NCV Only?

[facetguy]

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Is it ever appropriate/warranted to order an NCV alone, as opposed to EMG/NCV?

 

[ledo99]

sometimes it could be adequate to perform NCV without a needle exam.. for example, if you're checking for peripheral neuropathy NCV might give you all the info you need. in some cases of mononeuropathy too; though in those cases, a needle exam is usually indicated to confirm your findings. on the other hand, for conditions like radiculopathies, primary muscle problems you definitely need a needle exam. cervical or lumbar radiculopathy can have perfectly normal NCV exam

 

[bedrock]

Are you adding NCV to your chiropractic practice? Because no physician who underwent the standard 6 months to a year of residency/fellowship training to perform NCV/EMGs would ask that question. And physicians referring patients out for NCV/EMGs would rely on the physician performing that study to make that determination.

You're doing your patients a disservice to send them to a tech for a NCV if the tech can't recognize when the NCV are inadequate and then perform the EMG right then if needed to complete the diagnosis. That's why NCV/EMGs are best performed by physicians with the standard minimum of 200 electrodiagnostic studies during their residency training.

Having a tech come to your office to do NCV is moneygrubbing plain and simple

 

[facetguy]

Are you adding NCV to your chiropractic practice? Because no physician who underwent the standard 6 months to a year of residency/fellowship training to perform NCV/EMGs would ask that question. And physicians referring patients out for NCV/EMGs would rely on the physician performing that study to make that determination.

You're doing your patients a disservice to send them to a tech for a NCV if the tech can't recognize when the NCV are inadequate and then perform the EMG right then if needed. That's why NCV/EMGs are best performed by physicians with the standard minimum of 200elecrodiagnostic evals during their residency training.

Having a tech come to your office to do NCV is moneygrubbing plain and simple

This is exactly why I'm asking. A rep from some company that does this stopped by my office to try to sell this idea to me. For as long as I've been in practice, I've always referred patients to either a neuro or a physiatrist, and if memory serves they've always done both EMG/NCV. So, this guy's proposal didn't sound right to me. That's why I asked you guys.

Are these NCV tech setups common (albeit inappropriate)? I'm not familiar with them. The studies are said to be read by an MD somewhere. Seems like there's a loophole in the system or something.

 

[bedrock]

I appreciate that you're asking, not just going forward with this.

NCV companies love to visit the offices of primary care doctors offices and chiropractors and try to sell them a NCV machine and talk about how much money you'll make from NCV.
However, they gloss over the fact the NCV have to be reviewed by an MD to be legally billed. They also gloss over the fact that the because the NCV techs can't do EMG, that people get misdiagnosed all the time with these tech-only NCV setups.

It's like needing a cardiology workup and your initial consulation is with a cardiology PA when you need the complete expertise of the cardiologist. If it was my heart, I'd want to see the cardiologist.

 

[lobelsteve]

I've worked with 2 insurance companies, an lmrp, and a review company to assist in policy and prosecution. Ncv without emg is typically not paid for unless precert by MD or DO. FP docs writing reports have been fined and monies needed to be returned. Licensure issues and medical boards gave also taken action.

 

[Jcm800]

.

I appreciate that you're asking, not just going forward with this.

NCV companies love to visit the offices of primary care doctors offices and chiropractors and try to sell them a NCV machine and talk about how much money you'll make from NCV.
However, they gloss over the fact the NCV have to be reviewed by an MD to be legally billed. They also gloss over the fact that the because the NCV techs can't do EMG, that people get misdiagnosed all the time with these tech-only NCV setups.

It's like needing a cardiology workup and your initial consulation is with a cardiology PA when you need the complete expertise of the cardiologist. If it was my heart, I'd want to see the cardiologist.

 

[Pain_doc]

To continue with this discussion:

Are these machines "non-needle"? What information do they actually provide? Is there any clinical utility?
A family practice doc called the office yesterday and was asking if we do in-office "emg" type testing. He told the staff that these new machines do not use needles and thus are much more comfortable for patients. This doc is a "businessman". It was unclear whether he is selling, buying, or in cahoots with the local distributor.

