Surgical intern with PA taking chief call

[Logano2230]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

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[ACSurgeon]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

That sounds like a crappy setup. However, realize that while you have more medical education as an intern, you have less clinical experience and essentially no training yet. The real issue is why don't you have senior residents instead of APPs?

 

[Logano2230]

It's admittedly pretty rare that an APP is "chief" but occasionally happens. True, I have only ~7 months of inpatient experience beyond medical school; I wonder then what level of training an APP would equate to in most people's minds. PGY3? Medical residents are almost done with training at that level.

 

[deleted480308]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

I disagree that there "needs" to be a buffer between intern and attending....."there usually is" doesn't mean it's necessary

 

[caffeinemia]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

Just keep this in mind -- some of those PAs have been in that position for years if not decades. They are essentially eternal residents. Moreover, they may have worked with those attendings over so many years, that they essentially know a lot of the protocols and such. Don't let their title color your judgment. Instead reflect on whether their advice sounds reasonable or well thought out to you -- if it does, then what does it matter -- are you going to be an intern or resident subservient to them forever? Are they making you call them doctor or fetch their dinner? If not, then ehhh, suck it up and do right by the patient.

I can't tell you how many times one of the senior pa's in the SICU helped me out when 3 or 4 consults came in over night. Finally, take a chance sometime to ask those PA's how many years of residents they've trained. You may be surprised.

 

[dpmd]

Was this for general surgery stuff or subspecialty?

 

[Winged Scapula]

PAs have a long been a part of surgical teams, especially on Trauma, Ortho and Nsgy. I've worked with some good ones, some bad ones and some who seemed only to exist to provide sexual favors to the Chief residents. During residency we experimented with having them take call overnight on Trauma, as first call (not senior); they were awful. YMMV.

Point being that @caffeinemia is right: its probably not worth making a stink about given that in a few months/years you will be supervising them, as long as their plans are sound. However, this should be a minor part of your education. Senior residents don't just exist as a sounding board for interns; they are there to help train you, to train you to be a physician. A mid-level should never be regularly supervising you when physicians are available.

 

[caffeinemia]

We have a lot of VERY experienced PAs and I agree with pretty much everything you said.

However I will say I've never seen a call system where the "chain of command" truly puts PA above MD, even an intern.

Agree with this sentiment. Usually they are working actively with intern or pgy2 to get things done on floor/consults, but never as our supervising practitioner. I did have one situation where I totally thought that the PA in the SICU was just levels above me in intensive care. He'd been doing it for 4 or 5 years. I had done it for all of 12 hours... so I'm super glad he was there to bail my ass out. In that case, I deferred entirely to his wisdom as long as it didn't sound too cracked out to my novice judgment.

 

[Psai]

PAs have a long been a part of surgical teams, especially on Trauma, Ortho and Nsgy. I've worked with some good ones, some bad ones and some who seemed only to exist to provide sexual favors to the Chief residents. During residency we experimented with having them take call overnight on Trauma, as first call (not senior); they were awful. YMMV.

Point being that @caffeinemia is right: its probably not worth making a stink about given that in a few months/years you will be supervising them, as long as their plans are sound. However, this should be a minor part of your education. Senior residents don't just exist as a sounding board for interns; they are there to help train you, to train you to be a physician. A mid-level should never be regularly supervising you when physicians are available.

Brb transferring into ortho

 

[vhawk]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

I wouldn't worry about it, they don't have less medical training and education than you do.

 

[vhawk]

Brb transferring into ortho

Kind of puts "serving as a buffer between the resident and the attending" in a new light

 

[kitsunepixie]

When I was an intern and we were starting to cover another Level 1 trauma center in our city, they put us on call for the educational opportunity with a PA who had 20+ years of experiences who knew more about how that hospital worked than our chiefs did. Learned a lot but was still the one to do procedures and call the attending and scrub in when we went to the OR. I think it depends on how things are set up and the individual PA.

 

[deleted547339]

I've worked with some good ones, some bad ones and some who seemed only to exist to provide sexual favors to the Chief residents.

Really, we're just glossing over this....?????? lol.

