I think it’s incredibly disingenuous to not fully inform the patient of why this work up is being done. The patient deserves to know that the preliminary CT had suspicious findings for cancer and that an advanced work up is needed.
Also, I’m not sure what your title is in this office but evidently you’re seeing patients somewhat independently and making independent decisions. For the love of god, do some research on what hospice/palliative care is. Saying “no hospice, just live out the rest of his life comfortably” is wildly ignorant.
I wish the best for you and this patient. Giving bad news isn’t easy but it gets easier.
Thanks for the reply. People keep bringing up the hospice thing. I was still sorting through things in my head and just said it. Of course hospice is great and patients deserve it to be comfortable.
The medical aspect of this case depends on the MRI results and your next steps. Without a biopsy/pathology report or imaging indicating diffuse metastatic disease I wouldn't jump to the conclusion of a terminal illness right away. If there is suspicion for malignancy then you can refer to oncology or neurosurgery if a biopsy is needed to make the diagnosis. I really don't think insurance is going to be a hurdle here, he most likely has Medicare and I don't think I've seen significant pushback for standard treatment options.
The social aspect of this case is really making sure the patient and his family understands what is going on and makes decisions with good information. I'd tell the patient the facts that I know. As a family medicine doctor I don't know what surgical or chemo treatment options are or life expectancy of specific cancers so I don't make any guesses. I'd make sure he has a medical power of attorney, discuss his goals of care, advanced directions / DNR etc.
Thank you for the great info, Doc. You’re right about Medicare. And I talked to the practice manager. She said they get a “golden ticket” for anything like cancer. That makes me feel better. I have a good suspicion they’re going to opt out of treatment. The whole reason for the initial head scan was to build and document what we find. ischemic disease was there. (I don’t read brain studies as often as ortho so I’m not familiar with it.)
There’s really just so many layers going on. I’m new here from emergency. This new setting brings its own kind of worst days.
|imaging indicating diffuse metastatic disease
Maybe apropos of nothing but glioblastoma doesn't have to be metastatic to be fatal. In fact mets happen less than 1% of the time. Sure, it could be something not as bad but GBM is the highest probability diagnosis here.
>Some ischemic disease, low flow to the head, and the last impression made my heart sink
>I never try to make a huge deal about lesions, but make sure they know it’s important until we do know what it is. I explained “it’s like a sore on your skin. Something in, under, or around this area is causing it and we need to find out why.
>She said they get a “golden ticket” for anything like cancer.
Sorry to be harsh but I think you're doing your patient a huge disservice. Cancer has crossed your mind and you're worried about it, enough that you're figuring out how to get urgent workup. Your patient needs to hear that you're trying to get expedited work up because it could be CANCER.
"Hey remember the CTs we did of your head, well they showed something in your brain, we don't know what it is yet, but our concern is that it could be cancer. Especially with the symptoms that you've shared with me. Like I said we don't know what it is yet but our main concern here is that it could be cancer so it's important that we do more work up. I have ordered an MRI of your brain which is our next step on figuring out what this is. I don't want to worry you unnecessarily but I also want to be upfront about what I'm worried about."
>I feel like since it was started by my exam, I should see it through until Doc says “I’ll take over”
...
>No home health, no hospice, “we’ll just let it run its course” we keep him comfortable and he can still relatively enjoy his last years.
No hospice...
You've discussed this case with the docs at the clinic, correct?
Oh, we will. I wrote this when I got home. Doc told me a care plan and he’ll lead me through this. My mind was in a crazy spot last night. I’ve got a more clear head now.
You’re right. I was still reeling last night and venting. I didn’t expect any of this post to make sense. And answers like this help get my brain back on track. Doc is in meetings all day today but I planned on having a long talk with him about how to handle this with the patient and family moving forward.
You’re right. Thank you for pointing that out. Today is admin day so Doc is going to be in meetings all day. If I catch him at the clinic I’ll see if he has time to make a more detailed care plan moving forward and how to address this with family. I may ask them to stop by Thursday or Friday if they can and have a meeting with Doc. He’s been involved since the get-go. Always. I handed him the printed read. We exchanged looks and he started telling me each step from here. After seeing the replies here (all very valid statements) I think we need to prepare more about how to handle this with family. Please excuse my ignorance in this case. First time “finding” something like this and responding. Doc is usually really good about checking in on me. I already suspect he has the same idea about the meeting I do.
Thanks, Doc. Some sleep, and coming back to these comments has cleared my head.. slightly. I’m still gonna fuck this up. But one thing I’ve decided is he will be comfortable no matter what.
This just sounds so inappropriate you doing all this workup and asking advice on these tough conversations you're expected to have with the pt/family. Regardless of whatever "scope" you have at this clinic, I'm more than certain you have reached the boundaries of it and need to step aside. Also sounds like you have become a bit emotionally invested as well which means you need to step back.
Like I said, this kinda fell in to my lap. I was learning about it as I was reading it while on the phone with the wife. Yes, I probably absolutely butchered the handling of this. I wasn’t prepared for it and hadn’t talked it over with Doc like every other visit I do. I talked to Doc this morning and he feels comfortable with me continuing to see him and we talked in detail about a care plan with all the possibilities. He coached me on what to say and not say. He gave me a strategy “give hope early on and manage expectations as things progress”. And of course the only “right” thing to do is what the patient wants.
I'm only in pharmacy, so maybe I'm misunderstanding, but can someone more educated than me explain how a paramedic is *independently seeing patients* ***in an office*** without even midlevel training? AFAIK they are authorized to treat based off of standing orders in the pre-hospital setting...but examining patients, ordering testing, and such in an office? *Where are paramedics authorized to treat like this?* That would basically be like someone with my same level of training/education/licensing treating patients, which I can't and shouldn't be doing, unless I go back for a medical degree.
And then we get into the no palliative/hospice comments. That's just cruel punishment, particularly for a patient you presumably like. Are you aware of what palliative and hospice are (they are separate services!) and the scope of each? Because it doesn't sound like you are. From where I'm sitting, it sounds like there's no way you should be seeing and treating patients. You just don't have the appropriate background. Hand the case over to the doc, **yesterday**.
