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FMtoEM said:
So why not just do a rapid strep screen that way if negative you don’t write a prescription, the patient has an objective test stating they don’t need antibiotics, everyone is happy.
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A surprising number of patients have figured out that rapid strep has a fairly high false negative rate.
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VA Hopeful Dr said:
No, so long as patient satisfaction is a thing and we get penalized for it everyone gets antibiotics for their sore throats.
Click to expand...

Surprisingly, I use Centor and rarely test and my PG scores are pretty good. I actually care more about pt complaints, and as far as I know I haven't gotten any antibiotic-related complaints either. Been doing this for a year so maybe just haven't been practicing long enough, but my trick is...

MAKE THE PATIENT REFUSE

Make them refuse pretty much any stupid thing I don't want them to do but I think they might want to do. Testing, abx, admission, etc. Pretty much anything but narcotic rx, which I'm a total hardass about because I'm not gonna go messing up my community like that.

"""
Now Ms Sanchez, the good news is that I think Arya probably doesn't have Strep throat. Usually, Strep throat causes a fever and white stuff in the back of her throat and actually usually no cough. But the good news is she doesn't have a fever and does have a cough!

So I think Arya probably has a virus :(((. Unfortunately antibiotics probably won't help, but what they might do is give her nasty side effects like diarrhea and vomiting. I know y'all spent a ton of effort coming here in the middle of the night and you work all day, so I'd hate to see y'all have to come back in a few days because of something I prescribed.

[if they seem curious and can handle it, cue further discussion about viruses vs bacteria and the worst possible effect of Strep throat and the fact that that's like 1 in a million and the finding that abx don't even seem to reduce the duration of Arya's sxs, which is really what they're after]

Now, unfortunately I'm only human just like you and so sometimes I'm wrong about these things. So if you really want the Strep test, I'm happy to get it for you. The nurse would come in and tickle Arya's throat with a swab and then you'd need to wait about two hours to get the result.

So, I'll leave it up to you. Would you rather hang out here for a while and get the test, or go home with some really strong pain medicine and let her sleep and see her pediatrician in the morning? Don't worry, I'm happy to write y'all work and school notes if you want to stick around!
"""

And then, of course, I d/c them and document "Centor score 1 and patient was offered Strep test but refused" in MDM.

Similar canned speech for flu testing/Tamiflu and lots of other HCA moneymakers that I would never do to my own son. I try to tell my APCs to practice this way too but I rarely succeed. This might sound like it takes a really long time but I've gotten to the point where I can bash out the whole conversation in about 2-3 minutes after the exam.

Has anyone been burned by this approach? I'd love to hear that I'm doing it wrong, because at the end of the day keeping my job long enough to FIRE is more important to me than iatrogenically giving Arya diarrhea for a few days or chronic gastroparesis in 20 years because I nuked her GI flora or whatever. I am a selfish bastard, it is true.
 
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I just tell them this.
The antibiotics mean literally nothing about symptom resolution. They are only there to prevent rheumatic heart disease. It doesn't matter if the swab is negative today and the culture comes back positive. You'll be called, and the treatment and resolution will remain the same.
However, I can give you something to help the symptoms resolve faster, would you like that?
Everyone gets decadron. EVERYONE.



Also, I still can't decide if NPs prescribing zpacks for otitis is genius or malevolence. They don't do anything (which they don't need to 95% of the time), but they also don't do anything (which they sometimes do need)
 
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I admire you. That’s a lot of work you put into those conversations. I should do more of that. My speech goes more like: “swab is negative, it’s a virus. I’ll get you guys out of here now.”


hundreddaysoff said:
Surprisingly, I use Centor and rarely test and my PG scores are pretty good. I actually care more about pt complaints, and as far as I know I haven't gotten any antibiotic-related complaints either. Been doing this for a year so maybe just haven't been practicing long enough, but my trick is...

