studentdrtobe

26 is pretty young. Suck it up and go the MD route -- it offers the highest level of training in whatever field you end up in, hands down. The average age of matriculation in med school is a little over 24, so you won't really be that much older than your classmates and chances are that they'll be quite a few people older than you (we had many > 30 years old in my class).

Agreed.

This whole scenario reeks of unprofessionalism. I'm with the crowd that would have waited till leaving the room before discussing patient management rather than attempting to make the physician look like and idiot and laughing at her (wow!) in front of the patient (especially when you're "visiting" and don't have the entire clinical picture).

Thanks for the concern, netglow. I appreciate it. I'm not asking for sympathy or anything. However, I'm not worried about the future either. No matter what, I'll always be able to find a job. Pretty easily. The worst thing that'll happen to me, as a physician, is that reimbursements will continue to plummet (and they will), so I'll definitely make less than physicians in the past have and will have to adjust loan-repayments, house mortgages, etc, based on that. There will still be plenty of places looking to hire physicians though, so I'm not worried. All of our graduating residents last year got their top choice jobs in the salary range they were looking for, including in some very awesome big cities, and the current crop of senior residents are already getting offers from great places with the salary range we expect. The only medical specialty that currently is experiencing some issues with saturation and some trouble with finding jobs without a fellowship is pathology. And I'm not a pathologist! Phew. :) Thanks for the kind words! :) Don't get me wrong though, I LOVE working with midlevels. As a resident, they free me up for teaching opportunities, didactics, etc, and I'd imagine they'd make running a service a lot smoother. They do have more knowledge of pathophys and clinical management of patients compared to the regular nurses, so if that's a path you want to go down, that's great. I don't really see them as "stand-ins" -- rather, I like to think that they improve the flow of patient care and help make things in the department run more smoothly by freeing up residents and attendings so they can focus on more complicated patients. At least, that's been my experience. My personal opinion is that, regardless of what healthcare profession you go into, a significant portion of how much you learn and how large your knowledge base is is dependent on you. You don't have to only learn what a professor teaches you. It's easy to go beyond and get a more in-depth understanding of something. You just have to be willing to put in the effort to achieve that. Best of luck in whatever path you choose to pursue!

Why don't you focus on getting quality training instead of being worried about how quickly you can get through it? There are no shortcuts to developing into a good clinician.

