Not Knowing What You Don’t Know

“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.


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.


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.



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.

67 replies »

  1. 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.

  2. 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.

  3. 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?

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

  5. 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.

  6. 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.

  7. 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?

  8. 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”.

  9. 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.

  10. emedpa,

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

  11. agree with Dave. it’s silly to base an entire article on one bad encounter.
    I have seen numerous pts over the years with infected cat bites started on keflex(wrong abx) by their physician pcp who end up in the er and later the o.r. due in part to the physicians unfamiliarity with cat bites and their treatment.

  12. ” 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:

  13. 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.

  14. 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.

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

  16. 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!

  17. “I love the scientific analysis and discussion of a study with a N of 1”

    much like the original post…..

  18. 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.

  19. 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.

  20. 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.

  21. 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.

  22. Dr. Dinosaur,
    I suggest that you bear the onus here. If you are sending a cat bite to the ER because is is presenting in an unusual manner and appears to be more that the run of the mill cat bite, then it is incumbent upon you, the referring provider to call the ER and let them know the reasons your are sending the patient, and the fact that you have consulted hand already. When you pat yourself on the back for giving the patient explicit follow up instructions you should ask yourself about the issue of continuity of care. This whole scenario could have probably been avoided if you had given the ER a heads up.

  23. “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 am unsure why you think this is out of the ordinary response. Clearly he has a highly experienced clinician you should know better. Bites are mean and nasty however the data on him being more infectious than dog bites is suspect to a selection error which she can lie more bout with Web research. Obviously this is a pathoneumonic Pasteurella infection after a cat bite. Augmentin is the appropriate choice, Timentin can also be used IV. As well an animal bite form should be filled out and forwarded to the animal control officer.

    What struggles in the most is your biased attitude towards PA’s as well as anecdotal evidence. In your case presented you cannot state the patient would not have improved on the Augmentin yet immediately assume that the “midlevel” was at fault. As a prior ER PA I have seen literally hundreds of Cat bites on the hands. I feel very comfortable in handling them and likely have a broader skill set then a primary care.

    This is not an issue of what initials or after your name, this is an issue of a medical establishment which has refused to increase through flow/output of physicians to meet the needs of society. Now that PA and NP have involved and providing excellent care (I defy challenge you to find even a single study showing that we as a profession deliver a lower quality of care) and will continue to do so.

    Your admitted advanced age and experience is a great thing, and many PA and NP possess the exact same traits. I have seen some horrible and great PA, NP, DO, and MD’s. Honestly the one’s that scare me the most are the old time doc’s that are just trying to get a few more years of income in before retiring – they seem to miss a huge number of dx. But I do not go around saying all doc’s are bad….. but instead there is a few bad apples.

    Also, if you want to gripe about the situation how about the fact the 1/3 of the residence slots in the US go to FMG who have a far inferior (likely and possible in my experience) then most PA’s. And the chock hold that the medical colleges have on new Medical Schools. Simply keeping the supply of physicians low has created an supply shortage with in a free market creates an unmet demand and therefore higher valuation of the degree.

    Modern medicine is not rocket science and PA and NP are an essential part of the equation. We are not doc’s but we deliver world class care that is on par, or BETTER, then doc’. There is a study out proving that NPs actually managed patients in a certain subset BETTER then physicians so be careful about throwing around generic insults that can not be supported with good research/data – remember EBM is all of our guidelines of treatment.

    As a final thought – if you had already done all this leg work on the patient, why would you not call the local ER and advise them of all the work YOU did to this point? This is professional courtesy in my area and is good patient care, no provider can read your mind, or know what you already did. Also, it is prudent for a hand surgeon to at least LOOK at the hand prior to saying flat out that they have to be admitted.

    Overall pretty disappointed with your post and the fact you selectively pick apart a PA seems like a biased action only due to your own experiences…

    Parting question – why do you think the ER’s are using PA/NP? Not enough doc’s want to do the work for the pay, and the patients are overwhelming the ER’s due to not being able to get into a PCP or not even having insurance to see a PCP (and they can’t afford to be seen). This clearly has NOTHING to do with PA.

    Lets hold ALL PAs, NPs, AND Doc’s to the same standard – when a doc messes up they have be held accountable……..

