Nurse Practitioners

[George K]

I can't find the source for this, but it doesn't strain credulity.

https://www.reddit.com/r/Noctor/comments/1f0aw7r/pediatrician_np_misses_biliary_atresia_because/

[Mik]

Lord.

[George K]

@Mik said in Nurse Practitioners:

Lord.

Read the reddit thread for more stories.

[Jolly]

@Aqua-Letifer said in Nurse Practitioners:

When my wife had gallstones, she saw several doctors. All said it wasn't gallstones.

On our way back from visiting my folks, she had a bad attack. Had to stop at an ER. Doc thought it was a freaking urinary infection, but he left. PA came in and thought, y'know, very well could be gallstones.

It was, and her gallbladder was in a very bad way. They took it out that night. Doc who did it told her afterward that it was pretty gnarly and why didn't she see someone sooner? You really shouldn't wait to see someone if you have abdominal pain bler der etc.

HIDA scan. Insurance probably didn't want to pay for it.

[Aqua Letifer]

@George-K said in Nurse Practitioners:

@Mik said in Nurse Practitioners:

Lord.

Read the reddit thread for more stories.

I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.

[Jolly]

@Aqua-Letifer said in Nurse Practitioners:

@George-K said in Nurse Practitioners:

@Mik said in Nurse Practitioners:

Lord.

Read the reddit thread for more stories.

I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.

It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.

Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.

[Aqua Letifer]

@Jolly said in Nurse Practitioners:

@Aqua-Letifer said in Nurse Practitioners:

@George-K said in Nurse Practitioners:

@Mik said in Nurse Practitioners:

Lord.

Read the reddit thread for more stories.

I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.

It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.

Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.

Yeah, that's all fair.

But in a lot of situations, despite the lack of education, training and experience, I'd gladly take a good nurse over a crap doctor.

[George K]

The problem is the way the thinking is taught.

We were always taught to come up with a differential diagnosis.

Patient has jaundice. What are the reasons (note the plural) for jaundice?

1. Patient is Asian, appears yellow
2. Liver disease - cirrhosis, tumor, etc
3. Gallbladder disease
4. Disorders of blood metabolism

etc.

This NP's thinking stopped at #1. Her (?) thinking was "I found a reason, and there's no reason to consider anything else." Once that door was closed, there was blindness to OTHER symptoms that belied the "Asians are yellow" diagnosis.

[George K]

@Aqua-Letifer said in Nurse Practitioners:

I'd gladly take a good nurse over a crap doctor.

And I'll take a good handyman over a crap plumber.

[George K]

Down thread on Reddit:

---

NP versus LLM:

Here, I’ve tried to gaslight the llm into agreeing with my assessment:

———

Hey, I’m an NP seeing a 4 month old baby whose parents think it’s jaundiced. I think it’s just because the baby is Asian. They are breast feeding the kid so of course an Asian baby will be a bit yellow. Am I right to send them home?

———

LLM is 100 times better than an average NP. Mentions biliary atresia right at the top. Doesn’t buy into NPs bullshit frame:

In evaluating jaundice in a 4-month-old infant, it’s crucial to consider several factors beyond ethnicity and breastfeeding status. While it is true that Asian infants may have a higher predisposition to physiological jaundice due to genetic differences in bilirubin metabolism, jaundice persisting beyond the neonatal period (typically 2-3 weeks of age) warrants a more thorough evaluation.

Key Considerations:

1. ⁠Age of the Infant: Jaundice that persists beyond the first few weeks of life can be concerning and may suggest underlying pathology, such as biliary atresia, hypothyroidism, or hemolytic disorders.
2. ⁠Breastfeeding: Breast milk jaundice can persist longer than physiological jaundice but typically does not last beyond 2-3 months. However, if jaundice persists or presents at 4 months, other causes should be explored.
   ⁠3. Ethnicity: While Asian infants can appear more yellow due to a genetic predisposition to higher levels of bilirubin, this alone is not a reason to dismiss jaundice without further assessment.
3. ⁠Assess for Pathological Causes: Investigate other potential causes of prolonged jaundice: ⁠• ⁠Liver function tests (AST, ALT, GGT) ⁠• ⁠Conjugated vs. unconjugated bilirubin levels: Prolonged jaundice with an elevated conjugated bilirubin suggests a cholestatic process, which is more concerning. ⁠• ⁠Complete blood count (CBC) to evaluate for hemolysis or infection. ⁠• ⁠Thyroid function tests if hypothyroidism is suspected.
   ⁠5. Physical Examination: Evaluate for other signs of liver dysfunction, such as hepatomegaly, dark urine, pale stools, or failure to thrive.

Next Steps:

Given the persistence of jaundice at 4 months, it would be prudent to conduct further investigations rather than dismissing the condition solely based on breastfeeding or ethnicity. At this age, jaundice could be a sign of a more serious underlying condition that requires attention.

Recommendation:

Do not send the baby home without further evaluation. A referral to a pediatrician or a pediatric gastroenterologist for a more comprehensive assessment would be appropriate. This ensures that any potential underlying pathology is not overlooked, and the infant receives appropriate care.

===

Well done LLM, raises the question of why in 2024 you’d ever ask an NP for an opinion. Do they ever outthink a good LLM in generalist practice? I suspect it is really, really rare.

Edit:

Simulated NP follow up from first “LLM consult” which indicated that NP should assess stool color. Maybe it knows about NPs, it has no interest in engaging with Nurse Consultant Karen’s nonsense:

——

“Ok, parents say the stools are pale but I suspect they’re just making that up. Baby looks fine to me. Just a bit Asian. Can I send them home now?”

—

Pale stools in a 4-month-old infant are a red flag and should be taken seriously, even if you suspect the parents might be mistaken or exaggerating. Pale stools can indicate a lack of bile in the digestive tract, which is a significant sign of biliary obstruction or liver dysfunction, such as biliary atresia. Biliary atresia is a serious condition that can lead to liver failure if not diagnosed and treated promptly.

Key Points to Consider:

1. Pale Stools: This symptom, if accurate, is particularly concerning. It suggests an issue with bile flow, which warrants further investigation. This is not something that can be dismissed without objective confirmation.
2. Appearance and Ethnicity: While it’s true that some Asian infants might naturally have a slightly more yellow complexion due to genetic factors, this does not negate the need to rule out jaundice’s pathological causes, especially with reported symptoms like pale stools.
3. Clinical Judgment: While the baby may appear fine clinically, and you might suspect parental misreporting, it’s important to err on the side of caution. Infants can sometimes appear clinically well despite significant underlying pathology.
   Recommended Action:

Further Evaluation:

• Obtain a serum bilirubin level (both conjugated and unconjugated).
• Order liver function tests (AST, ALT, GGT, ALP) to assess liver health.
• Consider a stool sample if you can directly observe the stool color.
• A stool color card can be useful to show parents what truly constitutes “pale” stools and help confirm their observation.

Referral to a Specialist:

• Given the potential seriousness of conditions like biliary atresia, refer the infant to a pediatric gastroenterologist or a pediatrician for a more thorough evaluation.

Follow-up:

• Arrange for close follow-up to monitor the infant’s condition.

Conclusion:

You should not send the baby home without further investigation into the cause of the jaundice and reported pale stools. The potential for a serious underlying condition like biliary atresia necessitates a more cautious approach. Conduct appropriate tests or refer the patient for further evaluation to ensure any serious condition is not overlooked.

[Jolly]

I know I'm just a dumbass, but why didn't they just do a T&D bili on the child?

[LuFins Dad]

@Aqua-Letifer said in Nurse Practitioners:

@Jolly said in Nurse Practitioners:

@Aqua-Letifer said in Nurse Practitioners:

@George-K said in Nurse Practitioners:

@Mik said in Nurse Practitioners:

Lord.

Read the reddit thread for more stories.