Agreed. That's a huge reason why many of us in medicine have also preferred to hire PAs rather than NPs. Their curriculum is pretty solid! Plus, it's standardized! So we have a pretty good idea of what we're getting when we hire a PA. Full disclosure, in case people are confused -- I'm a PGY-2. My opinions, for the most part, are based on my own experiences (which is pretty extensive --- approx. 10,000 hours of clinical training already, if not more) and my talks with other colleagues (residents and attendings). I find this an interesting, but common, assumption amongst nursing midlevels. You actually don't do the same thing that I do. For any given set of symptoms that a patient comes in with, I (and physicians in general) can develop a much, much larger (and stronger) differential diagnosis. So, while we may often reach the same conclusion, as a physician, I'm ruling out a lot more problems than you are. As someone essentially practicing medicine, I'm sure you're aware of how important it is to rule out conditions - it's just as important as figuring out what the actual problem is. I'll give you a couple of examples in a later paragraph, but not developing a large enough differential to rule out subtle, but important, conditions can lead to devastating consequences for the patient (ex. missing cancer diagnoses because the symptoms were too subtle/"common"). You do your job. And I do mine. But, it's insulting to say that you do the exact same thing I do. That is not true. I've spent years in training and sacrificed a good chunk of my 20s studying so I can develop into this "differential diagnosis generating machine" (and I still have a long way to go). They have more freedom in the hospital systems I've worked in not because they're "good little soldiers and stay obedient to their MD masters" but because they receive much better training than our NPs do. In fact, our PAs tend to challenge our residents' plan of action, etc, a lot more than our NPs do. Our PAs' fund of knowledge regarding pathophysiology and clinical decision-making has been much better than the NPs', time and time again. This is just my anecdotal evidence and I don't know if any comparison between NPs and PAs exists in the literature (doubt it). However, looking through both midlevels' curricula, it's easy to see why PAs get more freedom -- their curriculum focuses on developing them as clinicians whereas the NP/DNP curriculum focuses on producing people with business and health policy smarts rather than pure clinical training. It's just the safer route for physicians to prefer PAs. We know a lot less about the training nursing midlevels get and many are unwilling to take that risk. If the cost isn't different, you want higher quality. Not service. It doesn't matter if you spend an extra hour with the patient if your training hasn't prepared you to develop an extensive enough differential to figure out what's going on with them. With that being said, the vast majority of patients ultimately do just fine seeing midlevels, so I agree with you (in a sense) there. Actually, that sounds more like what nurses and other ancillary staff tend to do, rather than doctors. These people go out of their way to "put doctors in their places" and try to show that they know more than the doctor, so this attitude has definitely been more prevalent in the non-physician community. I've seen everything from NPs who've been awesome at referring out patients when they realize it's beyond their scope to NPs who've refused to think that the underlying issue is something pretty bad - over the last year, we've had 2 patients come in with advanced stage cancer because their primary care providers (one was an NP and the other was a DNP) thought all their symptoms were something common. This type of thing is much less common in physicians, because of the way we form differentials. As physicians, we're taught right from the first day of school how little we actually know. It's engrained in our heads that we don't know everything and the length of our training makes that even clearer. I thought there was some recent survey showing that prior nursing experience did not translate over to producing better NPs? I would trust the opinion of the physician. I haven't come across many nurses that understood the subtleties of cardiac conditions and were able to thoroughly explain things like etiology, pathophysiology, pathogenesis, which choice of pressor, etc. Cardiovascular path is a HUGE part of medical training, whether you go into cardiology or not, because of how prevalent CV disease has been. So, a LOT of focus is placed on CV disease - unless you're super, super subspecializing, you have to know this. The general practice/internist physicians are probably second in line, after cardiologists, in terms of cardiology knowledge. The reason we see a lot more referrals to cardiologists rather than FP physicians taking care of it on their own is because of CYA medicine, not because of a lack of knowledge. And I find it incredibly insulting that you think we did "one or two cardiac rotations and during that time, 90% of [the] job rested around probably asking the nurses what so-and-so doctor normally did." No. It's clear that you don't understand how medical training works and even what it entails. By the time we're done with medical school (not even residency), we've already had multiple rotations where cardiology plays a significant role. And while we occasionally do ask nurses about what a particular attending might prefer, we don't blindly just go with what they suggest. We ask what the attending prefers because if their treatment plan and ours doesn't differ significantly, we might as well go with their plan since they're more used to it (ex. my choice of medications vs. the attending). If I feel that my choice is better, chances are I can reasonably explain it to my attending and get him/her to follow my plan instead. Physicians don't get their primary learning (which includes patient management) from nurses. We get that from residents who are above us in training and our attendings. We would be ripped apart if we blindly followed a plan that a non-physician, no matter what profession, suggested. ACGME requires that we be taught by physicians. That has a lot to do with how incredibly powerful the nursing lobby is. I can only wish that the medicine lobbies and PACs were even half as well-organized as the nursing lobbies are. So, kudos to your profession on mastering the art of lobbying politicians. I think I know what ED study you're talking about. And the conclusions you're drawing are not accurate. The emergency NPs had more than double the rate of missed injuries and/or inappropriate management - the only reason this did not come out of be statistically significant was because of how severely underpowered the study was. Not only that, it was the doctors who actually spent more time with patients, rather than the emergency NPs. And that was statistically significant (not that it means anything, considering how underpowered the study was). This is just from my memory, so feel free to look up the study. I remember going down to the ED for a consult last year and having this discussion with the ED attending and 2 of the ACNPs there. They were having a good chuckle at how easy it was to publish poorly-done studies. Both of those ACNPs also thought the study was essentially worthless. These multiple studies have pretty poor methodology (much more so than the avg. study does) or are severely underpowered to draw any meaningful conclusions from. Bad evidence is worse than no evidence (refer to the Wakefield study and the impact it has had, if you want an example). What these same studies also suggest is that nursing midlevels waste more money than physicians (by ordering more tests and referring patients out more) while taking a lot longer to reach the same diagnosis as a physician. Again, neither of those matter either, since the studies were badly designed and we can't make those absolute statements based on bad evidence. In conclusion, I'm sure there are excellent NPs (I work with a few of them!) and bad NPs just as there are excellent physicians and bad physicians. However, to state that you do exactly the same job that myself and my physician colleagues do is extremely, extremely insulting and completely inaccurate. Know your scope, practice within it, realize there's still a heck of a lot that you (and I) don't know, and you won't have any issues with physicians.