MAKE THE PATIENT REFUSE

Make them refuse pretty much any stupid thing I don't want them to do but I think they might want to do. Testing, abx, admission, etc. Pretty much anything but narcotic rx, which I'm a total hardass about because I'm not gonna go messing up my community like that.

"""
Now Ms Sanchez, the good news is that I think Arya probably doesn't have Strep throat. Usually, Strep throat usually causes a fever and white stuff in the back of her throat and actually usually no cough. But the good news is she doesn't have a fever and does have a cough!

So I think Arya probably has a virus :(((. Unfortunately antibiotics probably won't help, but what they might do is give her nasty side effects like diarrhea and vomiting. I know y'all spent a ton of effort coming here in the middle of the night and you work all day, so I'd hate to see y'all come back in a few days because of something I prescribed.

[if they seem curious and can handle it, cue further discussion about viruses vs bacteria and the worst possible effect of Strep throat and the fact that that's like 1 in a million and the finding that abx don't even seem to reduce the duration of Arya's sxs, which is really what they're after]

Now, unfortunately I'm only human just like you and so sometimes I'm wrong about these things. So if you really want the Strep test, I'm happy to get it for you. The nurse would come in and tickle Arya's throat with a swab and then you'd need to wait about two hours to get the result.

So, I'll leave it up to you. Would you rather stick around for an hour and get the test, or go home with some really strong pain medicine and see her pediatrician in the morning? Don't worry, I'm happy to write y'all work and school notes if you want to stick around!
"""

Similar canned speech for flu testing/Tamiflu and lots of other HCA moneymakers that I would never do to my own son. I try to tell my APCs to practice this way too but I rarely succeed. This might sound like it takes a really long time but I've gotten to the point where I can bash out the whole conversation in about 2-3 minutes after the exam.

Has anyone been burned by this approach? I'd love to hear that I'm doing it wrong, because at the end of the day keeping my job long enough to FIRE is more important to me than iatrogenically giving Arya diarrhea for a few days or chronic gastroparesis in 20 years because I her GI flora or whatever. I am a selfish bastard, it is true.
Click to expand...
 
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Your rapid streps take two hours? Mine take about 10 minutes, maybe 20 in the large hospital.

But I also generally discourage stuff I think is most likely useless, and then do it if they still want it.

We get PG scores or something similar dropped into our mailboxes on occasion. I toss them without looking.

hundreddaysoff said:
Surprisingly, I use Centor and rarely test and my PG scores are pretty good. I actually care more about pt complaints, and as far as I know I haven't gotten any antibiotic-related complaints either. Been doing this for a year so maybe just haven't been practicing long enough, but my trick is...

MAKE THE PATIENT REFUSE

Make them refuse pretty much any stupid thing I don't want them to do but I think they might want to do. Testing, abx, admission, etc. Pretty much anything but narcotic rx, which I'm a total hardass about because I'm not gonna go messing up my community like that.

"""
Now Ms Sanchez, the good news is that I think Arya probably doesn't have Strep throat. Usually, Strep throat causes a fever and white stuff in the back of her throat and actually usually no cough. But the good news is she doesn't have a fever and does have a cough!

So I think Arya probably has a virus :(((. Unfortunately antibiotics probably won't help, but what they might do is give her nasty side effects like diarrhea and vomiting. I know y'all spent a ton of effort coming here in the middle of the night and you work all day, so I'd hate to see y'all have to come back in a few days because of something I prescribed.

[if they seem curious and can handle it, cue further discussion about viruses vs bacteria and the worst possible effect of Strep throat and the fact that that's like 1 in a million and the finding that abx don't even seem to reduce the duration of Arya's sxs, which is really what they're after]

Now, unfortunately I'm only human just like you and so sometimes I'm wrong about these things. So if you really want the Strep test, I'm happy to get it for you. The nurse would come in and tickle Arya's throat with a swab and then you'd need to wait about two hours to get the result.

