Up and Down and All Around The Pandaverse

I Needed That

Let’s just say I don’t know as much about pediatric resuscitation as I should. I know the basics of course, but there are nuances in the the emergency treatment of children that are not as easy to remember as they are for a standard 75-kilogram adult. We also get many, many more adult trauma and critical patients then we do children so it’s a question of practice. I mention this because residency can be very humbling and never more so when you don’t have a good idea what to do and have to get more guidance from the attending than you probably should. I am extremely glad I have a year of training left because a pediatric respiratory arrest that came in the other night demonstrated, yet again, that despite the agitprop from the mid-levels, there is a purpose to residency training and you cannot just throw somebody out to the public with a couple of years of medical training.

Just to summarize, I asked for the wrong medications for sedation and paralysis, failed to intubate, had to pass it off to my attending, and even struggled to get a central line. Ouch. I have been reviewing Pediatric Advanced Life Support (PALS) since then so some good has come out of a bad experience but it is, as I said, very humbling. The Emergency Department is a team. The nurses know their job as do the techs, respiratory therapists, and everybody else. I don’t think it’s unreasonable that I should know mine.

So I was kind of moping around after that, seeing the drug seekers, emergency colds, constipation, and the only other patients with who I felt I could be trusted when I got called to a code on one of the medicine floors. I was the first one there, got a report from the patient’s nurse who was doing CPR, assessed the patient, and we ran a very strong code that I think gave the patient every possible chance to live even though he did not pull through. I think I successfully identified the problem, took the appropriate steps to resolve it, intubated a very difficult airway on the first pass, and generally did everything I was supposed to do and that I used to watch other residents do three years ago when I was a sheepish brand-new intern just trying to stay out of the way.

Residency is a series of highs and lows, at least for me. Some days nothing happens and I tool along complacently. Sometimes I royally screw up and feel like I’m never going to get it. And then sometimes I discover that I know what I’m doing.

Up and down.

Up and down.

You Have It Exactly Backwards

In regards to a recent article of mine detailing the differences between physicians and mid-level providers, a reader commented that patients neither care what initials are after our names nor about the “expansiveness” of our training but only that they are treated with compassion and understanding. This is another variation of the common mid-level mantra of “Anything You Can Do I Can Do Better Even Though My Formal Training in Medicine is a Small Fraction of Yours.”

The reader has it backwards. The patients don’t care about our initials, whether “MD,” “NP,” or “PA-C,” because they tend to assume anyone with a white coat is a physician. Mid-levels are not exactly quick to identify themselves as mid-levels although to be fair this is mostly because there is no clearly recognizable title that they can use. I walk into the room and say, “Hello, I’m Doctor Bear.” What do you say if you are a Nurse Practitioner? You’re not a Nurse and you’re not a doctor so first names are used and the patient assumes what they will. The key point is the assumption that the person in authority the patient finally sees after all the preliminaries is a physician with whatever training and education the patient imagines a physician should have.

So it’s not that the patients don’t care, it’s only that regardless of the complaining and dark conspiracy theories to which they subscribe when they are not under our care, patients have complete trust in the medical profession when it is up in their face and the mid-levels tap into this trust whether they deserve it or not. Physicians, especially residents, also tap into this trust, the coffers of which have been filled by every honorable physician who has practiced before us. It goes without saying that we may or may not deserve this trust either.

As to not caring about the expansiveness of our training, I am reasonably sure that most patients, if they knew the difference, would much prefer a residency trained physician leading the team resuscitating their drowned child (see the first part of this article) and would not tolerate anybody but a residency trained surgeon removing their gallbladder. Again, there is an assumption of a certain expansiveness and many patients would be appalled to discover that you can be a mid-level provider with only a couple of years of formal medical training. For the information of the laypeople who may be reading, the bare minimum for any physician in any specialty is seven years. I will have had eight years of formal medical training when I’m finally done (I am almost done with my seventh year) and some specialties train for upwards of a decade after medical school.

As for treating patients with compassion and understanding, this is probably the easiest thing about medicine and as it requires no special skills or training, has become the last refuge of egalitarian scoundrels who, when pushed into a corner will come out swinging, brandishing their superior compassion as if long periods of medical training somehow strip physicians of their basic humanity.

