Anyone else exhausted by managing midlevel screw-ups?

[GonnaBeADoc2222]

Patients sent home on wrong antibiotics. Patients sent home with obvious sepsis. Patients sent home with worrisome chest pain. MRIs ordered for "rule out cord compression" but then they let them sit for 12 hours. Then they admit a belly pain with negative CT and labs for "intractable pain."

I'm over it. My department should be attending only. We definitely have the attending hours to do it. Just fire all the low levels, I'll see more patients myself (I'm required to be there anyway, so who cares?), manage them correctly, give me 75% of whatever you were paying them on top of what I'm already making. The institution saves on salary and benefits.

I win, admin wins, patients win.

---

Members don't see this ad.

 

[RustedFox]

Yeah. You're not wrong.
The PLPs at New job aren't half as bad as they were at OldJob, but they still don't understand the basic sciences.
One of them won't stop asking me if I'll let (he/she) intubate, or place a central line.
I asked them to walk me thru an intubation procedure verbally; what drugs are you ordering?
No idea. They just want to play with the toys.

 

[Alvarez13]

Had a NP order a d-dimer for "medical clearance" on a 70 yo pt getting ready for a laminectomy "because he had a DVT 10 years ago". Pt was asymptomatic and sent to the ED.

This is what is causing me burn out. This is my most hated part of the job. Dealing with these midlevel *****s. Still enjoy taking care of the pts. But man, seeing these people get such garbage care is soul crushing.

 

[Angry Birds]

I prefer to just wait for the lawsuit.

 

[RustedFox]

Over at reddit, r/noctor has some terrifying stories.

The PLPs really just love to think of themselves as "equivalent".
I can't.

 

[GassYous]

Had a NP order a d-dimer for "medical clearance" on a 70 yo pt getting ready for a laminectomy "because he had a DVT 10 years ago". Pt was asymptomatic and sent to the ED.

This is what is causing me burn out. This is my most hated part of the job. Dealing with these midlevel *****s. Still enjoy taking care of the pts. But man, seeing these people get such garbage care is soul crushing.

I don't even look at midlevel "clearances". Completely worthless. I just look back until I can find a physician note. And 99% of things don't really matter in the end. Unless they're having something real bad like a chf exacerbation or unstable angina I pretty much just proceed with the case.

 

[southerndoc]

Cardiology APP aggravated me today. Elderly lady with 2 syncopal episodes presented with a documented 3rd degree block on EKG (transient, resolved by the time cardiology evaluated her). No prodomal symptoms. No chest pain, shortness of breath, leg pain, or leg swelling. No hypoxemia. Cardiology APP orders a d-dimer because she recently traveled. Of course, dimer came back elevated which bought her a CT. That showed an incidental pulmonary nodule which is going to buy her another CT in 3-6 months. As expected, no PE. WTH? I know they are ordering it when they are admitting the patient, but c'mon, use some common sense.

 

[turkeyjerky]

Truth. Seeing patients referred or mismanaged by their idiot noctor pcps is getting frustrating. So much polypharmacy, unnecessary referrals clogging up the system, idiotic comments to patients that get them worked up and overly anxious.

 

[Boatswain2PA]

65 yo 6 week s/p gastric bypass in for sinus congestion and cough x 4 days "not getting better". Normal vitals, well appearing, lungs CTAB. Seen in UC 2 days before, no labs or xray, rx'd prednisone AND Clinda in an apparent attempt to wipe out the upper AND lower GI tract.

Stop taking everything they gave you.....

 

[turkeyjerky]

So even noctors are ****ting on noctors now, it’s gotten that bad..,

 

[rickylafleur]

So even noctors are ****ting on noctors now, it’s gotten that bad..,

Where did a noctor **it on another noctor in this thread?

 

[Apollyon]

Where did a noctor **it on another noctor in this thread?

Directly above the post you quoted in your first post ever on SDN.

 

[rickylafleur]

Directly above the post you quoted in your first post ever on SDN.

He is not a noctor.

 

[Boatswain2PA]

This...

 

[Dred Pirate]

Over at reddit, r/noctor has some terrifying stories.

The PLPs really just love to think of themselves as "equivalent".
I can't.

we have a new one were I work - holy crap are they bad - like they miss basic mind-blowing obvious things. One of our calmest, cool tempered docs almost lost it on them the other day for some obvious misses.

