I had a very interesting encounter with a patient’s mother the other day and wanted to get some feedback from the Physician Assistant community on what you would have done? I am curious, how you would handle this situation?

This 25 year old Asian female presents to the clinic with a chief complaint of vaginal odor and some discharge for the last 3 days. I walk into the room, introduce myself and begin gathering some history from her. She is a sexually active female with multiple partners. She does not “need” to use condoms for protection because she takes birth control pills. She denies any other symptoms other than the “fishy odor” and mild discharge. I hope this is sounding like bacterial vaginosis to you, because it sure did to me. Our clinic is not the fanciest, we don’t have slides available to confirm with KOH or look for clue cells. We generally make this diagnosis clinically. I do like to do a urinalysis, pregnancy test, and STD screening. If the patient does not respond well to treatment, then we will work this up a little further with a vaginal swab. I explained to the patient a plan of treatment that included a few labs and a prescription for Flagyl to treat bacterial vaginosis. She asked me if it was ok to go get her mom from the lobby. Mom apparently is a certified nursing assistant and the daughter likes to run things by her.

“Sure, no problem. Bring her in.” (Stupid mistake)

Mom comes in and she is giving me the stink eye before I even say one word. (Click here to see how I managed to piss off another Asian Mom.) I start explaining to the mother the problem that her daughter seems to be having and that I would suggest that we do a urinalysis, pregnancy test and an STD…. (This is where she jumps in).

Her, “My daughter is not pregnant! She has a UTI.”

Me, “I understand that she takes birth control pills, but they are not 100% effective. I want to make sure she is not pregnant before we start dumping antibiotics on her.”

Her, “she is not pregnant! And she does not have any STB’s. (This is not a typo, she said STB’s)”

Me, “Do to the fact that your daughter has unprotected sex with multiple partners, I want to make sure she does not need to be treated for an STDeee as well as a bacterial infection.”

Her, “She has safe sex with birth control pills, she does not have an STBeee and she does not have a bacterial infection. She has a UTI.”

Me, (In my head. Oh god, what have I done? Why am I here? Please, take me now. Heart attack, stroke, pulmonary embolism; your choice.) “Ms. Smith (that’s a HIPPA name change), I have seen this many times in my career and your daughter seems to have bacterial vaginosis. It is easily treated with antibiotics. The tests are to rule out some more serious conditions that may require additional medicines.”

Her, “I have seen this many times in my career too. She does not have a bacterial infection, she has a UTI.”

Me, (I bite the hook) “What do you do Ms. Smith (HIPPA) that you have seen this many times?” (I damn well know what she does, her daughter told me already that she was a CNA.)

Her, “I am a CNA at Rest in Peace (Another HIPPA name change) retirement center. All the residents get this, and it is a UTI. None of the doctors at Rest in Peace (HIPPA) order all those tests. They treat a UTI with Levaquin 500 mg once a day for 7 days. My daughter needs Levaquin.”

Me, “Ms. Smith (HIPPA), those residents are probably not as sexually active as your daughter, and I am certain that none of them are pregnant. I don’t think that…. (Again with the interrupting!)

Her, “I don’t think either. I don’t think you know what you are doing.”

(I’m stopping this torrid tale here because I want you to really pay attention to the next sentence that came out of her mouth. This is the thing I am curious to find out about from other Physician Assistants. I will tell you how I responded and hopefully you will comment and let me know how you would have responded.)

She continues, “Are you even a real doctor or are you JUST a PA?”

“JUST” a PA. Is she F’n serious. “JUST” a PA. I mean, what the fu@^ does this lady know about becoming a Physician Assistant? Does she even have a clue what it takes to become a licensed Physician Assistant? My guess is probably not. I was freakin pissed off. All I wanted to do was rip into this lady, but I simply stopped talking. Wrote out the prescription for Flagyl, handed it to the daughter and walked out. I told reception to schedule this patient to see my supervising physician, took a few deep breaths and moved on to my next patient. I just didn’t want to waste my time with somebody like this. That was the last contact I had with the patient or her mother, but I keep asking myself; did I handle this correctly?

