tag:blogger.com,1999:blog-24021163.post5848539743230252751..comments2024-02-18T01:56:38.508-06:00Comments on M.D.O.D.: Whither the Generalist?911DOChttp://www.blogger.com/profile/06466669111561150174noreply@blogger.comBlogger41125tag:blogger.com,1999:blog-24021163.post-79367613882607503512011-08-06T11:49:28.798-05:002011-08-06T11:49:28.798-05:00dear anon.,
so when did you run your last code? b...dear anon., <br />so when did you run your last code? but i digress. i am now a primary care physician, and i now send sick people to the ER. life is good. it's easy. i have time to be thorough. i love it. and when i don't know something i look it up because people are not dying in my clinic. and i did not say the generalist does not save lives... obviously they do, but they can't do nearly as much on the procedural side as they did even twenty years ago. when is the last time you sutured a lac in your office? put on a splint? dug out a splinter? directly admitted a patient? when?911DOChttps://www.blogger.com/profile/06466669111561150174noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-81125705981656918492011-08-06T11:44:16.023-05:002011-08-06T11:44:16.023-05:00This blog underestimates the effect of preventativ...This blog underestimates the effect of preventative medicine and its benefits in the primary care arena. Just think about how often ED discharge instructions basically say "you're not going to die tonight so follow up with your primary doctor". Otherwise the admission note might say "You may die and need an ICU now" and in this case an internal medicine specialist will resume care over the next days to weeks in the ICU followed by transition to the medical floor where an IM doc with consulting IM specialists treat the WHOLE patient. As an emergency physician (EP), you have no choice but to treat the emergency- not the patient. You do not have the opportunity, time, or privilege of treating the patient as a whole. Much of the time EPs are unable to get a diagnosis (unless the patient presented with a known condition that was likely diagnosed by a medicine or family doctor), and often the presumptive diagnosis made in the ED turns out to be flat wrong. <br />My point is that glamorizing the procedures and somewhat hasty decisions that occur in the emergency setting is not endearing to anyone who imagines themselves or a loved one as an ED patient. Instead of glamorous, I would describe it as a necessary evil. A family medicine, internist, or cardiologist may not heroically through a breathing tube down a patient's throat on a daily basis but to say that they do not save lives my diagnosing, managing, and PREVENTING the progression of chronic disease is a gross underestimation of their value. Instead, the blogger incredulously pats himself and his emergency medicine colleagues on the derriere.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-7915295463960508002007-07-09T00:15:00.000-05:002007-07-09T00:15:00.000-05:00doctor bee, bless you. i must say that in my parti...doctor bee, <BR/>bless you. i must say that in my particular facility we have one group of great pediatricians who come in routinely, and another group that doesn't and wants to transfer all sick kids. good luck. you will be a valuable asset to whomever you work for and are already.911DOChttps://www.blogger.com/profile/06466669111561150174noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-66931890889324876502007-07-08T23:29:00.000-05:002007-07-08T23:29:00.000-05:00I am a peds resident (just started my PL-2 year an...I am a peds resident (just started my PL-2 year and am currently on night float, thankyouverymuch) and this post is perfect. I see both sides of this all the time. We have our own peds ER so we rotate down there as well as doing time (heh) on our three inpatient floors. When we're in the ER, we like to call the admitting resident to let them know we've got a possible admission. Their response is usually, "Do the work up and call us back." When I'm on the floor and the ER calls, my first question after, "Does the patient really need to be admitted?" is "What have you done so far?".