People who know me would probably attest that I am a very humble guy who is completely aware of his limitations. This does not mean that I feel compelled to subscribe to some politically correct, totally egalitarian word-view.

Futile is as Futile Does

I like Dinosaur and agree with much of what he says but I feel compelled to comment, yet again, about what I think is his misunderstanding of futile care. Of course we both agree that strictly being elderly is not an indication to pull the plug just as we agree that many of the elderly can walk out of the hospital after treatment for diseases that would have been a death sentence fifty years ago (and still are for the elderly in the Great Freeloader Kingdoms Across the Big Water). But seriously now. I had a patient about a month ago who had suffered a massive stroke a few years before and essentially spent her now diminished life laying in her own stool, breathing through a hole in her neck, eating through a hole in her belly, and making the occasional trip to the Intensive Care Unit when her lungs or upper airway became too full of fluid to be suctioned by the indifferent minimum wage hands in the warehouse where she is stored. She had a pacemaker to keep her heart beating, a defibrillator to jump start it when it didn’t, and a small pharmacy’s worth of medications to ensure that she will shuffle off her mortal coil in fits and starts.

As is common with bed-bound, demented patients who are only infrequently turned and cleaned, she had developed a large decubitus ulcer that had eaten into her back all the way down to her sacrum, the polished bone of which could be seen clearly when the nurse rolled her on her side. This particular ulcer had eroded almost to her anus and was almost impossible to keep clean as every one of her frequent bowl movements poured into and around it. The surgeon who we consulted suggested a colostomy to redirect bowl contents to a pouch on the abdomen as the first step to any definitive treatment.

Perhaps when the next step in your treatment is a surgical re-working of your guts to prevent complications from the complication of having no other function in life but to lay in your own stool staring blankly at the ceiling and all the pretty lights and alarms, well, perhaps it’s time to talk about quality of life and what, exactly, the couple of hundred thousand dollars on the table are buying us and the patient. Sometimes the line between futile care and reasonable medical efforts is not clear and I can’t always discern it. But what we do to some patients is madness. Utter madness.

37 thoughts on “Up and Down and All Around The Pandaverse

  1. One point I consistently see you ignoring is that midlevelers are meant to work with physicians, as part of the team you describe, not replace them. They wouldn’t be taking out gallbladders, because they aren’t trained to do so.

    Every midleveler I’ve ever seen I knew was a midlevel.

    (I was responding to a comment made to the article in the link.  Clearly the author of that comment thinks that there is no difference between the physicians and midlevels.  -PB) 

  2. Madness and clear disrespect to the person she once was by keeping her that way. If I end up in that position I pray someone has the compassion to kill me. How is it that the family feels it’s better for her to be in this state vs. letting her die and honoring her memory? When she finally does check out all they’re going to remember is the gruesome bed sore, the near-constant fecal smell during their infrequent visits, and the pity they felt every time they saw her. Their memories certainly won’t be of an active, kindly grandmother baking pies and leaving lipstick kisses all over her grandchildren.

  3. Up and down, repeat, huh?

    Wow, sounds like its many more years of the same. I’m just a first year and I’ve felt that the year has just been a roller coaster of up and down. But I guess it just doesn’t stop. Been stopping by your blog every once in a while for a long time, but first comment. Thanks for writing.

  4. Which specialty requires 10 years of training after medical school?

    (Neurointerventional Radiology, for a neurosurgeon, is seven years of neurosurgery plus two or three in neurointerventional radiology.  Electrophysiologists hace three years of internal medicine, three years of cardiology, and two years of EPS. -PB)

  5. Dude, thanks for the props, but we’re not disagreeing here.

    The reason all these demented grannies get ridiculous “care” is that once they hit your ER, you’re not given the authority to say, “No. Enough is enough; stop already.” Obviously the surgeon you’re consulting doesn’t feel it’s his responsibility either. That’s my job, and I’m good at it. What you’re seeing are people without strong relationships with a family physician who can make their families see when medicine crosses over into torture.

    I should think you’d agree with my proposal that admission to a nursing home should include a mandatory DNR order, which includes no transport” back to an acute care facility.

