Not Knowing What You Don’t Know

Not Knowing What You Don’t Know

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“The more you learn, the more you realize you don’t know.”

You will hear this statement not just from physicians, but from lots of other folks engaged in scholarly work of all stripes. That’s because it is not merely true; it is a deep and universal truth that permeates all of mankind’s intellectual endeavors.

The implication of this for the practice of medicine is that a little knowledge can be very dangerous.

What do I, as a fully trained, extensively experienced primary care physician bring to the evaluation of patients who seek out my care that cannot be matched by so-called “mid-level providers” (PAs and NPs)? It is not (always) my knowledge, but rather the experience to know when I do not know something. In short, I know when to ask someone else’s opinion in consultation or referral.

I had a scary experience lately with a PA who didn’t even know what she didn’t know (and who still probably doesn’t realize it.)

The patient had been bit on the hand by a cat. I saw the injury approximately 9 hours after it had occurred. The patient had cleaned it thoroughly as soon as it had happened, and by the time I saw it, it was still clean, bleeding freely, not particularly red or swollen, and only a little painful. Still; cat bites are nasty, especially on the hands. Therefore I began treatment with oral amoxicillin-clavulanate, and told the patient to soak it in hot water several times a day.

Six hours later (after one oral dose of antibiotic) the patient called me back: the wound was now much more painful, red, swollen, and there were red streaks going from the hand all the way up to his elbow. Frankly, I was a little puzzled. He was already on antibiotics; the single dose probably hadn’t had enough time to make much of an impact. And yet the infection was clearly progressing.

I called my handy dandy Hand man, my friend the hand surgeon I have on speed dial, whom I love because he answers my texts. This time, though, I picked up the phone and spoke to him. I explained the situation and my puzzlement. Here’s what he said:

Send him to the ER. He needs to admitted for IV antibiotics for 24 hours. If it’s not getting better by then, he needs a debridement [surgical procedure].

Okay then.

I called my patient and relayed the message. Just to be sure, though, I asked him to call me if they did NOT admit him.

On I went with my day.

Phone rings; it’s my patient calling from the ER:

They’re sending me home.

What?

They’re giving me a dose of IV antibiotics and sending me home on the one you gave me. They gave me the number of a hand surgeon to call tomorrow if it’s not better.

Hm.

I get on the phone to the ER, and ask to speak to the physician seeing my patient. Turns out it’s a PA, who proceeds to tell me that the hand doesn’t really look all that bad, she’s seen worse, and treated them like this before, sending them out with the blessing of the hand surgeon.

Hm. This is a fast moving infection that has worsened markedly in the last six hours while on oral antibiotics.

Did you consult Hand? I ask.

No.

Hm.

Long story short, I get the PA to call Hand Surgery (“Though I doubt they’ll come in,”) who successfully convinces the ER to admit the patient on 23 hour observation status with IV antibiotics. By morning (and 4 doses of IV antibiotics), the red streaks are resolving, the swelling and pain are decreasing, and the patient is good to go, to complete the course of orals.

I was concerned enough about this encounter to call the ER and speak to someone *in charge*. As part of our go-round, I was informed that there was always an ER physician available while the PA was seeing patients if there had been any concern, to whom the PA could turn. It was surprisingly difficult to convey the idea that the problem was that the PA did NOT have a concern. She did not believe that she needed to consult either with her supervising physician, or a specialist.

If I had not explained the (expected) plan to my patient, or specifically asked him to call if the plan was not carried out, or if I had meekly acquiesced to the “provider” on site since she was looking at the patient and I wasn’t (though the patient did take and send me a picture, which I was able to compare to one I took of the same injury 6 hours earlier), frankly I shudder to contemplate the outcome.

Primary care isn’t just about knowing stuff, and knowing what you know; more than that, it’s knowing enough to know what you don’t know.

Mid-level providers do not know enough to know what they don’t know. This makes them dangerous. Admittedly these situations are few and far between, which is what allows complacency to flourish. But make no mistake. Their education emphasizes what they know, leaving them with enormous blind spots of hubris into which more and more patients will fall, with predictably disastrous results.

