Reviewing MLP charts. FUN TIMES!

[MechEDoc]

I'm glad I'm not the only one who thought a troponin on a young person isn't completely unreasonable. I've seed STEMI/NSTEMIs in teenagers/young 20s (one later found to have ALCAPA, another with hypercholesterolemia, likely familial [other family members with MIs at very young ages]). Also myocarditis.

Reasonable.

Found a LAD dissection with STEMI pattern and + troponin on a 20 y/o who had epigastric pain in the setting of excessive Ibupofen use. Pain was eliminated by a GI cocktail.

Spend your patient's money, not your retirement.

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[deleted859535]

Reasonable.

Found a LAD dissection with STEMI pattern and + troponin on a 20 y/o who had epigastric pain in the setting of excessive Ibupofen use. Pain was eliminated by a GI cocktail.

Spend your patient's money, not your retirement.

Jesus. What made you get a troponin and EKG? Belly exam not what you expected, or just being ultra-cautious/aggressive? I get EKGs and/or troponins in epigastric pain all the time as do most EPs worth their salt, I'm sure -- but hardly ever in a 20 year old.

 

[MechEDoc]

Jesus. What made you get a troponin and EKG? Belly exam not what you expected, or just being ultra-cautious/aggressive? I get EKGs and/or troponins in epigastric pain all the time as do most EPs worth their salt, I'm sure -- but hardly ever in a 20 year old.

Very high acuity ER with zebras every shift. Patient was more tachycardic than I thought she should have been. I was willing to test more due to the crazy acuity there (lobar nephronia! gas forming pyelonephritis! DIC! etc). Guess I got lucky.

Patient also seemed sincere, showed up at an odd hour for a BS complaint, and just somehow spooked me.

 

[thegenius]

Midlevels (APPs, whatever) need to be supervised. In the ED that's you. If you want to see all the patients that come to the ED, then good for you. If you want to spend some time learning about, teaching, and supervising your midlevels, then you can make a LOT more money and your ED can flow a LOT faster.

Our midlevels are slower than docs. Midlevels are slower than doctors because they don't have the training we do.

 

[thegenius]

Well anyone can sue anyone for anything....I'd imagine (or maybe just hope) you'd be dropped from the suit....

without knowing specifics of the suit, i highly doubt you will be dropped.

I'm the plantiff lawyer. I don't give a rats ass about anyone besides my client. Doctors have a lot of money in insurance policies, so I'm keeping that doc on.

 

[thegenius]

Midlevels (APPs, whatever) need to be supervised. In the ED that's you. If you want to see all the patients that come to the ED, then good for you. If you want to spend some time learning about, teaching, and supervising your midlevels, then you can make a LOT more money and your ED can flow a LOT faster.

Then don't discharge patients without going to the doctor first, no matter how simple. The OP's problems are the chart sucks and the MLPs rarely or ever discuss with him.

 

[thegenius]

I don't have any mid-levels. However, a troponin on a 15 year old kid is total BS - until it isn't. Low impact, low downside. And, when it comes back positive, once in a blue moon, you/the mid-level look like heroes.

Oh God that is the NOT the way to practice medicine!!!!! Do you not believe in the teachings behind sensitivity, specificity, false positives, etc behind tests?

 

[TheComebacKid]

Eh?

Have you ever worked for a CMG? CMG docs have zero say in who a midlevel sees. Put another way, CMG pit docs have no power over staffing conditions and how a midlevel acts. If you work in an area where that's your only employment option, it may be the lesser of two evils (vs travel locums or moving) depending on your life circumstance.

CMG docs have the power to not work for a CMG. Yes, I agree with you, life circumstances are real and sometimes options are limited, but I find it hard to believe that for most docs, working for a CMG is literally the only option you have. I think the big salaries offered by CMGs in comparison to other practices lures many docs, especially those straight out of training, with hopes of paying off loans and starting to live the lifestyle they thought they were going to get as a physician. The lure is so powerful that you accept more risk without realizing how poor the care provided by some midlevels is and how you will be ultimately fully responsible for it.

I appreciate your sentiment but do you really think the average pit doc for USACS/Envision/Team etc is getting some big payout from them or making a ton of money off midlevels? The answer is no. Most are not the docs who sold out to the CMGs and yes many are getting a raw deal. But the vast majority of CMG pit docs are good folks who are trying to do the right thing for their patients and their own families.

The community docs who work for CMGs get paid more money per hour than other docs in academics or those who don't have midlevel staffing. If you can pay your midlevels less than you can a physician, you can theoretically get a good deal of RVUs and ultimately make more money. To accomplish this, you pay the ED doc more per hour.

So while the ED doc does not make more money off midlevels, they do get compensated better for taking on more risk. I know these are good physicians who are trying to do the right thing, but at the same time, you are allowing yourself to be taken advantage of for an extra 50 bucks per hour. It's a joke when you look at how much more money TeamHealth is making off the added risk you are taking on.

If you sue the doc, how does that make the system better?

From purely a patient standpoint, if I'm seen by a midlevel and I am sent home only to come back the next day with a ruptured ectopic pregnancy, who do I hold responsible? Surely the nurse practitioner does not assume any responsibility. That falls on the physician. If I'm a patient, I'm going to end up going after someone, and if that's the physician that never laid eyes on me, so be it. This does not make the system better but what other recourse does the patient have for the bad outcome they are dealing with?

Is that fair for the physician? Absolutely not, but the fact of the matter remains that someone has to take accountability when there truly is a bad outcome as a result of midlevel care. If you don't want to be sued, then you should A) not work for a CMG that mandates you take responsibility for a midlevel patient or B) not work at a place that has midlevels to begin with

The heavy utilization of midlevels by CMGs is a criminal practice, as what they are doing is using your medical license (which you worked your entire life to obtain) to subsidize their costs but allowing more unexperienced midlevels to work for less and bill for more money while simultaneously dumping all the medicolegal responsibility on you. You are being played for a fool (not YOU per se, but the ED doc in general) .

