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Discussion in 'Family Medicine' started by jl lin, Apr 17, 2012.
After >10 years in practice, I can state without any reservations that I would not want to do what I do every day with any less training than I have.
You may disagree at your own peril.
As I've said previously, primary care only seems easy to those who have never done it, or who aren't very good at it.
Primary care is easy to do badly, but very challenging to do well.
"Mama always said, 'Primary care is like a box of chocolates. You never know what you're gonna get.'
And that's all I have to say about that."
Critical care patients may represent a higher level of acuity of medical severity, but it is tempered by the fact that you have monitors, alarms, stat labs/imaging, 24/7 intensivist back up, coordinated code teams, easy access to pharmacy, medication compliance, 2:1 patient-to-nurse ratio, high precision of nutrition & fluid administration.
In primary care, you may have stable healthy patients, you may have chronic sick patients, you may have acute patients, or you may have acutely crashing patients. But, regardless of what type of patient you have, you NEVER have the same amount of information or diagnostic certainty as you do when all those resources are available to you in an instant that would make it so simple as to treat the obvious.
What makes primary care difficult is that there are so many uncertainties floating around that you actually need more knowledge, training, and intuition than you would expect. Patients don't present as "simple" or "complex" or "needs a specialist" or "good enough for a midlevel". Patients present as chest pain, abdominal pain, dizziness, leg pain... and it is YOUR job to figure out exactly what the heck is going on, and if indeed something is simple or complex. And, if you don't know what it is, it is YOUR job to figure out what you're going to do about it (or not, in some instances).
Put another way, it only AFTER the case has been evaluated can you say it is simple or complex, right? Why would you ask a lesser educated person to do that initial evaluation?
If all you did was specialize in the left big toenail, there's only a finite universe of possible things that can be wrong with it. In those cases, you can train an uneducated person to follow a simple cookbook you make up. But, in primary care, your universe of possibilities are infinite. It takes a bigger scope of understanding (not less) to do primary care.
So I'm in rural Oregon see patients who are desperate for a regular doctor.
I have an elderly lady who came in who had seen an NP 2 week2 before for "dizzyness". She was treated for vertigo and sent home. There was an incidental mention of "lipomas" on the lady's chest.
I see her on a thursday for the same complaint that is getting worse. This is the first time I have seen her. She shows me her "lipomas", and tells me "oh the NP told me not to worry, they are just lipomas". I just about flip out and the grapefruit sized tumors protruding from her ribcage (there where 5). I set her up for a CT of the chest and a consult with the general surgeon. I couldn't pinpoint the dizzyness at that point and was more concerned about the tumors since it was the first time I had met her. The daughter accompanied the patient and had no idea about the tumors.
I go home for the weekend......
I get a report on Monday. That patient had gone into seizures over the weekend. The tumors on her chest wall was metastatic lung cancer. The vertigo was from mets to the brain and she had a tumor that was displacing the brain stem. She died that Sunday night from complication of brain mets and seizures.
Thank you Nurse Practictioner who could have at least scanned her earlier.
NP's should be in urgent care and fast track ER only. They do not have the training to adequately deal with the complicated issues well.
I have friends who are NP's and they do a good job most of the time but the training of an FP is definitely superior. We aren't going anywhere folks.
@Blue Dog. Very nice analogy. Lovin' It every day. I totally agree.
i completely agree. primary care PAs and NPs should practice similar to CRNAs in anesthesia. all new patients need to be evaluated by a physician and their long term care/plan can be carried out by the midlevel including scheduling of preventive treatments, monitoring of response to medications/interventions. whenever an acute issue comes up, should again be evaluated by the physician.
OMG cabin. It's a very sad scenario you have presented. I can only say, Wow, and how scary and sad.
I could not agree more with what has been said in regards to the above.
I find this type of radicalized indoctrination of nursing personnel a significant disservice to health care.
NPs simply do not have enough training in order to function independently in primary care ( I believe it is in the neighborhood of 700 - 800 clinical hours). A family physician receives approximately 10,000 + hrs. When I finished residency, I still felt intimidated in regards to managing patients independently.
Here's another anecdotal example of NPs functioning independently with disastrous results ( i.e. multiple deaths ):
So what happens to these NPs that end up killing people due to their lack of knowledge, Do they lose their license or get sued? Or do they just slip through the cracks.
Cabin: horrific story, sadly not the first or last we'll hear. I have worked with a few excellent NPs who would have not been so cavalier/ignorant/stupid, but we must recognize the didactic and clinical education is much, much less than physicians and in most cases half that of PAs. I have been a FM and EM PA-C for 12 yr and taught PAs, and I am confident that any PA would have adequate medical knowledge to recognize the serious risk and red flags for your elderly patient. I am absolutely sure that a PA would have command of primary care dermatology and superior physical exam skills to evaluate those chest wall rumors and maintain a MUCH broader Ddx of "lipomas". Adenopathy much? Chest wall percussion, tactile fremitus, bronchophony, egophony, etc? Not to mention the complex Ddx of vertigo in elderly.
