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What do other providers do routinely that you just hate?


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It has been a little quiet in here since the AAPA conference and the OTP passed so I thought I'd chum the waters a bit. I am on a run of 10 and 12 hour days in the urgent care and, as is usual, there is a string of people with colds in the mix. When I review their charts, as I always do before I see them, I see visit after visit where they were seen for a cold for 2 days or a drippy nose, or a "sinus infection" x 3 days, and almost without exception every time whomever they have seen gives them an antibiotic and often a steroid too.It just galls me that these providers are so lazy or fearful of patient satisfaction surveys that they continue to do this over and over when it is bad medicine and bad science. I'm talking about patients with normal vitals, benign exams, and have been sick for very short periods when they were seen. It makes the life of everyone who wants to practice evidence based medicine 100x harder. And don't get me started on people who do a test and then ignore the results. Scratchy throat for 2 days. Negative strep. here is your antibiotic. Cough and no fever for 4 days? Negative flu test? Here is your Tamiflu. yes I know tests aren't perfect but if you want to treat them just sack up and do it. Don't order the test and then ignore the results.

 

*pant* *pant*

rant concluded

*mic drop*

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There are a couple I work with that make me feel like I'm the only one working...there is one of those that thinks they have to rewrite all orders on all their reassessments because nobody but they are right and the other is scared of their own shadow and is so obsessed with EBM that they get decision paralysis if there is conflicting evidence on anything...they also are the first to go look for blame if something goes pear shaped and writes up everybody for everything, yet won't say it to their/your face.  The first one is ALWAYS late and tries to leave early and spends so much time on breaks that they only get their handovers done...unless something cool comes in then everyone gets pushed aside, since they're the only one that knows anything.

 

I roll my eyes at work so much I can now see my cerebellum.

 

SK

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Different scenario ---

 

I bother to write a detailed assessment and plan including my specific questions. I separate like bullet points and avoid run on sentences. 

 

Sent a guy to the cardiologist with an enlarged aortic root, hypertension in his 50s, no hx of MI. He drives under NHRA and withstands up to 3 Gs on deceleration and acceleration.

 

My specific question to said cardiologist - can his enlarged aortic root handle Gs? I had researched this and called an Air Force friend and looked on the NASA website. Nothing satisfactory for normal mortal non-NASA sorts. 

 

Cardiologist sees him and says ----- wait ----- NOTHING about his NHRA. Not one stinking mention. NADA, Zip, zilch. I still can't sign off on the physical. He was dodging the issue - did not want his name on it. Didn't know where to look and didn't want to hazard a guess. 

 

I wrote a letter of clearance in the cardiologist's name and faxed it over to his nurse asking she put it in front of him to sign. Three days later - I got it back. He signed it with the specific statement that he did not feel that drag racing at rapid acceleration posed a distinct and acute threat to his heart at this time but required yearly evaluation. 

 

I get so sick of sending patients to specific specialists looking for specific answers or enlightenment and getting crap notes back stating "I have no records available during this visit and patient says they do not know why they are here" (they never asked)  or getting evaluations that are no more intense than my own with a nonspecific answer that is no more than my own preliminary assessment. No miracle answers sought - just advanced advice or suggestions. 

 

So, my gripe is not getting "specialist" assessments when requested. Feels like spinning my wheels in quicksand. 

 

I have a select group that are SUPER attentive and even call me with the weird-omas and "wow factor" stuff.  LOVE them but they don't see 100% of my patients.

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Guest JMPA

It has been a little quiet in here since the AAPA conference and the OTP passed so I thought I'd chum the waters a bit. I am on a run of 10 and 12 hour days in the urgent care and, as is usual, there is a string of people with colds in the mix. When I review their charts, as I always do before I see them, I see visit after visit where they were seen for a cold for 2 days or a drippy nose, or a "sinus infection" x 3 days, and almost without exception every time whomever they have seen gives them an antibiotic and often a steroid too.It just galls me that these providers are so lazy or fearful of patient satisfaction surveys that they continue to do this over and over when it is bad medicine and bad science. I'm talking about patients with normal vitals, benign exams, and have been sick for very short periods when they were seen. It makes the life of everyone who wants to practice evidence based medicine 100x harder. And don't get me started on people who do a test and then ignore the results. Scratchy throat for 2 days. Negative strep. here is your antibiotic. Cough and no fever for 4 days? Negative flu test? Here is your Tamiflu. yes I know tests aren't perfect but if you want to treat them just sack up and do it. Don't order the test and then ignore the results.