 

[TheComebacKid]

I COMPLETELY agree that the Docs are losing not only the PR battle, but the battle for medicine. Y'all are terrible managing things (see the complaining about MLPs instead of fixing what's wrong in YOUR department), so we now have a bunch of overpaid bureaucrats taking over hospital management and pushing down policies PG scores, poor MLP supervision, etc. Worse yet, y'all have done nothing to fight back against the encroachment into medicine by the NPs who now have independent practice "rights" in most states.

Truer words have never been spoken.

We can complain all we want but from the standpoint of advocacy, physicians have lost this battle awhile ago. The reason being we constantly make stupid excuses about why midlevels are useful (i.e. they see low acuity patients and allow me to do more higher acuity stuff!) and "some of them are really good!" and "we need someone to work in rural areas!". All these dumb excuses have destroyed our specialty.

ACEP is laughable. For years we were talking about how we only wanted board certified EM trained people to practice in EDs to provide better patient care, so how did we address this issue? Kick out all the family medicine and internal medicine PHYSICIANS to be replaced by a midlevel with LESS training. Well played ACEP, well played. I guess the TeamHealth executives that paid your organization are going to be getting huge bonuses this year.

 

[Apollyon]

Oh God that is the NOT the way to practice medicine!!!!! Do you not believe in the teachings behind sensitivity, specificity, false positives, etc behind tests?

Spaz much? Are you board certified yet? You call yourself "the genius", but I am one. I practice medicine. If my gestalt suggests it, I'll order it. That doesn't mean every patient, but, you know what? I'll bankrupt the system so I don't get sued.

I'll ask you - who doesn't care about sensitivity and specificity? The plaintiff's attorney. So, which side are you on? You have argued both.

 

[thegenius]

Spaz much? Are you board certified yet? You call yourself "the genius", but I am one. I practice medicine. If my gestalt suggests it, I'll order it. That doesn't mean every patient, but, you know what? I'll bankrupt the system so I don't get sued.

I'll ask you - who doesn't care about sensitivity and specificity? The plaintiff's attorney. So, which side are you on? You have argued both.

If you admit that you overtest which results in some patients getting seriously hurt, maybe bankrupting their savings - so you don't get sued....then I appreciate your honesty. I'll send my loved ones and friends to a different ER doc.

But if you are sending troponins on, say, 1 of 8 of all your pediatric patients who present with chest pain to rule out a disease that has an incidence of 2/100,000 because you think they have myocarditis, then I suggest you go back to medical school to learn more about it and the folly of tests themselves.

Lastly, I was not advocating for lawyers. Just writing on how they think.

 

[Apollyon]

If you admit that you overtest which results in some patients getting seriously hurt, maybe bankrupting their savings - so you don't get sued....then I appreciate your honesty. I'll send my loved ones and friends to a different ER doc.

But if you are sending troponins on, say, 1 of 8 of all your pediatric patients who present with chest pain to rule out a disease that has an incidence of 2/100,000 because you think they have myocarditis, then I suggest you go back to medical school to learn more about it and the folly of tests themselves.

Lastly, I was not advocating for lawyers. Just writing on how they think.

Are you always such a contentious *****?

And, if you have to send so many "loved ones and friends" to the ED, maybe YOU'RE the one harming patients. It certainly isn't me.

And, if you are looking for a black and white answer, you're doing it wrong. Do I overtest? Statistically, the least among all the docs in my ED. But I'm sure I do. If you are not, you are missing things, which, in our medicolegal climate, depending on what it is, unforgivable (at least to the lawyers). You are not so articulate online (strictly average), so I hope that you are that much more slick in person, if you can explain away missing an MI, because of statistics.

And, excellent work on Burnett's law. (Search for it.)

 

[Brigade4Radiant]

Oh God that is the NOT the way to practice medicine!!!!! Do you not believe in the teachings behind sensitivity, specificity, false positives, etc behind tests?

False positives will happen because we as a society have a zero miss philosophy. Also those findings apply to a general population coming to the ER means higher risk. Just look at sepsis for example.

 

[thegenius]

False positives will happen because we as a society have a zero miss philosophy.

The two mini-statements in above sentence are true, but not related. False positives happen because tests are imperfect. Has nothing to do with zero-miss philosophy.

100% agree though we that have, basically, no tolerance for missing certain diseases. Like ischemic chest pain.

 

[southerndoc]

Very high acuity ER with zebras every shift. Patient was more tachycardic than I thought she should have been. I was willing to test more due to the crazy acuity there (lobar nephronia! gas forming pyelonephritis! DIC! etc). Guess I got lucky.

Patient also seemed sincere, showed up at an odd hour for a BS complaint, and just somehow spooked me.

Do we work at the same shop?

 

[TheComebacKid]

And, if you are looking for a black and white answer, you're doing it wrong. Do I overtest? Statistically, the least among all the docs in my ED. But I'm sure I do. If you are not, you are missing things, which, in our medicolegal climate, depending on what it is, unforgivable (at least to the lawyers). You are not so articulate online (strictly average), so I hope that you are that much more slick in person, if you can explain away missing an MI, because of statistics.

I'll try to stay out of this pissing match as much as possible, but I do disagree with your practice of defensive medicine.

Just a genuine question, what is an acceptable miss rate for you? For every single patient that you see in the ED, even the simple cough/cold, medication refill, etc, there is some risk that you will be missing something serious, however infinitesimally small. Why not get a CT scan on every single patient who comes into the ED, even those without headache/belly pain since there is a "theoretical risk" that they have some occult problem?

As someone who has had a kid have a witnessed arrest in the ED from viral myocarditis, I can tell you that the kid did not come in with chest pain. They came in with fever, tachycardia, hypotension and a URI and I was convinced they were septic. I know you laugh at the utility of sensitivity or specificity of a test, but for myocarditis the sensitivity for troponin is ~70%. In other words, you could obtain a test, it could be negative, the kid could still have myocarditis and you could still get sued. The test doesn't save you. It doesn't change your management. Having a high index of suspicion and clinical experience is what matters. While it's true, good doctors get sued all the time despite all their training, you can only continue to do what you think is in the best interest of your patient, despite what the lawyers will say.

