Requirements

[Chickenandwaffles]

So i'm finishing completing my requirements for my new residency program. I have titers for Hep B which shows I'm immune to Hep B. I've never had Hep B either. They have some NP chick checking requirements, and she's telling me that I need "proof" of having received the vaccines.

How is someone that supposedly should have medical knowledge be so clueless as to not understand these basics that if you have titers proving immunity, you are IMMUNE to hep B!!!

I don't want to be rude and point out the obvious, but my first initial gut reaction says, "you are ******ed, get a clue" which obviously I won't say. But I'm tempted to ask her to check with a physician if she is unclear on how this works.

How do I go about this?

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[Shikima]

Just tell her the titers are the proof.

 

[VA Hopeful Dr]

I feel your pain. I have a pre-employment physical tomorrow for a new job and was told I'd be getting a PPD placed. They then said that I couldn't read it, nor could anyone in my office, since "we're not specially trained to read PPDs".

Infuriating.

 

[BlondeDocteur]

The titers are all that's needed for occupational health. In fact they're much stronger proof than some potentially faked record of administration saying you received the series 8+ years ago. If she still doesn't get it then you absolutely should contact the occ med director.

 

[Chickenandwaffles]

The titers are all that's needed for occupational health. In fact they're much stronger proof than some potentially faked record of administration saying you received the series 8+ years ago. If she still doesn't get it then you absolutely should contact the occ med director.

Cool. This is why no one other than doctors should be practicing medicine. Mid-levels have no basic understanding of medicine. They just basically do as written on a sheet of paper. I noticed that on the materials it asks for titers and proof of vaccination, which is probably a mistake. She's regurgitating information, which she clearly does not understand what titers are.

I remember even my current program checking titers since I told them I was pretty sure that I'd gotten all my vaccines but didn't remember dates/times and they said well we are not immunizing you again if no need, we'll get titers and go from there.

 

[Chickenandwaffles]

I feel your pain. I have a pre-employment physical tomorrow for a new job and was told I'd be getting a PPD placed. They then said that I couldn't read it, nor could anyone in my office, since "we're not specially trained to read PPDs".

Infuriating.

It is. That is why I have no qualms in being blunt with nurses and other midlevels who are clueless. I have a number of skin issues for examples, and get a reaction from PPDs, not because they are +, but because of my weird condition. The PPD always gets red but is never raised but nurses always think it's positive just because it's red. I have explained this numerous times, and ALWAYS have to get an attending to read the PPD because they can't understand this basic concept. I even asked to get a quant gold as this has been done a number of items in order to avoid this issue and I was recently told "It's too $$. We can't do it here" I said ok how $$ is it, because it's been done before. The answer "I don't know." Why tell me it's $$ if they have no clue how much it is? These people should not be practicing medicine in any capacity.

 

[Raryn]

I had an LVN yesterday arguing with me that she couldn't give Pneumovax and Zostavax to the same patient on the same day. Even after I brought up the CDC guidelines that it was perfectly fine, and the one small study that showed otherwise was considered to be clinically irrelevant by the CDC and various professional orgs of geriatricians, she refused. Said her RN told her she can't. And when I brought it up with the RN, she said she'd email their supervisor with the question but she wouldn't do it either.

Obviously by that time the patient was leaving, so hopefully he comes back to get his other shot at some point...

 

[Chickenandwaffles]

I had an LVN yesterday arguing with me that she couldn't give Pneumovax and Zostavax to the same patient on the same day. Even after I brought up the CDC guidelines that it was perfectly fine, and the one small study that showed otherwise was considered to be clinically irrelevant by the CDC and various professional orgs of geriatricians, she refused. Said her RN told her she can't. And when I brought it up with the RN, she said she'd email their supervisor with the question but she wouldn't do it either.

Obviously by that time the patient was leaving, so hopefully he comes back to get his other shot at some point...

yep. This is what happens when you have pseudo-health care workers. They don't know what they are doing, because they have no clue about the basics of medicine. It is outright dangerous. It's pseudo science, based on some sort of poorly thought out chart type scenario, where if anything deviates, they have no clue what to do.

