Working with difficult doctors

[Sunfire]

After some of the animosities I've perceived from some of the Doc/Med School posts towards PAs and NPs, I'm curious...are there any practitioners who've worked with such individuals, who have developed any pearls of wisdom that they care to share? Any suggestions on how to smooth over any humps that have presented themselves and how you were able to go on working efficiently and effectively in spite of any adversities?

I understand that people who've gone through an extended amount of training don't like feeling as if their job that they've worked so hard to achieve could be done by someone with somewhat less training. My personal feeling is that there's a place in this world for everyone, and that the professions have a brilliant record of overlap that has for the most part proved itself to be of outstanding quality. But situations do arise from time to time, and I'd be very interested in any accounts.

For the record, I'm sure that there will be a fair amount of Docs, Residents and Med Students who want to jump into this thread in an attempt to disparage and shout their opinions, but I'm asking these questions primarily of the PA and NP Professionals and Students.


Stories? Comments? Suggestions?

---

Members don't see this ad.

 

[bradt9881]

Pearl of wisdom:

Never confuse the animosity of a few message board warriors towards us as the expression of the majority....

 

[Chronic Student]

What is often encountered on this board is rarely something that happens in real life.

I have come across a few who had some problem. However, most docs are intelligent enough to judge people on their own merits.

That means that if you are an idiot they will treat you as such and if you do your job well and learn as much as you can, then you will be respected.

 

[Taurus]

Some people are never happy with what they have and always want more. There isn't enough 'respect' to go around in this world.

If you're having this much trouble accepting your midlevel role in the medical hierarchy, you may want to consider going to medical school.

 

[Sunfire]

Thanks brad and chronic, your words of wisdom are appreciated. I must say, I've been in healthcare for years, and other than the occasional personality conflict that can happen between two people of any professions, I have never once seen anything remotely near what I've observed on this board. I'm glad to know that my experiences have been the norm.

 

[Therapist4Chnge]

In most cases I've found people being treated by how they perform/interact, and much less along "party lines". There will always be some friction by the minority, but most people tend to avoid those situations, as they can be toxic (just like in other areas like business, academia, etc).

 

[primadonna22274]

Agree with other posters.
In eight years of being a PA I can count on a few fingers the times I've run into such hostility in actual practice as we see spouted on this board. That includes a clinical training year. Guess what? Every time I was pissed off, you bet, but every time I learned something useful. Like how NOT to repeat that dumb mistake, etc.
Much more often have I been judged on my own merits. Not as one of a nebulous population of PAs, but as an individual. Many times I've been told that I know far more than they expect of a PA (well gee, that's nice). A few times I've been told they trust me more than some of the docs I know. A nice pat on the back. I take it with a grain of salt, because I know I have certain areas of expertise and lack much depth in others. We all do. I think the trick is to read greedily, learn continuously, learn from anyone who will teach you (yes, even the *****holes) and remain humble.

 

[DocNusum]

1.) For eons, "healers" had been considered "GODS". In recent history, "healers" were considered semi-gods... that possessed the ability to alter the plan of the real gods. Lately, "healers" have been demoted to fallible human status... (which many healers don't like because when they started their journey... they signed up to be considered GODS...)

The question is, "Do I have a 'God Complex'?
Which makes me wonder if this lawyer has any idea as to the kind of grades one has to receive in college to be accepted at a top medical school.
Or if you have the vaguest clue as to how talented someone has be to lead a surgical team.

I have an M.D. from Harvard. I am board certified in cardiothoracic medicine and trauma surgery. I have been awarded citations from seven different medical boards in New England; and I am never, ever sick at sea.

So I ask you, when someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn't miscarry, or that their daughter doesn't bleed to death, or that their mother doesn't suffer acute neural trauma from postoperative shock, who do you think they're praying to? Now, you go ahead and read your Bible, Dennis, and you go to your church and with any luck you might win the annual raffle. But if you're looking for God, he was in operating room number two on November 17th, and he doesn't like to be second guessed.

You ask me if I have a God complex?
Let me tell you something: I AM GOD.

Alec Baldwin... in "Malice"​

2.) The selection process necessary to become a "healer" is arduous, long, competitive and expensive. Not everyone can endure/afford the process and those successful at it feel exclusive and "special."

3.) Many of those selected to undergo the process began preparing themselves during their early formative years. Lots of them (not all, or even the majority) are socially inept ("Gunners") and were socialized by the people who think/thought "healers" were gods ...

All of the above contributes to the toxic and sometimes "malignant" personalities of some of the "healers" we encounter while practicing medicine.

