Fox News Report on NPs

[NotAProgDirector]

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I find it amazing that AbbyNormal had to be sent from her PCP to a pulmonologist to an allergist to be treated for (presumed) asthma. Forget about who did or didn't listen to her lungs.

 

[GasEmDee]

I find it amazing that AbbyNormal had to be sent from her PCP to a pulmonologist to an allergist to be treated for (presumed) asthma. Forget about who did or didn't listen to her lungs.

Her PCP is a good doctor. That is not in question. He always listens to her lungs, regardless of her chief complaint. 🙄

 

[rock_climber]

Her PCP is a good doctor. That is not in question. He always listens to her lungs, regardless of her chief complaint. 🙄

👍

 

[deleted87716]

I´d like to see Jagger rocking the **** out of ´em on CNN or Blue Dog biting them on FOX!!

I vote for them making an appointment in any of these media...

While I appreciate the vote of confidence and have no fear of public speaking, I would have had to say very little to do more damage than this woman did by opening her own mouth.

 

[deleted87716]

I find it amazing that AbbyNormal had to be sent from her PCP to a pulmonologist to an allergist to be treated for (presumed) asthma. Forget about who did or didn't listen to her lungs.

I'm guessing chronic cough? Next thing you know, she'll be referred to a gastroenterologist. 😉

 

[notinkansas]

I'm not sure I agree that physical exam findings will always add to information in light of an extensive test. That said, patient expect doctors to do things even if it has no use. And if a midlevel does these things and a doctor doesn't...well.....

Example: If (as a former surgery resident) I was called to the ED to consult on a pt who has already had CT that shows appendicitis, all that pushing on his/her abdomen will do is cause more pain. (they might even be happy if I say, "since I already know you have appendicitis I'm not going to cause you more pain") In fact, in this setting the HPI doesn't much matter, either.... pt wins a trip to the OR based on CT alone. PMH is helpful to anticipate possible post op complications. (However documenting history and physical exam is important in order to bill!)

Now, if I had seen the pt BEFORE they got the CT, that's a different story. I might not even have needed the CT. For example, young male with classic hx for appendicitis and RLQ pain does not need CT. Often they get CT b/c ED thinks the surgeon will want CT. And sometimes attending surgeon in private practice who takes call from home will ask for CT to avoid coming in to ED in the middle of the night. ED can then admit with definitive dx and surgeon can add case on next day.

I don't know about PFT, that's not my field. But it does make sense to me that it is possible that PFT will give all the info you need, and that listening to lungs is redundant. It also makes sense that PFT is more for things like restrictive vs obstructive disease. If your PFT were normal but you are having sx it is possible that sx are triggered by allergy. So referral to allergist makes sense. Sounds like the most offensive thin the pulmonologist did was not explain things clearly enough for the poster to understand rationale for no tx and referral to allergist.

 

[notinkansas]

I'm guessing chronic cough? Next thing you know, she'll be referred to a gastroenterologist. 😉

We had department head in surgery whose focus was esophageal surgery. He would contend that a referral to a foregut surgeon (as he liked to be called) is in order. Chronic cough is a symptom of undiagnosed reflux and calls for a Nissen Fundoplication. He supports the body of research that suggests long term PPI use increases the incidence of esophageal cancer.

 

[Rabbit Hole]

I clicked on the site but it says:

This content is temporarily unavailable
Please try again shortly

Anyone else getting this message?

Edit: Nevermind.. it's working now.

 

[deleted307836]

... He supports the body of research that suggests long term PPI use increases the incidence of esophageal cancer.

Sorry if my sarcasm meter isn't working and for the off-topic post... but does such evidence actually exist? 😱

 

[VA Hopeful Dr]

Sorry if my sarcasm meter isn't working and for the off-topic post... but does such evidence actually exist? 😱

Yeah, we had a grand rounds about that when I was on surgery last year.

