Posted by: notdeaddinosaur | April 29, 2010

It’s the Diagnosis, Stupid

The topic of Nurse Practitioners in the context of primary care has been resurgent of late, most notably in this post by Maggie Mahar at Health Beat. Much of the conversation is dominated by assertions such as this:

…Nurse Practitioners have the needed training and that, in fact, doctors who have gone through the full medical school curriculum are over-qualified for a job that, today, is more about coordinating care than medical science

…“For most of these tasks, many primary care doctors are actually ‘over-qualified.’” YJHM continues. “Clearly, while they have taken on the role of health care ‘coordinators’ they have become more dependent on specialists to take care of the sickest patients. Their ‘scientific’ medical role has decreased while their ‘coordinating” role has increased. For many primary care physicians their medical training is of less importance in their new roles.

The problem is that although that description seems to be correct (and in far too many cases, is indeed all too accurate), it is because the practice of medicine in this country has deteriorated into an inappropriate emphasis on treatment while shamefully neglecting the necessary art of diagnosis.

Medicine consists of two distinct parts:

  1. Diagnosis: figuring out what is wrong with the patient, and
  2. Treatment: deciding what to do for the patient, and then carrying out the plan.

Far too many non-physicians seem to feel that medical diagnosis isn’t really all that complicated. Plug symptoms and exam findings into an appropriately sophisticated algorithm and out pops the answer. Hey, patients can even do it themselves on WebMD, right?

All the physicians reading this (especially those who saw a patient with a list from WebMD today) are shaking their heads sadly, knowing just how far this is off the mark. Correctly diagnosing what is wrong with a given patient is the sine qua non of practicing medicine, and although it seems simple with straightforward patients (and/or brilliant physicians), medical diagnosis is truly an art that takes years to fully master. Eliciting nuances of the medical history gleaned from extraordinary interview skills can only be demonstrated in medical school. Appreciating a subtle physical finding with painstakingly honed physical examination techniques can only be accomplished with time. These are skills only attained with copious hands-on experience. Dr. Robert Centor has written of this at much greater length, with far more eloquence than I. (Go to his blog and do a search on “Diagnosis.”)

Great physicians are great diagnosticians. And it is all those background years of education and training (the “full medical school curriculum” spoken of so disdainfully by the nurse practitioner advocates) that prepares us to master this critical skill. All that “extra” information provides us with the key knowledge patients (and nurse practitioners) are lacking when evaluating internet databases like WebMD: what to ignore. Recognition of what is not important is critical.

I am unswayed by the study quoted by Mahar, a survey of responses to a hypothetical patient with acute gastritis in which nurses were found to take a more complete history and prescribe fewer drugs than doctors. But the fact that the doctors did a lousy job (by report; might they be more complete when faced with the actual patient instead of just a study scenario?) is more a condemnation of the deterioration of American medicine than a paean to the diagnostic skills of nurse practitioners. As vital as it is to identify extraneous information, you cannot diagnose something if you’ve never heard of it. How about an adult with a sore throat and negative strep test who is getting worse over three to five days? How many nurses have even heard of Lemierre’s syndrome? My experience with nurse practitioners (anecdotal, I know; what can I say? I’m human) is that of very limited diagnostic acumen, coupled with a significant overuse of consultants and prescription medications, especially controlled substances.

It has been argued that treatment is far more straightforward than diagnosis, and in many cases, that is very true. “Cookbook” medicine often works well, but only to the extent that the patient’s condition has been correctly diagnosed. I won’t deny that treatment often needs tweaking for individual patients, but this is seldom as complex an endeavor as diagnosis. And this is where American medicine falls on its collective ass. We may have the best treatment in the world, but in general, our diagnostic skills suck! You can have self-service gas stations every half-mile along the highway, but that’s not going to get your car started if your battery is dead.

That said, I admit that far too many doctors — both primaries and specialists — are terrible diagnosticians. Whether due to lack of time or intellectual laziness, far too many of us don’t put forth the effort to properly diagnose our patients. Shotgun studies and referrals may have become the norm, but that doesn’t make it right.

The practice of medicine is the diagnosis of disease and the treatment of patients. “Coordination” of care (diagnosis and treatment; recurring theme here?) is certainly something that could be accomplished by non-physicians, as long as recognition remains that physicians are the ones best suited to diagnosing and treating (AKA practicing medicine). Maggie Mahar may prefer the “comfort and care” approach that nurses claim to offer instead of “the scientific perspective of medical schools that teach about disease processes and bodily interactions,” but without first having an accurate diagnosis, she and many others could find themselves in deep trouble.

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Responses

  1. What upsets me is that BOTH Nurse Practitioners AND Physicians could have a lot to show each other, considering the differences in their training. Why are we spending so much time tearing into each other’s qualifications instead of TREATING PATIENTS????

    (i really want to be able to get my NP degree in a few years)

  2. I wonder how many physicians actually know about Lemierre’s syndrome. Estimated incidence about 1-2 per million (medical students are allowed to Google, right?).

