Metformin PRN?!?!

[flightnurse2MD]

Last day of my family medicine rotation and I had a nurse practitioneer for my final patient of the day. Of course, she corrected me when I called her Mrs. instead of "Dr." She had been a diabetic for many years and we went over her insulin regimen. Apparently, she "tweaked" her own sliding scale and told me she takes metformin "as needed" and lispro at bedtime. Wtf? Do they not teach NPs about metformin increasing the sensitivity of insulin action? Did she not know lispro is a short-acting agent which provides absolutely no benefit at night when it should be given before a meal? And to think she corrected me on calling her a Dr. Classic....

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[Ismet]

Did you ask her why she does those things? You're going to see a lot of patients who have very poor understanding of their disease (yes even people in healthcare) and the first step towards helping them is for you to understand their misunderstanding. Also good practice for you to do some diabetes education. Maybe she'll listen, maybe she won't, but good learning and practice for you either way.

 

[Tenk]

Should have corrected her when she corrected you.

 

[Psai]

"No i meant what i said, Agatha"
-op

As a patient I don't introduce myself as doctor ever and I'm a real doctor. Not sure why these people have such a huge inferiority complex

 

[flightnurse2MD]

Did you ask her why she does those things? You're going to see a lot of patients who have very poor understanding of their disease (yes even people in healthcare) and the first step towards helping them is for you to understand their misunderstanding. Also good practice for you to do some diabetes education. Maybe she'll listen, maybe she won't, but good learning and practice for you either way.

I agree! But her telling me to address her as Dr. told me she wouldnt be up to any intervetions from a lowly medical student. So, I handed it off to my attending...

 

[flightnurse2MD]

"No i meant what i said, Agatha"
-op

As a patient I don't introduce myself as doctor ever and I'm a real doctor. Not sure why these people have such a huge inferiority complex

Word.

 

[Ismet]

I agree! But her telling me to address her as Dr. told me she wouldnt be up to any intervetions from a lowly medical student. So, I handed it off to my attending...

You never know. Maybe they don't go into mechanisms of action in DNP pharmacology courses. Maybe the doc that prescribed the metformin and insulin didn't explain their purpose and usage because they assumed she had that knowledge. And it seems like she hasn't done her own research (at least legitimate research) on this, so it really may just be lack of knowledge. Of course if someone is hostile or refusing to see you, then you get your attending, but it doesn't hurt to try first!

 

[Psai]

You never know. Maybe they don't go into mechanisms of action in DNP pharmacology courses. Maybe the doc that prescribed the metformin and insulin didn't explain their purpose and usage because they assumed she had that knowledge. And it seems like she hasn't done her own research (at least legitimate research) on this, so it really may just be lack of knowledge. Of course if someone is hostile or refusing to see you, then you get your attending, but it doesn't hurt to try first!

Sorry but if you're trying to get people to call you doctor, you should know the basics. You shouldn't need it to be explained to you by a student.

 

[W19]

"No i meant what i said, Agatha"
-op

As a patient I don't introduce myself as doctor ever and I'm a real doctor. Not sure why these people have such a huge inferiority complex

If the individual has a DNP, he/she is a DOCTOR .

 

[Lord_Vader]

If the individual has a DNP, he/she is a DOCTOR .

They should be called inferior doctor or second class doctor then because in all healthcare settings where MDs and NPs work together, MDs are always the superiors and bosses of NPs.

 

[Raryn]

Last day of my family medicine rotation and I had a nurse practitioneer for my final patient of the day. Of course, she corrected me when I called her Mrs. instead of "Dr." She had been a diabetic for many years and we went over her insulin regimen. Apparently, she "tweaked" her own sliding scale and told me she takes metformin "as needed" and lispro at bedtime. Wtf? Do they not teach NPs about metformin increasing the sensitivity of insulin action? Did she not know lispro is a short-acting agent which provides absolutely no benefit at night when it should be given before a meal? And to think she corrected me on calling her a Dr. Classic....