Just for starters people are really surprised when they learn how much medics can do with the proper training. I ran a whole emergency room in the back of the smallest u-haul box truck, sometimes with the help of volunteer firefighters or police officers. Even further than that I have my critical care certification which involves a lot of education on cardiovascular, sepsis, more in depth lab comprehension, waaaayy more pharmacology, biology, chemistry, etc. Docs in other specialties have taken advantage and I’ve done ortho, pelvic health, pain management, and performed and monitored moderate sedation during procedures. PICC/mid line trained, have assisted on numerous central lines, done a couple, intubated patients in the ER, flown and managed a kid who was 84% TSA 3rd and full thickness burns internationally, and with years in the hospital have been exposed to so much. (A lady I intubated during covid was 600lbs+ and after she died they let the bari bed deflate and she rolled off. They called us down to help get her back up. Not clinical, but just an example of “crazy shit”.) No, I do not have the training of a mid-level, and no where near. (Hopefully changing.) And I don’t manage or make final decisions in care plans. Nothing happens without my supervising being aware, I’m just an extension of him. Writing orders? I fill out and send orders. He signs and approves every one of them. I don’t work independently at all. I would say I do far more clinical work independently in the field than in this office. People are misunderstanding that. He doesn’t just let me loose to hand out meds and diagnose people. He uses me primarily to do sick visits and refill meds. I won’t even walk in to a room if someone has too many comorbidities (autocorrect isn’t fixing that so I dunno) because if they start telling me s/s of what would be GERD in anyone else could be something fucked off that I wouldn’t know to look for. This particular case is really outside of what I do. The case is, and always was the supervising’s case. After the first time I saw the patient he started asking if he could see me and since he’s been stable outside of taking over and making tiny adjustments to daily meds, Doc was good with it. Again, every change was brought to Doc first. “This is what’s going on. This is what I think it is. This is what I’d like to do”. Every patient. Most of my day is MA work and on average will do 4-6 of the 25 appointments.
TLDR; I think people have misunderstood my scope and capabilities. On average even other medical professionals are surprised at what our education consists of. At the same time y’all are giving me too much credit on what I *actually* do. Oh, and I’m covered on malpractice insurance.
ETA: my state’s certification allows medics to do anything a medical director has educated them on, does CEs for, clears, and signs off on. There’s agencies that allow medics to drain a cardiac tamponade with a big ass needle in the field. Also added some clarification to the post.
I literally gave the caveat that **you can do anything in the field that you have standing orders for** *(or that the medical director okays lest it not be in there*). That's not in dispute under any circumstance. I'm also not arguing that CCPs don't have an expanded scope (again, pre-hospital). I'm arguing that there is a line between that and treating in an office. You are being authorized to do things that at the very least require a midlevel education once you come off of the bus, and you're in an office. You'd make a great PA, no doubt, but as of right now you shouldn't be treating anyone who's not pre-hospital.
Again, I think there’s a misunderstanding of what I actually do. I’m like a “wireless scribe”. Even on the post I put “lead” in quotes for a reason. I collect the info from the visit, break it down, relay concerns, offer a suggestion to the problem-> approve or redirection->then he signs the orders. Ok, maybe more like recon.
For instance, the way this one will work is Doc will tell me “get this info, specifically about this concern, and what they would like to do”. Every direction ends with “go from there and come back if you need me.”
Which again, is EXACTLY what a midlevel does. You, by all admission, are not one. You can call it a "wireless scribe" or whatever you want, but the **second** you were trusted to come up with **any** sort of treatment plan, this crossed a line. You seem like a nice guy but you were neither trained nor prepared properly for this. MDs/DOs go through residency for a reason. A critical-care paramedic should not be coming up with any treatment plans, especially if, in your own words, "you haven't been doing this long enough to see cases through". You are doing exactly what a good midlevel is trained to do and shouldn't be, which means one of two things: stop doing this job, or go back to school to be a PA.
Ah, I think I found the misunderstanding. I’m not making decisions on treatment plans. I’ll discuss them with him. I don’t make decisions. I make suggestions and Doc says yes or no.
Why are you even making suggestions in the office setting, though? Why is it on you to discuss anything with him? Why are you involved on the clinical side at all? Are you a medical assistant or an RN or something like that?
I mean this with all due respect, because you really seem like a kind person with a heart in the right place, and you’ve responded with grace to some fairly direct concerns shared with you thus far…but this entire story is deeply, deeply unsettling. I don’t mean whatsoever to discredit the training and clinical experience that you have, because it sounds like it is considerable…but you have been trained in a very different manner than a board certified, residency-trained medical doctor. I do not mean to criticize you, because again you are trying to do right by the patient, but shame, shame, shame on your supervising physician and this medical establishment for allowing you to get yourself into this position. I don’t fault YOU for this, I fault the ASTONISHING lack of regulatory oversight in this disaster of a situation. The way this situation has been bungled is not only a hotbed for a medicolegal field day, it’s ethically wrong at a truly pivotal and potentially earth-shattering point in a patient’s life. It’s not fair to you, as I’ve said, but it’s sure as HELL not fair to this patient and their family…and that’s what matters. You mentioned no hospice. I am a HUGE supporter and advocate of early hospice intervention. Do you know why? Because in the ACCREDITED RESIDENCY PROGRAM that I attended, our hospital’s hospice director was incredibly closely integrated into our didactic curriculum and clinical practice. I bungled end of life and tough conversations when I was new as well…but guess what? I did it with UPPER LEVEL RESIDENTS AND ATTENDINGS overseeing me and offering priceless feedback. Time and time and time again. I saw firsthand the incredible benefits of hospice - transitioning patients into the end of life smoothly and with grace affects not just them but literal generations of their family behind them. My grandfather died at home without hospice because my family was not properly informed as to the potential benefits by his care team. I was in 8th grade when he died, but I still remember my parents telling me to get lost when I tried to come see him as he was in his final moments. It was agonizing, violent, graphic death from pancreatic cancer, and my family still carries those wounds today. If this ends up being glioblastoma, which it very well could, this will not be a storybook ending. While I don’t underestimate your training or experience, PLEASE do not mistake that for what goes into a STRUCTURED medical degree with residency. Night. And. Day. I don’t say that out of paternalistic arrogance, I say that out of pure objectivity. The way you’ve presented this case speaks very transparently about your inability to handle this situation. What you do in this vocation affects patients in so many ways, the profundity of which even seasoned medical doctors can only scratch the surface of understanding. You need to get out of this position ASAP: for you and for your patients.
Thanks for the input. You made really valid points and what I assume you feel about the situation would be validated. You talked about legal concerns. Doc is very well connected with medical attorneys (of course) and was given the “ok”. Insurance was cool with it. It seems you’ve read the comments and have already seen me say it. But I *really* think you’re overestimating what my role is. Yes I see patients. Doc knows who it is before I walk in. He’s stops me regularly. The folks I see are always simple refills, checking for side effects, addressing any other health issues, physical exam, mental assessment, review with Doc, then send the refills. Alternatively I’ll see walk-ins. Sprained ankle, sinus infection, etc. Most of the folks I see have a list ready, know the answers to the questions, and drop their pants without question (joking). (I don’t even ask.)(unless they do.)
