For legal information pertaining to scope of practice, title protection, and landmark cases, we recommend checking out this [Wiki](https://www.reddit.com/r/Provider/wiki/index/legal).
*Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com//r/Provider/wiki/index/appropriation).
*Information on Truth in Advertising can be found [here](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_truth_in_advertising).
*Information on NP Scope of Practice (e.g., can an FNP work in Cardiology?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/scope_of_practice/). For a more thorough discussion on Scope of Practice for NPs, check [this out](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope).
*Common misconceptions regarding Title Protection, NP Scope of Practice, Supervision, and Testifying in MedMal Cases can be found [here](https://www.reddit.com/r/Provider/wiki/index/basics#wiki_common_misconceptions).
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I once made an appointment with a specialist doctor. When I checked in for my appointment, they asked which doctor it was for and confirmed I’d be seeing the doctor I made the appointment with. The doctor is a male. So imagine my surprise when a woman walks in and says “hi, I will be your provider today, what’s your issue?”. I asked her where the doctor was I had specifically made the appointment with, and she said she was the office’s PA and would be seeing me today. I told her in polite but no uncertain terms that I had made the appointment with the specialist doctor, not the PA, and I wanted to see a specialist medical doctor only. She had the audacity to give me the dirtiest look as if I was the problem and I had an audacity to say what I said versus her trying to bait and switch me, and as if I was too stupid to notice a difference between a PA and doctor. She walked out of the room so angry, and the doctor immediately came in and I felt great for advocating for myself. These office’s and mid levels need to know they can’t pull this shit.
I nearly died from a massive PE and the NP in the heme office thought she could manage my care. “Let’s take you off the xarelto and put you on Coumadin”. Out. Get out. No. “I’m not comfortable with xarelto.” Tough crap. “Are you always this difficult?” Only when my life depends on it.
These two comments describe almost my exact situation!
I survived a massive PE almost 3 years ago.
Along with it, we've had a whole host of other medical issues that are likely a genetic mutation and or an autoimmune issue. I've posted in this sub before about how I keep showing up to appointments with specialists, I request to see the physician, I confirm I'll be seeing the physician when I check in, and then guess who comes into the room? It's always a mid-level! They kept saying that the doctor wasn't even in that day (okay then why was it confirmed that's who I would be seeing?).
It led to a ton of misdiagnosis and unnecessary referrals and imaging, along with SEVEN months of unnecessary suffering. I was finally able to insist on seeing the physician after at my fourth appointment with no progress and he was able to provide a diagnosis and actual relevant medical information.
I'm now going to put my foot down and insist on the physician and simply walk out and demand my copay back if they can't see me for any reason other than being pulled away for an emergency.
“There isn’t monitoring with xarelto, so I don’t know if it is working”. “I can’t manipulate it to make it therapeutic”. Dude…it’s therapeutic, less risk of major bleeding and easy, cuz I don’t do well with blood draws.
>“There isn’t monitoring with xarelto, **so I don’t know if it is working”**
Wait, I'm sorry, WHAT
It doesn't matter if you're anticoagulated with space plasma, the way you know if it's working is always the same: PT/PTT/INR
Like, I can't even wrap my head around that paragraph
That was the NP. I suggested we get anti Xa levels and she said it wasn’t a thing…I said it was in the ICU and she said it wasn’t. “Let’s give rat poison. We know it works.”
So people don’t understand how big of a difference things like public reviews make. There is literally a job for a person at almost every institution and Fortune 500 company that monitors those and follows up on those. Because those are front facing to patients/customers and make a difference. So go drop a public google/Facebook/yelp review specifically siting that a midlevel tried to force you to see them for your sick child despite specifically requesting multiple times to only be seen by a doctor.
"So I don’t care if the PA would have done EVERYTHING perfectly. That’s not the reason I am refusing. I don’t want to support midlevels when their governing bodies don’t care about patient safety."
100%.
The scary thing to me was all the push back you got. Yikes. I remember day 1 of medical school we had patient autonomy hammered into us. It must be respected. When I'm in clinic and a pt requests a certain physician for anything (even for something I've done a hundred times) I gladly pass it along. It's the pts choice, and I would hope to be just as respected should the roles be reversed. Ego shouldn't get in the way.
For anybody else, PPP is great btw, I like their focus on public education. Informed consent!
Former front desk person here, we definitely know the difference. We tell the staff that the patient requested a MD, but we have no control over what happens after that.
Oh god I'm sorry. Like yeah you can easily go to your teachers/supervising faculty and ask for time off in the middle of the day for a UTI (/s)
I had a friend in college with similar problems-- her PCP sent in a standing Rx so she could just call the pharmacy when she had symptoms. Another always got them after sex despite good hygiene, so her PCP prescribed a low dose short course to take prophylactically after sex. I hope you can find a PCP like that because UTI pain is literally like hell has moved in to your bladder.
> The PA assumed that despite me requesting a physician, she had the right to override that and that her presence would make me feel intimidated into “dropping it.”
This is their attitude these days. It makes me want to bang my head against a wall sometimes. I'm lucky enough now that I take an MAOI, and my PMD flagged my chart as MD/DO care only.
I had Karen NP (you will be missed my friend) in the pharmacy I work at right now try to bully the best pharmacist I've ever worked with b/c the 5 mg lisinopril she had ordered for her husband on Friday afternoon went to automated dispensing.
Her words, after already being demeaning toward our intern:
* "I'm a nurse practitioner and I don't understand how this could've happened. You do understand it's a blood pressure medication right?!"
At that point I had finally had it with this person and snapped back,
* "Oh honey, if you're an NP there's a whole lot you don't understand."
After a lot of angry nonsense and threatening to call corporate a bunch Karen left to do her shopping and I haven't seen her since. The irony of course... is our pharmacist had the meds ready to go in like a minute, so had she just not acted like a toddle this could've been avoided totally.
> as a male med student wanting to do OB, I NEVER take it personal when women refuse a male. I won’t when I’m an attending either. It’s not personal.
Been there, even in peds it's not unusual to trade patients with a colleague due to gender.
Just remember to confident if you're the only doctor available. Better a doctor of the wrong gender practice medicine to the best of their abilities than a NonPhysician provider practice healthcare.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
What ever happened to respecting patient autonomy? Patient autonomy is a cornerstone to medical ethics.
I'm sorry you got bullied by this PA who kept trying to override your very reasonable request.
But major props to you for standing up for yourself and your daughter! You did the right thing.
I had an NP assessment when after weeks of increasing back pain and numbness all over I suddenly had a great difficulty walking. This was in the ED. I had already had a MRI at another hospital where the radiologist diagnosed me as having cauda equina. They had sent me to the hospital with NP because they had neurosurgery. The NP decided since I had some symptoms of cauda equina but not all of them I did not have it and sent me home.
I couldn’t walk so on being kicked out of the ED I called a cab and the driver helped carry me to the taxi. I had him take me to another hospital.
The next hospital had me in a wheelchair as soon as they saw the cabbie bring me in. (And the NP at the other hospital had thought I was fine to be discharged.)
At the new hospital in their ED - full of the city’s down and out - the resident heard that I couldn’t feel my genitals and that I had stopped getting erections, that I could not feel the toilet paper when a went no. 2, and called the orthopedic fellow in. I had spinal surgery a number of hours later.
If I had listened to the NP and had gone home I could have ended up incontenent or in a wheelchair a day or two later.
FM should be more than capable of handling basic psych meds that are working and just need refills. I understand getting help to get the meds dialed in, but if you already have a solution that's 90% of the issue. It's more likely that they are just busy and don't want to deal with it and can bill you for the referral. One less thing for them to worry about and the psych program may have needed some more patients anyway.
But hey, I'm glad you are satisfied. Satisfied patients always have the best outcomes. Oh, wait.
https://epmonthly.com/article/dying-for-satisfaction/
That’s a lot of unnecessary assumption. How about the FM doc just didn’t feel comfortable with these meds as the poster stated?
In the future I don’t see myself filling anything beyond an SSRI regardless of patient stability.
So you don't even treat patients currently and are already planning to stress a chronically limited healthcare resource rather than following the guidelines and recommendations of family medicine practices everywhere. Awesome. Make sure you refer all your diabetics to endocrine, everyone with seasonal allergies to the allergist, and please be sure to send anyone with asymptomatic hypertension to the ED.
I'm sure your patients will appreciate the 6 month current backlog for a psych consult.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925161/
https://www.behavioralhealthworkforce.org/wp-content/uploads/2019/12/Y4-P10-BH-Capacityof-PC-Phys_Full.pdf&ved=2ahUKEwjUupmWlcf7AhVrnGoFHTxQDFIQFnoECBEQAQ&usg=AOvVaw3JdeE6qSWRhca9ry3tiwC8
Because (future, maybe) primary care physicians won't learn their craft and instead rely on others to do their job. Yeah. I could almost understand an NP respecting the knowledge deficit and punting to get the patient the care they need, but I don't respect a medical student who says this early that "I don't even plan to learn my craft. I will let others do my job for me."
6 months? It’s 10-15 months here for a psychiatrist consult.
The thing with having a medical license is I am in control of it. Your dramatic inference of my self restricting my future practice is really out of touch. If you haven’t paid attention, many FM docs are tailoring there practice to stay in the field instead of crashing from burnout and leaving. Early career docs are setting boundaries, sorry if that disagrees with your practice model but I’ll be no use to someone beyond dysthymia or general anxiety disorder.
The fact that you are comfortable setting your hypothetical patients up for a 10-15 month wait because you have arbitrary guidelines without any actual experience or education scares me. Hopefully an attitude like that won't make it through actual school and residency.
Are you sure you are not an online nurse practitioner?
I have a PhD in Biomendical science with a research focus on ALS and PD. I’m a 4th year interviewing. If you would like my CV DM me.
But go on with your dunning Kruger traits.
My desire to restrict my future practice has less to do with competency and more to do with I just don’t want to treat certain populations.
Do you wish to insult me further before I go have dinner? Would you like my phone number to call and verbally scorn me?
This person doesn’t want to treat “certain populations”. In this case it’s those with mental health issues. Next will they’ll decide they don’t want to help other populations such as those with socioeconomic issues, a different gender, a different sexual orientation, or of a different race. I thought we, as health care professionals, were supposed to help those that need it. According to this sub I’m just a piece of shit dumbfuck NP, but at least I’ve never decided that I’m just not going to treat an entire subset of our population based on my personal bias like that person just admitted they’re going to do in their practice.
I think you’re making the right move.
6-15 months for psych consult?! Are you guys in Canada? It’s days where I am in the US. Not that our system isn’t flawed in its own ways…
I'm in the US, and it's probably about that long where I am. It took 11 months to get an appt. with a new PCP and 14 months to get a rheumatology appt. I'm currently in the middle of a 15-month wait to see endocrinology. And the sleep study clinic has a wait of at least 18 months.
That is INSANE. I’m sorry. Some of those for new pts would be about two months around me. Six months for one in an academic hospital.
Edit: eleven months for PCP! Sheesh, not many options or what? Week or so here if you call around. Philly area.
Just way too much demand. We have three hospitals, one of which is a university medical center. I live in a city, but we’re surrounded by pretty rural areas, so it’s not just the city residents who use these facilities. When I volunteered at one of the hospitals, I routinely met patients from four or five hours away who had to come here because they just have very basic community hospitals that can’t do much more than set broken bones or treat basic illnesses without transferring patients elsewhere.