 

[McLovin]

I will come to your defense here. Listening to your lungs would have been the correct thing to do for two reasons. First off, he's a pulmonologist. You, much like every other patient there, expects a full evaluation of the lungs and even if he didn't feel it was necessary it should've been done for show. I know I know, this isn't how medicine should be practiced but unfortunately that's what it has come to. Second, it would be nice to know what your baseline is. Sure PFTs will tell you everything you need to know. But if at baseline you have mild wheezing, it would be nice to make a note of it so that next time you're in a doctor's office they don't think it's a new finding. Have you ever been tested for allergies? My guess is he didn't initiate treatment until it was determined what induces the attacks first (allergic vs. exercise vs. cold induced vs....). The least he could've done was given you an Albuterol prn acute episodes until your allergist appointment. But just like everyone else, I'm playing Monday morning quarterback. I'm not a pulmonologist.

I'm a pulmonologist. If I want to know what the exam showed, I'll get a CXR. If I want to know what the CXR shows, I'll get a CT.

I kid, I kid.

 

[GasEmDee]

I'm not sure I agree that physical exam findings will always add to information in light of an extensive test. That said, patient expect doctors to do things even if it has no use. And if a midlevel does these things and a doctor doesn't...well.....

This highlights two points made repeatedly by multiple participants in this thread:
1) Some things in medicine are done for show, even if they have no medical relevance
2) Most patients, even medically sophisticated ones, have a limited ability to judge the medical quality of their medical providers.

 

[Slack3r]

This highlights two points made repeatedly by multiple participants in this thread:
1) Many things in medicine are done for show, even if they have no medical relevance
2) Most patients, even medically sophisticated ones like an ICU nurse, have a limited ability to judge the medical quality of their medical providers.

All the more reason to use the cowbell approach mentioned earlier.

 

[J1515]

Her PCP is a good doctor. That is not in question. He always listens to her lungs, regardless of her chief complaint. 🙄

Now you are just fishing for arguments😉. Nobody ever said doing a thorough exam automatically makes you a good doctor. It is however one of the requirements in practicing good medicine. Taking a good hx, coming up with a good differential, knowing what tests you should and shouldn't order, and treatment rounds it all out. As to your example of the patient coming in with a cut on his/her finger, the answer is yes, most PCPs would auscultate the heart and lungs. Is it necessary? In 99.9% of patients no. But where should we draw the line? There has to be a bare minimum. When a patient comes in for a referral for a podiatrist, should we even bother examining the patient? How about a patient with a headache? How about a patient with a rash? It's my opinion that it takes a matter of 15 seconds to listen to the heart and lungs and is always good to document.

As far as your ill feelings towards the attitude of picking something up that we weren't looking for, I consider that part of the job of a PCP. I think we both agree there are plenty of conditions that present without symptoms. There is a reason for colonoscopy screening after 50 and mammography after 40. Obviously it's not good practice to go looking for every condition under the sun when the patient comes in with a cut on their finger, but I think it's good medicine to just keep an open ear/eye on everything else that's going on.

As you said, we should not be following protocols and algorithms. In abby's case, yes the differential could've included CHF, COPD, anemia, restrictive airway disease, and a host of other things. Obviously you need to take clinical scenario into account here. You mentioned ordering a bunch of tests to rule out these other etiologies. You can't compare doing a 20 second physicial exam with ordering a battery of expensive tests. I do however understand the point you are trying to make. We should not be doing things blindly without knowing what we are looking for (as in the NP protocols) and I agree with you on that point.

Lastly, I do agree that her PCP should be equipped to check PFTs and start her on a regimen without referring to a pulmonologist.

 

[GasEmDee]

Now you are just fishing for arguments😉. Nobody ever said doing a thorough exam automatically makes you a good doctor.

My statement was blatantly sarcastic. However, please reread AbbyNormal's post.

Yet my DO auscultates my lungs at every appt no matter what my CC. He is a good doc and I'll keep him.