So, I'll leave it up to you. Would you rather hang out here for a while and get the test, or go home with some really strong pain medicine and let her sleep and see her pediatrician in the morning? Don't worry, I'm happy to write y'all work and school notes if you want to stick around!
"""

And then, of course, I d/c them and document "Centor score 1 and patient was offered Strep test but refused" in MDM.

Similar canned speech for flu testing/Tamiflu and lots of other HCA moneymakers that I would never do to my own son. I try to tell my APCs to practice this way too but I rarely succeed. This might sound like it takes a really long time but I've gotten to the point where I can bash out the whole conversation in about 2-3 minutes after the exam.

Has anyone been burned by this approach? I'd love to hear that I'm doing it wrong, because at the end of the day keeping my job long enough to FIRE is more important to me than iatrogenically giving Arya diarrhea for a few days or chronic gastroparesis in 20 years because I nuked her GI flora or whatever. I am a selfish bastard, it is true.
Click to expand...
 
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Screen Shot 2019-12-19 at 8.44.34 AM.png
 
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Just thinking about reporting? I would throw that person under the bus. And perhaps tag their supervisor (if they have one) as well.
 
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As much as doctors would never like to be in a position to supervise NP/PA's, doctors may have a hard time finding a job if they stipulate not to supervise NP/PA's at work. Generally it's something that you can't opt out of.

Until this legal conundrum gets sorted out, I think the best thing do is allow doctors to define how they want to work with them. It's within the right of MDs to define how they work with NP/PAs, including asking them to present every case to the doctor. The doctor can reserve the right to see each PA patient as well.
 
One of the USF cardiovascular DNPs is bragging on Twitter about how she "resuscitated" a VF arrest patient in the USF ED earlier this month. I'm sure she was the one lining him up and starting pressors, etc.

Doesn't one of our members work there as an attending? GamerEMDoc? I'm sure they'd like to chime in about the realities of the matter.
 
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Mrs. Fox actually asked me to make a doc-to-doc phone call yesterday because she was concerned about the care that her "PA" was providing to her.

For reference, this my wife's PMD's office.
Its set up like this: They have a husband/wife team of DOs and 4-5 PA/NPs as the hierarchy of the patient care 'funnel'.
This was her third visit with the PA.
The concern is about rheumatoid arthritis, or a similar autoimmune condition.
From my perspective; my wife is the perfect rheumatoid arthritis patient.
Former ballerina, figure-skater, taught to stand in terribly painful (but graceful!) positions for days on end.
Now, she's in her late 30s.
The big joints hurt her, in an almost symmetric pattern.
Its steroid-responsive.
We have left movie theaters before because her shoulder and hip joints are causing her pain.
Still haven't seen the end of "Fantastic Creatures and Where to Find Them"
She gets to Jenny McJennyson, PA, who says to her:

"Do your joints swell up and get red?"

"No."

"Well. Then it can't be rheumatoid." (eye roll)

And that's where she left it. Dismissed.
No thought of "Gee; this could be one of many things. We should work it up."
Just [dismissed/ignored].
That was two visits ago.
Wife brought it up again last time: "Hey; this pain in my shoulders and high back is worse now."
Ignored again.

Mrs. Fox is crying right now because the baclofen isn't helping her high back and shoulders like it did before.

No joke, guys.
This could be polymyalgia rheumatica. Rheumatoid arthritis. MCTD. Could be multiple sclerosis.
It actually, really could be MS - the more I think about it. Steroid-responsive. Neuropathic components.
Could be nothing. But, I'll bet its not a nothing.

No inclination to work it up.
Just "dismissed".

Mrs. Fox is pretty damned mad.
I told her to tell the "PA" - "Good luck at the Dunning-Kruger Awards", and then went about finding the local rheum/neuro folks that I trust.

Did I mention that this was the third visit where Mrs. Fox brought up the same concerns, only to have them ignored by the PA?

Mrs. Fox is pretty private about her healthcare. For her to come to me and say "If I were the doc in charge of this office, I would want to know this"... is a pretty big deal.
 
