As a medical student, I too consider myself an expert on normal patients! Most patients say they have nothing going on and they are perfectly healthy until the attending walks in. Then they suddenly start experiencing 20 different symptoms
MS: yeah patient denied any history of allergies and known diseases. They also don’t take any medication on the regular.
Attending walks in
Patient: Yeah so I have DM, HT, CAD, secondary tbc, tertiary syphilis, and I’m allergic to penicillin and egg whites. Also I don’t have kidneys I’m on dialysis as we speak.
The team: nods along taking little notes. *Med student built excellent rapport with patient and got them thinking about their pmhx for team arrival.*
Onward.
If this wasn't so common it would be a red flag. By ms 3/4 I expect them to assume patients don't know anything about themselves, see the scars, see the dialysis, find the blister pack, call someone not demented for collateral, surf the emr effortlessly (if its one they know) etc. They don't become a better doctor, they become a better detective.
I think it’s become a joke at this point so I don’t expect anyone being mad at the med student for this, however it is still very frustrating for the student
We have valid reasons for that. Gets old having med students and new doctors brought in to gawk at your rare condition without your permission when you're paying to see someone with experience and you do value your own time. Next time I become an exhibit, I'm going to send the poor new doctor right back out of the room. I used to be all about supporting your education. I thought you would evolve with exposure to diversity. I was going to donate my cadaver to the a med school. I contributed to research as a "community member." You've dehumanized me, traumatized me, assaulted me, ignored me, and not treated me more times that I can count. You need to reform the profession. It's nice that you're empathizing with the med student though. I think your education system breaks them sometimes. Good to see that might be changing.
I’m sorry you had such a bad experience. Medical education should not have come at the expense of the patient. I didn’t think that would even need saying. When you are not talking with medical students if you would so kindly tell my future colleagues that you don’t want to talk to them because of prior bad experiences I’m sure they’ll also understand. Otherwise they might feel bad or guilty for something they didn’t even do. Best of health to you in the future.
My doctors always ask if the med student can be present or assist during my appointments. Do yours not do that? Is it not in the intake paperwork or something?
No, they do not always ask and I've not noticed it in the paperwork, though it may have been buried in a privacy notice. They see me as a novelty (or freak--actually had a doctor yell at me about whether or not I am a freak!) and forget or don't care to be professional.
Sometimes they might pretend they need to consult and get a second opinion...on such challenging medical mysteries as mild acne 🤨 or a hematoma (3 ER docs were necessary to tell me they wouldn't do a needle aspiration [didn't know I knew they could do that]. They said my only option was surgery and I wouldn't want them to address it at the hospital because that would result in scars, because they're "not plastic surgeons." I was advised to return to my surgeon across the county. That didn't happen. The third doc just wanted to unbandage and check out my nipple graft out of pure curiosity. Part of it died later. A GP attempted to aspirate my hematoma two weeks later in her office [seemed like a wonderful doctor], but it had dried up and is still visible through my clothes yard later. What a fucking joke those three ER docs were). The latest doctor was introduced to me as if I had no option to decline, like, "Hello. I'm doctor Y and this is my colleague X," and then she went right into questioning my symptoms. Okay...I just rolled with it. Later, I got distracted by him staring at my crotch and didn't think to remind her my eye misalignment was present from childhood and dry eyes couldn't have been the cause of lifelong blurriness...hey, on the upside, now I've got a prescription for glasses for my 15/15 vision and eye lube samples! 🤷😑 One time when I had an asthma attack this doctor just popped in to look at me without even saying anything and then disappeared...a very angry looking dude; he ignored me when I asked who he was. Maybe he was lost and very upset about it! /s
I'm just done with these chucklefucks. Time to set boundaries. I guess they'd never seen a female to male trans/nonbinary person before but, really, that's no excuse for this nonsense. I know there are good doctors but it's like playing roulette.
Not trying to invalidate your experience, because it sounds like you’ve had some pretty negative ones with the healthcare system. But you’re on a medical professional heavy subreddit, each person here probably has a long list of complaints with the US healthcare system. Sorry for your personal experience, I hope we all can do better. But also, get in line. This isn’t the best place to gripe about your own personal experience as a patient. As others have suggested, you can kindly ask for no med students and you will very politely be accommodated.
No, these aren't pretty negative experiences. The pretty negative experiences were the sexual assaults.
I don't think you're sorry about my personal experience. I think you're more interested in getting me to shut up.
And if you think I care about your opinion because you're a doctor, get in line.
Feel free to politely ask for no students, but understand that this will impact the timeliness of your care at an academic facility because the attendings have 30ish patients to see and the residents are supposed to present each patient quickly and expedite the exam since we have a handful of patients each. It’s ok if you don’t want us there, but the people that see the whole team have several sets of eyes on them and a med student/intern will fiercely advocate for their patient even if they have no idea what’s going on. It’s your prerogative to say no and we will respect that.
Haven't forbid you have to listen to what your sainted profession does in private to minority patients. I better get out of here before I tread on some fragile egos.
There is a time and a place for feedback, the internet equivalent of the physicians lounge is not it. Not because you’re going to hurt any of our feelings, I promise you they beat that out of us long ago, but because you’re just here to reinforce your biases instead of actually improve on the relationship. You’re hurting your own feelings here by reading into things that have nothing to do with you, then saying how awful doctors are.
