Treating Over the Phone...
Is not the same as diagnosing over the phone.
This post by Angry Doctor got me thinking about proper management of patients with abnormal laboratory values. KevinMD agrees with AngryDoc that "under no circumstance should physicians diagnose over the phone."
While that blanket statement is debatable, particularly with regards to diagnosis of urinary tract infections in females, I would submit that once one receives a straightforward abnormal laboratory value such as a potassium of 3.3 or an INR of 5, the diagnosis has been made. The only thing left to do is to decide the treatment. MD stands for "make decision," right?
Spare me the long-winded discussions about the importance of differential diagnosis in the assessment of hypokalemia, or the considerations regarding the etiology and potential dangers of overanticoagulation. I'm quite familiar with them, thank you. But you ought to realize that in the ER, the borderline hypokalemic is going to simply get a potassium tablet, and the asymptomatic coagulopath is going to be told to hold his Coumadin today and follow up with you tomorrow for further recommendations.
Can't you do that yourself, or do you really need me to do it for you?
I suspect that the reason some primary care physicians do not want to manage these types of patient issues over the phone is related to the lack of reimbursement for such "hands-off" management under our current system. I'm more than happy to charge your patient hundreds of dollars for doing something that you can't charge anything for. But is that really the right thing to do?
Financially, I understand your concerns. Ethically, I think you should take care of your own patients, like a physician is supposed to do. Put yourself in their place and honestly admit to yourself how you would like to be treated under similar circumstances.
This post by Angry Doctor got me thinking about proper management of patients with abnormal laboratory values. KevinMD agrees with AngryDoc that "under no circumstance should physicians diagnose over the phone."
While that blanket statement is debatable, particularly with regards to diagnosis of urinary tract infections in females, I would submit that once one receives a straightforward abnormal laboratory value such as a potassium of 3.3 or an INR of 5, the diagnosis has been made. The only thing left to do is to decide the treatment. MD stands for "make decision," right?
Spare me the long-winded discussions about the importance of differential diagnosis in the assessment of hypokalemia, or the considerations regarding the etiology and potential dangers of overanticoagulation. I'm quite familiar with them, thank you. But you ought to realize that in the ER, the borderline hypokalemic is going to simply get a potassium tablet, and the asymptomatic coagulopath is going to be told to hold his Coumadin today and follow up with you tomorrow for further recommendations.
Can't you do that yourself, or do you really need me to do it for you?
I suspect that the reason some primary care physicians do not want to manage these types of patient issues over the phone is related to the lack of reimbursement for such "hands-off" management under our current system. I'm more than happy to charge your patient hundreds of dollars for doing something that you can't charge anything for. But is that really the right thing to do?
Financially, I understand your concerns. Ethically, I think you should take care of your own patients, like a physician is supposed to do. Put yourself in their place and honestly admit to yourself how you would like to be treated under similar circumstances.
posted by scalpel at 7:59 AM
13 Comments:
Good Monday morning to you, Scalpel,
Ah, if your word could only become law.... But then common sense would reign.
But you ought to realize that in the ER, the borderline hypokalemic is going to simply get a potassium tablet, and the asymptomatic coagulopath is going to be told to hold his Coumadin today and follow up with you tomorrow for further recommendations.
Exactly. If everyone who had an INR that was off or a potassium that was a little off went to the ER, we'd see nothing else. Why are we drawing labs (INR excluded) like potassiums without examining the patient anyway?
I respectfully diagree.
The K of 3.3 or the INR of 5 may not reflect the value of the moment. It may have been drawn at 10 AM, and the PCP gets called after hours for it. The blood often waits around to be picked up by a lab. If an ER didn't draw a repeat K, nbut only gave K tablets, I would say they didn't meet the standard of care.
With all due respect to the nurses, I wish you wouldn't offer treatment decision opinions, since you have nowhere near the level of responsibility (i.e. liability) nor the experience to offer a valid and unbiased opinion.
Oh, don't worry. If you're going to bother to send them to the ER, I'll certainly bother to draw a repeat potassium for you. Most of the time it will be normal, and I won't have to give them anything.
Borderline low potassiums are not emergencies, sorry. You must be confused with high potassiums.
With you Mike!