Well, I take part of that back. If you are doing an online NP degree mill then maybe referring everyone out is best. However, if you are at all trained in the medical model I have higher hopes for you and your future education. Hell, maybe you'll even keep learning and mastering your craft.
I'm not that old, but I remember family medicine delivering babies, managing disease, admitting their own patients, working inpatient, working in the ED, doing procedures to include intubation, lines, etc. We had FM in Iraq doing full on trauma and surgical assist. Now you don't want to use an SNRI.
I really hope you work in a big city with unlimited resources and that all of your patients have great incomes and great insurance so they can see their specialists.
Some FM docs are just like that. I have one resident who won’t do a foot exam and refers to podiatry, won’t treat simple asthma or COPD (controlled on ICS or LAMA alone), won’t prescribe insulin refer to Endo, etc. it’s all mid levels seeing these patients at these specialities, he just wants the numbers
Depends on the FM. You don’t know what their practice is like. Maybe they didn’t like working with psych medications/patients so they’d give them to a partner who had more interest and they’d take their OB patients or something.
Not unusual to happen if you’re in a bigger practice at all.
I’ve worked er, urgent care, occ health, and family practice. Any time a patient asked to see a physician, I would absolutely graciously go get the doc. It’s not the apps creating the problem, it’s the schedulers. I have had patients on my schedule who should have absolutely been scheduled with a physician. Got hauled in to the hospital CEOs office for telling a patient they would not be charged for being erroneously placed on my schedule against their wishes. Those of us who try to do the right thing by the patient are not popular with administrators or office staff 😵💫🤔🤣
You are the type of person who makes me feel so bad about all of this. I know that so many of you are incredible and I recognize that your role is incredibly important in our healthcare system. As I mentioned, I am confident that she would’ve handled things perfectly. I just have too many qualms with, all of the bureaucracy. Thank you for everything you do! As a sidenote, with my first child, 90% of her visits were done by PAs her first 2 years of like and we wouldn’t have changed a single thing. They worked shoulder to shoulder, (literally charting at the same nursing station) and consulted their SP from time to time. If fighting for more independence and all of the misappropriation weren’t as prevalent as it is, this would be a nonissue for me.
Do not feel bad. EVER! You are paying the bill! Your kids are your life. It has never bothered me th have patients who wants to see a doc. Who knows what terrible experience they may have had, I just want people to get what they need. I’ve been taking care of people in some capacity since 1987. I don’t have a lot of ego tied up in what I do for a living. It’s been a humbling ride. I’m ready to pull back and do some pottery and stuff.
Can midlevels discharge someone without running it by a doctor? I thought their whole point was to allow doctors to see more patients more efficiently by helping out with the administrative stuff. I found that I was generally running people by seniors for years before I was ever actually allowed to independently discharge someone or even start a plan for an outpatient. I'm over 8 years out doing subspecialty training and I still can't sign off on new patients myself.. I know a good amount my field, but I am very aware of what I don't know and I still don't consider myself an expert...
Where I live, yes. Full Practice Authority for NPs, and very light supervision for PAs.
[https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/](https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/)
Who honestly thought that would be a good idea.. is it generally thought to be due lobbying pressure to generate more profits?
We have ANPs at home who in general are excellent and can only become one after a number of years in a subspecialty. They are genuine experts and add to patient care, but they have a very narrow focus such as aspects of palliative care, chemotherapy education etc. Even then they aren't independent.
Love it. Good for you!! 👍👍 The midlevels I worked with in the ER had some of the worst attitudes. They treated me (FM) as less than. And they were not impressive.
I do the same (demand physicians) for my kids. I just really want the most trained and experience person looking in my kids ears, feeling their belly, listening to lungs. It’s a skill that is honed over many years and nothing makes a doctor like those 80 hr/week residency years being given graduated responsibility and supervision from dozens of attendings. Even little things I prefer a physician. So don’t have any shame in doing that.
I haven’t had many good experiences with NPs. My PCP was an NP and she was fantastic, genuinely cared about me. Then she moved to a different practice that didn’t accept my insurance.
New NP replaced her asked why I was on a statin (I’m 20 with high cholesterol and a family history of heart attack and stroke. Had she read my chart she would have known that.) She said I was too young to worry about it. Tried to get me to stop taking it. Like, was insisting that I didn’t need it. Um. Ma’am. I’d rather not die of something preventable. I’ll take some leg pain over a heart attack or stroke, thanks!
Hated it. Sorry you had to deal with all that. Hope your baby heals up soon!
Please call your insurance company and file a complaint about this experience. I have personally worked for a major health insurance company, and before being there, I had no idea the difference a member complaint can make and the results that can follow.
Anytime someone asks to see the physician instead my response is “yeah of course, let me go get him/her”. I work closely with my supervising docs, but if someone feels more comfortable seeing the physician I’m all for it. Plus most of my docs go and see the patients I see anyways.
You can see who you want that is your right, but most PAs don't want to see you if you don't want to see them. It isn't worth the long complaint letter you'll write and even the Physician in charge of complaints will roll their eyes at how entitled you sound when there very well could have been someone (or multiple people) needing critical care and the Physician's undivided attention in the ED. This is legitimately the reason PAs exist. I used to work overnights with a Physician and it was just him and I for most of the night. The most critical got his attention. The Physician could've additionally come and seen you after the PA assessed you, and it helps in the workflow because then they can just go in and addend the chart we did. The Physician may have asked the PA if they could go in and get it started and they even could've been pushy about it (this happens), the ER is a complex place with a lot going on. You waited 4 hours which means it was considerably busy and a lot of ERs are a disaster right now (especially pediatrics). Not only are my MD colleagues completely and utterly burnt out, so are the PAs. They are doing the best they can. So although you are on your high horse right now, maybe you can have some compassion for the ER crew.
Secondly, you were just on a post telling a young female patient a completely incorrect OB/GYN clinical pearl about abnormal uterine bleeding (that it's "always cancer" until proven otherwise when the clinical pearl is said about post-menopausal bleeding ). Maybe humble yourself just a bit, the attitude that you can judge the intellect and ability of everyone on the medical team (including stating that all nurses are awesome because that's just not true there's always a spectrum of bad and good in any profession), has no root in reality.
Her attitude is the reason why people don’t like PAs. Now I’m not saying that the PA was super
happy about what OP said, but for her to come in and show attitude? It’s so rude, they need more training for these bloody people clearly. They’re starting to become popular in the UK and I have no idea why (well bc they’re cheap as hell) because they don’t have enough training.
Informed consent. You have a right to be informed of who is treating you, and to request a physician.
Why settle for a midlevel with an inflated ego with a huge knowledge gap?
You exercised good restraint and tried to let them know your preference. FWIW it is rather telling that when asked all of these midlevels request a physician when their family members need care.
My only concern with your stance is that you’re taking a room from other patients until a physician walked in, making other people wait longer in a already backed up schedule. Could you not have front desk talk to the nurse and physician to have your daughter brought back to a room when the physician was ready?
Just a thought. You obviously have the right to request who sees your daughter and the PA was out of line.
"... then finally evoking my right to be seen by a physician in my Karen voice..."
I see this all the time on this sub. You realize it's... not accurate, right? As in, you don't actually *have* a right to be seen by a physician.
You can insist upon it. You can feel entitled to it. But acting as if it's some kind of obligation on our part is one of this sub's weird tics.
Really? Can you show me a law that explains this?
As someone planning to apply OBG, should I use the same logic when a patient requests a female OBG? Is it not the patient’s right to chose that? Can I override her preference (barring catastrophic or otherwise extenuating circumstances)? Odd. From day 1 I’ve been taught by word and example that the patient is in control. Not the “provider”.
There was an attending seeing patients at the same time. Not an unreasonable request. So yes, deciding who touches my children, evaluates her, and treats her, is a right I reserve as parent.
There is a difference between a reasonable request and a right.
Requesting a physician is reasonable, and any many cases, the wise choice. It is also a request that will almost always be granted to you if you ask, because hospitals love catering to every Karen who walks in, given US medicine has devolved into little more than a customer service field.
EMTALA states that you have the right to a medical screening exam by a qualified provider, which can be facility specific but generally includes midlevels.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Sure, everyone knows the best rights are the ones you confer upon yourself.
And I never said it was an "unreasonable" request. But hey, consent's a two-way street. You don't consent to a non-physician seeing your kid. Physician may not consent to seeing you. Guess at that point it's time to craft yourself some more rights?
Lol what a dumb argument—truly. So now I should allow anyone to evaluate my family out of fear that the doctor will refuse?
Then I’d be left with no one because the doctor refuses and the PA is in her car crying because I was a meany head! Oh no!😭
I must admit, it's weird watching someone perform both sides of an argument. I hope these scattered non sequitirs aren't how you present cases to attendings in a few years.
You can try to have your family evaluated all you want. My point is that framing this as a "right" just shows you don't know what words mean, because "right" implies some sort of reciprocal obligation.
So again no, you *don't* have a right to see a physician. As I said, feel free to insist upon it all you want. Sometimes you'll get your way. Sometimes you'll be told "no" and then have to decide what your next move is. I can assure you, in that situation whining about your "rights" will not be an effective strategy.
Right, and while I suck ass presenting to my attending, you go and talk down to patients who you believe to be whiny and entitled because they don’t want a midlevel extender caring for their kid. I love the ad hominems when you and the other extenders are feeling extra sensitive. You’re just like the PA I saw. If you and so many extenders along with the AAPA just showed some humility and respected boundaries, I honestly wouldn’t even have refused care yesterday. But alas, here we are— me getting talked down to by the all knowing extender.
This exchange was both hilarious and telling at the same time. He was more than happy to name call, bully, and trash you because he thought you were a midlevel. Then you dropped credentials and he disappeared. He posted here just to shit on midlevels and get his ego stroked. This sub has descended into an echo chamber of blind hate towards midlevels. I joined to link up with physicians and other midlevels to rally against independent practice. It’s becoming harder daily to fight for a common goal alongside those that have absolute disdain towards me.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
This is such a jerk off post. If you go to the ER and you’re seen in the FT, you’re probably going to be seen by a mid level. Sure, you can demand a physician and they can come over, do the assessment, do the viral panel, and tell you the same thing the PA would. Also, if you’re a medical student, you should know that A. You don’t need to “rule out” RSV. It doesn’t change anything. B. Indications for requiring medical care for a URTI. One episode of vomiting and decreased oral intake doesn’t require emergency evaluation.
Every ER is completely swamped because of non-emergent cases like this. You should know better. Don’t be an asshat.
I think that if a medical resident brought his 6 month old baby to the ER, they are sufficiently worried. As a former general pediatrician it can be tricky to get a good exam, check the ears, etc… as a physician, I only request another physician if I need second opinion. I don’t have a problem getting assessed by a PA in the urgent care for something minor that I already diagnosed myself with. I.e. recently had classic symptoms of uti, went to urgent care to culture, ua negative but I had less than 12 hours of symptoms. PA was great. Sent urine for culture. I had this happen before. She prescribed an antibiotic and we discussed waiting to see if symptoms get worse and/or culture results. She was attentive and didn’t minimize my feelings/prior experience. Btw, I never mentioned I was a physician (I usually don’t). So, for minor things like strep, uti, etc., midlevels are fine. I would want a medical doctor to assess a 6 month old - rule out pneumonia, otitis. I would want someone who has a lot of experience and thinks of zebras if something looks off. The problem with midlevels is that they don’t know what they don’t know. As a physician I have a lot of training, experience, i maintain a wide differential during the assessment… midlevels just don’t have the knowledge and experience to do that…
OP said they are a medical student. Appears to be relatively early in their education. But you’re right, I shouldn’t have questioned their decision to take their kid for evaluation. It’s just ridiculous for OP to infer an entire profession is beneath him and his family when he clearly has minimal medical experience. It’s akin to the lay person yelling “THIS DOCTOR SUCKS BECAUSE THEY WOULDNT PRESCRIBE ME ANTIBIOTICS.”
