How would you reply to this facebook post?

[Planteater]

[h=6]The following is copied and pasted directly from my news feed on facebook. My friend, who is a physician (radiologist), posted this response to this NPR article. It burned me up just reading it. I did already post a response, but I would like to know what some of you would say to this friend (nicely please- this is an actual friend, not just an online "friend"). Here is the comment with the link to the article below:

 

 

+1, Great article. So many of the studies I do every day are unnecessary (from radiologists point of view). I can talk to referrers until I'm blue in the face about why they ordered this scan or that. Especially mid-level providers (PA's, NP's, etc.) who don't understand the pathophys fully and order shotgun studies. One more reason why health care costs are through the roof, but can't change. Also, ER doc are HEAVY utilizers of imaging, but as the article says, the American public has a zero tolerance for a missing a "zebra" (rarity) when we should be looking at the "horses". Lawyers have lots of power.[/h]Doctors Urge Their Colleagues To Quit Doing Worthless Tests

www.npr.orgNine national medical groups have identified 45 diagnostic tests, procedures and treatments that they say often are unnecessary and expensive. The head of one of the specialty groups says unneeded tests probably account for $250 billion in health care spending.

[Jason09]

This is a tough thing to balance as hindsight is 20/20. Yeah a lot of tests we order in the ER come up negative but it is our job to r/o certain pathology and sometimes expensive imaging and labwork is necessary. You cannot expect practitioners to order less tests without covering our asses with tort reform and protection for lawyers. How many AAAs or dissections will we see in our career? Probably not many but miss one in an over 50 y/o with "constipation" abd pain and the lawyers are waiting. It is easier to say d/c to home without imaging when their name is not on the chart. This holds true to admitting docs who don't want to admit borderline patients but also don't want to have their name on the chart. If this were my friend I would try and explain via phone or in person about the above. Agree that a lot of tests are not 100 percent necessary but what is the alternative and see what they say? I would ask them when they feel these tests are not necessary and what they would do differently? It is easier to say they are not needed but harder to come up with a valid alternative that protects us and the patient? I tend to try and not argue with people but come to an understanding. I would love to order less CT scans and LP's or things like that but often times there are no good alternative.

[ventana]

alot of what he says is correct - I can't count the number of times I have asked why a provider ordered a test and I get is a deer in the headlight look - this comes with time and experience and coaching from more knowledgable folks

 

honestly I would use it as an opportunity to set up some training that the Rad can do with local providers - ie PA/NP

Sucks he called us out on it as it is a systemic issue - - there might be jsut 1-2 local PA/NP who just order way to much stuff and he then wrongly applies this to all midlevels......

 

I am honestly amazed at what some people order on a regular basis that people don't question - I commonly see reproductive age females that have had 6-10 Abd Pelvis CT's with contrast..... we need to educate ourselves on how to avoid such situations.....

 

 

 

talk to him directly and NOT on facebook as this is a private matter - as for a response on FB - would keep it short - get a link to prove pa/np quality of care is no different - - then talk to him

[physasst]

Agree with Ventana. I would not confront him in a public forum if he is a true friend. I would speak to him privately. There is nothing to gain, and a lot to lose by calling him out publicly.

 

Secondly, you have to be careful about being so pro PA that you lose objectivity...I know, I've made that mistake on several occasions. It's very easy to become so wrapped up in advocacy that you forget that perhaps he has a point.

 

Personally, I think that would make a good study, comparing testing rates among providers on a certain set of diagnoses on a longitudinal basis. We may not like the results...or we might. We have to be honest about the fact that maybe PAs and NPs DO order more tests....

 

As far as testing.....Docs and providers like to cite Lawyers...but that's a scapegoat. Studies have shown that rates of testing went up in areas with tort reform, and one study demonstrated a HIGHER rate of c-section births after tort reform.

 

The simple truth is....docs and providers care about their patients. It's what drew us to medicine. We don't want to miss something either. We like to blame it on the fear of litigation, but I truly believe that is nothing more than a rationalization for our own personal fears.

 

For example, one physician I work with and I were discussing CT imaging, and I was discussing how, as I have progressed further in my career, I tend to order fewer and fewer tests. She remarked that she would like to get there some day, but now the possibility of missing something bothers her too much. She said it would keep her awake at night...

 

To which I replied, well, you need to really think then about whether you are ordering the test for the patient, or for yourself. And if it is the latter, perhaps it doesn't need to be done...

[andersenpa]

What I read on your post here is that

 

1. PAs/NPs over-order studies becuase they don't know what's going on

2. Docs over-order studies for medicolegal purposes

 

Uh-huh.......

