Overstepping FNP student gets put in her place

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Openly contradict your attending in front of a patient? Bad, bad idea.

Originally posted on r/nursepractitioner

To preface, I am in the final semester of my FNP degree. Because of Covid, I went a year without completing any hours. While this was nice to focus on didactics, it has left me with having to complete 400 hours this semester. I have already completed 150 of those with my first clinic, which even though there was some friction between the physician and me, she still allowed me a great bit of freedom to work and learn. Cue the problem yesterday. I began my internal medicine rotation at a one-physician office almost 2 hours from home. He is board-certified, astute, and practices the whole person/holistic care. After what I felt was a very paternal and authoritarian-like introduction where he explained that I am to shadow him until he can gain my trust before allowing any interaction, we began to see patients. 4 patients into the day; we had a young woman who was following up for urinary retention and had been treated in the ER over the weekend. After interviewing her, we found out she had been using Benadryl to treat a food allergy and recently been given an Epi-pen for said allergy (Red 40 dye). She admitted to not paying attention to what she ate and treating after the fact. The physician informed her to stop taking Benadryl because of the anticholinergic effects and suggested another anti-histamine. After a few moments, I piped up and suggested that she may want to consider taking it daily since there was no indication she was going to change her behavior (while I know that there are other risk factors for cardiac involvement, this woman was 19 and had no other risk factors). The physician shot that down immediately and began to question my choice in front of the patient to include asking about the said side effect of cardiac involvement. We went on to see a few more patients and then headed back to his office, where we had a little lull. About 15 minutes later, he turned around and told me that I could not interact with the patients in the way I did. He went on to say that I am there to shadow and not offer advice to any of the patients. I quickly apologized and said it would not happen again. I pulled out a snack I had with me, finished it, and a bottle of water and got up, and walked around the entire building for a few minutes.I feel completely demoralized, and I question what the point of going back is. I don't even want to record the hours that I completed. I am stuck between a rock and a hard place. I have 250 hours to go to graduate on time, with this location as my only place. I reached out to my placement coordinator to ask for another location, using the excuse that 2 hours is too far. I don't want to admit that I'm not too fond of the place for fear I will have to wait for long past graduation to find another location.

One of the greatest issues endemic to the education of midlevels is their lack of understanding and respect for the hierarchy of medicine - a hierarchy designed to protect patients by ensuring that physicians stand at the top by virtue of their advanced education and training. It would seem that this is not something routinely instilled into the nurse practitioner students of today, as evidenced by this Redditor's story. Can you imagine if a medical student or resident openly contradicting their attending physician's plan of care, in real-time, right in front of the patient? They would be burnt at the stake for attempting to do so, as this kind of conduct constitutes not only a gross overstepping of boundaries but also presents a major risk of confusing the patient. Not to mention that the "advice" this student decided to give to the patient - taking Benadryl daily - is outright terrible, given that the patient in question already seems to be experiencing some major anticholinergic effects with an ER visit for urinary retention.

It's good to see that in this case, the attending physician apparently put this nurse practitioner student in her rightful place by informing her that her conduct was unacceptable. Perhaps if more nurse practitioners and midlevels had proper appreciation and respect for the physician-led hierarchy of medicine, they would stop clamoring so fiercely for full practice authority.