Lucy E. Hornstein, MD is a solo-practitioner in Family Medicine. She is also a book author (Declarations of a Dinosaur) and posts frequently at her blog, Musings of a Dinosaur, where this post first appeared.

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71 Comments on "Not Knowing What You Don’t Know"


Guest
Mar 10, 2013

Thank you! Thank you! Thank you! Give then a few more years of schooling, slap a white lab coat on them and voila they determine whether they need a physician’s guidance, “supervision”, or opinion.

Guest
Richard Branson
Mar 14, 2013

There simply is not enough space available on the Internet to post the list of similar problems I’ve seen wrought by physicians in my 35 yrs of practice as a physician assistant.
I agree a simple phone call to the ER was the appropriate “best practice” thing to do and that was not done by the physician.

Guest
Sallie Porter
Mar 10, 2013

Communication is key. If the “fully trained, extensively experienced primary care physician” was “puzzled” by the patient’s situation, I think a quick call to the ER (in advance of patient to explain concerns) was indicated.

Guest
Minivet
Mar 10, 2013

I hate Donald Rumsfeld for his “unknown unknowns” line. Things we don’t know that we don’t know are a real phenomenon, but he used it in a poor attempt to obscure his own incompetence, making people skeptical of the whole concept.

Guest
killroy71
Mar 12, 2013

Try this instead: “Our knowledge is finite but our ignorance is infinite.”
–Austrian philosopher Karl Popper

It’s true in more than medicine, but probably not as dire in other fields.

Guest
Mar 10, 2013

That line was out of one of Mr. Rumsfeld poems that he quoted addressing a question regarding terrorism and weapons of mass destruction at a NATO conference. It was no riddle and while the subject was much different than this post, it most certainly applies here and has significant meaning.

Guest
SJ Motew, MD
Mar 10, 2013

The story to me highlights more of a communication breakdown, inappropriate use of the ED and lack of integrated sharing of findings/recommendations than the knowledge deficit of the PA in the ED.

The plan had already been determined through a successful interaction between the initial treating physician and the hand surgeon. Why did the hand surgeon/PCP send the patient to the ED? Why not asses the patient themselves or admit directly? The recommendation to admit for IV Abx and observation seems to have been made by the hand surgeon, who clearly did not see this a responsibility he needed to assume for care of this patient.

Introducing the additional layer of the ED provider into this loop without relaying the already identified appropriate plan was a setup for failure.

Perhaps a shared/integrated medical record would have helped in this case, the primary MD could have documented the interaction and recommendation from the hand surgeon (or better yet the hand surgeon could have placed a phone-call note with recommendation in the chart), the ED PA could then have seen this interaction. Then again a phone call could have accomplished the same thing.

Guest
Mar 15, 2013

I agree that a direct admission would have accomplished what needed to be done, bypassing the problem of a PA who was sure he knew what he was doing. Then again, when was the last time you tried doing a direct admit?:
http://dinosaurmusings.wordpress.com/2013/03/15/direct-admission-whats-that/

Also: to anyone who sees a lymphangiitis up to the elbow in 6 hours and says, “It’s not so bad,” I question their clinical acumen more than anything else. *This* PA; *this* situation; go away all you PA trolls, I’m not talking about trauma medics in Iraq.

Guest
Lisa CPNP
May 29, 2014

It’s unfortunate that this patient even had to see the inside of the ER. Putting the communication problems aside (a call ahead to say that you wanted the patient admitted), it’s a shame that this PA didn’t know better. A rapidly progressing lymphangitis in the face of initiated antibiotic therapy warrants a hospital admission. Period

You should know though that we’re not all bad. Last month the triage nurse sent me a 15 year old female with “arm pain” whom she deemed to be in no distress. The child was sent to the exam room (fully clothed …grrr) after receiving Tylenol. A thorough history by yours truly revealed no reason for her arm pain but I made her undress anyway. Wouldn’t you know it, she had this ever so subtle, barely visible red streak from her axilla to her elbow. So that’s what hurt. Any fever? Well that ridiculous TA thermometer said no, but why was her heart rate 130? Seems a retake of that temperature ordered by yours truly, the nurse practitioner, revealed 103 fever. I drew labs after consulting my attending and called the hospitalist for admission. And do you know that the hospitalist had the nerve to belittle this admission?