 

*pant* *pant*

rant concluded

*mic drop*

ugghhh, whats evidence based medicine? have doctors been practicing something else the past couple of hundred years?

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I wish all the providers who were giving my chronic pain med patients anything controlled in the ER would just stop.

It aint me brother. My standard line is "I don't refill chronic pain medications in the er, you need to call the provider who prescribed the pain medication"..... then wait for it...... wait for it..... pt response...you fking a $$hole, you won't help me!!!!? Can't you see I'm I pain? My response, I am helping you, call your provider, I can offer you tylenol or ibuprofen . The tirait then begins.... had this. Very conversation today. Funny how many times they can't explain why they ran out of their pain meds early. Not judging, just sayin

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Guest ERCat

PCPs sending people over for "high blood pressure." 90 percent of the time we do NOTHING in the ER. I force myself to get an EKG, BMP and urine even though it doesn't really change my management. My management is "Go home and see your PCP. Bye Felicia."

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Guest UVAPAC

From an Occupational Medicine standpoint....

 

Another provider putting a patient out of work (for an injury that nowhere near constitutes disability) then schedules a follow up appointment in 2-3 days with a different provider and write in their impression "Suspect patient will be ready to return to work at next visit."

 

 

 

The old give the patient what they want, and then dump the mess on somebody else.

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Not talking to their patients.  Not during the history, and certainly not when discussing with the patient what they have and how to treat it.  I have- we all have- patient coming in without a single clue of what they have or how they are treating it.  I get it, some of them are not so bright, and no matter what you tell them, they will ignore it, but maybe if someone took some time to explain what they have, there won't be so many misconceptions.  For example, the baloney about colored sputum.  So many people drop what they are doing- sometimes literally- whenever they cough up some yellow phlegm because somewhere, along the line, they were told it was an infection.  And that seemed to stick in their head. 

Anyways, remember, our job is not to satisfy our insurance overlords, or Press Ganey, or the CEO- it is to treat the human in front of us.  And that means slowing down.  Turning away from the computer.  Looking them in the eye.  Actively listening - not hearing, but listening to what they are saying to you.  They may be saying "I have a sore throat" or " I have a sinus infection", but maybe what they are saying is "I'm scared of being sick".  Tell them why they aren't. 

 

Did I write all that?  Forgive me, its early.  So my beef is not talking or listening to patients.  Boom.

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PCPs sending people over for "high blood pressure." 90 percent of the time we do NOTHING in the ER. I force myself to get an EKG, BMP and urine even though it doesn't really change my management. My management is "Go home and see your PCP. Bye Felicia."

 

I'll take that one step further - the pharmacist in WalMart, Safeway or wherever that sends someone over with a "dangerous" BP of 165/90 after taking their BP on the "Check your BP while you wait" machine...don't know about you, but my BP is always up when I'm in WalMart, Costco, etc...I want to believe that the pharmacist told them to see their FMD/PA/NP and they only heard "your BP is elevated and it'd bad(ish)", but they will sometimes give a note or call us even to let us know.

 

At least they call or send a note sometimes...

 

BTW - my cerebellum is not pretty.

 

SK

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Rehabs are the bane of our surgical practice: taking out staples/sutures from a surgical site without clearing with us first, purposely keeping the patient off of their operative limb when I clearly state that can bear weight, not contacting me about wound issues and instead managing them themselves, not doing prescribed wound care and instead following their own protocols, and the list goes on.

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It has been a little quiet in here since the AAPA conference and the OTP passed so I thought I'd chum the waters a bit. I am on a run of 10 and 12 hour days in the urgent care and, as is usual, there is a string of people with colds in the mix. When I review their charts, as I always do before I see them, I see visit after visit where they were seen for a cold for 2 days or a drippy nose, or a "sinus infection" x 3 days, and almost without exception every time whomever they have seen gives them an antibiotic and often a steroid too.It just galls me that these providers are so lazy or fearful of patient satisfaction surveys that they continue to do this over and over when it is bad medicine and bad science. I'm talking about patients with normal vitals, benign exams, and have been sick for very short periods when they were seen. It makes the life of everyone who wants to practice evidence based medicine 100x harder. And don't get me started on people who do a test and then ignore the results. Scratchy throat for 2 days. Negative strep. here is your antibiotic. Cough and no fever for 4 days? Negative flu test? Here is your Tamiflu. yes I know tests aren't perfect but if you want to treat them just sack up and do it. Don't order the test and then ignore the results.

