Have We Become Health Care-Minimalist?

[jmj11]

Some of you know that I was in a perfect state of health until January of this year. Then, virtually overnight, I became seriously ill and have remained quite ill since. Multiply Myeloma is the primary cancer, but it has taken out several other body systems. I completed an autologous stem cell transplant on June 22^nd.

So, I went from being a “no-health care system user,” to racking up about 1 million dollars’ (so far) worth of care in the past 8 months. This translates to hospitalizations, ER, and multiple outpatient visits with a variety of specialists and generalists, including PAs and NPs. During this process, I have learned a lot about being a patient and how our care looks from the outside.

One of the things, which I find astonishing, is how many providers refuse to touch anything “outside their area.” But, with one disease effecting so many body systems, the lanes are not well-defined. For example, my bone marrow cancer created so much light-chain proteins that is killed my kidneys. My kidney failure has caused serious and chronic anemia, as well as uncontrolled hypertension, neurological problems, and now (we think it is from the kidneys) resting tachycardia.

During these months I have seen many providers who shrug their shoulders and say, “I don’t know, that’s not my area.” Even my primary care will not address my uncontrolled hypertension as he says it is out of his area in someone as complicated as me.

Now, the one exception to this, was that I spent the summer at the Seattle Cancer Care Alliance and there they took on every facet of this terrible disease. But I’m back in the community and no longer under their care (they do the stem-cell transplants but don’t do chronic care). I’m really in a no-man’s land now and an often on my own, except I can’t prescribe for myself, nor do I want to.

I will switch gears from myself to mention another example of this. In mid-July I was so sick, that I gave up on reading or studying (which I had been doing up until that point) and watched mindless TV (TLC, or the “Loser’s Channel”) for a couple of days. One of the shows, which I had heard of before, was The Pimple Popper. If you are unaware, it follows a dermatologist (Sandra Lee) who excises a variety of cysts, such as epidermoid, pilar, or even lipomas. I have to say that the doctor was more professional than I had expected.

But on the show, I saw patient after patient with these huge, like 5-7 CM cysts. She asked them how long they have had them, and the patient says years. Dr. Lee looks perplexed each time and ask what they have done about it and most say (if you can believe patients) they have been to a variety of caregivers, Primary Care, Urgent Care, even ER, and they are told, with shrugged shoulders, “I don’t know what it is. There is nothing that can be done. Leave it alone and it will go away.”

The doctor had the same reaction that I do. “Say what?” They didn’t know what this is? It will not go away.”

If the patient is telling an accurate story, I have a feeling that someone just didn’t want to take the time to address the problem.

I shared an office once with a gynecologist. He was a great guy. I would notice him doing things like taking off ingrown toenails, excising pilar cyst, and treating hypertension. I asked him why was he doing these non-gyn things? He answered me, “I was a doctor before I was a gynecologist. If I did these things as an intern, surely, I can help my patient out who has no other resources.”

Now, certainly, we should not get in over our heads in things we don’t know. But, as a headache specialist, I can’t count how many times I’ve treated non-headache issues, for the sake of the patient. In the case of something like a cyst or rash (and we don’t have the equipment to care for that such as a punch bx) I would tell them that it can be treated and give them the name of a good dermatologist and never do the shoulder shrug.

So, what do you think? Do we ignore complaints because of the tight schedules that we must keep? Or, is this a good thing that we stay focused on the narrow lane in front of us? Mike
 

 

 

Edited August 8, 2019 by jmj11
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[LT_Oneal_PAC]

I think we’ve just become a field of specialists. Cardiologists won’t even prescribed amiodarone in my facility without talking with the EP cardiologist. It’s ridiculous. I get plenty of shrugs and eye rolls from colleagues, but I do lots of primary care from the ED and start chronic medications since I was in FM before. My dad, an IM physician, constantly complains about how no one is a real doctor anymore. No generalists who will manage all things. 

[Cideous]

The answer is pretty simple.  When something goes wrong, and it eventually will through no fault of the providers.....Lawyers will eat them alive for practicing "outside of their lane...".  Medicine is a long dark road built on fear.  Fear of missing something, fear of something just going wrong and fear of just bad luck being in the wrong place at the wrong time.  Deal with malpractice in this country and you will see a comeback in providers doing what they were trained to do...take care of people.