My point to you, with all due respect is that we should not all be measured by the overly confident PA that you dealt with. The same way I would never judge all hospitalists by the one I dealt with.
I’m good at what I do, but I’m humble. We can all learn from each other and I’m lucky to work somewhere where my medical director embraces that concept.
Most providers would have sent that kid home without undressing her. She was fortunate that she saw me that day and not someone else. Even the consulting physician was impressed with my exam findings. And do you know that she praised me for it in front of HER OWN peers?
I also promise you that had I missed the diagnosis she would have given me a fabulous teaching opportunity.

Guest
Mar 10, 2013

I am and ER doc (now retired) who spent many years learning about how much I don’t know, sometimes acting in a bubble of ignorance and thus learning the hard way from my short-sightedness, and sometimes obtaining wisdom via timely surgical consult. Although I worked with ‘midlevels’ throughout my career, and many were excellent clinicians by most standards, it was usually clear who had the broadest understanding of the clinical situation. Despite the many exceptions to the rule, I think Malcolm Gladwell’s 10,000 hours is relevant. Medical training significantly exceeds PA training in depth, breadth, scope, and duration of training, so it is no wonder that we expect more acumen of Docs than PAs. So the question is, why is a PA staffing an ER, where the ‘patient material’ is the most uncontrolled and requires the greatest level of sophisticated judgment? The answer is clearly economic: we are prepared to accept a lesser degree of expertise and wisdom because it is less expensive. The increased level of not knowing what isn’t known is acceptable, presumably because it has not been conclusively shown that outcomes are so different as to justify the increased expense of staffing ERs with MDs. The only problem is: when I am rolled into the ER, you can be sure I will demand to see a doctor, someone with a Doctor of Medicine degree. But I guess there is another problem: I will probably wind up talking to a computer screen.

Guest
GerardQ
Mar 10, 2013

This is a completely inflammatory and one-sided story: first off, to group all “so called mid-level providers” together and proclaim them to be “dangerous” is inappropriate. There are many “fully trained, extensively experienced primary care physicians” around who practice less than safely: does that mean that it is fair to brand all physicians as unsafe?
You prescribed an appropriate medication, but that does not mean your patient started it. Further, soaking animal bites is not a recommended practice as it raises the risk for infection in the wound. Surely a fully trained and extensively experienced physician would know that.
Who can say objectively how the patient presented to the ED, and what they told the provider? What the patient told you and you envisioned was obviously not what the ED provider saw.
It does not take a Medical Degree to understand that one does not know everything and that gaps in knowledge exist: it takes common sense. PAs and NPs are Master’s prepared professionals and again, grouping two groups of professionals together and calling them incompetent based on one experience shows that you don’t know what you don’t know about the profession or people.
As the target in your anecdote was a PA, did you discuss your concerns with the PA’s supervising physician? As you are well aware, the PA must have had a supervising physician available to sign off on the chart. Why not question the competency of the supervising physician?
You did not complete a PA program or NP program: do not profess to know what their education emphasizes. Instead of berating the PA and NP professions, and turning a blind eye to other areas that may have a played a major role in this case, you might want to work with them to help them become stronger providers.
Lastly, if you had put together a plan of care for this patient in conjunction with a hand surgeon, why did you waste everyone’s time by sending him to the ED as opposed to admitting the patient yourself?

Guest
Mar 11, 2013

Supervision? We could dance around that term all day! When it comes to supervision of mid-level providers it is poorly defined and executed.

Guest
GerardQ
Mar 11, 2013

Thats a reflection of the supervising physician, and not the PA or NP.

Guest
Mar 11, 2013

It is a reflection of the system.

