RN vs. MD

[laurie31]

I thought it might be fun, if any doctors and nurses here want to participate, to demonstrate for those who don't know but are interested, what it is we do when it comes to our respected professions and perspectives.

I'll give a fictional case study and you can briefly show what your diagnoses and plan of care would look like. (I am keeping it very simple - many patients have far more complex histories and presentations than this.)

Mrs B. is an 84 year old who lives alone. Her daughter brought her in today because she found her mother at home with shortness of breath, bilateral pedal edema, new confusion and states she does not think her mother has taken her medications in three days, the time since her last visit. Vital signs are BP 188/122, HR 112-130, RR 30, Room Air Saturation 88-90%, Blood Glucose 246. Her rythm is Atrial Fibrillation. Past Medical History: Hypertension (HTN), Diabetes - adult onset (AODM), Congestive Heart Failure (CHF). Past Surgical History: s/p Coronary Artery Bypass Graft (CABG).

What are the standards of care for this patient?

\

In my educated opinion, Mrs. B is a goner.




Sorry. I'm a pediatric nurse. I haven't laid a hand on an adult in over 25 years. Now if you ask about strep, ear infections, vomiting, MRSA, head lice, buckle fractures, and chicken pox, well I'm your girl.

Me too! To paraphrase Mammy from Gone with the Wind: I don't know nothin' 'bout no adults!

However, I think what you're getting at, is that a doctor would immediately focus on controlling her respiratory distress, CHF, hypertension, and hyperglycemia; while the nurse is going to focus on the patient's self-care abilities and discharge planning needs (in addition to carrying out the doctor's orders to control the above medical conditions).

Is this lady going to be able to be discharged to her home, or will she need an assisted living or a skilled nursing facility? Or does the family want to care for her in their home, and if so what kinds of support will they need (aides to assist with bathing, skilled nursing care for management of diabetes, etc). What education does the patient and her family need - not only regarding her current medical problems and their treatment, but the long-term prognosis. Does the patient have a living will or has she expressed her wishes for end-of-life care? Does she want a feeding tube? Does she want to be a DNR?

The nurse is also going to consider her needs during the hospitalization - ie- she's a fall risk, she's a risk for bed sores, her nutritional status needs to be assessed, in addition to her obvious immediate medical needs of oxygenation, blood sugar control, and control of her B/P and atrial fib. And probably some other things that I'm not thinking about since it's midnight - lol.

Good illustration!

 

[Pea-n-Me]

Me too! To paraphrase Mammy from Gone with the Wind: I don't know nothin' 'bout no adults!

However, I think what you're getting at, is that a doctor would immediately focus on controlling her respiratory distress, CHF, hypertension, and hyperglycemia; while the nurse is going to focus on the patient's self-care abilities and discharge planning needs (in addition to carrying out the doctor's orders to control the above medical conditions).

Is this lady going to be able to be discharged to her home, or will she need an assisted living or a skilled nursing facility? Or does the family want to care for her in their home, and if so what kinds of support will they need (aides to assist with bathing, skilled nursing care for management of diabetes, etc). What education does the patient and her family need - not only regarding her current medical problems and their treatment, but the long-term prognosis. Does the patient have a living will or has she expressed her wishes for end-of-life care? Does she want a feeding tube? Does she want to be a DNR?

The nurse is also going to consider her needs during the hospitalization - ie- she's a fall risk, she's a risk for bed sores, her nutritional status needs to be assessed, in addition to her obvious immediate medical needs of oxygenation, blood sugar control, and control of her B/P and atrial fib. And probably some other things that I'm not thinking about since it's midnight - lol.

You've got it, sister!

I'd add that nursing would also initiate consults for this woman, probably nutrition, physical therapy, social services, continuing care, and possibly chaplaincy, if desired, and geriatric service if her confusion doesn't clear. All of these with an eye toward eventual discharge needs, as you noted. In the hospital, the nurse would notify pharmacy services of the patient's admission and status in anticipation of getting medications quickly, when needed, and have IV therapy nurses (or themselves) place an IV in anticipation of receiving IV medications such as lasix, metoprolol, and maybe others. The nurse would also ask the daughter to help complete the nursing assessment since the patient herself is confused, and the nurse, doctor and patient's daughter would have a three way conversation in order to reconcile medicaitons the patient should be on at home and ones she'll be on in the hospital.

Problably more, but gotta go. Thanks for participating!

 

[justhat]

And everyone will know what the field lifestyles are like prior to matching. If you want a family and regular hours, you know which areas to go after. If you don't mind all nighters, then you'll know which areas to go into as well.