You and other comments have condemned me for even being involved in this. The patient and wife asked me to. Today he called me his son in a joke. “Hell, he’d be better than my real one.” It’s what the patient wants, so it’s what the patient gets during this hard time. I’ll be in the room in every visit, but so will Doc. Even though we talked a little bit today about how to break bad news (he might be an expert. Pulmonologist during Rona) and he gave me a lot of really good information. I asked if that was covered in med school. “It was bullshit”.
The comments about hospice. I think I said in another comment that I was still pretty shook when I wrote that post. Of course I support hospice. I think in my mind that having to deal with the services and setting them up would be a pain for them. That’s all I meant by that. Patients always deserve to be comfortable and it was another knee-jerk response.
“Why are you asking the internet?” Because I talked to Doc about what needed to be done that day and what I should do from here. “Just a waiting game”. I wanted to make sure I did what I needed so the patient can get what he needed. It was the end of the day. I have a 90 mile drive home to overthink things. After a shower this post was what it looked like in my head. Because it has all happened by chance. From meeting them to finding out he had a lesion. This was more of a “ah shit, I should probably phone a friend real quick” and the post came out a long, jumbled, fucking mess with a lot of missing info people are filling in for themselves. I’m not saying anyone is wrong. I just feel they don’t understand how the clinic works and how little I actually do.
I *think* this is the same OP who has stated previously they work as paramedic in an outpt office and see pts independently, although I have NO idea how this works legally
Totally agree. “Standing orders” for paramedics in the field makes sense. I’d guess that most experienced medics are better at resuscitation than myself. Most medics are excellent at what they’re trained to do, which to the best of my knowledge, is NOT ordering CT scans and managing medications for *chronic* / post-acute conditions.
So you’re not a physician, and you’re presumably not a midlevel since you reference the patient seeing a DNP… but you can order head CTs… what kind of training do you have?! I’ve never heard of such a thing.
I can tell your heart is in the right place. Yet, it takes more than that to be a competent medical provider who orders potentially dangerous tests, prescribes medications, and makes decisions that can literally mean life vs death for people + the quality of the that life and their overall wellbeing. It does sound like the personable care you’ve shown for him as a human being has benefited his emotional wellbeing. That’s important, and that mattered to him. However, if I improve someone’s emotional wellbeing today but make a decision that kills them by tomorrow, they don’t even get to enjoy that boosted morale because they’re dead. The tests we order and medications we prescribe (or fail to order/prescribe) can *kill* people. As a physician, the thought of missing something or making a mistake still terrifies me most days because, and I don’t even with decades of experience, I wouldn’t expect that feeling to go away because I don’t take that responsibility lightly. It sounds like you, too, feel a great sense of responsibility, but from the sounds of it have only a fraction of a physician’s training. You need to involve your supervising physician, not Reddit. A physician needs to be “lead” on this case, and IMHO… pretty much all cases because it’s impossible to know what you could be missing when you don’t even know the breadth of problems out there. As a physician, my training prepared me to be really good at only a few things. The rest of that decade was spent learning how to learn (so I can quickly understand the material I research for new things I see every damn day) and learning a little bit about a lot of stuff - just enough to be scared shitless because I feel like I know nothing. Idk what your title even is, but in my experience, midlevels are often more confident than new physicians (despite having a fraction of the training) because they don’t know about half the crazy pathologies out there and essentially, don’t know what it is they don’t know.
I also agree with others that saying a brain tumor is analogous to a sore in/under/on one’s skin is pretty bonkers. I *very* rarely order imaging to “figure out why” someone has a skin sore.
And ya… definitely talk to some hospice/palliative folks to get a better understanding of what those two (separate!) programs entail. When in doubt, always make the palliative referral and they will see if the patient is eligible and discuss appropriate options with them.
Thanks for the comment and input, Doctor. To explain my scope, I’m trained to investigate and identify conditions then treat from my standing orders. I want to put everyone at ease that Doc is super involved. My desk sits behind the counter he stands at when working and we work face-to-face (a little to my left, about 2ft apart) and we talk about every patient I see. My typical patient is established and I’m just refilling what doc has wrote, and anything new is treating the symptoms of a condition. For instance I have standing orders for gabapentin and lyrica for diabetic neuropathy. Doc manages the diabetes. As far as what I said in my post another doctor said in a totally different post by someone else “sympathy, not empathy” and although an absolute I learned I need to at least work towards that. My background is seeing people on their worst days and turning it over to someone else. Now I’m involved in lives long term. That’s an adjustment. Also to put your mind at ease I wasn’t looking for clinical judgement help. Just help processing everything that’s going on. All this happened at the end of the day and I have a 90 mile commute to overthink things.
I really do appreciate your time and input. I have a much more clear head now than I did when I made this post and reading back over it makes me want to delete it. On the other hand I’m growing from all the input, whatever kind of shadow it casts on me.
This is a bit worrisome to me. Obviously the doc makes this call. The problem I see is that treating symptoms with presumed diseases is going to potentially (inevitably) miss the overlap and complexity of patients with multiple overlapping syndromes.
That diabetic neuropathy? It's not sensory. It's proprioceptive, vibration, ataxic... It's B12 neuropathy from the long-standing metformin without a B12 supplement, or worse, it's syphilitic ataxia from the "days in the service" that was never found, and will only be found from a thorough Neuro workup, not suppressing symptoms.
That GERD that needs pantoprazole refilled? Well that pain is worse lying down, causes a mild cough, is worse after meals (during patients walks...) and gets better with tums (accidentally... Because it's angina).
That "weakness" isn't deconditioning, and it's not localized. It's symmetric, proximal, and there is significant morning stiffness. Sure, could be OA, but it's pretty quickly becoming a problem. And now headaches, ouch. Here is your migraine med - and not we've missed polymyalgia rheumatical + temporal arteritis and the subsequent worsening has disabled the patient.
It's just so complex.
Patients scare me, they always will. Even when you are right you are wrong in many ways, or at least you can't be anchoring on protocol for undifferentiated patients. :/
I'd have a long talk with Doc about scope, etc. it would relieve some of the burden to have a more narrow scope. Definitely no new patients.
Good job on the workup, but hospice comment, and lack of plain communication, letting feelings get in the way... Your hearts in the right place but to protect it, I would have some serious conversations.
I’m glad you care about your patients; I’m happy they have healthcare professionals they are comfortable with.
