Thursday, November 15, 2007

Automatic Automatons

There are some things in medicine that irk me beyond rational thought. These quick, “urgent care” clinics are definitely a topic that incites rage and hatred in me. They are, to a word, pathetic. Pathetic excuses for healthcare, pathetically trained or motivated people caring for patients, and pathetic attempts to “fix” the healthcare system in the US.

Part of the reason they are such a poor medical facility is due to the people treating most of the patients. NPs and PAs, free from a great deal of medical supervision, are often found handing out erroneous and falsified diagnoses - only to then treat everything with antibiotics or other unnecessary medications. An example of this irresponsible behavior is a story I heard recently encompassing most of these qualities:

A mother whose adult son had a sore throat and was too busy to get it evaluated, went to an urgent care clinic knowing that she could fake his symptoms and receive a Z-pack. This was done because her doctor wouldn’t normally give medicines unless specific tests were positive. She, of course, received the antibiotics (despite having ANY illness) and proceeded to give it to her adult son.

This kind of malpractice (for it really is irresponsible medicine) only increases the drug resistant bacteria that we’re seeing and encourages patients to demand drugs they don’t need. What’s worse is the notion that medicine is like a cookbook and all symptoms should be treated the exact same, regardless of testing and patient profiles.

For all the complaining patients do about their long waits, the doctor’s refusal to give them some drug they read or heard about, or their increasing dubious belief that they are as able to diagnose themselves as effectively as their PCP these clinics are not the answer.

Consider the story above: what if the antibiotics given reacted badly with another medication, or had to be altered due to liver or renal failure, or caused a severe allergic reaction? All things that a PCP would most likely catch through charting or questioning but would characteristically be missed by a NP or PA trying to get as many people in and out of their fast-food-medicine chain as possible.

What the hell do I care about giving medicines without proper test results? It’s a pain in the ass to do it any other way and it takes up valuable time. That's not what Walmart/ Walgreen's/ Target is paying me for”.

Instead of responsible and smart medicine, what you have are people who will not use medical evidence to properly treat patients and essentially run a medical McDonald’s – have it your way. Sore throat? STREP! Neck hurts? LORTAB! Sniffles? SINUSITIS! To add to this obvious disparity is the fact that these clinics are often owned by corporations who want people to be sick and have to go to their pharmacies. It's not rocket science to see how there's a conflict of interest.

Now I don’t think NPs, PAs, and CRNAs are entirely bad - quite the opposite. They are important in that their job role allows overworked physicians time to focus on the more complicated patients and running their practice while more minor ailments and procedures are analyzed and treated - after a quick review with the physician. However what I do find absurd is the idea that they can take care of patients without strict physician guidance as often occurs in these retail medical centers. Regardless of their time, they haven’t received the training requisite in order to differentiate between disease processes that appear very similar, nor is it expected.

If you still haven't jumped on the bandwagon, realize this: a nurse is trained in a very different way than a physician. They are not expected to figure out the pathophysiologic basis of a disease, the subtle interactions between comorbidities, the ever increasing need to be smarter about treating seemingly simple infections, and the evidence that alters treatment regimens amongst patients. Their training is based on recognizing a defect or a problem, alerting the appropriate people, and following a procedure or "order". If a patient has X, then give Y. If this happens, call the house officer or the patient’s doctor for direction. Adding a couple of years to the training does not inculcate the need to think beyond this automatic process, no matter how much you “shadow” a physician.

Experience certainly lends itself to making people think they know more than they really do. Twenty years in the ICU will definitely make you appear smarter than the intern or second year resident rotating through that service, but only for a brief period of time. Of course you’re going to know more about vent settings, how to respond to codes, etc. than a newly minted MD; but a seasoned physician, who has spent some of their time in the critical care arena will run circles around you - no matter how long you've worked there.

The physician trains in a wide array of specialties for which they are expected to understand a great deal of complexities, is responsible for the outcomes of their patients, and understands more about the overall process leading up to and currently occurring in that patient than an NP, PA, or tenured nurse could hope. A few decades of experience does not overcome the difference in education. A physician with twenty years including residency will always come out on top.

Residency is designed towards this goal. It is the resident’s training, adding on top of the knowledge procured through four intense years of medical school, that makes a physician more than just a “medical mechanic”. Performing a task a million times is not the same as medical knowledge. It is habit, and, as often seen when new policies are passed, is often hard to break.

Urgent care clinics are not the answer to the healthcare crisis. If we expect to take care of patients in better ways, to reduce drug resistant bacteria like the current MRSA “epidemic”, and have more advantagous outcomes we must realize that physicians are not replaceable by technicians. The years of training that doctors receive and the strict environment that they receive their education in makes a physician far more capable of truly evaluating patients. What you are receiving when you see a physician is a decade or more of increasingly detailed knowledge and arduous training that enables them to treat people effectively. Four to six years of training is not even close.

14 comments:

Anonymous said...