Can any of you provide info/reference about this? I want to be appropriately informed. thanks. I have always referred patients to local neurologists for emg testing when I felt it was appropriate. thanks

 

[ledo99]

To continue with this discussion:

Are these machines "non-needle"? What information do they actually provide? Is there any clinical utility?
A family practice doc called the office yesterday and was asking if we do in-office "emg" type testing. He told the staff that these new machines do not use needles and thus are much more comfortable for patients. This doc is a "businessman". It was unclear whether he is selling, buying, or in cahoots with the local distributor.

Can any of you provide info/reference about this? I want to be appropriately informed. thanks. I have always referred patients to local neurologists for emg testing when I felt it was appropriate. thanks

I've seen a couple of patients over the last few months who had some NCV testing in another office (one was at a PCP, one ortho guy), the "machine" that was used (according to the patient's description) was some kind of glove that they put on with preset electrodes...

I haven't seen that machine, but saw the reports.. not really your typical NCV report format... not to mention that we repeated the testing in our office using the "real" machine. the patinet who was read by the "glove" as normal had severe carpal tunnel with active fibs, the one who was read by the glove as positive carpal tunnel syndrome had an EMG that was negative for CTS, but very positive for active cervical radiculopathy.

 

[drusso]

I've also done medico-legal reviews/IME's on cases of EDX done by non-neuro/physiatry. I always notify state medical boards and the AANEM. These practitioners need to be shut down.

 

[lobelsteve]

I've also done medico-legal reviews/IME's on cases of EDX done by non-neuro/physiatry. I always notify state medical boards and the AANEM. These practitioners need to be shut down.

Ditto. Funny enough, got started the fight after a pep talk from a U Wash attending while he was testing me for oral boards at Mayo. Finished early and we were killing time.

 

[facetguy]

I've also done medico-legal reviews/IME's on cases of EDX done by non-neuro/physiatry. I always notify state medical boards and the AANEM. These practitioners need to be shut down.

I'm guessing the way around Board problems is that they have the techs come in and do the study, then a neuro or physiatrist reads/interprets off-site. It's not the off-site part that concerns me, but that there's no EMG component. From what I'm gathering in this thread, it is not appropriate to do just an NCV without at least having the option of adding the EMG. Do I have that correct?

 

[lobelsteve]

I'm guessing the way around Board problems is that they have the techs come in and do the study, then a neuro or physiatrist reads/interprets off-site. It's not the off-site part that concerns me, but that there's no EMG component. From what I'm gathering in this thread, it is not appropriate to do just an NCV without at least having the option of adding the EMG. Do I have that correct?

1. It is not appropriate to do NCV without EMG, without mitigating circumstances.

2. It is not appropriate for a tech to do a study and an MD to interpret the study. I did that for a company in residency/fellowship- te quality of the data obtained was clinically useless.

NCV is merely an electrophysiologic extension of the exam. Watch someone test motor strength, sensation, reflexes, provocative maneuvers and then write the H&P. To have any value, the test must be done from start to finish by an appropriately trained MD/DO.

 

[facetguy]

1. It is not appropriate to do NCV without EMG, without mitigating circumstances.

2. It is not appropriate for a tech to do a study and an MD to interpret the study. I did that for a company in residency/fellowship- te quality of the data obtained was clinically useless.

NCV is merely an electrophysiologic extension of the exam. Watch someone test motor strength, sensation, reflexes, provocative maneuvers and then write the H&P. To have any value, the test must be done from start to finish by an appropriately trained MD/DO.

Thanks for the responses. Regarding point #2, aren't techs often, or at least sometimes, the ones doing the NCV part of the EMG/NCV? It's not uncommon for a patient to mention that a tech did the NCV then the doc came in and did the EMG.

I appreciate the clarification y'all have given on this issue. I knew the sales rep's offer didn't sound quite right.

 

[lobelsteve]

Thanks for the responses. Regarding point #2, aren't techs often, or at least sometimes, the ones doing the NCV part of the EMG/NCV? It's not uncommon for a patient to mention that a tech did the NCV then the doc came in and did the EMG.

I appreciate the clarification y'all have given on this issue. I knew the sales rep's offer didn't sound quite right.

This is poor/reprehensible practice. Acquiring the data is quite simple. Knowing if it means anything is entirely different and must be done in the context of the examination and history.

Example: Patient sent for CTS screen for N&T in hand. Results come back for moderate CTS with demyelinating/axonal features. Call and ask for waveforms to be sent and they reveal a positive deflection before the actual waveform on the motor study and what is likely submaximal stim. 0/2 by the tech, and the conclusion was clearly cut/paste by tech. Signed off by FP doc.