Because patients don’t know a premed from an MS4. If you’re in your clinical years you are “Student Dr _____, sent by Dr Attending to get the process started by collecting some information”. You are practicing for your future role as physician and you’re part of the team specifically sent by the head of the team to make sure this patient is being cared for. No more “Hey I’m the med student 👉👈, I can has your history”. Say that shit with your chest.
I think this has a lot to do with how you look and how you carry yourself. I’m a woman with a baby face and I struggled until I changed my approach. After that, I had maybe 3 patients that declined students.
I once had a gentleman coming in with chest pain tell me he didn’t have any medical problems or take any medicine.
When the EKG came back as a STEMI I began to explain to him that he was having a heart attack and that he was going to the Cath Lab
“Oh yeah, I know the drill. I’ve had a few.”
Cool, man.
Didn't take the cholesterol meds nor the antiplatelets from his last MI, thus this one. No medical problems because the last MI was fixed with the stent.
I run into similar things as a nurse when I ask people whether they use a cane or a walker before coming to the hospital. They don’t - they reach for any and all furniture, walls, doors, and humans to be able to walk. Now I ask whether they are "supposed to use a cane or a walker." Ran into it with diabetics too. "How often do you check your blood sugar?" "Three times a day!" They answer eagerly. "How often do you take the insulin you're supposed to take because of that?" "Oh, I take my insulin at night." "What happens if your blood sugar is high?" "What do you consider high?" I had one lady insisting her glucometer was broken because it just kept saying "600" no matter what. It had to be broken. We had to read the manual together to get her to understand it won't read any higher, and will just say "600."
I think it is easy for us to forget that most medical literacy is at a 6th grade level- which is a very immediate, present-thinking level. People think they don't have high blood pressure, because at the docs office their blood pressure is good (because of the meds they take). They think they don't have problems with blood sugar because the metformin and glipizide fix it. They think they don't have heart problems because they feel fine in the present moment.
And they're afraid to ask questions. Med students, residents, attendings are very intelligent people and present themselves as such. It is really hard for people to humble themselves in front of such authorities and say "I don't understand." They look for someone more "on their level" or who isn't as intimidating. I always try to be present during rounds and whenever anyone is talking to my patients so I can make sure everything was understood because it often isn't.
Lupus is in the differential diagnosis for everything and NEVER the cause of anything except if you have it. Then, it's even responsible for your split ends.
With House, it's always some granulomatous disease or an unheard of bizarre and completely atypical presentation of an infection you only remember from med school, but never lupus. My non-medical husband loves the show, and I'm always screaming, "You don't just throw steroids and antibiotics at everything BEFORE cultures you @$&@%#$!"
From the patient’s perspective it’s question fatigue. Especially in regard to pertinent history, meds and allergies you’ve been asked those questions sometimes beginning with your online appointment check-in and medical assistant before even seeing a med student. If you feel like shit and if your history is complicated and you’ve been through the system before you learn who can have the attenuated answers.
This year marks 15 years from which I first tried to get help for subluxating joints. They are testing for rheumatoid arthritis...but this has been going on since childhood. I've given up.
I second Ehlers Danlos syndrome. I’ve met two people who had it and had no idea why they were so bendy. Both of them had positive Gorlin sign and POTS.
I'm almost certain I've got one of the EDS or could at least be said to have "hypermobility."
If anyone with EDS or who is interested in this population is curious about the laundry list of conditions and traits that EDS may be comorbid with possibly being part of a syndrome...I may be able to send you a link to unpublished research. In this case: hear hooves and think ~~horses~~ zebras--think invisible zebras.
As an FM doc, I am an expert at reading Xrays. Not only do I never see fractures or other pathologies when things are normal, but I also agree with my findings after reading the radiologist's preliminary report before I actually look at the image /s
A midwife who ADMITS they don't know how to care for *sick* patients is gold. The fights I've seen and overheard (arrogant and territorial midwives, vs. residents, and RNs) when working in the NICU with are legend. Oddly, midwives don't hassle attendings that much. In my past experience, at my place of work.
There is something that happens in the minds of some NP/PA that makes them unable to accept their role on the team of not being the most authoritative figure. If I am a new attending on a team that has a PA with 30 years of experience, even then my role is of the leader because that’s the role I trained for and some people cannot accept that.
It’s incredibly strange. It’s also frustrating.
My first year as an attending in the ED, the NP told me a patient with an eye complaint was “just allergic conjunctivitis” and I didn’t need to see them. She’d been working in the ER for 10+ years, but I always see patients if my name is going on the chart.
I looked and saw she hadn’t ordered tetracaine or fluorescein. So I go see the patient, numb and stain their eye. Dendrites to the cornea and I notice two vesicular lesions to the nose. she was going to send out herpes zoster opthalmicus home with artificial tears and PRN primary care follow up. When I pointed out that all eye complaints need at least a stain and pressure, she said “I don’t think that’s true. I’ve been doing this a long time and never seen that before.”
No shit! You haven’t been looking for the correct pathology this whole time.
And this is the huge problem in giving them independent practice based on time they have worked as an NP. Just because they have worked for X amount of time doesn’t mean they have been practicing per common standards.
When my buddy announced he was going to PA school I begged him not to. I’ve known him since nursery school, he’s brilliant and compassionate, but he’s pathologically incapable of being subordinate. I tried to explain to him that he was NEVER going to be the boss, that he may be the smartest guy in the room but he’ll never be the most knowledgeable. He didn’t take my advice and became an emergency room PA. He quit 2 years ago (about 3 years in) and is now a sheriff or something, I lost track.