As it stands right now, Dermatology and Radiology are the two most desirable areas based on pay and hours.

But it doesn't work that way. To begin with, radiology isn't just shift work. My friend's husband (the eye surgeon, mentioned in the earlier post) has to work weekends, take call, can't make definite plans, etc. No different than my husband in anesthesia. My friend and I took our kids to a school event and her husband planned to come, but was called to work for an emergency. His kids cried cause they planned on him coming and at the last minute he couldn't. My husband was also on call that night, but ended up not getting called in so he was able to stay home with our baby, but that was luck.


But the real flaw in that plan is that the "cushy" jobs are also very hard to get into. Just because you go to med school does NOT mean you can become any kind of dr you want. In order to get into residency you have to take the Step 1 (and Step 2, but the scores from Step 1 are what count for residency applications) Board Exams. Your score on that exam directly affects what type of residency you can apply for. Take anesthesia for example: board scores have to be above 222. Anything lower and your aren't even considered for a spot. There are too many vying candidates to waste time interviewing lower performers. My husband had a friend who failed his boards first time around and anesthesia was out for him. He couldn't match in any program and had to do a transitional year (basically general medicine), and then apply to residency from there. And academically he did well, just not a great standardized tester, so to speak.

So you might have your heart set on field A, but don't have the grades to get a residency in that field. Or, like a friend who is now an ER physician, he matched, but in a crappy location. So he and his family had to move to a remote town so he could fulfill his dream. His wife was miserable there for the 4 years and couldn't wait to flee.

It isn't just as cut and dry as "I'll be a dermatologist". Many, many people want the shift work, no call jobs (EMed included), so as a result, they have pretty high standards to get a residency spot. And there are a fixed number of residency positions in the country and that doesn't change from year to year.

 

[Jaime4004]

You've got it, sister!

I'd add that nursing would also initiate consults for this woman, probably nutrition, physical therapy, social services, continuing care, and possibly chaplaincy, if desired, and geriatric service if her confusion doesn't clear. All of these with an eye toward eventual discharge needs, as you noted. In the hospital, the nurse would notify pharmacy services of the patient's admission and status in anticipation of getting medications quickly, when needed, and have IV therapy nurses (or themselves) place an IV in anticipation of receiving IV medications such as lasix, metoprolol, and maybe others. The nurse would also ask the daughter to help complete the nursing assessment since the patient herself is confused, and the nurse, doctor and patient's daughter would have a three way conversation in order to reconcile medicaitons the patient should be on at home and ones she'll be on in the hospital.

Problably more, but gotta go. Thanks for participating!

And i'll throw in after she's stable and ready for discharge, if going home, hook her up with visiting nurses!

 

[RellaSprinkles]

Me too! To paraphrase Mammy from Gone with the Wind: I don't know nothin' 'bout no adults!

However, I think what you're getting at, is that a doctor would immediately focus on controlling her respiratory distress, CHF, hypertension, and hyperglycemia; while the nurse is going to focus on the patient's self-care abilities and discharge planning needs (in addition to carrying out the doctor's orders to control the above medical conditions).

Is this lady going to be able to be discharged to her home, or will she need an assisted living or a skilled nursing facility? Or does the family want to care for her in their home, and if so what kinds of support will they need (aides to assist with bathing, skilled nursing care for management of diabetes, etc). What education does the patient and her family need - not only regarding her current medical problems and their treatment, but the long-term prognosis. Does the patient have a living will or has she expressed her wishes for end-of-life care? Does she want a feeding tube? Does she want to be a DNR?

The nurse is also going to consider her needs during the hospitalization - ie- she's a fall risk, she's a risk for bed sores, her nutritional status needs to be assessed, in addition to her obvious immediate medical needs of oxygenation, blood sugar control, and control of her B/P and atrial fib. And probably some other things that I'm not thinking about since it's midnight - lol.

Good illustration!

That was pretty darn thorough (especially considering you wrote it at midnight!)

 

[horseshowmom]

That's terrible to hear... My sister didn't get in to the music program at the school she wanted and so she left music all together and has moved on to linguistics. I think she got discouraged and rather than try again she just decided to give up. Music is her entire life and she is so talented, I think it's a shame.

When I was applying to vet schools I got two rejection letters in the span of a few short weeks after I submitted my applications. I was expecting it, but that didn't make it any easier. I was wait-listed at the third but too far down on the list to have a serious chance of getting in. I was down to only one school left, and luckily enough they accepted me. I remember a few classmates bragging about how they got offers from multiple schools and I had to restrain myself from getting into an argument because there are so many students who are dying just to get in anywhere.