 

On a side note....I hope you are doing ok  

[Guest ERCat]

I agree that it is probably mainly about liability. When the gynecologist gets sued because he screws up someone’s toe after doing an ingrown toenail procedure the first thing that he will he asked in court is “What kind of doctor ARE you? A gynecologist? Is ir within the scope of practice of a gynecologist to treat an ingrown toenail...” I agree with you. But realize so many providers choose to “stay in their lane” not because they don’t care and want to shrug your concerns off; it’s all about FEAR of potential malpractice. 

[mgriffiths]

3 hours ago, ERCat said:

“What kind of doctor ARE you? A gynecologist? Is ir within the scope of practice of a gynecologist to treat an ingrown toenail...”

I know you are only using the toenail as an example...but in this situation why can't the answer be a resounding"YES!!!!!"?  As jmj11 stated, of course there are times where we have to be careful "not to get in over our heads" but general medicine is exactly what the name suggests...GENERAL MEDICINE.  By definition it is something that all providers should know how to treat.

[SedRate]

11 hours ago, jmj11 said:

In the case of something like a cyst or rash (and we don’t have the equipment to care for that such as a punch bx) I would tell them that it can be treated and give them the name of a good dermatologist and never do the shoulder shrug.

So, what do you think? Do we ignore complaints because of the tight schedules that we must keep? Or, is this a good thing that we stay focused on the narrow lane in front of us? 
 

 

 

As an Ortho trauma PA currently, I can't go outside of my SP's scope of medicine. But since I'm a generalist by schooling, for simple things, I ask my SP if he's ok with me treating X, and if so then I do it. Otherwise, I tell the patient, "It looks like you might have X, but you should see an X expert since I'm actually a broken bone expert and not an expert in X. I recommend that you see your Z for evaluation. +/- You might need Y treatment." I can't say that I've ever said, "I don't know *shrug*" and moved on without at least directing the patient to someone else. I think it's our duty to help others, even if it's just directing the patient to someone else. 

I have had my fair share of the Dr. Lee type reactions, but limited given current my scope in Ortho trauma where patients rarely get far without seeing us almost right away. 

I'm sorry to hear that you've had the experiences that you've had, especially during such a trying time. I hope you find the help you need.

[BruceBanner]

Mainly liability, but also managing your plate. There is so much administrative burden now. I constantly see patients who pull "oh by the ways" and "what about this". Our clinic even restricts each visit to one complaint, generally. But patients (humans) are rarely cognizant or sympathetic to the fact that maybe they are your 16th patient of the day or maybe you have 3 people in rooms waiting to see you, and you really dont have the time to dig into their other issues. You dont want to stay late and chart past dinner. They just want to get answers or get well. It's frustrating  as a patient feeling like every symptom needs it's own doctor! I dont think that is fair or efficient. 

But sadly the days of the country doc GP are gone. I worked for a guy like that once and he was awesome. Patients would follow him to the grave, literally.  

Also, I hope you are getting better and I think about you from time to time. Health can be a tenuous thing. 

Edited August 8, 2019 by BruceBanner

[rev ronin]

2 hours ago, BruceBanner said:

But sadly the days of the country doc GP are gone. I worked for a guy like that once and he was awesome. Patients would follow him to the grave, literally. 

Should they be, though?  There's a ton of things we don't learn in school, but we learn HOW to learn: how to read the literature, pick up on good CME, and keep up on medicine in general.  I switched from IT to medicine in large part because I ran out of things I cared to learn about in IT.  If I had enough time, I'd like to get better at a thousand things in medicine!  Off the top of my head, I'd like to be better in Ortho, derm, cardiology, nephrology, radiology, pulmonology, gerontology, psychiatric pharmacology, infectious disease, office procedures... and then everything else that I know I would love to know in a perfect world but really have no way to even get there from here like neurology, rheumatology, and heme/onc.

