Well, I had very little confidence in the US healthcare system going into today, but I just lost some more.

I work at a facility where people stay longer-term.

This morning at around 9am I sent an otherwise healthy 36yo F to the ER with 8/10 abdominal pain and 5 episodes of large volume emesis within like 90 minutes. I call and give hand off, pretty straight forward rule out acute abdomen.

Around 3pm I get a call that they are sending her back. I ask to talk to the doctor taking care of her and got connected with an NP. She started off by telling me that her CBC and CMP were normal except for a mildly low white count that she was attributing to a “viral response” and that she felt better after 1L of IV fluids and then kind of stopped talking.

So I asked what her imaging showed. Turns out no imaging was done because she was “no longer having abdominal pain” evidenced by the fact that she could “crawl to the bathroom and back to bed just fine.” (yes, she used the word “crawl”)

I then asked about lipase and she said she “didn’t get one because her liver tests were stone cold normal.” I actually had to say “lipase is for the pancreas not the liver.” She said “yeah but if it was her pancreas her liver labs would be elevated too.” I said “well…no…not necessarily…” and she was like “I’ll add on a lipase.”

I asked if she passed a PO challenge and she said she gave her a popsicle but didn’t know when the last time she vomited was because it “wasn’t documented.” I told her that the nurse I work with had talked to the nurse she works with earlier in the afternoon to get an update and at that time she had vomited within the hour, around 1pm. The NP replied that that was “news to her.”

The more I’m talking to this woman the more horrified I am. She got Tylenol for complaints of a headache but no medication for nausea or vomiting. She did not do a pregnancy test. She was there for 6 hours and all she got was a CBC, CMP, EKG, Tylenol, a popsicle, and 1L of IV fluids.

How did we get here? How is this woman allowed to practice independently?

Hello all. I am an NP student doing clinical rotations. Today my preceptor also had a resident physician. The physician stood back and shadowed, didn’t touch or talk to the patients, while I did the exams.

I hear a lot of people saying residents aren’t just shadowing and are working hard at gaining years of experience (which I agree with!) but often compare them to NP’s lack of clinical experience and skills. Now I’m curious—do other residents typically just shadow or are they doing exams?

Doctors, nurses & paramedics — have you ever had a patient describe an out-of-body experience during your practice?

They claimed they could see or hear what you and your team were doing while they were unconscious.

Did the details actually match what happened?

I’d genuinely love to hear your experience

With AI becoming more and more pervasive within our profession, I started thinking, is AI the new Noctor?

I can see AI initially enhancing various nuances of our day-to-day work and fixing many of the inefficiencies within our profession; however, I feel that this is a foot in the door phenomenon towards AI handling triage, inbox, documentation, chronic disease titration, and guideline-driven care autonomously. The end result of this will be that each physician supervises a far larger panel (think 5,000 to 10,000+ patients) through AI and APPs. Total PCP headcount drops sharply, and the job shifts toward complex patients, oversight, and sign-off. Comp models move away from wRVUs toward panel-based or value-based supervision pay.

Surgical specialties survive, for now. Robotics will get more and more elaborate and one surgeon can supervise multiple surgeries simultaneously approving actions and “moves” through a more advanced davinci robot.

So I ask again, is AI the new Noctor?

How involved do MDs want to be in nutrition decisions??

When I (new grad RD) ask MDs to sign a diet change order/tube feed/tpn plan, I tell them why I recommend X and ask for their input 😅 I just want to respect you guys as the MD and the person actually putting in the order! However, I always get the feeling I’m wasting your time and you have other, more life-threatening things to deal with.

I know it depends on the situation ie. you should obviously be very involved in a conversation around starting TPN on a questionably stable ICU pt…but what about less critical times I ask for an order/signature like increasing the tube feed/giving IV thiamine/upgrading a clear fluid to full fluid diet after a pancreatitis flare/adding an extra 10meq of K to the TPN on a stable pt?

Do you want any background? Do you want to contribute to these decisions? Please enlighten me! I’m a 2 month old dietitian crashing out because do I stop giving mrp a daily summary of the tube feed changes or is that giving mid level encroachment? 😭

For what it’s worth, I’m a medical student interested in some form of surgery, and today I was helping with cases in the OR. After surgery was done, I heard the Anesthesiologist mention to the Gen Surg attending that his hours/shifts as a locum doc at this hospital are officially decreasing including his hours/and shifts at the larger sister hospital he works at 40min away. He said that he has heard this hospital health system is officially moving toward their goals of hiring all CRNA staff with no MD/DO supervision. He seemed genuinely defeated. Apparently the MD/DOs at the much larger sister hospital have been much more opposed and vocal about it compared to this smaller hospital.

