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That works great... until there’s a subtle reason to think that it’s not streptococcus for reasons ABC or that’s not the proper treatment for reasons XYZ and yo

by jquery 9y ago

That works great... until there’s a subtle reason to think that it’s not streptococcus for reasons ABC or that’s not the proper treatment for reasons XYZ and you have a mild case of death.

wyldfire 9y ago
Physicians that you see in the office won't detect those reasons ABC and save you from death. The expert diagnosticians often work in hospitals and are only used when other PAs/Physicians tell them "I ruled out all of the common explanations for these symptoms, what could it be?"
- jquery 9y ago
  > Physicians that you see in the office won't detect those reasons ABC and save you from death. Any hard research showing this? Something that addresses confounding factors, overburdened doctors, etc.? Is there a study showing that spending 30 minutes with a physician is equivalent to 30 minutes with an RN or PA for all outcomes (not just death)? I have a feeling we're all acting like medical experts in this thread even though very few of us are. It's like when we see research about programming methodologies and are able to poke so many holes in the study it becomes swiss cheese.
  - paviva 9y ago
    > Any hard research showing this? Probably not. Or, better stated, not that I am aware of. Let's think. Seeing a doctor instead of a PA is associated with better outcomes if, and only if, your condition can benefit from the doctor's specialized knowledge. That means it requires treatment, the treatment is time-sensitive (i.e. worse outcomes if there's a delay), and there are significant adverse effects in case of a lack of appropriate treatment. The problem is, these conditions are either too rare to be studied in any meaningful way, or the patients' very obviously sick and taken directly to the hospital, where he is obviously seeing a doctor and not a PA. A lot of people go to the doctor for pretty benign ailments which don't really require a treatment, or for conditions that any intelligent, motivated patient is theoretically able manage himself without a doctor. Examples : virus infections, sprains, acid reflux, chronic conditions like hypertension, diabetes, and so on. E.g. : someone has type I diabetes, understands how and when to give himself insulin, checks his feet for infection and so on. In a case like this, the doctor can barely bring any plus value apart from ordering the regular blood work. Another frequent scenario is when the patient does have a time-sensitive, treatment-required condition, but does not follow the treatment. Again, him seeing a doctor is unlikely to result in any appreciable benefit.
    - jquery 9y ago
      Good thought experiment, thanks.
  - wyldfire 9y ago
    No, just intuition. 70% of the primary care medicine appointments are "eh, it's a virus, come back if symptoms persist." [1] 10% is casts/sutures/I&D/debridement. 15% are "I'm telling you, these symptoms are all due to your diabetes and your diet will kill you if you don't take it seriously." Maybe 4-5% are really diagnosing serious chronic issues. And generally it's just referral to a specialist who makes the official diagnosis. A missed diagnosis here can be a serious consequence in some cases, but symptoms that can indicate those diagnoses are big red flags. [1] http://extrafabulouscomics.com/comic/418/ http://extrafabulouscomics.com/comic/418/
    - jquery 9y ago
      Well, as someone who has a mildly life-threatening condition that manifested "off-book", and only one of several doctors I saw was able to identify it, I'm probably a bit more skeptical than average. But, it's worth noting that my symptoms were severe enough each time I had it that a PA would've certainly referred me to a doctor (I called an "advice nurse" each time who told me to see a doctor). So maybe that's a point in favor of PAs doing initial screens. With respect to that comic, I would've gladly paid $4k out of pocket for a diagnosis. I still think fondly of the doctor who quickly figured out the puzzle that tricked a couple other specialists, my PCP, an urgent care doctor, and an emergency medical doctor. The same doctor who quickly sent me to the hospital in an ambulance with a note on my chart that said "this is serious, don't send him home until you confirm my diagnosis."

by jquery 9y ago

That works great... until there’s a subtle reason to think that it’s not streptococcus for reasons ABC or that’s not the proper treatment for reasons XYZ and you have a mild case of death.

wyldfire 9y ago

Physicians that you see in the office won't detect those reasons ABC and save you from death. The expert diagnosticians often work in hospitals and are only used when other PAs/Physicians tell them "I ruled out all of the common explanations for these symptoms, what could it be?"

jquery 9y ago
> Physicians that you see in the office won't detect those reasons ABC and save you from death. Any hard research showing this? Something that addresses confounding factors, overburdened doctors, etc.? Is there a study showing that spending 30 minutes with a physician is equivalent to 30 minutes with an RN or PA for all outcomes (not just death)? I have a feeling we're all acting like medical experts in this thread even though very few of us are. It's like when we see research about programming methodologies and are able to poke so many holes in the study it becomes swiss cheese.
- paviva 9y ago
  > Any hard research showing this? Probably not. Or, better stated, not that I am aware of. Let's think. Seeing a doctor instead of a PA is associated with better outcomes if, and only if, your condition can benefit from the doctor's specialized knowledge. That means it requires treatment, the treatment is time-sensitive (i.e. worse outcomes if there's a delay), and there are significant adverse effects in case of a lack of appropriate treatment. The problem is, these conditions are either too rare to be studied in any meaningful way, or the patients' very obviously sick and taken directly to the hospital, where he is obviously seeing a doctor and not a PA. A lot of people go to the doctor for pretty benign ailments which don't really require a treatment, or for conditions that any intelligent, motivated patient is theoretically able manage himself without a doctor. Examples : virus infections, sprains, acid reflux, chronic conditions like hypertension, diabetes, and so on. E.g. : someone has type I diabetes, understands how and when to give himself insulin, checks his feet for infection and so on. In a case like this, the doctor can barely bring any plus value apart from ordering the regular blood work. Another frequent scenario is when the patient does have a time-sensitive, treatment-required condition, but does not follow the treatment. Again, him seeing a doctor is unlikely to result in any appreciable benefit.
  - jquery 9y ago
    Good thought experiment, thanks.
- wyldfire 9y ago
  No, just intuition. 70% of the primary care medicine appointments are "eh, it's a virus, come back if symptoms persist." [1] 10% is casts/sutures/I&D/debridement. 15% are "I'm telling you, these symptoms are all due to your diabetes and your diet will kill you if you don't take it seriously." Maybe 4-5% are really diagnosing serious chronic issues. And generally it's just referral to a specialist who makes the official diagnosis. A missed diagnosis here can be a serious consequence in some cases, but symptoms that can indicate those diagnoses are big red flags. [1] http://extrafabulouscomics.com/comic/418/ http://extrafabulouscomics.com/comic/418/
  - jquery 9y ago
    Well, as someone who has a mildly life-threatening condition that manifested "off-book", and only one of several doctors I saw was able to identify it, I'm probably a bit more skeptical than average. But, it's worth noting that my symptoms were severe enough each time I had it that a PA would've certainly referred me to a doctor (I called an "advice nurse" each time who told me to see a doctor). So maybe that's a point in favor of PAs doing initial screens. With respect to that comic, I would've gladly paid $4k out of pocket for a diagnosis. I still think fondly of the doctor who quickly figured out the puzzle that tricked a couple other specialists, my PCP, an urgent care doctor, and an emergency medical doctor. The same doctor who quickly sent me to the hospital in an ambulance with a note on my chart that said "this is serious, don't send him home until you confirm my diagnosis."