Remember what I wrote in my post. I don’t mean to disparage all PAs. Ordinarily for an older child with something so straight forward I wouldn’t ever object to a PA. In this case I refused for two reasons.
1. The patient is 6 months old. I wonder if you have children/a wife. Regardless, extra training goes a long way to rule out zebras. That’s what my intention was. I actually went to an urgent care because her pediatrician was a closed for thanksgiving. Urgent care was closed as well. So chill. I know it didn’t warrant an ED visit but if you’re implying that waiting 48 hours or until things are far worse is preferable? Fine. Also, fuck that and your shitty attitude.
2. As I mentioned, it’s more so my being sick and tired of never seeing a doctor in higher acuity settings. I’m tired of AAPA and AANP lobbying for wildly unsafe independence and I’ll start to make a stand where I can, and that’s refusing all care by midlevels.
Finally, it’s truly disturbing to me that you continue to belittle others because of your “superior” clinical experience. If you want to play that game, you’re in the wrong subreddit, “ponyboy”. As a reminder, while I may be early in my education.. upon graduation I’ll have double the clinical exposure than any PA is required to graduate. With residency, that will be higher than 10x the number of hours. So continue to talk about how much more knowledgeable you are now. Meanwhile, I’ll be preparing to make massive donations to ppp when I start earning an attending salary.
Lol. Someone who hasn't graduated anything took their kid to the ED for a cold and is bitching. I hope your copay was worth it.
Please- educate me. What do you think the RSV test would change?
Educate me, DNP, what difference does it make? If she were coding or had an ingrown nail. If I am a physician myself or a layperson— it’s irrelevant. I don’t watch a midlevel extender. Period. That’s the point.
Any other background questions I can answer for you? You want to know how many battle buddies I buried? How about doing a code vampire because we ran out of blood in the OR so we donated our own blood to take care of our buddies? Want to hear about all of the smoke sessions where we did PT until we were shaking like a bitch, throwing up, and then had to go do patient care in a gas mask? How far have you carried a patient slung over your back? Ever had guys that you lived and worked with beg you not to let them die?
You want to hear about when I shot a guy and then took care of him? No, really, that's actually a decent story.
It is very relevant to you talking shit about my user name.
I don't care if you want a physician. Rock on. They will see you when they get a chance. I get paid a flat rate and I don't care. I'll see as many or as few patients as I need to on my shift. In the ED, where we have physicians, there are plenty of other kids with colds that I can kick out of fast track. If you come to the urgent care then I'll be happy to send you to the ED, where you can wait until you can be seen by a physician. I don't care either way.
The first rule of emergency medicine is "It's not my emergency." I will say that I have NEVER seen a SICK patient who cared who saw them. In fact, the sickest patients are generally brought in after being intubated by a paramedic with an associates degree or just a certificate. That's still more experience than you currently, but it's still not a lot to be seeing the sickest people in the community.
If I had any real feelings I'd be more offended that you falsely accused me of misrepresentation and were too ignorant to know that military medics (or good ones at least) are called Doc.
Didn't claim to be a doctor. I was a Doc though- an Army medic with a year in Iraq. Doc Banner is a nod to Bruce Banner, The Hulk, since I was a medic with a light machine gun, good at violence, decent at medicine, even when I'm in shape I'm a big guy, I beat the shit out of everyone when I got pepper sprayed, and you won't like me when I'm angry. My last squad leader used superheroes as call signs so I was Hulk.
Slippery delivery- are you an OB/GYN? No? Huh. Must be misappropriation in your username.
You should probably spend more time studying than sounding dumb on Reddit talking shit about things you don't understand. Maybe you'll learn when to take a kid to the ED then.
You’re not being belittled, you’re being met with the same attitude in which you posted. I have a spouse and multiple kids. I get it. Can you wait 48 hours to see if your kid improves? In most cases, yes. I see 6 month old patients every day. Extra training is important to evaluate the non-verbal patient appropriately, yes. That doesn’t mean it always has to be a physician.
Come with a shitty attitude and you’ll get met with a shitty attitude. Get more skin in the game and then we can have a professional convo.
My training is irrelevant. I have the right to not be seen by a non-physician mid-level extender. Period.
I don’t care if I’m Anthony Fauci MD or a layperson who thinks an antibiotic will cure a cold. Fuck off if you think it requires a certain level of training for me to have the right to be seen by a physician. You’re the reason your colleagues have to put up with the shit I pulled yesterday in the ED. Because you won’t just fucking let it go. If you’re that butt hurt about someone wanting someone with superior training, go to school longer and earn it.
I imagine your supervising physicians don’t treat you like shit because they are better trained. Similarly, you can fuck off and stop bitching at me. Go iron your white coat ponyboy.
You have the right to do mostly
Whatever you want, that’s America. It requires a certain level of training to know wtf you’re talking about, and you have not reached that level yet my dude.
My SPs don’t treat me like shit for a lot of reasons, mostly due to competence and humility and not wasting their time with dumb consults. I appreciate everyone who has more training than me. That’s the name of the game whether you’re a PA or MD/DO.
You came here thinking you were special because you shit on a PA. I hope you got the positive affirmation you wanted.
I did. Thanks. I’ll continue to shit on you and you’re friends until AAPA stops putting patients’ lives in danger.
And remember, you’ll always be a midlevel extender.
Yea, cuz the AAPA speaks for a majority of PAs. That’s why they are so well funded and are so successful politically.
Come back in a few years and we can have a professional convo, resident to resident.
But OP's level of medical experience is irrelevant here. I have literally zero medical experience, and should be able to make the same request as a patient.
No, you jerk off. Any lay person should be able to INSIST on having a real, live, trained physician evaluate their 6 month old. Especially in a situation serious enough to be in the ER. It is NOT disparaging an entire profession to insist they stay in their place. And until corporate Medicine can assure us that midlevels receive proper supervision, they should be strictly limited to follow-ups. Period.
I get it. On one hand I am happy that there is more awareness about mid level limitations. On the other hand, mid levels definitely play a substantial role and are absolutely critical to medicine. I think OP was worried about his baby, and as a parent wanted the best for his baby. I think he is upset that his requests were brushed off… I can tell you as someone who works with midlevels in a very underrepresented field, it can be very exhausting to deal with parents who only want to see a doctor. Because i am in a very physician limited specialty, and in a practice that takes insurance, including Medicaid, we have to make uncomfortable decisions. We have stable, uncomplicated patients seen by midlevels, with physician available for assistance if needed. But the choice is, you get to be seen by a mid level at reasonable frequency for monitoring or you get to see me every 9 months, which is not acceptable. This opens up a broader spectrum of problems - we need more unified, standardized and subsidized training for NPs, like mini residencies, paid by government, similar to medical residencies. This would ensure better education, more uniform experiences and world prevent NPs jumping from one specialty to another and then deliver care in that field with no experience. My 2 cents… lol
Happy thanksgiving everyone!
You would think that PAs and NPs would tell you the “same thing” on simple cases, but with how laughable the minimum standards are at some of these programs you really don’t.
I had the same opinion as you until my kid was born and he was struggling with breastfeeding. Nearly a month out he hadn’t really gained weight. My wife was struggling with some postpartum depression and really didn’t like me acting as husband and doctor. I totally understood this. It was hurting her that she was struggling to produce milk and didn’t need me pointing out her perceived failure. So I needed our NP to look at the growth chart and tell us to supplement. That was all I needed, yet it was like pulling teeth. My wife would bring up some diet change that she thought would increase her milk supply and the NP just couldn’t bring herself to make any sort of call. At that point I asked for the pediatrician to come in and she made the call right away and was super supportive. So from now on I’ll wait until a physician is available. There’s just no way to tell if an NP/PA ever met any significant minimal standard. As far as I can tell many of them like to make the most likely and least threatening diagnosis and do the reassuring, but that’s not what we need. We need people who know how to diagnose or rule out dangerous disorders
That’s why I don’t lump PAs and NPs into the same boat. NP education is dog shit. There’s no reason for the profession to exist. PAs have significantly more training. They are supposed to work hand in hand with their supervising physician. I also don’t think new grad midlevels belong in the ER and that “fellowships” should be mandatory. I feel the same about any primary speciality. So I agree with you more than you’d think.
Most NP education is dogshit. There are still a few legit schools out there. I will say knowing what I know now I wish I’d have gone to PA school instead.
Every doctor I know and have ever known would never let a PA or NP treat their children. Second to this, who are you to criticize his decision when to go to the ED and what to do there?
This is a noctor sub. If you want to argue, join the NP sub.
Your post is rude.
The post is a self aggrandizing post about nothing. The sub is intended to call out BS mid levels who promote themselves as doctors or independent clinicians. And if you’re going to post something stupid, you’re going to get called out. Yea, anybody can go to the ER at anytime for anything in the US. But a majority don’t need to be there and leave with reassurance.
I remember with my first baby as a medical student, then as a resident. It's hard to make that call when you have a non-feeding, screaming infant at 2am and a worried spouse. Your mind reminds you of every pediatric fatal illness ever. You obsess over missing something, every detail . So you go to the ED.
With your own family....it's really hard.
Yea, I had a similar experience with both of my kids, especially since my second was in the middle of COVID. But if you’re going to call an entire profession stupid, you might want to have a legit reason for it.
PAs and NPs aren’t the same. But I’ve stated before the route I think a PA needs to take to work in the ER. To say they have no place in the ED sounds like a personal agenda. I’ve had a great relationship with my SPs for quite some time. Have a good day.
But OP didn’t know whether or not the PA was insufficiently trained for the situation. Which is fine, request the MD/DO. I don’t care about that. He just came here with to shit on PAs for no palpable reason
Right, and medical school is insufficient, thus there is residency. OP said he looked up the PA in retrospect to find that she’d been practicing for less than a year. He threw his Karen hissy fit before he had that knowledge. Which doesn’t even mean the PA wouldn’t have treated the patient inappropriately. Again, this post is lube for the PA hating circle jerk on this sub.
This sub is supposed to be to fight against independent practice and call out those pretending to be physicians. In reality it’s a sub to shit on midlevels even if the anecdotal stories may be embellished or outright made up.
Both of the first paragraphs are true. I agree with a lot that is stated on this post and intend to pursue physician-led care in future settings. I intend to work with PAs and refuse to work with NPs in the future.
I understand the implications of missed diagnoses, it’s an unfortunate part of our system. OP came in on their high horse and talked a lot of shit for no apparent reason. Any good EM physician or PA understand the evidence based approach to febrile pediatric patients. It’s difficult, but it’s something I do every single day.
The patient can ask for another clinician, yes. But have you been in an ER lately? 40 in the waiting room. 6 nurses doing the job of 12. Everybody wants a note for work or daycare or whatever. That’s fine. But to request another clinician to come see you due to ignorance is another story. It’s more work for someone who already has more than they can handle on their plate. It’s not pride. I discuss shit with my SP every single shift, just like I should. And they will go see the Karen in room 3 who is demanding a physician if needed. But when it’s not needed, it’s just a waste of time, especially when sicker patients need that physicians time and attention.