  6. Here’s a thought that I have on ED trips/critical care for the terminally demented fossils:

    I think it’s entirely possible that at some point in the future fMRI is going to allow us to determine a persons mental milieu even when they are incapable of conveying it verbally.

    That being the case, I think we might see a study where we image the glucose uptake of a few of our hopeless nursing home cases and see the PAIN centers in the brain firing on all circuits. I imagine this could include horrible physical pain as well as a vague sense of isolation and ongoing lonliness (“didn’t I have some kids? why don’t they visit me?”).

    All of our best-laid plans to preserve life at all costs may turn out to have been nothing more than a despicable racket of elder abuse perpetrated on the defenseless to assuage our own fear of death.


  7. Regarding the elderly patient and end-of-life care…we treat our pets better than we do our grandparents.

    We need the ability to euthanize family members when conditions X, Y and Z are met. But, I don’t see that happening in my lifetime.

    (Whoa, Whoa, Whoa!  I am completely against euthanasia both for religious reasons and because people are not dogs who we put down when they get too sick.  But withdrawing futile care or making the decision not to put a pacemaker in a demented, stroked-out, bed-bound eighty-five-year-old is not the same as killing them.  People for whom treatment is futile should be allowed to die with a little bit of dignity and some finality instead of our usual practice of stretching out death for months at a time. The fact that families cannot let go sometimes is understandable but after a decent interval, say a day or two, they should be presented with the bill and made to contribute to the insanity that they request. People stetch out the agony because someone else is paying. -PB)

  8. hak:

    Futile care isn’t limited to human medicine. The things some people put their cats and dogs through at the end of their lives is one of the many reasons I’m NOT going into small animal practice.

  9. “a reader commented that patients neither care what initials are after our names nor about the “expansiveness” of our training but only that they are treated with compassion and understanding.”

    I’d like to hear their thoughts on this when they’re faced with having a difficult brain tumor removed.

  10. Unfortunately, I’d argue that long periods of medical training sometimes do strip physicians of their basic humanity. The vast majority regain it again when training is over, but I’ve found that long, sleepless nights coupled with little food and the constant fear of disaster do not lend themselves to compassion and empathy. I’m always amazed when some of the house staff are able to achieve it anyway.

    When I first finished residency, it took me several months to stop hitting the ceiling every time my pager went off. My friend who is a psychologist said the same thing about her internship, with the added bonus that now her dog starts to howl at the beeper.

    Caveat: I finished training almost a decade ago, before the work hour rules changed. I’d imagine that some of the stressors have now improved, but others have been exacerbated.

    That being said, I’d still rather have a snappish, well-trained resident than a mid-level. 🙂

  11. Training is all well and good, but many medical professionals might still be far below average regarding patient outcomes. What do you think of medical professionals tracking outcomes and making the info public? Good in theory but not practical? I think it depends on diagnosis, but I wish it were emphasized at least as much as some number of years training.


  12. Panda, I love your stuff (including your politics, keep it up!)

    I’d like to comment on futile care from the perspective of a family member. My (adopted) father died 4 weeks ago. He suffered from Parkinson’s Disease for 15 years before dysphagia became a serious issue. On Easter he was rushed to the hospital, had his lungs suctioned out, had part of his right lung removed, and had a temporary PEG tube placed all under the assumption that his dysphagia was treatable. After all of this, the doctors who had been twisting our arms to put him through procedure after procedure told us the truth. He probably wouldn’t ever come home again and would be transferred to a skilled nursing facility. He might not get off the ventilator (after being reintubated due to a breathing scare) and no, we couldn’t extubate. My poor Pops was writing on his dry erase board furiously “Take the damn thing out. I don’t want to live like this.” to no avail. My mom and I were in the process of inquiring about legally removing the tube when he got free of his restraints and yanked the tube out himself. He refused a PAP mask and died two hours later after designating himself a “No Code.”