For three years, I worked in a 6 physician, 1 mid-level (me) SPECIALTY practice. 5 of the physicians were kind, compassionate, caring, down-to-earth mentors/providers.

1 physician was a complete ego-maniac. This guy looked "down his nose" at ALL who didn't have MD behind their name. He couldn't order a pizza without commenting about his assessment of the person he was ordering from intellectual capacity. Most of this physician's patients switched to a different physician within the group within 3-6 visits of meeting him.

Unfortunately, he had recently made partner... and the others in this group physicians decided NOT to accept patients that wanted to transfer from his care.

Since its a small town (isolated with ~90k people and 1 hospital) , this was/is the only practice that offered this specialty. The patients were stuck...

I finally quit after his ego/condescension got to big for me to deal with non-violently. Since it was 6 physicians and only me as the mid-level, we had been using a standard format and standard verbiage, templated test report for 3 years. The only changes he wanted me to make to the report were synonyms of a select few of the agreed upon words...!!!

Basically, this guy called me out of a exam room with a patient and down 3 stories of stairs to DEMAND/command that I edit a sanctioned "standardized" report with words of his choosing. I refused to alter it at his whim. The other physicians agreed with me in principle but wouldn't/couldn't back me (the mid-level) against a fellow physician.

This BS went back and forth for about a week. The discussions remained professional and behind closed doors. Then suddenly, I was being asked to leave provider meetings "so they... (the physicians)... could talk."

I gave them my resignation/2 week notice and moved on...

Lessons Learned:

The utility of a PA to the medical system/a practice is that we are a cheaper alternative held to THE SAME standard of care... (think $300k in services billed - $70k in salary paid + a 30%employee burden)...

Lose the idea that mid-levels can do anything physicians can.... (like become a partner/partial owner unless we actually start the practice)...

Just a few thoughts based upon personal experience...

DocNusum, FNP, PA-C

 

[isoman2000]

Most are easy only internet warriors like tarus are any problem and in real life they are pretty quiet, it is much harder to talk smack face to face.
As for respect there will clearly never be enough in the world to meet your ego needs tarus.

 

[PattiCPNP]

Some people are never happy with what they have and always want more. There isn't enough 'respect' to go around in this world.

If you're having this much trouble accepting your midlevel role in the medical hierarchy, you may want to consider going to medical school.

I am glad to hear that the negative opinions of the pre-med posters on here are not the norm that people encounter. I work in a community health center with PAs, NPs and physicians who all collaborate on patient care and genuinely respect each other as providers.
I am EXTREMELY happy with my "role". Never wanted to go to Med School, never will. What I am unhappy with it the term "mid-level" provider. What am I in the Mid-level of? I am a nurse with an advanced degree, at the TOP of my profession, not in the middle. I'm not a middle level doctor (remember..didn't want to go to med school). Just my 2 cents.
BTW, Taurus, maybe you are unhappy and want to join us since you're always posting on this board!!

 

[Taurus]

Most are easy only internet warriors like tarus are any problem and in real life they are pretty quiet, it is much harder to talk smack face to face.
As for respect there will clearly never be enough in the world to meet your ego needs tarus.

It's not my ego that needs the boosting. I respect the medical hierarchy and I know my place in it. It's for all those who went to NP or PA school thinking that it is a shortcut to being a physician. Reality will hit them hard in the face.

 

[PattiCPNP]

It's not my ego that needs the boosting. I respect the medical hierarchy and I know my place in it. It's for all those who went to NP or PA school thinking that it is a shortcut to being a physician. Reality will hit them hard in the face.

Taurus...what part of WE DON'T want to be physicians, don't you understand?!? Are you going to be a Family Physician and work in a rural, clinic that serves the underinsured, indigent populations?
The nurse practitioner role was born out of a need for providers to care for pediatric patients in areas of the country that physicians didn't want to establish a practice because of low pay!
Again....I am a NP...not MD...I know my scope of practice...know when I need to refer...know when I need to consult my physician preceptor. I don't let anyone call me "Dr"...I don't mislead patients on my identity as a provider.
I can't understand why, when you are only still a student (if I am reading your profile designation correctly), that you have developed such animosity towards a profession (NP and PA) that respects physicians for who they are and the care they provide. Why do you think we want your job? I have enough patients of my own to take care of...and by the way...they LOVE me!!!