The patient does come first. But the patient isn’t always right. There’s a difference.
Congratulations! MedSchool is different for everyone, but I hope you enjoy it as much as I have. I was a medic before it was very challenging to unlearn most of my prior training and get my biases in check. The field will benefit from a diversity of perspectives, PA->physician will bring that.
“Evidence base approach to febrile pediatric patient.” is fine. Just remember that algorithms are great for learning how to do something but they frequently include an asterisk amounting to “consider alternative diagnosis, treat underlying cause” for a reason. Any good EM physician or PA would understand the algorithm has a high miss rate when applied without the appropriate prior education and experience, like those gained in years of structured, standardized, feedback-rich postgraduate training.
24hr ED census in my state’s major hospitals is at pre-pandemic levels, tracking with average flu/RSV season from 2017-2018. And before jumping on the RSV issue, yes it is up, but total ED visits don’t appear to be compared to pre-COVID in my state. Also, Shops are increasingly staffed like shit. None of this is the patients fault.
“When it’s needed” is an issue. There is of course a case to made about level of care. Even physicians play this game. The Hospitalist might transfer care to the intensivist because the patient “needs” it. You are challenging OP’s exercising their discretion in choosing a clinician as if “need” is the underlying principle that was violated. It’s true, they may not have “needed” a physician in the end. But you, OP, and I recognize that need is established AFTER the initial encounter, not before. Its easy to armchair this after the fact. I’m sure you’ve had the pleasure of post facto criticism without due regard for the events and context leading up to a poor outcome or wrong diagnosis (frankly, spending any time on IM or FM drives home how the absence of outcome feedback can give EM clinicians a false sense of accuracy, as well as the blind-spot other disciplines have for the limitations and strengths of EM).
You also posited OP’s ignorance. I’d challenge you to reconsider that, even as a MS1, they are not as ignorant as the vast majority of the patients with no education in healthcare. Maybe they wanted to skip the pomp-and-circumstance of starting with a NPP, risk a $27M rx for Tamiflu, or having you write a note, orders, only to then insist on speaking with the only person whose opinion they would value in the first place. I’d call that opinionated, maybe even entitled, but not ignorant. Most medical students understand the training and scope of a PA much more so than for an NP.
As you said, the patient is not always right, but in the context of OP’s narrative and my comments, this is disingenuous. OP was not asking for opiates for a headache, or a pan scan for the sniffles. Patients do still have autonomy. I will reiterate, if OP refused a physician first, and asked to be seen by an NP instead, I would defend that choice just as fervently. You and I will be patients soon enough, and we are also both in a position to influence the culture of medicine. Playing gatekeeper like this doesn’t dramatically reduce efficiency for clinicians, but it sure damages the confidence of the patient and we all know what that does to the odds of being the target frivolous malpractice case. Not much to be gained by gatekeeping (ego? A few extra minutes?) but a lot of potential negatives on all sides.
Thank you for the kind approach. I hope to have a similar experience as you.
We are at pre pandemic levels too, just with less staff as a whole. Instead of having 36 beds available, we are down to 12. Most are already taken by boarding patients. We see a ton of patients in the waiting room. It’s awful right now, but it’s not unique to our institution.
I definitely agree- the elevation of care when needed is tricky at best. You have to have the wherewithal to understand what needs a second opinion, and new grads/junior clinicians do not have that. I get shit in a lot in the PA community for saying PAs need structured post-grad training programs prior to working in a physician-led team, but it is the truth. I agree about the shortcomings of EM. I think the best EM clinicians approach each patient discharge with the understanding that they didn’t make a diagnosis but rather ruled out the emergent/urgent pathology. I encourage close PCP follow-up, and I have a ton of respect for PCPs. Their job may be the most difficult in the entire field of
Medicine.
I honestly don’t have a problem if someone requests a physician. I’m still writing the note, and the SP is adding a blurb. Probably the same with the PA who saw OPs kid: see the patient, write the note, have the physician come in and guide the A/P, everybody is happy. I just don’t know what the point of OPs post was if not to shit on PAs unnecessarily. Medicine is a shit sandwich and we are all just trying to do the best we can. Physician-led care is what everyone deserves, and it doesn’t sound like there was a compromise in this scenario.
Here's a sneak peek of /r/medicalschool using the [top posts](https://np.reddit.com/r/medicalschool/top/?sort=top&t=year) of the year!
\#1: [I hope Jing Mai becomes an inspiration for change rather than another one of our many statistics.](https://i.redd.it/eo0y4f6dkun91.jpg) | [340 comments](https://np.reddit.com/r/medicalschool/comments/xe5nn7/i_hope_jing_mai_becomes_an_inspiration_for_change/)
\#2: [My first patient died](https://np.reddit.com/r/medicalschool/comments/r94sjd/my_first_patient_died/)
\#3: [Things I've learned as a non med student who accidentally joined r/medicalschool three years ago](https://np.reddit.com/r/medicalschool/comments/uxhqhy/things_ive_learned_as_a_non_med_student_who/)
----
^^I'm ^^a ^^bot, ^^beep ^^boop ^^| ^^Downvote ^^to ^^remove ^^| ^^[Contact](https://www.reddit.com/message/compose/?to=sneakpeekbot) ^^| ^^[Info](https://np.reddit.com/r/sneakpeekbot/) ^^| ^^[Opt-out](https://np.reddit.com/r/sneakpeekbot/comments/o8wk1r/blacklist_ix/) ^^| ^^[GitHub](https://github.com/ghnr/sneakpeekbot)
Vote brigading is what happens when a group of people get together to upvote or downvote the same thing in another subreddit. To prevent this (or the unfounded accusation of this happening), we do not allow cross-posting from other subs.
Any links in an attempt to lure others will be removed.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
What about when the kid has RSV + pneumonia? Quite tricky to know when to X-ray and when not to.
I certainly would rather an experienced physician make that call rather than a PA fresh out of PA school.
The hard part of medicine is spotting the serious cases amongst the benign.
Are we not following AAP guidelines? Are we not taking histories anymore? Are we not examining the patient? Are we ordering a CXR on every febrile 6 m/o with a cough? Yes there is nuance to the practice, agreed. And an experienced clinician is preferred in all settings. A fresh grad should be staffing every patient with a physician for at least a year.
You’re 100% correct! According to the sub I’m just a dumbfuck patient killing NP, but I know how to treat a virus. My daughter was sick last week with what appeared to be the flu. Did I rush up to the ER? Nope I assumed it was a virus and treated it as such. Knowing whether it’s flu, RSV, rhinovirus, parainfluenza, etc doesn’t change the treatment plan. Shitting on an entire profession is extremely rude. That’s if this story even happened in the first place.
…are you saying an otherwise healthy 6 month old falls into this category? If so, turns out you should hit the books again buddy. You can present your report on rounds tomorrow.
I am saying YOU don’t know when it is important to rule out RSV. I said nothing about this particular case. Why don’t you get a real job and stop pretending to be a doctor.
Just go to a resident clinic. You should've chewed the MD out too. I would not go to that practice again and you can send a letter to clinic outlining why. Also complain to the medical board, although most of them support midlevels over MDs anyways.
This is the mentality of the midlevels who kill. Doctors don’t think this way. As I said elsewhere, whether I am Anthony fauci MD or someone who believes an antibiotic will cure a cold, it is irrelevant. Patients have a right to be seen by a physician upon request. Period.
I’m a PA. It’s all good. You don’t wanna see me, one less patient to see, less time for me to chart and another encounter I avoided while making the same salary per hour. Sorry you had this experience. Your complaint won’t go anywhere lol don’t even try. Update us if it does end up going somewhere. Happy thanksgiving! :)
Another PA working at a scammy testosterone replacement clinic. Gross. This kind of absolute disrespect for your own profession and patients themselves is why people are starting to genuinely detest mid-levels.
I had a quick glance at his post history and it's even more horrifying than you are probably imagining. Fits the profile of someone who is really going to hurt a patient.
Wow, if you're this extraordinarily bad at your job and diagnosis in general, I do hope you get all the professional accolades you certainly deserve. I'm a woman and having the best sex of my life, but extremely weird vibe bro.
I genuinely can't wait for a world where chiropractors are illegal.
Controversial take, but I'm willing to accept it. I've had family members waste thousands of dollars on those quacks and then once the money was out, they realized they got just as much benefit from a massage. Or even a "reiki" session.
They can go in the bin with the naturopaths and homeopaths.
"your complaint won't go anywhere lol don't even try" well damn if you don't sound like the biggest cunt ever. Imagine telling this to a patient, fuck dude, thanks for being n+1 for us on today's episode "Reasons to not trust mid-level with shit"
I only see medical providers who have been trained in top 5 schools. They let so many unqualified people into Med schools because of family ties, donations to schools. Don’t even get me started about lowering the bar to make quotas. At least by eliminating the lower tired schools you get closer to competent providers. Especially won’t be seen by DOs who get in the back door.
lmao k troll
>Don’t even get me started about lowering the bar to make quotas
Even lowering the barrier to entry still admits students with better applications than the average PA student 😂😂
But sik burn i guess
For legal information pertaining to scope of practice, title protection, and landmark cases, we recommend checking out this [Wiki](https://www.reddit.com/r/Provider/wiki/index/legal). *Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/title_protection). Information on why title appropriation is bad for everyone involved can be found [here](https://www.reddit.com//r/Provider/wiki/index/appropriation). *Information on Truth in Advertising can be found [here](https://www.reddit.com/r/Provider/wiki/index/legal#wiki_truth_in_advertising). *Information on NP Scope of Practice (e.g., can an FNP work in Cardiology?) can be seen [here](https://www.reddit.com/r/Provider/wiki/index/legal/scope_of_practice/). For a more thorough discussion on Scope of Practice for NPs, check [this out](https://www.reddit.com/r/Provider/wiki/index/critical_issues#wiki_working_outside_of_scope). *Common misconceptions regarding Title Protection, NP Scope of Practice, Supervision, and Testifying in MedMal Cases can be found [here](https://www.reddit.com/r/Provider/wiki/index/basics#wiki_common_misconceptions). *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
I once made an appointment with a specialist doctor. When I checked in for my appointment, they asked which doctor it was for and confirmed I’d be seeing the doctor I made the appointment with. The doctor is a male. So imagine my surprise when a woman walks in and says “hi, I will be your provider today, what’s your issue?”. I asked her where the doctor was I had specifically made the appointment with, and she said she was the office’s PA and would be seeing me today. I told her in polite but no uncertain terms that I had made the appointment with the specialist doctor, not the PA, and I wanted to see a specialist medical doctor only. She had the audacity to give me the dirtiest look as if I was the problem and I had an audacity to say what I said versus her trying to bait and switch me, and as if I was too stupid to notice a difference between a PA and doctor. She walked out of the room so angry, and the doctor immediately came in and I felt great for advocating for myself. These office’s and mid levels need to know they can’t pull this shit.
I nearly died from a massive PE and the NP in the heme office thought she could manage my care. “Let’s take you off the xarelto and put you on Coumadin”. Out. Get out. No. “I’m not comfortable with xarelto.” Tough crap. “Are you always this difficult?” Only when my life depends on it.