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TooMuchResearch said:
Your rapid streps take two hours? Mine take about 10 minutes, maybe 20 in the large hospital.
Click to expand...

Huge variance w/ our lab, from 15mn to 2h. Seems to depend on our inpatient census. You'd think HCA would try to optimize this more. My understanding of AIDET is to give pt the top end of the duration.
 
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Dr.McNinja said:
I just tell them this.
The antibiotics mean literally nothing about symptom resolution. They are only there to prevent rheumatic heart disease. It doesn't matter if the swab is negative today and the culture comes back positive. You'll be called, and the treatment and resolution will remain the same.
However, I can give you something to help the symptoms resolve faster, would you like that?
Everyone gets decadron. EVERYONE.
Click to expand...

I've tried that shorter version of the speech, but I just see eyes glaze over. Too much unshared context. Dunno, maybe it's just my market. Agree I'd prefer that version if I were the pt and hadn't gone to med school.

I also rx a lot of Decadron for fanservice customer service purposes, but sometimes I get a bit anxious about that as it hasn't been around long enough for us to see the potential iatrogenic effects. Usually I'll only rx if pain is at least a 7 and they aren't diabetic/immunosuppressed/pregnant (seen some horrible bouncebacks w/ sugar through the roof s/p steroids).
 
Our group is having internal debates about how best to utilize our PAs. Some of us feel like they shouldn't be seeing complex patients, even with supervision. Others feel differently and aren't interested in entertaining the possibility of another model.
thegenius said:
As much as doctors would never like to be in a position to supervise NP/PA's, doctors may have a hard time finding a job if they stipulate not to supervise NP/PA's at work. Generally it's something that you can't opt out of.

Until this legal conundrum gets sorted out, I think the best thing do is allow doctors to define how they want to work with them. It's within the right of MDs to define how they work with NP/PAs, including asking them to present every case to the doctor. The doctor can reserve the right to see each PA patient as well.
Click to expand...
 
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Hope she gets some appropriate care.
RustedFox said:
Mrs. Fox actually asked me to make a doc-to-doc phone call yesterday because she was concerned about the care that her "PA" was providing to her.

For reference, this my wife's PMD's office.
Its set up like this: They have a husband/wife team of DOs and 4-5 PA/NPs as the hierarchy of the patient care 'funnel'.
This was her third visit with the PA.
The concern is about rheumatoid arthritis, or a similar autoimmune condition.
From my perspective; my wife is the perfect rheumatoid arthritis patient.
Former ballerina, figure-skater, taught to stand in terribly painful (but graceful!) positions for days on end.
Now, she's in her late 30s.
The big joints hurt her, in an almost symmetric pattern.
Its steroid-responsive.
We have left movie theaters before because her shoulder and hip joints are causing her pain.
Still haven't seen the end of "Fantastic Creatures and Where to Find Them"
She gets to Jenny McJennyson, PA, who says to her:

"Do your joints swell up and get red?"

"No."

"Well. Then it can't be rheumatoid." (eye roll)

And that's where she left it. Dismissed.
No thought of "Gee; this could be one of many things. We should work it up."
Just [dismissed/ignored].
That was two visits ago.
Wife brought it up again last time: "Hey; this pain in my shoulders and high back is worse now."
Ignored again.

Mrs. Fox is crying right now because the baclofen isn't helping her high back and shoulders like it did before.

No joke, guys.
This could be polymyalgia rheumatica. Rheumatoid arthritis. MCTD. Could be multiple sclerosis.
It actually, really could be MS - the more I think about it. Steroid-responsive. Neuropathic components.
Could be nothing. But, I'll bet its not a nothing.

No inclination to work it up.
Just "dismissed".

Mrs. Fox is pretty damned mad.
I told her to tell the "PA" - "Good luck at the Dunning-Kruger Awards", and then went about finding the local rheum/neuro folks that I trust.

Did I mention that this was the third visit where Mrs. Fox brought up the same concerns, only to have them ignored by the PA?