Guest
Ed
Mar 12, 2013

Supervision, and levels thereof, are defined by State Law. Typically it is up to the Physician and the PA to determine what is appropriate.

Guest
legacyflyer
Mar 10, 2013

First of all, “the cat is out of the bag”, “the train has left the station”, etc. There are going to be more and more “mid-level” providers out there whether we like it or not.

Secondly, there is no doubt that “mid-level” providers are fine for most minor to moderate problems. Now if only we could get the patient to come in color coded so we know which ones are serious and which ones aren’t!

Compared to ER docs, PAs in the ER order more XRays and have a lower hit rate. And the level of ignorance can be appalling – a PA who ordered a Pelvic Sonogram didn’t know what a hydrosalpinx was.

Guest
Daniel Freshour
Mar 10, 2013

And you assume that had this been a doctor or medicine or osteopathy that there is no chance the same decision would not have been made. I am sure that if you have been in medicine a few years you have seen some questionable decisions from both MD and midlevels. Do you mention this? Certainly not. Your goal is to be an arrogant pedestal placed fear monger. This is an anecdotal story at best and by no means shadows poorly on the midlevel professional as a whole and soley on one practitioner that is in fact human and therefore errors can occur. I wonder Doctor, have no medical mistakes occurred by actual MD or Osteopaths?

Guest
PA_Student
Mar 10, 2013

Dr. Dinosaur, perhaps you should consider precepting a PA student or lecturing at your alma mater’s PA program. I think if you had the opportunity to work with us, you would change your mind about us being dangerous.

PA students are generally very eager to learn and passionate about medicine and patient care. Most of us have years of experience working in the medical field prior to PA school so we understand how important it is to put the patient’s safety above all else. Entry into PA programs is highly competitive, the coursework is rigorous and the pace is relentless.

I started my medical career working as a CNA in a nursing home and hospice while taking my pre-med courses, and I later became a MA at a family practice clinic. I have spent many years of my life, driven myself deep into debt, moved across the country, and lost many friends so I could become a PA. For you to casually dismiss my profession, which has existed for nearly half a century, as “dangerous,” based on a single anecdote, is frankly pretty hurtful.

So even if you decide not to precept a PA student, I hope you will at least reconsider your assumptions about the profession I have worked for many years to be a part of.

legacyflyer – do you have a source for your “XRay” stat and what do you mean by “hit rate?” You don’ t sound like a clinician to me. Who says “sonogram” anymore?

Guest
legacyflyer
Mar 11, 2013

PA Student,

My comments are based on personal experience as a Radiologist who reads; XRays, CT, and sonograms (or ultrasound if you prefer) for 8 hospitals. I have been in practice since 1984 and have therefore seen a lot of water flow under the bridge.

What I mean by “hit rate” is this – the percent of cases for which an imaging study yields a positive result. Again, in my experience, the hit rate is highest for older docs, and lower for younger docs and PAs. This is obviously not a “study”, since generally MDs and PA are not seeing the same type of patients. And of course the PAs are under some kind of supervision, although I am sure that varies.

You could rightly ask: “Well are the older docs missing a lot because they order less?” to which I would respond – not much – in my opinion.

I agree with some parts of what you say. I have found that PAs, although generally less experienced and less well trained than ER docs, are generally good, hard working people doing their best. And I think that if they are working in the proper setting and have the proper backup, they are useful members of the medical team.

Ask yourself the following question: “If I had a serious legal problem, would I rather see; a lawyer who is experienced in that area, an inexperienced lawyer, or a paralegal?” If the answer is an experienced lawyer then you understand what some of this is about.

Guest
Ed Mathes, PA-C
Mar 12, 2013

LegacyFlyer,
I’m a season by 32 years PA, now working in interventional radiology. Anecdotal information is inaccurate at best. It reflects one person’s experience, which may be biased.

Show me the actual studies. I can tell you (and I’m sure as a Radiologist you already know), the Physical Exam, actually laying on of hands, is being supplanted by imaging. CT is king! And this is distressing for this Dinosaur PA.

