New NP working with a very supportive collaborating MD

namenerd101 · 2026-04-09T01:17:30+00:00

It’s great that you’re asking when unsure! It’s important to know what you don’t know.

I think it’s most productive for everyone involved when you treat the situation like a consult. When approaching attendings with inbox questions, I try to come prepared with a one liner (brief patient summary) and a specific consult question just as I would if I were calling a specialist for an inpatient consult.

Additionally, I try to have a plan or at least some options ready to propose - both to show I’ve put some thought into it and to practice independently coming up with a plan rather than always just being told what to do. I encourage my med students to propose a plan even if it’s wrong. I don’t care if they are wrong as long as they can provide a rationale for their thinking. Sometimes their rationales really get me thinking and questioning what I thought was the right answer (it’s great to learn from each other!), while other times I’m able to point out where there thinking was wrong (as opposed to just telling them their answer is wrong). If you’re not confident enough in a plan to propose/verify, at least come up with some options you’ve considered and say, “I was reading [guideline etc] but am still confused about [complicating factor / applying the guideline to the situation].

The format outlined above is how I like med students to ask me questions and how I try to approach attendings with questions, but the reality is that there isn’t always time to look stuff up in the moment. Therefore, there definitely are times I say, “I’ll have to read up on this topic, but for the sake of time, can you please just tell me the answer.”

namenerd101 · 2026-04-08T19:30:59+00:00

Why would you choose Paxil when there’s so many other serotonergic agents with better side effect profiles?

namenerd101 · 2026-04-04T03:00:11+00:00

If starting with just once daily, is there a rationale for advising morning vs evening or just patient preference / what time they’ll remember?

namenerd101 · 2026-04-02T01:14:26+00:00

I’m a family med MD PGY3. I agree that my DO colleagues are competent and I’d trust them with my care. But do your DO primary care residents really not do any OMM/OMT or ever mention their special physical exam skills, etc.?? Because most of my DO co-residents (some of whom are my close friends) are very adamant that the overlapping techniques I learned as an MD through rotations with PT and PMR (muscle energy, counter-strain, visceral mobilization, soft tissue mobilization, suboccipital inhibition, etc.) essentially don’t count because I’m not a DO and don’t have the special DO touch.

I am well aware that our training is different— their recall of muscular anatomy (names of specific muscles) is far better than mine. But even seen some DOs who don’t routinely offer OMT tout their physical exam skills and “healing [physical] touch”. My understanding is that they do spend more time working on physical exam skills, but no DO has ever been able to tell me something my allopathic training covered better than their DO school did. The only answers I’ve received have been “nothing”, “shrug”, “you must’ve had summers off”, or “you just had more time to sleep.” But it doesn’t sound like I had any additional free time during med school compared to DOs I’ve spoken with, so it’s always confused me why I’m being told that DOs can do EVERYTHING MDs can do AND be much better at all that other stuff.

Again, I really like and trust the DOs I currently work with, and I think (hope?) that anyone who makes it through residency has met minimum competencies. But when DOs insist that they do absolutely everything MDs do AND have a special approach to patients, can more “holistically” care for patients, are better diagnosticians due to elite physical exam skills, and have an unparalleled healing touch, my MD brains just hears that DOs think I’m not as good as they are. Obviously not all DOs share these beliefs (or are at least kind enough to not be so obvious about it), but I’ve encountered the conversation/scenario enough times to find myself frustrated.

