Venting

[Marinejiujitsu]

In the ER, we see a lot of patients. I have almost 10 yrs under my belt seeing patients. I've came across my fair share of little kids with significant swelling in the neck. We think mumps, abscess, salivary gland, abscess. Sometimes I have a high Suspicion for a bacterial infection or airway compromise. Last week I had a case of a four-year-old with ludwig's angina. Today I have a 5 year old with not really too tender to palpation swelling to the left sub mandibular area almost back underneath the ear. Totally lymphadenopathy. I've seen this many times and almost every time it ends up being Epstein Barr. I ordered labs, and an ultrasound. After discussing with the parents that CT scans have a lot of radiation and my suspicion is so low for airway issues due to location and an ultrasound can show pus. I also gave the kid Steroids which was helping with the swelling.

 

Of course the ultrasound comes back with large lymphadenopathies bilateral cervical lymph nodes greater on the left. No crap, totally expected.

 

And what does my attending say, go ahead and order the CT scan without seeing the patient. I knew it was over kill. I am assuming the mom started questioning my ability. Super paranoid mommy. Of course it came back as lymphadenopathy with no airway compromise.

 

Had fever and swelling for 2 days. I discharge patient with NSAIDS and said much likely viral and follow up with pmd in 1-2 days with return precautions. Then they want a second opinion because I added a CT scan I am assuming and lost confidence. Mom probably thought I am unsure of myself. After my new attending comes in; he orders an abdominal ultrasound and chest xray and decides to work up lymphoma/AML. Of course labs are normal. Of course, he agrees with me but doesnt tell the patient that.

 

It ended up being the all too common, lets make the PA look like a lesser practicioner. ER attendings are infamous. Some attendings are cool and will just reinforce your plan if you meet the standard of care. ER attendings magically see otitis media. Or saying its strep in a 6 month old with a fever. Blah blah.

 

Of course, in the end the patient goes home with likely viral, heres nsaids, follow up with pmd 1-2 days and return precautions. And mom and patient leaves thinking I am lesser of a provider because I didnt order an ultrasound of the abdomen or chest xray. Sheesh. Gotta love being a PA.

 

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[UGoLong]

I sympathize with how you feel. No one likes to be second-guessed.

At the same time, we spend 12-16 months learning hundreds conditions in PA school and a doc spends the better part of 4 years doing the same. It's not surprising that the zebras -- low likelihood but high impact possibilities in a differential -- may weigh heavily on their minds so occasionally a doc may want to go beyond a bit just in case and in the interest of the patient.

In the end, how we look to the patient isn't really the important thing.

On the other hand, I still have to laugh when I think about the one ED preceptor I had 15 years ago that insisted we do an LP on every patient with a headache, regardless of the presence or absence of other symptoms or the index of suspicion. When my lead preceptor came in the next day, I told him the story and, for the rest of the day, presented my plans to him with "And we'll start with an LP" and he'd respond, "Well of course; that goes without saying!"

 

Edited January 7, 2020 by UGoLong

[d-wade]

4 hours ago, Marinejiujitsu said:

 

In the ER, we see a lot of patients. I have almost 10 yrs under my belt seeing patients. I've came across my fair share of little kids with significant swelling in the neck. We think mumps, abscess, salivary gland, abscess. Sometimes I have a high Suspicion for a bacterial infection or airway compromise. Last week I had a case of a four-year-old with ludwig's angina. Today I have a 5 year old with not really too tender to palpation swelling to the left sub mandibular area almost back underneath the ear. Totally lymphadenopathy. I've seen this many times and almost every time it ends up being Epstein Barr. I ordered labs, and an ultrasound. After discussing with the parents that CT scans have a lot of radiation and my suspicion is so low for airway issues due to location and an ultrasound can show pus. I also gave the kid Steroids which was helping with the swelling.

 

Of course the ultrasound comes back with large lymphadenopathies bilateral cervical lymph nodes greater on the left. No crap, totally expected.

 

And what does my attending say, go ahead and order the CT scan without seeing the patient. I knew it was over kill. I am assuming the mom started questioning my ability. Super paranoid mommy. Of course it came back as lymphadenopathy with no airway compromise.

 

Had fever and swelling for 2 days. I discharge patient with NSAIDS and said much likely viral and follow up with pmd in 1-2 days with return precautions. Then they want a second opinion because I added a CT scan I am assuming and lost confidence. Mom probably thought I am unsure of myself. After my new attending comes in; he orders an abdominal ultrasound and chest xray and decides to work up lymphoma/AML. Of course labs are normal. Of course, he agrees with me but doesnt tell the patient that.