  3. Thanks for taking Maher on – she is a formidable force, well-written and well-respected, but on this one I must agree with you wholeheartedly. The solution to the deterioration of primary care is not to replace doctors wil less-trained nurses, but to reimburse primary care docs for the time it take to take a decent history and physical, diagnose and treat. “Ccoordination of care” does not mean making sure patients get to their specialist appointments on time. It means sifting through the consultant reports, weighing all the medications and thier interactions and side effects being predcribed by consultants, making recommendations and coming up with a comprehensive treatment plan together with a patient – most of which is unremibursed time.

  4. Thanks also for the Mahar review.

    I tried to give perspective on this issue and others from the MD point of view, and Maggie “shut me down” forceably. While I admire her analysis of the economics of medicine in the US, I was not pleased with her characterization and denigration of primary care, esp when “crowing” about the time spent by NPs and PAs.

    She’s spent alot of time beating on the medical “guild” not as a profession and pursuit of care, but as a closed society. Yet last time I looked, medical schools are accepting new students!

    Sorry, Maggie — differential diagnosis (figuring out what is wrong from a patient) is a learned, hands on experience taking many years of “apprenticeship” — if that is a “restrictive guild” so be it.

    Thanks Dr Dinosaur for taking her on — think I pointed her out to you a week or so if you didn’t see her blogs yourself 😉

    Dr Matlev
    Family Medicine
    25 years out (Dr Dino has been in practice in my home town for a couple years more than me!)

  5. Agree with you, Dino

  6. Dinosaur–

    Just spend quite a bit of time commenting on this thread.

    When I submitted the comment, it disappeared.

    (Perhaps it is waiting for approval . . .but I didn’t get a message saying that.)

  7. Interesting- I had kept a copy of my comment and once again tried to post it here –and once again it disappeared.

    But my comment above (saying that my response disappeard) made it through your filter. Not sure what’s going on.

    Readers who are interested in how Dinosaur misunderstood what I was saying can find a copy of the that I tried to post here on my blog. Go to http://www.healthbeatblog.org and scroll down to “Hey Nursie, . . . ”

    Peggy– I essentially agree with everything you are saying.

    Dr. Maltev– I didn’t shoot you down. You offered an interpretation of my book, and I explained what you had misunderstood.

  8. Maggie:

    First of all, apologies for your difficulties with comment posting. I have no idea what the problem might have been. I have no comment moderation enabled, and no filters that I know of. Then again, I just moved my blog over to WordPress, and there may be some kinks of which I am still unaware.

    Secondly, thank you so much for your thoughtful comments, both on Health Beat and here. As it happens, I am a VERY regular reader of Health Beat, and am quite aware of (and deeply appreciate) your views on primary care. Still, I think it is you who misunderstands my point.

    What I hear you saying is that because 1. doctors are no longer trained to diagnose properly, 2. primary care physicians are unhappy (mainly because of onerous administrative requirements and fear of random liability litigation), and 3. it is difficult to recruit medical professionals to rural areas, Nurse Practitioners should be utilized to provide primary care.

    Medical education does indeed need to be reformed to re-emphasize the primacy of listening to patients, diagnosing properly, thoughtfully, AND economically; curing when possible, and caring always (including hand-holding when appropriate).

    Fix the job that is primary care: pay for it (paying for time spent would work well, IMO), respect it (need to change the medical culture but if it starts to pay better, you’d be surprised how quickly that would follow), delegate non-medical “care management” (to the NPs, if you want), and for heaven’s sake, call off the lawyers by enacting meaningful tort reform!

    Providing care in underserved areas will always be a problem: few people want to go there because, well, there are few people there!

    To the non-medical professional, even someone as informed and savvy as you, Maggie, what the nurses are saying makes sense. We are trying to explain the flaws in their argument to you: they are not doctors, they cannot “take over” the job doctors are supposed to be doing, therefore they are not the answer to the nation’s primary care woes.

    I agree with you that CNMs (nurse midwives) can practice independently with great success. I went to midwives for both of my pregnancies. I do believe that expansion of their role (and numbers) in routine obstetrics in this country would be of huge benefit economically and in terms of outcomes (fewer c-sections and other labor interventions). But obstetrics is a very specialized area. Despite the popular perception that “every pregnancy is different”, there are widely accepted protocols for the management of uncomplicated pregnancy, down to the frequency of prenatal visits and what happens at each one. Because of this, though, it can also be clearly defined at what point referral is indicated.

    But it’s important to realize that these results can NOT be generalized to the rest of primary care. Perhaps the best role for NPs is in the care of healthy people; routine gynecology, well child care, periodic health examinations in patients who SELF-IDENTIFY as healthy. I have no problem “ceding” this part of primary care, if only the nurses would recognize that, bluntly, their training is inappropriate for first contact care of the sick.

  9. […] past week saw lots of discussion of primary care, its role, and its future.  Dinosaur talks about the different skills needed for diagnosis vs. treatment, and ill-care vs. well-care in the context of NPs and PAs filling the […]


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