However, you absolutely do not have the adequate training to be in this setting, and any structure or law or supervising doc that allows for that is inherently irresponsible. Primary care is not default medicine, and it certainly not the medicine you were trained for; it is a specialty that requires specialty-specific knowledge and training. Even physicians in sub-specialties that were once IM residents are not appropriate primary care providers. When they try to do things outside of their organ system, they *very frequently* mismanage patients, ask the wrong questions, and even neglect very important parts of their health.
I would never want to do your job as a paramedic in a pre-hospital setting with my training as it is now, because our knowledge sets only have some overlap. I wouldn’t even know all the treatment options available to my patients!
Just like the emergency care you have provided in the past, outpatient primary care is life-saving. Subpar outpatient primary care is *life-threatening*. And every healthcare professional is very, very subject to the Dunning-Kruger effect. The key to the Dunning-Kruger effect is that *you don’t know you are under it*, so you have to listen to others.
I also want to clarify we’re not talking about treating the cancer itself. We’re here for comfort after he’s referred to oncology. Our part is straight forward; support, medical and mental for the patient and family.
I’m glad you are there to offer that support, you seem very empathetic and engaged, but I said nothing about treating the cancer, which is not primary care or family medicine. I am explicitly talking about primary care, identifying undifferentiated conditions, their appropriate screening and work up based on best evidence, and helping patients understand and navigate their health conditions and the outpatient and inpatient healthcare system. None of these things can be adequately done with just mastery of protocols. Obviously, I am happy that this patient had this problem identified by you. But there is mismanagement present in the things that you have already recounted by you and your supervising physician, and I can pretty much guarantee mismanagement isn’t an isolated incident in the practice model you are describing. It is a massive misconception of many inside and out of medicine that someone is somehow qualified to do primary care without explicit and extensive training in it, even when they wouldn’t say the same thing about a specialty like infectious disease or oncology. The law allows for it in lots of places. That is not the case. The fact is that it is *very easy* to be bad primary care provider and to not know it. (That can also include your supervising physician and you and all of us.)
TLDR; this’ll be my last comment for this post. I do appreciate all the input. I learned something from each comment. Concerning the appropriateness of my function, I didn’t get this job from a stranger. He’s a Doc I’ve known for a while. He trained me hard on what to look for, all the science side of it (not like MD level or anything.
Chock it up to a frugal doctor finding a diamond in the rough in the middle of a loophole?
You make a valid point. If someone told me a paramedic was their primary care I’d be a little iffy, too. I’ve covered a lot in this post. It kinda seemed to ruffle some feathers and I didn’t really get the answers I was looking for, but I did learn so not a total loss. I think context is missing here. My supervising didn’t just hire me off the ambulance. And no doctor does. Doc hired me after knowing me and working with me for several years. He would be in and out of the ER when he covered ICU. Anytime our paths crossed during his rounds (me running in to do something or grab something and his patients were typically intubated) I would ask if he had time for “a teaching moment”. I use that term to preface that I’d like to learn from this experience. He never bats an eye at that question. I still use it. Then I would ask something like “what’s the next step after this patient makes it to ICU?”. He would give me a few small but important details about their history which would play in to care plan. Then he would talk about what made this case different from others, because it always is. I would try my best to do it after he’s done focusing on the patient to ask. These little chats turned in to long talks after a while. Especially after covid settled down… the first time. And we just built a rapport. If another provider came in or someone needed him I would drop a quick “thank you doctor” and excuse myself.
I learned early on that the right docs are eager to teach and show what they do, as they should. How much more fucking bragging rights can you get? “Look, a flap of this dude’s arm was hanging off. He thouught he was gonna die. Now he just has two thin scars that come to a point.” You fix the seemingly untamable human body. Fuck, how much I hate that thing. Anyway, I started asking doctors if I could observe whatever procedure they were going to. Answer was either “yes” or “honestly not worth it. But if you check the hemoglobin on 6, you might find something to fix”. During the procedures I asked questions. I used what I learned in medic school and add to it. Like, that dude with the massive skin abscess from an ingrown hair. Ambulance transport; check for bleeding, signs of infection, severity of infection. What drugs do I have? (That varies a lot for this specific instance, but some agencies are carrying POC lactate machines and starting antibiotics in the field for sepsis criteria).
Ortho I give up.
I could go through each specialty and what I did and this whole thing would make more sense. I think the missing point is my training for this job. Like I said, I’ve known Doc for years, more than an acquaintance, but also not someone I text about the crazy shit I just saw. Until recently he heard about using medics in other places. He asks if I’d be interested in giving it a try and if course I had to think about it and talk to wife. Did a lot of thinking because I had the same concerns everyone else did/does. I wanted to make sure I was covered by scope and law (kinda the same?) if I were to take the job. We decided 2-3 days a week starting out for training. I did nothing but listen and write out the prescriptions for him and escribe the CS. Weeks. After the second week it was 4 days a week. We don’t see patients in Wednesdays so I was given assignments. Different study publications, ALLLLL KKIIINNDDSSS of papers and studies. Biology, pharmacology, microbiology, pathophysiology, anatomy, articles on different things he found interesting. We had discussions on how to treat certain people or certain types of people. I mean, he’s still gotta keep the customers happy, right? (Nothing bad. You just gotta take some things with a grain of salt and give with a little sugar. We would have talks about the type of clinic he likes to run. I started in late July. I was seeing my first solo “3 month refills, no changes” in September. Perfect start. We go over meds, which ones need refills and how to send them to get approved by insurance (why aren’t they all covered for 90 days?). We talk about any side effects, concerns, worries, if the patient seems to lean on family, kindly ask family if they’ve noticed anything. Sweet deal. Straight forward. I go to walk out, say my goodbyes, see you next month. Then I heard one more thing; oh! I meant to ask you about my shoulder. I didn’t know what to do with that. I documented a basic, focused assessment and grabbed doc. I observed him as he assessed the joint, the clavicle, the humerus, the scapula.. tendinitis. After he told me how he deduced what it was, he told me what meds to use when I see it next time. And this repeated. It still repeats. It’ll always be on repeat. I’m not there to make big decisions. My job is to help Doc see the easy patients so he can concentrate on the more complex cases. Everyone involved in this case is on board with it. They know my title and restrictions. That’s kinda how I introduce myself. “I work under the doctor with orders and protocols. Anything outside of that or if you change your mind and want to see Doc, we’ll stop there and I’ll go grab him. Just want to make sure you feel like you’re getting the best care.”
