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.

Wednesday, December 24, 2008

Another Reason to Keep Your Socks On

Here's the latest salvo in the NP vs. MD wars:

Patient sees a GYN nurse practitioner for her annual GYN exam. Got that? A gynecological checkup which, last time I checked, involved a problem focused history and a physical exam limited to the thyroid, breasts, abdomen and a pelvic exam. This is actually one of the narrowly defined areas where I happen to believe physician extenders can be useful; but not in this case.

What this NP noticed was something on the patient's little toe that she "didn't like the looks of." Okay; I guess that's not unreasonable. I'm not saying that an NP should ignore a blatant abnormality that she may happen to notice. It was her response that is leading me to iatrogenic alopecia areata [jargon translation: physician-caused patchy baldness, as in tearing my hair out.]

Which of the following do you think this idiot "provider" said:
  1. You should see a real your family doctor about that.
  2. You should see a dermatologist about that.
  3. You should see a foot doctor about that.
  4. Here's a slip for some blood work to see if you're diabetic.
Numbers 1, 2 and 3 are all acceptable, presented in order of desirability. But no. This highly educated, trained professional that so many people seem to feel is capable of handling Primary Care medicine unsupervised actually sent the patient to rule out diabetes with a fasting blood sugar.

Luckily, the patient called me first and readily agreed to come in to let me see THE CORN ON HER TOE. That's right, boys and girls: a nasty, abraded, excoriated corn that I shaved for her, curing her on the spot. Oh, and her fasting blood sugar three months earlier had been 87, with an A1c of 5.5, ordered for her annual screening for her family history of diabetes.

I hardly know where to start:
  • Wrong diagnosis
  • Unnecessary test
  • Would not have helped the problem, whatever the result
About the only utility for a universally accessible personal health record (as opposed to a physician office based electronic medical record, which is what everyone is talking about) would be to allow morons like this to access the patient's recent blood work. But no; Americans are far too worried about strangers being able to find out what their last back MRI showed to ever allow implementation of something as useful as that. Never mind that they have perfect confidence -- mostly deserved, mind you -- in the security of electronic systems to do their banking online.

But I digress.

What was she thinking? That's what I want to know. "Diabetics have problems with their feet. This patient had something funky on her foot, therefore she might have diabetes." Semi-logical, so how about finding out what kinds of foot lesions are characteristic for diabetes and what they look like so you have a prayer of diagnosing them semi-accurately. What, exactly, did she think was going to be accomplished by obtaining a fasting blood sugar? If it was terribly high, then yes, the patient has diabetes, but how does that help her foot?

I frequently see specialists (not just NPs) ordering inappropriate tests to rule out conditions not supported by history or physical -- but out of their specialty. Gynecologists ordering coagulation studies to rule out congenital clotting defects on patients with no family history of bleeding problems who report that their gums bleed when they brush their teeth (but have delivered babies and had multiple surgeries with no problems); orthopedists ordering echocardiograms on patients who report that "someone once heard a heart murmur on me"; pulmonologists ordering lung function testing on everyone who walks in the door before ever being seen -- including the guy with a pre-employment positive PPD with no lung complaints at all. They may be experts in their own little fields of expertise, but they don't have to step very far outside those boundaries to look (and act) like flaming idiots.

How on earth can we keep people from causing mischief -- and wasting piles of money while they're at it -- by failing to recognize their limitations? I, for one, am not holding my breath.


At Thu Dec 25, 12:32:00 PM, Blogger Michele in Michigan said...

well, duhhhhh! Anyone with ANY nursing/medical training could see how she came up with the idea of ordering a glucose test for this patient:

1. corn syrup=sugar
2. corns MUST come from sugar
3. corns=elevated blood sugars

You're welcome :)

Found you via Cranky Prof

At Thu Dec 25, 08:19:00 PM, Blogger Arielle said...

What is it with GYN NPs and diabetes? The NP that I occasionally see for UTIs is always trying to offer suggestions on treatment for my (Type 1) diabetes. In fact, once she even tried to diagnose me with it based on sugar in my urine, despite the fact that it was clearly mentioned in my computerized file. (I've also had a GYN nurse tell me that my A1C of 6.3 was "way too high" and I needed to "get myself under control right away.")

At Thu Dec 25, 11:21:00 PM, Anonymous Anonymous said...

Ha Ha...not really funny but it reminds me of my trip to the NP's. Every once in awhile the lymph nodes at the base of my neck/head swell and become extremely painful. I went to a rural NP (newly added to my insurance list). She shrugs her shoulders and says: "if it gets worse just go to the ER." "I have no idea." I went to another practice, had some blood work done, they eventually went down. I still have no idea why my lymph nodes do that, but at least I have had a blood test to confirm my white blood cell counts are OK.

At Fri Dec 26, 09:48:00 AM, Anonymous Anonymous said...

Yes, the NP did something stupid. Yes, you're upset about it.

I think that one way to deal with this issue in the future--and I realise it may not work in your practice setting--is to do what I do.

I am a male internist and I have cultivated relationships with a couple of women's health nurse practicioners in my building and it has been to our mutual advantage. Many of my patients prefer to see a woman for their gyn/well woman care. I don't blame them at all. Furthermore, I don't particularly enjoy doing pap smears and prescribing birth control pills and IUD's and things and so it's nice to have some N.P.s I can refer my patients to for these issues.

In return, if one of their patients has some odd skin condition (one refered a patient with erythema multiforme the other day) or a heart murmur or something, they will send the patient my way for further evaluation. This sort of approach cuts down on unnecessary tests, both on my end and on the NP's end--and I think the patients are quite happy with the care they receive.

