Love Mids

[50960]

I am in love with midlevels!!! I admit it. It is easy to do where I work because they are all young women, but that is not the point. They are available, they are knowledgeable, and if the knowledge is not there they take the time to track it down and do it right. They care, and want above all to get a good outcome for the patients we share. They are competent, AND they are humble...this is a hard mix to find. They are REAL people wanting to help others...not scared people who are not doing unto others what they fear will be done unto them by their parents if they do not act appropriately. I love Docs as well, but I am falling in love with you NP and PA's....thank you for you!

cheers

SW Medical Psychologist

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[guetzow]

My wife thinks I'm young and sexy too

 

[Monika]

Thanks for your kind words!! It's nice to be appreciated every once and a while.

I'm sure the PAs and NPs that work with you appreciate your attitude.

 

[50960]

If it were not for PA/NP's healthcare in the US would be a mess for most of the people I treat. Thanks, you are appreciated..

 

[toughlife]

If it were not for PA/NP's healthcare in the US would be a mess for most of the people I treat. Thanks, you are appreciated..

it already is. Go to the VA and see how often they screw up with the patients they see. Can't even treat simple things like htn.

 

[PublicHealth]

it already is. Go to the VA and see how often they screw up with the patients they see. Can't even treat simple things like htn.

VA HTN isn't exactly simple HTN.

 

[Cap'nOblivious]

Toughlife: anti-midlevel crusader, protecting innocent civilians everywhere from hopelessly clueless, borderline-******ed non-MDs. We all must "say hello to his little friend" if we dare trespass on his medical turf. Go Toughlife!!

 

[hospitalistpac]

Toughlife: anti-midlevel crusader, protecting innocent civilians everywhere from hopelessly clueless, borderline-******ed non-MDs. We all must "say hello to his little friend" if we dare trespass on his medical turf. Go Toughlife!!

First of all I loved your post, It reminded me of the bud light commercials for "real american hero"
Second of all, his sentiment is a big concern for me.
Did you ever feel like, hey if a nurse screws up, no one avoids nurses or permanently declares them all idiots, if an MD screws up, again no one says all Doctors suck.
People have a bad encounter with a midlevel, which Toughlife obviously has, and has determined that therefore they all suck and are poorly educated.

 

[PublicHealth]

First of all I loved your post, It reminded me of the bud light commercials for "real american hero"
Second of all, his sentiment is a big concern for me.
Did you ever feel like, hey if a nurse screws up, no one avoids nurses or permanently declares them all idiots, if an MD screws up, again no one says all Doctors suck.
People have a bad encounter with a midlevel, which Toughlife obviously has, and has determined that therefore they all suck and are poorly educated.

How much bank are you making as a hospitalist PA-C?

 

[toughlife]

First of all I loved your post, It reminded me of the bud light commercials for "real american hero"
Second of all, his sentiment is a big concern for me.
Did you ever feel like, hey if a nurse screws up, no one avoids nurses or permanently declares them all idiots, if an MD screws up, again no one says all Doctors suck.
People have a bad encounter with a midlevel, which Toughlife obviously has, and has determined that therefore they all suck and are poorly educated.

well, I let the trends speak for themselves. I spent a month in the hypertension clinic at the VA and the whole day was spent just re-adjusting HTN meds for patients whose "primary care provider" were NPs. I got so sick of writing notes explaining why their approach was wrong that even the nephrologist I worked with, has learned to loath them for their incompetence.

Let me give you an example from two days ago.

65 y/o male referred to us by NP with orthostatic htn, bradycardic and poorly controlled htn. Had two falls in past month.
BP: 175-180/90s both arms. Pulse:39

Without saying anything else about him, let me post his meds that the NP had him on and I want you to tell me what you think.

-Diltiazem 300mg SA CAP po bid.
-Atenolol 200 po qd
-HCTZ 25 po qd
-Torazosin 5 mg bid
-Lisinopril 40 po qid
-Clonidine HCl 0.1mg po prn when BP >160 systolic (as per NP order).

can anyone in their right mind tell me this is how you manage htn?