    I’m on your side, I always have been. This experience has made me realize that a large part of the problem is the hospitals themselves. They are so lawsuit-shy (not their fault) that they push every possible procedure so we can all rest easy knowing “we did everything we could.” How about “we knew when to stop?” The physicians that treated my Pops went too far. They screamed “We don’t want to be charged with manslaughter” when my mom inquired about removing the ventilator. They balked and made empty promises to dissuade us from seeking palliative care instead of another “life-saving” (i.e. life-*prolonging*) surgery. It was horrifying. I couldn’t imagine, as a family member, putting a loved one through that purposefully. It’s an awful way to live and an awful way to die.

    P.S. The link to the decubitus ulcer was terrible! I should have known better than to click. 😉

  13. i work with many mid-levels in a nursing home, and the mantra is “i’m like the knowledge of a doctor with the compassion of a nurse”!!!

    And they go on to make ridiculous medication & diagnostic errors.

    And you’re very right – patients RARELY learn that they aren’t physicians, as long as they have a white coat & introduce themselves by name only (“Hi Mr. Jones, I’m Kerry Wallace from medical, and I’m here to examine you”)

  14. I am a PA, have been for almost 30 years, and every single conscious patient I have seen has been told that……”I’m sue jones, a physician assistant here at the Here Today, Gone Tomorrow, soon to Merge with Major Hospital System X Clinic/Emergency Room/Hospital”. Now, 30 years ago they either ignored that or said “what’s a physician assistant?”, Now they usually say, “that’s nice, my sister, brother, daughter, mother, father is a PA, where did you go to PA school?” So I know they know, and I don’t let people refer to me as doctor “You can call me Sue, I’m a physician assistant”. And it’s been literally years since someone has said that they didn’t want to see me because I wasn’t a doctor. And I know that most PAs do the same thing.

  15. Training is all well and good, but many medical professionals might still be far below average regarding patient outcomes.

    This is an absolutely idiotic thing to say, an example of the gross innumeracy that holds much of the civilized world in its grip.

    I can tell you for an absolute fact that many medical professionals are far below average regarding patient outcomes. Look up the meaning of “average” someday. Then look up “normal distribution”.

    Oy vey!

  16. Thrown to the wild I recently finshed my precepting as a paramedic after three months. Prior to that two plus years of education, clinical, field, etc and my first call? 80’s male face down on the bed and appeared to have had a massive stroke…first patient begging me for a tube two hours into my first shift.

    Morale of the story take advantage of the time you have cause one day you’ll look around the scene/room and see your the most experenced one there.

  17. Panda, two relevant stories for you –

    My father is in a nursing home 2 hours away from me, and he’s doing relatively well. Every month, I get his Medicare statements and see that his family doctor of 15+ years has billed for a routine visit to the home, usually every 4-6 weeks.

    Unbeknownst to me, it’s been the doctor’s physician assistant who has been seeing my father. When I get the Medicare statements, it’s always ‘Dr. S.’ who’s listed as the provider. A bit of a bait and switch, don’t you think? Or do you, because it’s a nursing home visit, think that the busy doctor shouldn’t have to be bothered, even though his office is a 5 minutes drive from the home?

    Another story – I had an initial visit at a university clinic with a neurologist, who prescribed a treatment and then he said I should have a follow-up in a month. The receptionist set up the appointment for me before I left. Two days before the appointment, the office calls to confirm my visit with someone I’d never heard of. Turns out, it was the doctor’s PA. Only then did I learn that I would never see the doctor again, that I would solely be under the care of the PA from that point on.

    Naturally, the clinic’s website makes no mention of this. The doctor certainly made no mention of this, nor did the receptionist. Of course, my insurer would be billed for a doctor visit, supposedly with a board-certified university-based specialist, not with a person with a 2 year post-college degree.

    A real bait and switch. I decided to cancel my visit with the PA. On my own, I found a board-certified, fellowship-trained neurologist out in the suburbs, who was able to help me, help me more than any PA could have. In my case, it wasn’t compassion or attention I was looking for, it was expertise and experience.

    What do you think of scenarios like the above?

  18. I sympathize with your high/low experience. OB was definitely the same way and I am proud to say that I was having more ‘highs’ than ‘lows’ midway through second year. I’m sure the upcoming second intern year I’m about to have will contain plenty of ‘lows.’

  19. Chris C and others interested,

    How far below average should a medical professional be allowed to go?

    How would you know that someone had reached that threshold if you didn’t track outcomes?