 

[qwerty89]

Cardiology APP aggravated me today. Elderly lady with 2 syncopal episodes presented with a documented 3rd degree block on EKG (transient, resolved by the time cardiology evaluated her). No prodomal symptoms. No chest pain, shortness of breath, leg pain, or leg swelling. No hypoxemia. Cardiology APP orders a d-dimer because she recently traveled. Of course, dimer came back elevated which bought her a CT. That showed an incidental pulmonary nodule which is going to buy her another CT in 3-6 months. As expected, no PE. WTH? I know they are ordering it when they are admitting the patient, but c'mon, use some common sense.

You mean the NP took her seriously while the doctor dismissed her symptoms. The NP saved her life by finding that 5mm nodule. The NP also sat at the bedside, held the patients hand, and wept.

Checkmate.

 

[turkeyjerky]

we have a new one were I work - holy crap are they bad - like they miss basic mind-blowing obvious things. One of our calmest, cool tempered docs almost lost it on her when she missed something I (as a pharmacist) saw in like 30 seconds by just sitting at my desk outside their room. He was less than pleased when I saw something in their history (ETOH abuse in a liver failure pt and then they seized because they didn't put the pt on CIWA protocol).

Indiscriminate CIWAs are a good way to kill HE patients.

Been there, done that.

 

[RustedFox]

Indiscriminate CIWAs are a good way to kill HE patients.

Been there, done that.

HE?

(Man, I really feel like I miss a lot of abbreviations on here.)

 

[Dred Pirate]

HE?

(Man, I really feel like I miss a lot of abbreviations on here.)

hepatic encephalopathy I think

 

[RustedFox]

hepatic encephalopathy I think

Maaan.
I really missed that one.
Plus, I'm status-post 12-hour nightshift.
Excuses, excuses. I know.

 

[EthylMethylMan]

Truth. Seeing patients referred or mismanaged by their idiot noctor pcps is getting frustrating. So much polypharmacy, unnecessary referrals clogging up the system, idiotic comments to patients that get them worked up and overly anxious.

A patient I had a couple months ago saw her primary care NP for what I presume is a basal cell carcinoma on her cheek. Literally nothing else going on, no acute issues. She was told to go to the ED. After performing a thorough HEENT exam, I asked the patient what exactly the NP wanted us to do for her today. She had no idea. "She said I needed to go to the ER right away to make sure this gets taken care of." I asked her if she was sent with some discharge paperwork that clarified anything. Nope. I called the office twice (at like 2 PM) and no one picked up. I left two messages, which included my cellphone number for callback. Never heard back. I wound up referring her to a dermatology group in town and discharging her. I have to assume the NP wanted the lady to get a biopsy or something. My blood was boiling the rest of the shift at the thought that this idiot was basically using the ED as a way to get her outpatient workups done quicker.

 

[Rekt]

A patient I had a couple months ago saw her primary care NP for what I presume is a basal cell carcinoma on her cheek. Literally nothing else going on, no acute issues. She was told to go to the ED. After performing a thorough HEENT exam, I asked the patient what exactly the NP wanted us to do for her today. She had no idea. "She said I needed to go to the ER right away to make sure this gets taken care of." I asked her if she was sent with some discharge paperwork that clarified anything. Nope. I called the office twice (at like 2 PM) and no one picked up. I left two messages, which included my cellphone number for callback. Never heard back. I wound up referring her to a dermatology group in town and discharging her. I have to assume the NP wanted the lady to get a biopsy or something. My blood was boiling the rest of the shift at the thought that this idiot was basically using the ED as a way to get her outpatient workups done quicker.

Why even waste time trying to contact them.

"Unfortunately today you saw a mid level nurse practitioner. They don't have any formal training in medicine. Although this is somewhat urgent, it's not emergent and can get taken care of by dermatology in follow up".

Discharge.

 

[Mount Asclepius]

One of the saddest cases I’ve had. 40’s year old, generally nice, otherwise healthy, family guy with several teenage daughters went to see a NP several times over the course of a year for new-onset increased gas, bloating and abdominal pain. No history of similar symptoms. She prescribed him Simethicone and various other similar meds over the course of multiple visits. Never ordered a CT or considered referring him to GI for a colonoscopy. I ordered a CT when he came into the ED with just his wife. It revealed widely metastatic colon cancer. Potentially completely curable with resection if caught earlier. When I broke the news to him he just started crying and only asked, “What do I tell my daughters?”