As an example (and we all have them), we (IR) was consulted by the surgery department to drain a supposed hepatic abscess in a 23 y/o girl. Long history of Crohn’s disease, in “deep remission” per her Gastroenterologist. Presented to the emergency department with GI complaints (Nausea, vomiting, diarrhea) for 3 days. Low grade fever, WBC 15K, no shift. LFTs, Chemistry normal. Not anemic. History significant for Sub-Sahara Africa travel into the boonies 6 months ago for 2 weeks (visiting a friend in the Peace Corps). CT scan demonstrated a “Fluid collection in the right hepatic lobe without rim enhancement, cannot exclude abscess vs. complex cystic structure. Recommend Ultrasound”.

Ultrasound demonstrated a “complex, multi-loculated collection with possible cystic component. Consider abscess, echinococcal cyst, or other infectious process”.

WBC is down to 4.5K after one dose of IV antibiotic, fever is gone, GI symptoms resovled with IV fluids and NPO.

Surgery service sends patient to us for US guided drainage of the hepatic collection.

The PA reviews the images and history, EXAMINES the patient with his hands and a linear ultrasound probe, then calls the IR Attending, the Surgeon, the GI attending and the Medicine attending.

Large bruise on the right flank overlying the hepatic collection with a hepatic capsular tear under the tip of the 11th rib, the tear coincides exactly with the collection. Looks like a hematoma due to hepatic laceration. How? Closer questioning reveals the patient was being carried by her boyfriend, he tripped and fell onto a parked car’s trunk edge, using her as a cushion, 2 weeks prior. Immediate pain, SOB on her part. Went to Urgent care, seen by an MD, who prescribe pain medications and hot soaks for “bruised ribs”. She got progessively better over the next 2 weeks until the GI symptoms occurred….. Was this history not pertinent?

She stated she mentioned the trauma to one of the residents who, in his note, makes no mention. 6 different MD’s looked at her; Attendings, residents, different services. Had they looked and touched and correlated, would she have made it to IR?

Now, infectious source for her liver collection is a reasonable hypothesis given her history of Crohn’s and her African bush travel. However, no one looked at her abdomen!
Amoebic cysts get better. Echinococcal should not be drained percutaneously, and an asymptomatic hematoma can and should be be left alone. Treat the patient, not the image.

Given she was improving, watchful waiting is the currrent plan.

I mention this case because…..

All health care providers have their areas of expertise. Expertise is developed by their education, how well they learn, their interest in learning, their experience, and the size of their ego. That includes MDs. As a PA for 32 years I can tell you, anecdotally, that most of us do know what we are doing. Most of us know when to ask for help. Most of us do know what we don’t know. And we all strive to help those that seek our care.

I ask, before you paint all of use with the bad brush, you take time to learn, observe, educate yourselves. Let he who is without sin cast the first stone!

Ed

Guest
legacyflyer
Mar 12, 2013

Ed,

I did Angio/Interventional for close to 30 years – so you and I are not as different as you might think. At the hospital where I did most of my work, there is now a PA who does most of the minor procedures I used to do. I fully supported the Chairman (and my friend) as he struggled to get the PA accredited to do these procedures. I fully supported him in this effort. The PA who does these procedures is named John, I think he does a good job and I am friendly with him. Before he was accredited to do these procedures semi-autonomously, he used to assist me in them.

I do NOT think that PAs are “bad”, nor do I paint them all with the same brush. I think well trained PAs functioning in an appropriate role are good for medical care. I have also seen a variety of problems with MDs over the years. Nobody is perfect.

However, I will re-iterate what I said above. In general experienced ER MDs are able to handle more complicated cases more efficiently than PAs. In general their knowledge base and experience is superior to a PA. I don’t think this is a complicated or controversial statement.

I will tell you that some of what is going on here has to do with the implicit threat to replace MDs with PAs and NPs. Some MDs look at this similarly to a union member who works at a factory and is told: “Hey, we can get a bunch of Mexicans in here to do what you do for half as much”. You can imagine how that factory worker would feel. As for me, I am old enough and close enough to retirement not to really care all that much.