  24. Depending on the state and ER directives, that “supervision” may require a chart review/signature before the patient leaves the ED. Perhaps, Dr. Dinosaur, you locked in on some verbage–“assistant,” “supervision,” and “mid-level.” None are appropirate terminology, but they are the legally acceptable terms. No other “assistants” practice medicine, nor are they licensed by their state boards of medicine. The original title of the profession was physician associates, which is a much better, and needed terminology.

    “Supervision” could easily be changed to collaboration–much better terminology for what you and I both do. BTW–when your patient decided against the hospital where you have admission privileges, would it not have been more appropriate to consult with a hospitalist or other specialist (including family practice) at the patient’s hospital of choice? You had already consulted with one specialist, why not another in a more formal setting.

    Another “legally acceptable” term is mid-level provider. That terminology implies that the provider only is capable of providing mid-level care. Far from it. When cases go to court (yes, PAs and NPs are subject to malpractice claims), those “midlevels’ are held to the same standard of care requirements as physicians.

    I spent many years as a medical malpractice review expert, reviewing and making “standard of care determinations” for and against my colleagues. As a PA reviewer, I could only legally make a SOC determination on the PAs involved in the case. I could make comments back to the medical law consultant on SOC issues by physicians involved in the case. It was rare that a PA violated the SOC. It was equally rare that the SOC of at least one involved MD/DO was not questioned.

    You and the hand surgeons used evidenced based medicine to do what was ultimately right for your patient. Why not used that same evidenced based science to determine how effective PAs are?

  25. Legacyflyer,

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


    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…

  26. It is unfortunate. This must be the same thing that went on with DOs for years.
    If a PA messes up (and yes, we do at times) then ALL PAs must be bad. If a physician messes up, that physician had a bad day.

    Dr. Dinosaur. The majority of advanced, YES ADVANCED trauma medicine practiced in Iraq and Afghanistan was done by PAs. The Flight Surgeon of the Year in the US Army is a PA. Many PAs are wonderful clinicians. We actually save lives. We actually know what we don’t know.

    I have encountered real errors made by physicians in my close to 40 years as a PA. Errors I knew better than to do, or better than to prescribe after reviewing the chart on the next visit. Guess that makes you just as bad as those physicians? Just as poor of a clinician? Or maybe they just missed something? Or maybe they were right out of school? Or maybe their Mom was being treated at Sloan Kettering that day? All those things should not matter but we all know they do.
    Except if you are god.

    Maybe the 250,000 PAs and NPs should start letting the public know when the physicians we work along side of mess up. Nice teamwork.
    Thanks for alerting the public.

  27. And I have one question for Dinosaur that perhaps should have been asked at the very beginning.

    Would you have written such a professionally disrespectful blog if the ER provider who had seen, evaluated and dismissed your patient wrongly were the ER Director or another one of the ER docs? And if so, would have you felt the need to call the “higher ups” to tattle if that had been the case? Or would have you just accepted it as the occasional error “that we all make.”

    I really do want to know.

  28. Then why such vitriolic ferver about our existence? Why not embrace our presence – blend us into the fold?

    I used to live in a cumbaya world and believed that my training, skills, willingness to learn and willingness to embrace the training and hierarchy of skilled professionals around me would pave the way to reasonable acceptance of my profession. I have fantastic relationships with the docs I’ve worked with over the years – so do the vast majority of my NP and PA counterparts. One would have assumed that those generally positive individual interactions coupled with our demonstrated value and competency would have transitioned into generalized acceptance by physicians macroscopically. Yet – it isn’t magically so…even after 40+ years of our existence and even at a time when a dramatic shift in healthcare is upon our doorstep.

    Time and experience have proven a few basic principles to me:

    1) Physicians will not collectively recognize our presence and contribution to medicine. Many will individually, but even when their backs are against the wall, most will denigrate our training, our skills and our experience – even when they need us most.

    2) Change in healthcare comes for two reasons – Necessity primarily and a far distant second, choice. We’re all about to abruptly experience the former whether we like it or not.

    3) The above said change is motivated by two primary reasons – MONEY overwhelmingly and quality of life a distant second. The obvious two reasons that many of the physicians that detest our existence employ us – it’s a truth that most physicians don’t want to say out loud. And then the unforseen reality hits them that we do better than they expected and they come to trust us and our skills – shocking.

