Medscape Oct 21, 2021: By Alok Patel MD:
“Patients want docs, not NP’s or PAs, leading their ER care:”
“Everyone has an opinion about the ED — the wait time, the workflow, the resources, whatever. As a hospitalist, I talk to ED staff and to patients about the ED on every single shift. Patients tell me everything. They tell me about their ED experience, how long they must wait, and worries about the cost. And recently, some of them told me that they couldn’t tell if they were being treated by a doctor or not.
“Nearly 80% of people said they most trusted a physician to lead their medical care, with 9% saying nurse practitioners, 7% saying physician assistants, and 5% saying nurses. This percentage increased as medical conditions became more severe, with more than 80% saying they preferred physician-led care for a heart attack, a stroke or after a car accident.”
Paul Goldfinger, MD:
When a close relative wound up in the Jersey Shore ER after a bad car crash, his care was turned over to the Trauma Team. But during the early hours of his care no physician saw him. He was fussed over by unidentified personnel who neglected to obtain xray reports. They said that he might be discharged.
But they misdiagnosed the seriousness of his injury and they missed a pelvic fracture that required major surgery that day. The diagnosis was finally made by a physician assistant to the trauma surgeon who showed up after too many hours and told us the truth, and still no physician saw him.
He was finally seen by an actual surgeon the next morning, just before being wheeled into the OR.
I was hospitalized recently at Jersey Shore and I couldn’t be sure who was coming into my room and what their qualifications were. The attending physician never came in at all, and a couple of doctors came in who were residents and who were clueless about my problem. Most doctors or other personnel who came in were in a hurry, and everyone ignored my request for a consultation with a specialist. I know what a quality house-staff is like, and the residents whom I met are not that.
On another occasion, at Monmouth Hospital, Eileen presented in the ER with a swollen knee. A person in a white coat came in and began an assessment. He was doing a sloppy job and I asked for his credentials. He said he was a physician assistant.
I told him that I wanted a physician to see her. He pointed to another white coat down the hall and said, “He is a physician and he could see her, but he won’t add anything to my evaluation because I can do what a doctor can.” He spent 5 minutes with her and ordered an xray. But it turned out later that he was wrong—inadequate history taking and failure to consider the correct diagnosis. Later an ortho physician assistant showed up to make the correct diagnosis and provide appropriate care. He just happened to be in the ER. No physician ever saw her.
These mid-level practitioners make mistakes and may overestimate their usefulness. And they cannot compare to a physician in quality.
When you visit a physician (inpatient or outpatient) make sure that you know who is evaluating your care. I have called a doctor’s office and found myself being questioned by some secretary who wanted to know why I wanted to see the doctor, what my symptoms were, etc. This is inappropriate.
In my cardiology group practice, if a patient called with a medical issue, the phone was handed to an RN—CCU trained. If she determined that a physician needed to get involved, she would make sure that we were apprised of the situation, put us on the phone with the patient, and she saw to it that one of our doctors saw the patient, either in the office that day or at the hospital where one our doctors was available as needed. And that RN would followup the next day .
Much of the time when I interact with the healthcare industry, I have something to complain about—-and not trivial complaints. Technology these days is remarkable, but physicians are being forced to follow the guidelines of efficiency experts. As a result, quality is often compromised in ways that patients may not detect. Patients don’t know how dangerous medical practice can be these days, and unfortunately, only 30% of physicians run their own practices. A pulmonologist I know was ordered by management to limit his office visits to 10 minutes. He ignored the order and wound up 2 hours behind.
One of the biggest areas of trouble are failures of communication. And then there are shortages of healthcare workers including nurses and doctors. Office staff is trained to prevent patients from actually speaking to or seeing a doctor. Efficiency experts try to finesse the resultant problems, but they know little about medicine. I don’t know why there isn’t a tsunami of malpractice suits across the country.
Maybe I will start a series of “medical process complaints of the day” as seen thorough the eyes of a physician.
So be alert and ask questions of everyone you see. Have an advocate with you if possible.
Paul Goldfinger, MD.
Interesting observations regarding the increasing reliance on non-physician medical professionals. As stated, many overestimate their expertise and diagnostic skills.
Five years ago, my 72 year old sister fell at home on a Tuesday morning and was transported by ambulance to the local ER where it was ascertained that her hip was broken in three places, she was admitted and an orthopedic consult immediately ordered from a large seemingly reputable local orthopedic practice. Every day when I asked, I was told that the ortho consult would occur that day. In fact, it did not occur until Friday evening at 8 PM, when a physician’s assistant from the Orthopedic practice stopped by, reviewed her films and stated that her case was too complex for them to address and required the services of a traumatic fracture specialist. The next day, she was transferred to a larger nearby university hospital who had three such specialists on staff.
Her surgery took place on Monday- a full 6 days after her injury. She complained of swelling and pain in her wrist, some six weeks after her fall, her wrist was finally x-rayed and it, too, was found to be broken.
Stories like like are all too common but they sound like something I would expect in a third world country. She has never regained anything close to full mobility, even after months at a rehab facility with twice daily therapy and years of 3x/week physical therapy. She uses a combination of a wheelchair and walker to get around. She is for all intents and purposes housebound.
Amen. I went to Jersey Shore Medical Center on a Friday afternoon last November with lower right quadrant pain. I never saw a physician until the next morning up in the OR ante room, prepping me for an appendectomy.
My appendix had not ruptured, but the surgeon said it was leaking and the size of a…. well, I’ll spare you the details. I had asked to see a physician while I was waiting in the ER halls and in an ED bed overnight, I asked again and again.
Never saw a doctor. When the nurse and a patient transport fellow were unlocking my bed the next morning to take me to the OR, it was the FIRST time I heard my diagnosis.