From an office perspective I did what I should have. I treated her problem, got the patient a visit with my supervising doctor, and did not start any static. On a personal level I am not exactly satisfied with how I dealt with this. It feels like something is missing. Kind of like eating a burger that is made with a tofu patty, turkey bacon, low calorie cheese, and light mayo. Sure it provides a sense of satiety, but somehow it just feels incomplete.

I really should have spent some time with this lady explaining exactly what it is I do. What a missed opportunity to educate the public about the Physician Assistant profession.

Yea, right!

Screw that!

What I really felt like doing was asking this lady how in the hell does she know anything about what is going on here? How does her being a CNA at Rest in Peace (HIPPA) have anything to do with her daughter’s condition? I am “JUST” confused about how a woman who takes a 12 week correspondence course online to become a CNA can know anything about this? I am “JUST” wondering how her job changing diapers and wiping wrinkled asses makes her qualified to understand anything that I do? I “JUST” want to know what role cleaning soiled bed linens plays in her ability to diagnose a UTI, from an STBeee, from BV, from a runny nose? This lady needs some serious ad”JUST”ment in her un”JUST” thinking. Her daughter would be better off if she would “JUST” stick to cleaning bed-pans and leave the diagnosis and treatment to someone that was trained for it.

I’m not saying that because she has fewer letters following her name than I do that she is incompetent or ignorant. What I am saying is that her level of education and expertise fall well below mine in this particular situation. She is only harming her daughter’s health by trying to be something she is not. I am not trying to belittle the woman for what she does for a living. In health care, every role is vital to overall patient care. I have a very healthy respect for the CNAs and MAs. At my clinic the MAs are extremely skillful at their job and I will freely inform patients that ask me to draw blood that the MAs are much more skilled than I am at venipuncture. It has been years since I drew blood for a patient, the girls at my clinic do it 20-25 times a day. I can tell you without reservation, that I would not want me to draw blood on me.

So I go back to the original question that I proposed to you. How would you have handled this situation? Would you have “JUST” ignored the lady as I did or would you have something more to say to her?

  1. trishx3 says:

    You did the right thing. If you would have gone any further she would have just got madder. It amazes me the way that some people can act because they are in the healthcare field. I’m not a Doctor but when I see a PA or Dr. I don’t act like I know more them, if I have a concern or I think something else maybe wrong with my child I mention it not completely disagree with someones interpitation. I’ve seen something similar happen, but it was a PA disagreeing with another PA over their childs treatment. If you seriously disagree with the diagnosis and treatment, go somewhere else or see another provider. It doesn’t require arguement, you went to school and had to learn and study hard and continue your education to be what you are, so you should be respected for what you do. People just think they know everything these days.

  2. Lane says:

    I am an emergency medicine doctor and believe that a degree means nothing in itself. There are PAs and NPs in the field that have much more experience than I and I will take their advice anytime. The problem with most of these type of people is that even though that all they might do is vaccuum the floors at at hospital they think that because they wear scrubs that they might as well have an MD behind their name. I hear it all the time – ‘Yes doctor, I understand because I work in healthcare. You don’t need to explain anything to me.’ Oh, really? What field are you in? Specialty? Where did you train? ‘I am the secretary for ….’ Arguing never helps. Change of face is the best thing to do because deep down even when you convince them that they are wrong that they bite down even harder.

    • qfwm2001 says:

      Thanks for the reply Doc. You are so dead on about this. The more you push the harder they push back. For this lady, the best thing to do was to just treat the girl and move on. The unique problem for me regarding this mom was that because I am a PA and not an MD, I was totally wrong. It sucks on one hand, but the upside is that I can just hand her off to my supervising physician. (As an update, this lady did bring her daughter back in to see my SP and was told exactly the same thing that originally said. Actually I should be doing this as protocol. We ended up billing another office visit to the patient. $$$) The thing that sucks on your end is that you’re the last stop. You just have to deal with them. Thanks again for the reply.