 

[Taurus]

Taurus...what part of WE DON'T want to be physicians, don't you understand?!? Are you going to be a Family Physician and work in a rural, clinic that serves the underinsured, indigent populations?
The nurse practitioner role was born out of a need for providers to care for pediatric patients in areas of the country that physicians didn't want to establish a practice because of low pay!
Again....I am a NP...not MD...I know my scope of practice...know when I need to refer...know when I need to consult my physician preceptor. I don't let anyone call me "Dr"...I don't mislead patients on my identity as a provider.
I can't understand why, when you are only still a student (if I am reading your profile designation correctly), that you have developed such animosity towards a profession (NP and PA) that respects physicians for who they are and the care they provide. Why do you think we want your job? I have enough patients of my own to take care of...and by the way...they LOVE me!!!

You're new to the debate, but this has been discussed for many years. Just do a search for some of the more interesting threads.

 

[isoman2000]

Yo tarus please explain the awsome clinical requirments by the ABA for anesthesiologists?

 

[Sunfire]

You're new to the debate, but this has been discussed for many years. Just do a search for some of the more interesting threads.

Taurus, maybe you could relate some of your own personal experiences in the clinical field, regarding the issue that this thread is focusing on?

 

[bradt9881]

Taurus, maybe you could relate some of your own personal experiences in the clinical field, regarding the issue that this thread is focusing on?

Tsk, tsk. Rule number one of message boards violated, no feeding the trolls allowed.

 

[Sunfire]

I hear what you're saying, but who knows, you know? Maybe Taurus has seen or heard something in their rotations, or from previous experience.

 

[8744]

After some of the animosities I've perceived from some of the Doc/Med School posts towards PAs and NPs, I'm curious...are there any practitioners who've worked with such individuals, who have developed any pearls of wisdom that they care to share? Any suggestions on how to smooth over any humps that have presented themselves and how you were able to go on working efficiently and effectively in spite of any adversities?

I understand that people who've gone through an extended amount of training don't like feeling as if their job that they've worked so hard to achieve could be done by someone with somewhat less training. My personal feeling is that there's a place in this world for everyone, and that the professions have a brilliant record of overlap that has for the most part proved itself to be of outstanding quality. But situations do arise from time to time, and I'd be very interested in any accounts.

For the record, I'm sure that there will be a fair amount of Docs, Residents and Med Students who want to jump into this thread in an attempt to disparage and shout their opinions, but I'm asking these questions primarily of the PA and NP Professionals and Students.


Stories? Comments? Suggestions?

Having been both a leader and a follower in the military, business, and medicine, I assure you that it is an order of magnitude more difficult to be in charge. It is a lot harder working with difficult subordinates than the other way around.

 

[Sunfire]

Having been both a leader and a follower in the military, business, and medicine, I assure you that it is an order of magnitude more difficult to be in charge. It is a lot harder working with difficult subordinates than the other way around.

If you'd care to share any type of personal experience or advice which specifically pertains to the medical field and topic of this thread, please do so. You may want to consider starting your own thread which might be able to better focus on the more general matter of management which you've suggested.

This thread was not intended as a showcase for med school students/residents to disparage or trample, it was meant to trend towards constructive development regarding a specific issue. Please take any other initiatives elsewhere.

 

[Tired]

Having been both a leader and a follower in the military, business, and medicine, I assure you that it is an order of magnitude more difficult to be in charge. It is a lot harder working with difficult subordinates than the other way around.

<sigh> Learning this the hard way right now.


Sunfire, probably the reason so few PAs have bad interactions with physicians is that physicians who do not want to work with them do not hire them.

 

[Sunfire]

Sunfire, probably the reason so few PAs have bad interactions with physicians is that physicians who do not want to work with them do not hire them.

This thread is intended for those with experience pertaining to the topic being discussed.

 

[core0]

This thread is intended for those with experience pertaining to the topic being discussed.

First trying to control the topic is really not going to happen here. If you look at the top of the Board it does not say PA network. We are guests here and you should respect that.

Second Tired is exactly right. Generally the physicians that want to work with PAs, understand the PA concept and understand the advantages and disadvantages of employing a PA employ PAs. Those that think that PAs are their personal slaves or subject to their ego driven practice may employ one for a short time. You can find these practices in every state PA job bank. They are the ones that have a perfectly reasonable looking job that hasn't been filled for two years.

The more worrisome trend is that now we are seeing physician practices hire PAs not because they believe in and understand the concept, but because their banker or "practice consultant" told them that they can make more money doing so. They have no interest in mentorship or building a professional relationship. What they are looking for is someone that they can exploit like a non partner physician but pay less. Some of these will develop into the group above but many will not.