 

[vhawk]

Kind of puts "serving as a buffer between the resident and the attending" in a new light

Really, we're just glossing over this....?????? lol.

Nope

 

[Logano2230]

I wouldn't worry about it, they don't have less medical training and education than you do.

If what you are saying is true then what is the point of medical school? This statement seems to support arguments that APP training is no different than doctors. If not, where do you think a resident crosses the threshold of a PA or NP?

 

[vhawk]

If what you are saying is true then what is the point of medical school? This statement seems to support arguments that APP training is no different than doctors. If not, where do you think a resident crosses the threshold of a PA or NP?

There isn't an actual answer to your question but someone earlier compared them to a pgy 3 and that's probably as good of a guess as any. Obviously a PA with 1 year experience is different from 20 years. But in my experience an experienced APP is basically like an outstanding junior resident.

Which is really just another way of saying that after your first 2 years of residency the focus of your training changes dramatically from being someone who can report data and execute plans to being someone who can take ownership and exercise judgment

 

[Winged Scapula]

Really, we're just glossing over this....?????? lol.

Oh that's old news.

Ive told that story here before about walking in on the both married PA and CT surgery fellow fooling around in the SICU call room more than once.


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[ThoracicGuy]

Really, we're just glossing over this....?????? lol.

I went to the wrong residency programs...

 

[deleted547339]

Oh that's old news.

Ive told that story here before about walking in on the both married PA and CT surgery fellow fooling around in the SICU call room more than once.


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I didn't mean to sound naive to this, I just meant that saying it seemed like it was there only purpose was surprising.

 

[beefballs]

When I was an intern and we were starting to cover another Level 1 trauma center in our city, they put us on call for the educational opportunity with a PA who had 20+ years of experiences who knew more about how that hospital worked than our chiefs did. Learned a lot but was still the one to do procedures and call the attending and scrub in when we went to the OR. I think it depends on how things are set up and the individual PA.

I have such a problem with this If you are there you are getting paid in your education that means THE RESIDENT goes to the OR. Im sorry but any attending who is using their PA as buffer with the residents needs their A$$ booted off of teaching service.

Residency is not med school year 5-9 for gen surg residents.

residents should be putting in lines, getting airway experience, experience managing codes etc.

 

[LucidSplash]

?? The post specifically said the resident WAS the one to do all the procedures and go to the OR?

Or did I horrifically misread something?

I have such a problem with this If you are there you are getting paid in your education that means THE RESIDENT goes to the OR. Im sorry but any attending who is using their PA as buffer with the residents needs their A$$ booted off of teaching service.

Residency is not med school year 5-9 for gen surg residents.

residents should be putting in lines, getting airway experience, experience managing codes etc.

 

[Winged Scapula]

I didn't mean to sound naive to this, I just meant that saying it seemed like it was there only purpose was surprising.

Perhaps you're taking my hyperbolic statement a little too literally.

I am sure they served some other purpose after all they did more in the operating room than the interns were allowed to do but they never rounded, didn't start before eight and wouldn't stay after five, always got a lunch. And then of course the sexual favors bit.


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[Danbo1957]

Ah... that's why all the CTS physician assistants look like fashion models.

 

[Psai]

Ah... that's why all the CTS physician assistants look like fashion models.

I dunno where you're at but tell them to hire me

 

[kemper6036]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

where i did my internship they had a set up like this in the SICU where your immediate superior was a nurse practitioner. i thought the set up was bizarre and didn't understand why a large academic center didn't have enough residents to run their SICU. i don't think you're wrong to feel the way you do ( I know I did), but in reality its probably not likely to change anything.

 

[dienekes88]

I'm a current intern at a university program and a handful of times this year my "chief" who I would call over night has been a PA or NP. While I understand there needs to be a buffer between attending and intern I'm wondering if I'm wrong to bristle at having someone with less medical training and education be my lifeline. Is this just my ego or would you feel resentful too?

As with most of life, it's probably a bit of both.

At the end of the day, the PA/NP knows the system, knows the attendings, and knows common stuff that happens. You as an intern (and the larger pool of interns) lack an adequate understanding of any of these things to make consistently sound decisions. Maybe you would be just fine, but that's not necessarily true of the next guy.