[GeneValgene]

Agree with Ventana. I would not confront him in a public forum if he is a true friend. I would speak to him privately. There is nothing to gain, and a lot to lose by calling him out publicly.

 

Secondly, you have to be careful about being so pro PA that you lose objectivity...I know, I've made that mistake on several occasions. It's very easy to become so wrapped up in advocacy that you forget that perhaps he has a point.

 

Personally, I think that would make a good study, comparing testing rates among providers on a certain set of diagnoses on a longitudinal basis. We may not like the results...or we might. We have to be honest about the fact that maybe PAs and NPs DO order more tests....

 

As far as testing.....Docs and providers like to cite Lawyers...but that's a scapegoat. Studies have shown that rates of testing went up in areas with tort reform, and one study demonstrated a HIGHER rate of c-section births after tort reform.

 

The simple truth is....docs and providers care about their patients. It's what drew us to medicine. We don't want to miss something either. We like to blame it on the fear of litigation, but I truly believe that is nothing more than a rationalization for our own personal fears.

 

For example, one physician I work with and I were discussing CT imaging, and I was discussing how, as I have progressed further in my career, I tend to order fewer and fewer tests. She remarked that she would like to get there some day, but now the possibility of missing something bothers her too much. She said it would keep her awake at night...

 

To which I replied, well, you need to really think then about whether you are ordering the test for the patient, or for yourself. And if it is the latter, perhaps it doesn't need to be done...

 

strong post

[Planteater]

Thanks for the feedback. I would love to see some real studies comparing outcomes, but separating PAs from NPs and comparing them to MDs. Is there anything like this out there or in the works? I've seen the NP study, but from what I have read it might not have been the most well designed study.

 

I already replied to this friend in FB before I got input from you guys. My reply was this:

 

"I was just reading about people who put their dogs through chemo & radiation....if we, as a culture, cannot even let go of our animals in a dignified way, is there hope that we will stop fighting human death so hard? I wish you would not group all mid-level providers together. There are many great ones who understand the pathophysiology very well and are wise enough to consult someone if they do not. Also, one could argue that MLPs have to follow the standard of care even more closely than physicians because their jobs are more tenuous. So, they might know very well that a test is unnecessary but order it anyway to cover their behinds."

 

Hopefully I did OK with that one...

 

There was some discussion above my comment about people convincing their older loved ones to endure cancer treatments that merely extend the life for a few months and make it miserable and also about standards of care and attorneys- just to explain some of my seemingly off-topic comments. The friend's reply was basically "I am not against MLPs- I just see a lot more unnecessary tests ordered by NPs". So, his original rant *may* have been directed more at NPs, but he grouped us all together as MLPs. IDK but I am not going to continue the conversation on facebook right now- I will save it for when we get to see them in person again (and I will probably be a PA-C by then because they moved across the country from us).

[MMiller]

What I read on your post here is that

 

1. PAs/NPs over-order studies becuase they don't know what's going on

2. Docs over-order studies for medicolegal purposes

 

Uh-huh.......

 

This was the first thing I took away from it as well.

 

As for what physasst stated, I have to agree with that as well. I do order tests that may ultimately be unnecessary, but the thought of sending someone home having missed something serious would be cause for a sleepless night/weekend. I'd sooner order a borderline test and be sure, rather than worry about the economics of it.

[Guest cabkrun]

Patient demands as well. The internet means everyone comes in with a potential self-diagnosis. 300 pound man with back pain wants an MRI cuz he read he might have a "blown disc". Even if he's told it probably won't change the course of treatment, he doesn't care... he wants his MRI. Most of the time he'll get it.

 

In terms of the sweeping generalization that a class of providers (PAs) order more tests because they know less physiology... well, obviously an unfair assumption since knowledge, skill and aptitude are so individual and also can grow with experience... so I'd certainly not fight about it over Facebook. Probably a losing battle :)

[JFarnsworth]

With the litiginous environment that all medical providers face, it's disingenuous to say that any one arbitrarily orders too many tests, and worse that they attribute ordering radiologic studies to a lack of pathophys knowledge. I've read the report about how a group of physicians are trying to cut down on healthcare costs by cutting back on "unnecessary" diagnostic tests. All it will take is one lawsuit and I bet they all give up on this idealistic premise (even though I agree with them. Who wants to be the first to put their money where their mouth is?). I worked with an ER doc who got sued no less than 12 times and you can bet that every patient he saw got the million dollar work up. It reminds me of the joke... how do you hide a dollar from a radiologist? Put it on the patient. Just an opinion.