Maybe I'm an idealist, maybe I'm still a resident who has the protection of my attendings who are the ones primarily named in lawsuits, and maybe my practice will change someday when I'm out on my own once I get out "in the real world" with the rest of you all. But I would argue that we can either succumb to the pressures of lawyers and order tests frivolously to stave off litigation and simultaneously drive up health care costs, or we can just do everything we can that we believe is in the best interest of our patients. Foregoing a troponin in a patient who you had low suspicion for myocarditis is not considered negligence, and I highly doubt any medical board would come after your license if you practiced sound medicine to the best of your abilities. But again, I still have a lot to learn about this

We have better clinical training that surpasses anyone else. We shouldn't just order tests like a midlevel with less training. Speaking of midlevels, can we go back to talking about how midlevels are screwing us?

P.S. I can't wait for the study that gets published that shows that midlevels actually drive up the cost of healthcare because of the additional unnecessary testing they order. Maybe if the physicians could grow a pair, that study would get done and drive them out of business.

 

[southerndoc]

If you admit that you overtest which results in some patients getting seriously hurt, maybe bankrupting their savings - so you don't get sued....then I appreciate your honesty. I'll send my loved ones and friends to a different ER doc.

But if you are sending troponins on, say, 1 of 8 of all your pediatric patients who present with chest pain to rule out a disease that has an incidence of 2/100,000 because you think they have myocarditis, then I suggest you go back to medical school to learn more about it and the folly of tests themselves.

Lastly, I was not advocating for lawyers. Just writing on how they think.

Keep in mind we're not talking about a heart catheterization. We're talking about an i-STAT troponin, which costs less than an EKG.

 

[enalli]

If you admit that you overtest which results in some patients getting seriously hurt, maybe bankrupting their savings - so you don't get sued....then I appreciate your honesty.

Jeeze. I haven't ordered troponins on children and wouldn't plan on doing so unless there are extenuating circumstances (hypercoagulable state is the one that jumps to mind), but is this really the hill you want people to die on? It's a troponin, not a lobotomy. In most situations I would argue a troponin is similar to an ECG--I don't care who ordered it or what their thought process was, if it's abnormal I'm glad it was ordered.

 

[CCM-MD]

Laryngoscope is in the right (wrong) hand.

 

[enalli]

View attachment 241075

Laryngoscope is in the right (wrong) hand.

Fixed it:

 

[Apollyon]

I'll try to stay out of this pissing match as much as possible, but I do disagree with your practice of defensive medicine.

Just a genuine question, what is an acceptable miss rate for you? For every single patient that you see in the ED, even the simple cough/cold, medication refill, etc, there is some risk that you will be missing something serious, however infinitesimally small. Why not get a CT scan on every single patient who comes into the ED, even those without headache/belly pain since there is a "theoretical risk" that they have some occult problem?

As someone who has had a kid have a witnessed arrest in the ED from viral myocarditis, I can tell you that the kid did not come in with chest pain. They came in with fever, tachycardia, hypotension and a URI and I was convinced they were septic. I know you laugh at the utility of sensitivity or specificity of a test, but for myocarditis the sensitivity for troponin is ~70%. In other words, you could obtain a test, it could be negative, the kid could still have myocarditis and you could still get sued. The test doesn't save you. It doesn't change your management. Having a high index of suspicion and clinical experience is what matters. While it's true, good doctors get sued all the time despite all their training, you can only continue to do what you think is in the best interest of your patient, despite what the lawyers will say.

Maybe I'm an idealist, maybe I'm still a resident who has the protection of my attendings who are the ones primarily named in lawsuits, and maybe my practice will change someday when I'm out on my own once I get out "in the real world" with the rest of you all. But I would argue that we can either succumb to the pressures of lawyers and order tests frivolously to stave off litigation and simultaneously drive up health care costs, or we can just do everything we can that we believe is in the best interest of our patients. Foregoing a troponin in a patient who you had low suspicion for myocarditis is not considered negligence, and I highly doubt any medical board would come after your license if you practiced sound medicine to the best of your abilities. But again, I still have a lot to learn about this

We have better clinical training that surpasses anyone else. We shouldn't just order tests like a midlevel with less training. Speaking of midlevels, can we go back to talking about how midlevels are screwing us?

P.S. I can't wait for the study that gets published that shows that midlevels actually drive up the cost of healthcare because of the additional unnecessary testing they order. Maybe if the physicians could grow a pair, that study would get done and drive them out of business.

Ever heard of Peter Rosen?

And I don't discount S&S. I just live in the real world. I even tell the pts that I am "right 19 times out of 20".

If you stay in the academic bubble, you may never see it. However, if you're ever out in the community, uncovered, you will see how stark is the landscape.

 

[CCM-MD]

Fixed it:

Noble attempt. But now the time and badges are flipped.

 

[Rendar5]

If you never test for myocarditis you will miss 100% of myocarditis cases. It is impossible to catch life threatening diseases without overtesting. Minimize overtesting? Sure. But it’s hard to call someone out for ordering a troponin on a kid if they’ve got clinical reasoning behind it and you don’t actually know their ordering patterns.

 

[thegenius]

Keep in mind we're not talking about a heart catheterization. We're talking about an i-STAT troponin, which costs less than an EKG.

I understand - the issue is not cost. It's not speed. (although I see a lot of inaccurate i-Stat lab values as compared to the traditional lab values). I understand that one is sending a troponin to "r/o myocarditis" and not for Type 1 MI in this case.

It's about testing characteristics and probabilities and pre-tests and post-tests of disease. We all learned this in medical school and in residency.

Sensitivity and Specificity, Likelihood Ratio Calculators - GetTheDiagnosis.org

On the bottom part where it says "Post-Test Probability Calculator" if you put the pre-test probability in (say 0.0001%) and troponin is 99% sen and spec, your post-test prob is still imperceptibly low. In reality there are few tests in all of medicine that are 99% sens/spec. Due to false positives (like the machine has a brain fart and returns a value of 10 when in fact there isn't any troponin in the blood at all), people suffer all the additional downstream testing for something that was due to a FP.

