The other day I was working with one of my attending physicians and we were busy dealing with a large influx of patients. I evaluated a child who had clear breath sounds and a fever. I treated the fever with some ibuprofen with plans to check back on the child later to see if there was any improvement in the overall appearance of the child. A few minutes later, the attending physician came into the station and mentioned that he had ordered a breathing treatment on the patient because he had thought he heard some wheezing.

I decided to pop back into the room to see if I could auscultate this wheeze. Again I did not hear it. Oh well, I thought, he must hear a wheeze somewhere, and I moved along to see the next patient.

A few hours later, we encountered another child with a similar presentation. I gave the child ibuprofen, but this time I added a breathing treatment because I thought there might be a slight wheeze present. I wasn’t overwhelmed by what I heard and probably would not have ordered it if the attending physician had not just ordered one on the other child. However, I was trying to think like the attending physician to be one step ahead. 

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A few minutes later, he sat down at the station again and asked why I ordered a breathing treatment on the patient, because he didn’t hear any significant wheezing. I told him I thought I might have heard a wheeze and decided to be proactive about it. The attending physician mentioned that we could always see how the ibuprofen worked and reevaluate the breathing to see if a treatment was necessary. I laughed to myself and thought — didn’t we just have this reverse situation a few hours ago? This attending physician happens to be one of my favorites to work with because we work well together, he vocalizes his opinions, and he has a way of making work fun. This situation made me think about one of the biggest difficulties of being an advanced practice provider — trying to work with a large number of attending physicians. 

Physicians develop their own practice styles, and if you work repeatedly with them you begin to anticipate their next moves and think like they do. You begin to understand what tests they would order in a certain situation and you try to work along these lines. This becomes a little more difficult if you work in a hospital or an emergency department where there are a large number of attending physicians, each with their own approach to evaluating patients.

In the emergency department where I work, the attending physician sees each patient. Therefore, trying to think like them and trying to run tests that they would order can save the patient a lot of time — especially if it is going to be a while before the physician can see the patient. The patient may have already gone for their imaging studies and the results of their laboratory studies may be available before you present the patient to the attending physician. If the attending physician wants to add on a different test, this can add a few more hours to the total length of stay for the patient. However, it can get confusing to try to remember which attending physician is going to undoubtedly order a certain test. Do they prefer to order lactic acid tests? Do they prefer to order ultrasounds in women with right lower quadrant pain? Do they love tissue adhesive or do they refuse to use tissue adhesive? Sometimes I feel like I need to write down a list to keep everyone straight.

Over time I have realized that I am never going to be able to get a perfect read on each attending physician. Especially in the world of medicine where everything is changing rapidly, physicians may develop a new style that will keep you on your toes. I have learned that in situations such as the one that I experienced, the best thing you can do is to use your best judgment. Unless you know for sure that the attending physician is going to order that lactic acid, if you don’t think that the patient needs it, then don’t order it.

You have to be confident that your history and physical skills will lead you in the right direction to determine what tests the patient needs. The attending physician may want to add on a test, and if they do, so be it. Trying to predict what the attending physician is  going to want will only end up driving you crazy in the end.

Jillian Knowles, MMS, PA-C is an emergency medicine physician assistant in the Philadelphia area.  

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