[Guest cabkrun]

Well I am not a PA yet but can say from both personal experience as well as some things I saw as an MA that it seems to be a very fine line to walk. Some patients are not good at describing symptoms, some hide things, etc. So an 'unnecessary' test could very well save a life. I think it's a good thing to always keep a handle on (insurance companies seem to make sure that happens), but to start taking it to the other extreme can only lead to problems. There is certainly a lot of defensive medicine practiced, yet I have also seen a lot of 'your symptoms are very strange but it's not cost effective to order that test' kind of thing too... And that test could have saved a lot of suffering and money in the long run.

Has nothing to do with what this radiologist is talking about in my limited knowledge opinion.... That seems like a cheap shot. Radiologists certainly make a living off this so called unnecessary testing ;)

So sure jfarsnworth, I think you make valid points.

 

 

With the litiginous environment that all medical providers face, it's disingenuous to say that any one arbitrarily orders too many tests, and worse that they attribute ordering radiologic studies to a lack of pathophys knowledge. I've read the report about how a group of physicians are trying to cut down on healthcare costs by cutting back on "unnecessary" diagnostic tests. All it will take is one lawsuit and I bet they all give up on this idealistic premise (even though I agree with them. Who wants to be the first to put their money where their mouth is?). I worked with an ER doc who got sued no less than 12 times and you can bet that every patient he saw got the million dollar work up. It reminds me of the joke... how do you hide a dollar from a radiologist? Put it on the patient. Just an opinion.

[Contrarian]

Umm... I do agree that lots of unnecessary testing occurs at the request of ALL providers as a whole.

 

But yeah... his is a interesting perspective when we consider that its coming from someone who by specialty likely RARELY ever interviews or even touches a patient.

 

So sitting in the dark, in the reading room, declaring the necessity of tests ordered by other clinicians on patients one has NOT interacted with, interviewed, examined is folly...

[Guest cabkrun]

The other thing I have noticed is that with the advancement of technology and all these tests, it seems so much easier to order an imaging study to look for causes of things such as pain vs. Actually touching and thoroughly examining the patient. Could be because of time constraints. Again, coming with very limited experiencing and I am in a thread in which I don't belong :).

 

Contrarian... Lol. Very true. You have to wonder how thorough they are in their readings if they look at a study and think it was unnecessary.

[True Anomaly]

Umm... I do agree that lots of unnecessary testing occurs at the request of ALL providers as a whole.

 

But yeah... his is a interesting perspective when we consider that its coming from someone who by specialty likely RARELY ever interviews or even touches a patient.

 

So sitting in the dark, in the reading room, declaring the necessity of tests ordered by other clinicians on patients one has NOT interacted with, interviewed, examined is folly...

 

Plus, also not knowing just how many patients are actually turned away without any imaging...ergo, a sort of referral bias emerges.

[True Anomaly]

The other thing I have noticed is that with the advancement of technology and all these tests, it seems so much easier to order an imaging study to look for causes of things such as pain vs. Actually touching and thoroughly examining the patient. Could be because of time constraints. Again, coming with very limited experiencing and I am in a thread in which I don't belong :).

 

Don't know where you are in your training, but hopefully once you get on clinicals (or if you already are on clinicals), you're rotating with clinicians who are actually doing a proper physical exam and ordering tests as appropriate. Perception is not always reality, young padawan- just because it seems like it's easier to order imaging tests rather than doing an exam doesn't necessarily mean it's happening, and it's borderline malpractice to do so in some instances. For example, the female of reproductive age with lower abdominal pain. I would really really really really hope that an abdominal AND pelvic exam is done before deciding even IF an imaging study is needed, let alone which one...

[brookspa]

a radiologist said that. It has been my experience that when questioned about the reading of the study and an inquiry about the underlying pathology, the radiologist is the first to deny ANY opinion whatsoever. Most of them are silent when it comes to pathology, medicine, examinations or differentials EXECPT when they request ADDITIONAL imaging studies (usually an MRI) so they are guessing less and reading a study more to their liking or expertise. but, maybe thats just me and my experience.

 

Kill all the lawyers, and i will consider fewer tests.

[ventana]

but what about the 33 yr old female that has had 10 ABD/Pel CT's with contrast to look for a new pathology (all ordered by ER doc's)

 

Now she is seeing me for primary care and I have to talk to her about radiation exposure and the risk to reproductive and abd organs......