 

[lizzied2003]

....that even the nephrologist I worked with, learned to loath them for their incompetence.

I see patients in our practice and often they are VA patients with HTN who come to see us in private practice . I think part of the VA problem is likely the system. How long does it take to get a referral to a HTN/Neprology Clinic? How many times in the last 6 months have i had to change from Norvasc to Cardizem or Altace to Liosinopril based on the VA telling me what I could prescribe for my patients?? Too many times to count.

And because I work in a large community type of hospital I also have seen countless times where the doctor and midlevel have missed the boat on taking care of HTN and doing an early referral. It doesn't matter your degree, I think many docs can't keep up with trends and JHC guidelines.

If i had nickel for every provider who started a patient with HTN on an ACE without even checking kidney fxn. or a potassium I'd be a rich woman.

Now toughlife I find it interesting that you had to 'teach' the nephrologist to loath the midlevel. Obviously you spent a fair portion of your time pointing out their downfalls. You'll find in the real world bad mouthing your peers (no matter what their level) doesn't fly too well.

 

[toughlife]

I see patients in our practice and often they are VA patients with HTN who come to see us in private practice . I think part of the VA problem is likely the system. How long does it take to get a referral to a HTN/Neprology Clinic? How many times in the last 6 months have i had to change from Norvasc to Cardizem or Altace to Liosinopril based on the VA telling me what I could prescribe for my patients?? Too many times to count.

And because I work in a large community type of hospital I also have seen countless times where the doctor and midlevel have missed the boat on taking care of HTN and doing an early referral. It doesn't matter your degree, I think many docs can't keep up with trends and JHC guidelines.

If i had nickel for every provider who started a patient with HTN on an ACE without even checking kidney fxn. or a potassium I'd be a rich woman.

Now toughlife I find it interesting that you had to 'teach' the nephrologist to loath the midlevel. Obviously you spent a fair portion of your time pointing out their downfalls. You'll find in the real world bad mouthing your peers (no matter what their level) doesn't fly too well.

I didn't teach him anything. He learned of the atrocious incompetence displayed by the NPs and that did it.

 

[hospitalistpac]

well, I let the trends speak for themselves. I spent a month in the hypertension clinic at the VA and the whole day was spent just re-adjusting HTN meds for patients whose "primary care provider" were NPs. I got so sick of writing notes explaining why their approach was wrong that even the nephrologist I worked with, has learned to loath them for their incompetence.

Let me give you an example from two days ago.

65 y/o male referred to us by NP with orthostatic htn, bradycardic and poorly controlled htn. Had two falls in past month.
BP: 175-180/90s both arms. Pulse:39

Without saying anything else about him, let me post his meds that the NP had him on and I want you to tell me what you think.



-Diltiazem 300mg SA CAP po bid.
-Atenolol 200 po qd
-HCTZ 25 po qd
-Torazosin 5 mg bid
-Lisinopril 40 po qid
-Clonidine HCl 0.1mg po prn when BP >160 systolic (as per NP order).

can anyone in their right mind tell me this is how you manage htn?

Well I'm in my right mind and I can tell you that is no way to tx this gentleman.
BTW did you mean orthostatic hypotension or autonomic dysfunction from DM with documented orthostatic hypertension?

 

[lizzied2003]

well, I let the trends speak for themselves. I spent a month in the hypertension clinic at the VA and the whole day was spent just re-adjusting HTN meds for patients whose "primary care provider" were NPs. I got so sick of writing notes explaining why their approach was wrong that even the nephrologist I worked with, has learned to loath them for their incompetence.

Let me give you an example from two days ago.

65 y/o male referred to us by NP with orthostatic htn, bradycardic and poorly controlled htn. Had two falls in past month.
BP: 175-180/90s both arms. Pulse:39

Without saying anything else about him, let me post his meds that the NP had him on and I want you to tell me what you think.

-Diltiazem 300mg SA CAP po bid.
-Atenolol 200 po qd
-HCTZ 25 po qd
-Torazosin 5 mg bid
-Lisinopril 40 po qid
-Clonidine HCl 0.1mg po prn when BP >160 systolic (as per NP order).

can anyone in their right mind tell me this is how you manage htn?