I've sent troponins on kids...they are usually sick and have thoracic complaints and maybe have a fever. It's pretty rare. I don't rule out MI in kids though unless there are really extenuating circumstances.

I'm not mad at you guys I don't want to get into a pissing match at all. I ain't mad at @Apollyon. This is a anonymous forum we wouldn't be talking like this if we were all at a bar enjoying a beer.

(those i-stat cartridges that I'm familiar with cost $75/each)

 

[southerndoc]

@thegenius An EKG and interpretation is usually over $500 in most places.

Pre and post-test probability is great. I'm not sending troponins on patients with leg pain. I've seen several cases of myocarditis in patients who do not appear ill and who have a sole complaint of chest pain. I work in a 160,000 volume ED, so I see a lot more than most ER's. I've seen 2 spinal strokes and more thoracic aortic dissections than I can count in my 8 years of being where I am. I see a case of myocarditis at least every other year (not counting what the other docs see; I'm speaking only for myself).

 

[thegenius]

Jeeze. I haven't ordered troponins on children and wouldn't plan on doing so unless there are extenuating circumstances (hypercoagulable state is the one that jumps to mind), but is this really the hill you want people to die on? It's a troponin, not a lobotomy. In most situations I would argue a troponin is similar to an ECG--I don't care who ordered it or what their thought process was, if it's abnormal I'm glad it was ordered.

The problem can snowball into the ridiculous. Kids can get PE's. Do you send a d-dimer or test all kids with pleuritic chest pain?

All i'm sayin is that at some point I think it's appropriate and necessary to consider the incidence of disease when deciding to work it up. If something is extraordinarily rare I need more than just gestalt to work it up.

Look....if a kid has a fever, URI, tachycardia, unexplained dyspnea, fever out of proportion, weird EKG findings, etc then I would consider testing for it. I would never criticize an ER doc in those cases. In my ER, we probably admit/transfer 10 of 500 kids we see. So 2% of the kids merit admission or transfer, and this is for all diseases we see. Myocarditis is really rare!

 

[thegenius]

@thegenius An EKG and interpretation is usually over $500 in most places.

Pre and post-test probability is great. I'm not sending troponins on patients with leg pain. I've seen several cases of myocarditis in patients who do not appear ill and who have a sole complaint of chest pain. I work in a 160,000 volume ED, so I see a lot more than most ER's. I've seen 2 spinal strokes and more thoracic aortic dissections than I can count in my 8 years of being where I am. I see a case of myocarditis at least every other year (not counting what the other docs see; I'm speaking only for myself).

What is your criteria for ordering a troponin on an 8 yo healthy child with complaint of chest pain and normal vital signs, normal PE and not sick? This isn't a trick question, I'm just curious. We all see this every day. On that child I would order an EKG, probably a CXR, given motrin for pain and if better d/c (provided EKG/CXR are normal). I do order an EKG on just about all chest pains no matter what age.

EKG RVU is like 0.2. Charging is one thing reimbursement is another. At the end of the day cardiologists make like $5-10/EKG. The hospital will also get reimbursed a pittance too. Anyway...this whole bit about cost is irrevelant.

 

[southerndoc]

@thegenius If your pretest probability is so low, why even get an EKG? You wouldn't even find the weird EKG findings to send a troponin then.

 

[thegenius]

@thegenius If your pretest probability is so low, why even get an EKG? You wouldn't even find the weird EKG findings to send a troponin then.

Yup...good point, the differential is broad for pediatric chest pain not just myocarditis. There is pericarditis, conduction abnormalities, etc. But overall it's do something for the sake of satifying. It is non-invasive. No blood is needed. I don't even really need the CXR either. Sometimes I don't do it.

 

[namethatsmell]

CMG docs have the power to not work for a CMG. Yes, I agree with you, life circumstances are real and sometimes options are limited, but I find it hard to believe that for most docs, working for a CMG is literally the only option you have. I think the big salaries offered by CMGs in comparison to other practices lures many docs, especially those straight out of training, with hopes of paying off loans and starting to live the lifestyle they thought they were going to get as a physician. The lure is so powerful that you accept more risk without realizing how poor the care provided by some midlevels is and how you will be ultimately fully responsible for it.

The community docs who work for CMGs get paid more money per hour than other docs in academics or those who don't have midlevel staffing. If you can pay your midlevels less than you can a physician, you can theoretically get a good deal of RVUs and ultimately make more money. To accomplish this, you pay the ED doc more per hour.

So while the ED doc does not make more money off midlevels, they do get compensated better for taking on more risk. I know these are good physicians who are trying to do the right thing, but at the same time, you are allowing yourself to be taken advantage of for an extra 50 bucks per hour. It's a joke when you look at how much more money TeamHealth is making off the added risk you are taking on.

From purely a patient standpoint, if I'm seen by a midlevel and I am sent home only to come back the next day with a ruptured ectopic pregnancy, who do I hold responsible? Surely the nurse practitioner does not assume any responsibility. That falls on the physician. If I'm a patient, I'm going to end up going after someone, and if that's the physician that never laid eyes on me, so be it. This does not make the system better but what other recourse does the patient have for the bad outcome they are dealing with?

Is that fair for the physician? Absolutely not, but the fact of the matter remains that someone has to take accountability when there truly is a bad outcome as a result of midlevel care. If you don't want to be sued, then you should A) not work for a CMG that mandates you take responsibility for a midlevel patient or B) not work at a place that has midlevels to begin with

The heavy utilization of midlevels by CMGs is a criminal practice, as what they are doing is using your medical license (which you worked your entire life to obtain) to subsidize their costs but allowing more unexperienced midlevels to work for less and bill for more money while simultaneously dumping all the medicolegal responsibility on you. You are being played for a fool (not YOU per se, but the ED doc in general) .

