Where does medicine begin and where does it end?

[FireMedic65]

It is pretty ignorant for people to say one person can make a "diagnoses" and another person cannot. Confirmation is of course required though. But who does the testing? The doctor will order the test, but a technician will do the actual testing. The doctor or whom ever will look at the results that confirm the tests. If a person comes into the ER complaining of, lets say chest pain. Labs are drawn up by a lab tech or ER tech. Those blood samples, are taken to the lab, where the lab technical will run tests on them. They are run through a computer and the results are printed. What diagnoses did the doctor make? None if you ask me. The computer did.

For those who are out in the field, doing pre-hospital care. I could not agree with ERDoc more. FOR THE MOST PART, paramedics are not morons. We are educated and trained very well. People will argue with the education issues on how long a certain program is. I am sorry so say, but it's not the schools fault for what you don't learn. Education in medicine is what you put into it. You are in a highly professional field where peoples lives are at stake. If you don't have the maturity to LEARN ON YOUR OWN, and not be spoon fed information, maybe this isn't the field of work for you. ERDoc, and all others, I am not saying that is what you were trying to say, those are my words and my opinion.

We often come across patients in the field who are having difficulty breathing. We don't just slap on an o2 mask and blindly gives medications to these people. We assess them. We listen to lung sounds, we do a 12 lead, we do capnography or sp02 at the very least. We ask questions, we check their medications, etc etc. We form an an educated "guess" if you will on what is going on with this patient, and we treat them appropriately. What much else can the doctor at the hospital do? Aside from ordering an x-ray and looking at it to confirming what the x-ray tech already knows, but isn't allowed to "say" what it is, and ordering lab work. The nurse already knows what tests should be run, and usually has them ready to be drawn up before the doctor can "order them".

All that being said, doctors, nurse practitioners, physician assistants are ALL a very important part of the profession. They are all highly trained and educated, as well as every other hospital/ems employee responsible in patient care and testing. I am not putting down any position or level of care. We all have our place. Saying one person can say "ok you are sick" just because they have more schooling, is just silly. Everyone should know what is going on with their patients to a certain extent.

[chbare]

I think my question goes beyond simply saying,"ok you are sick." What I am talking about is more like; "you are sick, I have interpreted the results of labs and diagnostics, I have interpreted your physical assessment and history, and this is your diagnosis. In addition, I will treat your problem using A,B & C." Not the A,B, & C on our guidelines or protocols, but the A, B, & C that we definitively decide.

In addition, I disagree with the computer making the diagnosis. At some point, somebody is going to make the decision to stay, leave, or transfer. For example, a chest pain with normal XII lead, labs, and PA chest. It is now decision time...

Unfortunately, the treatment and diagnosis may go far beyond a chest x-ray and labs. What's say that dyspnea patient is in Atrial Fibrillation. Now we ask, what is the cause, how do we treat (rate reduction versus conversion), where do we go from here? So many factors and considerations that we often take for granted. However, at the end of the day, the buck stops at somebody. My question revolves around the buck stopping at non-physician providers.

My question is based on autonomy. What I mean by this is the unilateral ability to make a definitive decision about the type of condition, treatment, and follow up. At what point does giving somebody this type of autonomy cross the line. Or, does a readily identifiable line exist? Currently, I think it is blurry and perhaps needs to be better defined. Of course, this could create additional problems.

Clearly, mid level providers can effectively provide care. However, my question is how much of what physicians have traditionally provided can effectively and safely be provided by non-physician providers?

Take care,

chbare.

Edited April 26, 2009 by chbare

[ERDoc]

If a person takes the DNP courses and they can pass the same exams that physicians have to take (USMLE steps 1-3 and the CCS) then maybe we should allow them to be independent practitioners. However, if the first round of the exam is anything it does not look hopeful. They were given a very watered down version created by the same people that write the physician exams (NBME) and they had a 50% pass rate. They should also be governed by the board of medicine and not the board of nursing as they have passed into the realm of practicing medicine and not nursing.

[chbare]

If a person takes the DNP courses and they can pass the same exams that physicians have to take (USMLE steps 1-3 and the CCS) then maybe we should allow them to be independent practitioners. However, if the first round of the exam is anything it does not look hopeful. They were given a very watered down version created by the same people that write the physician exams (NBME) and they had a 50% pass rate. They should also be governed by the board of medicine and not the board of nursing as they have passed into the realm of practicing medicine and not nursing.