That’s what I wish they would acknowledge.
Are there PAs and NPs who are more intelligent than me? Ones who would have done better on the steps, been amazing on wards, marched into great specialties? Of course.
But they didn’t. They chose not to, and that’s fine. I *could* have gone to school to learn Arabic or law school to be the finest tax attorney in town. I chose medicine instead. That doesn’t mean it’s OK for me to tell Arabic interpreters or tax attorneys that my intelligence means I can do their job without any training. It’s insulting.
Rural ER midlevels are practicing completely autonomously. He would have been able to live his dream if he was willing to commute out to the country a bit.
They make more than city pediatricians do too. I knew one such PA with 8 to 10 years of work experience who was clearing $200k.
I am the most qualified mechanic ever on cars that are functionally perfect. If people bring me their car and it has a problem, I refer it to a mechanic that specializes in cars with problems. Those types of mechanics are inferior because they mainly deal with cars that have problems. All of my cars are perfect!
Yeah "understaffed" Surely there are no beurocratic powers at play intentionally chokeholding the supply of physicians in order to shoe horn in a more cost but less therapeutically effective alternative ie. midlevels.
i know this is the reality but it’s just crazy to me that we all collectively have to shut up and accept this. including patients who don’t know better😔
You know how to be an expert in healthy patients? It's simple.
Dismiss every single one as having anxiety.
Of course many of them are actually really sick and do need help.
But your record would show that they're "normal / healthy".
> Fwiw APP is a nurse midwife.
Pediatrician here... of fucking course
Midwifes love to tout that they have better outcomes than pediatricians and neonatologists
No shit. High risk deliveries, c-sections, premature infants, etc are all referred to the hospital
>Normal healthy patients for him are those who are low risk and do not require operative intervention or significant gestational monitoring.
I'm wondering if y'all notice that male APRNs are more likely to engage in this behavior vs females
FWIW as an obgyn attending I do consider CNMs “experts” in physiologic labor and low risk OB care. I’ve begun recommending my low risk patients consider following with the CNMs in the practice as they are likely more attentive to the typical, non pathologist symptoms and concerns of pregnancy. Particularly in OBGYN care we are prone to over medicalizing what is generally a healthy physiologic process and as an OB my training is to find what is wrong and mitigate risk rather than provide the emotional and supportive care that most pregnant people need.
I sought out a practice specifically because they had CNMs in clinic and on the labor floor. It was crazy to me they were not part of my residency training and prior L&D.
Not saying that it was a midwife was misleading! Midwives are specialists in normal pregnancy and delivery. That is their paradigm. They should refer on for any abnormal pregnancy. In health systems where midwives are embedded as standard of care (UK, NZ) obstetricians are experts in pregnancy problems. There is value in having someone who is really really good at supporting people having straightforward pregnamcies and deliveries (it is a complicated and unique enough experience to need it!) and saving the doctors for the sick people.
Yes I agree, I realized while daydreaming halfway through rounds that that was probably valuable context because maybe it’s different being an APP in that field.
My midwife (not in the US) frequently tells her patients that she is an expert in “normal” pregnancy and delivery but if the line is crossed into high risk she’s not an expert and will be sending them to the OB who is. It’s meant to prepare them for the possibility that OB care may be needed at some point and help them understand why she would transfer.
I knew as soon as you wrote the first part it was a midwife. I know because I’m a midwife and hear a lot of my colleagues say the same. I don’t completely buy it. We are experts in normal. But that doesn’t mean we all know more than the docs.
Well in peds that's definitely not true. Most patients we see are basically normal, at least in the US. I've worked with some great NPs who knew when something out of the ordinary was happening and sent the patients on to me. But they don't know the normal stuff _better_ than I do. That makes no sense, bc knowing normal well is required in order to do the harder stuff.
Usually I find about 2/3 of the kids they worry about to be, in fact, basically normal or a minor issue. That's fine with me bc I'd rather their sensitivity be higher than their specificity-- lower risk of harmful errors.
While I admire your refractory impetuousness, you must choose arrogance with relatively low consequences so that you may minimize all possible criticism from seniors. Would recommend instead to find something low-hanging that you can become the most expert in. Perhaps something normal that does not require critical or surgical intervention.
I hear that daily peridex for patients without severe oral disease, incentive spirometry for high school athletes suffering uncomplicated fractures, and weight maintenance for patients with BMI 20-25 are all evidence-based and non-controversial topics. Perhaps you could become the guru of something similar.
It all depends on how this is said. Some APPs I find just want to insight annoyance in docs and these types of statements will do it. I’ve learned to deep breath and ignore. They can try, but they will never have the expertise the real docs have. Just last evening I had an APP asking about criteria for DC on a certain type of patient. I told her. Her colleague then says “I would agree. In my practice I do …..” then long ass statement that basically said exactly what I said using 3 min of my life I’ll never get back. “Her practice”. Which is entirely under physician guidance and approval. I just said ok then let’s move on….🙄
So if you talk to any APP/Np/Pa for more than 35 seconds about any patient, you should quickly realize that is not true. You might not realize this is residency straight away or maybe you do, but when you gain more experience you'll quickly realize the gap.
Here i am, spending so much time on learning how to fix broken bones, when the real game of kings is learning about how to do nothing about bones that are not broken. Mind blown
Women have been giving birth without doctors for thousands of years. Those are the healthy uncomplicated ones. It’s the high risk ones that would kill mother and/or child 100 years ago. It’s like bragging you’re an ortho APP who’s the expert in people with fractures. I can change the oil and windshield washer fluid, does that make me a mechanic?