In answer to your original question, I agree the meds are very heavy. That not withstanding...I've also seen docs load up or give some of this and some of that for no good reason. Yours is not to question. Just try to treat the patient and send the provider a nice note with what you did so your genius can be used to teach them something.

However;
I'm guessing that you mean HYPOTENSION when you say "orthostatic HTN" right?

In looking at his meds I'd likely dumpy the "Terazosin" (that's what you meant "by Torazosin right?) as that would be my first bet for ortho Hypotension. (As an aside are you sure the NP put him on that med or is he taking it for BPH from a urologist?)
I wouldn't do anything else until I reviewed his Echo, checked for a bruit, and reviewed all labs. I certainly wouldn't stop a beta blocker abruptley.

I'd also do 24 hour monitoring to r/o white coat htn or at least bring him back for a few visits for b/p monitoring with us. In the meantime You could do a plasma catecholamine or a 24 urine for same with metanephrines. By the way, what's his potassium high? low? Should you be looking for aldo? or Pheo(it's often a missed diagnosis) Also, I'd check his kidney function first and foremost. Is he on a high dose of ACE for proteinuria or HTN? Does he have renovascular HTN? Perhaps a MRA of his kidneys might not be a bad idea down the road.

In short....this is why the NP sent him to you. Not so you can complain about his/her stupidity. This is what your nephrologist is there for. Without providers who don't know everything specialists would be out of business.
My bread and butter is consults and referrals. Sure I say 'holy crap, how could they not figure this out...were they trying to kill the guy?" But in short, everyday there are dozens of things I don't know and neither do the docs i work with. That's why we send them to specialists.
It makes the world go round and will keep your family fed.
Good luck to you and your patient.
I'd love to know what you guys did and what you found.
thanks.

 

[50960]

Touche!!

I can't believe this thread got hijacked in this way. You are all appreciated...believe me!

 

[toughlife]

Well I'm in my right mind and I can tell you that is no way to tx this gentleman.
BTW did you mean orthostatic hypotension or autonomic dysfunction from DM with documented orthostatic hypertension?

I meant hypotension. My bad. I was trying to be lazy and not spell the whole word out.

Maybe I was just frustrated from the long ass month in that clinic and, maybe my exposure to NPs was skewed given it was the VA afterall. I am a 4th year med student and my interest in being a med student has decreased at this point and patience is short. besides, I am doing anesthesiology so clinic is not my gig.

At the end of the rotation, I told the nephrologist to plan some lectures and to give everyone in the NP clinic a review on JNC-7 as a refresher.

As far as what we did with this particular patient goes, we got a renal duplex + renal ultrasound and the u/s showed a rather small left kidney, about 50% smaller compared to the right one according to Clark Kent (x-ray man).
Renal artery duplex pending according to VA records given this was outpatient clinic but we believe RAS is likely.

As far as meds,

D/C torazosin (side effects and potentially > strokes and CHD). Asked about this and he had no history of BPH.
D/C Diltiazem (bad synergism with beta blockers) diltz acts more on the heart than peripheral vasculature.
Started felodipine 5 bid and recommended rapid increase felodipine
DASH diet, low salt
Tapered off the atenolol cutting by half every1-2 weeks depending on how the patient tolerated it (poor effects in the elderly plus bradicardia)

 

[lloydchristmas]

I meant hypotension. My bad. I was trying to be lazy and not spell the whole word out.

Maybe I was just frustrated from the long ass month in that clinic and, maybe my exposure to NPs was skewed given it was the VA afterall. I am a 4th year med student and my interest in being a med student has decreased at this point and patience is short. besides, I am doing anesthesiology so clinic is not my gig.

At the end of the rotation, I told the nephrologist to plan some lectures and to give everyone in the NP clinic a review on JNC-7 as a refresher.

As far as what we did with this particular patient goes, we got a renal duplex + renal ultrasound and the u/s showed a rather small left kidney, about 50% smaller compared to the right one according to Clark Kent (x-ray man).
Renal artery duplex pending according to VA records given this was outpatient clinic but we believe RAS is likely.