    The reality for everyone on this blog is that the chosen healthcare environment of yesterday is colliding with the necessary environment of tomorrow and none of us much like it, particularly physicians. Instead of realizing that the overwhelming majority of professionals – PAs, NPs, MDs, DOs are really just trying to survive a day at a time and not hurt anyone in the process, physicians are setting the stage for a turf war at a time when it just so wasteful of everyone’s time, energy and resources. Blogs like this one exemplifies that sentiment.

    The real truth for Dinosaur is that the original error was hers – as the provider who had not one, but two, interactions with the patient in question, she should have taken the time to make a simple phone call to the ER the patient was headed for (whether you were privileged there or not). Pre-empting the staff of his arrival and why you’d sent him would have solved the entire problem and you could have saved making yourself look less than competent for blaming someone else for your error.

  29. Oooops, sorry…the antecedent comment should have been juxtaposed with your last reply. Forgive the transgression.

  30. 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.

  31. This has degenerated into a “tit for tat”. Let me propose a couple of basic principles that (most) of us can agree to:

    1) Everyone makes mistakes – Docs, Nurses, PAs, etc.
    2) Generally, those with more experience and training generally do better with more complex cases.
    3) We need to have a system that appropriately assigns cases to people who are able to handle them efficiently.

    Beyond that, I doubt there will be a lot of agreement.

    There is no doubt that PAs and NP are here to stay. So are a lot of other things – not all good. Hopefully, we can have a system where the presence to PAs and NPs is a net benefit to our society.

  32. I’ve got anecdotal stories as well – who doesn’t? I work UC – high volume mostly independently with my SP. We consult with one another equally for our various areas of expertise.

    One recent anecdotal epic MD miss was the nice lady who had a TVH years ago – had a gush of bright red blood and sudden onset of pain. She proceeds to the ER – sees the “highly trained” doc who dismissively tells her it was probably hemorroidal bleeding – the ER record reflects that. He – GASP – didn’t even do a pelvic or rectal exam on this patient. Long story short, the patient’s daughter insisted that she come see me the next day – straight up 7 AM. The patient has a complete separation of the vaginal apex incision line from her vaginal hysterectomy from years ago. Completely unlikely, but a simple diagnosis to make with a simple exam based on simple history – even by someone who ‘doesn’t know what I don’t know’. I know my 20 years in OB/GYN means nothing to you, but I would have made the diagnosis at year one assuming I bothered with an exam. I made my call to the “higher ups” as well only to be told that the patient refused an exam according to our hightly trained MD. The patient (and her daughter who was with her the entire 3 minutes he was in the room with them) patently state that she did not refuse an exam – he simply LIED once the reality of his miss came to his attention. I’ve got others as I’m sure you do as well. And I imagine we could sit out on the playground and tit for tat all day.

    Keep drinking the kool-aid thinking that PAs and NPs will just magically disappear because you want us to go away. We’re 250,000 collectively and growing year by year. Even many of your physician peers are beginning to understand the realities of the healthcare environment and many are accepting that there are simply not enough physicians to take care of the tidal wave of patients infusing into the system. We’re here to stay and it will take all of us to solve the problems in the future. And if omnipotent physicians have all the answers and are the only folks with the skills necessary to lead the way out of the darkness, why is our healthcare system in such a miserable mess anyway. Seems to me the physician-driven monetary based system of the past 50 years is what has led us here in the first place.

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

  34. 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….


  35. 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.

  36. 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!


  37. I believe I scanned all the replies and do not believe I saw any mention of “IT”…Yes information technology. A core premise of the original post is that “no one” knows everything – historically, or from a research POV – what’s going on in every lab around the globe.

    An element of the solution to the issue of knowledge is to harness the capabilities of information technology in healthcare. While it is not a replacement for the knowledge of a long term practicing physician, it is certainly a step toward “leveling” the knowledge playing field. Is there a difference between a physician practicing for 30 years vs a 1st year…probably. Likewise, is there a knowledge variation in a physician practicing in the tropics, vs perhaps the Pacific Northwest; or a physician practicing primarily in urban settings vs rural/farm settings?

