You say you ran through the differential... do you actually think you KNOW the entire differential for chest disease? I know I don't. But let's say, for instance, your patient didn't have pneumonia. Let's say instead they had bronchioloalveolar carcinoma. It could present similarly. Should the patient be discharged based on YOUR diagnosis of pneumonia, or should the MD take a look? Also, let's say the MD did suspect this. Now, if you've written a 'diagnosis' of pneumonia in the chart, the MD is going to have to fight to justify additional testing with insurance companies and who knows what other administrators.
When the MD asks you 'what do you think it is', it's not because he needs your advice. he's including you in the discussion and helping you learn. He does want your input to the discussion. Hypothesize diagnoses verbally to your hearts content. But when you WRITE THAT OPINION INTO THE CHART, that is when you've crossed a boundary. You're not licensed to practice medicine, and yet you're placing a diagnosis into a legal document. That's the issue.
Assuming that the people in charge care about maintaining standard of care, the scope of midlevel providers should not change based on circumstance to include duties outside of their training. Obviously if you're the only person there, you do the best you can. But if there's an MD there, that person is the only one who should be practicing at the scope of practice that an MD typically does. He may have to work harder, but oh well. 'Battlefield promotions' don't increase your knowledge base. I'm sure they appreciate all the help you bring to the table, and would like to get you as much experience as they can, but it's just a matter of making sure you don't stick your neck out too far, because you may be inadvertantly putting someone else into a touchy situation.
I appreciate your candor, you do bring up some very valid points. But, I feel the need to clarify. Here's a general patient encounter:
Pt comes in w/ chief complaint of pleuritic chest pain and cough. The medic gathers up a good hx of present illness, a review of systems, and a focused physical examination. He gathers what he's found, finds the doc and relays the information.
The doc asks, "so what do you think it is?"
Medic: "I suspect pneumonia."
Doc discusses (pimp session) but ultimately agrees, and orders rads and labs to rule out or differentiate.
Medic carries out orders and documents his findings..."Poss. pneumonia, ordering [labs and rads] to r/o infection" into patient's chart.
Labs are back, xray is done, the medic documents a 'lay impression': "Results consistent with community-acquired pneumonia" and returns to the MD.
Doc reviews, discusses treatment (pimp session), declines sputum culture (pimps medic for suggesting a sputum culture), decides to see the patient, talks to him/her, signs script, goes back to his office.
Medic types up the note, doc reads.
Doc: You're a
medic blah blah blah, you are not a doctor. You can't use "language that suggests a diagnosis" and "you don't need to be making any kind of impressions...blah blah blah..."differential"...blah blah..."TB"..blah "idiopathic pulmonary fibrosis"...blah blah blah..."bronchioloalveolar carcinoma." LOL
Pt returns 5-6 days later, levafloxacin not relieving pneumonia.
Doc: Let's send him to the pulmonologist in XXXX for CT and sputum culture.
Thanks guys/gals, I'm really glad that I'm learning some humility now instead of later as a med student.
Pts are not being diagnosed and discharged by medics. Sorry if I misled you.
