Twenty Questions (More or Less) for Dr. Bear (Part the Fourth and Last)

Hey Dr. Bear, what do you really think about Physician Assistants and other mid-level practioners?

Nothing. Why should I? They have their job and and I have mine. The real question that most insecure medical students want answered is this: Is the training required for a physician too extensive and are a couple years of Physician Assistant school out of which all of the “useless stuff” is filtered all that is really necessary? In other words,”Am I wasting my time and enduring all of this crap for nothing?”

This is a ridiculous question, the ridiculousness of which may not be apparent to you when you first start medical school but which will eventually come into sharper focus as you advance through your training.
Consider the typical medical student. Even late in his clinical years, he is conditioned to respect just about anyone in the hospital who looks like they know what they’re doing. It’s the nature of medical training; there is so much to learn that he never quite feels as if he has a handle on anything. Enter the Physician Assistant or Nurse Practioner confidently striding around in his long white coat effortlessly working at the job to which he has become habituated. That it may be a limited job never enters the medical student’s head because on any particular rotation, the Physician Assistant knows what to do, knows what the attending wants, and knows how to wrangle the all-important paperwork. In other words, he’s running circles around the medical student in his one area of expertise.

Not to mention that medical students are a fed a steady stream of both propaganda and sedition. On one hand they hear the litany from mid-levels that the equivalent of four years of medical school and three to seven years of residency can be crammed into a two-year program. On the other hand they are surrounded by dark whispers from fellow students that most of what they have learned is of no practical value. A medical student might start to buy into the notion that a physician is nothing more than a technician who checks some boxes and that there is really nothing more to it than a few practical skills and some basic medical knowledge.

On starting as an intern, your perspective is even more skewed. It’s the nature of intern year. A Physician Assistant completes his two-years-or-so of training and arrives fully-formed to the medical world ready to earn a decent salary at the specialty upon which he has decided. Sure, there is some on-the-job-training required but it is not nearly the same thing as a rigorous period of residency training. As an intern however, you are usually barely half-finished with your medical training and while the midlevel may not be as well trained or knowledgeable, he is fully trained for the responsibilities of his job. You however, are without a doubt almost completely unsuited for yours.
Not to mention that interns are almost universely mistreated while Physician Assistants, as they can bloody well quit and go work for someone else, are not. Heck, even the phlebotomist must feel like a highly-trained medical professional compared to the bran-new cadre of scared interns who arrive every July. If you yell at a phlebotomist you can get fired. Yell at an intern on the other hand, and various cronies of the old-school will pump their fists, give each other high-fives, and applaud your hard-line approach to medical training.

So it’s a matter of perspective. As you know, I did two intern years and like most doctors training in the generalist specialties (Internal Medicine, Family Medicine, Pediatrics, and Emergency Medicine), each year was a hodge-podge of wildly diverse rotations. General surgery on one month, Obstetrics the next, followed closely by an inpatient pediatric rotation and a medicine month or two. To be precise, last year I did two months in the ICU, one month of trauma surgery, one month of cardiology, one month of pulmonary, one month in the pediatric ICU, one general medicine month, a smattering of orthopaedics, two weeks of oralmaxillofacial surgery (dental blocks, very important), a month of labor and delivery and two months in the Emergency Department. The year before included three months of pediatrics. Like I said, a hodge-podge. You show up every month and no sooner do you start to get the hang of things when you start all over again on a new rotation.
My wife, as a matter of fact, correctly diagnosed the source of most of my stress during my first intern year, namely the constant cycle of ignorance that begins every month. The cure, paraphrasing my wife (but only a little): just say “fuck it” and if you don’t know how they fill out their paperwork on a new rotation that’s their problem, not yours.

So you see my friends, if you are a Physician Assistant working with the pulmonologists, it is not very difficult to get a handle on the routine sort of things that go on. Not only are you fairly intelligent to begin with but you know the lingo and the general idea of what you are doing. Enter the new intern who doesn’t even know how to find the parking garage and it is easy for both of you to be deceived as to each other’s capabilities.

Now, are there mid-levels who are smarter than physicians? Of course there are. And there are mid-level providors who, by dint of independent study and natural ability, are better physicians than real physicians. But that’s just life on the old bell curve upon whose difficult slopes each of us finds the pasture to which we are suited. There is probably a lot of overlap between midlevels and physicians on the south side of their respective bell curves. On the north side, not so much.