 

It ended up being the all too common, lets make the PA look like a lesser practicioner. ER attendings are infamous. Some attendings are cool and will just reinforce your plan if you meet the standard of care. ER attendings magically see otitis media. Or saying its strep in a 6 month old with a fever. Blah blah.

 

Of course, in the end the patient goes home with likely viral, heres nsaids, follow up with pmd 1-2 days and return precautions. And mom and patient leaves thinking I am lesser of a provider because I didnt order an ultrasound of the abdomen or chest xray. Sheesh. Gotta love being a PA.

 

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Well, if he didn't have AML he does now. 

[ventana]

sad

 

another reason for independent practice.... you should own the liability on your patients and be able to be the decision maker

 

Takes 10,000 hours to learn a profession - you are double this and likely have FAR MORE experience in the realm and you did the initial work up.  Really sucks that the attendings over rule your thoughts, especially with out seeing the patient (I would have a beef with that)    Can you just stop asking them?  Honestly I never ask (but I am in IM outpatients) anymore unless I am truly questioning things.  Otherwise I just make my decision and move on.

 

as for the Doc' being more "trained" for zebra's - stop drinking the koolaide.  20,000+ hours in to a field with a decade of experience and this provider has got it - you do NOT work up AML on a typical viral infection in the ER - that is what PCP and IM is for especially if the PA is saying they are 100% sure it is just viral...... 

 

 

All a sad story and so sorry that you have to live it.   I truly believe once we are responsible for these decisions it will improve.

 

In your case, I would go small critical access and just not work with a Doc.

[Cideous]

2 hours ago, d-wade said:

Well, if he didn't have AML he does now. 

OMG, just spit out coffee reading this!

That's terrible!  And hilarious!  

[rev ronin]

I think we need to retitle the thread "when defensive medicine harms the patient but increases revenue"  We shouldn't be so narcissistic as to think that our feelings matter... it's all about the benjamins.

[Marinejiujitsu]

Another patient same doc; I asked him to lookat a genital lesion. I told him I think itsa chancre and I think it's syphilis but I never seen a chancre so I asked him to take a look at it. Of course he disagreed and said HSV. I was like, I don't think so. So, I ordered an RPR and a tzanck smear and guess who had to call the patient back?

Another time, a person came in and got hit and beat up with a baseball bat. He canceled my CT thorax and next day I seem him and I was like bullcrap and ordered another CT. Double pneumo.

I hate the piss on each other and I'm better than any other practitioner culture.

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[dfw6er]

I totally hear your frustration.  I'm sorry it happened to you.  Believe me you're not alone in this experience and it sucks to be undermined, especially in front of your patient/patient's family.  

I'm not sure how many docs are in your shop.....but folks like the one you've described were the ones I'd go out of my way to avoid listing as the attending for my cases that day.  I was fortunate to have so many docs I could cherry pick who I chose as my attending.  And I didn't have to touch base with them regarding my patient care unless they were ESI 2 or higher.  

It does suck that the guy was ordering CTs without laying hands on the patient....especially if it was a kid.  I, and nearly all of the docs in my shop, were hesitant to CT kids without a high index of suspicion.

But at the end of the day, the PA is part of the physician-led team and you'll have to defer to their decisions/judgment regarding treatment plans/disposition.  Everyone can argue about the years of experience you've had, the hours of preclinical/clinical education, etc.  But you're still not a BC/BE emergency physician.  You'll never have completely independent practice...which is why I went back to med school.  Easier to join them than beat them.  

[Marinejiujitsu]

I totally hear your frustration.  I'm sorry it happened to you.  Believe me you're not alone in this experience and it sucks to be undermined, especially in front of your patient/patient's family.  
I'm not sure how many docs are in your shop.....but folks like the one you've described were the ones I'd go out of my way to avoid listing as the attending for my cases that day.  I was fortunate to have so many docs I could cherry pick who I chose as my attending.  And I didn't have to touch base with them regarding my patient care unless they were ESI 2 or higher.  
It does suck that the guy was ordering CTs without laying hands on the patient....especially if it was a kid.  I, and nearly all of the docs in my shop, were hesitant to CT kids without a high index of suspicion.
But at the end of the day, the PA is part of the physician-led team and you'll have to defer to their decisions/judgment regarding treatment plans/disposition.  Everyone can argue about the years of experience you've had, the hours of preclinical/clinical education, etc.  But you're still not a BC/BE emergency physician.  You'll never have completely independent practice...which is why I went back to med school.  Easier to join them than beat them.  