The PA profession is a bell curve like anything else. There minimally qualified PAs out there doing a minimally qualified job. There are PAs doing purely technical tasks that are only done by a PA because they can bill. Similarly there are some that either didn't understand the concept or thought they understood the concept but now chafe at the limitations. However, those describe the outer 5% of the profession. Most PAs work in a constructive environment.

For the most part the relationship in the real world is reasonable. There are the occasional psychopaths but you always have the option of leaving.

While I respect Pandas opinion (and he's a much better writer than I am), his comments don't tell the whole story. It is harder to be in charge than not. However, at the end of the day if there is a disagreement who is going to have a job, the physician or the PA? If the PA disagrees with the practice of medicine our only real option is to walk. That's one of life's little tradeoffs.

David Carpenter, PA-C

 

[Taurus]

This thread is intended for those with experience pertaining to the topic being discussed.

http://forums.studentdoctor.net/showthread.php?t=539389

I'm inbetween studying for Step II CK (T-8 days) and doing sub-I's so I don't have much time to spend on SDN these days. But dude that was some funny reading! Got anymore A+ papers you wanna share?

 

[Sunfire]

http://forums.studentdoctor.net/showthread.php?t=539389

I'm in between studying for Step II CK (T-8 days) and doing sub-I's so I don't have much time to spend on SDN these days. But dude that was some funny reading! Got anymore A+ papers you wanna share?

Anytime you'd like to discuss gunshot trauma, I'd be happy to talk about it. Feel free to send me a PM or start a new thread. In answer to your question, I've written some excellent papers in my undergrad so far, on pediatric brain injury, neurogenesis in the adult human brain, effects of various antibiotics on P. aeruginosa, medical care of foster youth, pharmacology and the elderly, recent developments in Alzheimer's pharm, and medical outreach programs for migrant workers. Anytime you'd like to swap, let me know.

I'll take it from your lack of reply to my question, that you don't actually have any type of experience having to do with the topic of this thread. Fill us in if and when you do.

 

[Taurus]

I have a peer-reviewed first author 5000 word paper coming out this fall in a respectable journal. Although, it's pales in comparison to an A+ paper from a distinguished community college.

 

[Sunfire]

Glad to hear it. Please feel free to share it when it's done, it might very well contain information that's pertinent to a particular discussion. Until then, maybe you could leave this thread alone and refrain from personal attacks and vendetta?

Again, anytime you'd care to discuss gunshot trauma further, please let me know.

 

[Tired]

This thread is intended for those with experience pertaining to the topic being discussed.

Then what the hell are you posting in it for?

 

[Sunfire]

First trying to control the topic is really not going to happen here. If you look at the top of the Board it does not say PA network. We are guests here and you should respect that.

Second Tired is exactly right. Generally the physicians that want to work with PAs, understand the PA concept and understand the advantages and disadvantages of employing a PA employ PAs. Those that think that PAs are their personal slaves or subject to their ego driven practice may employ one for a short time. You can find these pactices in every state PA job bank. They are the ones that have a perfectly reasonable looking job that hasn't been filled for two years.

The more worrisome trend is that now we are seeing physician practices hire PAs not because they believe in and understand the concept, but because their banker or "practice consultant" told them that they can make more money doing so. They have no interest in mentorship or building a professional relationship. What they are looking for is someone that they can exploit like a non partner physician but pay less. Some of these will develop into the group above but many will not.

The PA profession is a bell curve like anything else. There minimally qualified PAs out there doing a minimally qualified job. There are PAs doing purely technical tasks that are only done by a PA because they can bill. Similarly there are some that either didn't understand the concept or thought they understood the concept but now chafe at the limitations. However, those describe the outer 5% of the profession. Most PAs work in a constructive environment.

For the most part the relationship in the real world is reasonable. There are the occasional psychopaths but you always have the option of leaving.

While I respect Pandas opinion (and he's a much better writer than I am), his comments don't tell the whole story. It is harder to be in charge than not. However, at the end of the day if there is a disagreement who is going to have a job, the physician or the PA? If the PA disagrees with the practice of medicine our only real option is to walk. That's one of life's little tradeoffs.

David Carpenter, PA-C

We are all guests here, and should respect each other. I don't see anything at the top of my screen that says 'pants down and bend over'.

I can certainly understand the points you're making. I'm sure you can also understand the frustration that can result from the damage that some of the more immature posters at this forum often attempt to inflict. Yes, I'm a bit on guard. The point of this thread was in seeking advice in how to smooth over conflicts that may arise with difficult Doctors, not to discuss who considers who more difficult or to strengthen the agenda for students who simply want to disparage the PA and/or NP professions out of concern for their own egos.