You're absolutely correct that the PRN metformin is nonsense and I do feel sorry for that NPs patients. Hopefully she doesn't treat diabetics. Metformin has a very complex mechanism, acting on a lot more bits than just insulin sensitivity, but none of them are really a short-term thing that you'd use prn.

As for the bedtime insulin... You could argue about the appropriateness depending on the patient's overall regimen. If the lispro is primarily given via sliding scale (or "correctional insulin"), it can sometimes make sense to give it at bedtime. You can think of the short acting insulin as given either for food or for the sugar already in the blood. Insulin administered via a fixed dose or by a carb ratio covers the food you're about to eat while a sliding scale covers the sugar that's in your blood already. You can take an extra dose of sliding scale before bedtime if you're running a little high at that time and we commonly do that in the hospital (and with some of our more motivated patients)... in addition to a basal (which can be taken any time of day really, bedtime is just traditional) and a bolus (with each meal).

Oh, and don't call women Mrs. Or Miss. Lots of people will be offended. Just stick with "Ms" ("Miz") for every woman, no matter now old, and if they correct you that they want to be preferred to be called Dr. (or any other professional title), just accept it. I'll never call a Doctor of Nursing Dr. where they're employed in a clinical setting, but I'm happy to call my patients Dr. if they earned the title, whether they're a Doctor of Nursing, SocialWork, English, or Underwater Basketweaving. I have a few college professors as patients that I call Dr. Whatever.

DNPs are welcome to put Dr. on their credit cards and introduce themselves as Dr. at restaurants and when teaching a class. More power to them. They earned a doctorate. They just shouldn't be able to demand they be called that when they're acting as a professional in a clinical setting any more than a PhD in English Literature who happens to be a respiratory therapist should be able to. In that setting, a Dr. implies being a physician (or dentist/podiatrist in limited circumstances).

 

[Ismet]

Sorry but if you're trying to get people to call you doctor, you should know the basics. You shouldn't need it to be explained to you by a student.

She has a doctorate. She's not a physician. The Mrs. title is technically incorrect as she has earned the title conferred to her by her degree. Personally I wouldn't correct someone who called me "Miss" or whatever, but hey if that's what she wants to be called, so be it. She's a patient in this setting, not providing care, so it's not like it's confusing anyone.

 

[Psai]

All I'm saying is that I've had multiple physicians under my care including academic physicians at my center and none of them have ever told me to call them Dr. whatever

I will call you whatever you want but I will look down on you for it

 

[akinetopsia]

All I'm saying is that I've had multiple physicians under my care including academic physicians at my center and none of them have ever told me to call them Dr. whatever

I will call you whatever you want but I will look down on you for it

It's funny how that works. Physicians are always like, "Hi, I'm Chris/Christina" and not "Hi, I'm Dr. Smith."

 

[julie walker]

They should be called inferior doctor or second class doctor then because in all healthcare settings where MDs and NPs work together, MDs are always the superiors and bosses of NPs.

 

[julie walker]

Last day of my family medicine rotation and I had a nurse practitioneer for my final patient of the day. Of course, she corrected me when I called her Mrs. instead of "Dr." She had been a diabetic for many years and we went over her insulin regimen. Apparently, she "tweaked" her own sliding scale and told me she takes metformin "as needed" and lispro at bedtime. Wtf? Do they not teach NPs about metformin increasing the sensitivity of insulin action? Did she not know lispro is a short-acting agent which provides absolutely no benefit at night when it should be given before a meal? And to think she corrected me on calling her a Dr. Classic....

That's an indication of low self-esteem. She is a simple patient. She yearns for recognition that's why she is making sure you acknowledge her title...smh.

 

[jw3600]

Oh, and don't call women Mrs. Or Miss. Lots of people will be offended. Just stick with "Ms" ("Miz") for every woman, no matter now old, and if they correct you that they want to be preferred to be called Dr. (or any other professional title), just accept it. I'll never call a Doctor of Nursing Dr. where they're employed in a clinical setting, but I'm happy to call my patients Dr. if they earned the title, whether they're a Doctor of Nursing, SocialWork, English, or Underwater Basketweaving. I have a few college professors as patients that I call Dr. Whatever.