Yeah, it's nothing new unless you work in a solo practice ER that a PA can work alone which is rare. You're gonna be a great doc to work for seeing both perspectives. You are welcome at my shop.

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[dfw6er]

Thanks.  Yeah I plan to get involved in hiring/education of APPs wherever I end up because I feel I'd be uniquely qualified for that job.  I'd like to see all the PAs at my shop get their EM CAQs and spend time in the main ED, not just triage or treating ESI 4/5.   I've always felt that PAs who feel they're being allowed to practice at the top of their license and are given room to grow in their skills/knowledge are the best/happiest employees who will also be the least likely to miss diagnoses.  

I've always been irritated that more docs don't take a proactive role in PA continuing education.  Knowing first-hand what the PAs in their practice do/don't know, are/are not competent at goes a long way towards building trust in their ability to correctly manage and disposition patients. 

[Marinejiujitsu]

Yeah, I still think it's great to be a PA. I will take the negative with the positives. I have been able to get in a great standing with my company and have a lot of credibility. Almost all my attendings trust my judgement but usually there is just that 1 or 2 that sour the party.

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[EMEDPA]

This is why I work solo now. No one needs to sign off on my treatment plans or notes. It is worth the driving. 

[SedRate]

11 hours ago, UGoLong said:

On the other hand, I still have to laugh when I think about the one ED preceptor I had 15 years ago that insisted we do an LP on every patient with a headache, regardless of the presence or absence of other symptoms or the index of suspicion. 

I think I saw this ED provider. The only time I've ever gone to the ED was back when I was a teenager and had a blistering headache that wasn't responding to OTCs and supportive care. Tried to wait till UC opened but my mom got too worried and brought me in. Guy said he didn't know and needed to do an LP. Suddenly, my headache got better. Poof, I was healed. I think this old preceptor of yours knew the secret to magically healing people AND getting whiny people out of the ED. 

[Hope2PA]

I have to agree with rev rovin, probably not always the case, but docs are very likely getting kick backs based on revenue. If they can some how  justify orders, they will  lean towards increase $$$. 

[fishbum]

14 hours ago, UGoLong said:

I sympathize with how you feel. No one likes to be second-guessed.

At the same time, we spend 12-16 months learning hundreds conditions in PA school and a doc spends the better part of 4 years doing the same. It's not surprising that the zebras -- low likelihood but high impact possibilities in a differential -- may weigh heavily on their minds so occasionally a doc may want to go beyond a bit just in case and in the interest of the patient.

In the end, how we look to the patient isn't really the important thing.

On the other hand, I still have to laugh when I think about the one ED preceptor I had 15 years ago that insisted we do an LP on every patient with a headache, regardless of the presence or absence of other symptoms or the index of suspicion. When my lead preceptor came in the next day, I told him the story and, for the rest of the day, presented my plans to him with "And we'll start with an LP" and he'd respond, "Well of course; that goes without saying!"

 

A few thoughts:

I think all of that extra education and training should make the BC emergency physician more capable of weighing all pertinent data and making a rational determination in a patient who could-but-almost-certainly-doesn't have a serious medical problem. In fact, from what I've seen, that's what really separates great EM clinicians from all of the rest. Anybody can work-up everything to the max and anybody can hunt down a reason to admit a patient "just in case". 

I agree that how we look isn't the important thing, but it does matter. It seems like a lot of the problems we have with "non-compliant" patients is related to mistrust in providers. One could make the case that the doc fostered some mistrust in medical providers, particularly the non-physician variety.

I worked in family medicine for a few months after graduation in an office without a physician. It was challenging in the way that primary care tends to be. I had SP support when I needed it and got some feedback from chart review. I left and went into a specialty to do the cool, high-speed sort of stuff that you don't do in family medicine. Now, a physician sees all of my patients in the hospital and my new patients in the office. Some physicians want to see the follow-ups and sick visits too. On more than one occasion, I've had my care plan changed from demonstrably evidence-based to inappropriate, always in the name of "just in case". I do love the medicine in acute care, but it gets old knowing that doing your job well might not really matter in the end, depending on what your doc wants to do on any given day. I love working on a team with physicians. But I hate being thought of, treated like, feeling like, and--ultimately--, being an assistant.