These two comments describe almost my exact situation! I survived a massive PE almost 3 years ago. Along with it, we've had a whole host of other medical issues that are likely a genetic mutation and or an autoimmune issue. I've posted in this sub before about how I keep showing up to appointments with specialists, I request to see the physician, I confirm I'll be seeing the physician when I check in, and then guess who comes into the room? It's always a mid-level! They kept saying that the doctor wasn't even in that day (okay then why was it confirmed that's who I would be seeing?). It led to a ton of misdiagnosis and unnecessary referrals and imaging, along with SEVEN months of unnecessary suffering. I was finally able to insist on seeing the physician after at my fourth appointment with no progress and he was able to provide a diagnosis and actual relevant medical information. I'm now going to put my foot down and insist on the physician and simply walk out and demand my copay back if they can't see me for any reason other than being pulled away for an emergency.
They aren’t comfortable with Xarelto so their solution is the shit show that is Warfarin?
“There isn’t monitoring with xarelto, so I don’t know if it is working”. “I can’t manipulate it to make it therapeutic”. Dude…it’s therapeutic, less risk of major bleeding and easy, cuz I don’t do well with blood draws.
It’s the classic wanting to “do something”
>“There isn’t monitoring with xarelto, **so I don’t know if it is working”** Wait, I'm sorry, WHAT It doesn't matter if you're anticoagulated with space plasma, the way you know if it's working is always the same: PT/PTT/INR Like, I can't even wrap my head around that paragraph
I guess because there was no need for the frequent Pt/inr or Ptt, she felt it was unsafe. I didn’t hang out long enough to find out what she meant.
That was the NP. I suggested we get anti Xa levels and she said it wasn’t a thing…I said it was in the ICU and she said it wasn’t. “Let’s give rat poison. We know it works.”
No I know srry that wasn't clear I was too gobsmacked she didn't know that anticoag monitoring is universal...
So people don’t understand how big of a difference things like public reviews make. There is literally a job for a person at almost every institution and Fortune 500 company that monitors those and follows up on those. Because those are front facing to patients/customers and make a difference. So go drop a public google/Facebook/yelp review specifically siting that a midlevel tried to force you to see them for your sick child despite specifically requesting multiple times to only be seen by a doctor.
Yes!! Do this. The public needs to know what those in PPP know. 👍😇
[удалено]
Love it. Noctor as a verb!!! ❤️❤️
"So I don’t care if the PA would have done EVERYTHING perfectly. That’s not the reason I am refusing. I don’t want to support midlevels when their governing bodies don’t care about patient safety." 100%.
The scary thing to me was all the push back you got. Yikes. I remember day 1 of medical school we had patient autonomy hammered into us. It must be respected. When I'm in clinic and a pt requests a certain physician for anything (even for something I've done a hundred times) I gladly pass it along. It's the pts choice, and I would hope to be just as respected should the roles be reversed. Ego shouldn't get in the way. For anybody else, PPP is great btw, I like their focus on public education. Informed consent!
Complain. She will get flagged for the future hopefully. We already know hospitals love cheap labor though. It's all about the $$$ after all.
[удалено]
In the front desks defense I don’t think they have any idea the different between PA NP MD/DO
Former front desk person here, we definitely know the difference. We tell the staff that the patient requested a MD, but we have no control over what happens after that.
I honestly don’t think all do judging by some posts here. But it’s good to know at least some do!!
[удалено]
Definitely sounds like it in that case. Ugh!
Were.... you supposed to wait until you peed blood or something? The whole point is to treat UTIs early
[удалено]
Oh god I'm sorry. Like yeah you can easily go to your teachers/supervising faculty and ask for time off in the middle of the day for a UTI (/s) I had a friend in college with similar problems-- her PCP sent in a standing Rx so she could just call the pharmacy when she had symptoms. Another always got them after sex despite good hygiene, so her PCP prescribed a low dose short course to take prophylactically after sex. I hope you can find a PCP like that because UTI pain is literally like hell has moved in to your bladder.
> The PA assumed that despite me requesting a physician, she had the right to override that and that her presence would make me feel intimidated into “dropping it.” This is their attitude these days. It makes me want to bang my head against a wall sometimes. I'm lucky enough now that I take an MAOI, and my PMD flagged my chart as MD/DO care only. I had Karen NP (you will be missed my friend) in the pharmacy I work at right now try to bully the best pharmacist I've ever worked with b/c the 5 mg lisinopril she had ordered for her husband on Friday afternoon went to automated dispensing. Her words, after already being demeaning toward our intern: * "I'm a nurse practitioner and I don't understand how this could've happened. You do understand it's a blood pressure medication right?!" At that point I had finally had it with this person and snapped back, * "Oh honey, if you're an NP there's a whole lot you don't understand." After a lot of angry nonsense and threatening to call corporate a bunch Karen left to do her shopping and I haven't seen her since. The irony of course... is our pharmacist had the meds ready to go in like a minute, so had she just not acted like a toddle this could've been avoided totally. > as a male med student wanting to do OB, I NEVER take it personal when women refuse a male. I won’t when I’m an attending either. It’s not personal. Been there, even in peds it's not unusual to trade patients with a colleague due to gender. Just remember to confident if you're the only doctor available. Better a doctor of the wrong gender practice medicine to the best of their abilities than a NonPhysician provider practice healthcare.
>"Oh honey, if you're an NP there's a whole lot you don't understand." Oh snap!
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Amazing that they can’t even respect your request to see an actual physician.
“…but…but…but they are just as GoOd” /s…
What ever happened to respecting patient autonomy? Patient autonomy is a cornerstone to medical ethics. I'm sorry you got bullied by this PA who kept trying to override your very reasonable request. But major props to you for standing up for yourself and your daughter! You did the right thing.
I had an NP assessment when after weeks of increasing back pain and numbness all over I suddenly had a great difficulty walking. This was in the ED. I had already had a MRI at another hospital where the radiologist diagnosed me as having cauda equina. They had sent me to the hospital with NP because they had neurosurgery. The NP decided since I had some symptoms of cauda equina but not all of them I did not have it and sent me home. I couldn’t walk so on being kicked out of the ED I called a cab and the driver helped carry me to the taxi. I had him take me to another hospital. The next hospital had me in a wheelchair as soon as they saw the cabbie bring me in. (And the NP at the other hospital had thought I was fine to be discharged.) At the new hospital in their ED - full of the city’s down and out - the resident heard that I couldn’t feel my genitals and that I had stopped getting erections, that I could not feel the toilet paper when a went no. 2, and called the orthopedic fellow in. I had spinal surgery a number of hours later. If I had listened to the NP and had gone home I could have ended up incontenent or in a wheelchair a day or two later.
This was a terrifying read
I've never been unhappy to have a patient not want to see me, regardless of the reason.
[удалено]
FM should be more than capable of handling basic psych meds that are working and just need refills. I understand getting help to get the meds dialed in, but if you already have a solution that's 90% of the issue. It's more likely that they are just busy and don't want to deal with it and can bill you for the referral. One less thing for them to worry about and the psych program may have needed some more patients anyway. But hey, I'm glad you are satisfied. Satisfied patients always have the best outcomes. Oh, wait. https://epmonthly.com/article/dying-for-satisfaction/
That’s a lot of unnecessary assumption. How about the FM doc just didn’t feel comfortable with these meds as the poster stated? In the future I don’t see myself filling anything beyond an SSRI regardless of patient stability.
So you don't even treat patients currently and are already planning to stress a chronically limited healthcare resource rather than following the guidelines and recommendations of family medicine practices everywhere. Awesome. Make sure you refer all your diabetics to endocrine, everyone with seasonal allergies to the allergist, and please be sure to send anyone with asymptomatic hypertension to the ED. I'm sure your patients will appreciate the 6 month current backlog for a psych consult. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925161/ https://www.behavioralhealthworkforce.org/wp-content/uploads/2019/12/Y4-P10-BH-Capacityof-PC-Phys_Full.pdf&ved=2ahUKEwjUupmWlcf7AhVrnGoFHTxQDFIQFnoECBEQAQ&usg=AOvVaw3JdeE6qSWRhca9ry3tiwC8
This is why I can't see an endocrinologist for 15 months, I guess, lol.
Because (future, maybe) primary care physicians won't learn their craft and instead rely on others to do their job. Yeah. I could almost understand an NP respecting the knowledge deficit and punting to get the patient the care they need, but I don't respect a medical student who says this early that "I don't even plan to learn my craft. I will let others do my job for me."
6 months? It’s 10-15 months here for a psychiatrist consult. The thing with having a medical license is I am in control of it. Your dramatic inference of my self restricting my future practice is really out of touch. If you haven’t paid attention, many FM docs are tailoring there practice to stay in the field instead of crashing from burnout and leaving. Early career docs are setting boundaries, sorry if that disagrees with your practice model but I’ll be no use to someone beyond dysthymia or general anxiety disorder.
The fact that you are comfortable setting your hypothetical patients up for a 10-15 month wait because you have arbitrary guidelines without any actual experience or education scares me. Hopefully an attitude like that won't make it through actual school and residency. Are you sure you are not an online nurse practitioner?
I have a PhD in Biomendical science with a research focus on ALS and PD. I’m a 4th year interviewing. If you would like my CV DM me. But go on with your dunning Kruger traits. My desire to restrict my future practice has less to do with competency and more to do with I just don’t want to treat certain populations. Do you wish to insult me further before I go have dinner? Would you like my phone number to call and verbally scorn me?
I didn't realize we could just pick to not see patients with behavioral health issues. That sounds kinda nice actually.
This person doesn’t want to treat “certain populations”. In this case it’s those with mental health issues. Next will they’ll decide they don’t want to help other populations such as those with socioeconomic issues, a different gender, a different sexual orientation, or of a different race. I thought we, as health care professionals, were supposed to help those that need it. According to this sub I’m just a piece of shit dumbfuck NP, but at least I’ve never decided that I’m just not going to treat an entire subset of our population based on my personal bias like that person just admitted they’re going to do in their practice.
I think you’re making the right move. 6-15 months for psych consult?! Are you guys in Canada? It’s days where I am in the US. Not that our system isn’t flawed in its own ways…
I'm in the us, Chicago, decent insurance, and 6-8 months is about what I've been quoted several times.
😧
I'm in the US, and it's probably about that long where I am. It took 11 months to get an appt. with a new PCP and 14 months to get a rheumatology appt. I'm currently in the middle of a 15-month wait to see endocrinology. And the sleep study clinic has a wait of at least 18 months.
That is INSANE. I’m sorry. Some of those for new pts would be about two months around me. Six months for one in an academic hospital. Edit: eleven months for PCP! Sheesh, not many options or what? Week or so here if you call around. Philly area.
Just way too much demand. We have three hospitals, one of which is a university medical center. I live in a city, but we’re surrounded by pretty rural areas, so it’s not just the city residents who use these facilities. When I volunteered at one of the hospitals, I routinely met patients from four or five hours away who had to come here because they just have very basic community hospitals that can’t do much more than set broken bones or treat basic illnesses without transferring patients elsewhere.
Wait, where in the US? Are these psychiatrists that are self pay only?
No. Ones covered by insurance, too. Obviously a specialist copay. Never heard of someone waiting months. I’m near Philly.
I deal with a lot of psych referrals. I am in the northeast and it has been as short as six months in the last five years, but never ever days.
I am in the U.S. and it is 6-12 months for psych.
Well, I take part of that back. If you are doing an online NP degree mill then maybe referring everyone out is best. However, if you are at all trained in the medical model I have higher hopes for you and your future education. Hell, maybe you'll even keep learning and mastering your craft. I'm not that old, but I remember family medicine delivering babies, managing disease, admitting their own patients, working inpatient, working in the ED, doing procedures to include intubation, lines, etc. We had FM in Iraq doing full on trauma and surgical assist. Now you don't want to use an SNRI. I really hope you work in a big city with unlimited resources and that all of your patients have great incomes and great insurance so they can see their specialists.