Conjecture: Patient goes for CTS release and then develops CRPS. Goes to court and expert witness gets a look at waveforms and reveals the whole thing was not necessary in the first place. Extra zeros for everybody....

 

[Cruiser]

Here is my opinion on this subject as someone who has done 2000+ electrodiagnostic studies.

1. Referring providers often do not know what NCS and EMG are, or how they are used. They just think the patient may need some type of electrodiagnostic testing. I have tried to educate many PCPs, and some get it, some don't.

2. Data obtained by a tech and sent out for an outside reading is a money grab with no concern for appropriate patient care. I called out a PCP one time who was doing this.

3. When the history and exam is performed by a physiatrist or neurologist, and the nerve conduction studies are obtained by the physician, it is reasonable in many cases to just do the nerve conduction studies (without doing EMG). We can discuss this more if needed. What is NOT okay, is for the patient to be sent for an electrodiagnostic test, and to have them get NCS done by a tech, with no possibility for getting EMG. Only after talking to the patient and doing a physical exam do I determine exactly what studies need to be performed.

 

[ledo99]

Here is my opinion on this subject as someone who has done 2000+ electrodiagnostic studies.

1. Referring providers often do not know what NCS and EMG are, or how they are used. They just think the patient may need some type of electrodiagnostic testing. I have tried to educate many PCPs, and some get it, some don't.

2. Data obtained by a tech and sent out for an outside reading is a money grab with no concern for appropriate patient care. I called out a PCP one time who was doing this.

3. When the history and exam is performed by a physiatrist or neurologist, and the nerve conduction studies are obtained by the physician, it is reasonable in many cases to just do the nerve conduction studies (without doing EMG). We can discuss this more if needed. What is NOT okay, is for the patient to be sent for an electrodiagnostic test, and to have them get NCS done by a tech, with no possibility for getting EMG. Only after talking to the patient and doing a physical exam do I determine exactly what studies need to be performed.

cannot agree more!

 

[stim4u]

I've worked with 2 insurance companies, an lmrp, and a review company to assist in policy and prosecution. Ncv without emg is typically not paid for unless precert by MD or DO. FP docs writing reports have been fined and monies needed to be returned. Licensure issues and medical boards gave also taken action.

I believe there is a FP doctor in NYC who billed medicare over 1 Million last year. She was audited. It appears she was billing a lot of these NCV w/o any training or evidence of certifications. If you can imagine, she will go down very quickly....

 

[lobelsteve]

I believe there is a FP doctor in NYC who billed medicare over 1 Million last year. She was audited. It appears she was billing a lot of these NCV w/o any training or evidence of certifications. If you can imagine, she will go down very quickly....

She should suffer financially, civilly (Loss of license), and criminally (jail time).

 

[SSdoc33]

Example: Patient sent for CTS screen for N&T in hand. Results come back for moderate CTS with demyelinating/axonal features. Call and ask for waveforms to be sent and they reveal a positive deflection before the actual waveform on the motor study and what is likely submaximal stim. 0/2 by the tech, and the conclusion was clearly cut/paste by tech. Signed off by FP doc.

axonal involvement is by definition "severe" CTS. completely not relevant to the conversation. just sayin........

 

[lonelobo]

To continue with this discussion:

Are these machines "non-needle"? What information do they actually provide? Is there any clinical utility?
A family practice doc called the office yesterday and was asking if we do in-office "emg" type testing. He told the staff that these new machines do not use needles and thus are much more comfortable for patients. This doc is a "businessman". It was unclear whether he is selling, buying, or in cahoots with the local distributor.

Can any of you provide info/reference about this? I want to be appropriately informed. thanks. I have always referred patients to local neurologists for emg testing when I felt it was appropriate. thanks

"neurometrix"
probably the biggest of these compainies

What pisses me off is that at the AAPMR conference, they let the company buy a booth at annual conference which is directly hurting it's own members
who perform EMG's and of course reimbursement will go down the tubes

 

[PMR 4 MSK]

1. It is not appropriate to do NCV without EMG, without mitigating circumstances.

2. It is not appropriate for a tech to do a study and an MD to interpret the study. I did that for a company in residency/fellowship- te quality of the data obtained was clinically useless.

NCV is merely an electrophysiologic extension of the exam. Watch someone test motor strength, sensation, reflexes, provocative maneuvers and then write the H&P. To have any value, the test must be done from start to finish by an appropriately trained MD/DO.

