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
Nov 15, 2014

The gambling sector, the pillar of Macau’s economy, earned a record 108.7 billion patacas (US$13.7 billion) in revenues last year, an increase of 31 percent year on year, according to government figures. But the figure was down 12 percent year on year in the first half of 2009 due to the economic downturn.

Guest
Kim, DNP, FNP-BC
May 20, 2014

No, I am not a physician. I am not a wanna-be physician, ,I am not a mid-level, a physician extender, etc. I am a NURSE with extensive education, clinical training and expertise.

Sadly, I feel that some physicians are under the impression that we are trying to replace or compete with them. Although there are always a few bad apples in the bunch, I believe that most Nurse Practitioners know what they don’t know and refer their patients appropriately. As we are not in this profession for the kudos, but for the patient.

The original post was offensive on at least two levels:
(1) The term “mid-level” is taken as a derogatory description by just about every NP and PA that I have ever met.
(2) NP’s and PA’s are not interchangeable. We have different backgrounds, training, and degrees. When we are lumped together as on in the same, we are not being given credit for our education and credentials.

By writing such an inflammatory and hostile blanket statement, you, the Doctor (by the way, I’m a Doctor too) have really highlighted your ignorance and insecurities. Should we then take the position that all physicians are ignorant and insecure? Absolutely not!!! Do you understand?

Guest
Former colleague of Lucy hornstein
Apr 20, 2014

Lucy, shame on you. You are afraid of the np/pa taking your job so you demonize them. Shame on you.

Guest
Jun 5, 2013

Dr. Dinosaur nice post and great experience, good sense of arranging the whole incidence in a manner so as to directly strike on to reader’s mind.

Guest
DianaS
Mar 21, 2013

I am always surprised that one of the anti-PA diatribes seems to assume that once their truncated educational program ends, they no longer learn. Yes, their traiing is considerably shorter and yes, you would be ill-advised to leave a new PA graduate to their own devices but for heaven’s sake people, just as we continued lo learn during and post-residency, so have they. I’ve never met a new grad PA who wanted to practice independently – in fact they are usually attached to my hip. But give the one who’s been out 5 years and has 10,000 hours under their belt a little credit.

Guest
JR
Mar 19, 2013

Dear Dr Dinosaur,
I too had a few very similar experiences. One was with a pt that came into my family practice office w/an obvious case of advanced cellulitis of right lower leg. I advised the pt to go to the local ED which he did w/ his wife. I advised he will need IV abx and quite possibly be admitted. Upon arriving at the ED they waited 3 1/2 hrs before being seen and promptly was Dx and given ceftriaxone 250mg IM and amoxicillin 500mg q8hr and keep elevated. When I called the pt wife later that night she said the assistant was very dismissive of my concerns, that I probably was inexperienced and blew it out of proportion. The wife did say I did a much more thorough exam however, but still in the ED they are experts at this. ME inexperienced?? out of proportion?? the hubris. Anyway I licked my ego wounds and said if I can be of any help let me know.
Next day the pt was in pain and leg had “blown up like a balloon, but upon calling the ED and getting a resident who dutifully checked the chart and said just keep taking abx as Rx and elevate the leg. The next morning I was called by pt wife and had them come in. The leg was indeed “blown up from distal thigh to toes. The edema was so bad that pt could not bend knee, ankle or foot. Borderline compartment syndrome. I sent a note on my Rx pad saying pt previously sent from my office please evaluate and Tx. I also mentioned family member is an attorney. Well long story short, he was admitted for I believe 8 days of IV abx. He still has edema of the ankle and foot where he can’t wear a shoe, which interferes w/ his livelihood. The course of Tx and medications is now being reviewed by virtue of impending malpractice suit. The Assistant turned out to the Attending in Charge of the ED and I… a humble PA who has always given full credit and respect to the time, effort and dedication of MD’s & DO’s. However I do know that I too practice medicine and also have experience and that my colleagues MD’s andDO’s are not infallible and that the system works better when we respect the pt, each other and work as part of a medical care system together. Should I write about the appendicitis cases that were turned away at the ED only to be operated on emergently at another hospital that same night?

Guest
kayakr
Mar 17, 2013

The PA may have made a mistake. We don’t have enough information and first-hand knowledge of the situation to definitely confirm this. However, I can say that IF the PA did indeed make a bad call, it wasn’t because they are a PA, specifically. Medical clinicians of all types (MD, DO, PA, NP) all make mistakes and bad calls. It was because they were human and maybe not that great of a clinician. It happens across the board, irregardless of your degree. PAs are more than capable medical providers; dont undermine the training they have just because they “didn’t go to medical school”.

Guest
emedpa
Mar 13, 2013

” And the cases that the PAs are seeing and that docs are seeing are NOT the same types of cases. I seriously doubt that one can easily “statistically correct” for such a profound difference in case mix.”
There are many rural facilities that only staff PAs seeing everything that comes in the door and others that are dual pa/md with both providers alternating charts regardless of acuity. During one of my last shifts at my rural job I was intubating a polysubstance overdose while the doc was seeing a kid with a cough and fever.
. see here for an example of a pa staffed dept:
http://www.startribune.com/printarticle/?id=37374164

Guest
legacyflyer
Mar 14, 2013

emedpa,

That is not how things work at the ERs I cover. Hence that is not what my observations are based on.