Sorry for the hijack, OP. I'm just feeling your pain on this one...and hoping it gets better for you.

Edited January 8, 2020 by fishbum

[Marinejiujitsu]

I have to agree with rev rovin, probably not always the case, but docs are very likely getting kick backs based on revenue. If they can some how  justify orders, they will  lean towards increase $$$. 

Yeah, we are a productivity site and I left before the ultrasound was read, I'm sure he swooped in for my rvus.

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[Marinejiujitsu]

Yeah, we are a productivity site and I left before the ultrasound was read, I'm sure he swooped in for my rvus.

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Yep, just looked it up. Swoop in and stole my RVUs and then used my discharge paperwork with my instructions that I use which are unique to me.

I really don't care about the money but I'm like, "This motherf'er". Lol.

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[YoungH89]

OP you've been a PA for 10 years and this still bothers you ? Onto the next one, make that $, and tomorrow's another day. BTW you said yourself this was just lymphadenopathy in setting of a viral syndrome and you've seen it a thousand times. You were concerned for possible EBV. Don't let these crazy parents make you uncomfortable and order a bunch of shit. It seems like you knew it wasn't an abscess so why even order any imaging. CBC/heterophile Ab and home. If they still wanted a second opinion , cool. Let the attending see them and they can order a bunch of wacky shit and you can move onto the next patient. It is what it is. 

[CAdamsPAC]

1 hour ago, YoungH89 said:

OP you've been a PA for 10 years and this still bothers you ? Onto the next one, make that $, and tomorrow's another day. BTW you said yourself this was just lymphadenopathy in setting of a viral syndrome and you've seen it a thousand times. You were concerned for possible EBV. Don't let these crazy parents make you uncomfortable and order a bunch of shit. It seems like you knew it wasn't an abscess so why even order any imaging. CBC/heterophile Ab and home. If they still wanted a second opinion , cool. Let the attending see them and they can order a bunch of wacky shit and you can move onto the next patient. It is what it is. 

I like taking care of kids, but I can't stand crazy, know it all parents! So I avoid peds and pandering attendings!!

[Marinejiujitsu]

OP you've been a PA for 10 years and this still bothers you ? Onto the next one, make that $, and tomorrow's another day. BTW you said yourself this was just lymphadenopathy in setting of a viral syndrome and you've seen it a thousand times. You were concerned for possible EBV. Don't let these crazy parents make you uncomfortable and order a bunch of shit. It seems like you knew it wasn't an abscess so why even order any imaging. CBC/heterophile Ab and home. If they still wanted a second opinion , cool. Let the attending see them and they can order a bunch of wacky shit and you can move onto the next patient. It is what it is. 

It really doesnt bother me too much. Its just an irritating part of the job.

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[UGoLong]

On 1/7/2020 at 9:50 PM, fishbum said:

A few thoughts:

I think all of that extra education and training should make the BC emergency physician more capable of weighing all pertinent data and making a rational determination in a patient who could-but-almost-certainly-doesn't have a serious medical problem. In fact, from what I've seen, that's what really separates great EM clinicians from all of the rest. Anybody can work-up everything to the max and anybody can hunt down a reason to admit a patient "just in case". 

I agree that how we look isn't the important thing, but it does matter. It seems like a lot of the problems we have with "non-compliant" patients is related to mistrust in providers. One could make the case that the doc fostered some mistrust in medical providers, particularly the non-physician variety.

I worked in family medicine for a few months after graduation in an office without a physician. It was challenging in the way that primary care tends to be. I had SP support when I needed it and got some feedback from chart review. I left and went into a specialty to do the cool, high-speed sort of stuff that you don't do in family medicine. Now, a physician sees all of my patients in the hospital and my new patients in the office. Some physicians want to see the follow-ups and sick visits too. On more than one occasion, I've had my care plan changed from demonstrably evidence-based to inappropriate, always in the name of "just in case". I do love the medicine in acute care, but it gets old knowing that doing your job well might not really matter in the end, depending on what your doc wants to do on any given day. I love working on a team with physicians. But I hate being thought of, treated like, feeling like, and--ultimately--, being an assistant.

Sorry for the hijack, OP. I'm just feeling your pain on this one...and hoping it gets better for you.

Good points. A really good board certified EM physician wouldn't do extra stuff that isn't called for. My point was that, by their training, docs consider quite a few more zebras than I would. It probably takes them time to become efficient just the way it takes us time.