I could not agree more. 👍

I have skipped the needle exam on maybe 3 or 4 out of the 400 - 500 EMGs I have done this year. Conversely, I've one needle-only exams on maybe 2 or 3. It's rare, usually in a follow-up exam or other mitigating situations.

These companies are unregulated and dont care if the docs they are using get targetted by CMS, they will cut-and-run, and get a new ***** to work for them. They are based purely on profit motive, no science, no medicine.

 

[PCP11]

I appreciate that you're asking, not just going forward with this.

NCV companies love to visit the offices of primary care doctors offices and chiropractors and try to sell them a NCV machine and talk about how much money you'll make from NCV.
However, they gloss over the fact the NCV have to be reviewed by an MD to be legally billed. They also gloss over the fact that the because the NCV techs can't do EMG, that people get misdiagnosed all the time with these tech-only NCV setups.

It's like needing a cardiology workup and your initial consulation is with a cardiology PA when you need the complete expertise of the cardiologist. If it was my heart, I'd want to see the cardiologist.

Hey guys let me introduce myself. I am a physician assistant. Just to reply to bedrock's comment. I find your comment somewhat discriminating 😕. I hope you guys get the chance to work next to a PA in your future careers. We are trained to give as much quality care as MD's and DO's are. Just like everyone in this field, with practice we can be awesome practitioners. What you are saying is just like discriminating against an MD who has just began to do his residency/fellowship stating that this person would never be able to examine, diagnose, and treat. I hope you guys can change your mindset, because you will be working along PA's in your careers, who can definitely make your practices stronger... just saying.
With this thought in mind just wanted to ask you a quick question. Is it ok to order NCV's without EMG's in the case of diabetic neuropathy?
Thanks for your answers guys =)

 

[Tenesma]

define quality of care...

i worked with PAs during training - worked with PAs/NPs in private practice, and currently employ my own NP...

there are some smart mid-level practitioners out there - however, they know NOTHING compared to a fully trained specialist... trust me on this...

i wish the opposite were true, because I could then hire them, have them do all my work for me, and just sit back and make money off of them... but that ain't happening.

 

[bedrock]

We are trained to give as much quality care as MD's and DO's are.

That's f#%king ridiculous !!!!!!!!!!!!!!!!!!!

If your quoted statement were true, then the insurance companies wouldn't contract with any MD/DOs and just work with PA/NPs (at lower pay)

How the hell can 2 years of training at 40-50hrs/week plus a year or two of gleaning occasional tidbits working for a physician compare to

4years at 60-80hrs/week during med school and 6 years of residency/fellowship at 90hrs/week?

Completely different level of understanding.

PAs and NPs can be valuable members of a health care team, but it is in a supporting role.

needing a cardiology workup and your initial consolation is with a cardiology PA when you need the complete expertise of the cardiologist.

Midlevels should never be doing solo initial consults on any patients particularly in specialty practices. Follow-ups and many other clinical services can be treated by PAs/NPs, but you're demonstrating extreme midlevel delusion to think you can do a cardiology consult on a complicated patient as well as a board certified cardiologist.

From your title, I suspect you're a primary care PA. Primary care evals of URIs, UTIs, HTN, and DM probably seem straightforward after a few years of doing them. That is a different universe from specialty care and the thousands of residency/fellowship hours spent evaluating and studying obscure pathology.
Midlevels can deliver good care in the right situations but don't delude yourself that you're a physician. If you want to be equal to a physician, don't bitch about it on an internet forum, go to medical school!

 

[painstop]

Physician Assistants play an important role in healthcare delivery but there is a reason they must work under the supervision of a physician within the confines of the Board of Medicine (I'm not getting into the whole independent CRNA under Board of Nursing problem)...I'm going to assume you mis-typed when you made some of those statements assuming equal competency to a board-certified specialist because it does take away from your credibility...BTW, if I were you, I would change my monicker from PCP11 to PCPA11.

 

[olafa]

That's f#%king ridiculous !!!!!!!!!!!!!!!!!!!

If your quoted statement were true, then the insurance companies wouldn't contract with any MD/DOs and just work with PA/NPs (at lower pay)

How the hell can 2 years of training at 40-50hrs/week plus a year or two of gleaning occasional tidbits working for a physician compare to

4years at 60-80hrs/week during med school and 6 years of residency/fellowship at 90hrs/week?