What I have mastered is listening to the patient and being a caring provider.  I know my basics, and I'm respectably good at a lot of things.  But I want to be better!  I want to grow old keeping up in medicine, learning how to make intelligent referrals and pose questions to specialists that they will relish digging into.

Had dinner with my 70's year old Alaskan SP a couple of weeks ago, and the topic of POCUS came up.  His comment?  In the near future, ultrasound will be as ubiquitous as a stethoscope.  That's an awesome, forward thinking perspective for someone who's practiced medicine for longer than I've had an email account.  I want to be like that when I grow up.

[ohiovolffemtp]

I think there's a big difference between treating an isolated acute condition that's outside of your specialty, like performing an office procedure, or managing a relatively straightforward chronic condition, like initial management of asthma or hypertension, vs attempting to manage a complicated condition where 1st and possibly even 2nd line treatments have been insufficient.

I do EM, so I'll do initial management of newly diagnosed conditions, like asthma, hypertension, hyperglycemia, but I won't make changes to someone's anti- fill in the blank - hypertensives, hyperglycemics, anti-epileptics, depressants, etc. especially when they're on multiple meds.  Lack of continuity of care is part of it, lack of knowledge of the subtleties of the patient and the 2nd & 3rd line treatments is another part.  Primary care hopefully gets the continuity, and hopefully knows more about the 2nd line treatments, but still have to punt on more complex cases.

It always depends on where you draw the line.  How much you do for 1 patient vs how many patients are left unseen is also relevant.

[jmj11]

I probably should not have used Dr. B (the gynecologist) as an example as he was the extreme, but I was staking out the argument. I am trying to think of a better example, without resorting to my own stories. because I don't want to give the impression that I'm seeking medical advice, which I'm certainly not. But I get confused (from my own experience and from what my patients have told me) that when, at the primary care things like hypertension is not addressed, or depression, or a new rash and etc.

So here's an example. A migraine patient comes to see me  for a routine follow up and they show me a new rash all over their body. I certainly look at it. First, I want to make sure it has nothing to do with what I'm prescribing or maybe it is something I can easily diagnose, (eg. Pityriasis rosea).

Then I ask, "Did you show your primary care provider?"

They respond, "Yeah, I went to see her and she has no clue."

I then ask, "Then, what was her plan?"

They say, "She didn't have a plan. She just shrugged her shoulders and said she didn't know what it was and that wasn't her area."

I ask, "Did she refer you to a dermatologist?"

Patient: "No."

Me: "Well, I will, because I'm not sure what it is, but someone does."

 

[DogLovingPA]

On ‎8‎/‎8‎/‎2019 at 12:39 AM, Cideous said:

The answer is pretty simple.  When something goes wrong, and it eventually will through no fault of the providers.....Lawyers will eat them alive for practicing "outside of their lane...".  Medicine is a long dark road built on fear.  Fear of missing something, fear of something just going wrong and fear of just bad luck being in the wrong place at the wrong time.  Deal with malpractice in this country and you will see a comeback in providers doing what they were trained to do...take care of people.

 

 

This.  We had a very sweet elderly pt the other day come to UC for assistance in taking off their bandage after pacemaker placement as they were too nervous to do it at home.  The doc I was with at first refused to do it as we had not placed it.   My coworkers are so terrified of litigation they literally were scared to remove a bandaid. 

[DogLovingPA]

But I agree, strange not to provide the patient with some direction if you are unable (or unwilling) to help them. 

[thinkertdm]

I get 

8 hours ago, jmj11 said:

I probably should not have used Dr. B (the gynecologist) as an example as he was the extreme, but I was staking out the argument. I am trying to think of a better example, without resorting to my own stories. because I don't want to give the impression that I'm seeking medical advice, which I'm certainly not. But I get confused (from my own experience and from what my patients have told me) that when, at the primary care things like hypertension is not addressed, or depression, or a new rash and etc.

So here's an example. A migraine patient comes to see me  for a routine follow up and they show me a new rash all over their body. I certainly look at it. First, I want to make sure it has nothing to do with what I'm prescribing or maybe it is something I can easily diagnose, (eg. Pityriasis rosea).