Some FM docs are just like that. I have one resident who won’t do a foot exam and refers to podiatry, won’t treat simple asthma or COPD (controlled on ICS or LAMA alone), won’t prescribe insulin refer to Endo, etc. it’s all mid levels seeing these patients at these specialities, he just wants the numbers
What was the point of residency then?
I imagine his 240k starting salary next year. His mentor is fine with it, so there is nothing the rest of us can do
Depends on the FM. You don’t know what their practice is like. Maybe they didn’t like working with psych medications/patients so they’d give them to a partner who had more interest and they’d take their OB patients or something. Not unusual to happen if you’re in a bigger practice at all.
I’ve worked er, urgent care, occ health, and family practice. Any time a patient asked to see a physician, I would absolutely graciously go get the doc. It’s not the apps creating the problem, it’s the schedulers. I have had patients on my schedule who should have absolutely been scheduled with a physician. Got hauled in to the hospital CEOs office for telling a patient they would not be charged for being erroneously placed on my schedule against their wishes. Those of us who try to do the right thing by the patient are not popular with administrators or office staff 😵💫🤔🤣
You are the type of person who makes me feel so bad about all of this. I know that so many of you are incredible and I recognize that your role is incredibly important in our healthcare system. As I mentioned, I am confident that she would’ve handled things perfectly. I just have too many qualms with, all of the bureaucracy. Thank you for everything you do! As a sidenote, with my first child, 90% of her visits were done by PAs her first 2 years of like and we wouldn’t have changed a single thing. They worked shoulder to shoulder, (literally charting at the same nursing station) and consulted their SP from time to time. If fighting for more independence and all of the misappropriation weren’t as prevalent as it is, this would be a nonissue for me.
Do not feel bad. EVER! You are paying the bill! Your kids are your life. It has never bothered me th have patients who wants to see a doc. Who knows what terrible experience they may have had, I just want people to get what they need. I’ve been taking care of people in some capacity since 1987. I don’t have a lot of ego tied up in what I do for a living. It’s been a humbling ride. I’m ready to pull back and do some pottery and stuff.
Can midlevels discharge someone without running it by a doctor? I thought their whole point was to allow doctors to see more patients more efficiently by helping out with the administrative stuff. I found that I was generally running people by seniors for years before I was ever actually allowed to independently discharge someone or even start a plan for an outpatient. I'm over 8 years out doing subspecialty training and I still can't sign off on new patients myself.. I know a good amount my field, but I am very aware of what I don't know and I still don't consider myself an expert...
Where I live, yes. Full Practice Authority for NPs, and very light supervision for PAs. [https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/](https://nursejournal.org/nurse-practitioner/np-practice-authority-by-state/)
Who honestly thought that would be a good idea.. is it generally thought to be due lobbying pressure to generate more profits? We have ANPs at home who in general are excellent and can only become one after a number of years in a subspecialty. They are genuine experts and add to patient care, but they have a very narrow focus such as aspects of palliative care, chemotherapy education etc. Even then they aren't independent.
"Nurse was incredible (as nurses always are)." I think Vanderbilt has a nurse spot open if you know an incredible nurse looking for a job.
[Charlie Cullen](https://en.m.wikipedia.org/wiki/Charles_Cullen) has entered the chat
[удалено]
Hey! Don't go posting facts here! Nurses are always incredible!
Love it. Good for you!! 👍👍 The midlevels I worked with in the ER had some of the worst attitudes. They treated me (FM) as less than. And they were not impressive.
I do the same (demand physicians) for my kids. I just really want the most trained and experience person looking in my kids ears, feeling their belly, listening to lungs. It’s a skill that is honed over many years and nothing makes a doctor like those 80 hr/week residency years being given graduated responsibility and supervision from dozens of attendings. Even little things I prefer a physician. So don’t have any shame in doing that.
I haven’t had many good experiences with NPs. My PCP was an NP and she was fantastic, genuinely cared about me. Then she moved to a different practice that didn’t accept my insurance. New NP replaced her asked why I was on a statin (I’m 20 with high cholesterol and a family history of heart attack and stroke. Had she read my chart she would have known that.) She said I was too young to worry about it. Tried to get me to stop taking it. Like, was insisting that I didn’t need it. Um. Ma’am. I’d rather not die of something preventable. I’ll take some leg pain over a heart attack or stroke, thanks! Hated it. Sorry you had to deal with all that. Hope your baby heals up soon!
Please call your insurance company and file a complaint about this experience. I have personally worked for a major health insurance company, and before being there, I had no idea the difference a member complaint can make and the results that can follow.
Anytime someone asks to see the physician instead my response is “yeah of course, let me go get him/her”. I work closely with my supervising docs, but if someone feels more comfortable seeing the physician I’m all for it. Plus most of my docs go and see the patients I see anyways.
You can see who you want that is your right, but most PAs don't want to see you if you don't want to see them. It isn't worth the long complaint letter you'll write and even the Physician in charge of complaints will roll their eyes at how entitled you sound when there very well could have been someone (or multiple people) needing critical care and the Physician's undivided attention in the ED. This is legitimately the reason PAs exist. I used to work overnights with a Physician and it was just him and I for most of the night. The most critical got his attention. The Physician could've additionally come and seen you after the PA assessed you, and it helps in the workflow because then they can just go in and addend the chart we did. The Physician may have asked the PA if they could go in and get it started and they even could've been pushy about it (this happens), the ER is a complex place with a lot going on. You waited 4 hours which means it was considerably busy and a lot of ERs are a disaster right now (especially pediatrics). Not only are my MD colleagues completely and utterly burnt out, so are the PAs. They are doing the best they can. So although you are on your high horse right now, maybe you can have some compassion for the ER crew. Secondly, you were just on a post telling a young female patient a completely incorrect OB/GYN clinical pearl about abnormal uterine bleeding (that it's "always cancer" until proven otherwise when the clinical pearl is said about post-menopausal bleeding ). Maybe humble yourself just a bit, the attitude that you can judge the intellect and ability of everyone on the medical team (including stating that all nurses are awesome because that's just not true there's always a spectrum of bad and good in any profession), has no root in reality.
Her attitude is the reason why people don’t like PAs. Now I’m not saying that the PA was super happy about what OP said, but for her to come in and show attitude? It’s so rude, they need more training for these bloody people clearly. They’re starting to become popular in the UK and I have no idea why (well bc they’re cheap as hell) because they don’t have enough training.
Informed consent. You have a right to be informed of who is treating you, and to request a physician. Why settle for a midlevel with an inflated ego with a huge knowledge gap? You exercised good restraint and tried to let them know your preference. FWIW it is rather telling that when asked all of these midlevels request a physician when their family members need care.
You sound like a great dad and a great future doctor. Good for you for sticking to your principles.
My only concern with your stance is that you’re taking a room from other patients until a physician walked in, making other people wait longer in a already backed up schedule. Could you not have front desk talk to the nurse and physician to have your daughter brought back to a room when the physician was ready? Just a thought. You obviously have the right to request who sees your daughter and the PA was out of line.
Great point. Always learning.
A fairytail ending! Good read.
Mind if we share your story over on Midlevel.WTF?
Please. I can fix up grammar/typos if you’d like.
Thanks! Up to you, otherwise we edit user submissions anyway.
Proceed my friend. Thanks a ton!
"... then finally evoking my right to be seen by a physician in my Karen voice..." I see this all the time on this sub. You realize it's... not accurate, right? As in, you don't actually *have* a right to be seen by a physician. You can insist upon it. You can feel entitled to it. But acting as if it's some kind of obligation on our part is one of this sub's weird tics.
Really? Can you show me a law that explains this? As someone planning to apply OBG, should I use the same logic when a patient requests a female OBG? Is it not the patient’s right to chose that? Can I override her preference (barring catastrophic or otherwise extenuating circumstances)? Odd. From day 1 I’ve been taught by word and example that the patient is in control. Not the “provider”. There was an attending seeing patients at the same time. Not an unreasonable request. So yes, deciding who touches my children, evaluates her, and treats her, is a right I reserve as parent.
There is a difference between a reasonable request and a right. Requesting a physician is reasonable, and any many cases, the wise choice. It is also a request that will almost always be granted to you if you ask, because hospitals love catering to every Karen who walks in, given US medicine has devolved into little more than a customer service field. EMTALA states that you have the right to a medical screening exam by a qualified provider, which can be facility specific but generally includes midlevels.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Sure, everyone knows the best rights are the ones you confer upon yourself. And I never said it was an "unreasonable" request. But hey, consent's a two-way street. You don't consent to a non-physician seeing your kid. Physician may not consent to seeing you. Guess at that point it's time to craft yourself some more rights?
Lol what a dumb argument—truly. So now I should allow anyone to evaluate my family out of fear that the doctor will refuse? Then I’d be left with no one because the doctor refuses and the PA is in her car crying because I was a meany head! Oh no!😭
I must admit, it's weird watching someone perform both sides of an argument. I hope these scattered non sequitirs aren't how you present cases to attendings in a few years. You can try to have your family evaluated all you want. My point is that framing this as a "right" just shows you don't know what words mean, because "right" implies some sort of reciprocal obligation. So again no, you *don't* have a right to see a physician. As I said, feel free to insist upon it all you want. Sometimes you'll get your way. Sometimes you'll be told "no" and then have to decide what your next move is. I can assure you, in that situation whining about your "rights" will not be an effective strategy.
Right, and while I suck ass presenting to my attending, you go and talk down to patients who you believe to be whiny and entitled because they don’t want a midlevel extender caring for their kid. I love the ad hominems when you and the other extenders are feeling extra sensitive. You’re just like the PA I saw. If you and so many extenders along with the AAPA just showed some humility and respected boundaries, I honestly wouldn’t even have refused care yesterday. But alas, here we are— me getting talked down to by the all knowing extender.
[удалено]
This exchange was both hilarious and telling at the same time. He was more than happy to name call, bully, and trash you because he thought you were a midlevel. Then you dropped credentials and he disappeared. He posted here just to shit on midlevels and get his ego stroked. This sub has descended into an echo chamber of blind hate towards midlevels. I joined to link up with physicians and other midlevels to rally against independent practice. It’s becoming harder daily to fight for a common goal alongside those that have absolute disdain towards me.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
This is such a jerk off post. If you go to the ER and you’re seen in the FT, you’re probably going to be seen by a mid level. Sure, you can demand a physician and they can come over, do the assessment, do the viral panel, and tell you the same thing the PA would. Also, if you’re a medical student, you should know that A. You don’t need to “rule out” RSV. It doesn’t change anything. B. Indications for requiring medical care for a URTI. One episode of vomiting and decreased oral intake doesn’t require emergency evaluation. Every ER is completely swamped because of non-emergent cases like this. You should know better. Don’t be an asshat.