Completely different level of understanding.

PAs and NPs can be valuable members of a health care team, but it is in a supporting role.

Midlevels should never be doing solo initial consults on any patients particularly in specialty practices. Follow-ups and many other clinical services can be treated by PAs/NPs, but you're demonstrating extreme midlevel delusion to think you can do a cardiology consult on a complicated patient as well as a board certified cardiologist.

From your title, I suspect you're a primary care PA. Primary care evals of URIs, UTIs, HTN, and DM probably seem straightforward after a few years of doing them. That is a different universe from specialty care and the thousands of residency/fellowship hours spent evaluating and studying obscure pathology.
Midlevels can deliver good care in the right situations but don't delude yourself that you're a physician. If you want to be equal to a physician, don't bitch about it on an internet forum, go to medical school!

well put!😀

 

[Aether2000]

The arrogance and delusions of grandeur of the PAs will be their undoing. They are NOT capable of providing the same care as a MD/DO. But the post here helped me make up my mind.....need to hire a NP or PA at this time. I have a PA candidate for the job that is well trained and would make an excellent addition to my practice, but after the post above by the PA, I will from now on avoid PAs in my practice. Thanks for helping me clarify PA attitudes.

 

[facetguy]

The arrogance and delusions of grandeur of the PAs will be their undoing. They are NOT capable of providing the same care as a MD/DO. But the post here helped me make up my mind.....need to hire a NP or PA at this time. I have a PA candidate for the job that is well trained and would make an excellent addition to my practice, but after the post above by the PA, I will from now on avoid PAs in my practice. Thanks for helping me clarify PA attitudes.

All this based on the opinion of one single PA?

 

[SSdoc33]

i have found that PAs are trained to think more like physicians, and therefore more likely to think of THEMSELVES as physicians. NPs have their core background in nursing, so there seems to be more of an acknowledgement of their role. pick your poison.

 

[specepic]

We have two PAs at my group. They do a pretty good job with ortho stuff (why they are there for the ortho surg's) and do a lot of post-op visits and also new evals for basic issues. They know their limits and are easy to work with. As I get busier I have tried having them do follow ups on some of my pain pts and they usually do not know what to do with them. And why should they? Fortunately they come ask me before doing something wrong and they are humble and teachable. One of they is a candy store for chronic ortho pts and I'm working on that (she is a 'pleaser' personality), then they come see me and the party is over. 😡

If I needed a Pain PA/NP then I would base it more on the person than the title. I do note NP groups advertising as PCPs in the paper (3-4 NPs with no MD/DO in the office, they own their own practice). I predict financial/legal mayhem for them.

The PA who posted is getting flamed, I think that could have been avoided had they chosen their wording better. For one, the use of the word 'discrimination'. It is in fact proper to discriminate b/t a MD/DO and PA. They are, in truth, quite different. The term gets a bad rap b/c of the analogy to racial discrimination where the term refers to improper differentiation b/t races of human.

 

[Aether2000]

I have been equally considering both, and yes, all I need is one jerk to convince me that some PAs consider themselves equal to MDs just as CRNAs do. I just don't need the headaches in my life of importing such attitudes. I would rather do without, thank you.

 

[facets]

Guys I worked with CRNAs for 10 years and both NPs and PA for another 10 years so I have watched this for over 20 years. In my experience the NPs are much worse about thinking they are equal to or even better than physicians. In Arizona they can practice independently and their patients routinely refer to them as doctor. "Dr x told me I have sciatica" you mean nurse x, arg. They are under the nursing board, which turns a blind eye to this and everything else they do. The board is extremely protective of NPs and view the medical board and most docs as the enemy. The PAs, being under the medical board are much more careful. If a patient calls a PA doctor, they are corrected straight away because misrepresenting yourself as a doctor is grounds for sanctions. The medical board in arizona is quite strict, the nursing board is a joke that lets NPs run wild.

 

[Aether2000]

A PA in a town nearby was listed under the website section entitled "Our Physicians" and not given any other designation. He called himself "doctor" and all the patients thought he was a doctor.
On second throught perhaps I should not hire anyone.

 

[facets]

Indiana must be lenient. The Arizona board has hung men for less. Wait, they can't do that anymore, but they can and do sanction that.