Then I ask, "Did you show your primary care provider?"

They respond, "Yeah, I went to see her and she has no clue."

I then ask, "Then, what was her plan?"

They say, "She didn't have a plan. She just shrugged her shoulders and said she didn't know what it was and that wasn't her area."

I ask, "Did she refer you to a dermatologist?"

Patient: "No."

Me: "Well, I will, because I'm not sure what it is, but someone does."

 

I get this a lot - “I was discharged from from the hospital and they had no clue what to do”

”the doc there had no no idea what this is”

but when I get the records, there is actually a clue, and a plan.  The failure was to tell the patient the plan, or the importance of following through with the plan, or of listening to the details.

trust the patient but also verify.  The human body is a mysterious thing, but the number of maladies that confound residency trained doctors is astounding and frankly, unbelievable.

[CAdamsPAC]

45 minutes ago, thinkertdm said:

I get 

I get this a lot - “I was discharged from from the hospital and they had no clue what to do”

”the doc there had no no idea what this is”

but when I get the records, there is actually a clue, and a plan.  The failure was to tell the patient the plan, or the importance of following through with the plan, or of listening to the details.

trust the patient but also verify.  The human body is a mysterious thing, but the number of maladies that confound residency trained doctors is astounding and frankly, unbelievable.

Patient don't speak "Doctor" and are often unwilling to say that they don't understand or worse they don't agree with the plan and then come to us to make things right.

[jmj11]

1 hour ago, thinkertdm said:

I get 

I get this a lot - “I was discharged from from the hospital and they had no clue what to do”

”the doc there had no no idea what this is”

but when I get the records, there is actually a clue, and a plan.  The failure was to tell the patient the plan, or the importance of following through with the plan, or of listening to the details.

trust the patient but also verify.  The human body is a mysterious thing, but the number of maladies that confound residency trained doctors is astounding and frankly, unbelievable.

I agree. It is not always good to believe everything a patient tells you.

I will come back to my story, only because I know it is accurate. Again, don't get bogged down in the specifics as I'm talking about the principles. So, out of the blue I developed hypertension (probably related to my renal disease) in July. The cancer center (which did get involved with every complaint) started me on a beta blocker. The first dose did not help and it was doubled. For the three weeks I've been home, the higher dose also hasn't make any difference. I am scheduled to see nephrology for follow up, but their first appointment is mid Sept. I went to my Family doc. I showed him my B/P readings (all high). He said yeah, he didn't like the med I was on (and I agreed having done my own research) and I asked him to change it to something (ACE-I) better. He refused because he said he wasn't getting involved with my hypertension care. That was puzzling to me as he knew the soonest I can see the nephrologist is 6 weeks and have only seen him as a inpatient consult. 

So, it is about me or hypertension, it is this pattern where providers don't want to get involved, even when it is within their usual scope of practice.

Edited August 10, 2019 by jmj11

[ohiovolffemtp]

Another factor could well be the difficulty in 1 provider being able to speak to another, e.g. your PCP not easily being able to have a 5 min phone conversation with your oncologist (or nephrologist) to discuss making a change to your anti-hypertensives.  I've waited hours at times for specialists or even patient's PCP's to return calls/pages from the EM.  Lack of a brief consult with the specialist can make me very reluctant to change a patient's meds unless they are way off.

[UGoLong]

This.  We had a very sweet elderly pt the other day come to UC for assistance in taking off their bandage after pacemaker placement as they were too nervous to do it at home.  The doc I was with at first refused to do it as we had not placed it.   My coworkers are so terrified of litigation they literally were scared to remove a bandaid. 

I would have had an MA call the EP guy’s office and ask when the bandage was sypposed to be removed (assuming the pt didn’t have her dc instructions with her) and then removed it. The steri-strips just fall off on their own.

Not doing something for a pt like this seems like excess fear to me.