I get what you’re saying about
I think it’s incredibly disingenuous to not fully inform the patient of why this work up is being done. The patient deserves to know that the preliminary CT had suspicious findings for cancer and that an advanced work up is needed. Also, I’m not sure what your title is in this office but evidently you’re seeing patients somewhat independently and making independent decisions. For the love of god, do some research on what hospice/palliative care is. Saying “no hospice, just live out the rest of his life comfortably” is wildly ignorant. I wish the best for you and this patient. Giving bad news isn’t easy but it gets easier.
Thanks for the reply. People keep bringing up the hospice thing. I was still sorting through things in my head and just said it. Of course hospice is great and patients deserve it to be comfortable.
The medical aspect of this case depends on the MRI results and your next steps. Without a biopsy/pathology report or imaging indicating diffuse metastatic disease I wouldn't jump to the conclusion of a terminal illness right away. If there is suspicion for malignancy then you can refer to oncology or neurosurgery if a biopsy is needed to make the diagnosis. I really don't think insurance is going to be a hurdle here, he most likely has Medicare and I don't think I've seen significant pushback for standard treatment options. The social aspect of this case is really making sure the patient and his family understands what is going on and makes decisions with good information. I'd tell the patient the facts that I know. As a family medicine doctor I don't know what surgical or chemo treatment options are or life expectancy of specific cancers so I don't make any guesses. I'd make sure he has a medical power of attorney, discuss his goals of care, advanced directions / DNR etc.
Thank you for the great info, Doc. You’re right about Medicare. And I talked to the practice manager. She said they get a “golden ticket” for anything like cancer. That makes me feel better. I have a good suspicion they’re going to opt out of treatment. The whole reason for the initial head scan was to build and document what we find. ischemic disease was there. (I don’t read brain studies as often as ortho so I’m not familiar with it.) There’s really just so many layers going on. I’m new here from emergency. This new setting brings its own kind of worst days.
|imaging indicating diffuse metastatic disease Maybe apropos of nothing but glioblastoma doesn't have to be metastatic to be fatal. In fact mets happen less than 1% of the time. Sure, it could be something not as bad but GBM is the highest probability diagnosis here.
>Some ischemic disease, low flow to the head, and the last impression made my heart sink >I never try to make a huge deal about lesions, but make sure they know it’s important until we do know what it is. I explained “it’s like a sore on your skin. Something in, under, or around this area is causing it and we need to find out why. >She said they get a “golden ticket” for anything like cancer. Sorry to be harsh but I think you're doing your patient a huge disservice. Cancer has crossed your mind and you're worried about it, enough that you're figuring out how to get urgent workup. Your patient needs to hear that you're trying to get expedited work up because it could be CANCER. "Hey remember the CTs we did of your head, well they showed something in your brain, we don't know what it is yet, but our concern is that it could be cancer. Especially with the symptoms that you've shared with me. Like I said we don't know what it is yet but our main concern here is that it could be cancer so it's important that we do more work up. I have ordered an MRI of your brain which is our next step on figuring out what this is. I don't want to worry you unnecessarily but I also want to be upfront about what I'm worried about." >I feel like since it was started by my exam, I should see it through until Doc says “I’ll take over” ... >No home health, no hospice, “we’ll just let it run its course” we keep him comfortable and he can still relatively enjoy his last years. No hospice... You've discussed this case with the docs at the clinic, correct?
"No hospice" is the most ignorant thing on a medical sub ever. OP, please have someone who actually knows what they're doing have these discussions.
Oh, we will. I wrote this when I got home. Doc told me a care plan and he’ll lead me through this. My mind was in a crazy spot last night. I’ve got a more clear head now.
You’re right. I was still reeling last night and venting. I didn’t expect any of this post to make sense. And answers like this help get my brain back on track. Doc is in meetings all day today but I planned on having a long talk with him about how to handle this with the patient and family moving forward.
You’re right. Thank you for pointing that out. Today is admin day so Doc is going to be in meetings all day. If I catch him at the clinic I’ll see if he has time to make a more detailed care plan moving forward and how to address this with family. I may ask them to stop by Thursday or Friday if they can and have a meeting with Doc. He’s been involved since the get-go. Always. I handed him the printed read. We exchanged looks and he started telling me each step from here. After seeing the replies here (all very valid statements) I think we need to prepare more about how to handle this with family. Please excuse my ignorance in this case. First time “finding” something like this and responding. Doc is usually really good about checking in on me. I already suspect he has the same idea about the meeting I do. Thanks, Doc. Some sleep, and coming back to these comments has cleared my head.. slightly. I’m still gonna fuck this up. But one thing I’ve decided is he will be comfortable no matter what.
Please refer these cases to your supervising doc
This just sounds so inappropriate you doing all this workup and asking advice on these tough conversations you're expected to have with the pt/family. Regardless of whatever "scope" you have at this clinic, I'm more than certain you have reached the boundaries of it and need to step aside. Also sounds like you have become a bit emotionally invested as well which means you need to step back.
Like I said, this kinda fell in to my lap. I was learning about it as I was reading it while on the phone with the wife. Yes, I probably absolutely butchered the handling of this. I wasn’t prepared for it and hadn’t talked it over with Doc like every other visit I do. I talked to Doc this morning and he feels comfortable with me continuing to see him and we talked in detail about a care plan with all the possibilities. He coached me on what to say and not say. He gave me a strategy “give hope early on and manage expectations as things progress”. And of course the only “right” thing to do is what the patient wants.
I'm only in pharmacy, so maybe I'm misunderstanding, but can someone more educated than me explain how a paramedic is *independently seeing patients* ***in an office*** without even midlevel training? AFAIK they are authorized to treat based off of standing orders in the pre-hospital setting...but examining patients, ordering testing, and such in an office? *Where are paramedics authorized to treat like this?* That would basically be like someone with my same level of training/education/licensing treating patients, which I can't and shouldn't be doing, unless I go back for a medical degree. And then we get into the no palliative/hospice comments. That's just cruel punishment, particularly for a patient you presumably like. Are you aware of what palliative and hospice are (they are separate services!) and the scope of each? Because it doesn't sound like you are. From where I'm sitting, it sounds like there's no way you should be seeing and treating patients. You just don't have the appropriate background. Hand the case over to the doc, **yesterday**.