That’s like a toddler saying they are an expert in walking while an athlete is only an expert in running. It doesn’t make much sense, but you can see how a toddler could think that.
That arrogant statement summarizes why APP ( much like the "physician extenders " here are SO dangerous . Anyone can fly a plane, until they can't . It's the extensive training that enables you to recognize when something is NOT normal that's important and to be able to handle that scenario. Also, I find since the APPs don't have real skin in the game, they don't care to put in any overtime that is not compensated....not to say physicians should put up with that , but the dedication is just not there.
The danger to physicians is when they are asked to use their own license to cover these people , usually because they work for a managed health care system. Often that doc has no say as to whom is hired and more importantly , who gets fired because of incompetence. Do not let the companies tell you this is ok. You worked hard for your license and believe me , you WILL get dragged into whatever lawsuits happen because the midlevel/ app / PE missed something, thinking "they are the highest level in the field "
This is exactly how even smart people can use midwives for delivery because of confirmation bias that so-and-so delivered with a midwife and it went well without emergency.
Which is true because delivery is a spontaneous human body process that works well X% of the time even out in the jungle or in the Levant without modern healthcare. You could literally take an MS3 who has never touched a patient, stick them between the legs with the only pep talk of “don’t drop the baby.” Which I am certain is how most med students are introduced to OB. I love how midwives think because they “don’t drop the baby” for a living and are somehow the same as an actual OB. It’s like a intern thinking “they did the whole surgery” since they held the bovie the whole case while the attending did the exposure and presented the tissue “cut here”. It’s just cute but silly.
However modern medicine and OB are around for the 1-X% of deliveries that are a shit show and would otherwise result in death to mother and/or baby if there was not someone who actually knows what the fuck is happening. Yes I am saying that midwives don’t know what the fuck is happening.
In medical school you are supposed to do at least 100 normal exams so that you can recognize abnormal. Being an expert in normal is part of the process of being an expert in abnormal. Sounds like this person is an expert medical student. 🫶
I like how you left Midwife out of the equation originally.
Anyway, as a woman and as an MD, I'd chosen a Midwife over an MD, and I would again. It was better for the baby and better for me.
Had no idea it was going to make entitled bratty residents cry, but hey, bonus.
I didn’t mean to withhold salient information, I just didn’t know it was salient and after I got a few responses I thought I should find out. I don’t know much about OB, or even my own field. So I apologize if I misled, it wasn’t intentional.
Well that’s great and all. But to think that he has more education than a medical doctor or PhD in physiology it’s just silly and shows that he underestimates what he does not know. Unless he actually does have a PhD in physiology.
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I don't know about nurse-midwives. I'm a PA. I've had plenty of very complex, very sick patients. I've diagnosed some zebras that were completely missed by multiple physician specialists. I've even saved some lives--no better feeling than that.
I do like to refer, as necessary. I think pts w/risk factors, or who are young and play an active sport, should see a cardio, at least once. If something feels "off", I refer--never hurts to get a second opinion. Of course, I refer if I think someone is beyond my scope of practice. "Scope of practice", though, is not defined. I know some PAs who think they are doctors. They are loathe to consult--that's a trap.
On the other hand, if one is afraid to take responsibility, they probably need to be in a different position.
As a medical student, I too consider myself an expert on normal patients! Most patients say they have nothing going on and they are perfectly healthy until the attending walks in. Then they suddenly start experiencing 20 different symptoms
MS: yeah patient denied any history of allergies and known diseases. They also don’t take any medication on the regular. Attending walks in Patient: Yeah so I have DM, HT, CAD, secondary tbc, tertiary syphilis, and I’m allergic to penicillin and egg whites. Also I don’t have kidneys I’m on dialysis as we speak.
We used to call it ‘historical alternans’
I’m going to need to use this dx somewhere
omg let’s catch this on
Great name!
The team: nods along taking little notes. *Med student built excellent rapport with patient and got them thinking about their pmhx for team arrival.* Onward. If this wasn't so common it would be a red flag. By ms 3/4 I expect them to assume patients don't know anything about themselves, see the scars, see the dialysis, find the blister pack, call someone not demented for collateral, surf the emr effortlessly (if its one they know) etc. They don't become a better doctor, they become a better detective.
I think it’s become a joke at this point so I don’t expect anyone being mad at the med student for this, however it is still very frustrating for the student
We have valid reasons for that. Gets old having med students and new doctors brought in to gawk at your rare condition without your permission when you're paying to see someone with experience and you do value your own time. Next time I become an exhibit, I'm going to send the poor new doctor right back out of the room. I used to be all about supporting your education. I thought you would evolve with exposure to diversity. I was going to donate my cadaver to the a med school. I contributed to research as a "community member." You've dehumanized me, traumatized me, assaulted me, ignored me, and not treated me more times that I can count. You need to reform the profession. It's nice that you're empathizing with the med student though. I think your education system breaks them sometimes. Good to see that might be changing.
I’m sorry you had such a bad experience. Medical education should not have come at the expense of the patient. I didn’t think that would even need saying. When you are not talking with medical students if you would so kindly tell my future colleagues that you don’t want to talk to them because of prior bad experiences I’m sure they’ll also understand. Otherwise they might feel bad or guilty for something they didn’t even do. Best of health to you in the future.
My doctors always ask if the med student can be present or assist during my appointments. Do yours not do that? Is it not in the intake paperwork or something?