 

[JAFERD_MD]

Similarly, I had a middle aged gentleman come in complaining of mouth pain. Known heavy smoker. Documented by NP and NP student that they saw an oral mass a few weeks prior in clinic. Diagnosis: periodontitis. See a dentist. Have some benzocaine.

When I saw him, I immediately scanned it and it was an ENT cancer with necrotic lymph nodes. A month later, he came in again, but for SI due to his whole situation. :\

On the other hand, I recently had another sent in by his primary care PHYSICIAN, a 2021 Internal Medicine graduate that I knew. The middle aged, also heavy smoker, gentleman had come in for a few months of neck fullness. With the IV contrast shortage, his PCP got special permission from radiology (as is currently the protocol for all outpatient studies needing IV contrast), got the CT and read, called ENT who reviewed the imaging and said to send him to the ED for a trach for airway protection. This was all done in 2 days.

 

[EctopicFetus]

I love seeing them cause I belittle the terrible care they give the patient. It’s also a paying customer. Love them. Noctors don’t see uninsured people in urgent cares or urgent cares or clinics. $$$ plus education 2/2.

 

[MechEDoc]

One of the saddest cases I’ve had. 40’s year old, generally nice, otherwise healthy, family guy with several teenage daughters went to see a NP several times over the course of a year for new-onset increased gas, bloating and abdominal pain. No history of similar symptoms. She prescribed him Simethicone and various other similar meds over the course of multiple visits. Never ordered a CT or considered referring him to GI for a colonoscopy. I ordered a CT when he came into the ED with just his wife. It revealed widely metastatic colon cancer. Potentially completely curable with resection if caught earlier. When I broke the news to him he just started crying and only asked, “What do I tell my daughters?”

Umm, "don't choose NPs?"

Seriously though, that's super sad. I've had midlevels kill or nearly kill a few that I've been later involved in the care of.

 

[RustedFox]

Umm, "don't choose NPs?"

Seriously though, that's super sad. I've had midlevels kill or nearly kill a few that I've been later involved in the care of.

/b/

be me.
working at country klub medical center
chadwick and buffy and their kids kensley and kyler all goddamned day long
"No, we don't serve caviar and bubbly in pre-op, Mrs. Howell."
hate these people; they're not at all sick - but they're dramatic AF
kids have behavioral health problems out the waz00 because daddy is too busy shuffling papers to hit them and mommies are too busy doing cocaine and not eating.
learn to recognize those horsebit loafers as "the mark of the corporate @sshole"
these people aren't sick, so the pretend-level-providers dont know what sick looks like
PLPs get really comfy and get really mouthy
"The eye does not see what the mind does not know".
PLP picks up patient. 54 year old man with diabetes. Steps in canoe in awkward fashion, gets hit in the groin and falls in brackish water yesterday.
3 stooges were funny
Groin pain today.
dont' know if PLP even did an exam or even looked at vital signs, but ordered US testicles.
Physical exam as written in chart: "Swelling to groin". Yep. That was it.
US normal. only mentions testicles.
Discharges patient hypotensive.
I was at home at the time. Chart comes to me for signature.
I put in attestation: "I was available for teh lulz. I reviewed the chart because reasons."
Walk into shift next day.
Director asks me if I know anything about the case in room 8.
[record scratch, freeze-frame]
Its Curley from yesterday with gas gangrene all thru his groin.
Homeboy struggles on in the ICU for a few days before dying.
Yay for being sued because PLP cant recognize nec.fasc.
hello, darkness my old friend
This was the beginning of my giant meltdown wherein I left clinical medicine for almost a year.

