dental student being instructed by hygienists? Blasphemy.
A flight student being instructed by a stewardess? Blasphemy.
A pharmacy student being instructed by a pharmacy technician? Blasphemy.

A medical student being instructed by a midlevel? Totally fine, because, you know, mEdIcInE iS a TeAm SpOrT

Yeah, both "team sport" and "professionalism" are buzzwords/phrases that are used as clubs to beat down med students who don't like the idea of having people who are not physicians training them/being the leader of the medical team.

 

[Matthew9Thirtyfive]

This is an important anecdote. We are the only profession where this "PC" culture of accept anything and everything may directly affect the education of the future generation.

A law student being instructed by paralegals? Blasphemy.
A dental student being instructed by hygienists? Blasphemy.
A flight student being instructed by a stewardess? Blasphemy.
A pharmacy student being instructed by a pharmacy technician? Blasphemy.

A medical student being instructed by a midlevel? Totally fine, because, you know, mEdIcInE iS a TeAm SpOrT

And the only people who say that are people who aren’t physicians or academic physicians simping for midlevels.

 

[Lawpy]

This is an important anecdote. We are the only profession where this "PC" culture of accept anything and everything may directly affect the education of the future generation.

A law student being instructed by paralegals? Blasphemy.
A dental student being instructed by hygienists? Blasphemy.
A flight student being instructed by a stewardess? Blasphemy.
A pharmacy student being instructed by a pharmacy technician? Blasphemy.

A medical student being instructed by a midlevel? Totally fine, because, you know, mEdIcInE iS a TeAm SpOrT

Who thought a midlevel precepting a med student is ok?? Must be some dumb admins who want to cut costs by refusing to pay attendings anything for teaching

 

[Lawpy]

I had a buddy who got pushed off by the pediatrician at a rural clinic that was supposed to be his preceptor. Ended up having to rotate with their PA. He noted that the PA lacked a lot of basic clinical knowledge, almost missing a textbook classic T1DM until my buddy brought it up as a differential.

PA offered him a letter of recommendation. He did not take them up on the offer.

Why would your school be ok with your buddy being supervised by a PA?

 

[Lawpy]

This is the disastrous failure of modern medical education

 

[Steve_Zissou]

Why would your school be ok with your buddy being supervised by a PA?

Because the MD is “technically” his preceptor. MD that agrees to do it is a POS though, lots of bad stories coming out of that practice. Students don’t say **** though, because it’s far too easy to lost everything we’ve worked for at this stage.

 

[VA Hopeful Dr]

Because the MD is “technically” his preceptor. MD that agrees to do it is a POS though, lots of bad stories coming out of that practice. Students don’t say **** though, because it’s far too easy to lost everything we’ve worked for at this stage.

Stories like that bug the heck out of me.

Until this month, I've always taken 1 student for the full 4 week block. After at most 1 day, they see patients independently and present them to me. They do the easy procedures (usually knee injections and cryo, most recent guy did about 2/3rds of a toenail before I took over: he was being too gentle at the end).

My practice got merged with another one. The 5 doctors there split a student every month. That's OK, gets you more exposure to different practice styles. But, I just learned that for the most part they had the students just shadow them and then are wondering why their practice didn't get students actually interested in FM.

We're having a meeting this week so I can hopefully get them to loosen up a bit.

 

[Steve_Zissou]

Stories like that bug the heck out of me.

Until this month, I've always taken 1 student for the full 4 week block. After at most 1 day, they see patients independently and present them to me. They do the easy procedures (usually knee injections and cryo, most recent guy did about 2/3rds of a toenail before I took over: he was being too gentle at the end).

My practice got merged with another one. The 5 doctors there split a student every month. That's OK, gets you more exposure to different practice styles. But, I just learned that for the most part they had the students just shadow them and then are wondering why their practice didn't get students actually interested in FM.

We're having a meeting this week so I can hopefully get them to loosen up a bit.

My best rotations have been like this. The oral and maxillofacial surgeon who let me pull teeth, the spine surgeon who let me put screws in a spine, the FM doc who let me see a new patient for the first time and come to the right diagnosis of MS before presenting, etc. Most of my preceptors have been fantastic, but I’m also rotating at a small community hospital where many of them are willing to let me jump in and be hands-on. Some of my classmates are not so lucky. DO school rotations are always a bit finicky though.

 

[armytrainingsir]

if you don’t have NP preceptors, how will you ever learn to write Z paks for viral infections?

 

[emergentmd]

Too lazy to read everything.

When I was in med school/residency, we never had a PA/NP teach us anything prob b/c they were so rare.

Now they have penetrated almost every field and attendings have become lazy and dump some teaching responsibilities to them.

Not saying this is right or wrong, it just shows you how medicine is changing and the lines continue to blur.

Now if you see you OB, PCP and want to be seen quickly most likely you are seeing an APC. Hell, for primary care/simple OB evals, they probably give more compassionate care than Docs. Sad, but this is what we have allowed our profession to be devalued. On one hand docs complains how APCs are over stepping the boundaries and on the other, docs are too lazy/overworked so they hire a bunch of APCs to do the simple stuff which eventually becomes 90% of what they typically do.