 

[Jcm800]

i have found that PAs are trained to think more like physicians, and therefore more likely to think of THEMSELVES as physicians. NPs have their core background in nursing, so there seems to be more of an acknowledgement of their role. pick your poison.

dead on!

if you are looking for HELP, and not someone TO DO YOUR WORK, or THINK they are doing your work, a well trained/or well-trainable NP is the way to go...

less ego, and more understanding of their "role" as a "provider"

 

[Jcm800]

A PA in a town nearby was listed under the website section entitled "Our Physicians" and not given any other designation. He called himself "doctor" and all the patients thought he was a doctor.
On second throught perhaps I should not hire anyone.

i also know of a PA for a NSG who is referred to as Dr. and refers himself by it also...

but uses his first name, so like Dr. Bob... versus Dr. Smith or whatever (i hope there is no Dr. Bob Smith out there , this is just for example puroposes...)

and the patients think he is a doc, because that is who they ALWAYS see...

 

[Ligament]

I think at this stage, if we hire any midlevels for any reason, we are contributing to our own demise. I personally am more supportive of PAs, as they tend to have less delusions of independence and and their very title of Physician assistant helps to keep this their role.

I have known excellent NPs, but yes many do think they are as good as physicians, which is wrong. The "doctorate" of nursing practice is especially worrisome and obviously designed to obfuscate the role of the nurse practitioner with that of a physician. After all, "I'm Dr. X" says the nurse...

 

[emd123]

A PA is exactly that: an assistant. There should never be any expectation that a PA function at the physician level; either by the PA or physician. When the s--t hits the fan, it's the doc that takes the fall, not the "assistant". "I'm only his assistant, Your Honor...". The deepest pocket always falls the farthest.

 

[PCP11]

Physician Assistants play an important role in healthcare delivery but there is a reason they must work under the supervision of a physician within the confines of the Board of Medicine (I'm not getting into the whole independent CRNA under Board of Nursing problem)...I'm going to assume you mis-typed when you made some of those statements assuming equal competency to a board-certified specialist because it does take away from your credibility...BTW, if I were you, I would change my monicker from PCP11 to PCPA11.

First of all is PCP as in primary care practice... not primary care physician. Believe me, I am one of the big bunch who knows where our limits stand in this practice. I would never have someone believe I'm a doctor and I know what I am and how to explain my patients my role in the health care fiel and their care. I did not mean to insult anybody and think I was polite enough for some of your replies in this page!! I did not mean to say we are better than anybody in this field, I was just hoping to demonstrate that as PA's we strive to make part of a team and a good physician-pa relationship. Believe me, we know you guys have way more practice and more schooling than we do. What I was trying to say, is that with practice and experience working with MD and DO's we can become an asset to your practice. I just hope that we are not looked at as egotistic and delusional like some of you said. We are not... we know well where our ground stands and our role as midlevel practitioners.

now... could someone please answer my questions about NCV's for diabetic neuropathy??? thanks!! Believe me, I just want to learn from you guys... I did not join this forum to argue about titles and training. I just want to learn more and grow as a professional, which I had my first impression is what this forum is for... thanks guys!!

 

[mdvol]

PCP11, like your wording better now, so to answer "Is it ok to order NCV's without EMG's in the case of diabetic neuropathy? " If the order comes to me and i feel, after H&P, they need the EMG, even though not ordered, then I will do it anyway.

 

[axm397]

PCP11, We have been burnt a few times by NPs and PAs and CRNAs who post on these forums just to start a flame war so we do get defensive too quickly.

Answering your question: If it was a pure neuropathy screen, You can get away with only NCSs. However, if there's any question of weakness or an entrapment neuropathy (carpal tunnel, cubital tunnel, etc.), the EMG will help show how severe it is (denervation = severe).

Also, it's important to decide WHY you want the study. is it to confirm the diagnosis? is it to assess severity? is it to rule out other nerve related pathology? That will all change why, when, and how you order the test.

 

[lobelsteve]

NCV for DM-PN is useful only for service connection rating at the VAMC. It cannot possibly change the treatment and if the symptoms are concordant with HgBA1c, then no study is warranted.

Now if someone has a DM-PN and suggestion of comorbid CTS, it may be warranted to differentiate the two as treatment can change.

My2c.

 

[mdvol]

i will not do these just to confirm DM PN but if there is something else in the differential you can sometimes ferret out other entrapment or radic etc.