    Fortunately, we as a society and culture have attained a level of information processing that can normalize the knowledge level across physicians and healthcare providers in general. While Dr. D maintains a local network of colleagues that are available to him to help on an informal consult basis, a computer terminal is available to virtually everyone. A “diagnostic assist” function could easily process through all known symptoms, treatments, research activities, protocols and return a summary of tailored information – from likely condition, to extreme; from generally prescribed protocols to latest research activities. Again – not a replacement for a physician’s judgment, but an augmentation to the total “system”.

    We can be pretty confident physicians will be in short supply as more people come into the healthcare system. We must better utilize all resources across the provider continuum so that the primary care physician is seeing the conditions that warrant their attention, just as the specialist is only dealing with the “exceptions”.

  38. 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.

  39. I thoroughly enjoyed most of the replies to this particular posting and, as one of those nasty physician assistants..oops, mid-level providers…, I feel rather compelled to agree that indeed we are all idiots and unless we attain higher ranks of degrees we should never, ever be allowed to come close to an individual heretofore classified as “patient”. This realization is, by logic, akin to agreeing that all African Americans are lazy welfare cheats, all Gays want to have sex with your children because after all they are all pedophiles, all Jews belong to that mysterious cabal of international banking controllers and wizards, all of the Irish are alcoholics or recovering, etc etc etc yadda yadda yadda.. Yes Dr Dinosaur it’s a damn shame you had a bad experience with one of us and your commentary borders on the line of demonizing our profession as incompetent. Now…perhaps I can edify you with horrifying stories of your ilk that unfortunately continue to practice their “art” of medicine. Would you be able to handle that or would you come to the rescue of your fellow colleagues and comrades…for, after all…they ARE doctors? I have to wonder of the underlying philosophy and emotion that really motivated your letter. I now look forward to the vicious replies I will soon get…this should be fun!

  40. 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.

  41. paul clark,

    You hit the nail on the head here. The fragmentation and lack of transparency in our health care system is truly shocking; I see it every day and it makes me shake my head in exasperation. You should see what it’s like in an overcrowded inner city ER or primary care clinic. Many of these patients are functionally illiterate and incapable of relating a coherent medical history and as they drift from provider to provider, they get each of their conditions treated in a piecemeal fashion, often without proper follow through and comprehensive management of their health. We need more primary care providers, including midlevels, to help manage this mess.

  42. Dr. Dinosaur,
    What strikes me as the most preposterous in this blog is that, as a person of science, you disregard the decades of evidence that demonstrate the efficacy of PA practice throughout the country. Having spent the better part of three decades trying to convince those in medicine that safe effective care is delivered by those without a MD/DO, I continue to be amazed at the arguments that are used.

  43. 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 $

  44. Well heck! I’ll throw in an “OOPS” for an MD and that will help everyone feel better. The anesthesiologist was called in after the hour mark and successfully intubated me with zero amnestic. I remained paralyzed and intubated for god knows how long and this entire time still wide awake and completely aware. I was able to experience awake paralysis and anesthesia awareness all within the same morning. How is that for an OOPS!

    Everyone screws up! The mistakes that you learn from are just on human beings.

  45. This sounds like a game of Telephone, as played within the fractured communications of the U.S. health care system. A specialist tells another doctor what a patient should do. The doctor tells the patient what the specialist said the patient should do. The patient then goes to an ER and tells the PA what the doctor told her the specialist told the doctor what to do. When the PA doesn’t do exactly what the specialist said to do, it’s the PA’s fault.

    Last fall, my 88-year-old mother had her gall bladder removed. Great care from the team of doctors and surgeons at the hospitals. Sucesful uneventful surgery. Though when she was discharged not one of the doctors thought to look at the meds she was taking to see if the dosages needed to be adjustd to account for the fact she no longer had a gall bladdrer. She went on dutifully taking her meds for a day or two until her blood pressure dropped, she passed out at home and hit her head and had to be transported back the hospital via ambulance. (She’s OK.) All the various well-trained doctors could say was, “oops . .. we kinda blew it on her discharge instructions.”

  46. 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.

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

  48. 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.

  49. 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.

  50. 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.

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

  52. 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

  53. 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.

  54. 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)

  55. 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?

  56. 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?

  57. 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.

  58. 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?

  59. 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.

  60. 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.

  61. 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.

  62. 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.

  63. 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.

  64. 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.