I get it. You blame the CMG docs. Cool. You're making some points we agree on and some blanket statements we don't agree on like:

Your idea that CMG docs are being showered with riches compared to other EM docs. In my experience this is untrue. In many places CMG doctors get pain LESS than others groups in the area. It's the CMG admins who are making a killing. Stating that CMGs make more than academics and thus makes them greedy ignores the fact that academics are generally paid less then other employment setups. So Kaiser, VA, SDG docs make more than academics--are they just following the $$$ too?

Your idea that docs who work with midlevels should blame themselves when they are sued. This kinda sounds like victim shaming. Yeah, it's easy to connect the dots to make that argument but it misses the larger system issues at play which are frankly a way bigger problem IMHO. Put another way, if you get assaulted by a patient at work, shouldn't you have expected it and accept responsibility since you work in an ED which we all know can be a dangerous and unpredictable place? How about if you get burned out--is that your fault too? After all, didn't you chose to go into EM despite knowing you'd have rowdy/violent patients in the ED and everybody telling you that EM has a high rate of burnout?

I don't know if you're an attending or a resident or how much experience you have working in various settings. I have worked as an attending at CMG, SDG, academic, and larger quasi-SDG places and those experiences inform my opinion. I respect you have your own background which informs your opinion. I think we should probably agree to disagree and try to keep things sunshine and rainbows around here and move on.

 

[littlejuan]

Fixed it:

Now photoshop a glidescope in his hand or his collar off with someone holding C-spine. Good luck getting that mouth open and a good view like that. Also photoshop a freaken mask on that bag.

 

[TheComebacKid]

If you never test for myocarditis you will miss 100% of myocarditis cases. It is impossible to catch life threatening diseases without overtesting. Minimize overtesting? Sure. But it’s hard to call someone out for ordering a troponin on a kid if they’ve got clinical reasoning behind it and you don’t actually know their ordering patterns.

If you have a clinical suspicion for myocarditis, by all means, order the test. I'm talking about the people who see a chief complaint of "chest pain" in the chart and throw in a troponin even if it's an 8 year old. Or the nurses that protocol a troponin for every patient that walks in the door.

If you have a kid with chest pain and zero index of suspicion, you should not order the test "because it's cheap". That's not how to practice medicine IMO.

In addition, as I stated in my prior post, even if you suspect myocarditis and order the test, there is an alarmingly high false negative rate for troponin in myocarditis depending on the phase of illness they are in, in which case, you obtain a false sense of security, and still miss the diagnosis and still get sued.

Clinical judgement is king. It is the key part of all testing, including common clinical decision rules we use in practice everyday (i.e. Wells criteria etc). This judgement is what makes us physicians, and what often times differentiates us from other "providers".

If all you are going to do is order a troponin on every single kid with chest pain, then honestly, midlevels can do that for less money than you can, and you become expendable. Your judgement and experience on the other hand is why you are the most valuable player in the house of medicine. But I promise you, one of the reasons NPs and PAs have gained so much traction is because someone said, "see that doc? he just orders troponin on every single kid with chest pain! You don't need to go to medical school to do that. I can do that too!"

 

[Boatswain2PA]

I would have agreed five years ago, but in our area three new PA schools have cropped up. We used to just get students from the local university, who were fabulous, but now we have students from these for-profit monsters, and the quality has dropped drastically. On an EM rotation and unable to take a basic history. I'm sure online schools are soon to follow, and frankly these aren't any better.

Let all "APPs" practice independently, and don't involve me. Sink or swim on your own terms.

Huge problem with the growth of new PA schools. Not enough quality precepting sites, and now Yale has an "on-line" PA program that I'm sure will expand to other schools (while still charging $150,000+ for tuition).

However, and this is a huge however, all PA programs are still standardized by the NCCPA, all PA programs require 2000+ clinical hours, and include rotations in EM, cards, surg, pediatrics, geriatrics, women's health, and others. Then we all take the same standardized general medicine test. This is the minimum for PA programs.

The minimum for NP programs is much, much less.

I'll bitch at you as long as I have to sign your charts if you give me any flak.
If you're listing me as your "supervising physician", then you do as I tell you, and the answer is "yes, sir."

We don't know each other personally, so please take this in the charitable manner I am trying to send to you....but maybe your MLPs suck because the good ones won't work for this kind of attitude. I know I wouldn't.

Can you request the PAs call the patients back if you are dissatisfied with their crap care?

I would rather call my own patients back.

Attestations are your friend. Here's the one I use on those types of charts:

"I was available for consult in real time but was not asked to participate in the care of this patient nor was I asked to assist in management. The APC functioned independently in this pt's care. I am unable to determine appropriateness of management without obtaining a personal history and exam."

I've thought of doing a similar attestation to cover myself from the CMG I work part-time for who has a bunch of policy restrictions requiring me to document discussing certain patients with the EP, such as before CT scans, pelvic exams, discharging chest pains, etc. Yet time I work for a new doc there I bring up the corporate rules, and the doc says "boats...let me know if you have any questions or need anything."

I work with really great docs, who lead a really great team in that shop.

Our midlevels are slower than docs. Midlevels are slower than doctors because they don't have the training we do.

I generally agree with you (although I have worked with docs, even EPs, who were outliers). I am sometimes utterly amazed at how many patients my EPs can manage at one time and not lose the bubble. I've had shifts where I have seen >2 pph, and the doc next to me is doing way more than me (while keeping up with my patients as well)...and this is in a high acuity shop with about 30% admission rate. I think much of this is training/education, but there are two other reasons as well. First, they have scribes, and I don't. Second, they have to practice for their OWN style and nobody else's. Meanwhile I have to not only maintain my own practice style, but also cover my EPs ass by doing additional testing/MDM.

Then don't discharge patients without going to the doctor first, no matter how simple. The OP's problems are the chart sucks and the MLPs rarely or ever discuss with him.

Some shops operate like that....and most good MLPs won't work there.

Medicine is difficult. You can be super-brilliant with deep understanding of how the nephron works, or you can memorize the sensitivity and specificity of all of the testing we do and be the "perfect" clinician...and still not have the leadership ability to mentor a group of girl scouts. MLPs aren't going away, especially not in the ED. EPs can either bitch and moan about how terrible we are, wail about how unfair life is, and drive their departments into the ground thus ensuring no quality MLP ever works there.