I find it odd that some people would be unable to deal with the topic being discussed versus attempting to turn the tables to their upper hand, without responsible consideration of the topic before them. It's called empathy, and it's really not too tough to put into practice. That being said, it would be interesting and educational to hear what some experienced Doctors could relay back regarding some difficult PAs or NPs they've worked with and how they were able to resolve any conflict.

I have heard some of those horror stories that you mention, a bit of that has even been disclosed in this thread. I think such exploitation is a sad thing on the sides of more than one group involved (including the patients), and I would assume that it more often than not results in an eventual collapse of the attempted system. I guess in that case the pieces fall where they may, and life goes on. If that's the answer, that difficult Doctors are simply those who have the authority to hire their own PAs and NPs but don't truly want them, then things are a lot better than I thought, because I firmly believe they are the minority.

Again, it's good to know that my experiences up until this point have been the norm. Thanks for that input.

 

[tkim]

Again, anytime you'd care to discuss gunshot trauma further, please let me know.

Uh, like how many you've seen, or research you've done?

It's dick-swinging, either way.

 

[Sunfire]

Uh, like how many you've seen, or research you've done?

It's dick-swinging, either way.

Interesting way to look at it. I personally see it as education, something I'm always open to (or try to be).

I don't think I'm doing this thread any favors by giving these off-topic squabbles any fuel. Actually, I think I might just go start a gunshot trauma thread and see where that goes. Feel free to come pitch in, anyone!

 

[Therapist4Chnge]

So far all I've seen:

I'd really prefer to see some constructive discussion, and not make this a 'tape measure' type thread.

 

[bradt9881]

I don't think I'm doing this thread any favors by giving these off-topic squabbles any fuel.

As I already tried to point out to you. The best way to stop a troll is to ignore it, not rant....

 

[fab4fan]

I am glad to hear that the negative opinions of the pre-med posters on here are not the norm that people encounter. I work in a community health center with PAs, NPs and physicians who all collaborate on patient care and genuinely respect each other as providers.
I am EXTREMELY happy with my "role". Never wanted to go to Med School, never will. What I am unhappy with it the term "mid-level" provider. What am I in the Mid-level of? I am a nurse with an advanced degree, at the TOP of my profession, not in the middle. I'm not a middle level doctor (remember..didn't want to go to med school). Just my 2 cents.
BTW, Taurus, maybe you are unhappy and want to join us since you're always posting on this board!!

Wow...I can see Taurus's face melting, just like the Nazis' in that scene from Raiders of the Lost Ark. (I am borrowing that line from someone else--I read it somewhere once and thought it was great. If I could give it the appropriate attribution, I would. Now that I think about it, I think it's a Dave Barry line.) That was way too much hubris for "just a mid-level," let alone a mere NP. Not that I mind, since I'm even lower on the totem pole as an unworthy RN.

As far as dealing with difficult docs, most docs are reasonable. The bad ones out there, you just get to know what sets them off and, as dumb as it sounds, don't do what sets them off. There are always the very few who are flat out jerks that you can't work around--those you have to find your own way of dealing with.

 

[fab4fan]

So far all I've seen:

I'd really prefer to see some constructive discussion, and not make this a 'tape measure' type thread.

I'm saving that!

 

[bradt9881]

http://forums.studentdoctor.net/showthread.php?t=539389

I'm inbetween studying for Step II CK (T-8 days) and doing sub-I's so I don't have much time to spend on SDN these days.

Good luck on the exam. I have been using Exam Master to help prep for the PANCE; the step 1 and 3 questions are tough, but good prep in addition to the PANCE/PANRE section....

 

[8744]

We are all guests here, and should respect each other. I don't see anything at the top of my screen that says 'pants down and bend over'.

I can certainly understand the points you're making. I'm sure you can also understand the frustration that can result from the damage that some of the more immature posters at this forum often attempt to inflict. Yes, I'm a bit on guard. The point of this thread was in seeking advice in how to smooth over conflicts that may arise with difficult Doctors, not to discuss who considers who more difficult or to strengthen the agenda for students who simply want to disparage the PA and/or NP professions out of concern for their own egos.

I find it odd that some people would be unable to deal with the topic being discussed versus attempting to turn the tables to their upper hand, without responsible consideration of the topic before them. It's called empathy, and it's really not too tough to put into practice. That being said, it would be interesting and educational to hear what some experienced Doctors could relay back regarding some difficult PAs or NPs they've worked with and how they were able to resolve any conflict.