 

[NotAProgDirector]

It is. That is why I have no qualms in being blunt with nurses and other midlevels who are clueless. I have a number of skin issues for examples, and get a reaction from PPDs, not because they are +, but because of my weird condition. The PPD always gets red but is never raised but nurses always think it's positive just because it's red. I have explained this numerous times, and ALWAYS have to get an attending to read the PPD because they can't understand this basic concept. I even asked to get a quant gold as this has been done a number of items in order to avoid this issue and I was recently told "It's too $$. We can't do it here" I said ok how $$ is it, because it's been done before. The answer "I don't know." Why tell me it's $$ if they have no clue how much it is? These people should not be practicing medicine in any capacity.

To be fair, the reason most occ med systems based in hospitals will not allow outside providers to read PPD's is for the reason you state above -- they often screw it up, and then by the time Occ Med actually gets to see it, it's outside the window where it should be read. "Not specially trained to read PPD's" = we've seen too many people screw it up, so we stop letting anyone else do it. They usually don't let you read your own PPD since some people would report a negative test even if positive, to avoid the testing/treatment that follows.

All that said, I agree that some health care providers come up with rules / systems / plans that simply make no sense at all. I have seen the "no two vaccines on the same visit", usually explained with "if they have a reaction, we wouldn't know which vaccine it was". Although that is true, my answer is usually: 1) Serious vaccine reactions are quite rare; 2) Minor vaccine reactions are common, and not a reason to stop using the vaccine; 3) the downside of the patient never getting the other vaccine is quite high; 4) if they really do have a serious reaction, not getting either vaccine again is really not a big deal; 5) if they get a serious reaction to one vaccine, they usually refuse all future vaccines anyway; and 6) they do it to kids all the time.

 

[Chickenandwaffles]

To be fair, the reason most occ med systems based in hospitals will not allow outside providers to read PPD's is for the reason you state above -- they often screw it up, and then by the time Occ Med actually gets to see it, it's outside the window where it should be read. "Not specially trained to read PPD's" = we've seen too many people screw it up, so we stop letting anyone else do it. They usually don't let you read your own PPD since some people would report a negative test even if positive, to avoid the testing/treatment that follows.

All that said, I agree that some health care providers come up with rules / systems / plans that simply make no sense at all. I have seen the "no two vaccines on the same visit", usually explained with "if they have a reaction, we wouldn't know which vaccine it was". Although that is true, my answer is usually: 1) Serious vaccine reactions are quite rare; 2) Minor vaccine reactions are common, and not a reason to stop using the vaccine; 3) the downside of the patient never getting the other vaccine is quite high; 4) if they really do have a serious reaction, not getting either vaccine again is really not a big deal; 5) if they get a serious reaction to one vaccine, they usually refuse all future vaccines anyway; and 6) they do it to kids all the time.

What about the ******ed NP woman who doesn't realize that having titers is more than enough proof of having immunity to hep B?

 

[Top Gun]

So i'm finishing completing my requirements for my new residency program. I have titers for Hep B which shows I'm immune to Hep B. I've never had Hep B either. They have some NP chick checking requirements, and she's telling me that I need "proof" of having received the vaccines.

How is someone that supposedly should have medical knowledge be so clueless as to not understand these basics that if you have titers proving immunity, you are IMMUNE to hep B!!!

I don't want to be rude and point out the obvious, but my first initial gut reaction says, "you are ******ed, get a clue" which obviously I won't say. But I'm tempted to ask her to check with a physician if she is unclear on how this works.

How do I go about this?

Yet another reason why NPs shouldn't be allowed to practice medicine without supervision by an MD.

 

[Chickenandwaffles]

Yet another reason why NPs shouldn't be allowed to practice medicine without supervision by an MD.

Yes, thank you dude, this is exactly my point. The lack of *basic* knowledge in medicine that they have is truly terrifying. How can these people practice by themselves?

 

[VA Hopeful Dr]

To be fair, the reason most occ med systems based in hospitals will not allow outside providers to read PPD's is for the reason you state above -- they often screw it up, and then by the time Occ Med actually gets to see it, it's outside the window where it should be read. "Not specially trained to read PPD's" = we've seen too many people screw it up, so we stop letting anyone else do it. They usually don't let you read your own PPD since some people would report a negative test even if positive, to avoid the testing/treatment that follows.

And I could get behind that idea if my response had been something like "I'm going to get my 2nd cousin to read this, he's an OR tech". But to not allow either my staff, who reads at least one of these a week, or my partner, y'know a doctor, is infuriating.

 

[Chickenandwaffles]

And I could get behind that idea if my response had been something like "I'm going to get my 2nd cousin to read this, he's an OR tech". But to not allow either my staff, who reads at least one of these a week, or my partner, y'know a doctor, is infuriating.