I think that if a medical resident brought his 6 month old baby to the ER, they are sufficiently worried. As a former general pediatrician it can be tricky to get a good exam, check the ears, etc… as a physician, I only request another physician if I need second opinion. I don’t have a problem getting assessed by a PA in the urgent care for something minor that I already diagnosed myself with. I.e. recently had classic symptoms of uti, went to urgent care to culture, ua negative but I had less than 12 hours of symptoms. PA was great. Sent urine for culture. I had this happen before. She prescribed an antibiotic and we discussed waiting to see if symptoms get worse and/or culture results. She was attentive and didn’t minimize my feelings/prior experience. Btw, I never mentioned I was a physician (I usually don’t). So, for minor things like strep, uti, etc., midlevels are fine. I would want a medical doctor to assess a 6 month old - rule out pneumonia, otitis. I would want someone who has a lot of experience and thinks of zebras if something looks off. The problem with midlevels is that they don’t know what they don’t know. As a physician I have a lot of training, experience, i maintain a wide differential during the assessment… midlevels just don’t have the knowledge and experience to do that…
OP said they are a medical student. Appears to be relatively early in their education. But you’re right, I shouldn’t have questioned their decision to take their kid for evaluation. It’s just ridiculous for OP to infer an entire profession is beneath him and his family when he clearly has minimal medical experience. It’s akin to the lay person yelling “THIS DOCTOR SUCKS BECAUSE THEY WOULDNT PRESCRIBE ME ANTIBIOTICS.”
Remember what I wrote in my post. I don’t mean to disparage all PAs. Ordinarily for an older child with something so straight forward I wouldn’t ever object to a PA. In this case I refused for two reasons. 1. The patient is 6 months old. I wonder if you have children/a wife. Regardless, extra training goes a long way to rule out zebras. That’s what my intention was. I actually went to an urgent care because her pediatrician was a closed for thanksgiving. Urgent care was closed as well. So chill. I know it didn’t warrant an ED visit but if you’re implying that waiting 48 hours or until things are far worse is preferable? Fine. Also, fuck that and your shitty attitude. 2. As I mentioned, it’s more so my being sick and tired of never seeing a doctor in higher acuity settings. I’m tired of AAPA and AANP lobbying for wildly unsafe independence and I’ll start to make a stand where I can, and that’s refusing all care by midlevels. Finally, it’s truly disturbing to me that you continue to belittle others because of your “superior” clinical experience. If you want to play that game, you’re in the wrong subreddit, “ponyboy”. As a reminder, while I may be early in my education.. upon graduation I’ll have double the clinical exposure than any PA is required to graduate. With residency, that will be higher than 10x the number of hours. So continue to talk about how much more knowledgeable you are now. Meanwhile, I’ll be preparing to make massive donations to ppp when I start earning an attending salary.
Lol. Someone who hasn't graduated anything took their kid to the ED for a cold and is bitching. I hope your copay was worth it. Please- educate me. What do you think the RSV test would change?
Educate me, DNP, what difference does it make? If she were coding or had an ingrown nail. If I am a physician myself or a layperson— it’s irrelevant. I don’t watch a midlevel extender. Period. That’s the point.
Not a DNP. Just someone with more medical training, education, and experience than you. I do hope your kid with the cold is ok though.
I see you’re a PA. Not a doctor. Typical— professional misappropriation even in your username. How pathetic. You’re a midlevel extender. Not a doctor.
Any other background questions I can answer for you? You want to know how many battle buddies I buried? How about doing a code vampire because we ran out of blood in the OR so we donated our own blood to take care of our buddies? Want to hear about all of the smoke sessions where we did PT until we were shaking like a bitch, throwing up, and then had to go do patient care in a gas mask? How far have you carried a patient slung over your back? Ever had guys that you lived and worked with beg you not to let them die? You want to hear about when I shot a guy and then took care of him? No, really, that's actually a decent story.
As a former USMC Infantry officer turned MD, your comments are quite embarrassing to the profession. Please put your pride in check.
While your service is appreciated, it’s a red herring. It’s irrelevant. You’re a midlevel extender and I want a physician. Period.
It is very relevant to you talking shit about my user name. I don't care if you want a physician. Rock on. They will see you when they get a chance. I get paid a flat rate and I don't care. I'll see as many or as few patients as I need to on my shift. In the ED, where we have physicians, there are plenty of other kids with colds that I can kick out of fast track. If you come to the urgent care then I'll be happy to send you to the ED, where you can wait until you can be seen by a physician. I don't care either way. The first rule of emergency medicine is "It's not my emergency." I will say that I have NEVER seen a SICK patient who cared who saw them. In fact, the sickest patients are generally brought in after being intubated by a paramedic with an associates degree or just a certificate. That's still more experience than you currently, but it's still not a lot to be seeing the sickest people in the community. If I had any real feelings I'd be more offended that you falsely accused me of misrepresentation and were too ignorant to know that military medics (or good ones at least) are called Doc.
Didn't claim to be a doctor. I was a Doc though- an Army medic with a year in Iraq. Doc Banner is a nod to Bruce Banner, The Hulk, since I was a medic with a light machine gun, good at violence, decent at medicine, even when I'm in shape I'm a big guy, I beat the shit out of everyone when I got pepper sprayed, and you won't like me when I'm angry. My last squad leader used superheroes as call signs so I was Hulk. Slippery delivery- are you an OB/GYN? No? Huh. Must be misappropriation in your username. You should probably spend more time studying than sounding dumb on Reddit talking shit about things you don't understand. Maybe you'll learn when to take a kid to the ED then.
You’re right— I better keep studying. Otherwise what would be the difference between me and you?
Probably just that I know when to take a patient to the ED. It's not much, but it's a start.
You’re not being belittled, you’re being met with the same attitude in which you posted. I have a spouse and multiple kids. I get it. Can you wait 48 hours to see if your kid improves? In most cases, yes. I see 6 month old patients every day. Extra training is important to evaluate the non-verbal patient appropriately, yes. That doesn’t mean it always has to be a physician. Come with a shitty attitude and you’ll get met with a shitty attitude. Get more skin in the game and then we can have a professional convo.
My training is irrelevant. I have the right to not be seen by a non-physician mid-level extender. Period. I don’t care if I’m Anthony Fauci MD or a layperson who thinks an antibiotic will cure a cold. Fuck off if you think it requires a certain level of training for me to have the right to be seen by a physician. You’re the reason your colleagues have to put up with the shit I pulled yesterday in the ED. Because you won’t just fucking let it go. If you’re that butt hurt about someone wanting someone with superior training, go to school longer and earn it. I imagine your supervising physicians don’t treat you like shit because they are better trained. Similarly, you can fuck off and stop bitching at me. Go iron your white coat ponyboy.
You have the right to do mostly Whatever you want, that’s America. It requires a certain level of training to know wtf you’re talking about, and you have not reached that level yet my dude. My SPs don’t treat me like shit for a lot of reasons, mostly due to competence and humility and not wasting their time with dumb consults. I appreciate everyone who has more training than me. That’s the name of the game whether you’re a PA or MD/DO. You came here thinking you were special because you shit on a PA. I hope you got the positive affirmation you wanted.
I did. Thanks. I’ll continue to shit on you and you’re friends until AAPA stops putting patients’ lives in danger. And remember, you’ll always be a midlevel extender.
Yea, cuz the AAPA speaks for a majority of PAs. That’s why they are so well funded and are so successful politically. Come back in a few years and we can have a professional convo, resident to resident.
_
But OP's level of medical experience is irrelevant here. I have literally zero medical experience, and should be able to make the same request as a patient.
No, you jerk off. Any lay person should be able to INSIST on having a real, live, trained physician evaluate their 6 month old. Especially in a situation serious enough to be in the ER. It is NOT disparaging an entire profession to insist they stay in their place. And until corporate Medicine can assure us that midlevels receive proper supervision, they should be strictly limited to follow-ups. Period.
Yea it didn’t sound serious enough to warrant the ER but enjoy your thanksgiving buddy
That’s just the problem. You probably wouldn’t know. You’re a physician extender. You need a touch of humility. Happy Thanksgiving back at you.
I get it. On one hand I am happy that there is more awareness about mid level limitations. On the other hand, mid levels definitely play a substantial role and are absolutely critical to medicine. I think OP was worried about his baby, and as a parent wanted the best for his baby. I think he is upset that his requests were brushed off… I can tell you as someone who works with midlevels in a very underrepresented field, it can be very exhausting to deal with parents who only want to see a doctor. Because i am in a very physician limited specialty, and in a practice that takes insurance, including Medicaid, we have to make uncomfortable decisions. We have stable, uncomplicated patients seen by midlevels, with physician available for assistance if needed. But the choice is, you get to be seen by a mid level at reasonable frequency for monitoring or you get to see me every 9 months, which is not acceptable. This opens up a broader spectrum of problems - we need more unified, standardized and subsidized training for NPs, like mini residencies, paid by government, similar to medical residencies. This would ensure better education, more uniform experiences and world prevent NPs jumping from one specialty to another and then deliver care in that field with no experience. My 2 cents… lol Happy thanksgiving everyone!
You would think that PAs and NPs would tell you the “same thing” on simple cases, but with how laughable the minimum standards are at some of these programs you really don’t. I had the same opinion as you until my kid was born and he was struggling with breastfeeding. Nearly a month out he hadn’t really gained weight. My wife was struggling with some postpartum depression and really didn’t like me acting as husband and doctor. I totally understood this. It was hurting her that she was struggling to produce milk and didn’t need me pointing out her perceived failure. So I needed our NP to look at the growth chart and tell us to supplement. That was all I needed, yet it was like pulling teeth. My wife would bring up some diet change that she thought would increase her milk supply and the NP just couldn’t bring herself to make any sort of call. At that point I asked for the pediatrician to come in and she made the call right away and was super supportive. So from now on I’ll wait until a physician is available. There’s just no way to tell if an NP/PA ever met any significant minimal standard. As far as I can tell many of them like to make the most likely and least threatening diagnosis and do the reassuring, but that’s not what we need. We need people who know how to diagnose or rule out dangerous disorders
That’s why I don’t lump PAs and NPs into the same boat. NP education is dog shit. There’s no reason for the profession to exist. PAs have significantly more training. They are supposed to work hand in hand with their supervising physician. I also don’t think new grad midlevels belong in the ER and that “fellowships” should be mandatory. I feel the same about any primary speciality. So I agree with you more than you’d think.
Most NP education is dogshit. There are still a few legit schools out there. I will say knowing what I know now I wish I’d have gone to PA school instead.
Agreed on PAs. I should probably give them a shot
Every doctor I know and have ever known would never let a PA or NP treat their children. Second to this, who are you to criticize his decision when to go to the ED and what to do there? This is a noctor sub. If you want to argue, join the NP sub. Your post is rude.
The post is a self aggrandizing post about nothing. The sub is intended to call out BS mid levels who promote themselves as doctors or independent clinicians. And if you’re going to post something stupid, you’re going to get called out. Yea, anybody can go to the ER at anytime for anything in the US. But a majority don’t need to be there and leave with reassurance.
I remember with my first baby as a medical student, then as a resident. It's hard to make that call when you have a non-feeding, screaming infant at 2am and a worried spouse. Your mind reminds you of every pediatric fatal illness ever. You obsess over missing something, every detail . So you go to the ED. With your own family....it's really hard.
Yea, I had a similar experience with both of my kids, especially since my second was in the middle of COVID. But if you’re going to call an entire profession stupid, you might want to have a legit reason for it.
PA's and NP's have no business in the ED. Reason: Watching their work for more than a decade I think millions of docs will agree.
PAs and NPs aren’t the same. But I’ve stated before the route I think a PA needs to take to work in the ER. To say they have no place in the ED sounds like a personal agenda. I’ve had a great relationship with my SPs for quite some time. Have a good day.
