IM diagnosing vs. management

[ztwebb]

How much of IM is working up an undifferentiated diagnosis and how much of it is managing patients who present with exacerbation of previously diagnosed illnesses??

Is there any difference between the two (diagnosis vs. management) in terms of intellectual stimulation?

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[drfunktacular]

How much of IM is working up an undifferentiated diagnosis and how much of it is managing patients who present with exacerbation of previously diagnosed illnesses??

Is there any difference between the two (diagnosis vs. management) in terms of intellectual stimulation?

My impression (and also my personal bias) is that most physicians tend to be much much more interested in the intellectual stimulation of a challenging diagnostic puzzle and the exercise of outlining the initial Dx/Tx plan for a patient, and then quickly lose interest when it comes to chronic management of stable diseases.

I was actually thinking about this the other day. I think we're already seeing the implementation of the future model of IM practice in many places with NP's.

I think in general most MD's prefer diagnosis to treatment, hence the difficulties doctors have in successfully managing chronic diseases. MD's are properly educated and trained to make diagnoses, both through the rational, scientific ordering of laboratory studies as well as the intuitive insights that come with extensive experience with many patients.

NP's on the other hand have much less in the way of scientific training necessary for basic-principles understanding of disease, and in general practice with algorithms and cookbooks. This approach does not lend itself well to intuitive or insightful diagnosis, but does lend itself to the methodical systematic management of pre-diagnosed conditions with standard, established treatment regimens available.

So, in the future, MD's do the initial Dx and work-up of patients with new presentations, and outline the treatment plan for that patient. Then they turn the patient and Tx plan over to their NP's for chronic management, e.g. med checks, warfarin levels, dietary counseling, patient education... basically anything that you can do with basic medical knowledge and a checklist. If new problems arise, or complications occur with the management plan that has been outlined by the MD, the NP can refer the patient back to the MD and the process begins again. That way the physician spends his/her time on the things that he/she is interested in and suited for by training, and the NP is given the proper scope to use his/her skills under the MD's supervision. I think one of the places where NP's start to get out of line is when they want to be utterly independent and do the initial Dx and management of patients; I don't believe they are properly trained for this portion of patient management. I do believe they are well-trained to function under a physician's supervision in the stable portion of a patient's management.

 

[DarthNeurology]

How much of IM is working up an undifferentiated diagnosis and how much of it is managing patients who present with exacerbation of previously diagnosed illnesses??

Is there any difference between the two (diagnosis vs. management) in terms of intellectual stimulation?

Neither the diagnosis or the management can be totally left the in the hands of junior internal medicine residents, and it is the management that often offers more intellectual challenge, IMHO, although both are challenging.

Management requires real experience and is what internal medicine physicians are basically hired to do. A multitude of time IM residents will correctly make a diagnosis of say acute hepatic failure, but as for "what to do" i.e. the minutiae of what medications to use, how to setup outpatient treatment, when to refer to transplantation services, this is where residents scratch their heads and wait to see what "the attending will do" or wait to see what "hepatology says." Management issues are complex and involve tailoring treatment to many different facets of a patient's life.

Diagnosis is not that big a deal. Common things are common, and knowing how to do a more detailed workup can be easily learned. Most IM residents when admitting a patient from the ER have the correct diagnosis in the top 5 in their head . . . it is the management that is at issue.

Say, as an intern, you admit a patient with acute pancreatitis, or "presumed acute pancreatitis" as the diagnosis, i.e. past history of multiple admissions for this, and say the attending agrees, and the lab work is consistent. Maybe even a third year medical student could make the diagnosis.

The real art of medicine then comes when the attending's experience with hundreds of cases of acute pancreatitis come to play. Perhaps during rounds, the attending notes a subtle shortness of breath or something in the vitals that lead him/her to order a chest x-ray and they pick up earlier on a case of ARDS. So, the management will change a bit . . . Or perhaps the attending when reviewing the CT with the radiologist comes to a different conclusion about the severity of the pancreatis and decides to consult surgery for necrotizing pancreatis and possible resection. Point being, it is easy to make the diagnosis, but do you know when to refer to surgery? The attending takes the whole picture together and decides on the management which is what really affects the patient and what requires the most experience.

Intellectually if you have seen hundreds of cases of pancreatitis each one is different and probably approached from a different standpoint, this is what makes medicine interesting and intellectually challenging to tailor care to a specific patient.

Diagnosis is "fun" as well, as more junior internal medicine residents are still figuring out how to master their diagnostic skills. But management is a higher level skill and therefore more challenging in a way.

I think that mid-levels like NP are taught to diagnosis common conditions, and manage common conditions. Complex medical patients will always be managed by internists. Nurses traditionally do initial assessments such as a triage nurse in the ER, they diagnosis everything and have a category for "out of my league" i.e. when to have the ER doctor evaluate. I don't agree with the above post that doctors will diagnosis and outline treatment and then NPs will implement. More knowledge is required in the implementation and management. For a typical geriatric patient on coumadin and multiple drugs on a physician can manage who knows all the side effects and has the training. Sure an NP could monitor PT and adjust warfarin, but the patient probably also has A-Fib or CHF and needs a physician to be managing the big picture.