DNPs are welcome to put Dr. on their credit cards and introduce themselves as Dr. at restaurants and when teaching a class. More power to them. They earned a doctorate. They just shouldn't be able to demand they be called that when they're acting as a professional in a clinical setting any more than a PhD in English Literature who happens to be a respiratory therapist should be able to. In that setting, a Dr. implies being a physician (or dentist/podiatrist in limited circumstances).

I think this is a generational thing and I'm quite glad. Titles themselves (outside of professional settings) are just a ridiculous concept. It's archaic thinking to think that the correct title or EVEN a title is required to show respect. It's quite easy to call someone Jim and be 100% courteous and professional.

 

[NickNaylor]

It's funny how that works. Physicians are always like, "Hi, I'm Chris/Christina" and not "Hi, I'm Dr. Smith."

If I'm treating someone that I know is a physician (very rare - I have only had this happen once or twice), I will refer to them as Dr. X. Part of it is that I have respect for the "hierarchy" of medicine - something that I know is not a popular opinion around here. For the same reason I refer to recently graduated residents that are now my attendings as Dr. X when, just a few months ago, I referred to them by their first name. If we're in a social setting, that's something else. But in clinical settings - even if a physician is a patient - I will refer to them by their title.

But I suspect that I'm a bit more uppity than most.

 

[QualityProcess]

But I suspect that I'm a bit more uppity than most.

in health care, being formal is just the smart thing to do. call people with doctorates doctor. address people by last name until invited to do otherwise. buy into the hierarchy until you get an indication that it's ok to act differently.

then go home and log in to sdn and vent about how you hate calling your patients with DNP degrees "doctor" and hate dealing with 10 phone calls/day about VIP patients and hate patient survey scoring. we empathize here

 

[Raryn]

I think this is a generational thing and I'm quite glad. Titles themselves (outside of professional settings) are just a ridiculous concept. It's archaic thinking to think that the correct title or EVEN a title is required to show respect. It's quite easy to call someone Jim and be 100% courteous and professional.

It's not archaic to show respect to your patients by referencing them in a formal manner unless explicitly told otherwise. And a formal manner is Mr or Ms X, with a higher title if they're entitled to it.

 

[jw3600]

It's not archaic to show respect to your patients by referencing them in a formal manner unless explicitly told otherwise. And a formal manner is Mr or Ms X, with a higher title if they're entitled to it.

You literally just repeated your opinion. I acknowledge you feel that way.

 

[username456789]

If I'm treating someone that I know is a physician (very rare - I have only had this happen once or twice), I will refer to them as Dr. X. Part of it is that I have respect for the "hierarchy" of medicine - something that I know is not a popular opinion around here. For the same reason I refer to recently graduated residents that are now my attendings as Dr. X when, just a few months ago, I referred to them by their first name. If we're in a social setting, that's something else. But in clinical settings - even if a physician is a patient - I will refer to them by their title.

But I suspect that I'm a bit more uppity than most.

There is nothing uppity about any of that. That is how I handle things and believe they should be handled by everyone in a similar situation.

 

[VA Hopeful Dr]

You literally just repeated your opinion. I acknowledge you feel that way.

A) Your future patients will feel that way too

B) Basic courtesy isn't an opinion

 

[jw3600]

A) Your future patients will feel that way too

B) Basic courtesy isn't an opinion

My future patients might feel that way. At that point in time we will see where society is to see if I have to adapt.

What does your second point mean? I feel like true genuine courtesy is always the best even without use of title.

 

[VA Hopeful Dr]

My future patients might feel that way. At that point in time we will see where society is to see if I have to adapt.

What does your second point mean? I feel like true genuine courtesy is always the best even without use of title.

Or you can do what we've been doing for the last 50+ years and call people by title when first meeting them which is what basic courtesy distates.

 

[W19]

Americans are fixated on title and prestige... Why do people think we have PharmD, DPT, DNP etc...?