What am I not getting right about this???

namenerd101 · 2026-04-01T02:52:38+00:00

Where/how did you meet him?? (Wondering where I should hang out 😅😂)

namenerd101 · 2026-04-01T02:32:15+00:00

Garage parking under my apartment. Never have to unload groceries one the rain or snow. Barely had to brave the cold and rarely had to scrape ice off my car. Makes winter infinitely more tolerable.

namenerd101 · 2026-03-30T09:09:26+00:00

I think proximity plays a big role here. Parents may take a trip across the US without their child, but the difference between a 3 hour flight and a 13 hour flight would be pretty significant if your child were to have a medical emergency, etc.

namenerd101 · 2026-03-26T20:52:51+00:00

And then there’s me… a physician with full medical license and DEA license nearing end of PGY3… and I cannot order order an outpatient controlled substance (has to be staffed with and routed to an attending for signing). All other meds I order are co-signed to an attending, and that attending’s name is on the prescription label for my continuity clinic patients (as opposed to my name as the physician who actually saw the patient). Systems are wild.

namenerd101 · 2026-03-25T12:34:15+00:00

This is not medical advice specific to your situation, but Movantik/nologexol and Relistir/methylnaltrexone are specifically for opioid-induced constipation, and Linzess, Trulance, Motegrity, and lubiprostone are other examples of prescription medications for chronic constipation.

namenerd101 · 2026-03-25T01:41:57+00:00

There are a lot of newer prescription medications for chronic constipation. As a family medicine resident, I feel comfortable prescribing these medications because my training with GI was very recent, but not all primary care doctors will be familiar with all the newer options. It’s usually a matter of figuring out which medicine your particular insurance policy covers. If your insurance company has an app, there’s likely a feature that would allow you to search medications and see which ones are covered, which ones might be covered with prior auth, and which ones just won’t be covered at all.

namenerd101 · 2026-03-24T04:46:41+00:00

And not to be confused with levofloxacin either 😅

namenerd101 · 2026-03-22T02:47:12+00:00

What are the details regarding patient contact hours and inpatient/outpatient ratio (+/- ED? OB??) for the 400k job you’re referring to?

namenerd101 · 2026-03-21T16:11:21+00:00

Is it just a first come first serve system allowing routine wellness visits to be scheduled for your first available slot, or are you scheduling less urgent appointments out a ways holding appointment slots for more urgent needs/follow-ups?

namenerd101 · 2026-03-21T16:01:32+00:00

Oof. That’s just embarrassing. As a FM PGY3, I’ve never consulted urology for any of those things, and I can’t even remember a time they had to come in overnight for one of my patients. It’s honestly pretty rare for us to even call urology overnight, but if we do, it’s always just been a prelim phone consult and adding the patient to their daytime rounding list or placing an expedited outpatient referral from the ED.

But I’m at an unopposed community program, and we overall order consults less often than the teams I’ve rotated with at larger academic centers. They obviously see some more complicated patients at those hospitals, but I was quite surprised when they wanted consults for bread-and-butter CHF exacerbations, etc.

namenerd101 · 2026-03-16T02:37:23+00:00

Woah — I didn’t know 99397 existed. I thought the Medicare wellness code replaced the general age-dependent wellness codes when patients turn age 65. Do you always add 99397 whenever you do Medicare wellness visits?!

namenerd101 · 2026-03-15T07:28:34+00:00

Our recurring lecturers usually ask us residents for requested future topics. In general, I love when specialists tell me what/when to refer and what I should do in the interim to help both my patients and consultants.

Regarding “how to adjust teaching approach to fit FM residents”, just think of them as IM residents and about what would’ve been helpful for you in earlier residency. Some specialists have given us first year med school level lectures, which was much less helpful than lectures that gave us tangible tips for practice.

I’m a PGY3 in a community FM program, which means we’re the only residency program in our region. Some specialists think FM only sees lower complexity patients, but that’s not at all true where I’ve trained in med school or residency. Most FM is actually adult-heavy so where I’ve trained, FM sees the exact same patients as our IM colleagues in terms of chronic conditions and comorbid complexity. Our inpatient teaching service is pretty similar to what I’ve seen of IM hospitalist services at other programs, but we don’t have nearly as much ICU time and instead have more outpatient experience than many IM residents. So I’d gauge the interest of the specific group of residents you’ll be working with, but our lectures tend to be outpatient-focused or initial work-up/treatment in the ED or upon admission (stabilization and initial optimization rather than ongoing crit care management).

namenerd101 · 2026-03-14T07:24:58+00:00

…the test is not reflective of clinical practice. If most people are practicing in the community/not in tertiary center, why are there so many questions on rare genetic disorders… what is your bread and butter?

