Midlevels: A Pathologist’s Perspective

Submitted anonymously. Lightly edited for formatting, clarity, and grammar.

My interactions with midlevel practitioners come from discussing pathology results with them. I always call with any results that are a new malignancy, likely unexpected, or require immediate attention. The resulting conversations are often frustrating as I feel as though no matter how plainly I explain things, the full import of what I am saying isn’t getting through. I end up telling them what they need to do next, which isn’t appropriate for a pathologist, in my opinion. I prefer to stay in my lane and give my clinical colleagues the information they need to make their own decisions. But sometimes I feel like I have no choice but to pseudo-staff these midlevels, who in my state are allowed to practice without physician supervision.

I used to work in a practice that had a contract with a small hospital that was essentially run by nurse practitioners. The NPs loved to do punch biopsies on rashes. I received one with the usual one-word history of “rash” and took a look. Along the deep edge of the biopsy, I saw a thin rim of necrotic adipose tissue with marked acute inflammation as well as a thrombosed vessel. I immediately called the NP. She told me the patient was an older man who had been admitted for DKA and incidentally found to have an ischial pressure sore. He developed some erythema near the wound, which she attributed to a reaction to the tape they’d used in the bandage, but despite removing the tape, the erythema was spreading. The patient was also complaining of pain in the area. She had started steroids (in a patient still recovering from DKA?) for what she was sure was contact dermatitis (spreading?) but since there had been no improvement, she’d done a punch.

I told her that I couldn’t be sure based on the shallow depth of the biopsy, but that I strongly suspected necrotizing fasciitis. There was a long pause where I swear I could hear the wheels in her head spinning, so I gave her a brief summary of necrotizing fasciitis, heavily emphasizing its rapid course and high mortality rate. She asked me if the patient needed antibiotics, and if so, which one. I told her to call a surgeon for an emergency consult. She asked me again about antibiotics. I told her to hang up the phone and call a surgeon. Then I hung up.

I waited a few minutes and then did something I have never done before in my entire career: I called the OR front desk and asked to speak to any surgeon who might be around. I managed to get connected to an MD and explained the situation. He said he would look into it.

We received a large amount of tissue from a debridement procedure. The necrosis was extensive and included skeletal muscle and bone. Cultures grew MRSA. Usually in cases like this, there are multiple procedures over time, but nothing else came through, so I suspect the patient died.

More memorable midlevel experiences...

2nd place

Telling a NP that her patient had a new diagnosis of acute myeloid leukemia (AML) with nearly 100% blasts and then arguing that no, this wasn’t something the patient could wait to follow up on as an outpatient.

3rd place

Surprising a PA with the stunning revelation that melanoma in situ is malignant, it just hasn’t invaded yet. I don’t think he believed me, but he did agree to refer the patient to a dermatologist.

4th place

The NP who couldn’t grasp the concept of herpes encephalitis, because how could a genital virus infect someone’s brain? After arguing about the implausible geography, she gave me a weird lecture about the blood-brain barrier and how it kept things like that from happening. I really, really thought the situation was too unbelievable not to be a prank, but sadly, it wasn’t.

Bonus

The nursing student at autopsy brain-cutting conference who asked if the stroke patient I was presenting had survived. It was very difficult to maintain a professional demeanor as I replied that the patient, whose brain I was at that minute holding in my hands, had not in fact recovered and discharged from the hospital without her brain.