It is however one of the requirements in practicing good medicine. Taking a good hx, coming up with a good differential, knowing what tests you should and shouldn't order, and treatment rounds it all out. As to your example of the patient coming in with a cut on his/her finger, the answer is yes, most PCPs would auscultate the heart and lungs. Is it necessary? In 99.9% of patients no. But where should we draw the line? There has to be a bare minimum. When a patient comes in for a referral for a podiatrist, should we even bother examining the patient? How about a patient with a headache? How about a patient with a rash? It's my opinion that it takes a matter of 15 seconds to listen to the heart and lungs and is always good to document.

Exactly my point. In that other .1%, there should be a specific reason to auscultate the lungs, not just because "it is the thing to do".

As far as your ill feelings towards the attitude of picking something up that we weren't looking for, I consider that part of the job of a PCP. I think we both agree there are plenty of conditions that present without symptoms. There is a reason for colonoscopy screening after 50 and mammography after 40. Obviously it's not good practice to go looking for every condition under the sun when the patient comes in with a cut on their finger, but I think it's good medicine to just keep an open ear/eye on everything else that's going on.

Is an asthma flair that is worthy of medical attention one of these conditions that presents without symptoms? If we do not screen for asthma on regular intervals, will it someday become so serious that it is too late to treat it? Do you understand the difference between this and the colon/breast cancer scenario that you have raised?

As you said, we should not be following protocols and algorithms. In abby's case, yes the differential could've included CHF, COPD, anemia, restrictive airway disease, and a host of other things. Obviously you need to take clinical scenario into account here. You mentioned ordering a bunch of tests to rule out these other etiologies. You can't compare doing a 20 second physicial exam with ordering a battery of expensive tests. I do however understand the point you are trying to make. We should not be doing things blindly without knowing what we are looking for (as in the NP protocols) and I agree with you on that point.

That is my entire point. You need to take into account the entire clinical scenario. You do not grade a physician simply because he did or not do a specific test, unless you understand his reasoning. A test is a test, regardless of how quick or cheap. And there should be a reason for doing it. I mentioned that battery of other tests, because based on your reasoning, those tests should have been done -- because you might have just found something. This is a very slippery slope. Where will you stop? Will you palpate lymph nodes on each appointment in your clinic? That is "quick" and free.

Lastly, I do agree that her PCP should be equipped to check PFTs and start her on a regimen without referring to a pulmonologist.

Where are you in your training? You state a lot of things that are really obvious. But despite saying it multiple times throughout your post, you frequently discount another obvious point, which is that exams/tests should be done base on clinical judgement, not for the nebulous reason that it is the thing to do.

 

[cali-ob]

.... Nobody ever said doing a thorough exam automatically makes you a good doctor. It is however one of the requirements in practicing good medicine. Taking a good hx, coming up with a good differential, knowing what tests you should and shouldn't order, and treatment rounds it all out. As to your example of the patient coming in with a cut on his/her finger, the answer is yes, most PCPs would auscultate the heart and lungs. Is it necessary? In 99.9% of patients no. But where should we draw the line? There has to be a bare minimum.

There is a bare minimum, but only someone with good clinical judgement would know what that bare minimum should be based on presenting complaints/history. This is a requirement in practicing good medicine. I would not ascultate lungs if a patient came in with a cut on his/her finger. I would deal with the finger.
There's a reason step three tests for this type of judgement.

 

[J1515]

Is an asthma flair that is worthy of medical attention one of these conditions that presents without symptoms? If we do not screen for asthma on regular intervals, will it someday become so serious that it is too late to treat it? Do you understand the difference between this and the colon/breast cancer scenario that you have raised?

You completely missed the point. Just because a patient doesn't have a specific complaint doesn't mean a PCP should disregard the remainder of a physical exam that takes literally 20-30 seconds to do. Not every condition presents with symptoms. See my point below.