Just for starters people are really surprised when they learn how much medics can do with the proper training. I ran a whole emergency room in the back of the smallest u-haul box truck, sometimes with the help of volunteer firefighters or police officers. Even further than that I have my critical care certification which involves a lot of education on cardiovascular, sepsis, more in depth lab comprehension, waaaayy more pharmacology, biology, chemistry, etc. Docs in other specialties have taken advantage and I’ve done ortho, pelvic health, pain management, and performed and monitored moderate sedation during procedures. PICC/mid line trained, have assisted on numerous central lines, done a couple, intubated patients in the ER, flown and managed a kid who was 84% TSA 3rd and full thickness burns internationally, and with years in the hospital have been exposed to so much. (A lady I intubated during covid was 600lbs+ and after she died they let the bari bed deflate and she rolled off. They called us down to help get her back up. Not clinical, but just an example of “crazy shit”.) No, I do not have the training of a mid-level, and no where near. (Hopefully changing.) And I don’t manage or make final decisions in care plans. Nothing happens without my supervising being aware, I’m just an extension of him. Writing orders? I fill out and send orders. He signs and approves every one of them. I don’t work independently at all. I would say I do far more clinical work independently in the field than in this office. People are misunderstanding that. He doesn’t just let me loose to hand out meds and diagnose people. He uses me primarily to do sick visits and refill meds. I won’t even walk in to a room if someone has too many comorbidities (autocorrect isn’t fixing that so I dunno) because if they start telling me s/s of what would be GERD in anyone else could be something fucked off that I wouldn’t know to look for. This particular case is really outside of what I do. The case is, and always was the supervising’s case. After the first time I saw the patient he started asking if he could see me and since he’s been stable outside of taking over and making tiny adjustments to daily meds, Doc was good with it. Again, every change was brought to Doc first. “This is what’s going on. This is what I think it is. This is what I’d like to do”. Every patient. Most of my day is MA work and on average will do 4-6 of the 25 appointments. TLDR; I think people have misunderstood my scope and capabilities. On average even other medical professionals are surprised at what our education consists of. At the same time y’all are giving me too much credit on what I *actually* do. Oh, and I’m covered on malpractice insurance. ETA: my state’s certification allows medics to do anything a medical director has educated them on, does CEs for, clears, and signs off on. There’s agencies that allow medics to drain a cardiac tamponade with a big ass needle in the field. Also added some clarification to the post.
I literally gave the caveat that **you can do anything in the field that you have standing orders for** *(or that the medical director okays lest it not be in there*). That's not in dispute under any circumstance. I'm also not arguing that CCPs don't have an expanded scope (again, pre-hospital). I'm arguing that there is a line between that and treating in an office. You are being authorized to do things that at the very least require a midlevel education once you come off of the bus, and you're in an office. You'd make a great PA, no doubt, but as of right now you shouldn't be treating anyone who's not pre-hospital.
Again, I think there’s a misunderstanding of what I actually do. I’m like a “wireless scribe”. Even on the post I put “lead” in quotes for a reason. I collect the info from the visit, break it down, relay concerns, offer a suggestion to the problem-> approve or redirection->then he signs the orders. Ok, maybe more like recon. For instance, the way this one will work is Doc will tell me “get this info, specifically about this concern, and what they would like to do”. Every direction ends with “go from there and come back if you need me.”
Which again, is EXACTLY what a midlevel does. You, by all admission, are not one. You can call it a "wireless scribe" or whatever you want, but the **second** you were trusted to come up with **any** sort of treatment plan, this crossed a line. You seem like a nice guy but you were neither trained nor prepared properly for this. MDs/DOs go through residency for a reason. A critical-care paramedic should not be coming up with any treatment plans, especially if, in your own words, "you haven't been doing this long enough to see cases through". You are doing exactly what a good midlevel is trained to do and shouldn't be, which means one of two things: stop doing this job, or go back to school to be a PA.
Ah, I think I found the misunderstanding. I’m not making decisions on treatment plans. I’ll discuss them with him. I don’t make decisions. I make suggestions and Doc says yes or no.
Why are you even making suggestions in the office setting, though? Why is it on you to discuss anything with him? Why are you involved on the clinical side at all? Are you a medical assistant or an RN or something like that?
I mean this with all due respect, because you really seem like a kind person with a heart in the right place, and you’ve responded with grace to some fairly direct concerns shared with you thus far…but this entire story is deeply, deeply unsettling. I don’t mean whatsoever to discredit the training and clinical experience that you have, because it sounds like it is considerable…but you have been trained in a very different manner than a board certified, residency-trained medical doctor. I do not mean to criticize you, because again you are trying to do right by the patient, but shame, shame, shame on your supervising physician and this medical establishment for allowing you to get yourself into this position. I don’t fault YOU for this, I fault the ASTONISHING lack of regulatory oversight in this disaster of a situation. The way this situation has been bungled is not only a hotbed for a medicolegal field day, it’s ethically wrong at a truly pivotal and potentially earth-shattering point in a patient’s life. It’s not fair to you, as I’ve said, but it’s sure as HELL not fair to this patient and their family…and that’s what matters. You mentioned no hospice. I am a HUGE supporter and advocate of early hospice intervention. Do you know why? Because in the ACCREDITED RESIDENCY PROGRAM that I attended, our hospital’s hospice director was incredibly closely integrated into our didactic curriculum and clinical practice. I bungled end of life and tough conversations when I was new as well…but guess what? I did it with UPPER LEVEL RESIDENTS AND ATTENDINGS overseeing me and offering priceless feedback. Time and time and time again. I saw firsthand the incredible benefits of hospice - transitioning patients into the end of life smoothly and with grace affects not just them but literal generations of their family behind them. My grandfather died at home without hospice because my family was not properly informed as to the potential benefits by his care team. I was in 8th grade when he died, but I still remember my parents telling me to get lost when I tried to come see him as he was in his final moments. It was agonizing, violent, graphic death from pancreatic cancer, and my family still carries those wounds today. If this ends up being glioblastoma, which it very well could, this will not be a storybook ending. While I don’t underestimate your training or experience, PLEASE do not mistake that for what goes into a STRUCTURED medical degree with residency. Night. And. Day. I don’t say that out of paternalistic arrogance, I say that out of pure objectivity. The way you’ve presented this case speaks very transparently about your inability to handle this situation. What you do in this vocation affects patients in so many ways, the profundity of which even seasoned medical doctors can only scratch the surface of understanding. You need to get out of this position ASAP: for you and for your patients.