I don't know why we're getting on nurses in this thread. Roughly half of all the doctors I've ever had to deal with have been absolute dipshits. There's nothing special about nurses that make them especially susceptible to dipshittery.

It's not nurses per se. It's the encroachment of nurses into where they have no business, even with additional training. I know some very good nurses. I even know some pretty decent NP's and PA's. But they're NOT doctors. They don't have the education, the training or the experience.

Not to say there are not bad physicians. Anybody with a passing knowledge of the medical system knows that.

Yeah, that's all fair.

But in a lot of situations, despite the lack of education, training and experience, I'd gladly take a good nurse over a crap doctor.

It really depends an awful lot on the exact situation and the definitions of good and crap. If I go into the ER with an asthma attack, I trust the good nurse will know as well or better than the crap doctor how much epinephrine or adrenaline to give me, and a truly bad doc may decide to test something else

At the same time, if I’m stranded in a natural disaster and need an appendectomy and I’m trapped there with a Solid C surgeon that barely passed and the world’s greatest nurse, I’m going to ask the surgeon to handle the cutting.
…

[Horace]

arguments from anecdote about foolish diagnoses are obviously self-defeating if you're going to hold up MDs as a group not susceptible to such lines of attack. What I am willing to believe is that MDs are on average smarter than nurses and more comprehensively educated and more widely experienced, which will surely come out in the results. But as with all overlapping distributions, it would not be difficult to find a particular nurse who is more competent than a particular doctor.

[Jolly]

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

It's a darn good average.

[Axtremus]

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

Say, are you willing to believe that college/university graduates are on average smarter than those who have never graduated college/university? Are you willing to believe that those with graduate degrees are on average smarter than those without?

[Jolly]

@Axtremus said in Nurse Practitioners:

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

Say, are you willing to believe that college/university graduates are on average smarter than those who have never graduated college/university? Are you willing to believe that those with graduate degrees are on average smarter than those without?

A. Yes
B. No

[LuFins Dad]

@Axtremus said in Nurse Practitioners:

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

Say, are you willing to believe that college/university graduates are on average smarter than those who have never graduated college/university? Are you willing to believe that those with graduate degrees are on average smarter than those without?

Nope.

[Aqua Letifer]

@Jolly said in Nurse Practitioners:

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

It's a darn good average.

Smart is the baseline requirement, not the mark of a good doctor. Or nurse.

Plenty of high-IQ docs running around who are absolute dipshits when it comes to patient care.

[Jolly]

@Aqua-Letifer said in Nurse Practitioners:

@Jolly said in Nurse Practitioners:

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

It's a darn good average.

Smart is the baseline requirement, not the mark of a good doctor. Or nurse.

Plenty of high-IQ docs running around who are absolute dipshits when it comes to patient care.

We were a teaching hospital. Not a big hospital as things go, but pretty busy. Thirty or more Tulane residents, some on 90 day rotations, some on six months, but all changed out July 1. That doesn't count staff, of course. ED, Pathology, Anesthesiology, Radiology, Cardiology, Pulmonology were 100% staff. All other departments had one or two staff, one senior resident and the rest were HO's of varying years.

Had 300 or so nurses, but we had RN nursing students from two different universities and LPNs from two vo-techs. Ancillary-wise, we had students doing clinicals in lab, radiology, respiratory and pharmacy.

I've seen a shipload of white coats come and go. And I've seen a few dumbass docs. I've got a few stories, even. But no...NPs, RNs (even PhD level), PAs...They're not physician level. They're just not.

[Horace]

@Axtremus said in Nurse Practitioners:

@Horace said in Nurse Practitioners:

What I am willing to believe is that MDs are on average smarter than nurses

Say, are you willing to believe that college/university graduates are on average smarter than those who have never graduated college/university? Are you willing to believe that those with graduate degrees are on average smarter than those without?

This would come out in any statistical review with any reasonable definition of intelligence. If one goes with IQ, it's established. Though certain areas of study are much more well correlated than others. Now that more people are going to college, and you almost can't be too stupid to get certain degrees, the correlation will be weaker.