Like scalpel, am a BC internist; unlike scalpel, I have not totally disengaged myself from managing CHRONIC illnesses in the comfort of an ER where you get labs -repeat or not- fast enough to truly make meaningful decisions, i.e. w/o worries whether the value stabilizes where its ought to be, or it has gone exactly opposite and the patient is on the way to the ER via 911.
Internists and FPs in the trenches follow chronic patients with globally complicated and chronic problems. Yes, GLOBALLY COMPLICATED AND CHRONIC PROBLEMS! ISOLATED K 3.3 on relatively stable HTNsive diuretic regimen - like scalpel said, let them eat bananas. BUT how many IM/FP patients have that isolated condition? If they are getting INRs too, chances are they must be at least cardiomyopathic, fibrillating geriatrics! I wont dare play with hypoK and dig...if they have COPD, yes - Mg to boot!
To nurse K,etc. - again you are way out of turf in your critique. Take MCAT and be on your way to your missed calling. If you cannot pass the MCAT, it should tell you how little you know about simple reading and comprehension. Whatever indicated to you the labs were drawn without exam of the patient?
And if I can "see" hypoK or INR elevation by physical exam...that patient needs to be in the ER pronto!
Do you have a slightest clue how outpatient medicine workflow goes? Or has your [hated] long hours in the ER made you think that outpatient offices have capabilities just like an ER, except office hours are 8-5? Where are you coming from?
PS:
What's that differential diagnosis for hematuria again nurse k?
I can't recall any primary care doc ever sending a patient to the ER solely for a potassium of 3.3, and I've seen probably 50,000 patients in my ER career. If any of you are actually that overcautious, I would suggest that YOU are not meeting the standard of care.
Besides, if that is your practice, then their 3.3 potassium level probably is caused by your patient hyperventilating themselves into respiratory alkalosis because they are scared you will send them to the ER if they have any minor abnormalities on their lab panel.
That drives potassium into the cells and makes their measured value artificially low. That's why when we finally see them, it has normalized.
If you guys are so worried about potassium dramatically shifting from 3.3 to 2.3, perhaps you should draw weekly or even daily labs on all of your patients. Just in case.
If you guys are so worried about potassium dramatically shifting from 3.3 to 2.3, perhaps you should draw weekly or even daily labs on all of your patients. Just in case.
Ha ha ha!
I wish I had just said K=6.0. Would that have eliminated the off point comments? Because I stand by my original post and I can't imagine ER docs wouldn't rather rule out life threatening K abnormalities than treat another drunk loser who will just leave AMA the next morning. So stop b&*%*ing.
If you'd said 6.0 we wouldn't have had this discussion. Because hyperkalemia is actually a medical emergency, unlike mild hypokalemia.
Get it?
I don't care who comes in, I treat everybody. But I hate to see patients unnecessarily inconvenienced and overcharged because their primary physicians are incapable of managing simple problems.
For the record, Mike, I didn't say anything about treatment decisions....I just said if everyone with an asymptomatic lab value was sent to the ER, we'd see nothing else (not exactly true, but hyperbolically true). That has nothing to do with treatment decisions.
It has a lot to do with my job though...everyone who walks in the door we have to see eventually. Guess who will be sitting in the lobby for hours, watching all the other people go back before him? The asymptomatic patient with the INR of 5.0. If you want that for your patient, that's your choice, doc.
nurse k,
please do not designate yourself as a 'generic' ER nurse? although there are a number of them behaving like you, you are giving a majority of sensible, real ER nurses a bad name.
also, try to reconcile the meaning and sense of "assymptomatic lab tests" and "doing tests without [according to you] examining the patient"?
by some post u had when i used to wander into your blog, you have an insulin pump? well, well, well...it won't be too long before you would have to deal with the dilemmas faced by those who live with chronic diseases. when that time comes, it might put your uninformed pomposity and arrogance in its place, unless of course you have gone too demented to even realize it. if you are not diabetic, perhaps something else will catch you...and accept my apologies for a bad memory
POed at ER people with retrospectoscopes, et al.
What Im not getting is why this has anything whatsoever to do with nurses? Nurses jobs and doctors jobs are not the same so why are there some nurses here who think they can offer an input on something totally out of their expertise?
Are nurses not supposed to take care of patients and follow some type nursing guidelines? if a dr. is depending on any nurse to do his job then he needs to be replaced.
Nurse K needs to stick to what she was trained to do and leave the doctoring, well, to the doctors.
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