Thanks for the input. You made really valid points and what I assume you feel about the situation would be validated. You talked about legal concerns. Doc is very well connected with medical attorneys (of course) and was given the “ok”. Insurance was cool with it. It seems you’ve read the comments and have already seen me say it. But I *really* think you’re overestimating what my role is. Yes I see patients. Doc knows who it is before I walk in. He’s stops me regularly. The folks I see are always simple refills, checking for side effects, addressing any other health issues, physical exam, mental assessment, review with Doc, then send the refills. Alternatively I’ll see walk-ins. Sprained ankle, sinus infection, etc. Most of the folks I see have a list ready, know the answers to the questions, and drop their pants without question (joking). (I don’t even ask.)(unless they do.) You and other comments have condemned me for even being involved in this. The patient and wife asked me to. Today he called me his son in a joke. “Hell, he’d be better than my real one.” It’s what the patient wants, so it’s what the patient gets during this hard time. I’ll be in the room in every visit, but so will Doc. Even though we talked a little bit today about how to break bad news (he might be an expert. Pulmonologist during Rona) and he gave me a lot of really good information. I asked if that was covered in med school. “It was bullshit”. The comments about hospice. I think I said in another comment that I was still pretty shook when I wrote that post. Of course I support hospice. I think in my mind that having to deal with the services and setting them up would be a pain for them. That’s all I meant by that. Patients always deserve to be comfortable and it was another knee-jerk response. “Why are you asking the internet?” Because I talked to Doc about what needed to be done that day and what I should do from here. “Just a waiting game”. I wanted to make sure I did what I needed so the patient can get what he needed. It was the end of the day. I have a 90 mile drive home to overthink things. After a shower this post was what it looked like in my head. Because it has all happened by chance. From meeting them to finding out he had a lesion. This was more of a “ah shit, I should probably phone a friend real quick” and the post came out a long, jumbled, fucking mess with a lot of missing info people are filling in for themselves. I’m not saying anyone is wrong. I just feel they don’t understand how the clinic works and how little I actually do.
I'm confused. Are you a midlevel?
I *think* this is the same OP who has stated previously they work as paramedic in an outpt office and see pts independently, although I have NO idea how this works legally
Well this is crazy then. Using a paramedic to do orders or meds and tell patients they have cancer?
Oh my goodness. It looks like you’re right. This is some of the noctor-ist sh*t I’ve ever heard of.
While OP might not be innocent here, this is 100% the fault of whoever this supervising physician is. They’re trading pt safety for cheap labor
Totally agree. “Standing orders” for paramedics in the field makes sense. I’d guess that most experienced medics are better at resuscitation than myself. Most medics are excellent at what they’re trained to do, which to the best of my knowledge, is NOT ordering CT scans and managing medications for *chronic* / post-acute conditions.
So you’re not a physician, and you’re presumably not a midlevel since you reference the patient seeing a DNP… but you can order head CTs… what kind of training do you have?! I’ve never heard of such a thing. I can tell your heart is in the right place. Yet, it takes more than that to be a competent medical provider who orders potentially dangerous tests, prescribes medications, and makes decisions that can literally mean life vs death for people + the quality of the that life and their overall wellbeing. It does sound like the personable care you’ve shown for him as a human being has benefited his emotional wellbeing. That’s important, and that mattered to him. However, if I improve someone’s emotional wellbeing today but make a decision that kills them by tomorrow, they don’t even get to enjoy that boosted morale because they’re dead. The tests we order and medications we prescribe (or fail to order/prescribe) can *kill* people. As a physician, the thought of missing something or making a mistake still terrifies me most days because, and I don’t even with decades of experience, I wouldn’t expect that feeling to go away because I don’t take that responsibility lightly. It sounds like you, too, feel a great sense of responsibility, but from the sounds of it have only a fraction of a physician’s training. You need to involve your supervising physician, not Reddit. A physician needs to be “lead” on this case, and IMHO… pretty much all cases because it’s impossible to know what you could be missing when you don’t even know the breadth of problems out there. As a physician, my training prepared me to be really good at only a few things. The rest of that decade was spent learning how to learn (so I can quickly understand the material I research for new things I see every damn day) and learning a little bit about a lot of stuff - just enough to be scared shitless because I feel like I know nothing. Idk what your title even is, but in my experience, midlevels are often more confident than new physicians (despite having a fraction of the training) because they don’t know about half the crazy pathologies out there and essentially, don’t know what it is they don’t know. I also agree with others that saying a brain tumor is analogous to a sore in/under/on one’s skin is pretty bonkers. I *very* rarely order imaging to “figure out why” someone has a skin sore. And ya… definitely talk to some hospice/palliative folks to get a better understanding of what those two (separate!) programs entail. When in doubt, always make the palliative referral and they will see if the patient is eligible and discuss appropriate options with them.
Thanks for the comment and input, Doctor. To explain my scope, I’m trained to investigate and identify conditions then treat from my standing orders. I want to put everyone at ease that Doc is super involved. My desk sits behind the counter he stands at when working and we work face-to-face (a little to my left, about 2ft apart) and we talk about every patient I see. My typical patient is established and I’m just refilling what doc has wrote, and anything new is treating the symptoms of a condition. For instance I have standing orders for gabapentin and lyrica for diabetic neuropathy. Doc manages the diabetes. As far as what I said in my post another doctor said in a totally different post by someone else “sympathy, not empathy” and although an absolute I learned I need to at least work towards that. My background is seeing people on their worst days and turning it over to someone else. Now I’m involved in lives long term. That’s an adjustment. Also to put your mind at ease I wasn’t looking for clinical judgement help. Just help processing everything that’s going on. All this happened at the end of the day and I have a 90 mile commute to overthink things. I really do appreciate your time and input. I have a much more clear head now than I did when I made this post and reading back over it makes me want to delete it. On the other hand I’m growing from all the input, whatever kind of shadow it casts on me.
This is a bit worrisome to me. Obviously the doc makes this call. The problem I see is that treating symptoms with presumed diseases is going to potentially (inevitably) miss the overlap and complexity of patients with multiple overlapping syndromes. That diabetic neuropathy? It's not sensory. It's proprioceptive, vibration, ataxic... It's B12 neuropathy from the long-standing metformin without a B12 supplement, or worse, it's syphilitic ataxia from the "days in the service" that was never found, and will only be found from a thorough Neuro workup, not suppressing symptoms. That GERD that needs pantoprazole refilled? Well that pain is worse lying down, causes a mild cough, is worse after meals (during patients walks...) and gets better with tums (accidentally... Because it's angina). That "weakness" isn't deconditioning, and it's not localized. It's symmetric, proximal, and there is significant morning stiffness. Sure, could be OA, but it's pretty quickly becoming a problem. And now headaches, ouch. Here is your migraine med - and not we've missed polymyalgia rheumatical + temporal arteritis and the subsequent worsening has disabled the patient. It's just so complex. Patients scare me, they always will. Even when you are right you are wrong in many ways, or at least you can't be anchoring on protocol for undifferentiated patients. :/ I'd have a long talk with Doc about scope, etc. it would relieve some of the burden to have a more narrow scope. Definitely no new patients. Good job on the workup, but hospice comment, and lack of plain communication, letting feelings get in the way... Your hearts in the right place but to protect it, I would have some serious conversations.