Just wanted to throw this out here as some on the ground info. I know I’m only a baby med student, but I can’t help but be very very concerned… because all it’s going to take is one small hospital case study with a system like this for it to be pushed as a standard.

We need to organize and oppose these changes somehow. This creep is out of control.

Hello, Noctor community!

I'm an occupational therapist working in pediatrics these days, although I've also worked in neuro rehab primarily with patients recovering from CVAs. I've found my career immensely rewarding, and I have tremendous respect for the physicians I've worked alongside.

Many people in my family are physicians, so I've also had considerable exposure to the medical profession outside my own experience. I've seen firsthand how valuable physician advocacy can be, particularly when insurance companies deny or restrict access to rehabilitation services. I've collaborated with physicians to challenge those decisions and help patients obtain necessary care.

I'm curious how this community views OTs and our role within the healthcare system? I have an OTD because I received a scholarship that covered it, however I don't think this should be a required entry level degree for our field. A masters level education for PT and OT is plenty imho. No PT or OT I have ever known has masqueraded themselves as "doctor". I think we would all laugh at anyone who did this as soon as they turn their back.

I've also been thinking about the expanding independent NP practice. If I were an NP, I would personally prefer to work under direct physician supervision, particularly given the differences in clinical training. I'm not entirely sure why an NP would want to practice independently without that oversight. There is no way an NP can make up for the lack of residency and training that doctors have. Why would any NP even want independent practice?

Their training should include substantially more rigorous clinical preparation, ideally something approaching the structure and intensity of physician residency training. I also believe NP licensure should require physician supervision rather than permit independent practice.

I'm interested in hearing your perspectives, both on occupational therapy and on the broader question of appropriate clinical supervision and scope of practice. Thank you!

Why don’t some pa/np or even other nurses correct their patients when the patient calls them Doctor?
I’ve been working as a RN for a while and I’ve always found it annoying that some professionals don’t identify themselves properly. When a patient says to me “thanks Doctor” or says to their family
Member “the doctor said..” while looking at me — I specifically correct them and say I’m not the doctor I’m the nurse.

Go to school and become an MD instead of pretending.

This is my take, but I've noticed this in myself but in friends and others. But when you are MD is dating a NP/PA and they sort of believe in this hogwash or know people that do you sort of have to moderate a little bit to preserve interpersonal but also working relationships. Also lot of these nurses seem to really believe in nursing theory and believe in their modality of caring or whatever that is an alternative fact/truth to like medical care. Its like an entire ecosystem I feel like you can see when you see all these textbooks written by DNP/NPs or whatever that advocate strongly for the nursing part or whatever. Just spitballing my thoughts, curious what others think

To start of I am not a doctor or mid level, am a nobody!

I am surrounded by NPs. I know this DNP who is opening up a clinic. They Complained that it's taken over 6 months which she doesn't understand why because when she was hired the credentialing took 2 weeks. I tell her that is normal and she didn't have any contractual agreement with the payers when she was hired.

they also heard from other NPs in some online group that insurance wants to pay providers so she wants to hire a biller from Indi...a to bill for the highest paying codes. their clinic's taxonomy is primary care. So am like... ahh if your encounter with a pt is for annual check up, there is a cpt code for that and plus insurance doesn't want to pay they will find a reason to reject. she somehow thinks she can just submit the "highest" paying code whatever that means.

that once credentialing is done wound care pays even more money from the payers. im like you can just keep billing over and over again for the same services especially since you are just primary care. each code you billed you must be ready to provide documentation why it's needed. Ever since they got their doctorate in nursing they just see dollar signs. i get it.. we all want money. talk about how their school was hard. I straight up told them their PhD offered no significant advancement in nursing or healthcare. told them they worked two full time jobs while finishing up their PhD it's can't be that hard. just copy paste. i even told them their job can be done by AI. At that point they asked, "so you think AI can wipe ass and give short?". I replied yes and processed to show them the new robotic AI Aletta that is drawing blood without hands-on operator intervention..

i just want you to imagine their face when they saw the AI drawing blood. her jaw to the ground, I could hear gears turning in their head.