Having said that, there's a huge amount of variation in their ability and also their attitudes. Some are truly indispensible. Some are less so.

 

[Psai]

Meh I think as interns the midlevels know more about the system as they've been working in the hospital for longer than us. Some of them are truly excellent at their jobs and know who to talk to to make the transfers, discharge to rehab, etc. I can see why attendings would want a buffer if they're taking home call to try to avoid getting inappropriate middle of the night calls or having interns not contact them when they need to come in. But that's the job and that's what you signed up for.

 

[kemper6036]

i don't think anything said above is in dispute, the real issue is should midlevels be supervising physicians?

 

[ProfMD]

Attending needs a buffer? Especially if this is relatively rare?

Lame.

There is no reason an attending can't take call with the intern. I did this as an intern when the senior had a weekend off. My service now doesn't get interns, but I routinely take call with PGY 2-3, rarely PGY 4.

 

[vhawk]

To take the attendings side of it a bit since several people have posted talking about how lame it is to need a buffer. The buffer isnt solely to prevent the attending from having to talk directly to the intern. The buffer is also for the calls that DONT get made when its just an intern and an attending, which are the ones that really matter

 

[ProfMD]

To take the attendings side of it a bit since several people have posted talking about how lame it is to need a buffer. The buffer isnt solely to prevent the attending from having to talk directly to the intern. The buffer is also for the calls that DONT get made when its just an intern and an attending, which are the ones that really matter

I agree 100% that not calling when needed is a huge problem. Calling too much should not be.

If a resident of any level feels they cannot call and attending when needed, then there is a problem with the attending.

 

[deleted547339]

where i did my internship they had a set up like this in the SICU where your immediate superior was a nurse practitioner. i thought the set up was bizarre and didn't understand why a large academic center didn't have enough residents to run their SICU. i don't think you're wrong to feel the way you do ( I know I did), but in reality its probably not likely to change anything.

Eh - my big academic SICU doesn't have enough residents. About half of our patients have NPs as their primaries. Same where I did residency.

 

[vhawk]

I agree 100% that not calling when needed is a huge problem. Calling too much should not be.

If a resident of any level feels they cannot call and attending when needed, then there is a problem with the attending.

Seems a little reductive. Its easier to discuss things with a senior resident than an attending. Weren't you ever an intern? Didnt you hate calling your attending for things that you werent sure he cared about? Didnt you cherish your independence? What you are saying is true in the "put it on a bumper sticker" sense but there is almost no possible way that "intern>senior resident>attending" is not better for patients than "intern>attending." Its just human nature.

 

[ProfMD]

Seems a little reductive. Its easier to discuss things with a senior resident than an attending. Weren't you ever an intern? Didnt you hate calling your attending for things that you werent sure he cared about? Didnt you cherish your independence? What you are saying is true in the "put it on a bumper sticker" sense but there is almost no possible way that "intern>senior resident>attending" is not better for patients than "intern>attending." Its just human nature.

I see your point, but I still think it is incumbent on attendings to make themselves available.

As an intern I was on a service on which it was me an the attending for a few days. As an attending, I take calls with R2 regularly. I have partners on other services who take calls from interns. Works out fine for everyone.

 

[kemper6036]

Eh - my big academic SICU doesn't have enough residents. About half of our patients have NPs as their primaries. Same where I did residency.

i guess i could see having NP as the primary person for patients, but are they supervising the residents?

 

[deleted547339]

i guess i could see having NP as the primary person for patients, but are they supervising the residents?

No. About half of our patients have NPs as their primaries in all of our surgical ICUs, fewer in our medical ICUs. They function similarly to the residents on most services. They work in parallel to the interns/residents and under the fellows.

 

[cpants]

I know when I was an intern on SICU rotation, I did not have the chops to be taking primary care of these patients. Do you really think you do? They are sickest in the hospital --- shocky, coding, and with complex vent, pressor, and procedural needs. In a lot of programs it makes a lot of sense both in terms of staffing resources and patient safety to have seasoned midlevels in place in these settings, and yes, calling the shots. Sure a chief or upper level resident could also safely manage the unit, but they need to be in the OR and don't want to spend a month or two of chief year rotting in the SICU (nor will you, BTW). There frequently aren't enough fellows to have someone there all the time.