    John McCain has proposed tracking outcomes in health care and creating incentives for delivering better care, so it is not quite as irrelevant a question as you make it out to be. Would he be better off just rewarding medical intituitions for having the properly degreed personnel? Maybe it would, but I’d like to see the outcome data to prove it.


  20. Mr Chase- as Chris said above, given a normal distribution, half of your outcomes will be worse than average. No more, no less. You could look it up.
    It’s perfectly legal for an MD or DO to have a PA or NP see her patients, and then bill for it. Medicare pays ~80% for the “extender’s” services for someone who costs ~50% of a primary care MD. Good deal, if you’re not too sick. Unlike Dr. Panda with respect to peds life support, “extenders” don’t know what they don’t know, unless they don’t know anything. When they know a little bit about an area of medical practice, they think that that is all anyone would need to know. Patients have no way to evaluate medical competence- they can and do evaluate friendliness, and use it as a surrogate for competence, because that’s all they know.
    Panda, the ups and downs never stop. I’m into my 3rd decade of general surgery practice, and it’s always been true that “you’re as good as your last case.” If the patient does well, I’m borderline euphoric. If there is a complication, even if it’s not preventable, I feel like it’s at least partially my fault. Time does take the sharp edges off the highs and lows to a degree, but they never go away.

  21. What’s with the disrespect for mid-levels? After a lot of soul-searching, I have just reluctantly decided to drop my dream of applying for med school and aim for PA school instead. Not because I don’t have the great grades or scholastic profile or whatever to make it in… but because I’m middle-aged and making (for my own reasons) a career jump into health care.

    If I follow the path through med school and residency, I’ll be pushing 60 when I finally finish residency, and likely would have trouble practicing enough years to pay off the loans for med school. PA school, on the other hand, offers me a decent chance to pursue a career after two years of post-graduate study, which I am assuming are not a walk in the park.

    If I was 20 years younger, I’d be shooting for med school, but at my current age, PA school is the only thing that’s realistic for me now. It doesn’t mean I’m less intelligent, less dedicated, less ambitious, or less competent than some of the schmucks that will be accepted to med school. Although I might end up working for one.

    Why all this “Ewww, PA’s are ICKY!” attitude from so many of you? It’s depressing. Don’t you all believe it’s a respectable career path?

    (There is no disrespect.  For my part, I am just pointing out the obvious, namely that two years is less than eight.   Also, that the subjective admission standards for medical school are higher than they are for PA school. -PB)

  22. Panda:
    I’m a pediatric intensivist with 30 years experience and my heart rate still kicks up a notch with a tough intubation. And I still miss a central line now and then. So just keep at it and you’ll be OK. Because on the mid-level question, there is nothing that needs a trained physician more than a pediatric resuscitation. Believe me, I know.

  23. Mr. Chase: Why get the federal government more involved than it already is? That’s not a solution; it’s a big part of the existing problem.

    Outcomes are not a good way to judge physician or institutional effectiveness. The best of them get the hardest cases for which chances of a positive outcome are worse than most. Your system would penalize the best as if they were the worst.

    “Far below average” is purely relative. Anyone performing lower than 2 or 3 standard deviations below average, representing 2.1% and 0.1% of the total respectively (assuming an impartial measure can be devised in the first place, which I doubt) fits that description, and there are always going to be doctors there regardless of how good they are. Really, apart from a few truly incompetent outliers, the worst doctors aren’t all that much worse than the best. The training regimen which they are certified as having completed virtually assures it.

  24. My posts must really be poorly written because they provoke responses that seem to make the assumption that I am idiot.

    I know what an average is and the difference between 1 and 2 standard deviations from the mean.

    I am in the mental health field. I track outcomes. I use statistics. nuff said.

    All branches of medicine are different, and mental health isn’t even necessarily properly placed under the auspices of medicine. But I have wondered how medical professionals think about this stuff. Thus this post. I think if I swing one more time and miss, I’ll need to have a seat and leave y’all alone.

    I am not knocking training in the least. I am just wondering if we can trust training and the market system by themselves to determine quality as patients, professionals, and as a society.