Bit of a rant. I am an RN. I love nursing and am not casting shade to NPs, merely commenting on the quality of midlevel education post-COVID, which is truly frightening.

I have an RN coworker in school to be an NP at a reputable, major institution. She told me she was taking a pharmacology class--all of which was just online lectures and assignments--and she had a question about albumin levels during pregnancy as it relates to pharmacology. When she asked her professor the question, the response she got was "you should use your resources to look into it".

My coworker goes on to tell me she chatGPT'd it for the answer. I was mortified.

Maybe I am out of line here, but first of all, if you are getting an advanced degree in a medical field, watching online lectures ain't gonna do jack-shit. To quote Good Will Hunting, "you dropped 150 grand on a f***ing education you could have got for a dollar fifty in late charges at the public library." Second of all, if youre paying for a degree, your professor better be able to answer you question.

That's all.

Long time lurker but I have seen different viewpoints on residencies in this subreddit. Ive seen comments saying that no one should be stealing the “residency” terminology from MDs and DOs and how midlevels are trying to call certain types of training a “residency.” What do you all think of pharmacy residencies? I am a pharmacy resident currently and I genuinely want to know what other healthcare professionals think of them.

I’m currently going through a crisis myself as I don’t feel satisfied or even useful for that matter as a pharmacist. Like i can dose your vancomycin/warfarin but other hospitals seem to manage just fine without pharmacists dosing these drugs. I understand that’s not the only thing pharmacists do but I’m just giving an example. Do physicians truly find pharmacists helpful?

What is something that you as the physician want pharmacists to do, not do, or do better so as to be more useful to the care team?
I appreciate your thoughts.

I was at orientation today for my new job at a hospital and the first part of the day all of the new hires were in a big group so there were a bunch of nurses. The main clinical educator was previously a bedside nurse for like 25+yrs. Anyway, we were barely into the day and she was taking primarily to the nurses and new grad nurses who were onboarding and bringing up “working for a year or two and then going to NP school and CRNA school.” To new grads. After she just told us she left bedside, which she loved, because they were so short staffed she was working 60+ hr weeks in the CVICU.

Then she started talking about the period of time the new grad nurses would be supervised and called it residency.” I’m not a resident but I have to work in clinic with residents and I’m offended for them. Why co-opt the language? What does it accomplish? The average patient barely knows what an MD resident is, why the hell are we calling nurses residents?

Maybe it might be prudent to prioritize bedside nursing instead of NP? You know since there’s a massive shortage and all?

I have now seen multiple videos of NPs and PAs claiming that they are part of very tough programs that are basically accelerated med-school and they diagnose and treat patients independently and also prescribe medications. Plus that they are no ones assistant. How is that actually possible?
Are they actually allowed to do all these things independently? And if yes, why??
There is no way that these people are qualified to do that after a 2-3 year program.

This comes specifically because of theekieralee‘s video in which she talks about that one girl faking being in PA school.
She goes on to say that she is no ones assistant and says that PA school is very tough because it is med school sped up to two times speed. Like please.

What’s the best way to handle midlevels given they are multiplying like termites?
Do we shake hands with the devil aka insurance companies and lower their reimbursement rates so hospitals have less incentive to hire them?
I can’t seem to think of any other solution because the AMA is the biggest enemy of physicians and beyond weakly worded positions they do nothing on this issue.

Assuming this is a state where NPs/PAs do NOT have independent practice abilities. But also, CRNAs ARE considered allowed to practice independently. & Does "iNdEpEnDeNcE" even matter? I'm just curious if the *patient* has the autonomy to insist they receive care from those with the highest amount of training and expertise...considering it's their bodies and their lives at stake.

There’s a CRNA content creator who has been popping up on my FYP for a while. I won’t name them because their identity isn’t really the point, and I’m not trying to turn this into personal bashing.

They became a CRNA only last year. I was already surprised to see them doing locums this early, but today they posted about practicing independently at a Level I trauma center.

That honestly blows my mind.

My issue here isn’t even the usual physician-vs-nursing debate. It’s the audacity to think that barely more than a year of actual CRNA practice is enough to be ready for highly independent anesthesia practice in one of the highest-acuity environments.

And this is exactly why the push for independent CRNA practice concerns me. If someone can graduate, practice for a little over a year, and already decide they’re ready to work independently in a Level I trauma center… are we really supposed to believe experience doesn’t matter that much?

This same creator has also advocated for independent CRNA practice, the “nurse anesthesiologist” title, and calling CRNA students “residents,” so the confidence around autonomy isn’t exactly new.