Good luck in your career – we are not enemies.

Guest
Ed Mathes, PA-C
Mar 12, 2013

Thank YOu! I should clarify.

The first segment was directed to LegacyFlyer…

“Show me the actual studies. I can tell you (and I’m sure as a Radiologist you already know), the Physical Exam, actually laying on of hands, is being supplanted by imaging. CT is king! And this is distressing for this Dinosaur PA.”

The rest was a general comment on the blog and some of the responses.

I am glad you have a PA and he is helpful. In our (university based) practice, we have 7 PAs. We have a great working relationmship with the physicians, we do a lot of cases, have been given the oopportunity by our Chair to pursue areas of interest (mine is chest and thyroid intervention), and allows us to do academic things. I have several published articles and have 2 majors studies going. One a prospective analysis of lung biopsy complications/risks, the other a novel treatment of abscess’s in conjunction with a microbiologist and a physicist….

Ed

Guest
Dr. Research, PA-C
Mar 13, 2013

Legacyflyer,

You apparently do not know what you do not know either….for one of your own journals looked at this..

http://www.ajronline.org/doi/full/10.2214/AJR.11.8303

They found PAs and NPs LESS likely than physicians to order CTs in Emergency Department encounters.

Now, you will disagree, but anecdotal being well anecdotal…

Guest
legacyflyer
Mar 13, 2013

Thanks for bringing that article to my attention. I was unaware of it.

That being said, I doubt that it is accurate. In most ERs there is a very significant stratification of patients by triage. The more serious patients go to the MD, the less serious to the PA. I would be more impressed by a paper in which patients were randomly assigned – which of course would be a hard study to do.

So, I will stand by what I said – even though it is anecdotal.

What I also said is that younger MDs order more studies than older ones. I stand by that as well.

Guest
Dr. Research, PA-C
Mar 13, 2013

Sure, and I agree that methodologically, that study leaves a lot to be desired. I don’t think you can take away that PA/NPs order FEWER CT scans than physicians, but I do think that you can certainly infer that we do not order MORE imaging studies.

Now, there are always anecdotal experiences, but anecdotal experiences shouldn’t be used to really guide practice. One example I can think of was a surgeon I knew 15 years ago who used to rail about others making clinical decisions using anecdotal data. Until the one day he did it….whereupon I pointed out that irony was in fact, ironical. I can think of another time when I was practicing clinically and a patient presented with symptoms consistent with gastroenteritis presented. Young female who also had some mild left shoulder achiness. She thought she merely slept on it wrong. Labs normal and responding to meds and fluids, I was going to dismiss her, when the young ED attending said “There are some rare case reports of splenic infarct presenting with left shoulder achiness”….I was like Umm, no, she has gastro. He wanted a CT. I told him that he needed to order it himself as I was not going to do that. Of course, it was negative.

One of my research domains is in decision making and the use of decision rules to move towards evidence based practice and reduce practice variance. Too many physicians and other providers are practicing with too much variance. That needs to stop. I’ve actually talked with my legislators about tying guideline adherence to reimbursement. You don’t follow the guidelines? You don’t get paid.

Guest
Mar 11, 2013

A PA made a mistake. Clearly something no MD has ever done–including the one supervising the MD.

Def a problem here but Dino MD doesn’t point out what it actually is. But other THCB commenters do (communication and better diagnosis CDS)

Guest
Dr. Rick Lippin
Mar 11, 2013

A large dose of humility is key to our success as a profession. Saying “I don’t know” much more is a good beginning.

Being kind is infintely more important than being right.

I culivate people with more questions than answers.

Dr. Rick Lippin
Southampton,Pa

Guest
Rich (MD)
Mar 11, 2013

Let’s call a spade a spade. PAs are not assistants, they’re doc replacements.

They look, dress, and act like docs and their level of supervision is determined by them coming forward and asking for help when they think they feel they need to. Would you send your kid out to the garage to play with power tools and say “call me if you need help”? That’s how PAs are “supervised”.