 

or what about the 50 yr old with a history of kidney stones that has had more noncontrast Abd/Pal ct's then I can count...... we are harming the patient by being lazy and just ordering a CT instead of an US to ensure no hydro

 

 

 

 

Radiation exposure causes cancer - this is a know fact although we do not know much more then this or rather is a a threshold issue - but I have seen both PA's and NP's as well as doc's ordering what I consider stupid CT's for simple abd complaints..... and some are my patients that I know very well and SHOULD NOT be getting more radiation exposure.

 

 

 

 

High speed MRI is going to be a game changer that takes the cancer risk out but for the time being I think imaging is indeed ordered to much.....

[Guest cabkrun]

My statement was not worded correctly. It's not something that I personally believe ... :)

 

Don't know where you are in your training, but hopefully once you get on clinicals (or if you already are on clinicals), you're rotating with clinicians who are actually doing a proper physical exam and ordering tests as appropriate. Perception is not always reality, young padawan- just because it seems like it's easier to order imaging tests rather than doing an exam doesn't necessarily mean it's happening, and it's borderline malpractice to do so in some instances. For example, the female of reproductive age with lower abdominal pain. I would really really really really hope that an abdominal AND pelvic exam is done before deciding even IF an imaging study is needed, let alone which one...

[brookspa]

CT is still the study of choice...quick to do and get read. U/S is fine, with an operator and a machine available and much more operator dependant. (i have u/s 1 or 2 days a week..ct 24/7). Not to mention no prep for CT whereas U/S requires no sodas/gassy belly on board for study. and as an ER guy...please keep your 33 yoa female coming to the office or see her in less that 3 weeks qnd keep her out of my ER for these "required" belly scans. yes, its mostly to cover my ***. my index of susp. is LOW. But i love my lisc. and ct is almost bullet proof in court when negative for acute path. as long as she cant get in to see you in a timely manner, <24 hrs, she will continue to come to see me. Educate her, delight her, soothe and reassure her but please keep her out of the ED for these rout. c/o. just another perspective.

[pagirl82]

It really annoys me when the MD/DO crowd acts like they make all decisions based on their knowledge of pathophysiology and PA/NP's make all decisions based on "algorithms".

 

First of all, despite all of our amazing scientific advances, there's still plenty of physiology that is unknown or uncertain. I'd be pretty uneasy if someone tried to diagnose a medical problem I had based solely on their knowledge of physiology. It's not realistic and it's shortsighted. There's not enough certain knowledge to connect all of the dots. Even if there were, there's likely plenty of mechanisms that are yet to be "discovered". If someone, based on history and physical exam, launches into a conversation consisting of only pathophysiology with themselves to come up with an appropriate assessment and plan, I'd like them to write down exactly what their thought process is. I'd love to see it.

 

I can't speak for all PA schools, but mine DID have dedicated physiology, pathophysiology, and pathology courses. They were taught by professors from our medical school. I lived with a med student at that school. We had nearly identical courses. I do realize that medical schools, in general, teach more pathophys. than PA schools. However, all PA and med schools are required to include pathophysiology in their curriculum. The quality and quantity will vary greatly among both PA and med schools, but we all know that you just learn the basics in school and eventually what you learned might become outdated. Any physician with extensive knowledge in pathophysiology is likely self-taught. The same goes for PA's.

 

Second, I didn't learn any algorithms in PA school. I learned clinical medicine. I learned physical exam skills. I learned diagnostic medicine. I learned critical thinking. I learned pharmacology. I never saw an algorithm or flow chart. Not once. Yes, they do exist in medicine and they serve a purpose, but their roots don't come from PA education. I don't understand where that rumor got started.

 

I've heard a lot of physicians make claims that PA/NP's make more referrals and order more tests than MD/DO's, so I'm inclined to believe that's true. I've heard physicians tell stories of dumb mistakes made by PA/NP's. We can be defensive and say they ignore mistakes made by physicians and zero-in on us, but that doesn't change anything. Yeah, we make mistakes. Sometimes really dumb mistakes. I remember a conversation between an experienced ER doc and an experienced PA, who was complaining about the fresh out of residency ER docs. He laughed and told the PA to go easy on them, while recalling all of his unfathomable mistakes early in his career. A high percentage of PA/NP's are in the early stages of their career. Bad decisions are probably due to inexperience, not lack of proficiency in pathophysiology.