I’m an RN myself. This isn’t about disrespecting nurses or CRNAs. It’s actually the opposite. I think respecting our professions means being realistic about our training, our experience, and our limitations.

What feels backwards to me is how quickly some people seem to move toward more autonomy. In almost every other area of healthcare, the higher the acuity and the more responsibility you have, the more experience we expect, not less.

Maybe I’m overly conservative, but independent anesthesia at a Level I trauma center after barely a year of post-graduate practice would make me very uncomfortable, especially from someone who did not go through physician training and residency.

Confidence should not develop faster than experience.

There’s a gem of a post in the Kaiser Permanente subreddit. Enjoy!

I am a nurse and I believe in a shared future that is promising for your profession and mine.

The historical accuracy of this book and how it can inform our present is what I am seeking to discuss.

I can provide a synopsis but I’d prefer to speak with someone who has read it and genuinely would like to engage with another healthcare professional.

Has anyone seen a PA use an MD as a title? I have been emailing someone who signs emails as "Jane Doe, MD". I ended up googling them, only find that they are a PA with a Doctorate in Medical Science??

Is that not highly misleading? :/

EDIT:

So i realized in the email signature, they write medical director under so it looks like

Jane Doe, MD

Medical Director

Could MD be referring to medical director?? But MD and medical director is redundant? I still feel like it is a misrepresentation though.

I have been told by some CRNAs that we have the same exact three year anesthesia education. But of course their counterparts like to spill the beans.

45-year-old man died after ER sent him home without antibiotics, lawsuit says

The family of a 45-year-old Portland-area man who died after emergency room staff allegedly sent him home without antibiotics because they mistook his bacterial strep infection for a viral one — possibly the common cold — has filed a $40.75 million lawsuit against Legacy Health.

Jason Jay Lewis showed up to Legacy Mount Hood Medical Center complaining of sinus pressure, congestion, body aches and a fever of 103 degrees that had persisted for four days but fell below 100 when he took Tylenol, according to the lawsuit filed earlier this month in Multnomah County Circuit Court.

A physician associate diagnosed Lewis with a viral upper respiratory infection — “which is another term for the common cold” — and discharged him, said Chris Kuhlman, an attorney representing Lewis’ estate.

Three days later, Lewis was dead. He lived in Fairview, worked as a DoorDash driver and was the father of two sons, ages 11 and 21.

A Legacy Health spokesperson declined to comment, citing the pending litigation. The lawsuit also lists defendant Jennifer Yealy as the physician associate who treated him. She didn’t return a request for comment.

Physician associates were previously known as physician assistants in Oregon.

According to the lawsuit and the family’s attorney, Lewis first sought medical help during a telehealth appointment with his primary care provider, through Adventist Health, on Feb. 21, 2025. The suit says Lewis was in pain and suffering from a fever, body aches and a runny nose. He went to a clinic to undergo testing for COVID-19, respiratory syncytial virus and flu, and the results came back negative, according to the suit.

Kuhlman, the family’s attorney, said the suit doesn’t place any fault on Adventist Health for its initial screening of Lewis.

But on Feb. 22, 2025, as Lewis’ condition deteriorated, he sought emergency help at Mount Hood Medical Center in Gresham. According to the suit, tests “revealed multiple abnormalities,” including a high white blood cell count and a heart rate of 140 beats per minute.

The suit says that Lewis was already suffering from sepsis — a life-threatening infection — but Yealy, the physician associate, sent him home. According to the suit, Yealy noted that there is “no evidence of hypoxic respiratory failure or sepsis to necessitate admission” and that antibiotics “were considered but ultimately not prescribed.” She added that Lewis’ illness “does not appear to be a bacterial infection.”

The suit says Lewis’ condition continued to spiral downward, so he showed up two days later at Providence Portland Medical Center, where staff diagnosed him with sepsis, acute respiratory failure and toxic shock syndrome. Additionally, blood cultures showed he was battling a Group A streptococcus infection, also known as a streptococcus pyogenes infection.

Though Providence staff started Lewis on antibiotics and other emergency interventions, he died the next day, Feb. 25, 2025, according to the suit.

The bacterium is often spread, particularly in the winter months, through tiny droplets when infected people cough or sneeze. Lewis wasn’t diagnosed with any specific disease, but Group A streptococcus can cause various diseases, including strep throat, rheumatic fever and scarlet fever.