    I imagine that there are PA’s that may get better outcomes on average than many MD’s with certain diagnoses, but the MD might be better at spotting those more rare diagnoses. WHo is more valuable? The consequences for missing a rare diagnosis may be dire, while the consequences of missing more benign diagnoses more often may just be annoying to the patient.

    So there are various factors to consider when determining the value of degrees.

  25. Ok, so ignoring some of the ridiculousness going on here right now, I’ll interject some ridiculousness of a different sort. Being a rather conservative individual Panda, but suspecting that does not necessarily mean what many think the word “conservative” means these days, here’s a nice article guaranteed to annoy a lot of people (including me and my ovaries):

    Female doctors working only 47 hours a week vs. male doctors 53

  26. PS that should have been “being you are a rather conservative individual Panda…”

    I should really learn to proofread.

  27. “The best of them get the hardest cases for which chances of a positive outcome are worse than most”

    I think well-designed outcome measures with ‘handicaps’ could take that into account.

    ” the worst doctors aren’t all that much worse than the best.”

    This may be true, but I’d like to see the data. i imagine that you have seen studies with outcome data demonstrating this already, or are you making the assertion anecdotally?

    It may be that generally there isn’t much of a difference between the best and the worst and it could be waste of time to pay attention to all outcomes all the time. But with some diagnoses there may be an alarming disparity between the best and the worst and the government may need to look at it as a public health concern . All those curves are not nice and tight little uniform bells. Transparency about some certain selected outcomes would be a beginning, just to see if there is something to be concerned about.

    “The training regimen which they are certified as having completed virtually assures it. ”

    Even if this is true at the moment certification is received, it assumes that MD’s are equally able to maintain the skills they demonstrated while in training.

  28. I’ll take the liberty of speaking anecdotally about a difference in ability between physicians: effective communication skills. I have observed that some MD’s are much better than others at acquiring information from patients and motivating patients to be compliant with treatment. Also, some MD’s are able to sustain their own motivation better with difficult patients and their persistence often pays off.

    Patients dumb this down by saying things like,

    “My doc cares/doesn’t care about me.”

    MD’s called this ‘bedside manner’. It had gotten short shrift in residency programs and only recently has gotten any formal attention. I bet it has fancier names now.

  29. You’re absolutely right about midlevels if you actually expect us to be running resuscitations or doing surgeries (I’m not as clear about PAs training, so this refers just to nurse practitioners). My scope of practice clearly does not include resuscitations, surgeries, codes, and other life threatening illnesses. We are trained to know our boundaries, when to consult and when to refer. Our scope of practice is limited because our training is limited.
    Where I work, we introduce ourselves as nurse practitioners and patients are told when booking an appointment the credentials of the providers they will be seeing.

  30. My physiotherapist was smarter than my doctor in detecting inflammation in my back. My family doc just told me that I had sprained my back when the results turned out to be more malignant.

    There will unfortunately always be a rotten apple in the bag.

    And this whole business of diagnoses isn’t as black and white as it seems. I believe that having hospitals report outcomes will be detrimental in the long run. It’s impossible to give “handicaps”. It’s really easy to just throw abstract ideas around and saying that it will provide traction.

    What I want to see is actual evidence that this outcome reporting actually works. What type of markers do you expect? What kind of markers will be objective? Mortality rate? Hardly. Some hospitals serve sicker patients than other ones. Medicine is really hit and miss sometimes. You can do everything in the book and the patient will still die.

    Mental health itself brings a whole bag of issues with diagnoses. How do you differentiate certain psychological illnesses easily? The DSM IV TR isn’t the bible for proper diagnoses. The authors know about it too. Outcomes really don’t mean that much. I believe it’s really the process and that’s what all those medical licencing tests, etc are about. People who suck would have been failed out AGES ago. Those many years of residency are there for a reason and honestly PA’s cannot match that, unless of course you are comparing a PA with 30 years of experience with a newbie 1st year resident. Maybe even a 4th year resident.

    If only my family doc did more than 2 years of post residency training.. and if those two years were actually DONE in north america.. then maybe the results would have been different. I blame the medical licensing test… He probably wrote the dino age tests many many years ago… but I’m pretty sure he would have had to rewrite the tests after… oh wait… that’s only IF the “body” decides so… Now there’s a problem. Even though I don’t like the idea of having to write tests every few years… it may be necessary.