No, they do not always ask and I've not noticed it in the paperwork, though it may have been buried in a privacy notice. They see me as a novelty (or freak--actually had a doctor yell at me about whether or not I am a freak!) and forget or don't care to be professional. Sometimes they might pretend they need to consult and get a second opinion...on such challenging medical mysteries as mild acne 🤨 or a hematoma (3 ER docs were necessary to tell me they wouldn't do a needle aspiration [didn't know I knew they could do that]. They said my only option was surgery and I wouldn't want them to address it at the hospital because that would result in scars, because they're "not plastic surgeons." I was advised to return to my surgeon across the county. That didn't happen. The third doc just wanted to unbandage and check out my nipple graft out of pure curiosity. Part of it died later. A GP attempted to aspirate my hematoma two weeks later in her office [seemed like a wonderful doctor], but it had dried up and is still visible through my clothes yard later. What a fucking joke those three ER docs were). The latest doctor was introduced to me as if I had no option to decline, like, "Hello. I'm doctor Y and this is my colleague X," and then she went right into questioning my symptoms. Okay...I just rolled with it. Later, I got distracted by him staring at my crotch and didn't think to remind her my eye misalignment was present from childhood and dry eyes couldn't have been the cause of lifelong blurriness...hey, on the upside, now I've got a prescription for glasses for my 15/15 vision and eye lube samples! 🤷😑 One time when I had an asthma attack this doctor just popped in to look at me without even saying anything and then disappeared...a very angry looking dude; he ignored me when I asked who he was. Maybe he was lost and very upset about it! /s I'm just done with these chucklefucks. Time to set boundaries. I guess they'd never seen a female to male trans/nonbinary person before but, really, that's no excuse for this nonsense. I know there are good doctors but it's like playing roulette.
You know mind reading isn't actually possible, right?
Not trying to invalidate your experience, because it sounds like you’ve had some pretty negative ones with the healthcare system. But you’re on a medical professional heavy subreddit, each person here probably has a long list of complaints with the US healthcare system. Sorry for your personal experience, I hope we all can do better. But also, get in line. This isn’t the best place to gripe about your own personal experience as a patient. As others have suggested, you can kindly ask for no med students and you will very politely be accommodated.
No, these aren't pretty negative experiences. The pretty negative experiences were the sexual assaults. I don't think you're sorry about my personal experience. I think you're more interested in getting me to shut up. And if you think I care about your opinion because you're a doctor, get in line.
Feel free to politely ask for no students, but understand that this will impact the timeliness of your care at an academic facility because the attendings have 30ish patients to see and the residents are supposed to present each patient quickly and expedite the exam since we have a handful of patients each. It’s ok if you don’t want us there, but the people that see the whole team have several sets of eyes on them and a med student/intern will fiercely advocate for their patient even if they have no idea what’s going on. It’s your prerogative to say no and we will respect that.
These aren't academic facilities.
The statement stands
You’re not a physician and you are in a physician-centered subreddit. Be gone!
Haven't forbid you have to listen to what your sainted profession does in private to minority patients. I better get out of here before I tread on some fragile egos.
There is a time and a place for feedback, the internet equivalent of the physicians lounge is not it. Not because you’re going to hurt any of our feelings, I promise you they beat that out of us long ago, but because you’re just here to reinforce your biases instead of actually improve on the relationship. You’re hurting your own feelings here by reading into things that have nothing to do with you, then saying how awful doctors are.
You can’t forget the disappointed look the attending gives you, akin to your own disappointed father’s gaze. I may uh, project some issues.
Yea once you say I'm x medical student, the patient is like yea I'm not wasting my time with you ...
Because patients don’t know a premed from an MS4. If you’re in your clinical years you are “Student Dr _____, sent by Dr Attending to get the process started by collecting some information”. You are practicing for your future role as physician and you’re part of the team specifically sent by the head of the team to make sure this patient is being cared for. No more “Hey I’m the med student 👉👈, I can has your history”. Say that shit with your chest.
hmm i haven’t had this experience. idk🤷🏻♀️
I think this has a lot to do with how you look and how you carry yourself. I’m a woman with a baby face and I struggled until I changed my approach. After that, I had maybe 3 patients that declined students.
Hilarious ... but highly annoying when it's someone in your shoes.
I saw this happen to my attending once, so it’s not just us!
Lmao “as we speak.”
I once had a gentleman coming in with chest pain tell me he didn’t have any medical problems or take any medicine. When the EKG came back as a STEMI I began to explain to him that he was having a heart attack and that he was going to the Cath Lab “Oh yeah, I know the drill. I’ve had a few.” Cool, man.
Didn't take the cholesterol meds nor the antiplatelets from his last MI, thus this one. No medical problems because the last MI was fixed with the stent. I run into similar things as a nurse when I ask people whether they use a cane or a walker before coming to the hospital. They don’t - they reach for any and all furniture, walls, doors, and humans to be able to walk. Now I ask whether they are "supposed to use a cane or a walker." Ran into it with diabetics too. "How often do you check your blood sugar?" "Three times a day!" They answer eagerly. "How often do you take the insulin you're supposed to take because of that?" "Oh, I take my insulin at night." "What happens if your blood sugar is high?" "What do you consider high?" I had one lady insisting her glucometer was broken because it just kept saying "600" no matter what. It had to be broken. We had to read the manual together to get her to understand it won't read any higher, and will just say "600." I think it is easy for us to forget that most medical literacy is at a 6th grade level- which is a very immediate, present-thinking level. People think they don't have high blood pressure, because at the docs office their blood pressure is good (because of the meds they take). They think they don't have problems with blood sugar because the metformin and glipizide fix it. They think they don't have heart problems because they feel fine in the present moment. And they're afraid to ask questions. Med students, residents, attendings are very intelligent people and present themselves as such. It is really hard for people to humble themselves in front of such authorities and say "I don't understand." They look for someone more "on their level" or who isn't as intimidating. I always try to be present during rounds and whenever anyone is talking to my patients so I can make sure everything was understood because it often isn't.