 

[bedrock]

Hey guys let me introduce myself. I am a physician assistant. Just to reply to bedrock's comment. I find your comment somewhat discriminating . I hope you guys get the chance to work next to a PA in your future careers. We are trained to give as much quality care as MD's and DO's are. Just like everyone in this field, with practice we can be awesome practitioners. What you are saying is just like discriminating against an MD who has just began to do his residency/fellowship stating that this person would never be able to examine, diagnose, and treat. I hope you guys can change your mindset, because you will be working along PA's in your careers, who can definitely make your practices stronger... just saying.
With this thought in mind just wanted to ask you a quick question...

now... could someone please answer my questions about NCV's for diabetic neuropathy??? thanks!! Believe me, I just want to learn from you guys... I did not join this forum to argue about titles and training.

PCP11,

What exactly did think was going to happen when the first 7-8 sentences you posted on a forum for pain physicians were disparaging comments about physician attitudes towards PAs and only the last sentence was a medical question?

You're playing nice now, because you want an answer to your question, but 90% of your first post on this board was complaining about physician attitudes towards PAs. This is the very concern than many physicians have about midlevels. That they appear all sugar and sweet when they want an easy answer (without looking it up yourself) that we've learned through thousands of hours of reading and clinical experience, but inwardly thinking to themselves "I'm just as good at this as he is"

I believe PAs/NPs can be worthwhile members of various health care teams, but your words still reinforce my reservations about hiring a PA/NP for my practice.

 

[pjuer]

In Illinois PA's are regulated by the medical board. NP's by the nursing board. Had a group of independant CRNA's in our area practicing Interventional pain , nursing board not concerned. Doubt it would happen with a PA.

 

[PMR 4 MSK]

EMG and NCS are very valuable for w/u of numbness and limb pain in the diabetic patient. Periphal polyneuropathy can be made as a clinical diagnosis, but most PCPs will not be able to clinically differentiate PPN from CTS, TTS, polyradiculopathy from stenosis or arterial insufficiency.

NSC should not be done without EMG in 99% of cases. Yes, you could get a diabetic who's peroneal/fibular amplitudes are around 1.0, tibials at 3.0 with CV of 35 and delayed f-waves and call it PPN. You still need a needle exam to show the distal muscles are chronically denervated (reduced IA, polys, reduced/incomplete recruitment) and proximals are relatively spared, with intact paraspinals. Diabetics can still get other problems.

The axiom still stands that EMG is an extension of the physical exam, and most EDx DOs can be Dx'd clinically. But we live in a world of CYA. When ortho refers a patient for UE EMG and the patient is diabetic they need to know if the CTS is the cause of the symptoms or the PPN is, and whether they should cut. They also need it to tell the patient that if they do cut, they likely have higher odds than a non-diabetic of getting less satisfactory results.

Also, sometimes it's a good kick in the butt to a diabetic to give them an exam that shows them their poor compliance is damaging their nerves and could result in loss of feeling and even amputation.

 

[facets]

In Illinois PA's are regulated by the medical board. NP's by the nursing board. Had a group of independant CRNA's in our area practicing Interventional pain , nursing board not concerned. Doubt it would happen with a PA.

Its the same in AZ, which was my point earlier. The nursing board turns a blind eye to everything, including massive doses of narcotics

 

[Jcm800]

ill take it one step further, are PAs and NPs ALLOWED on this forum? i though this was for physicians...and when i mean physician i mean those with MD/DO trainining

PCP11,

What exactly did think was going to happen when the first 7-8 sentences you posted on a forum for pain physicians were disparaging comments about physician attitudes towards PAs and only the last sentence was a medical question?

You're playing nice now, because you want an answer to your question, but 90% of your first post on this board was complaining about physician attitudes towards PAs. This is the very concern than many physicians have about midlevels. That they appear all sugar and sweet when they want an easy answer (without looking it up yourself) that we've learned through thousands of hours of reading and clinical experience, but inwardly thinking to themselves "I'm just as good at this as he is"

I believe PAs/NPs can be worthwhile members of various health care teams, but your words still reinforce my reservations about hiring a PA/NP for my practice.

 

[PMR 4 MSK]

ill take it one step further, are PAs and NPs ALLOWED on this forum? i though this was for physicians...and when i mean physician i mean those with MD/DO trainining

This is the open forum. The subforum is private.