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
- You should see
a realyour family doctor about that.
- You should see a dermatologist about that.
- You should see a foot doctor about that.
- Here's a slip for some blood work to see if you're diabetic.
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
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.