I have heard some of those horror stories that you mention, a bit of that has even been disclosed in this thread. I think such exploitation is a sad thing on the sides of more than one group involved (including the patients), and I would assume that it more often than not results in an eventual collapse of the attempted system. I guess in that case the pieces fall where they may, and life goes on. If that's the answer, that difficult Doctors are simply those who have the authority to hire their own PAs and NPs but don't truly want them, then things are a lot better than I thought, because I firmly believe they are the minority.

Again, it's good to know that my experiences up until this point have been the norm. Thanks for that input.

We had a PA arguing with our attending about admitting a patient. Both our attending and the PA's attending agreed to admit, the PA who was sent to write the orders didn't think is was a strong admission and didn't want to do it.

Well Katie bar the door! A weak admission for chest pain rule out? Why, it's unheard of! It's like this guy was trying to make a stand against the fifty percent of American medicine that is absolute bull****. This wasn't even a particularly weak admission anyway. No worse than the usual "Chest pain, negative enzymes, normal EKG, negative stress test, don't let the door hit you on the ass." This kind of thing is just a fact of life and if we didn't have plenty of these kinds of patients mid-levels would be out of a job.

The guy was making a scene and stormed off muttering darkly about his lack of an "MD" after his name. Now, how should my attending respond to that? It's not as if we can put in our chart, "Discussed with mid-level who says patient is OK for discharge and outpatient follow-up." That would go over well with the jury when the patient went home and is the one in a hundred who is really sick and the one in a thousand who drops dead. I see about 500 chest pains a year of which only maybe fifty are obvious, no question about it, ST elevation MIs. The rest are mostly nebulous and I don't like those odds.

 

[Sunfire]

Well, I guess it was two against one, so tough patooties. But why admit without some type of indicator? That strikes me as odd. If vitals are decent, labs come back negative, you can always get xray and CT and figure from there that it's probably gerd or some sort of muscle spasm, right? Surely you're not saying that you admit every nebula that comes through the door. There has to be more to the story, I'm sure of it. I'm not siding with the PA, please don't misinterpret. One of the ethical questions in two of my program interviews was along the lines of, 'what do you do if you're given instructions by a physician that you feel places the patient's health in jeopardy'? I said that I'd call for a second opinion before I did anything further, and trust me when I say that would apply just as much to a senior PA.

Causes of chest pain, that I can think of, could be:

MI
PE
dissected/transected aorta
endo/pericarditis
neoplasm
abscess
GERD
skeletal muscle spasm
psych-related

An ER MD told me a few weeks ago that he had never come across any sort of pulmonary or aortic aneurysm that presented as chest pain, and that when labs and scans all come back clear that GERD or muscle spasm is a good guess.

What signs was the patient exhibiting that made the attendings decide to admit in spite of, do you know?

 

[deleted6669]

at my facility we have a fairly low threshold to admit chest pain for further workup.
unless the story is obvious muscular(17 yr old with chest pain starting doing push ups) or obvious gi( it hurts when I eat habanero peppers only) then most folks over 30 with neg ekg and neg enzymes will get admited to our chest pain unit for ongoing telemetry, trending the enzymes, and repeating the ekg in 6 hrs. after the 2nd neg set of enzymes/ekg they get a stress test overseen by one of the em pa's. if we read it as negative and an attending we run it by reads it as neg the pt goes home with close f/u. if anyone thinks it's abnl a cardiologist does the 3rd read and either admits or d/c's the pt at that point.
we have actually caught some fairly significant cases of cardiac ischemia in low risk folks that sent them right to the cath lab for stenting....

 

[Sunfire]

Wow. Good to know.

 

[group_theory]

Well, I guess it was two against one, so tough patooties. But why admit without some type of indicator? That strikes me as odd. If vitals are decent, labs come back negative, you can always get xray and CT and figure from there that it's probably gerd or some sort of muscle spasm, right? Surely you're not saying that you admit every nebula that comes through the door. There has to be more to the story, I'm sure of it. I'm not siding with the PA, please don't misinterpret, I'm really just curious to know.
...

What signs was the patient exhibiting that made the attendings decide to admit in spite of, do you know?

It is the difference between reading/textbook/writing a paper and having actual experience in clinical situations. It is the difference between writing a paper on penetrating trauma and being part of the trauma team involved with a penetrating trauma. It is the difference between talking to someone about how one should run a trauma versus being the one who runs the trauma.

Why admit? Because people have been burned in the past. Because Panda Bear does not want to risk his licensure and more importantly his family's financial securities on the gamble that the 50 yo male with known GERD who is having mild epigastric pain does not have any cardiac related issues going on.