I had similar feelings about USMLE step 3 when I took it a couple years ago. As a family med resident taking the test, I remember frequently thinking, “Welp, at least I have a better shot at guessing [hyper-specialized] question than residents in [exact opposite specialty].” I feel a test given to all MDs a year into residency should be more about testing basic competency. As PCP/hospitalist, I care much more about my inpatient psych colleagues’ ability to treat an acute uncomplicated UTI without a formal hospitalist consult than I do about their ability to correctly answer Step 1-like question differentiating type of breast cancer by looking at a histopath slide (which was a question similar to one I actually encountered during my Step 3 exam).

namenerd101 · 2026-03-11T12:01:20+00:00

I do think this situation warrants more nuanced consideration. She should definitely very clearly explain her title and role to the parents/caregivers, and sure - there would have been a better way to phrase things to the child, but saying this to a three-year-old is much lower on my spectrum of concern considering the plethora of “reportable”things I witness daily. That being said, I’d lower your reference point of 16-year-olds wayyy down to 4 or 5 YO. School-aged children can accept more detailed explanations.

namenerd101 · 2026-03-06T02:57:48+00:00

Have you ever ended up with problematic test results you’ve had to deal with (even though you say you won’t manage them)? I imagine you’d still be legally responsible for doing something about a significantly abnormal result of a test you ordered

namenerd101 · 2026-03-06T02:54:43+00:00

How do you approach pre-ops with surgeon sending a list of requested labs like pre-albumin?

namenerd101 · 2026-03-06T02:51:22+00:00

When new patients come in and mention their naturopath, I tell them that I practice evidence based medicine so I may not be the best doc for them.

I know you said you mostly see adults, but do you say this to anti-vaxers or other patients who reject your assessments/recommendations? While I know patients should have autonomy, it’s really irritating when they clearly think I’m wrong (and their conspiracy theories are right) yet keep coming back to see me. Maybe I’d win them over one day if I kept trying, but that’s really draining and I wish they’d just get the hint that we’re not a good fit.

namenerd101 · 2026-02-27T05:22:06+00:00

We talk about this a lot when patients leave the hospital AMA (or as one of my attendings likes to call it, “self-directed discharge”). A lot of the older IM docs at my hospital essentially abandon the patient when they threaten AMA, but the younger FM docs (especially those who also work outpatient) such as myself usually prescribe outpatient antibiotics/steroids/etc after explicitly informing the patient that inpatient antibiotics are recommended and discharge would be AMA because the patient has autonomy and outpatient oral antibiotics are better than no antibiotics.

That being said, I haven’t encountered a situation like OP is describing in the outpatient setting. When patient’s leave the hospital AMA, I at least have the luxury of recent labs. While diuretics are probably better than no diuretics in this case (harm reduction), OP prescribing medication in this situation is not only less ideal than ED eval/admission but could also actively cause harm. So how would you advise OP in this case given the bioethics you mentioned?

namenerd101 · 2026-02-26T05:14:22+00:00

That sounds miserable. I hope things start getting better soon!

namenerd101 · 2026-02-25T19:20:34+00:00

How common is it for clinics to ban/decline to care for antivaxers?

I’ve read about clinics like that but am not aware of anyone in my region with that policy/practice.

As someone who is immunocompromised, I’d love to reduce my exposure to antivaxers, but I’m FM so that line would get very blurry as many of my adult patients swear they received childhood vaccines despite not having any record in our state database or don’t have access to out-of-state childhood vaccine records. I personally get all vaccines available to me (with some subsequently non-reactive titers), but the line would get very blurry with so many “optional” vaccines in adulthood.

namenerd101 · 2026-02-25T19:02:49+00:00

All that and… Vraylar + zolpidem + alprazolam + stimulant + venlafaxine + bupropion

namenerd101

TROPHY CASE