It's really sad, I have no doubt that this girl would make a great vet. She has extensive personal background experience (pets, goats, rehabbing wildlife, etc.). Add to that the years spent at the vet's office (both of whom recommended her unconditionally) with both small and large animals (country vet - no specialization here ).

She only applied in state. I think out of state tuition was prohibitive in her case. A young woman who works for our vets (co-owners of the clinic) told us that one of her checks per month goes to pay student loans (and she was in-state).

I'm glad that things worked out for you though!

 

[DonDraper]

But it doesn't work that way. To begin with, radiology isn't just shift work. My friend's husband (the eye surgeon, mentioned in the earlier post) has to work weekends, take call, can't make definite plans, etc. No different than my husband in anesthesia. My friend and I took our kids to a school event and her husband planned to come, but was called to work for an emergency. His kids cried cause they planned on him coming and at the last minute he couldn't. My husband was also on call that night, but ended up not getting called in so he was able to stay home with our baby, but that was luck.


But the real flaw in that plan is that the "cushy" jobs are also very hard to get into. Just because you go to med school does NOT mean you can become any kind of dr you want. In order to get into residency you have to take the Step 1 (and Step 2, but the scores from Step 1 are what count for residency applications) Board Exams. Your score on that exam directly affects what type of residency you can apply for. Take anesthesia for example: board scores have to be above 222. Anything lower and your aren't even considered for a spot. There are too many vying candidates to waste time interviewing lower performers. My husband had a friend who failed his boards first time around and anesthesia was out for him. He couldn't match in any program and had to do a transitional year (basically general medicine), and then apply to residency from there. And academically he did well, just not a great standardized tester, so to speak.

So you might have your heart set on field A, but don't have the grades to get a residency in that field. Or, like a friend who is now an ER physician, he matched, but in a crappy location. So he and his family had to move to a remote town so he could fulfill his dream. His wife was miserable there for the 4 years and couldn't wait to flee.

It isn't just as cut and dry as "I'll be a dermatologist". Many, many people want the shift work, no call jobs (EMed included), so as a result, they have pretty high standards to get a residency spot. And there are a fixed number of residency positions in the country and that doesn't change from year to year.

Of course. Bottomline though: If you work hard and go after what you want, you can get it.

I sure hope if your kids say they want to be a dermatologist that you don't tell them, "well sweety, I'm sorry to say that you should probably go into area because that is too hard."

 

[MomRN]

I came back to the thread too late, it appears the hypothetical patient scenerio has already been answered.

 

[Pea-n-Me]

I came back to the thread too late, it appears the hypothetical patient scenerio has already been answered.

Please feel free to add to what we've already posted! I'm sure there's more...

 

[justhat]

Of course. Bottomline though: If you work hard and go after what you want, you can get it.

I sure hope if your kids say they want to be a dermatologist that you don't tell them, "well sweety, I'm sorry to say that you should probably go into area because that is too hard."

I would never, but I also think they need to be realistic. Having gone through it with my husband, I just know certain things aren't realistic. I mean, I'd love to think my kids will be highly intelligent, but I certainly won't act like they are if they turn out to be mediocre. While I of course will encourage my kids to pursue their dreams, I also think it's a waste of time to give them false hopes if it just isn't an attainable goal. Not everyone can do every job. I went to grad school for clinical psychology, so similar outcome to a psychiatrist, but I know med school would have been extremely difficult for me. It was initially what I thought I wanted (to be a psychiatrist), and my mother did in fact strongly encourage my goals. But what she failed to see was that they weren't attainable for me. Science didn't come as easily and naturally to me as it does to, say, my husband. So those courses were a huge struggle for me. Once I realized that what I really wanted out of life was the psych/therapy aspect, not the medicine, I switched gears and did very well and had zero issues getting into my top 5 doctoral programs. Had I applied to med school, well, I know the acceptance rate would not have been the same.

So take my husband's friend, who really wanted anesthesia but didn't get accepted into an anesthesia residency. He then had to do the transitional year I spoke of and is now doing general medicine. He did NOT want this path at all. He did well in school, even graduated in the top 20% of his med school class. But his test scores simply weren't there. So no instead of doing an alternative field that he enjoyed (like pediatrics, which he also liked and it's easier to get a peds residency), he's now stuck being a GP. So, had he been realistic from the start, known he wasn't getting an anesthesia slot, and just chosen something within his reach, things would be better for him right now.

Oh, and when you don't match, like he didn't, then you are stuck in the "scramble". That's when you get to vie for the unfilled positions with the other non-matched people. Not a position anyone wants to be in.