Not really for those reasons. Trust me, no physician is "fearful" of midlevel incursion. We still know we have the highest level of training in our fields, by far. It's mostly the bad associations with online degrees. When someone says they got a degree online, for me personally, I immediately think of all those UofP and Devry commercials on TV -- and these programs in general do have a bad rep of taking in anybody with a pulse (as long as they can pay tuition). So, there's that strong negative connotation there. Additionally, my own opinion is that it's harder to communicate/problem-solve with colleagues and teachers via online communication vs. real-life interactions. I can speak out a question much more clearly and quickly than type it out, wait for a response, then respond back to them with follow-up questions, etc. Combine that negative stereotype involving for-profit schools, along with lack of convincing evidence showing that online education is at least equivalent to classroom learning, you can see why some people are hesitant of online degrees. Online programs are their own worst enemies. They're popping up left-and-right at a ridiculous rate, which further pushes the stereotype that they're just out for making money rather than ensuring quality.

+1. Best post of the thread!

Again, I don't really see what the big deal here is. If I was your physician, I wouldn't give out a referral either. Especially if you call me and say you need a referral to get some steroids. That's my license on the line; in the off-chance that you're wrong, I could easily be taken to court for making a judgment call without physically assessing you myself. How can I defend myself in that case? It's an entirely lose-lose situation for me. I wouldn't care if you were an attending or a world-renowned pulmonologist with years and years of experience! I would still direct you to the ER. And I would say the majority of practicing physicians today would do the same. It's simply not worth the risk in the current medicolegal environment. I think you're over-analyzing this situation and taking things a bit too personally. Relax. If anything, he was probably trying to compliment you with the "medical training" comment, but worded it poorly. Could he have communicated this better? Yes. Do I think he was intentionally trying to insult you? Probably not. Hope you're feeling better.

Yea, no. This may have been true a few decades ago, but certainly isn't true anymore. Are there still a lot of nerds who make it to med school? Absolutely. You have to be smart and, more importantly, have a strong work ethic in order to survive the difficulty of med school, residency, and beyond. Just because we're nerdy doesn't mean we never had friends in school. Who says that being smart is equivalent to being socially awkward/stunted? That's a ridiculous statement to make, with no substantive evidence behind it. Nor are we "out for revenge." Attitudes like yours only work to worsen the relationship between physicians and nurses -- trust me, I encounter enough nurses with these types of attitudes and it certainly doesn't endear you to us. To the OP, I apologize on behalf of the doctor that yelled at you. Saying that he'll get your home phone number and call you in the middle of the night to hassle you is incredibly unprofessional and I do hope that he gets written-up/talked-to about that. That kind of behavior is simply unacceptable. With that being said, learn from this mistake and absolutely make sure you have all pertinent patient info on hand before making a call in the middle of the night. Nothing sucks worse than being woken up in the middle of the night and having the person on the other side have no objective data on hand or be struggling to explain why they called us in the first place. Be ready with your clinical reasoning (whether it's lab values or your subjective assessment of the patient) when you call in the middle of the night so you're not fumbling around during the call. To those who think physicians should memorize the lab values, vitals, medications, etc, of the huge volume of patients we have on service, that's completely unrealistic. Just because you're carrying only 10-15 patients during your shift doesn't mean the attendings are -- they're generally responsible for many times that number of patients when they're on call. Heck, the interns easily cross-cover 80+ patients on night float and our service alone has maybe 40. And considering the laundry list of medications each patient comes with these days, it's pretty unrealistic to expect us to memorize all of these and recall them quickly after being woken up at 3 am.

Why would the physician risk a potential lawsuit in case you turned out to be wrong? I refuse to give anyone a referral just because they ask if I don't physically assess them myself. The physician did the absolute right thing here, especially given the current medicolegal environment. It had nothing to do with your education.

It's where residents present articles and dissect them. Ex. the results of a large, potentially practice-changing clinical trial are published. A resident presents this data, along with a thorough background (which includes past clinical trials, retrospective studies, etc, and their pros/cons), the basic science mechanisms, their interpretation of the results, etc. And then, the presenting resident (and, often, the other trainees in attendance) are grilled with questions by the attendings (ex. "What would you do when a patient with XYZ comes in? Would you consider extrapolating data from this trial? What would your first step be? How would you proceed if the patient is refractory this your first-line treatment?", etc). It can be exciting, but downright scary! But, for the most part, they're very educational since it pretty much forces all the trainees to study so they don't look like fools in front of the entire department! :) Yea, I agree with ya there. I love the medical education I've received so far and it has been, for the most part, very well-organized. We're incrementally given more and more autonomy as we progress through our training and show that our clinical decision-making is sound. As another poster mentioned though, there is a very rigid hierarchy in medicine and you have to conform to it. Attending > fellow > senior resident > junior resident > intern > med student. No ifs, ands, or buts. You have to put in the time and effort to work your way up the totem pole. You disagree, as an intern, with the treatment plan the attending decides on? Deal with it. Once you become a senior resident, you're much more likely to engage in academic discussions with the attending regarding the subtleties of patient care and convince them that your plan is just as good or better. The hierarchy is there as a way to provide appropriate level of supervision (based on where you are in terms of training) as well as being a net for catching mistakes. Additionally, residency spots get funding from Medicare. Not sure where the money comes/would come from for nursing residencies or whatever. And for more than a decade, Medicare funding for residency spots has essentially flat-lined.