Guest
legacyflyer
Mar 13, 2013

Dr Research, PA-C,

I don’t think we are as far apart as you might think. I am not a PA or Nurse “hater” and I think some of what is going on is the “playing” of one group (MDs) against another group (PAs, NPs) by our “fearless leaders”. As I said before, some docs see PAs the way some blue collar workers see Mexicans – as a low paid threat to their livliehood.

I remember some of the most valuable lessons I learned about how to read IVPs (an archaic study of the kidneys) were from an experienced X-Ray tech during my first year of Residency.

She would say to me:
“Dr., would you like to get a ________ view”

I would say:
“No, I don’t need that”

Often about a half hour later, I was saying to myself – “I wish I had gotten a ______ view” “I wonder how she knew that?”

In general, it pays to pay very close attention to suggestions from other experienced people.

Having said all that, I see the ordering habits and hit rate of cases emanating from 7 hospitals (with a combined bed total in excess of 2,000 beds) in my metro area. I have read over 200 cases in a 10 hour period at night and have done it for more than 5 years.

I may be biased, but I stand by what I said previously. Old experienced docs (and perhaps also old experienced PAs) order fewer cases and have a higher hit rate than their younger peers. And the cases that the PAs are seeing and that docs are seeing are NOT the same types of cases. I seriously doubt that one can easily “statistically correct” for such a profound difference in case mix.

Guest
M-E Onieal
Mar 13, 2013

oops I can spell, but can’t type (I know what I don’t know)
“decades of experience”

Guest
M-E Onieal
Mar 13, 2013

Recall that many of the MDs during their clinical rotations RELIED on the very RNs, NPs and PAs they are denigrating to assit them in their learning- and vice versa.
Last time I checked, aside from my multiple degrees, years of education, and decades of eperience – the initials after my name or those of my physician colleagues did not render us omnicient or infallible.
Let’s stop the denigration and back-biting and work together as a team to care for the patient- and stop worrying about who knows more– together we know a lot!

Guest
emedpa
Mar 13, 2013

“I love the scientific analysis and discussion of a study with a N of 1″

much like the original post…..

Guest
Dr Dee
Mar 13, 2013

I love the scientific analysis and discussion of a study with a N of 1. Evidence not opinion is what is necessary. You know what they say about opinions; they are much like an anus, everyone has one and no one thinks theirs stinks.
DrDee

Guest
emedpa
Mar 13, 2013

Role of Physician Assistants in the accident and emergency departments in the UK
Ansari U, Ansari M, Gipson K. Accident and Emergency Department; Warwick Hospital, UK
Published in 11th International Conference on Emergency Medicine, Halifax, Nova SCotia, Canada, June 3-7 2006 and Journal of Canadian Emergency Medicine, May 2006, Vol 8 No 3 (Suppl) P583

Introduction: The Accident and Emergency departments in the UK are under severe pressure to expand their staffing levels in a bid to try and comply with the 98% target for 4-hour waiting times set by the government. Increasing staffing levels is proving to be very difficult when a majority of Staff Grades have already left or are leaving to become General Practitioners for financial gains and better working hours. This combined with a limited number of FY2 doctors being allowed to work in Accident and Emergency departments poses new challenges to staffing within Accident and Emergency. The objective of this study was to evaluate the training requirements, GMC regulations and supervision required to perform a suitable role in Accident and EMergency following the appointment of two Physician Assistants at City Hospital, Birmingham. Methods: The activities of two Physician Assistants at City Hospital were monitored for two months. All case records were reviewed and the number and type of patients seen by the assistants recorded. These were then compared with the records of those patients seen by Senior House Officers. Monitored information included number of patients seen, type of patients seen as well as the quality of the notes. Results: On average, Physician Assistants at City Hospital treated 3-5 patients/hour compared to 1.5-2.5/hour seen by Senior House Officers. Physician Assistants were able to deal with most medical, surgical, orthopaedic and gynaecological problems with minimal supervision. The medical records revealed that documentation was better by Physician Assistants. Conclusion: Senior Physician Assistants from the USA are an effective way to improve staffing within Accident and Emergency Departments with the UK. Physician Assistants saw more patients and required less supervision than Senior House Officers. Physician Assistants proved to be a cost effective method of supporting Accident and Emergency doctors at City Hospital, Birmingham.

Guest
George
Mar 13, 2013

Life is short, the are is long, and your logic is less than impressive.

1. Who is to say that the patient would not have had a successful outcome with the treatment course the PA had prescribed? Perhaps a single dose of antibiotics would have gotten the patient over the hump so to speak – and at less time and cost to the patient and the healthcare system. Your supposition that having a physician’s involvement produced some sort of deus ex machina ending is purely a supposition.

Furthermore, maybe everyone was malpracticing here? Some regard it as standard practice to shoot a film of a cat bite. Cat’s teeth are relatively needlelike and prone toward breaking off and being retained that other common bite inuries are.

2. Relying on the letters after someone’s name to judge their clinical acumen is generally reckless. Many PA schools have students who are international medical graduates. Many of these clinicians trained in setting where they were exposed to resource poor environments and developed much better hands-on skills than US medical graduates.

3. If you want to contend experience is king, that is fine. If I am a PA working 10 years in cardiothoracic surgery and I decide to moonlight in the ER, who do you want reading your ECG – me, or someone a year out of their ER residency? Remember, 10,000 hours.