Or EPs can take the leadership role in their department by learning the strengths and weaknesses of the individual MLPs, and spend some time on correcting those weaknesses so the MLP can take more and more of the load off of you, all the while making you more money.

Your choice.

 

[enalli]

Some shops operate like that....and most good MLPs won't work there.

Why? I'm not suggesting your attending needs to shadow you taking a history and doing a physical exam, but a simple one-sentence conversation for the simple cases shouldn't burden you. A case discussion isn't adversarial--as a senior resident a lot of my presentations were along the lines of "the kid in 7 has had URI symptoms for 3 days, the vitals and exam are reassuring and I'm discharging them" followed by a "sounds good" from my attending. If you are not willing to discuss cases with a physician in real time, you are either not confident in your clinical skills or not confident in your attending's clinical skills; in either scenario the case presentation is the least of your problems.

 

[thegenius]

It's pretty ballsy to suggest that the "good MLPs" will want to work at places where they have (near) 100% autonomy - despite a legal environment where the law says they need to be supervised.

If you want to have autonomy, then you need to work in a state that permits that.

 

[Rendar5]

Why? I'm not suggesting your attending needs to shadow you taking a history and doing a physical exam, but a simple one-sentence conversation for the simple cases shouldn't burden you. A case discussion isn't adversarial--as a senior resident a lot of my presentations were along the lines of "the kid in 7 has had URI symptoms for 3 days, the vitals and exam are reassuring and I'm discharging them" followed by a "sounds good" from my attending. If you are not willing to discuss cases with a physician in real time, you are either not confident in your clinical skills or not confident in your attending's clinical skills; in either scenario the case presentation is the least of your problems.

Exactly why do I need to be interrupted and have my workflow disrupted by my mid level telling me that sentence. What exactly was accomplished in that scenario. Am I supposed to stop what I’m doing to see that patient? If I’m not supposed to, then what did my “sounds good” accomplish? Make the mid level feel good about themselves? Make me feel like they’re doing the right thing? How the hell would I know based on that little info if they’re doing the right thing?

In short I don’t want an extra 30 interruptions on my shift that accomplish nothing. Interruptions are dangerous and affect ones train of thought. Unnecessary task switching is not a good thing. Leave the interruptions for when you need my input on something.

 

[d2305]

The problem is that the ER is so hectic that one can end up charting on the wrong Pt. I'm glad none of my young healthy teens with chest pain had bad outcomes as I never got cardiac labs.

 

[enalli]

Exactly why do I need to be interrupted and have my workflow disrupted by my mid level telling me that sentence. What exactly was accomplished in that scenario. Am I supposed to stop what I’m doing to see that patient? If I’m not supposed to, then what did my “sounds good” accomplish? Make the mid level feel good about themselves? Make me feel like they’re doing the right thing? How the hell would I know based on that little info if they’re doing the right thing?

In short I don’t want an extra 30 interruptions on my shift that accomplish nothing. Interruptions are dangerous and affect ones train of thought. Unnecessary task switching is not a good thing. Leave the interruptions for when you need my input on something.

It sets the expectation that every case needs to be discussed with you real-time so you can decide to see them or not. That way when a new MLP says (to quote one of the examples that started this thread) "I'm discharging a 4 year old with a head injury that just had swelling to the head" which they thought would be met by a useless "sounds good," you can ask what exactly "swelling to the head" means, how the child is behaving, or just go see the patient.

Absolutely, unnecessary task switching is not a good thing, but real supervision is not unnecessary. Sure, being interrupted is annoying, but now you won't have (as many) surprises when signing your MLP charts the next day and will probably catch a few things you would do differently.

 

[GonnaBeADoc2222]

We don't know each other personally, so please take this in the charitable manner I am trying to send to you....but maybe your MLPs suck because the good ones won't work for this kind of attitude. I know I wouldn't.

If you're a neurosurgical PA and you're assisting in a surgery and the attending gives you a direction...you would comply, right?

If you're a hospitalist PA, and the attending says to consult ID about something...you would comply, right?

Why does this change in the ED?

I will always take the perspective and input of my midlevels into consideration, however, as the attending, I reserve the right to override you.

I honestly don't care about this PA vs NP war. I acknowledge that NP education is inferior in most cases, but really, I've seen both acceptable and horrid PAs and NPs. TBH I lump you all in the same bucket. They are physician extenders, and the buck stops with the attending.

 

[RustedFox]

We don't know each other personally, so please take this in the charitable manner I am trying to send to you....but maybe your MLPs suck because the good ones won't work for this kind of attitude. I know I wouldn't.

This? From you again? I've heard this from you before. You're right. We don't know each other, so please take this in the charitable manner that I am trying to send to you.

How can a PA get pissy [?] about needing to report to an attending when that requirement is present in the freaking NAME of their JOB as a - Physician Assistant - .
The job title isn't "Junior Doctor", or even "Resident".
Its like I went to medical school, and now I'm upset because I'm not given a badge and a gun and get to arrest bad guys and yell things like: "Freeze, scumbag!"
I have worked with some really good PAs. There's a trend... The ones that are "really good" are generally young, generally err on the side of caution, and don't cop this attitude of: "I'm not feeling respected like the professional that I am because I've been doing this job for eleventeen years and w.h.a.t.e.v.e.r." Its those "grandfathers/grandmothers" that suck, can't chart for $hit, can't interpret scientific literature, and generally make life more difficult that it needs to be.

Medicine is difficult. You can be super-brilliant with deep understanding of how the nephron works, or you can memorize the sensitivity and specificity of all of the testing we do and be the "perfect" clinician...and still not have the leadership ability to mentor a group of girl scouts. MLPs aren't going away, especially not in the ED. EPs can either bitch and moan about how terrible we are, wail about how unfair life is, and drive their departments into the ground thus ensuring no quality MLP ever works there.

Or EPs can take the leadership role in their department by learning the strengths and weaknesses of the individual MLPs, and spend some time on correcting those weaknesses so the MLP can take more and more of the load off of you, all the while making you more money.