I get your point and agree that antibiotics are given out all too frequently and that minute clinics probably aren't the way we should want medicine/health care to go. However I would bet the majority of PAs and NPs are not the way you describe them. I see both an NP and a PA for different conditions and feel they are both well qualified for their positions. In fact, both spend more time with me than MDs have and have listened more carefully than MDs have. I'm not slamming MDs. I don't think the majority of them don't listen. I just don't think we can or should make broad, sweeping generalizations about anyone.

Old MD Girl said...

Anon,

I've had the opposite experience with the NPs who I see in student health. They spend less time with me, are quick to dismiss and are irritated by my questions. While I know there must be good NPs out there, I know I personally have not yet been cared for by one. And frankly, having primary care turn into this for everyone scares the crap out of me.

Anonymous said...

Old MD Girl,

Maybe the difference for me is that I see an NP who specializes in the condition for which I see her.

I also agree that I hope that Primary Care doesn't turn into this for everyone. For me it has been a choice to see an NP and a PA and I'm very happy with those choices. Do I think this is the route for everyone? No, I don't.

What I do like about my PA is that if she runs into something she's not comfortable treating, she refers me to someone else. I trust her judgment. The practice in which she works has several physicians (MDs and DOs) whom she consults on a regular basis...which is another reason I feel comfortable with her. My NP treats a very specific condition and she also works with MDs whom she consults on a regular basis...I guess this isn't always the case from what you're saying and from what MSG is saying and that's unfortunate.

Rory said...

how cute... to be so naive as to think that having an MD behind your name imparts some magical wisdom about future effects of medication on a patient... of course a free economy (ostensibly ours), allows people to choose to seek the services of someone lesser trained in exchange for a cheaper service. get off your high horse, the Current and ePocrates applications work the same on my pda as yours.

MSG said...

Rory,

The idea that an MD imparts some kind of magical thinking, to understand that a patient will experience some form of side effect later on, is absurd. What was being said, had you read more carefully, was that people staffing urgent care and minute clinics will not have the necessary information at their disposal, nor will they have the time/ motivation to check out a patient thoroughly.

Personally I don't think this attacked anyone other than the farce that are these retail clinics, but you get mad when something hits home a little too much.

Anon,
It's great that you're seen by an NP who makes you feel comfortable. The fact that they work in an office with several MDs and DOs just illustrates my point - free to take care of patients as they are qualified, with physician guidance. Minute clinic and urgent care NPs and PAs often do not have these items at their disposal, which is rather dangerous.

Old MD Girl said...

I thought Rory was joking.....

Anonymous said...

i don't even know where to start. i have seen plenty of PCPs (old and new) and ER physician's give patients antibiotics and pain medications because it is easier than telling the patient no. i also think i would rather send a patient to a walk in clinic than send someone to the ER because the PCPs office has such poor access. i wish our health care systems problems were as clear cut as you present them. time and experience will cure that.

Ladyk73 said...

Hmmm.....I worked in a mostly NP ran family health clinic. Their supervising MD was only available by phone. There "analogs" were very limited. The senior NP's were great. They practiced exactly within their training, including doing some advanced procedures. Sometimes, as a consumer of medicine, you would rather have a 'technician' perform common procedures on you. I had some wonderful suture's by a PA, and I would only go to a NP for my yearly gyn (cause they do it ALL the time).

I did have an experience with my own health when I was seeing an NP in a practice, and I felt I needed a second opionion and she wouldn't allow me to see a MD in the practice.

Anyways, NPs, RNs, LPNs, MD's, Phd, DOis, PT's....are all part of the same team. Each profession has it's own strength and abilties.

I agree with you in the way NPs are trained, cause that is very very true.

By the way, the outpatient urgent medical care places in these parts of the world...are manned by resident doctors. We have a few residency programs here, and well...I think it is extra income for all.

I would rather people go to a clinic like you described than the ER. They have their strong limits, great for those weird non-emergency things that happened outside of doctors hours. But they are no replacement for a good family/internal doctor. I have a great one.

I wished our local urgent care place was open when I got bitten by a ferral cat. I felt stupid going to the ER, but I really needed medical attention, a tenus shot....and antibotics. I became very ill in a matter of hours.
Not to mention the rabies scare.

MSG said...

Perhaps the issue is that people are getting upset at the fact I seemed to segregate the professions. Mostly I was targeting the urgent care and minute clinics that are supposed to replace FP and PCP offices with greater access and people who can treat you just as well as an MD. I laugh at the idea.

There are lazy docs out there and I honestly think they're worse when ignoring medical facts just to save time/ money. However, what concerns me are the people who think they know more than they actually do because they don't have someone pulling them off their high horse - like a resident has to endure for years. The training is not the same and therefore the expectations cannot be either.

Liz said...

Those minute clinics are so scary. I really hope they don't catch on too much.

Going along with what OMDG said... i once had an NP at my student health clinic in Ithaca try to give me amoxicillin even though my chart had a bright red "penicillin allergy" sticker on it. I was the one who had to point out to her that someone with a history of anaphylactic penicillin allergy shouldn't be given amoxicillin. She actually arugued with me for a minute on this and then finally gave me something else.

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