As a doc in many Urgent Care systems, I don’t like working with mid-levels. Why? They only represent an uncontrollled, uncompensated liability for me. I work with different ones every day, have no idea of their clinical experience or any say in their care plan. I had an argument with one once because she wanted to see a chest pain because it was her “turn” to get something interesting – I got reprimanded for making her feel bad.

I don’t like the dishonesty and obfuscation of the whole setup for the patients. Why, why, why is it that no one says, hmmm ……., PA with less training, doc with lots – “I’d like to see the guy who invested lots more time and money in his training”? People are sick, don’t know the difference, they’re not shopping for a car, and they don’t want to offend someone who might be about to stick their finger in their bottom.

Here’s a thought for transparency and economic justice. Have the PAs wear short blue coats, large ID badges that say “Physician Assistant”, and give patients half the copay to see a PA . At intake, have a script that says “your insurance covers a physician visit, but for a lower copay and possibly shorter wait you may elect to see a PA”.

It’s a bad system. We are seeing the “McDonaldization” of medicine – trying to get the lowest cost, least trained people for the job. The ER is not the place to start. I think an FP clinic with a vested supervisor doc (income and liability tied to performance of the PA) with 1-2 PAs would work.

Guest
Mar 11, 2013

Thank you Rich (MD)! That needed to come from the mouth of an MD. I was horrified when I learned that the mid level provider determines whether they need supervision or not. It is their call if they feel a situation may be beyond their scope of practice. Big badges with definitions should be worn, bc I have never been told that I was being anesthesized and monitored by a mid level practitioner instead of an anesthesiologist. Before anyone goes to jump on that one, most patients assume an anesthesiologist is providing their care. I should not have to ask. I should be told. I was almost killed as well as my unborn child due to a mid level practitioner thinking they could “handle” it. Oops! Treat me for a cold, bandage my boo boo, etc, but to pass yourself off as a practitioner equal to that of an MD is just wrong. It is all to save a buck at the expense of the patient.

Guest
CerNerd
Mar 11, 2013

Of course we’re trying to get the “lowest cost, least trained people for the job” …(with the caveat that they can still appropriately do the job)! Why not aspire, at least in part, for a “McDonaldized” system that is highly accessible, able to efficiently deliver value to billions of people with very little variance all wrapped up in a sustainable business model? At least you know what you’re getting …and perhaps it can help offset the “Ponzi-esque” form of our existing, unsustainable health care system.

Guest
Jamie Salcedo
Mar 11, 2013

I’ve had both good and bad PAs when I’ve gone to the hospital. The good time, the PA was super-efficient and effective, while the bad one I had to rely on the help of a woman doing echocardiography training to bring my wound to the attention of the PA.

Guest
Daniel Freshour
Mar 11, 2013

And your reason for the mistakes made by the bonafide doctors?? You guys and your anecdotes make me sick

Guest
legacyflyer
Mar 11, 2013

Many of the other articles posted on this blog rely on anecdotes. Do they make you sick too?

I agree that anecdotes are not as definitive as a study. Tell me, how would you design the study?

And the question is not whether doctors make mistakes – of course they do. The question is at what rate to doctors make mistakes as compared to PAs and what is the difference in cost and availability between docs and PAs.

I think it is inevitable that PAs and other “physician extenders” will need to be used in the years ahead. But let us not delude ourselves into thinking that this is due to anything other than $

Guest
Daniel Freshour
Mar 11, 2013

That is certainly the question. My point is that this was based on one case and brought into question the entire pa profession. It’s not a fair assumption. I know very well what I don’t know and I know the supervision of pas is not simply when the pa feels like asking. I try to deal in facts in this case and its not a fact that pas are dangerous based on this one case. If the pa makes the right decision. I’m sure you say it’s dumb luck. If they make the wrong it’s the profession as a whole that is inept.

Guest
legacyflyer
Mar 12, 2013

You are correct that one case proves nothing. And I don’t even think this one case was particularly well chosen.

As I have said in another post in this same thread, anecdotes and illustrative cases have their place. How relevant the particular case/anecdote is can be up for debate.