    For example, if a family doc is so used to seeing muscle spasm type back pains and forgets about the inflammatory types… a test that tests more about simulated patient encounter settings rather than MC questions might force him to think about a proper differential than just going on autopilot with the most common dx.

    This comment is turning into an essay, so I shall stop here. I’m too lazy to edit. I have to study.

  31. I began working several months ago as a disability examiner for claimants who apply for Social Security disability benefits (please don’t hate me on reflex for that). We have been taught that any medical evidence that can prove disability must be from an acceptable medical source, which except for a very few situations has to be from a physician, an M.D. I have ceased to be amazed at the medical records I receive from whom the claimant called “Dr. Jones,” with said doctor turning out to be a PA. Unless we can get a doctor to sign off on those records, which we usually can’t after the fact, those records can be used as ancillary documentation, but not as primary evidence to establish a disability.

    PAs, if you have social security disability claimants as patients, please have a doctor sign off on your patient contacts, lest you do them a disservice. We can’t use your dx’s and findings alone. And have someone type up your stuff, please, doctors and PAs (although by now I can guess that if I have records in which nothing is typed, only handwritten, it’s usually from a PA), if your handwriting is not noted for its legibility.

    When it comes to government work in this case, astoundingly enough, there are high expectations. A diagnosis of L5 to S1 radiculopathy has ultimately got to come from an M.D., not his stand-in.

  32. Hi, I am a new graduate PA, and I just wanted to give my perspective. I always introduce myself and state that I am the PA. My white coat says physician assistant, and I wear a name tag with the same. Patients in our practice always have the option of seeing the doctor if they wish to do so, and most of the time they are fine seeing me. I have a solid base of medical knowledge, but I do not claim to have the experience that my supervising physicians have. If I feel that something is out of the scope of my practice, I get my supervising involved. Also, I’ve heard the whole midlevels “care more” stuff, and as a midlevel, I don’t tout this. I think that there are just as many caring doctors. I have had a few patients thank me for spending so much time listening to them in a way that the doctor doesn’t always do, but I know this is because my schedule is a good bit lighter than theirs and I have the time to sit and listen. I don’t appreciate the “us against them” implications of your post. PAs are trained to work with physicians, not competing against them. I understand that you have probably run into a few midlevels with an attitude, but I do hope you realize that most have a good understanding of their strengths and limitations. Just like any profession, there will be a few that give the rest a bad reputation.

  33. I want to comment on the titles for MDs/NPs/PAs and what patients want and that whole discussion. First of all I would like to make it clear that as a family nurse practitioner in NY state, I have 6 years of education and I am board certified, not to mention all my experience as a registered professional nurse. I had very high academic standing and diverse professional experience including preventative medicine and functional medicine (treating underlying causes for illness rather than masking symptoms).

    I always introduce myself as a NP b/c quite frankly I want my patients to know who I am when they receive quality care. Many of my patients tell me they prefer NPs over MDs because we listen and have less of a tendency to be “pill pushers.” Research supports that satisfaction rates for NPs are higher than MDs and I do not contribute that to patient ignorance but rather a consumer focused health care market, where patients are learning to ask questions and shop for the best health care. I do not pretend to be superior to a physician. In all honesty our educations are different and our strengths are different. When I can find a physician to work with that does not think he/she is superior and has similar philosophies to mine, we make an awesome team.

    I personally believe that I have the best of both worlds, I have a nursing education so I am trained in therapeutic communication, a wholistic approach, utilization of non-pharmacologic interventions, functioning as a patient-advocate and a resource for the patient and family members. I practice medicine as a NP and before starting my graduate studies had experience in post-operative inpatient care, school health, GI Research, Pediatrics and Community Health to name a few. As a NP I have experience in college health, primary care for urban uninsured and primary care (for the insured) in the suburbs and now occupational health including athletic physicals and pre-employment/DOT/bus driver physicals and worker’s comp. Needless to say, I won’t be removing any gall bladders anytime soon, nor do I have a desire to.

