Posted on 02/22/2014 7:50:33 AM PST by Kaslin
Soooo WebMD does not make a good primary care physician? Who knew???
In my case, the doc refused to prescribe the antibiotics or run the tests and I ended up on doxycycline for eight months when I finally started to show more serious symptoms and they ran then the tests.
So in all three cases, tests showed that we were positive for Lyme disease, and in all three cases the physicians had botched the diagnosis. A good protocol could have prevented that. On the other hand a bad protocol could have denied us ever getting tested.
My point in saying this is that either proper protocols or physician discretion can be a good thing or a bad thing depending upon the type of case. Had I been the usual compliant patient, the latitude of physician discretion could have been debilitating or fatal. Had there been protocols in place denying testing at all the results would have been just as bad.
If you have the time both methods are recommended. Getting a second opinion from a craftsman couldn’t hurt too much.
Wait ‘till they find out you can’t sue the government!
There will be a dimunition of malpractice justice for deserving patients, and, consequently a drop in quality of care...that is, among the doctors who will buy into this system, which will be extremely diminutive.
The surgeons who finally came to visit asked me why I waited so long....
And MOST patients will not be seeing an MD anyway. Nurse practitioners will be the primary visit attending. Then maybe a Dr. And then, if he hasn’t had too many referrals that month, you might be referred to a specialist for your acute problems. Good luck to us under Obamacommiecare!
We are well on the way of educating all independent thought out of our medical students and residents.
Innovative approaches and individualized treatment based on understanding of pathophysiology, pharmacology, genomics, and psychosocial concerns will completely disappear in not very long.
Cookbook medicine works best in patients with straightforward conditions who are likely to get better on their own or with minimal intervention. Thus, many cookbook approaches wind up overtreating patients who need little or no treatment. The expensive and unnecessary emergency room care that is routinely delivered according to “metrics” is a good example.
Cookbook becomes less effective, and even injurious, as patients and their illnesses become more complex. A well-trained experienced physician who is trained to “split hairs” can usually tune through the static and deliver effective and focused treatment earlier, when it is likely to be more effective. This requires detailed analysis, careful analytic thought, and usually, approaches outside the algorithms that direct our modern trainees.
On a personal note, on a daily basis I receive faxes from insurance drug plans wanting to know the patient’s DIAGNOSIS. Now, some of these drugs are prescribed for only one reason, e.g. HIV/AIDS, so only a clueless moron would need a diagnosis code.
More importantly, it not necessary for a dispensing pharmacy to know the patient’s diagnosis: all they need is a legible prescription from a licensed physician. Adding a diagnosis code just makes it easier for a patient’s private information to be divulged by unauthorized database access or a malicious drone working for the insurance plan.
So far, good humor and politesse have ruled my responses to these requests: I write “You do not need this information to dispense this drug” in the space for “Diagnosis.”
I can forsee the day when I snap and enter, “None of your f***ing business!”
“Both my kids and I were (upon separate occasions) nearly condemned to denial of treatment for Lyme disease simply because the physicians involved did not believe that the Brucellosis bacterium was in our area. They showed the classic bulls-eye rash but the docs would not run the tests. A proper protocol would have saved me a ton of trouble in getting us to an infectious disease doc. When I finally did, his comment was, “Good job.” The tests showed that the kids were positive.
There is no substitute for a careful history and physical, critical thought, and asking for help when you are in over your head.
In my case, the doc refused to prescribe the antibiotics or run the tests and I ended up on doxycycline for eight months when I finally started to show more serious symptoms and they ran then the tests.
So in all three cases, tests showed that we were positive for Lyme disease, and in all three cases the physicians had botched the diagnosis. A good protocol could have prevented that. On the other hand a bad protocol could have denied us ever getting tested.
My point in saying this is that either proper protocols or physician discretion can be a good thing or a bad thing depending upon the type of case. Had I been the usual compliant patient, the latitude of physician discretion could have been debilitating or fatal. Had there been protocols in place denying testing at all the results would have been just as bad.”
I am glad that you and the kids were diagnosed and treated correctly. (BTW, the agent of Lyme is a Borrelia, not Brucella).
You are correct that the appropriateness of treatment is based on how well the algorithm is written. It is likely that the algorithm for a skin rash for a Nurse Practitioner in San Diego would likely be very different for one in White Plains, NY.
In San Diego, where there are very few cases of Lyme Disease reported annually, treatment for wasp or spider bite would likely be the protocol-directed “Correct” treatment. In White Plains, which lies in one of the most heavily Lyme-endemic counties in the Northeast, the protocol would likely (correctly) direct the NP to treat for Lyme Disease based on the appearance of the rash alone.
You are also correct that an early referral to an ID specialist would likely have unravelled the story earlier and saved you unnecessarily prolonged treatment.