 

[CoolDoc1729]

/b/

be me.
working at country klub medical center
chadwick and buffy and their kids kensley and kyler all goddamned day long
"No, we don't serve caviar and bubby in pre-op, Mrs. Howell."
hate these people; they're not at all sick - but they're dramatic AF
kids have behavioral health problems out the waz00 because daddy is too busy shuffling papers to hit them and mommies are too busy doing cocaine and not eating.
learn to recognize those horsebit loafers as "the mark of the corporate @sshole"
these people aren't sick, so the pretend-level-providers dont know what sick looks like
PLPs get really comfy and get really mouthy
"The eye does not see what the mind does not know".
PLP picks up patient. 54 year old man with diabetes. Steps in canoe in awkward fashion, gets hit in the groin and falls in brackish water yesterday.
3 stooges were funny
Groin pain today.
dont' know if PLP even did an exam or even looked at vital signs, but ordered US testicles.
Physical exam as written in chart: "Swelling to groin". Yep. That was it.
US normal. only mentions testicles.
Discharges patient hypotensive.
I was at home at the time. Chart comes to me for signature.
I put in attestation: "I was available for teh lulz. I reviewed the chart because reasons."
Walk into shift next day.
Director asks me if I know anything about the case in room 8.
[record scratch, freeze-frame]
Its Curley from yesterday with gas gangrene all thru his groin.
Homeboy struggles on in the ICU for a few days before dying.
Yay for being sued because PLP cant recognize nec.fasc.
hello, darkness my old friend
This was the beginning of my giant meltdown wherein I left clinical medicine for almost a year.

We had a similar case several years ago. The PLP documented an exam of thigh tender and red and called it …sciatica!?!! Came back within 8 hours, died within an hour on the way to OR. Thankful I was in no way involved. This particular PLP was always sleeping with the ortho residents, so hopefully she’s not “practicing” anymore …

 

[Dr Mantis Toboggan]

We had a similar case several years ago. The PLP documented an exam of thigh tender and red and called it …sciatica!?!! Came back within 8 hours, died within an hour on the way to OR. Thankful I was in no way involved. This particular PLP was always sleeping with the ortho residents, so hopefully she’s not “practicing” anymore …

Fairly common miss even for docs honestly. Easy to rule out if such patients are always in a gown and you can do/document a quick skin peek. But they never are, are they?

 

[bronx43]

Fairly common miss even for docs honestly. Easy to rule out if such patients are always in a gown and you can do/document a quick skin peek. But they never are, are they?

Not missed as sciatica… especially not after documenting red and tender.

That’s like documenting hot, swollen knee. Diagnosis: fibromyalgia.

 

[southerndoc]

/b/

be me.
working at country klub medical center
chadwick and buffy and their kids kensley and kyler all goddamned day long
"No, we don't serve caviar and bubby in pre-op, Mrs. Howell."
hate these people; they're not at all sick - but they're dramatic AF
kids have behavioral health problems out the waz00 because daddy is too busy shuffling papers to hit them and mommies are too busy doing cocaine and not eating.
learn to recognize those horsebit loafers as "the mark of the corporate @sshole"
these people aren't sick, so the pretend-level-providers dont know what sick looks like
PLPs get really comfy and get really mouthy
"The eye does not see what the mind does not know".
PLP picks up patient. 54 year old man with diabetes. Steps in canoe in awkward fashion, gets hit in the groin and falls in brackish water yesterday.
3 stooges were funny
Groin pain today.
dont' know if PLP even did an exam or even looked at vital signs, but ordered US testicles.
Physical exam as written in chart: "Swelling to groin". Yep. That was it.
US normal. only mentions testicles.
Discharges patient hypotensive.
I was at home at the time. Chart comes to me for signature.
I put in attestation: "I was available for teh lulz. I reviewed the chart because reasons."
Walk into shift next day.
Director asks me if I know anything about the case in room 8.
[record scratch, freeze-frame]
Its Curley from yesterday with gas gangrene all thru his groin.
Homeboy struggles on in the ICU for a few days before dying.
Yay for being sued because PLP cant recognize nec.fasc.
hello, darkness my old friend
This was the beginning of my giant meltdown wherein I left clinical medicine for almost a year.

I hated that you went through that.

I've been told by a defense attorney that it's best to just cosign a midlevel note without writing anything else unless you examined the patient. Writing "I was available" or "was not consulted" etc. opens the door for why you didn't proactively see the patient, you were available and not consulted was it customary that they consult you for every patient, etc.

Unfortunately, it's one of those catch 22s. You're hosed either way.

 

[Dr Mantis Toboggan]

Not missed as sciatica… especially not after documenting red and tender.

That’s like documenting hot, swollen knee. Diagnosis: fibromyalgia.