I am totally with you. Again who is likely to read it correctly, the physician or the nurse? The doctor. In my case as I said, they always have to bring a doctor to read it ultimately. It's a terrible waste of time. In part, I have noticed midlevels are terrified of doing something wrong/screwing up, "not doing as they have been told" because they have no idea what they are doing or the real reason why they are doing something.

 

[colbgw02]

I see the PPD thing as purely an issue of liability. The provided explanation notwithstanding, I don't think it really has anything to do with being better or more qualified to read the skin test. I would imagine they just want all of their paperwork lined up correctly in case an employee seroconverts, yada...yada...yada...

The positive titer question is different because it's just an issue of ignorance. Something similar happened to me, whereby my initial series of vaccinations weren't adequately documented. I checked out okay with the titer, so case closed, right? Nope, for some reason the "system" didn't show me as immune for another 3 years. Any time I had some sort of occ. med. check up, I ended up getting another HBV vaccine. Technically, I was given a choice - redraw a titer vs. booster, but I would have had to come back a second time to follow-up on the titer results, and who's got time for that in residency?

 

[Chickenandwaffles]

I see the PPD thing as purely an issue of liability. The provided explanation notwithstanding, I don't think it really has anything to do with being better or more qualified to read the skin test. I would imagine they just want all of their paperwork lined up correctly in case an employee seroconverts, yada...yada...yada...

The positive titer question is different because it's just an issue of ignorance. Something similar happened to me, whereby my initial series of vaccinations weren't adequately documented. I checked out okay with the titer, so case closed, right? Nope, for some reason the "system" didn't show me as immune for another 3 years. Any time I had some sort of occ. med. check up, I ended up getting another HBV vaccine. Technically, I was given a choice - redraw a titer vs. booster, but I would have had to come back a second time to follow-up on the titer results, and who's got time for that in residency?

Yeah, but that's different. I submitted not one, but TWO, titers showing immunity to Hep B since I could not find the original paperwork when I started my current residency, so they took a titer. Then I also found my OLD papers with the titer showing immunity, so BOTH of them demonstrate titers that show immunity to hep B. When I'm 60 or whatever are they also going to ask me for "proof" of when I got vaccinated, 40 years in the past? That's just plain stupid. The tiers are by far the best proof. In fact, a small % of people even after being vaccinated are still not immune, so just getting the vaccines in and out of itself is worthless for a certain % of the population. The titer for sure will demonstrate whether I have immunity or not. I would imagine any doctor would know that. NP has no freaking clue. I even went the extra mile and explained that a titer is all the proof that is needed to demonstrate immunity. If she doesn't get that simple concept, I will simply go over her simple head and talk to the Occupational health director as BlondeDocteur suggested, because my patience with these fake healthcare practitioners is running low.

I can understand that they may not know more complex things, sure. But give me a break this is incredibly basic, and they are supposed to be in charge of checking this!!!!!

It's as if I'm a neurosurgeon and I don't know how to perform a craniotomy. Gimme a break!

 

[Law2Doc]

Just a probably stupid question -- and forgive me for forgetting most of what I learned in my virology classes. if one had a chronic shouldering case of hepatitis might one also have positive titers without clinical symptoms? Wouldn't evidence someone's titers were caused by a vaccine distinguish this?

 

[colbgw02]

Yeah, but that's different. I submitted not one, but TWO, titers showing immunity to Hep B since I could not find the original paperwork when I started my current residency, so they took a titer. Then I also found my OLD papers with the titer showing immunity, so BOTH of them demonstrate titers that show immunity to hep B. When I'm 60 or whatever are they also going to ask me for "proof" of when I got vaccinated, 40 years in the past? That's just plain stupid. The tiers are by far the best proof. In fact, a small % of people even after being vaccinated are still not immune, so just getting the vaccines in and out of itself is worthless for a certain % of the population. The titer for sure will demonstrate whether I have immunity or not. I would imagine any doctor would know that. NP has no freaking clue. I even went the extra mile and explained that a titer is all the proof that is needed to demonstrate immunity. If she doesn't get that simple concept, I will simply go over her simple head and talk to the Occupational health director as BlondeDocteur suggested, because my patience with these fake healthcare practitioners is running low.