We are trained to evaluate people based on history of travel, occupation, exposures in a way that you don’t get when people are following protocols. Medical diagnosis is very much a function of complex pattern-recognition, but you won’t see the pattern unless you take the time to get all the information. And, as I am wont to tell my students and residents, “When all else fails, LISTEN TO THE PATIENT!”
A few years ago, my friend’s daughter drove cross-country from her Connecticut home to California. By the time she reached Las Vegas, she had a peculiar blistering rash behind the knee. She was given steroids for a spider bite. She texted a photo to me, and it was clearly a typical rash of Lyme, which often blisters behind the knee.
I phoned in an Rx for doxycycline, and obtained a confirmatory blood test (positive) when she arrived in California.
Now, if the Las Vegas ER doc had trained in the Northeast, he might have made the diagnosis. But based on his experience, the low prevalence of Lyme Disease in Nevada, and the ER prorocol there, the correct diagnosis was missed.
This was fifteen years ago. Memory failed. Brucellosis is a tick borne disease, as is human monocytic erlichiosis.
Now, if the Las Vegas ER doc had trained in the Northeast, he might have made the diagnosis. But based on his experience, the low prevalence of Lyme Disease in Nevada, and the ER prorocol there, the correct diagnosis was missed.
We have Western black legged ticks here in California, which are an ixodid capable of transmitting Lyme. At the time, there had been only four documented cases here, but that more likely means there were many that had gone undiagnosed.
We are trained to evaluate people based on history of travel, occupation, exposures in a way that you don’t get when people are following protocols.
I think expert systems in the hands of a nurse practitioner with specialist backup have a real future. Nurse practitioners equipped with such tools probably have better diagnostic capability available now than were available to physicians twenty years ago. With the broad availability of antibody detection sticks, that point of service detection capability could be amplified considerably.
The vast bulk of cases physicians see are either obvious (an injury) or fairly routine. Hence, teaching the NP when to punt will be a real challenge.
Medical diagnosis is very much a function of complex pattern-recognition, but you won’t see the pattern unless you take the time to get all the information. And, as I am wont to tell my students and residents, “When all else fails, LISTEN TO THE PATIENT!”
Learning how to ask questions and engage the patient to search and evaluate his or her experience so as to deliver relative or quantifiable distinctions are equally subtle. In terms of pattern recognition, teaching the physician to reconstruct a progression of symptoms by which to make such distinctions is still an art-form. As you know, it is not at all uncommon for a tick bite to fail to show the classic rash.
In a completely different vein, I think medical science is so distorted by a legal environment that presumes anything is treatable as long as it comes from a government-sanctioned therapy that we have blown off totally broad spectrum treatments with a very solid history. There is such a thing as 'do something as long as it is not harmful' as opposed to 'do nothing unless you know for certain what you are treating.' There are a LOT of pathologies out there about which we have little to no idea.
Case in point, I think viruses as inducing immune system disorders are behind a host of 'treatable' diseases, particularly cascading consequences of inflammation, such as causes of heart disease (for example as aggravated by oral gingivitis), rheumatoid arthritis, consequences of apnea, and kidney disease. I believe I have such a malady, possibly analogous to Wegener's granulomatosis. My gums were going bad. My fingers were so painful I couldn't negotiate buttons. My nose was bleeding. All of those symptoms were stopped cold and reversed to a degree by sublingual colloidal silver. It's not gone, but life is at least functional again to the degree that I'm back to climbing trees with a chainsaw. It sure as hell beats the prognosis of a lifetime course of methotrexate and cortisone shots.
Thanks for the thoughtful post.
The cookbook approach is being pushed within psychology (mainly by academics who shouldn’t be allowed alone in a room with anyone). It is sooooooooooooo wrong and inadequate for the nuances of mental health treatment.
I like WebMD. Sure, it can't replace physician services, but it still provides decent information. A patient who wants to learn more about his/her diagnosis can find out more about it at websites like WebMD, Mayo Clinic, etc.
The twin ideas of state medical licensure and psychological disorder as a disease were guaranteed to produce such a result. To it we have added state control of morality, with the state having a direct interest in immorality as a means to increase demand for police powers. It is a terrible feedback loop.
"Don't worry, scrote. There are plenty of 'tards out there living really kick-ass lives. My first wife was 'tarded. She's a pilot now."
I've seen way too much of doctors dealing with the effects rather than the causes. It's why I avoid doctors; they've done so much harm to so many people not treating these underlying causes.
Does it take a nurse to put low value information into a computer terminal? / rhetorical question
LOL!
I beg your pardon, but this is not the case. A pharmacist's mandate includes dispensing the correct drug for the patient's disease, and the pharmacist is both ethically and legally liable if a drug is dispensed for an inappropriate indication. They may not ask all the time, but if they do they generally have a good reason.
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