Yup I agree. My post is dumb on review. I shall try and do better next time.

 

[GonnaBeADoc2222]

I hated that you went through that.

I've been told by a defense attorney that it's best to just cosign a midlevel note without writing anything else unless you examined the patient. Writing "I was available" or "was not consulted" etc. opens the door for why you didn't proactively see the patient, you were available and not consulted was it customary that they consult you for every patient, etc.

Unfortunately, it's one of those catch 22s. You're hosed either way.

Back when I worked in CMG land, we were all tired of signing PLP notes for patients we did not see...so we just stopped doing it. Eventually the site director just signed all of them.

 

[deleted725838]

had a kiddo discharged from UC w/ NP diagnosis of gastro. Instructions: Zo/PO/go. Parents said they saw a 'doctor' and believed them.

Luckily parents had spidey sense so 6 hrs later he's in the ED. "he's not normally like this, he and his sister have a metabolic disease." Parents have poor health literacy and a language barrier, but you gotta listen and talk to the parents. They are telling you this is a zebra not a horse. The first thing they said was his medical history. I an't imagine they neglected that part a few hours earlier.

Ammonia level was through the roof. Went to PICU hours after being discharged from NP.

 

[wholeheartedly]

had a kiddo discharged from UC w/ NP diagnosis of gastro. Instructions: Zo/PO/go. Parents said they saw a 'doctor' and believed them.

Luckily parents had spidey sense so 6 hrs later he's in the ED. "he's not normally like this, he and his sister have a metabolic disease." Parents have poor health literacy and a language barrier, but you gotta listen and talk to the parents. They are telling you this is a zebra not a horse. The first thing they said was his medical history. I an't imagine they neglected that part a few hours earlier.

Ammonia level was through the roof. Went to PICU hours after being discharged from NP.

How often do these people or their superiors get feedback that they royally screwed up? Because if they don’t realize how bad they’re screwing up they have no incentive change.

 

[RustedFox]

had a kiddo discharged from UC w/ NP diagnosis of gastro. Instructions: Zo/PO/go. Parents said they saw a 'doctor' and believed them.

Luckily parents had spidey sense so 6 hrs later he's in the ED. "he's not normally like this, he and his sister have a metabolic disease." Parents have poor health literacy and a language barrier, but you gotta listen and talk to the parents. They are telling you this is a zebra not a horse. The first thing they said was his medical history. I an't imagine they neglected that part a few hours earlier.

Ammonia level was through the roof. Went to PICU hours after being discharged from NP.

Urgent care... "Where medicine goes to die."

 

[GassYous]

Urgent care... "Where medicine goes to die."

And where you make millions judging by some on these forums

 

[RustedFox]

And where you make millions judging by some on these forums

Right?

 

[Apollyon]

And where you make millions judging by some on these forums

Well, in those cases, at least, "Ownership matters"!

 

[EMhawkeye]

Noctor sends patient to ER for abnormal hemoglobin.
Patient's hemoglobin on routine labs- 18.5.
Patient is a smoker who has a bmi of 45.
I think we know why.


Another recent example that had me absolutely livid. Elderly african american gentleman sees the noctor for fatigue. Says he has been experiencing some fatigue recently as well as weight loss, increasing abdominal distension, abdominal pain, urinary retention, and constipation. Has never had nor been offered a colonoscopy by pcp noctor. She started him empirically on vitamin d. Had a cbc that showed microcytic anemia, gave some iron tabs. No GI referral, no imaging despite 2-3 visits over 6 months for this. Comes to me in the ER with melena. CT shows 10 cm colonic mass and mets to the liver. This one I actually spoke to the physician who oversaw them at the clinic. I told him on the phone "I don't think I've met a single med student that would miss that many red flags. She has no business treating patients"

 

[RustedFox]

Reddit: r/noctor

 

[thegenius]

Reddit: r/noctor

I subscribed to that for a time and it's non-stop ranting on noctors. Actually got tiresome at some point.

 

[DeadCactus]

Urgent care... "Where medicine goes to die."

The whole idea of urgent care seems to be a concession to the failure of our primary care system. An entire industry around illnesses that don't need emergent care but can't wait util a PCP appointment shouldn't exist but our system can't provide meaningful phone advise and timely PCP follow-up.