Would this apply to non DPN nurse practitioners? I understand PA's have their own certification process and do not take the USMLE. More specifically, where would you place the line on requiring a provider to pass the USMLE. What type of line would need to be crossed? For example, NP's who have physician supervision or collaborative relationships? Is this within the line and outside the line when a provider seeks total independent practice? Or, does another line exist.

This is the link to the data ERDoc stated earlier:

http://www.abcc.dnpcert.org/exam_performance.shtml

Take care,

chbare.

[ERDoc]

If they want to function as a physician they need to meet the same standards as a physician. NPs and PAs still work under a physician so they have some oversight, but if they want to be able to practice under their own license they need to meet the same standards. That being saidm they need to be honest with the pts as to who they are. Though the have a doctorate degree they should make it clear that they are a nurse. I can see pts becoming confused when a DPN comes in with a white coat and says, "I'm Dr. X." I understand that anyone who has a doctorate is entitled to be called doctor, but in a healthcare setting that title has a specific meaning.

[chbare]

If they want to function as a physician they need to meet the same standards as a physician. NPs and PAs still work under a physician so they have some oversight, but if they want to be able to practice under their own license they need to meet the same standards. That being saidm they need to be honest with the pts as to who they are. Though the have a doctorate degree they should make it clear that they are a nurse. I can see pts becoming confused when a DPN comes in with a white coat and says, "I'm Dr. X." I understand that anyone who has a doctorate is entitled to be called doctor, but in a healthcare setting that title has a specific meaning.

Got it.

Take care,

chbare.

[HERBIE1]

Interesting topic. My take-

The autonomy issue is very relative. Are you operating in a remote village where there is no other medical care for miles around? Is your "medical control" in the next room, on the other end of a radio, or phone?

We've all been taught that only a doctor makes a diagnosis. We have "impressions". I agree that for all intents and purposes, we DO make a diagnosis every time we treat someone but ultimately, the MD is the one who is left holding the bag. We take someone to a hospital, they receive definitive care by a doc, and hopefully confirm our "impression". The difference, the doc is responsible for their diagnosis, we defer ours to our medical control and/or the physician at the receiving ER.

For years, I worked in a very busy Level 1 trauma center. Although we performed many of the skills that we did in the field, we also were taught many others. I learned how to insert Foley's, sutures, 12 leads, NG tubes, gastric lavages, order simple Xrays, do ortho work such as posterior molds- and assisted in many other procedures- chest tubes, thoracotomies- quite a learning experience. Most of the time we started a triage note on a patient and generally would establish an IV and do required bloodwork. Obviously if there were questions, we would ask the doc, but for routine issues, most of the time this stuff was done even before the doc would see the patient. We learned which labs were required for whch complaints. Clearly, the docs needed to be able to trust you and be confident in your skills, and without their blessing, you would NOT be allowed to do all these things. Were we making a definitive diagnosis-of course not, but we did know which tools the doc would need to come up with that diagnosis.

Autonomous in this case meant you did not need to always wait for a doctor's order, but the only way this could work is that you must know your limitations. Even doctors have resources to call in when they are stumped-ie an anesthesiologist to help with a tough tube, or help in any specialty they need. Many times I presented a funky looking EKG to an ER attending and they told me that a cardilogist would need to make the definitive call on that rhythm- they were not sure either.

In the prehospital setting, all we have is a radio and our partner for backup. With out level of training, that can be a scary proposition with a medically complicated patient.

Personally, I think that the more you learn, the more you learn just how much you don't know.

Edited April 27, 2009 by HERBIE1

[rock_shoes]

If they want to function as a physician they need to meet the same standards as a physician. NPs and PAs still work under a physician so they have some oversight, but if they want to be able to practice under their own license they need to meet the same standards. That being saidm they need to be honest with the pts as to who they are. Though the have a doctorate degree they should make it clear that they are a nurse. I can see pts becoming confused when a DPN comes in with a white coat and says, "I'm Dr. X." I understand that anyone who has a doctorate is entitled to be called doctor, but in a healthcare setting that title has a specific meaning.

I can't see NPs or PAs ever working without physician oversight. If they are to be examined to the same standards then they should be educated to the same standards. If that were the case they would no longer be NPs or PAs. They would be physicians and so the circle goes around. I see mid-level providers as having a more indirect form of medical oversight as opposed to a "mother may I" situation.

As for someone misrepresenting themself as a physician I whole heartedly agree. Everyone assumes you are a MD If you say "I'm doctor X" in a hospital or clinic setting.

Edited April 28, 2009 by rock_shoes