Clinical judgement is based on experiences as well as medical knowledge. Would you admit this DKA to the ICU or Intermediate Care unit? Is the patient stable enough to go home or admit to floor? Should I admit this sickle cell patient who has a fever?

 

[Sunfire]

Would you or anyone else rather I not have written that paper at all? Would that have been better?

How am I supposed to learn, if I don't do research and ask questions? I haven't yet had the opportunity to work in gunshot-related trauma, the ED I've been working in doesn't take traumas. Trust me, I know that what you are saying is completely true, it's just insulting to think you assume I don't know that already. However, there's still something to be said for research. I wouldn't have known about common medical issues of foster youth had I not written the paper. I'd rather try and know something about a situation before I'm ever possibly presented with it.

For your information, I went to the ER a few weeks ago with chest pain. My post above basically relayed everything that the MD and I worked through, from my own personal experience. I'm 37, and I wasn't admitted. So, is that enough of a validated curiosity for you? I do appreciate your explanation, but I really was looking more for specifics (thanks emedpa). My pain didn't continue as acute, so I'm thinking that's why I was let go...and that the decision was based on the knowledge and experience of the clinical provider who took care of me. At least, I certainly hope so!

And now that I have steered this thread completely off track...it's late and I'm cranky. Good night.

 

[dfk]

Would you or anyone else rather I not have written that paper at all? Would that have been better?

actually,
yes.

 

[bradt9881]

But why admit without some type of indicator? That strikes me as odd. If vitals are decent, labs come back negative, you can always get xray and CT and figure from there that it's probably gerd or some sort of muscle spasm, right?

When tests are not 100% sensitive and specific, there will always be some doubt. Physical exam can also be misleading. As one of my emergency preceptors pointed out to me, you can actually get reproducable chest wall tenderness in AMI patients. GI coctails that work can still be an AMI. H&P will give you roughly 85% of the picture, labs/radiology 10%, and that other 5% is experience and intuition. Its at that point you are going to have to apply a bit of experience and make the call. And on graduation, I will most certainly be running the case by my supervising physician for his input. Never ever forget, there is always some ambulance chaser out there ready to make you write out a check with a 1 and 7 zeros for making a mistake and causing a wrongfull death out there, and ruining your career.

 

[Taurus]

But why admit without some type of indicator? That strikes me as odd. If vitals are decent, labs come back negative, you can always get xray and CT and figure from there that it's probably gerd or some sort of muscle spasm, right? Surely you're not saying that you admit every nebula that comes through the door.

There's a very good reason why none of us are engaging you in clinical discussion. On the wards, it's an important skill to know when to ask questions and when to listen. Good luck in PA school.

 

[8744]

Well, I guess it was two against one, so tough patooties. But why admit without some type of indicator? That strikes me as odd. If vitals are decent, labs come back negative, you can always get xray and CT and figure from there that it's probably gerd or some sort of muscle spasm, right? Surely you're not saying that you admit every nebula that comes through the door. There has to be more to the story, I'm sure of it. I'm not siding with the PA, please don't misinterpret. One of the ethical questions in two of my program interviews was along the lines of, 'what do you do if you're given instructions by a physician that you feel places the patient's health in jeopardy'? I said that I'd call for a second opinion before I did anything further, and trust me when I say that would apply just as much to a senior PA.

Causes of chest pain, that I can think of, could be:

MI
PE
dissected/transected aorta
endo/pericarditis
neoplasm
abscess
GERD
skeletal muscle spasm
psych-related

An ER MD told me a few weeks ago that he had never come across any sort of pulmonary or aortic aneurysm that presented as chest pain, and that when labs and scans all come back clear that GERD or muscle spasm is a good guess.

What signs was the patient exhibiting that made the attendings decide to admit in spite of, do you know?

It was not "two against one," it was "two against zero." If my attending and the PA's attending had been in disagreement it would have been "one to one" with the tie going to the cardiologist who would have had to document that the patient was alright to discharge but the opinion of the mid-level in this matter is irrelevant except that his opinion was duly noted and rejected.

I'm a real, licensed physician but I wouldn't argue with my attending about an admission. I do give my opinion on whether the patient should stay or go (the fundamental question of Emergency Medicine) but once she decides I say, "Aye Aye Ma'am" and get the patient admitted. And I don't tell the admitting doctor, "My attending made me do it," if I think it is weak but take full responsibility as if it were my decision and "sell it" with all my heart.

The point is that the PA has nothing to lose and to him it was just a question of being tired and overworked and not wanting to do any more work towards the end of his day. It's was simple as that and highly unprofessional.