 

I'm not trying to state that PA's are equal to or better than MD/DO's. I'm not saying that our education is the same. Their schooling is longer. They learn more in school. Their training is longer. They master more skills before they begin independent practice. What I am saying is that I hate PA's being portrayed as lacking any education in the sciences, while physicians are portrayed to utilize "science" almost exclusively in their practice. It's just not true. I don't mind so much that there are misconceptions about PA's. Physicians (with the exception of those who have gone PA-->MD/DO) don't know exactly what PA school (and their undergrad experience) is like or how much learning individual PA's have done on their own. Physicians DO know what medical school is like. They have DO know what their own thought processes are like. Most physicians who claim that their decisions are completely/mostly based on advanced knowledge of pathophys./pharmacology/thinking at the "molecular level" aren't being truthful (yes, there will be exceptions). Such claims don't even make sense.

[ventana]

CT is still the study of choice...quick to do and get read. U/S is fine, with an operator and a machine available and much more operator dependant. (i have u/s 1 or 2 days a week..ct 24/7). Not to mention no prep for CT whereas U/S requires no sodas/gassy belly on board for study. and as an ER guy...please keep your 33 yoa female coming to the office or see her in less that 3 weeks qnd keep her out of my ER for these "required" belly scans. yes, its mostly to cover my ***. my index of susp. is LOW. But i love my lisc. and ct is almost bullet proof in court when negative for acute path. as long as she cant get in to see you in a timely manner, <24 hrs, she will continue to come to see me. Educate her, delight her, soothe and reassure her but please keep her out of the ED for these rout. c/o. just another perspective.

 

 

first I am ER & Primary care so I feel your pain - just finished a block of 3 x12 in the ER

 

second - how on earth am I supposed to keep her out of the ER - I can't lock her up or restrain her - lets get real here

 

third - ER providers have got to look back in the EMR (if you have one) or at least ask the patient about past scans - it is stupid and bad medicine to get the 13th scan for the same pain they have had 12 times before in the past few years with 12 negative scans - you are correct it is study of choice for an acute abdomen, but to merely lump every belly pain into the acute abd catagory is not fair to the patient

 

No one will ever get sued for ordering a CT when the patient gets cancer 20-40 years later from to many CT's (literally dozens in some patients) but that does not mean that you can just ignore the risk of repeat radiation exposure and honestly your kurt reply shows me that you really don't care and that is a problem.

 

Have you ever gone into an exam room, sat down and had a discussion with the patient about the risks of a CT? I have and do and will continue to even if it is a "waste of my time". Many times when I have a ? belly I can talk to the patient and offer alternative SERIAL EXAMS ARE AN ALTERNATIVE that is much safer for the patient - and still gold standard medicine (go look it up....) or get a surgeon to see them.... Or just talking to the patient about the risks of CT and suddenly theri presentation changes a fair amount and I become more comfortable with not scanning them.

 

 

 

 

 

We are going to be having a HUGE number of cancers develop that we have caused (typically in the drug seeking patient) from the repeat numerous CT's given. No you can't ignore an acute abd, but you can talk to your patient (and don't babble on about lack of time - I see 30+ patients ina 8 hour shift at one job and 22-30 in a 12 hour shift at another job and still manage to do this because it is important!)

 

Sorry to climb on my soap box but this is going to be a HUGE issue (and one that moves the ER imaging world to high speed MR and improved US - 3d reconstruction would cool) that we should be being proactive on.

 

 

And don't pick on the primary care folks by saying we can some how magically keep patients out of the ER when in fact it is likely the repeat dosing and administration of controlled substances from the ER that keeps the drug seekers coming back for more......

 

 

 

 

I've heard a lot of physicians make claims that PA/NP's make more referrals and order more tests than MD/DO's, so I'm inclined to believe that's true. I've heard physicians tell stories of dumb mistakes made by PA/NP's. We can be defensive and say they ignore mistakes made by physicians and zero-in on us, but that doesn't change anything. Yeah, we make mistakes. Sometimes really dumb mistakes. I remember a conversation between an experienced ER doc and an experienced PA, who was complaining about the fresh out of residency ER docs. He laughed and told the PA to go easy on them, while recalling all of his unfathomable mistakes early in his career. A high percentage of PA/NP's are in the early stages of their career. Bad decisions are probably due to inexperience, not lack of proficiency in pathophysiology.

.

 

Actually interesting study out recently that Doc's in primary care have changed their refereal rate to specialists from about 3% years ago to about 10% now - it is not PA/NP driving this - and really who knows what is driving it. But I in my little world I see 50+ year old doc's that are tired of practicing and having to work harder to get paid less and instead of working with the patients they just refer out. Especially with the annoying high time patients that just are time black holes - instead of managing that simple ankle sprain with an air cast and PT they send to ortho - this allows them to see 2 more patients that day and get a tiny bit more revenue for the practice to help pay the bills......