Actually, that's completely wrong. We "go back to the classroom" throughout residency training and beyond. During residency, we have mandatory conferences, grand rounds, journal clubs, and weekly didactics. Some residencies even have an entire day of the week dedicated solely to didactics and conferences. While, yes, it's not as much classroom learning as the first two years of med school, it's completely wrong to say that there's no classroom education beyond med school. Hard to keep up with changes in the basic sciences and mechanisms of pathophys/pharm/etc if you're only in the clinic doing hands-on work.

I'm not DocsWifey, but no, pH isn't the only measurement you look at when trying to figure out compensation. You also have to take into account the HCO3- and pCO2 levels, along with the rest of the clinical picture (including anion gap, etc). There are also additional calculations we generally use in the clinic with acid/base disturbances (ex. Winter's formula, etc). These help in evaluating compensation mechanisms. I personally prefer to stick with basic chemistry principles when working with acid/base disturbances rather than working with various formulas, etc. It makes more intuitive sense, in my opinion. Take a look at the following article to get a more thorough understanding of this stuff. It's a very, very quick read and pretty easy to understand: A practical approach to acid-base disorders. [West J Med. 1991] - PubMed - NCBI Understand the concept of the carbonic anhydrase mechanism and Le Chatelier's Principle, as I mentioned in my previous post, and it'll make the reading much more simpler and intuitive. Seriously, when learning this stuff, it's better not to get bogged down on details or formulas or whatever. Understand the concept and add more layers of complexity afterwards. Hope this helps.

Use a systematic, step-wise approach to acid-base physiology: 1) What's the pH? If it's below 7.35, it's acidosis. If it's above 7.45, it alkalosis. Now, you've established whether the patient is within normal limits, acidotic, or alkalotic. Simple so far, right? 2) Next, you want to figure out whether that acid/base disturbance is metabolic in origin or respiratory in origin. 3) If it's metabolic in origin, you'll see changes in bicarb levels. If it's respiratory in origin, you'll see changes in pCO2. Decreases in bicarb would be mean metabolic acidosis, while increases in bicarb would mean metabolic alkalosis. Increased pCO2 means respiratory acidosis, while decreased pCO2 means respiratory alkalosis. Keeping up with me so far? 4) Now, to compensatory mechanisms. An easy way to remember this is that compensation will always be the opposite of what the primary disturbance is. For example, if the primary disturbance is metabolic acidosis (ex. DKA), the compensatory mechanism will be respiratory alkalosis -- what that means is that respiration rate is going to increase and because of increased ventilation rate, the pCO2 is also going to drop. Another example would be if a patient is in metabolic alkalosis, for example from excessive vomiting or something like that. In this case, the compensatory mechanism will be the opposite of metabolic alkalosis -- respiratory acidosis. So, you'll see decreased ventilation rate and an increase in pCO2. This is the just basic gist of acid/base mechanisms. It gets a bit more complicated when you're dealing with mixed disorders, but the same basic principles still apply. If you want to get a true, conceptual understanding of why all these things occur, all you need to understand, simply, is the carbonic anydrase mechanism and Le Chatelier's Principle from basic chemistry: CO2 + H2O H2CO3 H+ + HCO3- If you have metabolic acidosis, and HCO3- decreases, the reaction is going to be pushed to the right because of Le Chatelier's Principle (essentially to re-establish equilibrium). If the reaction is pushed to the right, we'll see a decrease in pCO2. So, what does that equation and concept tell us? With metabolic acidosis, we see a respiratory compensation where pCO2 drops -- respiratory alkalosis. Same idea with metabolic alkalosis -- HCO3- increases, so the reaction will be pushed to the left this time in order to re-establish equilibrium. What happens if the reaction is pushed to the left? There will be a rise in pCO2. And that's what the normal compensatory mechanism for metabolic alkalosis is -- respiratory acidosis! Same rules will apply when approaching disturbances due to respiratory issues. Does all of that make sense? If you approach it with the above equation and concept in mind and go through each scenario in a systematic, step-wise fashion, you'll see that it's not so bad at all! Just remember back to what you learned in chemistry class! Hope this helps.