Your choice.

Yeah, you know - I've tried your latter approach for years. The "come and sit with me; let me teach you something" approach. The "old Chinese man on top of the mountain" approach.
You know where it gets you? As said above by another poster, it is generally met with the oppositional/defiant attitude of a teenager, and a talk from the CMG about "not being a team player".
Thus, these MLPs have dictated my attitude by declaring themselves "unteachable". Don't want to learn anything ? Fine. Now simply shut-up and do as you're told. Act like a child, and you'll get treated like one.

Same shift as in the original post.... You'd think the MLP should be able to handle simple cystitis/dysuria, right? That's "right in their wheelhouse". Asked the "15+ year experience" PA what the presence of nitrites indicated. He had no idea. NO IDEA. After about 8 seconds of panicked silence, he spat out a guess of: "Well, it - uh... means there's MORE bacteria in there to be enough to make nitrite.[*]" That's seriously the answer that I got... in all of its eloquence and sophistication. This is the same PA with no knee exam in the chart, and who was 0/6 on neurovascular exams before/after splint placements.

[*] - If you're wondering, the correct answer to that question would have been: "I don't know."
Instead, he "faked it".

 

[d2305]

I wonder how he passed the certification test, which isn't easy?

 

[RustedFox]

I wonder how he passed the certification test, which isn't easy?

Maybe it was easier awhile back (guy is at least in his late 50s), when PAs knew their role.

 

[Boatswain2PA]

It's pretty ballsy to suggest that the "good MLPs" will want to work at places where they have (near) 100% autonomy - despite a legal environment where the law says they need to be supervised.

If you want to have autonomy, then you need to work in a state that permits that.

Supervision should be determined between the doc and the PA. Not by law, not by the CMG, and not by the hospital. Sometimes that supervision SHOULD include briefing on every patient, or even the doc seeing every patient. On the other end of that spectrum, if the PA has earned that doc's trust, supervision can be as simple as being available for questions.

No state permits PAs to practice autonomously. Unfortunately most state allow NPs to practice autonomously, despite their vastly poorer education.

It sets the expectation that every case needs to be discussed with you real-time so you can decide to see them or not. That way when a new MLP says (to quote one of the examples that started this thread) "I'm discharging a 4 year old with a head injury that just had swelling to the head" which they thought would be met by a useless "sounds good," you can ask what exactly "swelling to the head" means, how the child is behaving, or just go see the patient.

New MLP should have close enough supervision. But if you and I worked together in the ED you would feel comfortable with my practice patterns, how I apply the PECARN rules, how I'm cautious and would frequently do a 4 hour obs for such patients, etc.

I will always take the perspective and input of my midlevels into consideration, however, as the attending, I reserve the right to override you.

Of course. Nobody is disputing the authority of the attending.

How can a PA get pissy [?] about needing to report to an attending when that requirement is present in the freaking NAME of their JOB as a - Physician Assistant - .

Because there is no requirement to report every patient to an attending. You are welcome to make one up in your shop, or with your particular staff. If you want to use MLPs most effectively, you would only set that requirement for the MLPs who you don't have faith in (new grads, new to your practice, or folks like you describe below).

You'd think the MLP should be able to handle simple cystitis/dysuria, right? That's "right in their wheelhouse". Asked the "15+ year experience" PA what the presence of nitrites indicated. He had no idea. NO IDEA. After about 8 seconds of panicked silence, he spat out a guess of: "Well, it - uh... means there's MORE bacteria in there to be enough to make nitrite.[*]" That's seriously the answer that I got... in all of its eloquence and sophistication. This is the same PA with no knee exam in the chart, and who was 0/6 on neurovascular exams before/after splint placements.

Yeah, and I was running a code on a middle-aged choking victim, PEA, got airway cleared and tubed, end-tidal at 45 (started significantly higher), beautiful regular and narrow QRS on monitor at 160, but no other signs of life. We couldn't find a pulse anywhere, even with doppler. Quick sono of heart showed good contractility...this guy obviously isn't dead yet. In walks physician who picks up the sono probe, orders cessation of compressions and puts probe on chest. I have no idea what they were looking at because I couldn't identify landmarks, but then the doc declares them dead and walks out. I'm like W....T......F. Okay, Doc's patient now, not mine, so I walk out of resus. Nurses stunned as well and don't take off monitor. It's a full 15 minutes later when RT notices that there is STILL a beautiful narrow QRS sinus tach on monitor, checks for a pulse and low-and-behold the guy is alive. Bag, vent, pressors, steroids, I put in CVL and we transfer to tertiary.

Bottom line is that some people do stupid things, no matter what their title.

 

[Boatswain2PA]

Maybe it was easier awhile back (guy is at least in his late 50s), when PAs knew their role.

We have to retake the test every 6-10 years, just like physicians. Unlike NPs who take their test once and then good forever.

 

[Groove]

The biggest problem I have is with the MLPs who have been doing this for a few years and have ingrained bad habits and are generally recalcitrant to education and/or retraining. In general, they are competent..and hence require little oversight, but that yields an overconfidence with higher acuity patients that when combined with things like premature closure bias makes them decidedly dangerous. However, when I try to correct or educate them, which should be very simple and shouldn't really (in my mind) insult them, they shut down. The ones I actually enjoy working with are the ones who are not only well trained, but new...and tend to be a bit overcautious (because they are new) and come to me even when they really don't need to (I don't mind).

I don't think the answer is to eschew MLPs from this specialty. If that's really what you want, then you need to embrace the further ensuing onslaught of EMTALA blessed "non emergent" complaints that you not only see now but will continue to see more of in the future. The ED is fastly turning into nothing more than an [ER + public 24/7 "free" clinic] for the consumption of the general public. There just simply aren't enough of us to handle this volume. MLPs are perfectly suited to help us offload and process the majority of non emergent cases. Sure, there's nothing wrong with training them to handle more urgent/emergent cases but that's honestly not where we need them in the majority of emergency rooms....not now, not in the foreseeable future. I really need them in fast track. I not only need them there, but I appreciate them there. There's absolutely no use in fighting it. CMGs already control the majority of EDs. Why on earth are they going to hire additional MDs when they can save money in hiring NP/PAs to run fast tracks and see lesser acuity patients? If your current medical dir wants no MLPs you can bet your lucky stars they will find one who will want them and will hire them. I think the answer lies in better selection of MLPs and better QA/lower tolerance in "bad behavior".