As far as meds,

D/C torazosin (side effects and potentially > strokes and CHD). Asked about this and he had no history of BPH.
D/C Diltiazem (bad synergism with beta blockers) diltz acts more on the heart than peripheral vasculature.
Started felodipine 5 bid and recommended rapid increase felodipine
DASH diet, low salt
Tapered off the atenolol cutting by half every1-2 weeks depending on how the patient tolerated it (poor effects in the elderly plus bradicardia)

You're right, that management was rediculous. But, you are generalizing all midlevels with what you've seen in the VA. Are you serious, student??? Do you actually mean to tell me that you think the VA midlevels are the top of the class, cream of the crop??? Working for $50K/yr, seeing non-compliant multi-complexity VA patients that take an hour. No thanks!!! There are learning curves in all disciplines, and believe me, just like in your class, I could look around the room and pick out the one's I could probably see all the way through when looking into their ear w/ an otoscope. One student in my class actually asked, "What is an oxygen saturation?" Their answer to your problem above would've been... "increase the Atenolol to TID and add some Cialis for good measure!!!" (pun intended)

disclaimer: no, I don't think if you who are reading this who are working with VA patients are all dumb. That would be an equally inaccurate generalization.

 

[ProZackMI]

My wife thinks I'm young and sexy too

She might want to visit the psychiatry forum or the ophthalmology forum.

 

[ProZackMI]

it already is. Go to the VA and see how often they screw up with the patients they see. Can't even treat simple things like htn.

The VA employs poorly trained FMGs to treat our veterans. Ever see VA records? It's like a lobotomized lab rat wrote the chart notes. Not only are there frequent errors in grammar, punctuation, and spelling, but often, the patient's gender and age change, the sentence structure is confusing or illogical, and the salient parts of the exam, whether physical or mental status, are missing.

At least the NPs, PAs, and RNs who work at the VA have a clue. The IMG/FMG "MDs" have none. A great deal of the time you see entries like "counseled patient to stop smoking, drinking ETOH, and advised to wear seatbelt." Keep in mind, the patient is in treatment for oat cell carcinoma.

By in large, the NPs and PAs I work with do a great job.

 

[fab4fan]

In answer to your original question, I agree the meds are very heavy. That not withstanding...I've also seen docs load up or give some of this and some of that for no good reason. Yours is not to question. Just try to treat the patient and send the provider a nice note with what you did so your genius can be used to teach them something.

However;
I'm guessing that you mean HYPOTENSION when you say "orthostatic HTN" right?

In looking at his meds I'd likely dumpy the "Terazosin" (that's what you meant "by Torazosin right?) as that would be my first bet for ortho Hypotension. (As an aside are you sure the NP put him on that med or is he taking it for BPH from a urologist?)
I wouldn't do anything else until I reviewed his Echo, checked for a bruit, and reviewed all labs. I certainly wouldn't stop a beta blocker abruptley.

I'd also do 24 hour monitoring to r/o white coat htn or at least bring him back for a few visits for b/p monitoring with us. In the meantime You could do a plasma catecholamine or a 24 urine for same with metanephrines. By the way, what's his potassium high? low? Should you be looking for aldo? or Pheo(it's often a missed diagnosis) Also, I'd check his kidney function first and foremost. Is he on a high dose of ACE for proteinuria or HTN? Does he have renovascular HTN? Perhaps a MRA of his kidneys might not be a bad idea down the road.

In short....this is why the NP sent him to you. Not so you can complain about his/her stupidity. This is what your nephrologist is there for. Without providers who don't know everything specialists would be out of business.
My bread and butter is consults and referrals. Sure I say 'holy crap, how could they not figure this out...were they trying to kill the guy?" But in short, everyday there are dozens of things I don't know and neither do the docs i work with. That's why we send them to specialists.
It makes the world go round and will keep your family fed.
Good luck to you and your patient.
I'd love to know what you guys did and what you found.
thanks.

Wow...that post was a thing of beauty!