I agree with BlueDog that anyone who undervalues FM has never done it or does it badly. I am in medical school now and struggle with choosing FM just because it is SO broad, but I admit it's highly flexible and excellent training.
OP: you are wise to be circumspect. Your NP preceptor is parroting the NP mantra but is naive. I cannot envision a future where skilled physicians with broad scientific training and clinical preparation at least 5 times that of NPs will be redundant.
I used to see an NP for annual physicals. She didn't manage my thyroid meds well, but was competent with other things... Either way, there are pros/cons... but the article posted above should really make some people think about how the licensing works... if a PA, who has more education, cannot practice independently, an NP shouldn't be able to either!
Welcome to medicine in Oregon. NP's stand alone but PA's don't. Hmmm. Something wrong with that in so many ways.
Have you personally noticed a significant difference between the two? In my experience, I've seen PAs make equally negligent mistakes compared to the unfortunate situation you mentioned.
We all make mistakes. However, I would argue that MDs make less harebrained ones than the lesser trained midlevels.
I think the point being here is that it simply insane to expect any practioner to be ready for independent practice after such a ridiculously short training period.
I personally find it offensive that the NP propaganda machine spouts out drivel that they are more " cost effective " by churning out these quacktioners quicker, for a significantly lesser price.
Yes, this is true - but at what true cost ?
I think we've all seen mistakes by PAs, NPs, and fellow MD/DOs. However, the scale and frequency of those mistakes is very different. I think the difference is the three is where is the floor so to speak. The bottom graduate of a family medicine residency is still going to be much more prepared to practicie independently than most NPs and PAs. Even though they were ther worst in their class, they were just exposed to so much more supervised clinical time than the mid-levels. However, the worst PA or the worst NP in their class my in fact be dangerous in their care. I think the minimal training or the floor is much lower for the mid-levels, but this is not easily seen or measured. If a NP barely graduates and barely passes whatever test they have, they can still practice independently. However, I have seen PAs and NPs that were clearly top of their class and were very clinically competent. I have no doubt that these providers could probably give better primary care than a some physicians. This points to the fact that the ceiling on medcial potential is very high for PAs and NPs. As physicians, we don't have a monopoloy on the medical knowledge out there. The books, journals, and review courses are available to all of us and there are some PAs and NPs that take advantage of that. The one thing they can't do on their own is the intense training and supervision that comes with residency. That just cannot be replaced. I can't imagine going out and trying to treat patients on my own after graduating medical school. That training was twice what the PAs get and still more than what the NPs get. Probably the best bet to get a fair comparison is to talk to someone who was a mid-level at one point and then decided to go to medical school. We had a few in my medical school and they'll tell you that they didn't know what they didn't know. They often were excited to learn why they were doing what they were doing before. Some of them had a hard time with clinical care initially though, because they had to un-learn bad habits they'd picked up from their on-the-job training.
There are different roles for different levels of training. No physicians want to get rid of NPs or PAs. Just be cautious with an NP who thinks he/she can replace a competent MD/DO.
That's what i think too .
I have found that the PA will tend to come get me if they have questions. Many NP's will not. I have a very close friend who is an NP and I have no problem with her care. But just like all of us, you have to realize when you are over your head and at least ask someone what they think, get a referral, DO SOMETHING. The scary thing about Oregon is that there are way more NP's than PA's floating around because they can have their own office and I spend half of my time picking up the pieces for the poor patients who have gotten poor care.
How did it get this way? The PA will ask because you're holding the license, and they can be dismissed for not following the protocols set for their standards of care. A NP has their own license, why would they ask you? They basically can do whatever they want and unless they keep getting malpractice claims the clinic/state/etc will likely do nothing. How does it get fixed? How do we as a group get the legislature to see that this isn't in the best interest of the population?
Do we use NP`s and PA`s to generate more revenue or to get some help to take care of more patients ?
What`s the financial impact of not using NP`s or PA`s ?
Solution: If you are going to hire a mid-level (yes DNP's, you are mid-levels), hire a PA.
How did it get this way? A big part of it is that nurses have some powerful pull as a collective whole out there. They band together and make $#!+ happen, for better or worse.
I would be very interested in seeing the stats of how many NPs have been :
1. Publicly disciplined / reprimanded for practicing below ( their ? ) standard of care.
2. Losing their license.
It surprised me ( a lot ) that the group who ran that the narcotic pill mill up in Vancouver didnt have their licenses yanked. I mean , jiminy, peeps died. How much more of an adverse outcome can you get ???