 

[VA Hopeful Dr]

if you don’t have NP preceptors, how will you ever learn to write Z paks for viral infections?

Come rotate with me, because I absolutely do that (well doxy, but same idea).

After losing 2 jobs for being strict about antibiotics, I gave up fighting that battle.

 

[Matthew9Thirtyfive]

Come rotate with me, because I absolutely do that (well doxy, but same idea).

After losing 2 jobs for being strict about antibiotics, I gave up fighting that battle.

You write doxy for viral URIs?

 

[Mass Effect]

There's much hypocrisy in the field of medicine. Unmatched MDs and DOs are not allowed to work in the role of a PA or NP (I'm well aware of the assistant physician program, doesn't matter) because some regulatory body(ies) has determined that our training is different. If our training is different enough to prevent unmatched MDs and DOs from working as a midlevel, then WTH is a midlevel doing training med students? Can't have it both ways.

 

[Mass Effect]

Maybe I’ve just had crappy preceptors,

You have, unfortunately.

 

[VA Hopeful Dr]

You write doxy for viral URIs?

Yep

 

[Lawpy]

There's much hypocrisy in the field of medicine. Unmatched MDs and DOs are not allowed to work in the role of a PA or NP (I'm well aware of the assistant physician program, doesn't matter) because some regulatory body(ies) has determined that our training is different. If our training is different enough to prevent unmatched MDs and DOs from working as a midlevel, then WTH is a midlevel doing training med students? Can't have it both ways.

I blame the dysfunctional capitalist culture

 

[Matthew9Thirtyfive]

Yep

Wow. That blows that you’re being bullied into that practice for fear of bad patient satisfaction scores hurting your job. What a world we live in where patients who have zero medical knowledge whatsoever are empowered to bully us because they have been just turned into entitled dinguses.

 

[Redpancreas]

In our program, we have both teaching and non-teaching services in several different disciplines

The teaching service doesn't guarantee good teachers. The non-teaching services are when the attending rounds at 9, sits in his office until closing time, and only goes to the floor for emergencies or patient questions. On teaching it's similar but there's a huge focus on details related to patient care, not necessarily clinical reasoning.

 

[VA Hopeful Dr]

Wow.

Yeah, its very unfortunate.

 

[armytrainingsir]

Tell you what, why don't you lose 2 jobs in the space of 4 years due to patient satisfaction scores directly related to antibiotic prescribing then come back and see how you feel about it.

You could at least write for zithromax because the ship sailed long ago on that one being effective for anyone actually sick.

 

[VA Hopeful Dr]

Tell you what, why don't you lose 2 jobs in the space of 4 years due to patient satisfaction scores directly related to antibiotic prescribing then come back and see how you feel about it.

I'll expand on this a little bit so its not me just being angry about the whole thing.

Second year out of residency I took an urgent care job. Was supposed to be 3 months there and then get moved to a FM office. 2 months went by and I didn't hear anything about that move, called admin. My satisfaction scores were low so they weren't willing to move me (still doesn't make sense, but whatever). So I asked for and received the satisfaction reports. 90-ish% were from patients I hadn't given antibiotics to. The next 3 months I worked my tail off to get better scores: spent more time in the room, gave out my number to worried patients, made small talk, followed AIDET to a stupid degree. Didn't change my antibiotic prescribing pattern. Satisfaction scores unchanged except now more like 99% of the negative scores were from the antibiotic patients. Was told that still wasn't good enough to get moved to the FM practice, so I quit. Started my own practice.

2 years later I sold that so we could move. Got a new job as one of the in house doctors for a large employer. Still strict on antibiotics. Once again, awful satisfaction scores. Had to endure weekly satisfaction lectures. I decided to run a little experiment. For the next month, I gave out antibiotics to everyone who came in with URI symptoms. My history got shorter, my exam got shorter, my treatment discussion went from 5 minutes on "here's why you don't need an antibiotic and what to do instead" to 30 seconds of "this antibiotic should get you feeling better in the next week". Satisfaction scores tripled despite being less thorough and spending less time with patients. Gave my notice. Got a call the next day from admin, basically said "this saves us the trouble of spending the next 3 months building up a paper trail to fire you".

To paraphrase an amazing movie: I wish I could tell you that VA Hopeful fought the good fight, and administration let him be. I wish I could tell you that - but medicine is no fairy-tale world.

 

[VA Hopeful Dr]

You could at least write for zithromax because the ship sailed long ago on that one being effective for anyone actually sick.

Rookie mistake: the average URI lasts 7-10 days. If you give a 5 day antibiotic, you're getting lots of calls about either a) this antibiotic didn't work I need a different one or b) needing a 2nd zpack since the first one didn't do the job.

Doxy is 7 days, causes some stomach upset (so you know its a "strong" antibiotic), seems to have a very low c. diff rate, actually works for the handful of people who likely do have bacterial respiratory stuff going on, and despite being almost 20 years older than I am doesn't have a huge amount of resistance built up.