As an intern you are learning to manage these sick patients, and hopefully you are most of the way there by the end of the year. Certainly a mistake to have an inferiority complex about being "managed by an NP". Just be humble, work hard, and learn as much as you can. I was able to put in tons of lines and learned a ton of medicine from these trusted midlevel providers. I enjoyed working under them a lot more than fellows for the most part -- because the fellows usually want to do all the procedures themselves.

 

[droliver]

I think some residents literally "don't know what they don't know" here and are getting caught up on feeling disrespected.

You will find there are some very bright and experienced RN, CRNA, NP, and PA's who actually know a lot more about taking care of people or doing certain procedures then you do, particularly during the first few years of residency or in practice. On a teaching service, an experienced NP or PA on board is often the resouvoir of continuity for practice patterns as the residents come and go. Don't get offended, take the opportunity to learn from them when possible. I still stay in touch a almost 15 years later with the spectacular PA's from my 3rd residency who I worked with and taught me an awful lot of skills and habits to be the best technical surgeon I could.

 

[LucidSplash]

I think some residents literally "don't know what they don't know" here and are getting caught up on feeling disrespected.

You will find there are some very bright and experienced RN, CRNA, NP, and PA's who actually know a lot more about taking care of people or doing certain procedures then you do, particularly during the first few years of residency or in practice. On a teaching service, an experienced NP or PA on board is often the resouvoir of continuity for practice patterns as the residents come and go. Don't get offended, take the opportunity to learn from them when possible. I still stay in touch a almost 15 years later with the spectacular PA's from my 3rd residency who I worked with and taught me an awful lot of skills and habits to be the best technical surgeon I could.

Agreed on this. The OP needs to tell his ego to STFU and learn from whoever he can. As an intern, an advanced practice nurse taught me how to put in an Aline, because that was who was around. Experienced CRNAs gave me invaluable tips on intubating. At the intern level, an experienced NP/PA/CRNA can teach them a ton of tricks of the trade and be a great resource.

Now, as a senior/chief, they defer to me and call when they have a problem because I have always treated them with professional respect. Getting a chip on your shoulder about learning someone with a different degree type is silly. Knowledge is knowledge. Get it wherever you can.

 

[kemper6036]

No. About half of our patients have NPs as their primaries in all of our surgical ICUs, fewer in our medical ICUs. They function similarly to the residents on most services. They work in parallel to the interns/residents and under the fellows.

seems like an optimal setup

 

[kitsunepixie]

I have such a problem with this If you are there you are getting paid in your education that means THE RESIDENT goes to the OR. Im sorry but any attending who is using their PA as buffer with the residents needs their A$$ booted off of teaching service.

Residency is not med school year 5-9 for gen surg residents.

residents should be putting in lines, getting airway experience, experience managing codes etc.

Residents were the ones to do the procedures.

 

[mimelim]

I really do despise the us vs. them mentality in this. I find it to be shockingly similar to Republican vs. Democrat or any other political divide.

Who should be supervising interns? The people in the best position to a) train them and b) keep the services running. Every hospital is different. We already have a lack of academic faculty across the country in most, if not all specialties. Sure, it is easy to say at big academic centers that attendings should do this or that. But, that is not the real world. Not every attending has the same vision of what they want their job to look like.

The concept that only MDs are qualified to teach MDs is just plain idiotic. Yes, the bulk of what you learn should be coming from residents/fellows senior to you as well as faculty. But, by far the biggest enemy that I face in junior residents is hubris. It is far more dangerous to patients than virtually any other correctable issue.

 

[Psai]

I really do despise the us vs. them mentality in this. I find it to be shockingly similar to Republican vs. Democrat or any other political divide.

Who should be supervising interns? The people in the best position to a) train them and b) keep the services running. Every hospital is different. We already have a lack of academic faculty across the country in most, if not all specialties. Sure, it is easy to say at big academic centers that attendings should do this or that. But, that is not the real world. Not every attending has the same vision of what they want their job to look like.