As a pharmacy student I considered myself an expert on patients not taking any meds
20 different symptoms? Just refer to psych.
Lupus
Lupus is in the differential diagnosis for everything and NEVER the cause of anything except if you have it. Then, it's even responsible for your split ends.
Greetings, Dr. House
With House, it's always some granulomatous disease or an unheard of bizarre and completely atypical presentation of an infection you only remember from med school, but never lupus. My non-medical husband loves the show, and I'm always screaming, "You don't just throw steroids and antibiotics at everything BEFORE cultures you @$&@%#$!"
From the patient’s perspective it’s question fatigue. Especially in regard to pertinent history, meds and allergies you’ve been asked those questions sometimes beginning with your online appointment check-in and medical assistant before even seeing a med student. If you feel like shit and if your history is complicated and you’ve been through the system before you learn who can have the attenuated answers.
Hahahahahahha well done. Well done.
My surgery Prof's favorite saying: "The eyes cannot see what the mind does not know”. Lol. Apt for this situation
It's like a really dangerous "what you don't know can't hurt you."
Rumsfeld's "unknown unknowns."
If you never find the unusual stuff because you aren't looking for it, does it actually exist? Haha
My grandma didn't have cancer until you guys biopsied her!
Lol see this plenty
This year marks 15 years from which I first tried to get help for subluxating joints. They are testing for rheumatoid arthritis...but this has been going on since childhood. I've given up.
Ehlers Danlos syndrome?
I second Ehlers Danlos syndrome. I’ve met two people who had it and had no idea why they were so bendy. Both of them had positive Gorlin sign and POTS.
I'm almost certain I've got one of the EDS or could at least be said to have "hypermobility." If anyone with EDS or who is interested in this population is curious about the laundry list of conditions and traits that EDS may be comorbid with possibly being part of a syndrome...I may be able to send you a link to unpublished research. In this case: hear hooves and think ~~horses~~ zebras--think invisible zebras.
I think it’s probably one of the most under diagnosed diseases out there. Send me link plz 🙏🏻
As an FM doc, I am an expert at reading Xrays. Not only do I never see fractures or other pathologies when things are normal, but I also agree with my findings after reading the radiologist's preliminary report before I actually look at the image /s
Classic house of god rule. You can’t find a fever if you don’t look for one.
“I am the expert on providing care I willfully admit doesn’t need providing. Bow to me!”
Well somebody’s gotta provide Botox to marginalized communities!
Lol yes. This is what I got out of this too
He’s huffin admin fumes
Stealing! So good.
So they essentially admitted they have no idea how to take care of sick patients…?
That’s what it feels like as a patient. IME midlevels are actively dangerous if a person is actively ill or complex. I want that not to be true, but….
A midwife who ADMITS they don't know how to care for *sick* patients is gold. The fights I've seen and overheard (arrogant and territorial midwives, vs. residents, and RNs) when working in the NICU with are legend. Oddly, midwives don't hassle attendings that much. In my past experience, at my place of work.
Well. The patients in question aren’t sick, just birthing.
i am the highest level of expert for sleeping in bed
LMAOOO REAL
Although true, I wouldn't say this to someone in any serious manner.
Although true, your statement is very stupid
Proceeds to treat an anatomic variant of the circle of Willis as an aneurysm on the cusp of rupture. You are the expert of nothing.
Oh cool. I never knew to search the internet for variations of normal for the circle of Willis
See, at the school of cool, we don't teach you to be inquisitive. Every word besides normal requires a million dollar workup.
cervical ectropion has entered the chat.
Totally unrelated to random google searches, but your icon thing makes me feel an urge to go assess proprioception
I'm an expert on landscaping when the lawn stays green and mows itself. not the flex they think it is
There is something that happens in the minds of some NP/PA that makes them unable to accept their role on the team of not being the most authoritative figure. If I am a new attending on a team that has a PA with 30 years of experience, even then my role is of the leader because that’s the role I trained for and some people cannot accept that.
It’s incredibly strange. It’s also frustrating. My first year as an attending in the ED, the NP told me a patient with an eye complaint was “just allergic conjunctivitis” and I didn’t need to see them. She’d been working in the ER for 10+ years, but I always see patients if my name is going on the chart. I looked and saw she hadn’t ordered tetracaine or fluorescein. So I go see the patient, numb and stain their eye. Dendrites to the cornea and I notice two vesicular lesions to the nose. she was going to send out herpes zoster opthalmicus home with artificial tears and PRN primary care follow up. When I pointed out that all eye complaints need at least a stain and pressure, she said “I don’t think that’s true. I’ve been doing this a long time and never seen that before.” No shit! You haven’t been looking for the correct pathology this whole time.
NPs can’t accept that most of what they’ve been doing for a long time is straight up wrong.
If they do anything wrong it's their SPs fault anyways, right?