 

[VA Hopeful Dr]

Americans are fixated on title and prestige... Why do people think we have PharmD, DPT, DNP etc...?

An expected consequence of so much of our identity being tied up in our jobs, I think.

 

[akinetopsia]

If I'm treating someone that I know is a physician (very rare - I have only had this happen once or twice), I will refer to them as Dr. X. Part of it is that I have respect for the "hierarchy" of medicine - something that I know is not a popular opinion around here. For the same reason I refer to recently graduated residents that are now my attendings as Dr. X when, just a few months ago, I referred to them by their first name. If we're in a social setting, that's something else. But in clinical settings - even if a physician is a patient - I will refer to them by their title.

But I suspect that I'm a bit more uppity than most.

I guess what I meant was doctors are just as likely as other members of the healthcare team to introduce themselves with their first name whether they are a patient or working. At least, that's what I've noticed. But I agree, absolutely, I will refer to doctors as "Dr. ____" until they tell me otherwise, e.g. "please call me John/Jane" out of respect.

 

[AlbinoHawk DO]

They should be called inferior doctor or second class doctor then because in all healthcare settings where MDs and NPs work together, MDs are always the superiors and bosses of NPs.

I like the term Noctor then if they complain ask them if they are embarassed of their nursing roots.

 

[cbrons]

"No i meant what i said, Agatha"
-op

As a patient I don't introduce myself as doctor ever and I'm a real doctor. Not sure why these people have such a huge inferiority complex

BC they are inferior

 

[cbrons]

If the individual has a DNP, he/she is a DOCTOR .

In a health care setting in this state they aren't

 

[Raryn]

In a health care setting in this state they aren't

They aren't as providers, and if I were referencing another employee I'd never call them Dr.

But I have had patients that are college professors with PhDs in physics and other completely nonclinical fields. I still address the patient to their face as Dr. X unless they tell me not to.

 

[GoljansRightBicep]

I'll never call a Doctor of Nursing Dr. where they're employed in a clinical setting, but I'm happy to call my patients Dr. if they earned the title, whether they're a Doctor of Nursing, SocialWork, English, or Underwater Basketweaving. I have a few college professors as patients that I call Dr. Whatever.

DNPs are welcome to put Dr. on their credit cards and introduce themselves as Dr. at restaurants and when teaching a class. More power to them. They earned a doctorate. They just shouldn't be able to demand they be called that when they're acting as a professional in a clinical setting any more than a PhD in English Literature who happens to be a respiratory therapist should be able to. In that setting, a Dr. implies being a physician (or dentist/podiatrist in limited circumstances).

Out of genuine curiosity, how do you deal with non-physician coworkers who want to be addressed as "Dr." in a clinical setting (like DNPs, PhDs, etc.)? This is a scenario that really grinds my gears because I feel that it's being intentionally deceptive to patients, but I honestly wouldn't even know how to begin to address this issue appropriately.

 

[Raryn]

Out of genuine curiosity, how do you deal with non-physician coworkers who want to be addressed as "Dr." in a clinical setting (like DNPs, PhDs, etc.)? This is a scenario that really grinds my gears because I feel that it's being intentionally deceptive to patients, but I honestly wouldn't even know how to begin to address this issue appropriately.

If they're a psychologist, dentist, or podiatrist? I call them Dr. They're the pre-eminent specialists in their field. Psychiatrists who also do therapy nonwithstanding (and I suppose orthopods who specialize in the ankle, but podiatrists are up there with them).

If they're a nurse or pharmacist? It's never happened to me. I think there might be a hospital policy against it. I'd probably refuse to give them that title in a clinical setting.

I'm not sure what to do with optometrists. I just call them whatever they introduce themselves as, but I honestly know jack-squat over how much training they actually get.

 

[jw3600]

They aren't as providers, and if I were referencing another employee I'd never call them Dr.

But I have had patients that are college professors with PhDs in physics and other completely nonclinical fields. I still address the patient to their face as Dr. X unless they tell me not to.

Ok from now on I want to you call me "Jerry the Great."