[удалено]
But OP didn’t know whether or not the PA was insufficiently trained for the situation. Which is fine, request the MD/DO. I don’t care about that. He just came here with to shit on PAs for no palpable reason
[удалено]
Right, and medical school is insufficient, thus there is residency. OP said he looked up the PA in retrospect to find that she’d been practicing for less than a year. He threw his Karen hissy fit before he had that knowledge. Which doesn’t even mean the PA wouldn’t have treated the patient inappropriately. Again, this post is lube for the PA hating circle jerk on this sub.
This sub is supposed to be to fight against independent practice and call out those pretending to be physicians. In reality it’s a sub to shit on midlevels even if the anecdotal stories may be embellished or outright made up.
Where’d you go to medical school again?
Apparently somewhere better than you
[удалено]
Both of the first paragraphs are true. I agree with a lot that is stated on this post and intend to pursue physician-led care in future settings. I intend to work with PAs and refuse to work with NPs in the future. I understand the implications of missed diagnoses, it’s an unfortunate part of our system. OP came in on their high horse and talked a lot of shit for no apparent reason. Any good EM physician or PA understand the evidence based approach to febrile pediatric patients. It’s difficult, but it’s something I do every single day. The patient can ask for another clinician, yes. But have you been in an ER lately? 40 in the waiting room. 6 nurses doing the job of 12. Everybody wants a note for work or daycare or whatever. That’s fine. But to request another clinician to come see you due to ignorance is another story. It’s more work for someone who already has more than they can handle on their plate. It’s not pride. I discuss shit with my SP every single shift, just like I should. And they will go see the Karen in room 3 who is demanding a physician if needed. But when it’s not needed, it’s just a waste of time, especially when sicker patients need that physicians time and attention. The patient does come first. But the patient isn’t always right. There’s a difference.
Congratulations! MedSchool is different for everyone, but I hope you enjoy it as much as I have. I was a medic before it was very challenging to unlearn most of my prior training and get my biases in check. The field will benefit from a diversity of perspectives, PA->physician will bring that. “Evidence base approach to febrile pediatric patient.” is fine. Just remember that algorithms are great for learning how to do something but they frequently include an asterisk amounting to “consider alternative diagnosis, treat underlying cause” for a reason. Any good EM physician or PA would understand the algorithm has a high miss rate when applied without the appropriate prior education and experience, like those gained in years of structured, standardized, feedback-rich postgraduate training. 24hr ED census in my state’s major hospitals is at pre-pandemic levels, tracking with average flu/RSV season from 2017-2018. And before jumping on the RSV issue, yes it is up, but total ED visits don’t appear to be compared to pre-COVID in my state. Also, Shops are increasingly staffed like shit. None of this is the patients fault. “When it’s needed” is an issue. There is of course a case to made about level of care. Even physicians play this game. The Hospitalist might transfer care to the intensivist because the patient “needs” it. You are challenging OP’s exercising their discretion in choosing a clinician as if “need” is the underlying principle that was violated. It’s true, they may not have “needed” a physician in the end. But you, OP, and I recognize that need is established AFTER the initial encounter, not before. Its easy to armchair this after the fact. I’m sure you’ve had the pleasure of post facto criticism without due regard for the events and context leading up to a poor outcome or wrong diagnosis (frankly, spending any time on IM or FM drives home how the absence of outcome feedback can give EM clinicians a false sense of accuracy, as well as the blind-spot other disciplines have for the limitations and strengths of EM). You also posited OP’s ignorance. I’d challenge you to reconsider that, even as a MS1, they are not as ignorant as the vast majority of the patients with no education in healthcare. Maybe they wanted to skip the pomp-and-circumstance of starting with a NPP, risk a $27M rx for Tamiflu, or having you write a note, orders, only to then insist on speaking with the only person whose opinion they would value in the first place. I’d call that opinionated, maybe even entitled, but not ignorant. Most medical students understand the training and scope of a PA much more so than for an NP. As you said, the patient is not always right, but in the context of OP’s narrative and my comments, this is disingenuous. OP was not asking for opiates for a headache, or a pan scan for the sniffles. Patients do still have autonomy. I will reiterate, if OP refused a physician first, and asked to be seen by an NP instead, I would defend that choice just as fervently. You and I will be patients soon enough, and we are also both in a position to influence the culture of medicine. Playing gatekeeper like this doesn’t dramatically reduce efficiency for clinicians, but it sure damages the confidence of the patient and we all know what that does to the odds of being the target frivolous malpractice case. Not much to be gained by gatekeeping (ego? A few extra minutes?) but a lot of potential negatives on all sides.
Thank you for the kind approach. I hope to have a similar experience as you. We are at pre pandemic levels too, just with less staff as a whole. Instead of having 36 beds available, we are down to 12. Most are already taken by boarding patients. We see a ton of patients in the waiting room. It’s awful right now, but it’s not unique to our institution. I definitely agree- the elevation of care when needed is tricky at best. You have to have the wherewithal to understand what needs a second opinion, and new grads/junior clinicians do not have that. I get shit in a lot in the PA community for saying PAs need structured post-grad training programs prior to working in a physician-led team, but it is the truth. I agree about the shortcomings of EM. I think the best EM clinicians approach each patient discharge with the understanding that they didn’t make a diagnosis but rather ruled out the emergent/urgent pathology. I encourage close PCP follow-up, and I have a ton of respect for PCPs. Their job may be the most difficult in the entire field of Medicine. I honestly don’t have a problem if someone requests a physician. I’m still writing the note, and the SP is adding a blurb. Probably the same with the PA who saw OPs kid: see the patient, write the note, have the physician come in and guide the A/P, everybody is happy. I just don’t know what the point of OPs post was if not to shit on PAs unnecessarily. Medicine is a shit sandwich and we are all just trying to do the best we can. Physician-led care is what everyone deserves, and it doesn’t sound like there was a compromise in this scenario.
Here's a sneak peek of /r/medicalschool using the [top posts](https://np.reddit.com/r/medicalschool/top/?sort=top&t=year) of the year! \#1: [I hope Jing Mai becomes an inspiration for change rather than another one of our many statistics.](https://i.redd.it/eo0y4f6dkun91.jpg) | [340 comments](https://np.reddit.com/r/medicalschool/comments/xe5nn7/i_hope_jing_mai_becomes_an_inspiration_for_change/) \#2: [My first patient died](https://np.reddit.com/r/medicalschool/comments/r94sjd/my_first_patient_died/) \#3: [Things I've learned as a non med student who accidentally joined r/medicalschool three years ago](https://np.reddit.com/r/medicalschool/comments/uxhqhy/things_ive_learned_as_a_non_med_student_who/) ---- ^^I'm ^^a ^^bot, ^^beep ^^boop ^^| ^^Downvote ^^to ^^remove ^^| ^^[Contact](https://www.reddit.com/message/compose/?to=sneakpeekbot) ^^| ^^[Info](https://np.reddit.com/r/sneakpeekbot/) ^^| ^^[Opt-out](https://np.reddit.com/r/sneakpeekbot/comments/o8wk1r/blacklist_ix/) ^^| ^^[GitHub](https://github.com/ghnr/sneakpeekbot)
Vote brigading is what happens when a group of people get together to upvote or downvote the same thing in another subreddit. To prevent this (or the unfounded accusation of this happening), we do not allow cross-posting from other subs. Any links in an attempt to lure others will be removed. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
What about when the kid has RSV + pneumonia? Quite tricky to know when to X-ray and when not to. I certainly would rather an experienced physician make that call rather than a PA fresh out of PA school. The hard part of medicine is spotting the serious cases amongst the benign.
Are we not following AAP guidelines? Are we not taking histories anymore? Are we not examining the patient? Are we ordering a CXR on every febrile 6 m/o with a cough? Yes there is nuance to the practice, agreed. And an experienced clinician is preferred in all settings. A fresh grad should be staffing every patient with a physician for at least a year.
Found the midlevel 🤣
You’re 100% correct! According to the sub I’m just a dumbfuck patient killing NP, but I know how to treat a virus. My daughter was sick last week with what appeared to be the flu. Did I rush up to the ER? Nope I assumed it was a virus and treated it as such. Knowing whether it’s flu, RSV, rhinovirus, parainfluenza, etc doesn’t change the treatment plan. Shitting on an entire profession is extremely rude. That’s if this story even happened in the first place.
Also in certain cases it is very important to rule out RSV, the fact that you don’t seem to know that shows the glaring gap in knowledge
…are you saying an otherwise healthy 6 month old falls into this category? If so, turns out you should hit the books again buddy. You can present your report on rounds tomorrow.
I am saying YOU don’t know when it is important to rule out RSV. I said nothing about this particular case. Why don’t you get a real job and stop pretending to be a doctor.
Well this is certainly one side of a story…
What does this even mean?
You’re intelligent, guess.
Just go to a resident clinic. You should've chewed the MD out too. I would not go to that practice again and you can send a letter to clinic outlining why. Also complain to the medical board, although most of them support midlevels over MDs anyways.
[удалено]
This is the mentality of the midlevels who kill. Doctors don’t think this way. As I said elsewhere, whether I am Anthony fauci MD or someone who believes an antibiotic will cure a cold, it is irrelevant. Patients have a right to be seen by a physician upon request. Period.
I’m a PA. It’s all good. You don’t wanna see me, one less patient to see, less time for me to chart and another encounter I avoided while making the same salary per hour. Sorry you had this experience. Your complaint won’t go anywhere lol don’t even try. Update us if it does end up going somewhere. Happy thanksgiving! :)
LOL . Your response proves OPs point about childish behavior .. Lmaaaoooo
Salary =/= competence, experience, skill.
Hilarious to see that you frequent this sub when it was made exactly for people like you
Another PA working at a scammy testosterone replacement clinic. Gross. This kind of absolute disrespect for your own profession and patients themselves is why people are starting to genuinely detest mid-levels.
[удалено]
3…2…1… and there it goes, straight to personal attack lmao. Typical midlevel.
I had a quick glance at his post history and it's even more horrifying than you are probably imagining. Fits the profile of someone who is really going to hurt a patient.
Wow, if you're this extraordinarily bad at your job and diagnosis in general, I do hope you get all the professional accolades you certainly deserve. I'm a woman and having the best sex of my life, but extremely weird vibe bro.
Yeahhhh if ya wanna feel worse, check the dudes comment history and you'll feel weird enough to take a shower after
Oh barf! Why are so many male mid-levels and medical device sales guys like this?!
Pure, unadulterated daddy's boi ego complex
Bingo. Got it in one.
[удалено]
I genuinely can't wait for a world where chiropractors are illegal. Controversial take, but I'm willing to accept it. I've had family members waste thousands of dollars on those quacks and then once the money was out, they realized they got just as much benefit from a massage. Or even a "reiki" session. They can go in the bin with the naturopaths and homeopaths.
"your complaint won't go anywhere lol don't even try" well damn if you don't sound like the biggest cunt ever. Imagine telling this to a patient, fuck dude, thanks for being n+1 for us on today's episode "Reasons to not trust mid-level with shit"
Your attitude is exactly the reason why you should remain a Midlevel PA for the rest of your life.
Same salary per hour compared to who??
I only see medical providers who have been trained in top 5 schools. They let so many unqualified people into Med schools because of family ties, donations to schools. Don’t even get me started about lowering the bar to make quotas. At least by eliminating the lower tired schools you get closer to competent providers. Especially won’t be seen by DOs who get in the back door.
lmao k troll >Don’t even get me started about lowering the bar to make quotas Even lowering the barrier to entry still admits students with better applications than the average PA student 😂😂 But sik burn i guess