  3. Jess says:

    You did the right thing. I’ve never had this specific type of encounter (thank goodness), but I do get patients that argue with my treatment (or lack there of for viral infections). I simply respond that they are more than welcome to reschedule with another provider to have another opinion if they don’t agree with my care. I am so non-confrontational so I tend to always try the “kill them with kindness” approach. But I think in this situation that would have not got you anywhere. I think you absolutely did the right thing by walking away. Good job.

    • qfwm2001 says:

      I tend to let this go as well, but every now and then I just want to let them know how I really feel. Most often it is just the best to give them the option to follow up for a second opinion and move on. Thanks for the reply.

  4. Mina says:

    You did the right thing. I’ve never worked in healthcare a day in my life, however, from being a peer health educator when I was a teenager, I knew just from the patient saying there was a fishy, discharge, that cued STD, and since I’ve had a UTI before, which has completely different symptoms by the way, I knew from the very beginning of your conversation that it was gonna turn bad.
    Unfortunately, in any type of situation, people can encounter a “know it all.” I don’t even know why this woman is so involved in her 25 year old daughter’s doctors appointments anyway. Her STbee comment killed me (seriously do you have a camera stuck up her vagina monitoring her?) LOL The education differences and job differences between CNA and PA are SUBSTANTIAL and a lot of people are unaware of what PAs do. I’m figuring since she’s asian, she must be from another country, with a completely different culture, and figures that the MD/DO is the be-all/end-all to healthcare. It wasn’t even worth getting upset over, some people are/choose to be ignorant. All you can do is ignore! Love your blog!

    • qfwm2001 says:

      As you progress further into becoming a Physician Assistant you will run into this frequently. Having someone think they know more than you do is not unique to Physician Assistants. The difference with us is that they think we don’t know what we are doing because we are Physician Assistants. It takes some getting used to. At times it is usefull both for you and the patient to spend some time explaining what it is you do and how you can help the patient. More often than not it is best to jut throw in the towel and punt that patient to the SP. Thanks queen for the reply and good luck in you endeavor to become a PA.

  5. Sue says:

    No comparison between a CNA and PA. A CNA’s education consists of weeks as compared to a PA’s who is full time meaning 40 hour weeks at most colleges and universities. If she had done that in the NH where she worked she could have been fired since making a diagnosis is not within her scope of practice. PA’s take a lot of crap for being “just PA’s” from physicians and patients.

    PA’s are great IMO. I have one as a PCP at the Community Health Center I go to and my neurosurgeon has one-she did my pre-surgery exam and I saw her for two post op visits. She was the First Assistant during my surgery. She’s the one I saw in the hospital after the surgery during morning rounds. She knows what she is doing and I have a lot of respect for her and trust her judgement. She and my NS make a great team!

    • Sue says:

      I also wanted to add that most PA schools also want you to have some prior PAID medical experience plus a bachelor’s degree plus several prerequisites as compared to the weeks of education a CNA has(which would probably qualify as the medical experience) Then there is the competitive field-unlike CNA school where they accept just about anyone, PA school doesn’t.

      There are people who do appreciated the “lowly” PA and value their judgement and treatment plans for us.

    • qfwm2001 says:

      Sue, thanks for the reply. Most people simply have no idea of what a PA does or the training that is required to become a PA. The patients that just don’t know are easy to deal with. A little education about the role that PAs fill and they normally will come around. This situation was completely different. This patient’s mom knew exactly what PA’s do and the training it takes to become a PA. I really feel like she is a touch bitter about where she sits on the health care totem pole. I am very happy that you have had some good experiences with PAs. Every time a PA does good work it strengthens the profession as a whole. Thanks again for the comments.