<BR/><BR/>Most of our community docs are great - they direct admit the grand majority of their bili babies (rather than sending a 5 day old through the germtastic ER to get a heel poke for a bili check) and more often than not, they call to ask us if we think the patient needs to come in and what we want them to do before the patient gets to us. It's nice. Of course, most of them also went through our residency program at one point or another. :)<BR/><BR/>I've decided I want to be a hospitalist when I grow up and during my residency, I'm gunning for procedures as often as possible because I want to be "that gal" during my attending years - the one that does the conscious sedations for CT scans, the one that does the LPs and IVs and helps the residents with such.<BR/><BR/>The ER is there for a reason: to take care of the emergently sick. The hospitalists also have their place - to manage, diagnose and treat.Beth Nelsenhttps://www.blogger.com/profile/04489498223489567024noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-46432223482477802007-07-01T09:03:00.000-05:002007-07-01T09:03:00.000-05:00HA! When I was an Anesthesia resident I got calle...HA! When I was an Anesthesia resident I got called to the ER to<BR/>do an LP. Not cause it was a difficult one,just that the ER doc[an experienced internist]didn't do them. He wasn't happy when I tossed aside the doo-hicky to measure opening pressure[I truly didn't know what it was for]or when<BR/>I offered to set the guy up for an<BR/>epidural blood patch.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-77949035785965160112007-07-01T06:05:00.000-05:002007-07-01T06:05:00.000-05:00Dearest Happy,In fact, you don't sound so "happy"....Dearest Happy,<BR/>In fact, you don't sound so "happy"...maybe you need a little trip to your local ER for some "happy pills." Oh say, how about some Lortab or Dilaudid...<BR/>Really, you should be very proud of yourself that you accept calls in the middle of the night about YOUR patients when they are actually sick enough to be admitted to the hospital. That is probably why they come to you (either that or are assigned to you through medicaid...) But here's the thing...I did't go to med school because of the commitment that was required. Yes, I do a 12 (+!!!!) hour shift and sometimes without breaks (!!!!!) and go home. That is what I committed myself to. You on the other hand, with your far more knowledge and training (I will not include intelligence here) have just a few more responsibilities than pulling a few 12 hour shifts! Or even six 12 hour shifts/week (what I have done for the last 3 weeks.)<BR/>Surely you don't believe that most FP's are taking calls and coming into EDs to assume care. Not where I work now, nor where I have worked in the past 4 years (in other states) has that been the case.<BR/>Would love to work with more of FP's like you, though<BR/>Hugs,<BR/>RRNRealisticRNhttps://www.blogger.com/profile/04578587938149321482noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-69863053746600221692007-06-28T21:53:00.000-05:002007-06-28T21:53:00.000-05:00anon 7:58-apparently, cardioNP and the practice s...anon 7:58-<BR/><BR/>apparently, cardioNP and the practice s/he is at does...that's why they can earn those inflated salaries and get blown up egos with arrogance to boot...<BR/><BR/>those who hire and cuddle these mid-levels should be burned at the stake for reducing primary care to the level that it is todayAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-12354947332276772312007-06-28T19:58:00.000-05:002007-06-28T19:58:00.000-05:00Who gets TWO HUNDRED BUCKS for a EKG ??I don't get...Who gets TWO HUNDRED BUCKS for a EKG ??<BR/><BR/>I don't get anywhere near that in my FP practice.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-42514239535802297762007-06-28T18:44:00.000-05:002007-06-28T18:44:00.000-05:00Excellent post.Your observations about the changin...Excellent post.<BR/><BR/>Your observations about the changing face of generalist medicine are dead on. And though the romantic notion of the one-doctor-does-all appeals to all of us, it's an impossibility. Ok, maybe an improbability. Why?<BR/><BR/>1. Medical knowledge is expanding so rapidly. Keeping up with outpatient care standards is about as much as I can handle. Maybe I could handle inpatient. But certainly not critical care on top.<BR/><BR/>2. As Panda has discussed so much more eloquently than I, there is a no-error standard in medicine these days. That's why the 28 year olds end up in the ER with chest pain. Not because I really think they're having an MI.