"Why do they keep coming back?"

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"Why do they keep coming back? I don't know what's going on with this patient!" At first, I didn't realize how alarming that statement was. I was a second-year medical student, participating in my school's longitudinal clinical immersion program in which we were supposed to learn directly from a physician preceptor. My preceptor owned a busy practice, and would often send me to his newly-hired FNP because her patients were "more interesting" than his.

The NP was nice enough. She spoke confidently about her 15-year nursing background before making the decision to enroll in online NP school, so she could move forward in her career and take care of her daughter. Okay reasonable, I thought to myself as a naïve M2. So once a week, I saw patients with her and then we'd go back to her office to informally chat about what was going on with the patient and what the next steps would be. That's when I began to notice the constant "I'm not sure what's going on..." and "Maybe we could try this..." and "I saw this patient last week, not sure why things haven't improved..."
And being the naïve M2, I figured maybe these are really complicated patients. But as I progressed through my second-year studies, my knowledge level and clinical reasoning skills basically sky-rocketed past hers and it was quickly becoming evident. Some of these "complicated" patients actually had classic presentations of relatively simple "high-yield" pathologies that medical students have to learn for the USMLE Step 1.

This all came to a head for me when we saw a patient who regularly visited the NP with a new onset of symptoms every month. The NP seemed exasperated at the thought of having to face this patient yet again, not knowing "what her deal is." But after a quick review of her chart, alarms were going off in my head that she might be showing early signs of cholestasis: a young woman with jaundice, diffuse itching, bruising, abdominal pain, and elevated cholesterol. The NP looked at me and then back at the patient chart in confusion. She decided to just order a CBC and told her to take Benadryl for the itching.

Sadly, this happened on my final day of my program, so I don't know how that worked out for the patient. She was also on Medicaid and had only ever been evaluated by NPs, so who knows how long things may progress until she's seen by a qualified physician. Honestly, I hope I'm wrong and all of her issues magically vanish from the Benadryl. I wonder if I should have expressed concern to my physician preceptor sooner. It's worrying that even though I was only with this NP once a week, I saw too many examples of her questionable clinical reasoning skills. It's as if she recognizes the deficit in her knowledge but blames it on the patient being difficult, which is so dismissive and dangerous. Yes, sometimes the most intelligent, dedicated physicians in their field will encounter cases that stump them, but even the shitty ones had to know enough to complete residency.