That is my entire point. You need to take into account the entire clinical scenario. You do not grade a physician simply because he did or not do a specific test, unless you understand his reasoning. A test is a test, regardless of how quick or cheap. And there should be a reason for doing it. I mentioned that battery of other tests, because based on your reasoning, those tests should have been done -- because you might have just found something.

No, a test isn't a test regardless of how quick or cheap. There is the physical exam component, and then there is the laboratory/radiologic testing. They are two separate things. If you are trying to tell me an MRI should be thought of the same as auscultating the lungs then there's no point carrying on this argument anymore. There IS a difference between doing a 20 second physical exam and ordering a battery of tests that cost time and money.

This is a very slippery slope. Where will you stop? Will you palpate lymph nodes on each appointment in your clinic? That is "quick" and free.

Before starting third year rotations we needed to be seen in the school clinic for a general physical exam. It was basically bs or so everyone thought. On one student the doctor palpated an enlarged lymph node, and wouldn't you know it, Hodgekins Lymphoma. An anecdote, yes... but a real life scenario. Granted this was an appointment for a complete physical, but if that same person presented for a sprained ankle a month before the results would've been comparable. A 30 second palpation of the lymph nodes, auscultation of the heart and lungs, and palpation of the abdomen is all it takes.

Where are you in your training? You state a lot of things that are really obvious. But despite saying it multiple times throughout your post, you frequently discount another obvious point, which is that exams/tests should be done base on clinical judgement, not for the nebulous reason that it is the thing to do.

For any family practitioner or internist, there should be a bare bones basic physical exam screening on all patients regardless of their complaint (and this is what most PCPs do, regardless of the fact you are in disagreement with it). Note this doesn't mean a pulmonologist needs to check lymph nodes in every patient. I'm talking about PCPs. It takes seconds to do, it's virtually free (30 seconds of your time), can detect asymptomatic pathology, and last and certainly least it makes the patient feel better. A positive finding on exam doesn't mean you necessarily need to then order 1000's of tests. It could simply mean that you document it and followup at the next visit. It's part of practicing good medicine (most important), covering your ***** legally, and keeping the patient happy.

 

[deleted87716]

I've actually heard patients claim that they "didn't have a physical because they had their shoes on the entire time."

OTOH, some doctors have their patients disrobe for every visit (nurse has them put on a gown).

I think there's a happy medium somewhere. The exam is certainly important, and I agree that there's value in the therapeutic "laying on of hands," even if we don't see any clinical value in a quick heart/lung exam for every complaint. Eighty percent of the time, however, you can make the diagnosis based on a good history alone (according to Osler, anyway).

Of course, some people don't even do that.

 

[Eta Carinae]

I've actually heard patients claim that they "didn't have a physical because they had their shoes on the entire time."

OTOH, some doctors have their patients disrobe for every visit (nurse has them put on a gown).

I think there's a happy medium somewhere. The exam is certainly important, and I agree that there's value in the therapeutic "laying on of hands," even if we don't see any clinical value in a quick heart/lung exam for every complaint. Eighty percent of the time, however, you can make the diagnosis based on a good history alone (according to Osler, anyway).

Of course, some people don't even do that.

Hey, if it keeps the sheeple happy, why not.

I can just hear the comments: "Dr CYA-medicine is so wonderful, he never misses a thing. He's so thorough, even when I go in for my seasonal allergies, he runs through the eye chart thingie with me ..."

 

[GasEmDee]

You completely missed the point. Just because a patient doesn't have a specific complaint doesn't mean a PCP should disregard the remainder of a physical exam that takes literally 20-30 seconds to do. Not every condition presents with symptoms. See my point below.

I haven't missed any point.

Are you a medical student? Are you trying to lecture to me that not every condition presents with symptoms? Your position is not strengthened by padding your post with statements that are blatantly obvious to everyone here, but that are irrelevant to the discussion.