<BR/><BR/>3. Primary care ain't the only ones with banker's hours. If there's a rectal abcess at 4:30 on a friday afternoon, every surgeon I call would tell me to "Send 'em to the ER." <BR/><BR/>I, with many of my colleagues, have embraced the "new" family medicine. I have a great outpatient practice, I work hard to keep my patients healthy as long as possible, and when I think they need to be there I send them to the ER. (I always call, by the way, even when I feel like a schmuck for sending them in.)<BR/><BR/>And I don't apologize for my banker's hours. It's about all we in primary care have left.Dr. Smakhttps://www.blogger.com/profile/11578423336319528698noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-16046459082892614752007-06-28T13:17:00.000-05:002007-06-28T13:17:00.000-05:00I really like happyman. He funny, and mildly less ...I really like happyman. He funny, and mildly less bitter at the world than I. GET SOME!!!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-26357511797706330162007-06-28T10:46:00.000-05:002007-06-28T10:46:00.000-05:00Cardio NP [and other 'specialist' NPs/PAs] :Consid...Cardio NP [and other 'specialist' NPs/PAs] :<BR/>Consider yourself LUCKY riding the coat tails of cardiologist[s]<BR/><BR/>Do you even think about how your supervisors can afford to pay your inflated 'specialist' salary? <BR/><BR/>Is it part because of the referrals that your group gets from the primary care physicians you denigrate? <BR/><BR/>The state of primary care is so messed up that there is no real good derived from trying to diagnose ACS in the office! What about compensation for EKGs? Do you realize how much more it is if done by a cardiologist or his/her office than by a generalist? The $200 your group gets for that EKG passed on by the referring PCP helped compensate your inflated salary and blow up your ego...Talk about the fly sitting on an elephant's back, believing he is bigger than the beast he is sitting on...the arrogance this begets! Think about it!!! That is, if you have any more thinking and feeling cells not consumed by your ego and arrogance.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-21990255320364901292007-06-28T09:26:00.000-05:002007-06-28T09:26:00.000-05:00Round 1 goes to Happyman![Sorry, CardioNP]Round 1 goes to Happyman!<BR/><BR/>[Sorry, CardioNP]Nurse Khttps://www.blogger.com/profile/06408755992926959084noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-59832336803518837942007-06-27T19:26:00.000-05:002007-06-27T19:26:00.000-05:00cardioNP:one more thing - your statement that "an ...cardioNP:<BR/><BR/>one more thing - your statement that "an appropriate history" to "determine that the symptoms were not cardiac" in itself makes my point - you need to go back to cardio NP school (what is that, like 6 weeks?)<BR/><BR/>"specialist" NPs and PAs need to remember that just because they work for a specialist MD they do not automatically have all their boss' knowledge & judgment magically imparted on them. Humility comes in handy, especially when you're in a crunch and you don't know a lick outside your "specialty" - you might then need the help of a doctor.<BR/><BR/>Or perhaps you can go solo & practice as a cardiologist? then let's see if you send your atypical chest pains to the ER or just sit & wait for the 5% of them to have an MI.Happymanhttps://www.blogger.com/profile/08682200319832416757noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-52122373303837611602007-06-27T16:14:00.000-05:002007-06-27T16:14:00.000-05:00cardioNP-how many patients with CLEARLY atypical c...cardioNP-<BR/><BR/>how many patients with CLEARLY atypical chest pain actually have ACS? the answer is probably more than you think.<BR/><BR/>and as a "withering generalist" i believe i have a bazillion more years of training than you, and was probably able to glean more cardiology out of my 6-months combined in a CCU & telemetry floor during residency than your entire career. <BR/><BR/>I don't think NPs are ignorant idiots at all - in fact i work with some WONDERFUL NPs in geriatrics, to whom I'd trust the care of my own family assuming they're being adequately supervised by a physician.<BR/><BR/>I do, however, take issue with the NP who feels, as you apparently do, that she knows more than the "withering generalist" who graduated at the top of his class in high school, went ivy league for 4 yrs, then 4 yrs of med school, then 3 yrs of a grueling residency, then hung out a shingle and started a solo practice, only to be downtalked by those with far less knowledge, training, and intelligence.