As for your differential diagnosis, well, those are all causes of chest pain but some can be excluded reasonably by history alone and some take a little more digging. We don't get a CTA of everybody with chest pain even though they may in fact have a PE or a dissecting aorta because then we'd be getting CTAs of everybody who walked in the door. You have to exercise a little clinical judgment. The patient in question had a typical story of vague, chest pressure associated loosely with exertion but reproducible, lasting hours at a time, and not associated with any nausea, sweating, or shortness of breath. No real risk factors except age and hypertension and completely normal EKG, first set of enzymes, chest xray, and electrolytes.

So what are you going to do? Outpatient stress test? Sure. In a reasonable world with no lawyers if he had good follow-up we'd set him up and send him home. Inpatient stress and then discharge the same day if negative? Again, very reasonable in a perfect world.

But a non-compliant, uninsured patient with no primary care doctor on a Friday afternoon after the techs have gone home? Not a chance. I have sent guys with worse stories than his for stress tests which came back positive and, after their heart caths, were found to have significant lesions in their coronaries. It takes just one patient to drop dead on you after discharge to lose your house, your income, and years off of your life. Malpractice carriers no longer cover you for everything and in some states, lawyers can and will go after your personal assets to make up the difference in what was awarded and what your policy covers.

So it's like this. If I see 200 "bogus" chest pains a year, that is, those who turn out to be nothing at all even remotely life threatening, if I am mistaken on just one a year I have a substantial risk in my lifetime of getting sued and sued big ten or twenty times in my career. Considering the consequences, it's not worth the risk to me.

 

[Sunfire]

actually,
yes.

...and I couldn't care less.


Thanks for all the info, from the licensed as well as the fully licensed , I'll do my best to make sure it's stored away up there for good.

I'm a real, licensed physician but I wouldn't argue with my attending about an admission. I do give my opinion on whether the patient should stay or go (the fundamental question of Emergency Medicine) but once she decides I say, "Aye Aye Ma'am" and get the patient admitted. And I don't tell the admitting doctor, "My attending made me do it," if I think it is weak but take full responsibility as if it were my decision and "sell it" with all my heart.

The point is that the PA has nothing to lose and to him it was just a question of being tired and overworked and not wanting to do any more work towards the end of his day. It's was simple as that and highly unprofessional.

That's good advice.

 

[Tired]

An ER MD told me a few weeks ago that he had never come across any sort of pulmonary or aortic aneurysm that presented as chest pain . . .

That's both staggering and pathetic.

Kind of like saying, "I've never run across a broken ankle that presented with medial malleolar swelling."

I have seen (literally) at least 10 in one year of internship training, counting both the TAAs and PEs.

Either the guy has a terrible memory, or he's missing a lot of diagnoses.

 

[deleted6669]

That's both staggering and pathetic.

Kind of like saying, "I've never run across a broken ankle that presented with medial malleolar swelling."

I have seen (literally) at least 10 in one year of internship training, counting both the TAAs and PEs.

Either the guy has a terrible memory, or he's missing a lot of diagnoses.

AGREE- it's a common presentation....

 

[Sunfire]

That's what I thought, especially after our AAA discussion emedpa, which was one of the reasons behind my hightailing it over there...maybe he was a newbie? He seemed like he was in his late 40s. I might have asked him if a pulmonary aneurysm would have shown as chest pain, and not the aortic, I can't remember...but I'm thinking an aneurysm anywhere in the thoracic would still be an aneurysm...in the end, he said they reviewed my CT and that nothing looked unusual, so that was good enough for me...

 

[schutzhund]

Pulmonary aneurysm? Your "ER MD" that has never heard of Fourniers or hasnt seen a thoracic aneurysm is either a) a complete ***** b) purchased a medical degree online c) isn't a qualified ER doc.

Look Sunfire, I've been trying really hard not to bash you but you are really asking for it. Dude, you don't know jack about jack. That's fine. Your a pre-PA student. Nobody expects you to know anything. The problem is you come to this site, try to impress us with all your hours in some ER, with your community college papers on whatever and then bash people with real experience and call them "bad doctors."

Do you know who is the worst PA (or doc for that matter)? The one that thinks he knows everything. You know almost nothing about medicine now and you still wont know a fraction of medicine when you get done with your training. Do you really think you should argue with residents about medical management? Really???? Are you really that clueless? If you continue with the attitude you have you will be a very dangerous practitioner and the kind of PA that makes the others look bad.

Again, I don't hate PAs but these kind of threads make me have a negative impression of the field.