Let me refocus this conversation. I got into this thread, because I disagreed with AbbyNormal's position that, in all cases, lack of auscultation constitutes lack of assessment.. I gave an example (the cut finger in an otherwise asymptomatic patient) where not auscultating the lungs did not constitute medical malpractice. I stand by my original position.

Now, you and I got into a tangent -- which I will address in a separate message, for simplicity's sake.

 

[GasEmDee]

This is to address our conversational tangent.

Yes, a test is a test. Think about this more abstractly for a moment:

From a purely medical standpoint (i.e., ignoring the psychosocial aspects of medicine), the work we do can be divided up into diagnostic maneuvers and treatments.

A diagnostic maneuver should be done when its expected value is greater than its cost. That applies to ALL diagnostic maneuvers.

Lung auscultation is a diagnostic maneuver.
CT imaging is a diagnostic maneuver.

Just as it is not necessary to scan every patient without a reason, it is also not necessary to listen to every patient without a reason. Now granted, listening to the lungs is cheap and it makes some people feel better, so in practice we do not get all worked up doing medically unwarranted lung exams. But that DOES NOT change the point.

Now, it is utterly worthless to cite anecdotes like that incidental discovery of lymphoma. We all have stories like that to tell, but that should not change medical practice, without more information on disease incidence and the natural course of that disease. I have a colleague who was found to have a renal cell carcinoma incidently on a CT scan that was done as part of voluntary participation in a research project. I don't hear anyone arguing that we should do preventative CT scans.

For any family practitioner or internist, there should be a bare bones basic physical exam screening on all patients regardless of their complaint (and this is what most PCPs do, regardless of the fact you are in disagreement with it).

And finally, let me address this central point, bolded above for emphasis. Let's assume that "most" PCPs do this basic screening. The fundamental question underlying my series of posts in this thread is this:

Is the PCP who did not do the basic exam in a patient with unrelated complaints, committing medical malpractice?.

You tell me.

 

[GasEmDee]

I agree that there's value in the therapeutic "laying on of hands," even if we don't see any clinical value in a quick heart/lung exam for every complaint.

I accept this reason wholeheartedly, as long as we call it what it is.

 

[J1515]

I haven't missed any point.

Are you a medical student? Are you trying to lecture to me that not every condition presents with symptoms? Your position is not strengthened by padding your post with statements that are blatantly obvious to everyone here, but that are irrelevant to the discussion.

I'm a resident. The <obvious> point that plenty of conditions present without symptoms was made to prove that a PCP should not go into a patient's room with blinders on. Just because a patient has a rash on their foot doesn't automatically mean there isn't something else going on (as in my lymphoma story). That "something else" may be picked up by doing a 30 second physical exam. There is nothing lost... only gained. That was the point of me bringing up screening colonoscopies and mammographies. It wasn't to compare the morbidity and mortality of asthma vs. colon cancer. I was proving a point that it's the PCPs job to make sure the patient is in good overall health, regardless of the complaint. The most cost efficient and time efficient way to do this is with a quick physical exam.

 

[J1515]

A diagnostic maneuver should be done when its expected value is greater than its cost. That applies to ALL diagnostic maneuvers.

Lung auscultation is a diagnostic maneuver.
CT imaging is a diagnostic maneuver.

If you want to argue semantics then go ahead. If you want to call everything we do after a history "diagnostic maneuvers" that's fine. The cost of a 30 second physical exam is nothing except 15 mins of your time in a day (assuming you see 30 patients in a day, none of which needed a physical exam in your eyes). You once again brought up an expensive test (CT to dx RCC) and compared it to a physical exam maneuver (palpating lymph nodes). There is no point in arguing this any further since you are hung up on principles.

Is the PCP who did not do the basic exam in a patient with unrelated complaints, committing medical malpractice?.

You tell me.