Mrs. Fox is pretty private about her healthcare. For her to come to me and say "If I were the doc in charge of this office, I would want to know this"... is a pretty big deal.
Click to expand...
 
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Dr Mantis Toboggan said:
I admire you. That’s a lot of work you put into those conversations. I should do more of that. My speech goes more like: “swab is negative, it’s a virus. I’ll get you guys out of here now.”
Click to expand...

Aw, thanks. Once you get the general pattern it's pretty easy to propagandize like this for anything you think is against the pt's best interest.

This was just an evolution from reading some of the excellent pt scripts of many in this forum over the past few years.
 
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TooMuchResearch said:
Hope she gets some appropriate care.
Click to expand...

Thanks. She will, come hell or high water.
This anecdote just goes to show that the MLP crowd really is stuck on the peak of "Mt. Stupid" of the Dunning-Kruger curve.

I'm sure I mentioned this in a different thread, but we have had 100% turnover of our MLPs since the new CMG.
Our lives are 100% better, as the message has been clear that: "You're not here to argue; you're here to take orders and see dumb things quickly. Quickly."
 
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Dr.McNinja said:
Also, I still can't decide if NPs prescribing zpacks for otitis is genius or malevolence. They don't do anything (which they don't need to 95% of the time), but they also don't do anything (which they sometimes do need)
Click to expand...

It's definitely not genius
 
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I don’t post here very often (I do browse the threads because I’m interested in the specialty), but I was actually just posting about this on Facebook today and a friend of mine who is also an MS1 at another med school came out to defend MLPs by saying that me pointing out they have 5% of the education of a physician is inflammatory and not in the spirit of team based healthcare. Lord.
 
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RustedFox said:
We have left movie theaters before because her shoulder and hip joints are causing her pain.
Still haven't seen the end of "Fantastic Creatures and Where to Find Them"
Click to expand...
Let me help you out with that. They all die in the end.

(I've been saying this about every movie for the past 30 years.)
 
Matthew9Thirtyfive said:
I don’t post here very often (I do browse the threads because I’m interested in the specialty), but I was actually just posting about this on Facebook today and a friend of mine who is also an MS1 at another med school came out to defend MLPs by saying that me pointing out they have 5% of the education of a physician is inflammatory and not in the spirit of team based healthcare. Lord.
Click to expand...

lol

Wait till your friend is a resident working 4x as many hours weekly as an MLP with 10x the responsibility and ½ the compensation. They'll see the light soon enough.
 
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Fox800 said:
One of the USF cardiovascular DNPs is bragging on Twitter about how she "resuscitated" a VF arrest patient in the USF ED earlier this month. I'm sure she was the one lining him up and starting pressors, etc.

Doesn't one of our members work there as an attending? GamerEMDoc? I'm sure they'd like to chime in about the realities of the matter.
Click to expand...

MSMentor and DrQuinn both worked there although I haven't seen either on SDN recently.
 
hundreddaysoff said:
I've tried that shorter version of the speech, but I just see eyes glaze over. Too much unshared context. Dunno, maybe it's just my market. Agree I'd prefer that version if I were the pt and hadn't gone to med school.

I also rx a lot of Decadron for fanservice customer service purposes, but sometimes I get a bit anxious about that as it hasn't been around long enough for us to see the potential iatrogenic effects. Usually I'll only rx if pain is at least a 7 and they aren't diabetic/immunosuppressed/pregnant (seen some horrible bouncebacks w/ sugar through the roof s/p steroids).
Click to expand...

I have no proof of the following, but the reason why I treat confirmed strep throat is I suspect people feel better more quickly with antibiotics (in the near term) than without. The graph below hasn't been studied, but is what I think happens. It's not all about length of symptoms, it's how you do during that time. For instance, if you can get back to work 2 days quicker that could be one reason to prescribe them. Plus, IDSA says to treat strep throat. It's could be indefensible if you don't, even if the complication rate for untreated strep throat is very rare.

strep throat.jpg


Similar to how antibiotics for acute UTI / cystitis fare - usually dysuria improves markedly within the first 12 hours.
 