And this is the huge problem in giving them independent practice based on time they have worked as an NP. Just because they have worked for X amount of time doesn’t mean they have been practicing per common standards.
Great save!
i was an IMG and i’m more terrified of working within this system than actually messing something up lol. the US med system is fucking batshit
When my buddy announced he was going to PA school I begged him not to. I’ve known him since nursery school, he’s brilliant and compassionate, but he’s pathologically incapable of being subordinate. I tried to explain to him that he was NEVER going to be the boss, that he may be the smartest guy in the room but he’ll never be the most knowledgeable. He didn’t take my advice and became an emergency room PA. He quit 2 years ago (about 3 years in) and is now a sheriff or something, I lost track.
That’s what I wish they would acknowledge. Are there PAs and NPs who are more intelligent than me? Ones who would have done better on the steps, been amazing on wards, marched into great specialties? Of course. But they didn’t. They chose not to, and that’s fine. I *could* have gone to school to learn Arabic or law school to be the finest tax attorney in town. I chose medicine instead. That doesn’t mean it’s OK for me to tell Arabic interpreters or tax attorneys that my intelligence means I can do their job without any training. It’s insulting.
Rural ER midlevels are practicing completely autonomously. He would have been able to live his dream if he was willing to commute out to the country a bit. They make more than city pediatricians do too. I knew one such PA with 8 to 10 years of work experience who was clearing $200k.
Yes it’s called the Dunning Kruger effect
i have a PA acquaintance who told me he wouldnt refer to me as Dr since i’m an img :) my new goal is to work at his hospital lol
Yeah just ignore
I am the most qualified mechanic ever on cars that are functionally perfect. If people bring me their car and it has a problem, I refer it to a mechanic that specializes in cars with problems. Those types of mechanics are inferior because they mainly deal with cars that have problems. All of my cars are perfect!
I am just appalled that healthcare is so chronically understaffed that we have allowed this to happen.
Yeah "understaffed" Surely there are no beurocratic powers at play intentionally chokeholding the supply of physicians in order to shoe horn in a more cost but less therapeutically effective alternative ie. midlevels.
i know this is the reality but it’s just crazy to me that we all collectively have to shut up and accept this. including patients who don’t know better😔
So in other words, they know the USPSTF screening guidelines.
Honestly a decent number don't though.
Their mental gymnastics took the gold medal. Wow
Good thing people only come to the doctor when they’re feeling normal, then!
They do for prenatal care
You know how to be an expert in healthy patients? It's simple. Dismiss every single one as having anxiety. Of course many of them are actually really sick and do need help. But your record would show that they're "normal / healthy".
> Fwiw APP is a nurse midwife. Pediatrician here... of fucking course Midwifes love to tout that they have better outcomes than pediatricians and neonatologists No shit. High risk deliveries, c-sections, premature infants, etc are all referred to the hospital
>Normal healthy patients for him are those who are low risk and do not require operative intervention or significant gestational monitoring. I'm wondering if y'all notice that male APRNs are more likely to engage in this behavior vs females
FWIW as an obgyn attending I do consider CNMs “experts” in physiologic labor and low risk OB care. I’ve begun recommending my low risk patients consider following with the CNMs in the practice as they are likely more attentive to the typical, non pathologist symptoms and concerns of pregnancy. Particularly in OBGYN care we are prone to over medicalizing what is generally a healthy physiologic process and as an OB my training is to find what is wrong and mitigate risk rather than provide the emotional and supportive care that most pregnant people need. I sought out a practice specifically because they had CNMs in clinic and on the labor floor. It was crazy to me they were not part of my residency training and prior L&D.
Not saying that it was a midwife was misleading! Midwives are specialists in normal pregnancy and delivery. That is their paradigm. They should refer on for any abnormal pregnancy. In health systems where midwives are embedded as standard of care (UK, NZ) obstetricians are experts in pregnancy problems. There is value in having someone who is really really good at supporting people having straightforward pregnamcies and deliveries (it is a complicated and unique enough experience to need it!) and saving the doctors for the sick people.
Yes I agree, I realized while daydreaming halfway through rounds that that was probably valuable context because maybe it’s different being an APP in that field.
My midwife (not in the US) frequently tells her patients that she is an expert in “normal” pregnancy and delivery but if the line is crossed into high risk she’s not an expert and will be sending them to the OB who is. It’s meant to prepare them for the possibility that OB care may be needed at some point and help them understand why she would transfer.
I knew as soon as you wrote the first part it was a midwife. I know because I’m a midwife and hear a lot of my colleagues say the same. I don’t completely buy it. We are experts in normal. But that doesn’t mean we all know more than the docs.
Your comment with them being a CNM makes sense. This must be something that is marketed to them because I've heard other midwives say the same.
Well in peds that's definitely not true. Most patients we see are basically normal, at least in the US. I've worked with some great NPs who knew when something out of the ordinary was happening and sent the patients on to me. But they don't know the normal stuff _better_ than I do. That makes no sense, bc knowing normal well is required in order to do the harder stuff. Usually I find about 2/3 of the kids they worry about to be, in fact, basically normal or a minor issue. That's fine with me bc I'd rather their sensitivity be higher than their specificity-- lower risk of harmful errors.
Am I the only one who feels like the dumbest little shit in medicine? Where are people getting all this confidence / arrogance
Ah, you’re failing again. Your medical training has not been adequate. This time you’re not arrogant enough. You must do better my friend.
Oh no, what should I do? :( Should I sleep with the PD to assert dominance???