 

[thegenius]

The whole idea of urgent care seems to be a concession to the failure of our primary care system. An entire industry around illnesses that don't need emergent care but can't wait util a PCP appointment shouldn't exist but our system can't provide meaningful phone advise and timely PCP follow-up.

I agree..I'm pretty much willing to bet my life savings that urgent care medicine doesn't actually benefit the patient as a group. It just takes their money and drives up premiums.

I would have no problem with Urgent care if it was paid for, 100%, with patient money. If people want to spend their hard earned dollars talking to a doctor about their chronic cough...then let them. Don't make insurance pay for it.

 

[VA Hopeful Dr]

The whole idea of urgent care seems to be a concession to the failure of our primary care system. An entire industry around illnesses that don't need emergent care but can't wait util a PCP appointment shouldn't exist but our system can't provide meaningful phone advise and timely PCP follow-up.

Its not entirely our fault. I can get pretty much anyone in within 1-2 days and yet I still get several patients per day going to UC or the ED with nonsense.

 

[wholeheartedly]

agree with most of thread, but i moved to a new state, apt to establish with new doc is 2 months out. get uti so go to UC, get abx, get better. i’m ok with that system.

 

[thegenius]

Its not entirely our fault. I can get pretty much anyone in within 1-2 days and yet I still get several patients per day going to UC or the ED with nonsense.

The best way to minimize that crap is make people pay 100% of the UC or ED visit.

We would be saving a lot of money in this country with no change in outcomes.

EDIT: I'm 100% serious about UC...not sure about ED. Problem is people will then just come to the ED if UC is too expensive!!! People just want the free shiiit

 

[CoolDoc1729]

I’m primary. I once had a patient go to the ED because she didn’t want to wait 3 hours for her appointment (she came at the wrong time). So, yes the system sucks, but it’s not always our fault (I’ve got tons of examples like this).

It’s almost never the actual PCPs fault. Sometimes their receptionist or the stupid insurance or people just being unreasonably impatient (well yeah .. of course if you say chest pain they’re going to send you to the ER) (didn’t you think your toe pain for 4 months could wait another 2 hours until 0800 Monday morning?) (have you tried to reach your Dr for this 3 month old problem? “No”)

 

[turkeyjerky]

Had a lady sent in yesterday for "cold foot". She'd had classical claudication for 2-3 mo now, had an US last week was back in clinic today for scheduled followup. Shocking twist--foot wasn't cold.

Even the good ones are annoying. I was working w/ our best PA tonight. Lady checks in w/ 5 days of constipation, I order a KUB while she's waiting in triage so that she'll think we did something. He picks her up, adds labs (that come back normal) and then a CT and signs it out. Shockingly, her abd is benign, she's just constipated and CT shows nothing.

 

[kme243]

Noctor sends patient to ER for abnormal hemoglobin.
Patient's hemoglobin on routine labs- 18.5.
Patient is a smoker who has a bmi of 45.
I think we know why.


Another recent example that had me absolutely livid. Elderly african american gentleman sees the noctor for fatigue. Says he has been experiencing some fatigue recently as well as weight loss, increasing abdominal distension, abdominal pain, urinary retention, and constipation. Has never had nor been offered a colonoscopy by pcp noctor. She started him empirically on vitamin d. Had a cbc that showed microcytic anemia, gave some iron tabs. No GI referral, no imaging despite 2-3 visits over 6 months for this. Comes to me in the ER with melena. CT shows 10 cm colonic mass and mets to the liver. This one I actually spoke to the physician who oversaw them at the clinic. I told him on the phone "I don't think I've met a single med student that would miss that many red flags. She has no business treating patients"

2nd year med student and I knew that. Literally every single alarm symptom you can think of in a test question!

I was working in the ED on one of my first rotations. Had a patient come in with a water bottle cap stuck in their throat. Got a history and they tell me about their GI doc who diagnosed them with eosinophilic esophagitis and is being treated with fluconazole?? I figured they just misspoke and said that instead of fluticasone. There was something else they also said that just made everything sound suspicious so I did a bunch of digging into their outside records and found out it was an NP who scoped them for some reason. Diagnosed without any biopsies and prescribed fluconazole. Our GI docs took the bottle cap out, looked at her esophagus, said the NP was crazy and stopped the fluconazole.