<BR/><BR/>And I am indeed happy overall (thanks for your concern), just not with what has become of primary care - don't you think that the future is grim for EVERYONE in medicine when it's not just insurers/pharma/malpractice ruining primary care, but other physicians are too???<BR/><BR/>this is where there's an ER crisis in the first place - because nobody is doing primary care anymore! but you go ahead and continue to keep your head in the sand, & just deal with bullshit rule-out MI cases & administering stress tests for some jerkoff ripping off medicare & running a procedure mill. ignorance is bliss.Happymanhttps://www.blogger.com/profile/08682200319832416757noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-68528445984642835282007-06-27T15:27:00.000-05:002007-06-27T15:27:00.000-05:00Weren't FP's spending the last couple decades figh...Weren't FP's spending the last couple decades fighting, and losing, privilege fights over just about everything in the hospital? Surgery, endoscopy, obstetrics, ER, nursery, ICU, on and on.....<BR/><BR/>A lot of FP's decided since they aren't deemed smart enough to do anything in the hospital, why not stay in the office and max out what you can do there? Which, by the way, in my office at least, means a CLIA-moderate lab where I can do all that stat work, and I run my own IV's for the dehydrated patients.<BR/><BR/>Personally, (I'm a FP) I still do my own hospital work. I do my own office work, without mid-levels. My father was referred to a neurosurgeon last week and got seen by the neurosurgeon's PA. My mother gets treated by the cardiologist's NP. And I had to diagnose my mother's ACE-inhibitor angioedema by telephone several states away, missed by the "cardiology-NP".<BR/><BR/>That you see less generalist involvement in hospitals is unfortunate, but hardly surprising to anyone who has practiced in the last 20 years.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-6068517833887258042007-06-26T22:58:00.000-05:002007-06-26T22:58:00.000-05:00Happyman -Atypical chest pain symptoms can be the ...Happyman -<BR/><BR/>Atypical chest pain symptoms can be the real deal in ANYONE, not just diabetics. <BR/><BR/>But in your blindered view, in which you appear to think that NPs are ignorant idiots, you failed to appreciate my point. I stated that pts with CLEARLY atypical non-cardiac chest pain were sent for unnecessary evaluation. In part due to the fact that the <I>whithering generalist </I> did not take the time to get an appropriate history and determine that the symptoms were not cardiac.<BR/>Fleeting sharp pin pricky pain occuring at rest 2 months ago does NOT require an ED visit. Yet have seen a pt sent to the ED for this.<BR/><BR/>Your moniker is a bit incongruous as you seem perhaps more angry or bitter than happy.<BR/><BR/>CardioNPAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-3531841354950462192007-06-26T21:25:00.000-05:002007-06-26T21:25:00.000-05:00cardio-np says "Clearly atypical non-cardiac CP re...cardio-np says "Clearly atypical non-cardiac CP reported during an office visit? Forget doing an EKG, VS assessment, or a focused hx. Straight to the ED, do not pass go, do not collect $200."<BR/><BR/>atypical chest pain that is actually ACS is one of the most common reasons for a malpractice lawsuit. "atypical" symptoms can be the real deal especially in diabetics.<BR/><BR/>this is why almost anyone who enters the ER with a cc of chest pain will ultimately be admitted.<BR/><BR/>and a spot EKG (especially without a baseline) tells you nothing if the patient isn't actively having pain at that moment. same for vitals, even WITH pain - if someone has cardiac chest pain & abnormal vitals they are already far gone & probably need to be in a CCU.<BR/><BR/>why don't you practice on your NP license & see what happens the first time you miss a cardiac chest pain? or a gastroenteritis that turned out to be appendicitis? or a URI that developed meningismus?<BR/><BR/>people just love to talk about what they don't know about, especially those who are undertrained & then thrown into the ring & expected to wrestle with the big boys.Happymanhttps://www.blogger.com/profile/08682200319832416757noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-44119977808495583752007-06-26T21:02:00.000-05:002007-06-26T21:02:00.000-05:00RealisticRN says "Because they have gotten too dam...RealisticRN says "Because they have gotten too damn lazy and want their damn banker's hours! They are only there during business hours...ER docs are there all the time as are the hospitalists."