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Except, symptom resolution isn't better with antibiotics. It's been studied. You want them to feel better faster? Give steroids?
Del Mar CB, Glasziou PP, Spinks AB. Should sore throats be treated with antibiotics? (Review). Cochrane Database of Systematic Reviews 2006 Issue 4. CD000023 PMID: 15106140
 
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All of these studies ask when are the sore throat symptoms gone. They don't ask on a day to day basis how much better they feel. They only look at the end.
 
Matthew9Thirtyfive said:
I don’t post here very often (I do browse the threads because I’m interested in the specialty), but I was actually just posting about this on Facebook today and a friend of mine who is also an MS1 at another med school came out to defend MLPs by saying that me pointing out they have 5% of the education of a physician is inflammatory and not in the spirit of team based healthcare. Lord.
Click to expand...

Your friend is an idiot.
 
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TheSingularity said:
Your friend is an idiot.
Click to expand...

He’s my “friend.” But yes, I think he’s been brainwashed. They have an entire interprofessional class at their school where they basically get told that physicians are no more important to the team than anyone else and “midlevel” is a dirty word they aren’t allowed to use.
 
Matthew9Thirtyfive said:
He’s my “friend.” But yes, I think he’s been brainwashed. They have an entire interprofessional class at their school where they basically get told that physicians are no more important to the team than anyone else and “midlevel” is a dirty word they aren’t allowed to use.
Click to expand...

WTF I’d be asking them in that class where the transfer forms are so I can hand them out to everyone and transfer to an BSN to NP program for half the price.
 
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My med school in the 90s tried to brainwash us all into becoming primary care providers. Managed care was the future and specialists weren’t going to be able to find jobs...


Matthew9Thirtyfive said:
He’s my “friend.” But yes, I think he’s been brainwashed. They have an entire interprofessional class at their school where they basically get told that physicians are no more important to the team than anyone else and “midlevel” is a dirty word they aren’t allowed to use.
Click to expand...
 
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calvnandhobbs68 said:
WTF I’d be asking them in that class where the transfer forms are so I can hand them out to everyone and transfer to an BSN to NP program for half the price.
Click to expand...

For real. I posted some info from the PPP site, and he didn’t respond lol. Sad that docs are graduating from that school thinking like that.
 
Matthew9Thirtyfive said:
He’s my “friend.” But yes, I think he’s been brainwashed. They have an entire interprofessional class at their school where they basically get told that physicians are no more important to the team than anyone else and “midlevel” is a dirty word they aren’t allowed to use.
Click to expand...

If we are no more important than the “team” why do we hold the liability bag for the whole “team”?

if they want to be a team, take the liability, otherwise it’s going to be done my way
 
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I am aware of a malpractice suit where that defense was used and it resulted in a defense verdict. A surgical instrument was brought out and placed on top of the abdomen by a scrub tech after being sterilized but before it had cooled off. The patient was burned and sued the surgeon. The surgeon basically argued he was just part of the team and it wasn’t his mistake. It worked.


NYEMMED said:
If we are no more important than the “team” why do we hold the liability bag for the whole “team”?

if they want to be a team, take the liability, otherwise it’s going to be done my way
Click to expand...
 
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NYEMMED said:
If we are no more important than the “team” why do we hold the liability bag for the whole “team”?

if they want to be a team, take the liability, otherwise it’s going to be done my way
Click to expand...

I agree. Glad my school doesn’t “teach” us that crap (so far anyway).
 
Nursing board won't care.
Just goes to show how useless these boards are in the MLP world.
Ohh, you have a BOARD? How CUTE!
Guess what? The DOC still has the responsibility!
My license? My way. Now, do as you're told.
 
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Collaborator huh?
Yeah, the problem is the docs who actually do this.
 
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