    In primary care, I had more patients tell me they would rather see me than the doctor than I can count and many said the same of the PA I worked with as well. I educate my patients but I am not afraid to admit my limitations. I think NPs are quicker to refer when it is appropriate because we are very self-aware of when it would be prudent whereas MDs in general may feel they can “handle it themselves.” This is a generalization, but just a trend I have observed.

    I admit that NPs would have a better reputation if there was standardization of the scope across the country, so that there would be no question as to what a NP is “allowed to do.” When some states do not offer prescriptive privileges and others allow NPs to work independently without any supervision or collaboration it can create some confusion. Also, it is confusing for patients to understand the differences between PAs and NPs although they seem quite clear on their opinion of them. Many assume a PA has more autonomy b/c “physician” is in the title….they are quite surprised to learn a PA only has a 4 year degree and NPs have a Masters degree and legally can work more independently than PAs (at least in NY).

    I think MDs are threatened by NPs/PAs and instead of working as a team and utilizing all their colleagues’ strengths they try to discredit them. It is unfortunate because pride does not promote quality patient care and actually encourages patients to find another provider.

    I also do not refer to myself as a *mid-level* provider b/c this implies I am only ‘middle of the road.’ I actually am an *advanced practice nurse* aiming for excellence in my patient care and I am not substandard to a MD. I actually practice quite differently. MDs diagnose and treat diseases (for which they can name). My philosophy is to treat the patient and the underlying cause of the symptoms which can mean adjusting diet or lifestyle and when necessary prescribing medications. I look at the details as well as the big picture.

    The bottom line is NPs get results. This does not mean we are better than MDs or that we want to replace MDs. Education is very important and I respect anyone dedicated to their education to spend time getting a Masters or a Doctoral degree, but education is not just quantity, it is also quality or content. Not all universities are created equal and not health care professionals provide the best care possible. Some of the best test takers have little people skills or “bedside manner” (including nurses…I met a few that either had a poor work ethic or a nasty disposition).

    Seriously, we would do our patients a favor to work side-by-side without trying to “be smarter” than our colleagues. Together we have a lot to offer our patients but there needs to be a self-awareness of our own limitations and a mutual respect for our colleagues that excel at what they do.

    Thank you for hearing me out.

    (The difference between me and you is that I don’t need a page of new-age duckspeak to describe my job. “Holistic approach.” Good grief. I diagnose, treat, and manage medical complaints. The rest is gobbledygook, the quantity of which is inversely proportional to real medical knowledge. As for “treating underlying causes for illness rather than masking symptoms,” the implication that you somehow have the market cornered on this is preposterous. If anything, secondary to a deficiency of knowledge, mid-levels are far more likely to do this sort of thing. Heck, most of my training seems to be considering every possible bad outcome and ruling them in or out.

    For the record, most patients would prefer to be treated by a doctor. Nobody ever says, “I don’t want to see the doctor, send in the Nurse Practitioner.” It just ain’t like that. -PB)

  34. First off I’d like to say I love reading your blog and hope you keep up the good work.

    I don’t start medical school until August but I’ve been a nurse for 3.5 years. I’ve worked in a nursing home/SNF the whole time and have met many MD, DO, and PA’s (surprisingly only 1 DO). MD’s do seem threatened by “mid-levels.” In my experience patients just assume anything with a stethoscope and a white coat is a doctor. Hell, I have lots of patients call me a doctor b/c I’m a man with a stethoscope even though I’m wearing scrubs and have an ID that clearly says nurse on it. Anyway the point is docs shouldn’t be so threatened by other professions b/c we’re all part of the same team and have one common goal: taking care of patients.

    Oh and to comment about the old patient with the ulcer and trach and feeding tube, being around nursing homes has given me so much end of life experience and the majority of the time the families are so unrealistic it’s almost disgusting. I understand that they love their families and all but I personally couldn’t let someone I cared about lie in a bed all day with a feeding tube pretty much like a shell. I had a similar situation when my grandma had a massive stroke. My whole family wanted to put in a feeding tube immediately but I said no, let’s do the hospice thing and get it over with b/c my grandmother told me that she never wanted to be an “invalid” or a “burden” as she used to put it. It wasn’t the easiest thing in the world but I’m glad I had the guts to do what needed to be done.

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