  6. David says:

    Take it in stride; there is no winning in an encounter like the one you described, unless of course, you conceder a “win” as an encounter that doesn’t end in a formal complaint to your supervisor. Its days like this when I take a deep breath and thank god that all my patients are not of similar caliber, smile and move on to the next patient.

    As far as having to defend the PA profession to someone like that, it’s not worth the stress. Plus, her comment to you was in all probability aimed less at your position or level of education and more at trying to irritate you and at striking a guttural responsive chord in you, which she appears to have done. You have to put less energy in what people like that say and do. Who are they to you that you would allow them the privilege of causing a reaction like the one you had? Answer: No one. Just unhook your emotions and let it go. If your wife, husband, mother, father, etc said something like that, I could understand the reaction. Pardon the expression, but to take a verse from Matthew 7:6; “Do not give dogs what is sacred; do not throw your pearls to pigs. If you do, they may trample them under their feet, and then turn and tear you to pieces.” I.e., (loosely and in context to this situation) don’t offer your emotions, or logic to those who were unable to value and appreciate it.

    You are obviously a well seasoned and caring PA. Take pride in that fact, and in the amount of education that you have, and serve with the capacity of your heart. Do the most good to the people you can, and then call it a day, and rest well knowing that you did what you can.

    • qfwm2001 says:

      David, thank you so much for taking the time to post such a well thought out response. I think you are right on about not letting this lady get to me. She came in looking for a fight and I bit on the bait. I appreciate the advice and support. Thanks again

  7. Karla says:

    There are many teachable moments in regards to our profession (ie,”so are you going to go on to be a doctor?”). To me, this was not one. And it was not anything to be taken personally. As I see it, this was a mother who did not want to think of her daughter having a STD.
    I agree with the above post, your work will speak for itself. It is often a thankless job so we have to look to ourselves for validation with the occasional “thank you” as the cherry on top:)

    • qfwm2001 says:

      Thanks for the reply. Sorry it took me so long to get this up. I forgot to pay rent-a-center for my computer and it took me some time to steal enough copper wire from construction sites around town to get the money together. I do agree that this is often a thankless job and it’s rewards are not in the praises and accolades, but in the outcomes we see in our patients health. It does not hurt to get the occasional cherry on top. Thanks again for the reply.

      • Paul says:

        Everyone needs to know their limitations! First,you seem to be insensitive to a cultural difference. I had 11 years experience as Navy Corpsman three of which were in combat in Vietnam. Next, Duke PA program grad. I think given the way you demeaned the CNA you do not have the emotional skills to keep a professional position in such circumstances. I had a very dangerous experience with the PA that practices at my PCP. i do not think that paying more attention to a computer screen than patient dialogue is good medicine. Check with a therapist before you blame an Asian CNA for your internal feelings of dealing poorly with your own professional identity.

        • qfwm2001 says:

          Paul, first I want to thank you for your service to the country. Secondly, I appreciate you taking the time to respond to one of my ramblings about being a PA. Okay. That’s about where the civility and niceness ends.

          I agree that everyone needs to know limitations and I am unclear if you are stating I overstepped mine or if the CNA overstepped hers. My assumption is that you agree with me in her not knowing her limitations. (So nice for us to get along so well)

          As far as me not being culturally sensitive, we would agree again. I was not and am not very culturally sensitive, but please take into account that I did not go to Asia to treat her daughters vaginal condition. She came here, to the United States and needed treatment. This begs the question of who should be sensitive to who. In my culture your 24 year old daughter is treated as an adult that makes independent decisions and speaks for herself, not someone to be talked over and talk for.

          You said I demeaned her. How exactly did I do that? Did you read the text? Did you see how I walked to the front and got her daughter a RX and even got her an appointment to see my supervising doc. The demeaning part was what I “wanted” to do. Paul, please don’t tell anybody, but that part was made up. Like a dream sequence in a movie, mostly for visual effect and such.

