Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, January 16, 2007

"Uncomplicated Problems"

"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
(For non-doc readers, those are all very low; white blood cells dangerously so.) Pancytopenia (bone marrow suppression) from a viral syndrome? Nope.

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?


At Tue Jan 16, 05:48:00 PM, Blogger MedStudentGod (MSG) said...

Wow. Great reminder as to why those clinics are dangerous. I have recently learned that NPs don't have to have some "clinic time" before they apply for a NP program (depends on what state I imagine). In fact, here they can go straight through and be out treating you with 2 years less experience than a medical student. No doctor would think someone right out of medical school knows enough to take on diseases, so why are NPs?


At Tue Jan 16, 06:32:00 PM, Blogger james gaulte said...

"Uncomplicated problems" are defined in retrospect.You learn the problem was uncomplicated after it turns out well.Physicians do not know that in advance.Somehow NPs seem to be able to-probably because they have so much less training.

At Tue Jan 16, 08:50:00 PM, Blogger Big Lebowski Store said...

This is a perfectly terrible counter example with which to argue against protocol-driven medicine.

You mention nothing in the history or physical to suggest this guy had a high enough pre-test probability to justify a CBC.

I know a lot of docs, present company included, who would not draw a CBC on this guy.



At Wed Jan 17, 12:25:00 AM, Blogger Dreaming again said...

I have a girlfriend ... her baby was exhibiting 'ear infection like behavior' ... she was very uncomfortable.

She took her to the ER .. and thankfully got an on the ball doc ... She's in her 7th month of fighting an ATRT brain tumor. Originally they said she had a 10% chance of survival ... only 1 in 10 babies under 3 survive this cancer ... at 17 months old, it was grim ...

However, thanks to the early diagnosis ... it is appearing ...she just might be the one in 10!!!!!!!!!

A Walmart clinic (available at the Walmart 2 miles from me) would have sent her home with antibiotics for the red ears from crying ...not infection.

The ER doc ... tested further because ...he can't explain it, it just appeared to be necessary.

At Wed Jan 17, 06:21:00 AM, Blogger #1 Dinosaur said...

Flea: My "sore throat protocol" at the time was to r/o strep in the office. I used the "2 of 3" rule: fever, abnormal throat exam (here red, but an impressive red even without exudates) and nodes. (More recently I've added "absence of cough" and age constraints.) If the rapid strep was negative (and I'd always confirm those by sending out a TC) I'd look for mono: CBC and heterophile. Also send-outs. I didn't get results back until the next day, and as it happens, I had a devil of a time convincing him he was really that sick.

I realize that the way I presented it made for a bad counter-example. Then again, I still get a lot of CBCs on people with sore throats. I'm not sure how a retail clinic determines the need for send-out testing. My understanding was that their schtick was treat 'em and street 'em.

At Wed Jan 17, 08:40:00 AM, Anonymous Anonymous said...

Let's not get too much of a swollen head about this case. The patient presents with a sore throat. Strep is ruled out, and the patient gets sent home with a diagnosis of a viral infection with instructions to return if not getting better in a couple of days. He doesn't get better and returns. Because of his age, you test for mononucleosis. Almost everyone orders a CBC along with the mono spot test. That's how this rare presentation of ALL gets diagnosed. A reasonably thought out protocol would pick this up. The Wal-Mart clinic merely needs to offer a "no charge re-evaluation" for patients who are not improving. It would make good business and legal sense.

At Wed Jan 17, 09:00:00 AM, Blogger MedStudentGod (MSG) said...


Most likely the Wal-mart clinic would change the Abx or suggest that he go see his PCP if symptoms continued to worsen. There would never, at any moment, be a time when the patient would be evaluated for something more serious - because that's not good economical. Thinking for a second that a retail-driven, urgent care clinic would be able to do *anything* more than a simple dx and tx is absurd. It's not good business and it doesn't make sense. Perhaps Dr. Dino goes above and beyond, but the results are there to support that thinking. However, a retail-clinic would never do that. EVER. Some of the worst customer service I've ever experienced happen in these large box stores. How is it then, that anyone would think good healthcare would result from their clinics? It's so absurd it's laughable.

Let's not even start on the fact that good business and legal sense truly have screwed up medicine. It is because of that kind of thinking that FP's and PCP's are being sacked constantly. People need to realize that faster, quicker, and more convenient does not make something better. Just more dangerous.

At Wed Jan 17, 11:15:00 AM, Blogger Sara said... did you suspect it? I've seen more than one thing picked up like this though.

What I always wonder is what will happen when those clinics hit legal action. On one hand, they will get sued when some kid with an ear infection also happens to have HiB meningitis that they missed. Not sure what that kind of PR and cash settlement will do.

On the other hand, they, unlike doctors and hospitals, can afford fancy legal defense, and may end up slowing down the frivolous lawsuits and setting legal precedents in favor of evidence based medicine and good practice.

At Thu Jan 18, 07:50:00 AM, Blogger Judy said...

I haven't used a Walmart clinic, and I'm not likely to, but I don't think "free rechecks" is a good policy. See your PCP or go to the ER if you're not getting better is almost certainly on the written instructions. The patient in this example might have gotten better briefly, but would have shortly been so sick that he couldn't ignore the symptoms.

I'm not defending Walmart, but when I got sick in another state last year, I saw a physician in a doc-in-the-box place whose parting instructions included "See your PCP or go to the ER if you get sicker or don't get better with this treatment." It just makes sense when you're dealing with a patient you don't know well and aren't likely to see again.

Oh, and when my youngest son's pediatrician ordered a CBC on a first visit for a sore throat, I nearly passed out. I was pretty sure he was looking for something MUCH more serious than strep. Fortunately, he has a machine in his office, because I wasn't going to be able to drive home safely without that information. I'd have had to call my husband to come get us if the CBC hadn't been WNL for a nasty infection and not at all suspicious for one of the leukemias.

At Thu Jan 18, 05:29:00 PM, Anonymous Anonymous said...

medstudentgod- CBCs are incredibly cheap and could easily have been done. There would have been no antibiotic changed because none would have been given for a negative strep test. Most of the clinics are set up so that if a patient doesn't have a PCP, they can refer that patient to a provider in the community to provide follow-up care.
I'm an NP student and am very early into the program and a bright red sore throat, with high fever, and no lymphadenopathy would raise a red flags. Would I have ordered a CBC right away? Not sure. I'd have ordered strep and mono testing and had him come back if both were negative and he still felt that sick in a day or two. Would the couple day wait have harmed him further? I don't know. His counts are very low.

I don't see the redi clinics as being any more dangerous as having NPs as providers in general. They have PCPs to refer to if necessary.

At Tue Jan 23, 01:15:00 PM, Blogger Emily DeVoto, Ph.D., said...

There's more to any health care setting, and the quality of care it provides, than a clinician and his or her qualifications. What worries me are (1) no chance for follow-up, despite the disclaimers about going to an ER or your own doc if you don't get better, and (2) lack of access to health records (i.e., context), which I suppose is true of your average ER as well. I don't think there's anything wrong with an NP working alone, btw; I think by and large they not only follow protocol but are just as thorough as docs (isn't that what the research shows?). But what about the context? How accessible are the docs with whom the NPs are connected? Are there multiple options, and what if any specialty consultation is available to the nurse?


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