By the time you get a couple of years of residency under your belt your perspective will change yet again and you will start to feel a lot more comfortable in your medical skin. This is not to say that you are going to become arrogant. It is impossible (well, almost) for a resident to be truly arrogant, especially as our entire job seems to involve being corrected or trying to win approval. But eventually you get the hang of the mundane things and start to notice that you know what to do and to whom to do it. There is a purpose to residency training and medical school after all. I won’t strain my credibility by insisting that everything we learn is necessary and useful but I would cut out a lot less than most of you might imagine.

What Are You Reading Nowadays?

Pudd’nhead Wilson by Mark Twain. The First World War by Martin Gilbert. Just finished Our Mutual Friend by Charles Dickens.

Now Charles Dickens, he could write. The opening paragraph of Bleak House, for example, is one of the most masterful pieces of prose in English literature. I have read almost everything Dickens ever wrote and I have been deeply influenced by both his style and his talent for intricately constructed descriptions of just about anything to which he set his mind.

No, I don’t read crap.

And I don’t read medical novels. I have never read the House of God, the one about the Hmong (whatever it’s called), or any of the other must-reads. I get enough of that sort of thing at work.
Any Hobbies?

Not really. Just my blog. Can’t afford too much else. My older son and I love Star Wars legos and we build them whenever we can scrape together some money for a set. I used to own a lot of assault rifles but my arsenal has dwindled as of late. Money, you understand.

My dogs, of course; Zoe, Penelope, Daphne, Hector, and Persephone, my faithful black lab.

10 thoughts on “Twenty Questions (More or Less) for Dr. Bear (Part the Fourth and Last)

  1. Greetings great and powerful Odd. Love the blog, love the scrubs even more. Where can I get a set of those? 🙂 I think you underestimate yourself (or if not yourself, then other interns) and your worth to the department. Yes, the nurses all make a big deal about “Oh look at the virgin doc, isn’t he cute?!” but deep down many of them are just looking for a way to make themselves look better by calling you (or someone like you) out when you (or someone like you) make an error. Silly, truthfully, since the hospital wherein you reside, oh resident, is a teaching hospital, although the stakes for making a Mis are often wrought with dire consequences. It is here where the residents shine because often, the residents are more apt to be overcautious than the old guard. I have to warn against a full cardiac workup for that ankle injury… unless it’s warranted of course.

    I’ve been nothing but impressed with your skill and frank way you deal with patients. Remember when you told that whiny patient to “leave the nurses alone.” You shined that day, and my respect for you grew by leaps and bounds for that one simple thing.

    Keep up the good work pb.

  2. You have such an incisive way of describing what this is all really like. “Our entire job seems to involve being corrected or trying to win approval.” PAs, unlike interns, can quit. Ahh. So true.

    My bottom line is: I would never be content, as an RN, NP, or PA, to be always obliged to take orders. Residency is bearable because sometime I’ll be done, and I can make the decisions. I struggle just with being told to order one of two good treatment options, when I like the other one better – let alone doing everything like that, forever.

  3. Bleh Dickins. Never could get into him.

    Your comment about having to move to something new the minute you feel you are beginning to master things. It’s good to know that’s not going to go away any time soon. Just knowing that, and keeping things in perspective is a big help for keeping your sanity.

    And at very least, since your rotations consist of a month here and a month there, if you get stuck with a crappy team, it’s only for a short while.

  4. Dear god I shouldn’t try to write comments before I’ve had my coffee. Complete sentences, people! I’m pretty sure my point was clear even though I was illiterate though.

  5. Sometimes I think you are all about being an arrogant pr***, and then you write something that shows you are human (and smart and a good writer).

  6. Some “mid-levels” are content with the current state of practice. Our patient satisfaction and patient outcome data are equivalent to physicians. I think that the difference is that our interpersonal skills are generally better than physicians: we are less bitter, less beaten and more content to work in primary care settings. This could be an artifact of our more humane training or our satisfaction with being “just” NPs.

  7. it seems crazy to me that physician assistants and nurse practictioners are given so much power to prescribe. at most, i feel they should not be allowed to prescribe unless a doctor is on the premises. i also feel no more than 2 non-physician providers should be assigned to any one doctor(MD or DO)

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