The problems now? In most shops, you get paid more based on how many charts the MLPs send to you! If you think that's not a clear disincentive for you to correct them, critique their management or piss them off, you're crazy. If they don't like you or don't like presenting to you, they'll just send the charts to someone else. "Fine by me!" you might say, but if you work in our ED, that's probably on the order of at least ~$25/hr cut in your salary. It's a fundamental flaw in the system that promotes, condones and perpetuates unsafe practice patterns in MLPs. Until that can better be addressed, I don't really see an answer to the problem. If you work in a straight hourly ED with no productivity incentive that is dependent on signing of MLP charts then consider yourself lucky.

Arguing that MLPs have no place in the ED when most can work unsupervised in family practice clinics (where few of you would probably truly fault them for providing basic access in medical care to the public) just doesn't make sense when such a large amount of FM comes through the ED every day. I don't know about you guys, but I really don't want to see all that stuff. I'm completely happy that the MLPs can see the majority of those cases and leave the higher acuity stuff to me. I think it's a great relationship and I personally don't feel threatened in the slightest. Sure, encroachment is a concern in any specialty and even though there are some similarities to Anesthesia, I think we have tremendous differences in MLP utilization and placement within the emergency department.

 

[MechEDoc]

Supervision should be determined between the doc and the PA. Not by law, not by the CMG, and not by the hospital. Sometimes that supervision SHOULD include briefing on every patient, or even the doc seeing every patient. On the other end of that spectrum, if the PA has earned that doc's trust, supervision can be as simple as being available for questions.

Hah! That's some sovereign citizen level stuff there.... Everyone works for someone else. No matter how big a fish you are. Even sole proprietors are under the Board of Medicine, the Board of medicine is under the state legislature, and to some degree the state legislature is under the control of the voters.

I welcome you attempting to define your role irrespective of the powers that be.

Thankfully I'm currently employed in a role where I am no longer my brother's keeper.

 

[Rendar5]

It sets the expectation that every case needs to be discussed with you real-time so you can decide to see them or not. That way when a new MLP says (to quote one of the examples that started this thread) "I'm discharging a 4 year old with a head injury that just had swelling to the head" which they thought would be met by a useless "sounds good," you can ask what exactly "swelling to the head" means, how the child is behaving, or just go see the patient.

Absolutely, unnecessary task switching is not a good thing, but real supervision is not unnecessary. Sure, being interrupted is annoying, but now you won't have (as many) surprises when signing your MLP charts the next day and will probably catch a few things you would do differently.

This is needed for a rookie mid level or someone who doesn’t know what they’re doing. This is not needed for a mid level you know and are comfortable with. It is annoying and dangerous. If I had a mid level I know present those one word sentences on every single patient. I would think that they had absolutely no confidence in their skills or abilities. My midlevels give me blurbs on about 10-15% of their patients. That is more reasonable. I don’t have time as an attending to see or hear about every single patient of theirs in addition to dealing with my patients and my residents patients on top of things. I see double a residents load of patients if not more.

Now I realize at more academic places midlevels will function as residents like in my own place of training. In that case I’m directly supervising them and need to know all their cases. In most community places though I am their boss and their go to consultant but I don’t need to know every case. I don’t need to micromanage them. I don’t need to burn out. I don’t need to know about 7 patients an hour. ( my load plus their load). If you want to be a micromanager and you want a ridiculous patient load be my guest but don’t hoist your ideas on every EM physician telling every mid level to discuss every single case with every physician. It’s truly ridiculous.

 

[Boatswain2PA]

Hah! That's some sovereign citizen level stuff there.... Everyone works for someone else. No matter how big a fish you are. Even sole proprietors are under the Board of Medicine, the Board of medicine is under the state legislature, and to some degree the state legislature is under the control of the voters.

I welcome you attempting to define your role irrespective of the powers that be.

Thankfully I'm currently employed in a role where I am no longer my brother's keeper.

Most BOM's license PAs to practice medicine, under the supervision of a doc. Some BOMs require chart signing, others require more stringent supervision requirements, meanwhile others don't require anything but having a doc on file. How is that helpful to ACTUAL supervision?

Hospitals have credentialing as a way of ensuring qualified providers.

CMGs just have rules to protect their asses and move the liability toward us.

The best supervision is determined between the doc and the PA. That may be being available for questions, occasional chart review, all the way to seeing every patient on admission and before discharge.

 

[Rendar5]

For a tamer response, what you propose may be correct for select settings depending on the mid level and working environment. I may have had those views myself as an academic resident, but as a community attending, the approach is unnecessary and overburdening in majority of cases. It is also quite contrary to how most EDs work.

 

[Boatswain2PA]

This is needed for a rookie mid level or someone who doesn’t know what they’re doing. This is not needed for a mid level you know and are comfortable with. It is annoying and dangerous. If I had a mid level I know present those one word sentences on every single patient. I would think that they had absolutely no confidence in their skills or abilities. My midlevels give me blurbs on about 10-15% of their patients. That is more reasonable. I don’t have time as an attending to see or hear about every single patient of theirs in addition to dealing with my patients and my residents patients on top of things. I see double a residents load of patients if not more.

Now I realize at more academic places midlevels will function as residents like in my own place of training. In that case I’m directly supervising them and need to know all their cases. In most community places though I am their boss and their go to consultant but I don’t need to know every case. I don’t need to micromanage them. I don’t need to burn out. I don’t need to know about 7 patients an hour. ( my load plus their load). If you want to be a micromanager and you want a ridiculous patient load be my guest but don’t hoist your ideas on every EM physician telling every mid level to discuss every single case with every physician. It’s truly ridiculous.

You hiring? Lol