Also, something like dermatology, it's only a lucrative field if you do a plastics/reconstructive surgery fellowship. Plain old derm won't get you far money-wise. But the fellowship certainly isn't a guarantee either, similar to the match process. So if you're doing it for the money/lifestyle, but then dont' get accepted into a fellowship program, you're stuck with regular derm and that isn't so great.

 

[DonDraper]

So take my husband's friend, who really wanted anesthesia but didn't get accepted into an anesthesia residency. He then had to do the transitional year I spoke of and is now doing general medicine. He did NOT want this path at all. He did well in school, even graduated in the top 20% of his med school class. But his test scores simply weren't there. So no instead of doing an alternative field that he enjoyed (like pediatrics, which he also liked and it's easier to get a peds residency), he's now stuck being a GP. So, had he been realistic from the start, known he wasn't getting an anesthesia slot, and just chosen something within his reach, things would be better for him right now.

Oh, and when you don't match, like he didn't, then you are stuck in the "scramble". That's when you get to vie for the unfilled positions with the other non-matched people. Not a position anyone wants to be in.

Sounds to me like your husband's friend didn't play his cards right when it came to the matching process. By the time matching comes around, I think folks should have a pretty good idea of the fields they can get into and which ones are a bit of a stretch. You can select as many residency programs as you want when you rank them. I'm guessing this guy just marked down all his anesthesiology choices thinking he would for sure get into one of them? That's unfortunate. That sounds like the applicants who have a 4.0 undergrad, 40 MCAT, and only apply to Harvard/Johns Hopkins/Cal-SanFran thinking they're guaranteed a slot. Not a particularly astute move.

 

[cm8]

Oooh.. fun, OK, I'll play:

Mrs B. is an 84 year old who lives alone. Her daughter brought her in today because she found her mother at home with shortness of breath, bilateral pedal edema, new confusion and states she does not think her mother has taken her medications in three days, the time since her last visit. Vital signs are BP 188/122, HR 112-130, RR 30, Room Air Saturation 88-90%, Blood Glucose 246. Her rythm is Atrial Fibrillation. Past Medical History: Hypertension (HTN), Diabetes - adult onset (AODM), Congestive Heart Failure (CHF). Past Surgical History: s/p Coronary Artery Bypass Graft (CABG).

What are the standards of care for this patient?

Medical thought processes:
1) Why is mom confused to make her go into failure - is she infected (high likelihood?) (check WBC, BC's, UCx, CXR) or did she just forget her meds (but why?) - is her underlying dementia perhaps worse. Dx: Delirium, but why, other than crappy controlled BP and hypoxia. Did she throw an embolic stroke (afib) - is her Coumadin off. Are her electrolytes off because she hasn't eaten/drinken! CT head... (does she have a bleed)

2) How to make her feel better: what Deb recommended of course - diuretic - have to be aware of possible underlying renal issues. Check a BNP - might help solidify dx. Does she need to be in stepdown or ICU - is she going to crash on me in the middle of the day, etc, etc

3) Monitor BS - hold metformin if on, needs less insulin if not eating -

4) Think also about Low Sa/high RR/tachy - impending sepsis - ? aspiration. consider Emperic Abx coverage -

5) Don't forget to talk to family
6) Don't forget to ask about code status
7) Don't forget to chart on patient
8) Don't forget coders want 'acute on chronic systolic chf' specifically
9) Don't forget to consider IV access needs - don't forget to monitor urine output
10) Don't forget she's at high risk for DVT - consider LMWH

And!! this doesn't include all the things nurses have already probably nicely considered for you..
1) They documented decubiti and skin changes
2) They documented family issues and contact info
3) They have already helped consider d/c planning, home health issues

The list goes on.. sorry, got to go to kid's karate.. but you get the idea

!!

 

[Pea-n-Me]

And yet you chose to imply that I was less than intelligent when I jokingly said "call the doctor".

Just seeing this.

I never said you weren't intelligent, I was talking about the response.

we are nothing without them

But you're right - you and I think very differently. It saddens me that you have this view of yourself and your profession. And for the record, I couldn't disagree more. Where I work we are teams, and each role is as important as the other.

For those reading this thread and contemplating nursing as a career, I'll say it again. Choose where you work very carefully. There are people and places out there still that perpetuate these types of beliefs and eventually, you may even come to view them that way yourself. (BTDT, and here to say, it doesn't have to be that way.) Find an employer with nursing leaders and other nurses that celebrate nursing and the important work we do. Don't settle for less.