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[UGoLong]

I agree. It is not always good to believe everything a patient tells you.
I will come back to my story, only because I know it is accurate. Again, don't get bogged down in the specifics as I'm talking about the principles. So, out of the blue I developed hypertension (probably related to my renal disease) in July. The cancer center (which did get involved with every complaint) started me on a beta blocker. The first dose did not help and it was doubled. For the three weeks I've been home, the higher dose also hasn't make any difference. I am scheduled to see nephrology for follow up, but their first appointment is mid Sept. I went to my Family doc. I showed him my B/P readings (all high). He said yeah, he didn't like the med I was on (and I agreed having done my own research) and I asked him to change it to something (ACE-I) better. He refused because he said he wasn't getting involved with my hypertension care. That was puzzling to me as he knew the soonest I can see the nephrologist is 6 weeks and have only seen him as a inpatient consult. 
So, it is about me or hypertension, it is this pattern where providers don't want to get involved, even when it is within their usual scope of practice.

Doubt I would have changed a beta blocker to an ACEI in a patient being followed for a renal disease. Amlodipine, maybe. With HTN being the most frequent dx in the US, we shouldn’t be afraid to do something if the bp is significantly elevated, if we feel up to it professionally.


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[jmj11]

6 hours ago, UGoLong said:

 

Doubt I would have changed a beta blocker to an ACEI in a patient being followed for a renal disease. Amlodipine, maybe. With HTN being the most frequent dx in the US, we shouldn’t be afraid to do something if the bp is significantly elevated, if we feel up to it professionally.


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I trust what you say as HTN is not my area, no pun intended. But here is a paper I reviewed and my FP-MD agreed but said he was not getting involved by prescribing me anything.

 

[EndBulbsOfMouse]

I generally do not get involved in managing a medication if another physician is managing it.  I think multiple people managing a single issue can lead to major problems.  I think what your FP can do is call the nephrologist and come up with a plan prior to your nephrology appointment.  

[sas5814]

On 8/9/2019 at 5:31 PM, DogLovingPA said:

This.  We had a very sweet elderly pt the other day come to UC for assistance in taking off their bandage after pacemaker placement as they were too nervous to do it at home.  The doc I was with at first refused to do it as we had not placed it.   My coworkers are so terrified of litigation they literally were scared to remove a bandaid. 

I have had several people come to the UC to get the dressing changed on a PICC line. Nope. I haven't touched a PICC line in years and the staff didn't even know what one was. 

That may seem extreme but what if any complication had arrised? Particularly a bad one.

The questions start with "how much training and experience have you had with PICC lines?" and it just gets worse after that

Edited August 12, 2019 by sas5814

[mgriffiths]

2 hours ago, sas5814 said:

I have had several people come to the UC to get the dressing changed on a PICC line. Nope. I haven't touched a PICC line in years and the staff didn't even know what one was. 

That may seem extreme but what if any complication had arrised? Particularly a bad one.

 The questions start with "how much training and experience have you had with PICC lines?" and it just gets worse after that

I would say there is pretty big difference between a pacemaker incision and a PICC line.  They should be following with someone pretty regularly if they have a PICC line and have someone to call if there is an issue, so I would agree no reason to touch it.

[Cideous]

I won't take staples out in Urgent Care that a Surgeon put in and the patient says are "ready to come out".  That thing dehisces and I am screwed.

[sas5814]

20 minutes ago, Cideous said:

I won't take staples out in Urgent Care that a Surgeon put in and the patient says are "ready to come out".  That thing dehisces and I am screwed.

My policy as well. When did surgeons stop following their own patients and when did OBs start sending everything to the UC or ER? When I was a young pup they would have ripped your head off for getting involved in their patients care without an invite.

[SedRate]

I have had physical therapists and PCPs intervene without contacting us, only to cause a dehisence and in some cases infection. I had one pt who saw her PCP for all of her post-op care for an open fracture in the setting of significant tobacco use only to finally follow up with us 3 months later after three rounds of antibiotics failed to heal her infected wound dehisence, nonunion, and stiffness due to failure to do PT (never prescribed or instructed to do or go to a PT). Do not mess with the special dressing, sutures or staples of surgical wounds without first contacting the surgical service! 

3 hours ago, Cideous said:

I won't take staples out in Urgent Care that a Surgeon put in and the patient says are "ready to come out".  That thing dehisces and I am screwed.