I can understand that they may not know more complex things, sure. But give me a break this is incredibly basic, and they are supposed to be in charge of checking this!!!!!

It's as if I'm a neurosurgeon and I don't know how to perform a craniotomy. Gimme a break!

Yes, I understand it's different. That's why I said something similar happened to me, not that something identical happened.

I think it's fine to go over the NP's head, and it's fine to use SDN to vent. I just wouldn't let the latter sneak too much into the former when you speak to the director.

 

[Chickenandwaffles]

Just a probably stupid question -- and forgive me for forgetting most of what I learned in my virology classes. if one had a chronic shouldering case of hepatitis might one also have positive titers without clinical symptoms? Wouldn't evidence someone's titers were caused by a vaccine distinguish this?

You can distinguish natural infection immunity (from having had Hep B) vs. vaccine immunity (my situation) from the types of antigens and antibodies that will show up on the titer. My titer shows that Ag/Ab that demonstrate immunity from vaccination. So if NP chick would know something basic like this OR would care to look it up OR ask someone who would know, then this would be a non-issue. But she probably doesn't even understand this.

 

[Raryn]

Just a probably stupid question -- and forgive me for forgetting most of what I learned in my virology classes. if one had a chronic shouldering case of hepatitis might one also have positive titers without clinical symptoms? Wouldn't evidence someone's titers were caused by a vaccine distinguish this?

Normally when you check anti hep B surface antibody you'll also get a Hep B antigen level and possibly an anti hep B core antibody along with it. If the former is + and the latter is negative, you're immune and not infected. The anti-core antibody does also give the information if you're immune from vaccination or from natural exposure, but as long as the antigen is negative you're not actively infected.

That said, I have no idea which hep B panel occ health checks at the gazillion hospitals around the country, but I doubt they check just an anti surface antibody alone.

 

[BlondeDocteur]

Btw I think the rule re: PPDs is a good one, even if it's logistically annoying. We would all otherwise just get our residency buddies to sign off. This way Occ Med has quality control-- the reading was done in the correct window of time, by someone who really does see a lot of them. [Not being in ID, I've never actually seen a positive PPD in real life, just textbok pics].

 

[VA Hopeful Dr]

Just a probably stupid question -- and forgive me for forgetting most of what I learned in my virology classes. if one had a chronic shouldering case of hepatitis might one also have positive titers without clinical symptoms? Wouldn't evidence someone's titers were caused by a vaccine distinguish this?

I'm not sure you can have a positive surface antibody and still be actively infected

 

[Raryn]

I'm not sure you can have a positive surface antibody and still be actively infected

You can most certainly have a positive surface antibody and still be infected. You just also have a positive surface antigen.

 

[VA Hopeful Dr]

You can most certainly have a positive surface antibody and still be infected. You just also have a positive surface antigen.

Just hit up to date (which I should have done before opening my big mouth) and you're absolutely right. Apparently that's the "carrier" state for hep B.

 

[Elisabeth Kate]

I think it's fine to go over the NP's head, and it's fine to use SDN to vent. I just wouldn't let the latter sneak too much into the former when you speak to the director.

Ditto. I'd eliminate the word "******ed" from my vocabulary (and demeanor). And throw out the word "chick" too.

 

[CaptainSSO]

You can most certainly have a positive surface antibody and still be infected. You just also have a positive surface antigen.

Do you have a source for that? I was always under the impression that anti-HBsAg indicated immunity, either due to vaccination or recovery.

http://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf

 

[deleted116380]

Do you have a source for that? I was always under the impression that anti-HBsAg indicated immunity, either due to vaccination or recovery.

http://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf

Your own link explains the HBsAg is found only in acutely or chronically infected patients and not vaccination (the antigen). The chart you link correctly shows in vaccinated patients, only anti-Hep B surface antibodies are present. Not just the antigen (Ag) or core antibodies.

 

[CaptainSSO]

Your own link explains the HBsAg is found only in acutely or chronically infected patients and not vaccination (the antigen). The chart you link correctly shows in vaccinated patients, only anti-Hep B surface antibodies are present. Not just the antigen (Ag) or core antibodies.

Yes, I get that...perhaps I could have been clearer but what I meant to refer to was the simultaneous presence of Hep B surface antigen and Hep B surface antigen antibody.

But he was right, it does happen about 10% of the time in pts with chronic Hep B infection. It appears to be some sort of immune escape phenomenon of the surface antigen.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1395421/#!po=29.0816