          Exactly what does you statement about the computer have to do with anything I did. I actually agree with you about it being bad medicine to stare at the screen while patients are speaking. My office is still on paper so everything is handwritten. Although, I wish I had a computer in the room so I could have been playing solitaire while this lady was running on about STB’s and UTI’s.

          Thanks again for replying to the post. I really hope that this will get us on the same page and you will agree with me that this Asian lady was crazy.

          P.S., I spoke with my therapist and after a RX of Xanax and Haloperidol, I have finally become comfortable with my internal feelings about my own professional identity. Q

  8. Anon says:

    Ok I know this is super old but I just wanted to give my opinion. I agree that the “just” a PA comment was rude.
    However, I think I would have dealt with the mother a little differently though. Ok obviously, no mother likes the idea that their daughter might have a surprise pregnancy and/or STD. Honestly, you didn’t even have to say a “pregnancy test” or “STD test” though. You could have just said “I’m sending her for a series of tests to rule out any other possibilities and to prevent complications.” The point is: buzz words like “pregnancy” and “STD” freak people out so it’s better to be discreet in those aspects.

    • qfwm2001 says:

      Thanks for the reply. It is an old post and I don’t post much anymore, but I do continue to monitor the site. As a general rule, I tend to disagree with most replies to my post. I am breaking my rule and agreeing with you about your assessment. I could have toned it down a bit so this crazy a$$ overbearing know it all mom would have calmed the F down. And truth be told, probably should have. For this patient encounter it was more about this mom knowing everything and the “just” a PA having no idea what the hell he was talking about. Thanks again for the reply, Q.

  9. Mimi says:

    Just curious on why you feel the need to describe someone’s race when describing a rude patient/family member. Do you think adds to the story by perpetuating stereotypes and already gets your readers on your side? Like, I was driving and suddenly a white an crossed the street, or I bought my bag from a black salesperson, I was giving a flu shot to a Hispanic man…

    To the poster who said “I’m figuring since she’s asian, she must be from another country, with a completely different culture…”, uh yeah, because everyone knows that if you’re of color, you’re definitely from a different country.

    This is the sort of thing that makes us look bad.

    • qfwm2001 says:

      Mimi, since you are so sensitive I will try and answer your post in the most inoffensive, bland, generic, pleasant, innocuous, unoffending, neutral, unobjectionable, safe way I can. Umm, NO! I changed my mind and won’t be doing that. I will apologize in full to you that you are so F’n sensitive that my stupid little blog has somehow offended your very delicate nature. I am sorry as well that you fail to see the humor in this Asian patient’s mother pronouncing STD as STB. It was actually very funny to me. (I still laugh thinking about it) I should also apologize to you for laughing when I think about it, sorry. I included the fact that she was Asian because I started the post as a case presentation. But, I am sure at your clinic you don’t consider race important so it is probably not listed on every single chart. You probably never start a case presentation with age, sex, RACE, then whatever the case may be. But as I started writing the post this massive urge to become a raging Asian hating racist took over me, I swear I could not control myself any longer. Mimi, get over it. Stop with the PC BS. I don’t make “us” look bad, you have saved yourself with your reply. All the Asians that I have offended will leave you be. I only make “me” look bad, and I can still sleep at night. Stop making something out of nothing. I also apologize for you making something out of nothing.

  10. Anon says:

    Based on the patients complaints, high risk behavior, and obvious lack of general medical knowledge (safe because she uses ocp’s) I think it is irresponsible to simply write a script for flagyl without performing a physical exam/wet prep.
    This patient should have received treatment for chlamydia and ghonorrhrea prior to the results of the STD screening.
    She also should have had a full pelvic exam to evaluate for PID, herpes, foreign body, etc

    • qfwm2001 says:

      I could not agree with you more. Hindsight is always the best vision and mine is showing me that I should have done this differently. I should have been more insistent for a work up and covered STD’s with the ABX choices. I will say that her situation was more like BV than anything else. It probably does not come off that way on the post so much. Thanks for taking the time to post.

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