 

[Pea-n-Me]

I have just one question for Dr. Booger.

Please tell me you're not an ENT.

 

[luvmarypoppins]

can I ask a slightly OT ?
about applying to nursing school for my ds

I have been reading allnurses.com about the program my ds wants to get into
The application must be done by Jan. 5th, so I am trying to see what he needs to put himself in the best position.
This year the thread comments were 50 were accepted into the bsn program, very competitive, 2 males wrote they were accepted.They prefer students already enrolled at this univ. which he wil be as a transfer student in the fall

1 girl had a 4.9 gpa, 400 hours of volunteering at the univ. hosp etc.got REJECTED!
I told my ds I think the only thing he has going for him is he is a male and they want a diverse class etc.The one male who got accepted had only a 3.3 gpa, but had leadership roles in a club,only 40 hours of volunteer work at the hosp. but had 4 good rec. letters and a good essay.

Ds right now has aed and cpr from lifeguarding, but its red cross and they say they want american heart.
He wiorked 4 months at a pt office.
Organized a blood drive last year

Right now his gpa is 3.5, but he will see what they transfer etc.
I told him he needs to go to the pre nursing club, volunteer etc.

They did say if you get rejected they will more than likely take you the following year, but that is a whole waste of a year etc. He could take other health related classes then etc.

So any advice?

 

[goofy!]

RN vs MD

My take on it:

The doctor cures (hopefully) my disease.
My nurse cures Me.

My nurse may not be able to give the tylenol without the doc, but he/she sure knows when I need that tylenol.

They can both function independently, but are best together.

 

[cab0899]

You've got it, sister!

I'd add that nursing would also initiate consults for this woman, probably nutrition, physical therapy, social services, continuing care, and possibly chaplaincy, if desired, and geriatric service if her confusion doesn't clear. All of these with an eye toward eventual discharge needs, as you noted.

Problably more, but gotta go. Thanks for participating!

And of course an occupational therapy consult!

 

[DonDraper]

can I ask a slightly OT ?
about applying to nursing school for my ds

I have been reading allnurses.com about the program my ds wants to get into
The application must be done by Jan. 5th, so I am trying to see what he needs to put himself in the best position.
This year the thread comments were 50 were accepted into the bsn program, very competitive, 2 males wrote they were accepted.They prefer students already enrolled at this univ. which he wil be as a transfer student in the fall

1 girl had a 4.9 gpa, 400 hours of volunteering at the univ. hosp etc.got REJECTED!
I told my ds I think the only thing he has going for him is he is a male and they want a diverse class etc.The one male who got accepted had only a 3.3 gpa, but had leadership roles in a club,only 40 hours of volunteer work at the hosp. but had 4 good rec. letters and a good essay.

Ds right now has aed and cpr from lifeguarding, but its red cross and they say they want american heart.
He wiorked 4 months at a pt office.
Organized a blood drive last year

Right now his gpa is 3.5, but he will see what they transfer etc.
I told him he needs to go to the pre nursing club, volunteer etc.

They did say if you get rejected they will more than likely take you the following year, but that is a whole waste of a year etc. He could take other health related classes then etc.

So any advice?

My advice would apply to several schools. He's only willing to go to this one particular school?

He should contact some nurses at teaching hospitals and see if they will let him tag around for a day to see how they do things. Then he can put that on his application. Also will give him something interesting to talk about during an interview rather than the standard volunteer work that everyone has.

 

[disfan07]

Dermatology residency programs are very hard to get into. At least the really good ones.

My derm. did her residency at Johns Hopkins. She said that back when she did her residency (about 8 years ago) that they accepted 4 residents for the first year and after that, they only select 3 residents to finish the program.

So they have 10 residents at any one time.
4- PGY 2
3- PGY 3
3- PGY 4

They get up to 500 applicants and only interview 30---and they only choose 4

 

[luvmarypoppins]

My advice would apply to several schools. He's only willing to go to this one particular school?

He should contact some nurses at teaching hospitals and see if they will let him tag around for a day to see how they do things. Then he can put that on his application. Also will give him something interesting to talk about during an interview rather than the standard volunteer work that everyone has.

His #1 is a teaching hospital. There is no way they would let him shadow an rn. Even the volunteers I saw when I had 7 operations at this hospital gave me some shampoo,toothpaste kit and a cup of ice once.

His #1 school has NO interview process. Its only a minimum of 3 recommendations. He does have a number 2 school in mind. The only issue would be housing, at the teaching hosp./univ where he will be a student, he just commutes.Where I live, housig is VERY expensive! #2 he would probably have to rent somewhere$$.