I think for the above poster that diagnosing looks hard as he/she is a medical student, but most people can "name" the disease, but aren't expert enough to treat and manage it. When you do residency you will gain a new respect/understanding for why management requires more skill and training and experience than diagnosis.

 

[drfunktacular]

I don't agree with the above post that doctors will diagnosis and outline treatment and then NPs will implement. More knowledge is required in the implementation and management. For a typical geriatric patient on coumadin and multiple drugs on a physician can manage who knows all the side effects and has the training. Sure an NP could monitor PT and adjust warfarin, but the patient probably also has A-Fib or CHF and needs a physician to be managing the big picture.

I think for the above poster that diagnosing looks hard as he/she is a medical student, but most people can "name" the disease, but aren't expert enough to treat and manage it. When you do residency you will gain a new respect/understanding for why management requires more skill and training and experience than diagnosis.

I guess I made this sound like a positive development in my previous post; I don't necessarily think that it is. However, I do think that this is still the model of future primary medicine practice. This is already the way it's done in many PCP's offices now. And, with the ongoing power-grabs of NP's, declining number of residents going into primary care, and defection of general internists to hospitalist practice, it's only going to be moreso.

 

[DarthNeurology]

I guess I made this sound like a positive development in my previous post; I don't necessarily think that it is. However, I do think that this is still the model of future primary medicine practice. This is already the way it's done in many PCP's offices now. And, with the ongoing power-grabs of NP's, declining number of residents going into primary care, and defection of general internists to hospitalist practice, it's only going to be moreso.

My exeperience with NPs and pediatric PAs in emergency rooms is that under a doctor's supervision they can see a patient pretty by themselves, but the cases are easier things, and even then they mess up a lot. This is the future model of primary care is that an NP under a pediatrician supervision, maybe by phone even if needed, can deal with a sore throat. The thing is that they do it all, get the h and p, diagnose and then do the treatment. This is different from a system where the physician diagnoses the problem and then "outlines" treatment. It would be a waste of time to have physicians diagnosing sore throats and not following through with the management. The role of the physician in this case is to manage, i.e. to say, hey I think the kid needs to be admitted.

For example. I worked in a pediatric ER with pedi-PA's. They would see the patient on their own, present to the attending and the attending would veto or not the managment plan. There wasn't discussion about if the "diagnosis" was right much.

The system you are describing is not in place now where a physician is focused on diagnosis and then gives a "treatment outline" to be followed and walks away. Far from it. The most detailed part involves management, and this is what physicians are trained to do!

REAL case example. A pediatric ER PA sees a 28 day old child with an apparently low grade fever, no sign of infection, feeding normally. Kids looks "ok" although there is some sort of infection. The pediatric PA then tells the physician the info and say we should send the kid home. Big mistake. The pediatrician starts IV antibiotics and admits the neonate as fever is more serious in a child this age, i.e. could possibly be sepsis, or not, but have to take seriously. A pediatrician admits a child to the hospital, not a PA, this is one of the big distinctions between a PA and a pediatrician in the ER. Diagnosis is not so much of an issue, but more or less, judging what level of care and management is needed. Management or lack thereof is where lawsuits occur and where patients get hurt, this should pretty much be under the skill of a physician. Maybe this isn't the perfect example, but plenty of times NP and PAs nail the diagnosis, but mess up the treatment and management plan which is different for each patient, I have seen it myself. It would hurt a lot of patients to have an internist say, "Well, Timmy here has pneumoniae you guys take care of it" to the NP, and walks out. Even an "outline" for management doesnt work as Timmy might become sicker or things might changes in unexpected ways.

As a medical student you can tell if a child has broken arm, scarlet fever or something else, but only after *managing* hundreds of such cases as an orthopod or pediatrician are you competent in the management of patients.

If you aren't in third year yet, then you will see no doubt that the hardest part of your SOAP note is the plan, not the assessment, no the subjective or objective. This is what you can only learn by seeing thousands of patients and refining your skill as a physician. A physician who only diagnoses and leaves management up to an NP, no matter how detailed the instructions, will have adverse outcomes that could have been prevented if the physician directly supervised the managment.

What exactly do you think happens on rounds? Residents present the whole workup, usually the right diagnosis to the attending who then modifies or completely changes the management. Attendings on a medical service are needed more for their management skills than diagnostic skills.
Chronic care patients, even those with established diagnoses like CHF,AFib 100% undoubtedly need to see an internist or family practicioner. What NPs do is deal with mostly easy and acute stuff, at least in my years of clinical experience. You won't see anybody who has a grandmother with CHF, COPD, AFib being managed by an NP, no way, they have to have a physician, NPs are NOT trained to deal with such complex geriatric patients.

NPs and PAs are taught to diagnose and treat and "manage" common things, they can and usually diagnose common things just fine, these are usually self-limited acute things. If a NP or PA can't describe the most recent trials involving AFib medications, they could *never* stay up to date with treating the dozens of such common diseases. This is where doctors are needed , for patients with many chronic medical conditions.

There isn't a split between diagnosis and managment, more with dealing with simple things (acute self-limited diseases) and with more complex things (diseases) and patients.

If you are a first or second year, all you are being feed right now is history taking, and diagnosis and "outlines" treatment, maybe. Third and fourth year is learning how to get into the mind of an internist or ob/gyn and figuring out how to "manage" stuff.