We can tell anecdotes all day. We could even start talking about mistakes physicians have made, too. I, too, have seen more than my fair share of PA/NP errors. I agree, that the PA is more likely to come and ask questions or admit the mistake and that the NP is more likely to blame someone else, and just plow through. I've met plenty of knowledgeable mid-levels whose experience dwarfs my own. We've met mid-levels who are always reading and interested in learning.
In the end, though, we need detailed evidence-based information before vilifying an entire field. OR, and what I think is more likely, a huge nationwide media-attention lawsuit.
It would make your instructor's life a lot easier if there weren't a ton of highly trained physicians as competition when they are trying to negotiate [pay, patients, etc.]
Agreed. PA's are trained in the medical model and they don't want to be independent. NP's (for the most part) strive to be independent.
But the 2nd part of your statement is actually the problem I have found with the care of many mid-levels. They seem to have trouble with diagnosis based on H&P so they do DO SOMETHING. They order a huge number of tests -- some invasive, often unneccessary, and occasionally lead to dangerous overdiagnoses and overtreatment of incidental findings. ...great for the finances of the hospital and horrible for your patients.
I just got a call from a PA in a GI practice who ordered a D-dimer on a mutual patient because she was complaining of exertional dyspnea for several months.
I'd already worked her up with labs, CXR, PFTs and a Cardiolyte - all normal. She is obese and sedentary. She's had no chest pain or hypoxia, and she has had no symptoms of DVT. Her dyspnea is likely restrictive, with a little deconditioning thrown in.
Of course, the D-dimer was positive, so now I'm obligated to order a CT angiogram to rule out a PE. Thanks a lot.
Darn, I hate that. In fairness to the specialty PA, I'll betcha the pt didn't tell her about the previously complete and negative work up....
No, she did, actually.
Ok, double whoops.
I hate D-dimers.
On a related note, valuable lesson this PA once learned from a very wise family physician supervisor: never order a test unless you know what you're going to do with the results.
QUOTE=Blue Dog;12522196]No, she did, actually.[/QUOTE]
I'll make sure to communicate the results of the (undoubtedly) negative CT angiogram back to the GI PA. I wish I could send him the bill.
Where's the darn dumb grin emoticon when you need it? Darn iPad technology!
I have to agree. In my FP rotation, I saw a smoker woman w/ COPD + recent flu who came for antibiotics. She said she has chest pain from lots of coughing-entirely reasonable. My attending decided to do a EKG and found she had a MI. A week later, a woman with abdominal pain turned out to be a retroperitoneal abscess. Its very easy to miss stuff like that. Missing just 2 of these cases probably would've been enough for any doc to loose his license/get sued. FM isn't all little kids with ear pain.
The number one reason primary care physicians are sued is failure to diagnose or delay in diagnosis. Breast CA is the most common missed diagnosis.
Ah, Jean-Luc...my girlhood crush
Whomp there it is.
Not to mention the fact that a D-dimer is a totally inappropriate test to order in the ambulatory setting unless you're in the ED.
If a patient has an acute PE (or even if I think they might have), they don't need to be in my office. They need to be in the ED. There's no point in me ordering a test that takes hours to days to get resulted for a potentially life-threatening acute problem, that would then need to be followed up by another test that takes days to obtain in the outpatient setting (a VQ scan or CTA).
This woman's had symptoms for months.
I honestly don't know what the hell they were thinking. Except that they weren't.
on the other hand if the chest ct shows a solitary malignancy missed on cxr then they just saved your bacon...remember malignancy will raise a d-dimer too....
I've seen the PE negative/"incidental" malignancy several times...but to your primary point, I agree that an outpt d-dimer is not the best idea...given the pts symptoms it sounds like she probably would have been perc criteria negative so I probably would not have even ordered the d-dimer in the e.d..
I heard a great cme talk recently at an em conference called "the road to hell is paved with d-dimers, bnp's, and ultra-sensitive troponins." very true.
I'm not holding my breath. It's not likely something that small would make anyone dyspneic.
There's a good chance, however, that we'll find some sort of incidentaloma that we'll have to follow up.
Victim Of Modern Imaging Technology
probably....I'm not a big fan of ct/mri on many pts like most of my colleagues(both md and pa). I recently found that I am the dept clinician who utilizes mri the least. some of my colleagues order more in a shift than I order in a year. my list for an emergent mri is pretty short.
the recent announcement validating ct colonoscopy did not make me happy. they will end up doing lots of workup on stuff that would be clearly nl through a scope.
I am totally going to work this into my next radiology powerpoint to the residents next month!
Update: the CTA was, not surprisingly, negative for PE. However, it did reveal a small, benign-appearing solitary pulmonary nodule which will now require periodic CT follow-up to ensure stability, and has already resulted in an additional office visit to explain this to the patient, who is now somewhat understandably anxious. Swell job, Mr. GI PA.
Hoping all turns out well for your patient.