"I know just what I need."
Does this sound familiar?
"When I go to a doctor I know exactly what's wrong and just what I need. I know my body and I've read all about my symptoms on the internet. I know when I need antibiotics. What I don't need is some high-and-mighty doctor with an overinflated ego trying to tell me something different. I think those new Walmart clinics are great!"These are the patients who are heading off to all those new retail medical clinics opening soon at a CVS near you, where the NPs have "evidence-based protocols" for "straightforward, uncomplicated" problems like earaches and sore throats.
Sore throats, eh? Like this:
25 year old Marine previously in perfect health with a sore throat and fever of 102. On exam his throat is red without exudates or tonsillar hypertrophy; no cervical adenopathy (no "swollen glands"); strep test negative. What would you do? In-office mono test? I didn't have one at the time, but the blood test I sent out came back negative.
What would an NP do here? Probably diagnose a viral infection and send him home with symptomatic care, per protocol. Thousands of identical patients before him had viral infections, as have thousands of patients since. How often would a protocol recommend a blood count?
I did one, though. Any guesses?
- WBC 1.1 (4% polys, 86% lymphs; absolute polys: 44)
- H/H 9.9/27.7
- Platelets 86,000
Acute lymphoblastic leukemia.
To shorten the ensuing sad story, he was admitted, transfused and treated aggressively. Chemo got into remission several times, once long enough for a bone marrow transplant, although he eventually succumbed to his disease in less than five years.
No way to pick that up on a protocol, unless you're going to do CBCs on everyone with a sore throat, fever and negative strep test. There goes all your cost containment. (Pure coincidence: as I sit down to write this, Dr. Bob has a post on the value of CBCs in diagnosing sore throats. It looks like an inpatient study, though, so I'm not sure how it generalizes to the office.)
So perhaps I can be forgiven for cringing when I hear of NPs in retail clinics following "standard protocols" for "uncomplicated problems." Maybe every febrile patient with a sore throat doesn't need a doctor, but how would you feel if it were your husband/brother/child whose leukemia was missed in a Walmart?