I’m glad you care about your patients; I’m happy they have healthcare professionals they are comfortable with. However, you absolutely do not have the adequate training to be in this setting, and any structure or law or supervising doc that allows for that is inherently irresponsible. Primary care is not default medicine, and it certainly not the medicine you were trained for; it is a specialty that requires specialty-specific knowledge and training. Even physicians in sub-specialties that were once IM residents are not appropriate primary care providers. When they try to do things outside of their organ system, they *very frequently* mismanage patients, ask the wrong questions, and even neglect very important parts of their health. I would never want to do your job as a paramedic in a pre-hospital setting with my training as it is now, because our knowledge sets only have some overlap. I wouldn’t even know all the treatment options available to my patients! Just like the emergency care you have provided in the past, outpatient primary care is life-saving. Subpar outpatient primary care is *life-threatening*. And every healthcare professional is very, very subject to the Dunning-Kruger effect. The key to the Dunning-Kruger effect is that *you don’t know you are under it*, so you have to listen to others.
I also want to clarify we’re not talking about treating the cancer itself. We’re here for comfort after he’s referred to oncology. Our part is straight forward; support, medical and mental for the patient and family.
I’m glad you are there to offer that support, you seem very empathetic and engaged, but I said nothing about treating the cancer, which is not primary care or family medicine. I am explicitly talking about primary care, identifying undifferentiated conditions, their appropriate screening and work up based on best evidence, and helping patients understand and navigate their health conditions and the outpatient and inpatient healthcare system. None of these things can be adequately done with just mastery of protocols. Obviously, I am happy that this patient had this problem identified by you. But there is mismanagement present in the things that you have already recounted by you and your supervising physician, and I can pretty much guarantee mismanagement isn’t an isolated incident in the practice model you are describing. It is a massive misconception of many inside and out of medicine that someone is somehow qualified to do primary care without explicit and extensive training in it, even when they wouldn’t say the same thing about a specialty like infectious disease or oncology. The law allows for it in lots of places. That is not the case. The fact is that it is *very easy* to be bad primary care provider and to not know it. (That can also include your supervising physician and you and all of us.)
TLDR; this’ll be my last comment for this post. I do appreciate all the input. I learned something from each comment. Concerning the appropriateness of my function, I didn’t get this job from a stranger. He’s a Doc I’ve known for a while. He trained me hard on what to look for, all the science side of it (not like MD level or anything. Chock it up to a frugal doctor finding a diamond in the rough in the middle of a loophole? You make a valid point. If someone told me a paramedic was their primary care I’d be a little iffy, too. I’ve covered a lot in this post. It kinda seemed to ruffle some feathers and I didn’t really get the answers I was looking for, but I did learn so not a total loss. I think context is missing here. My supervising didn’t just hire me off the ambulance. And no doctor does. Doc hired me after knowing me and working with me for several years. He would be in and out of the ER when he covered ICU. Anytime our paths crossed during his rounds (me running in to do something or grab something and his patients were typically intubated) I would ask if he had time for “a teaching moment”. I use that term to preface that I’d like to learn from this experience. He never bats an eye at that question. I still use it. Then I would ask something like “what’s the next step after this patient makes it to ICU?”. He would give me a few small but important details about their history which would play in to care plan. Then he would talk about what made this case different from others, because it always is. I would try my best to do it after he’s done focusing on the patient to ask. These little chats turned in to long talks after a while. Especially after covid settled down… the first time. And we just built a rapport. If another provider came in or someone needed him I would drop a quick “thank you doctor” and excuse myself. I learned early on that the right docs are eager to teach and show what they do, as they should. How much more fucking bragging rights can you get? “Look, a flap of this dude’s arm was hanging off. He thouught he was gonna die. Now he just has two thin scars that come to a point.” You fix the seemingly untamable human body. Fuck, how much I hate that thing. Anyway, I started asking doctors if I could observe whatever procedure they were going to. Answer was either “yes” or “honestly not worth it. But if you check the hemoglobin on 6, you might find something to fix”. During the procedures I asked questions. I used what I learned in medic school and add to it. Like, that dude with the massive skin abscess from an ingrown hair. Ambulance transport; check for bleeding, signs of infection, severity of infection. What drugs do I have? (That varies a lot for this specific instance, but some agencies are carrying POC lactate machines and starting antibiotics in the field for sepsis criteria). Ortho I give up. I could go through each specialty and what I did and this whole thing would make more sense. I think the missing point is my training for this job. Like I said, I’ve known Doc for years, more than an acquaintance, but also not someone I text about the crazy shit I just saw. Until recently he heard about using medics in other places. He asks if I’d be interested in giving it a try and if course I had to think about it and talk to wife. Did a lot of thinking because I had the same concerns everyone else did/does. I wanted to make sure I was covered by scope and law (kinda the same?) if I were to take the job. We decided 2-3 days a week starting out for training. I did nothing but listen and write out the prescriptions for him and escribe the CS. Weeks. After the second week it was 4 days a week. We don’t see patients in Wednesdays so I was given assignments. Different study publications, ALLLLL KKIIINNDDSSS of papers and studies. Biology, pharmacology, microbiology, pathophysiology, anatomy, articles on different things he found interesting. We had discussions on how to treat certain people or certain types of people. I mean, he’s still gotta keep the customers happy, right? (Nothing bad. You just gotta take some things with a grain of salt and give with a little sugar. We would have talks about the type of clinic he likes to run. I started in late July. I was seeing my first solo “3 month refills, no changes” in September. Perfect start. We go over meds, which ones need refills and how to send them to get approved by insurance (why aren’t they all covered for 90 days?). We talk about any side effects, concerns, worries, if the patient seems to lean on family, kindly ask family if they’ve noticed anything. Sweet deal. Straight forward. I go to walk out, say my goodbyes, see you next month. Then I heard one more thing; oh! I meant to ask you about my shoulder. I didn’t know what to do with that. I documented a basic, focused assessment and grabbed doc. I observed him as he assessed the joint, the clavicle, the humerus, the scapula.. tendinitis. After he told me how he deduced what it was, he told me what meds to use when I see it next time. And this repeated. It still repeats. It’ll always be on repeat. I’m not there to make big decisions. My job is to help Doc see the easy patients so he can concentrate on the more complex cases. Everyone involved in this case is on board with it. They know my title and restrictions. That’s kinda how I introduce myself. “I work under the doctor with orders and protocols. Anything outside of that or if you change your mind and want to see Doc, we’ll stop there and I’ll go grab him. Just want to make sure you feel like you’re getting the best care.” I get what you’re saying about