I don't have a clear cut answer for you. If a patient leaves their internist's office after being examined for a cut on their foot and loses consciousness as they're walking down the stairs out of the building, would your argument hold up in court if medical documents showed the physician didn't listen to their lungs, heart, or do any component of a physical exam? Maybe it was due to severe AS or occluded carotids which you would have heard on a physical exam, maybe it was due to something we wouldn't have picked up. I have a feeling the jury would side with the patient either way. I know what your feeling is and how you would defend yourself. If you know of a case that proves one way or the other I'd like to see it.

Either way, we'll agree to disagree. You can continue to see patients and practice medicine based on principles, and I will continue to see patients and practice medicine based on what I think is good patient care, even if I waste 15 mins a day listening to heart and lungs when not necessary.

 

[GasEmDee]

I don't have a clear cut answer for you.

Exactly. Thus, my point is proven. The lack of clarity hinges specifically on clinical judgement. The statement "lack of auscultation is lack of assessment" is not a tautology. And that is all that I have ever argued.

 

[GasEmDee]

There is no point in arguing this any further since you are hung up on principles.

I am not hung up on principles. In my particular practice, I actually do a fair amount of physical exam just for show and reassurance. I do not, however, criticize fellow practitioners who decide not to put on this act. What I am hung up on is your lack of appreciation for the principles.

And finally, if principle fails to triumph over anecdote for you, then this conversation really is moot.

 

[GasEmDee]

none of which needed a physical exam in your eyes)

Please quote me where I say physical exams are never needed.

 

[Maybeknot]

I'm guessing chronic cough? Next thing you know, she'll be referred to a gastroenterologist. 😉

Everyone forgets the otolaryngologist.

 

[LadyWolverine]

The <obvious> point that plenty of conditions present without symptoms was made to prove that a PCP should not go into a patient's room with blinders on. Just because a patient has a rash on their foot doesn't automatically mean there isn't something else going on (as in my lymphoma story). That "something else" may be picked up by doing a 30 second physical exam. There is nothing lost... only gained.

But the OP stated clearly that s/he went to a specialist, not her PCP, where s/he received the alleged sub-par care because lungs were not auscultated. While a PCP should do a thorough physical, the specialist is just that - a specialist. They are there to treat your pre-defined problem that requires specialist intervention. Not to look for melanoma if you're a pulmonologist or aortic stenosis if you're a dermatologist.

I agree with GasEmDee - being a competent physician means not only knowing the tools you have in your bag, but knowing when to employ them, and more importantly, what information you will gain by using them, and how you will use that information to develop a plan. Like a game of chess, you have to see all of the potential outcomes and plan for any one of several different paths several steps in advance. If the goal of this office visit was to assess whether or not this patient had asthma, and, if present, the degree of severity his/her asthma (to determine what course of treatment, if any, was warranted), listening to the lungs would not have provided any useful information relevant to this particular office visit that the PFTs would not have. Why perform a subjective exam when you are performing a much more objective exam, which will give you more accurate information then interpreting some sounds? Sure, the pulmonologist could've gotten an echo, a PPD, a sputum sample, a CT scan, and done a thorough skin exam to look for incidentalomas, but none of these tests were indicated by the CC of "asthma" for which the patient was referred. Your doctor is an expert, and knows what he/she is doing. That's why you go to them for a medical complaint. Second-guessing someone with more training and experience than you and calling them a "bad doctor" because they didn't perform a test that they deemed unnecessary for a legitimate reason makes absolutely no sense to me. Just because you think that something "should be done because that's what my DO does" is silly reasoning - and this is part of what is wrong with American health care. There are so many patients out there who think they "know better" than their doctors, and if their doctor doesn't give them what they want or do what they expect, then that makes them a bad clinician. I guess that successful completion of medical school, licensing exams, and residency isn't enough to earn someone's trust that maybe they have a little better inkling of what's relevant and what's not than you do.

I'd contend that it is NOT good medicine for specialists (like this pulmonologist) to examine, act, and think like a PCP, because that de-centralizes a patient's care. The PCP can take care of the thorough physical exam. You refer to a specialist for a specific condition that is outside your scope/comfort zone/capabilities.