The concept that only MDs are qualified to teach MDs is just plain idiotic. Yes, the bulk of what you learn should be coming from residents/fellows senior to you as well as faculty. But, by far the biggest enemy that I face in junior residents is hubris. It is far more dangerous to patients than virtually any other correctable issue.

You know who sets up the us vs them mentality? Sure as hell ain't us. I don't try to outsmart them or say things like "med school is basically like np school but faster" or call myself nurse psai dnd nd dmp bcnd

Every news article even remotely related to doctors or nurses have comment section full of midlevels trying to **** on our training and our place in the world. "I have practiced 20 years independently and outperform every doctor" "I am a doctor of nursing I am better than a medical doctor" "Doctors don't care about their patients and don't listen to me I have the brain of a doctor and the heart of a nurse" "Look at all the research that shows that nurses are better than doctors at being a doctor"

I'm sick of it.

 

[Winged Scapula]

I am coming to the belief that the mid-level hubris iss more common in the community setting than academic.

For example, our own office PA who is fabulous and knows her limits had no idea what a surgical residency entails or how many hours we worked etc., as residents. We've certainly had a couple of bad experiences with some who believed the trope that they were just as well educated, to the point where one said, "I know more than two thirds of the family doctors around town" ( said three months after her graduation from PA school ). I see this with other surgical PAs at the local community hospitals ( I hear them talking amongst themselves; sometimes laying low has advantages).

On the other hand the nurses and PAs that work at the local academic hospital, in direct contact with residents and medical students, seem to have different mentality. I never hear them talk about how they have just as much training as physicians or "I can do the same work" outside of a couple of outliers I met during residency.

 

[mimelim]

You know who sets up the us vs them mentality? Sure as hell ain't us. I don't try to outsmart them or say things like "med school is basically like np school but faster" or call myself nurse psai dnd nd dmp bcnd

Every news article even remotely related to doctors or nurses have comment section full of midlevels trying to **** on our training and our place in the world. "I have practiced 20 years independently and outperform every doctor" "I am a doctor of nursing I am better than a medical doctor" "Doctors don't care about their patients and don't listen to me I have the brain of a doctor and the heart of a nurse" "Look at all the research that shows that nurses are better than doctors at being a doctor"

I'm sick of it.

This is like going to fox news.com and getting upset at the comments section on whatever political topic you want.

And honestly, "it is all their fault, they started it!" is pretty juvenile. You are the one with the attitude of, "only MDs are qualified to teach MDs", ie. putting down every other profession below your own. Never mind the blatant self serving practices of physicians for decades at the expense of others in the health care system. Maybe you feel justified in hating on mid-levels at every turn based on mass media comment sections, but an equally valid argument can be made by many mid-levels about physicians. Certainly there are many mid-levels out there that are crusading on, "we are better or equal to physicians", but as others have chimed in repeatedly in this and many other threads, they are the vocal minority.

 

[Vandalia]

Medicine is easy... until something blows up into your face. (Sometimes literally I suppose.)

My first MS III rotation, IM. Everything was pretty cut and dry. Simple cases were simple cases. The MI's looked like MI's, the cancers behaved like cancers are supposed to look like, and I was wondering why everyone was saying this medicine thing was so difficult. Sure I understood the need for medical school, and perhaps an internship, but residency? fellowship? Then a patient came in with a classic presentation of "stomach flu." I gave the normal spiel, and was ready for the resident to send them out the door. However, he said something didn't seem right and did a neuro exam. An hour later the patient was in the ICU, the next day being operated on for a cerebral aneurysm. Lets just say that after that, those cases didn't seem so simple anymore.

If you are a licensed physician, you are going to see enough cases in training to realize that a 1% chance of something still means it can happen. Even when it can't happen it can happen. I have had a patient claim their GB was removed, the records said it was removed (second hand), they had appropriate scars, and upon imaging they still had their GB. Figure that one out. And remember that one when the EM physician calls you about an appy on a patient who the records say had it already removed.