Granted, whether you could establish relationships like this with the women's health NPs in your area depends on location, insurance contracts and all sorts of things.

But a cooperative relationship is always to be prefered to an adversarial one.

At Sat Dec 27, 12:41:00 AM, Anonymous Anonymous said...

Lord. Don't even get me started.

At Sun Dec 28, 02:09:00 PM, Blogger ema said...

Gynecologists ordering coagulation studies to rule out congenital clotting defects....

Hey, hey lay off the Gyns. They are, after all, the smartest, beautifulest, infalliblest of them all.

At Mon Dec 29, 09:35:00 AM, Anonymous Anonymous said...

"involved a problem focused history and a physical exam limited to the thyroid, breasts, abdomen and a pelvic exam"

You're kidding, right? I've NEVER had a gyn ask about or check my thyroid.

At Mon Dec 29, 10:01:00 AM, Anonymous Anonymous said...

Nurse Practitioners and PAs do not receive enough training.

At Mon Dec 29, 10:30:00 AM, Anonymous Anonymous said...

May I hold your coat while you continue?? Several years ago, a kidney stone visit to the ED led to the discovery of a 12 cm pelvic mass (Ca in situ, prompt TAH/BSO) about 6 WEEKS after a clean bill of health from, you guessed it, a GYN NP. Unless I or my family member have a clearly defined, simple problem that even I can spot, we refuse NP's. A little knowledge is a dangerous thing, and before any NP' go ballistic, I am..Pattie, RN, BSN, CHPH, CRRN.

AND I still don't know as much as a doc...

At Mon Dec 29, 12:15:00 PM, Anonymous Anonymous said...

You're quite a piece of work doc. In an earlier blog you cite that schooling and education only gets you basically prepared for outside work and you really don't know anything until you've been out there, in the trenches so to speak, doing the job before you access any level of competency. Now you insinuate in your blog that ARNPs don't have the training to perform primary care nursing and then you cite that many specialists also either order unneeded tests or whif on the suspected problem and order an incorrect test.

So, Doctor training doesn't matter, unless you're an ARNP and then it matters. ARNPs are screwups and we fail to recognize their limitations because they sometimes order the wrong tests, but we don't hold the same opinions for the MDs mentioned in the same blog entry when they do the very same thing.

I agree with James, you should counsel the ARNP to train her (because as you've said school doesn't get it done all the way) and then you've improved the system for everyone. Whining that someone is an idiot (as opposed to simply doing something idiotic) or a moron (as opposed to simply doing something moronic) doesn't really do anything but make you look like a typical prima donna MD.

Called for a lack of consistency.

At Mon Dec 29, 03:29:00 PM, Blogger researchernurse said...

And why did you not do the annual pelvic? APRN's can do routine care for individual and many Internists/Family medicine doc now refuse all GYN and OB care. If you aren't doing total patient care, perhaps dogging on the APRN who noticed the patient's toe is unfair.

At Mon Dec 29, 08:54:00 PM, Anonymous Anonymous said...

What does CHPN and CRRD stand for?
And a to internist/family medicine refusing OB/GYN care, our family practice docs still offer GYN care. We've been priced out of the OB side by malpractice premiums and pushed out by OBs (and some OB nurses as well). I wouldn't see a midlevel either unless I knew darn well what the problem was and that it was straightforward. Course, there are some MDs I wouldn't see unless those conditions were met either.

At Tue Dec 30, 01:55:00 AM, Anonymous Anonymous said...

Do you ever engage in self-analysis? If so, have you noticed that there's a significant double standard for you vs. the world? We ALL need to know our limits: NPs, family docs, internists, specialists. Here's an NP who tried to diagnose something herself without referring out. Perhaps we can remember a family doc who failed to diagnose Ramsay-Hunt, in spite of multiple visits, and who didn't bother to consult a specialist, an internist or just a colleague? And for all the excuses "patient was still managed appropriately; medical therapy would not have changed," I say a wrong diagnosis, especially by a trusted family physician, is always, always detrimental (just think of the unnecessary anxiety for both the patient and his family, as well as diminished trust in you and doctors in general).

I have read this blog for years, but your complete disdain and disregard for consultation and collegiality is a disservice to your patients and your readers. You perpetuate a "know-it-all, God-like" doctor image, where you think you always have all the answers and everyone else (ER physicians, pharmacists, NPs, specialists) are stupid. I've yet to read a post from you praising another medical professional. Surely, there must be someone there worthy of a good word?

I understand you consider yourself part of a dying breed (and as another family doc in a larger practice, I share you concerns), but seriously, "no man is an island," especially in medicine.

At Tue Dec 30, 10:14:00 AM, Anonymous Anonymous said...

Cut Dino a break. We all have dealt with the unnecessary/inappropriate testing and its aftermath. What I particularly hate is when another practioner orders a test then the patient is sent to me for interpretation of something trivial like a white count of 11.2 or a choesterol of 230 in a 25 year old.

I was once referred a 22 year old female from a GYN because of a C reactive protein level of 20. Why was that test even ordered?

At Wed Dec 31, 02:27:00 PM, Blogger knitalot3 said...

We are all diabetic.... it's just a matter of time until our pancreases give out.

At Mon Jan 05, 05:31:00 PM, Anonymous Anonymous said...

How did the referring GYN respond when you asked "why was that test even ordered?"
Do referrals to you not come with a history-just a "number"-which in this case is significantly elevated?
Some of the causes (PID, HRT, BCP's) of an elevated CRP should be addressed by a GYN. OMG perhaps the patient is obese and the GYN does not want to be bothered with counseling?
I doubt that many MD's receiving referals have ever called up the referring MD to let them know they are an idiot.


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