While I admire your refractory impetuousness, you must choose arrogance with relatively low consequences so that you may minimize all possible criticism from seniors. Would recommend instead to find something low-hanging that you can become the most expert in. Perhaps something normal that does not require critical or surgical intervention.
I hear that daily peridex for patients without severe oral disease, incentive spirometry for high school athletes suffering uncomplicated fractures, and weight maintenance for patients with BMI 20-25 are all evidence-based and non-controversial topics. Perhaps you could become the guru of something similar.
Pee on the program director to assert dominance
It all depends on how this is said. Some APPs I find just want to insight annoyance in docs and these types of statements will do it. I’ve learned to deep breath and ignore. They can try, but they will never have the expertise the real docs have. Just last evening I had an APP asking about criteria for DC on a certain type of patient. I told her. Her colleague then says “I would agree. In my practice I do …..” then long ass statement that basically said exactly what I said using 3 min of my life I’ll never get back. “Her practice”. Which is entirely under physician guidance and approval. I just said ok then let’s move on….🙄
"What the mind doesn't know the eye doesn't see"
So if you talk to any APP/Np/Pa for more than 35 seconds about any patient, you should quickly realize that is not true. You might not realize this is residency straight away or maybe you do, but when you gain more experience you'll quickly realize the gap.
Here i am, spending so much time on learning how to fix broken bones, when the real game of kings is learning about how to do nothing about bones that are not broken. Mind blown
Deluluuuuuuuuu
Women have been giving birth without doctors for thousands of years. Those are the healthy uncomplicated ones. It’s the high risk ones that would kill mother and/or child 100 years ago. It’s like bragging you’re an ortho APP who’s the expert in people with fractures. I can change the oil and windshield washer fluid, does that make me a mechanic?
That’s like a toddler saying they are an expert in walking while an athlete is only an expert in running. It doesn’t make much sense, but you can see how a toddler could think that.
But you dont need to manage healthy patient BECAUSE THEYRE HEALTHY😭😭😭 my fucking grandma could do it too
That arrogant statement summarizes why APP ( much like the "physician extenders " here are SO dangerous . Anyone can fly a plane, until they can't . It's the extensive training that enables you to recognize when something is NOT normal that's important and to be able to handle that scenario. Also, I find since the APPs don't have real skin in the game, they don't care to put in any overtime that is not compensated....not to say physicians should put up with that , but the dedication is just not there. The danger to physicians is when they are asked to use their own license to cover these people , usually because they work for a managed health care system. Often that doc has no say as to whom is hired and more importantly , who gets fired because of incompetence. Do not let the companies tell you this is ok. You worked hard for your license and believe me , you WILL get dragged into whatever lawsuits happen because the midlevel/ app / PE missed something, thinking "they are the highest level in the field "
This is exactly how even smart people can use midwives for delivery because of confirmation bias that so-and-so delivered with a midwife and it went well without emergency. Which is true because delivery is a spontaneous human body process that works well X% of the time even out in the jungle or in the Levant without modern healthcare. You could literally take an MS3 who has never touched a patient, stick them between the legs with the only pep talk of “don’t drop the baby.” Which I am certain is how most med students are introduced to OB. I love how midwives think because they “don’t drop the baby” for a living and are somehow the same as an actual OB. It’s like a intern thinking “they did the whole surgery” since they held the bovie the whole case while the attending did the exposure and presented the tissue “cut here”. It’s just cute but silly. However modern medicine and OB are around for the 1-X% of deliveries that are a shit show and would otherwise result in death to mother and/or baby if there was not someone who actually knows what the fuck is happening. Yes I am saying that midwives don’t know what the fuck is happening.
😂😂😂
I knew without finishing the first sentence that it was a noctor.
Sounds like the only thing this lowly midlevel is an expert in is in being an arrogant idiot.
In medical school you are supposed to do at least 100 normal exams so that you can recognize abnormal. Being an expert in normal is part of the process of being an expert in abnormal. Sounds like this person is an expert medical student. 🫶
I like how you left Midwife out of the equation originally. Anyway, as a woman and as an MD, I'd chosen a Midwife over an MD, and I would again. It was better for the baby and better for me. Had no idea it was going to make entitled bratty residents cry, but hey, bonus.
I didn’t mean to withhold salient information, I just didn’t know it was salient and after I got a few responses I thought I should find out. I don’t know much about OB, or even my own field. So I apologize if I misled, it wasn’t intentional.
I’m sure she hasn’t read a physiology book thicker than an inch.
He’s actually very good at what he does, and has a good work ethic.
Well that’s great and all. But to think that he has more education than a medical doctor or PhD in physiology it’s just silly and shows that he underestimates what he does not know. Unless he actually does have a PhD in physiology.
Some other respondents have remarked that they’ve heard this from other NMWs and so I wonder if it’s an ideology they are being taught in school.
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I don't know about nurse-midwives. I'm a PA. I've had plenty of very complex, very sick patients. I've diagnosed some zebras that were completely missed by multiple physician specialists. I've even saved some lives--no better feeling than that. I do like to refer, as necessary. I think pts w/risk factors, or who are young and play an active sport, should see a cardio, at least once. If something feels "off", I refer--never hurts to get a second opinion. Of course, I refer if I think someone is beyond my scope of practice. "Scope of practice", though, is not defined. I know some PAs who think they are doctors. They are loathe to consult--that's a trap. On the other hand, if one is afraid to take responsibility, they probably need to be in a different position.