My concern is that the "mid-level" training does not provide the volume of cases to "learn fear" before they hit the streets. Until you see a patient with your own two eyes have appy-symptoms end up with an MI you really don't believe it can happen. It makes sense that if you are in an academic setting, you are going to see more of the crazy cases and begin to learn fear. It also makes sense that after a decade or two of practice, PA/NP will pick up that fear. But I do worry that the ones straight out of training who are practicing independently haven't learned that yet. And that it is based on direct experience.

 

[Psai]

This is like going to fox news.com and getting upset at the comments section on whatever political topic you want.

And honestly, "it is all their fault, they started it!" is pretty juvenile. You are the one with the attitude of, "only MDs are qualified to teach MDs", ie. putting down every other profession below your own. Never mind the blatant self serving practices of physicians for decades at the expense of others in the health care system. Maybe you feel justified in hating on mid-levels at every turn based on mass media comment sections, but an equally valid argument can be made by many mid-levels about physicians. Certainly there are many mid-levels out there that are crusading on, "we are better or equal to physicians", but as others have chimed in repeatedly in this and many other threads, they are the vocal minority.

Does it really make you feel that mature and special when you try to put down others?

 

[mimelim]

Does it really make you feel that mature and special when you try to put down others?

Yes, pointing out blatant hypocrisy of someone bashing an entire profession is me trying to feel mature and special.

 

[vhawk]

Medicine is easy... until something blows up into your face. (Sometimes literally I suppose.)

My first MS III rotation, IM. Everything was pretty cut and dry. Simple cases were simple cases. The MI's looked like MI's, the cancers behaved like cancers are supposed to look like, and I was wondering why everyone was saying this medicine thing was so difficult. Sure I understood the need for medical school, and perhaps an internship, but residency? fellowship? Then a patient came in with a classic presentation of "stomach flu." I gave the normal spiel, and was ready for the resident to send them out the door. However, he said something didn't seem right and did a neuro exam. An hour later the patient was in the ICU, the next day being operated on for a cerebral aneurysm. Lets just say that after that, those cases didn't seem so simple anymore.

If you are a licensed physician, you are going to see enough cases in training to realize that a 1% chance of something still means it can happen. Even when it can't happen it can happen. I have had a patient claim their GB was removed, the records said it was removed (second hand), they had appropriate scars, and upon imaging they still had their GB. Figure that one out. And remember that one when the EM physician calls you about an appy on a patient who the records say had it already removed.

My concern is that the "mid-level" training does not provide the volume of cases to "learn fear" before they hit the streets. Until you see a patient with your own two eyes have appy-symptoms end up with an MI you really don't believe it can happen. It makes sense that if you are in an academic setting, you are going to see more of the crazy cases and begin to learn fear. It also makes sense that after a decade or two of practice, PA/NP will pick up that fear. But I do worry that the ones straight out of training who are practicing independently haven't learned that yet. And that it is based on direct experience.

I have solved your gallbladder mystery for you. Partial cholecystectomy is a thing, but most non-surgeons dont realize it. Your scenario isnt even that uncommon. I've done like 5 "redo" cholecystectomies.

 

[Vandalia]

I have solved your gallbladder mystery for you. Partial cholecystectomy is a thing, but most non-surgeons dont realize it. Your scenario isnt even that uncommon. I've done like 5 "redo" cholecystectomies.

No, not partial. I am aware of the concept, it not the technical details. I am talking, virgin, "imaging straight out of the radiology textbook", gallbladder.

I double-checked with them and both the woman and her husband swore that she had her gallbladder removed twenty some years before. He remembered the details of the evening and the talk with the surgeon afterwards. Nothing else on imaging to suggest that there was another procedure done they could have confused it with. She was married when she claimed it was done so it wasn't like she was 3 at the time and misunderstood what her parents said. They didn't seem so out of it that it was like they were doing surgery on each other for recreation. But like I said appropriate surgical scars (for about 30 years ago, now).

Now it was done at a somewhat rural hospital some 500+ miles away. Maybe it was some sort of intentional fraud. Maybe they mixed her up before surgery, closed her up and the patient was confused afterwards about what exactly was (not) done. Maybe she was abducted by aliens.

But back to my main point, you soon realize that even if it isn't part of the differential, it can still happen.