As promised.
Can you spot the difference between the species above? HINT: One knows WHY it's doing what it's doing.
So, this actually happened with the MLP crew at my hospital system. Our MLPs go between two hospitals, one higher volume, "downtown" hospital with more subspecialties under one roof, and one smaller "suburbia" hospital. Our Docs are privileged at both, but generally stay put at one site. We have a "home team", but the MLPs do not.
Sometime last year, I noted two rather disturbing trends in the MLP practices. Now, they see a lot of these MVCs that need clearance, and have "head pain/back pain/neck pain" and other associated minor complaints.
1. There was no use or documentation of the New Orleans or NEXUS criteria (or any other CDM) in their charts, nor was there any decent head/neck exam commonly written.
2. Many of these patients had their c-spines "cleared" after 2 or 3 view x-rays. Collars removed, no follow-up exam documented... discharged.
I tried to engage the MLPs directly as to why they did this, when the overwhelming body of evidence states that c-spines cannot be cleared with x-rays, and how they were sure (or not sure) that there was no significant intracranial injury. This is something we all learned in month 1 of residency.
The response that I got for head injury was "if they didn't lose consciousness, I don't CT them" (nevermind that 2/3rds of our patients are 60 and older, and on lots of narcs to begin with, or "can't tell if they blacked out or not").
The response that I got for x-rays and c-spine clearance being an acceptable practice was "That's not how they do it at OtherHospital".
I dug deeper. "Who does it this way at OtherHospital?"
"Doctor XX does. Does it all the time. Says it okay."
This struck me as bizarre. Doctor XX is the site medical director at OtherHospital, but... any BCEP knows how to use a CDM rule.
I was not comfortable with this practice, especially in our patient population who is elderly, unreliable, narc'ed up, and frequently anticoagulated.
This was not going to fly with any chart that had my name on it. I engaged each MLP in real-time regarding using and documenting the CDMs, and that c-spine films are clearly inferior, and below the standard of care.
The pushback was outstanding. I asked, given the scientific data that I had provided... why this practice change was not adopted.
The response was the same: "Doctor XX says so."
That's it. That was the depth of their understanding of the matter. Not a one of them could tell me the sensitivity/specificity of plain films vs. CT, or the limitations of plain films, or any of that. Why? Because science is hard, and they found a way that was easy, and they liked, and they got a doc to say that this was okay. I can't even verify that this was Doc XX's practice pattern.
I had to push harder. "Okay. You're not working as Doc XX's MLP now. You're working under me. You'll do as I instruct you to do."
Pushback was even worse. Doc XX's name got tossed around harder and harder. How dare I act like I know more than Doc XX?! Doc XX has been practicing emergency medicine for twice as long as I have been alive.
Maybe Doc XX does practice like this. But I don't. Maybe he or she needs to be updated. I suspect that he/she is up to date, and that this little bit of local culture has just been hanging on since before 200X, before the CDM rule really made it to prime time.
It took me to engage my site director and to enact a departmental policy regarding how to handle imaging in trauma to get any change in the practice pattern. EVEN STILL, I get fallouts all the time... and when I call them on it, I get the glare and scowl from the MLPs, because I upset their little world, and they want to somehow prove to me that they're RIGHT.
That's the thing. They weren't interested in what was best for the patient. They were only interested in being
right. Scientific data? Pfft. No interest in that... its too hard to understand.
Hence my attitude. If you're working for me as an *assistant*... then you do as you're told. No talkback. No excuses. You want independent practice rights? Buckle up, and at the very least... be able to know WHY you are doing what you are doing. Don't ask me for help if you don't want direction.
Its much easier to be a mimic.