 

*pant* *pant*

rant concluded

*mic drop*

 

 

 

 

 

Easy.  

 

Providers who won't go to the bathroom without a positive "Go to the bathroom" test.   I've seen more false negative flu and strep tests then I care to remember.  People left untreated and MUCH worse off then they would of been had treatment been started.  With both conditions treatment initiation being time sensitive, it drives me nuts when providers can't make an independent decision without the help of a rapid test.  I had a very smart doc tell me many years ago:  "Tests sometimes lie.  If it looks like a duck, walks like a duck and you feel in your gut it's a duck?  Shoot it!  Ok, we are in Texas.  I think he meant treat it, no matter what the user error prone rapid fire test says.

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I repeat, "Don't ask the question if the answer doesn't matter." Nothing wrong with low dose, two day course of oral prednisone/prednisolone for pharyngitis inflammation (more effective than abx). OK, so you may get some mild GI upset but that's the cost of being a contestant. Justification for same found in literature. W/O culture (which I can't get), how are compadres excluding newest, most CRITICAL excuse for abx.? Your friend and mine, F. necrophorum. Remember, everyone's favorite abx, wait for it....THE Zpak(!)....doesn't cover it.

 

Oh, slap me, beat me, tie me up; I do give them a door prize for if their odynophagia lasts for longer than a week (ENT recommendation) to cover for that other common complication....wait....Mr. non-existent RF that occurs in every tens of thousands of cases. As long as you cover w/i 14-17 days your (they) covered for bad complications.

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Easy.  

 

Providers who won't go to the bathroom without a positive "Go to the bathroom" test.   I've seen more false negative flu and strep tests then I care to remember.  People left untreated and MUCH worse off then they would of been had treatment been started.  With both conditions treatment initiation being time sensitive, it drives me nuts when providers can't make an independent decision without the help of a rapid test.  I had a very smart doc tell me many years ago:  "Tests sometimes lie.  If it looks like a duck, walks like a duck and you feel in your gut it's a duck?  Shoot it!  Ok, we are in Texas.  I think he meant treat it, no matter what the user error prone rapid fire test says.

Treat the patient not the test. Heard it early and often but, like most pearls, doesn't always apply. Flu tests are the least reliable rapid test we do so I tell the staff "don't do one unless I ask for it." I use it as often to convince the patient they don't have the flu as anything else.

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An NP I work with used to dump problem patients on my schedule without consulting me first. In other words if I had an opening and there was something she didnt want to see she move it over to my schedule, saying she was "too swamped" or some other transparent excuse. 

 

First couple of times there was a polite conversation, and the third (and last) time there was a very uncomfortable closed door confrontation. Needless to say it stopped. 

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PCPs sending people over for "high blood pressure." 90 percent of the time we do NOTHING in the ER. I force myself to get an EKG, BMP and urine even though it doesn't really change my management. My management is "Go home and see your PCP. Bye Felicia."

So if someone with a bp of 220/120 has 4+ protein in their urine that will not change your decision making?

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So if someone with a bp of 220/120 has 4+ protein in their urine that will not change your decision making?

I think it was more referring to the DUMP patient who has a 140/90 or 156/96 who just hasn't been addressed in FP or was scared by a dentist or pharmacist and sent to ER to make sure they aren't having a stroke.

 

It isn't right. Sometimes you have to deal with BP but it is no life threatening.

 

Of course, 220/110 with signs of end organ damage is hypertensive emergency or malignant HTN and needs to be dealt with.

 

Would be nice to have community support from FP offices to deal with this outside the ER.

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So if someone with a bp of 220/120 has 4+ protein in their urine that will not change your decision making?

The only indication for quick intervention, at least according to an article I read a few days ago, is indication of end organ damage or some kind of related symptoms. Outcome with and without immediate intervention is otherwise the same. I work in UC and we get patients in daily for "high blood pressure this morning." 180/96, asymptomatic. "See your PCP"

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