<BR/><BR/>So you work 24/7 and I don't???<BR/><BR/>That's funny, because when I get called in the middle of the night, even possibly coming into the hospital to admit a patient, i STILL have to work a regular day the next day!<BR/><BR/>In other words, i am NEVER off, whereas you do a 12-hr shift and then wash your hands & go home.Happymanhttps://www.blogger.com/profile/08682200319832416757noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-22884360313534721552007-06-26T20:15:00.000-05:002007-06-26T20:15:00.000-05:00realistic RN -you answered/negated your own rant a...realistic RN -<BR/>you answered/negated your own rant about 'lazy' PCPs, by your congratulatory remarks...<BR/><BR/>to whom it may concern- <BR/>has anyone considered the fact that plenty of community PCPs have been marginalized by the endless accreditation/certification processes foisted by administrators, nurse managers - who left the job of triaging and frontline nursing to the cloud-minded antagonists of PCPs here?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-46433728466708571152007-06-26T15:05:00.000-05:002007-06-26T15:05:00.000-05:00MyOwnWoman: Congrats to your daughter. We who feel...MyOwnWoman: Congrats to your daughter. We who feel the same about what we do welcome her and wish her the best.#1 Dinosaurhttps://www.blogger.com/profile/01357845504444464397noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-33872854939739722882007-06-26T13:55:00.000-05:002007-06-26T13:55:00.000-05:00dear anonymous. i do get out of the ER on a daily ...dear anonymous. i do get out of the ER on a daily basis, to run codes and do the occasional LP for our hospitalists (and for our our critical care guy who is never around for some reason). all i can say is, please come work at my hospital.911DOChttps://www.blogger.com/profile/06466669111561150174noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-13394840115914318692007-06-26T12:37:00.000-05:002007-06-26T12:37:00.000-05:00911 doc:I don't know where you work but I suspect ...911 doc:<BR/>I don't know where you work but I suspect you need to get out of that box called the ER and walk around the hospital a little to see what is really goes on. I'm a hospitalist. I manage pt's in the ICU. I run codes, I place lines, I do LP's. For every horror story about an IM/FP doc I can give you a horror story about an ER doc (but not limited to) doing the following: Admitting pt's with no risk factors having clear MS type chest pain", missing an obviously present fracture, not appropriately evaluating a trauma, c/s to determine whether a pt needs an admission just to make sure another doc's name is on the chart, refusing to see pt's that left AMA and have come back to the hospital because "they should just be readmitted", etc, etc. I could go on and on. Unlike you, I don't blame a whole specialty rather just the lazy ones in it.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-49570216031438233162007-06-26T08:25:00.000-05:002007-06-26T08:25:00.000-05:00Cat: I must continue the mutual onanism. This is t...Cat: I must continue the mutual onanism. This is the greatest blog I've seen - O.K., the only blog - but the posts are great. Tell your lovely wife to check out Euler's Identity - that's all I'm sayin'.<BR/><BR/>RG: Stalkers welcome! Maybe it's weird that I like people watching me go to the bathroom, but that's just my thing.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-24021163.post-74415834927325390022007-06-26T05:39:00.000-05:002007-06-26T05:39:00.000-05:00dear anonymous surgeon. please come work here! God...dear anonymous surgeon. please come work here! God bless you.911DOChttps://www.blogger.com/profile/06466669111561150174noreply@blogger.comtag:blogger.com,1999:blog-24021163.post-56932731804467823532007-06-25T23:50:00.000-05:002007-06-25T23:50:00.000-05:00Cat,Perhaps Etotheipi could assist me in figuring ...Cat,<BR/><BR/>Perhaps Etotheipi could assist me in figuring out why you are a cat, yet have Under<B>DOG</B> as your avatar.<BR/><BR/>Re: whithering generalists....<BR/>those at the Spa have already shriveled up and died. All they do now is to send consults for each and every thing. Clearly atypical non-cardiac CP reported during an office visit? Forget doing an EKG, VS assessment, or a focused hx. Straight to the ED, do not pass go, do not collect $200. <BR/><BR/>CardioNPAnonymousnoreply@blogger.com