Nurse practitioners, doctors, and the lost art of diagnosis

The topic of nurse practitioners in the context of primary care has been resurgent of late, most notably in this post by Maggie Mahar. 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.’” “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.

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.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • SarahW

    Amen.

  • Concerned Patient

    Right on target. Although there is always a danger in applying group stereotypes to individuals, I must say that as an patient who actively tries to keep himself informed about his health and conditions I have found nurse practitioner care to, indeed, be kind but lacking in actual knowledge. I’ve been fortunate enough to have kind and caring physicians (contrary to the typical stereotype), but even if my doctors were unkind, I’d still sacrifice “kindness”
    for the knowledge and diagnostic acumen that comes with medical education.

  • bw

    I appreciate the Editor’s note.

    It’s a sad state for the medical system. I understand the author’s point of view of the necessity of the accurate diagnosis, but with the current state of affairs, one can’t help but see Maggie Maher’s point as well. If physicians currently “suck” at clinical diagnosis, as stated by the author, then it seems like it wouldn’t be that big a deal for NPs to “suck”at it for a cheaper price.

    But Dr. Hornstein’s point of what should be (versus what currently is) is very well taken. The question remains how to get primary care physicians to use their substantial training to diagnose for themselves instead of referring to specialists, and to provide the “comfort and care” that should be requisite from all physicians.

  • http://www.healthbeatblog.org maggiemahar

    Lucy–

    You’ve responded to my post on NPs in a couple of places, and I’ve replied. So let me reply here as well.

    First, I couldnt agree wtih you more about the importance of diagnosis. Unfortuantely it’s bocoming something of a lost art, not only in medical practice, but in medical education.

    A couple of years ago I spoke at a conference on medical education at the Mayo clinic. An intern who was in the audience stood up to complain that med schools in this country aren’t teaching students the old-fashioned art of diagnosis (listening to the patient, talking to the patient, taking a history, laying hands on the patient.) Instead, students are taught to “diagnose” by taking tests.

    The room was filled with doctors and nurses involved in medical education, and the consensus seemed to be that this is generally true. (Patients also complain that doctors don’t listen–or, in some cases, even look at them. They’re looking at their computer screen, ordering tests.)

    So, when it comes to diagnosis a medical education may not be providing the advantage that you assume.

    I would also note that in ERs, the person who separates the most seroius cases from the others is typically a “triage nurse”—trained to listen to the patient, and spot the symptoms that make a case an emergency.

    The study which I cited (and that you just don’t believe.”) showed the NPs took a better history because they spent more time listening to the patient. MDs were in more of a hurry.

    Reserach also shows that nurse midwives are more willing to let nature take its course during a delivery. They are far less likely to call for inducation or a C-sectoin. In some regions of the country Ob/GYNs are doing so many of both that, for the first time in decades, maternal mortalities are rising.
    In Europe, nurse midwives do 85% of all deliveries; in the U.S. they do 15%. Outocomes, for mother and child, are better in Europe. (There are, of course, many factors involved, but reserachers believe that the higher number of C-sections in the US is key, and nurse-midwives are trained to favor natural deliveries.)

    Childbirth is a situation where the emphasis on comfort and care in a NPS training is very useful. Typically nurse midwives stay with the patient through much of labor. MDs dart in and out.And patients compalin that too often, a doctor pressures them into a C-section.. (C-sections are up mainly among younger moms under 27– they are more malleable–less likely to resist the doctor.)

    Nurses specially trained in palliative care also use their “comfort and care” training to good advantage. Too many MDs have never learned to talk to patients about death and dying. Dr, Diane Maier, a palliative care pioneer, points out that this is a huge hole in medical education.
    She also notes that most MDs do not know how to control pain.

    You say that in your experience, nurses order more controlled substances. I wonder if this is becuase a nurse is taught that pain is a disease that must be treated? Some doctors are less than empathetic when a patient is in pain–and they actually don’t know how to adjust pain medication so that the patient is consicous, but not suffering.

    Your first quote from my post, taken out of context, is potentially confusing. I am talking about primary care and saying that NPs are trained to provide primary care. In some cases they do this independently, particularly in parts of teh coutnry (usually poor rural areas) where primary care docs just aren’t willing to work.

    I would imagine that you are right that an MD is more likely to spot a rare disease. But if an NP can’t diagnose what is wrong, she is trained to refer the patient to an M.D.

    Finally, thee are NPs and there are NPs. just as their are M.D.s and MDs (As Dr. ATul Gawande points out, MDs, like all of us, live on a Bell Curve. In the middle, the vast majorityi are “average”. At the far right, a small number are exceptoinal, And on the far left of the curve, a small number shouldn’t be practicing medicine.

    Also, training of NPs has improved greatly in recently years (more and more are getting Ph.D’s in various areas.

    Bottom-line: In certain areas, well-trained NPs can do an excellent, job and in some specialits their training as nurses seems to be a plus (deliveries, palliative care.)
    PCPs who work with NPs also have told me that NPs can be better at caring for the “worried well” as well as some older patients.

    IN comments on my post, I’ve heard from doctors who believe that NPs are making a huge contribution to 21st century medicine and will be even more important in the future. Ideally, MDs and NPs wil be trained together, so that they can learn to collaborate, and complement each other.

  • Kelly

    There are several issues here. The first is that allied health professions are constantly asked to prove their worth while physicians can get by on history and anecdote. I’m a health services researcher and a pharmacist. We have repeatedly shown on randomized controlled trials that pharmacists can treat chronic health conditions better than usual care. Yet we face the same arguments from physician lobby groups. Pharmacists have a minimum of 5y university, 4 of which includes pharmacology-based courses. Many other pharms, myself included have an additional 3y of clinical training. The primary care system is strained, family physicians can no longer do their diagnostic jobs and turf wars are complicating everything else. NPs and other allied health profs can help lift the burden. Physicians just need to let it happen. Maybe then their diagnostic skills will return to their former glory.

    • http://www.arnp.blogspot.com Jennifer Scott ARNP, FNP-BC

      I agree with you Kelly in regards to this issue. Turf wars are really making it difficult to stay focused on the problem of acute and chronic illnesses that are not being taken care of. Patients cannot afford to come to the office or to take their meds. I have an excellent relationship with our local pharmacists and yet a somewhat strained one with the larger chain stores (mostly over the inability to understand plain English) but that’s a whole other problem in itself..

  • Tricia

    I think there’s a time and place for a low level, quickie, diagnosis. For example, if a child is healthy and just gets ear infections or strep throat every now and then, most parents will know what’s wrong and just need someone to peer into an ear or swab a throat.

    A triage system would be nice. It’s not even about the funds, it’s about the wait once you get to the doctor’s office.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    As an MD, I will gladly take the NP recertification exam if their skills are equal to mine.

    Where do I sign up?

  • http://Drackies@blogspot.com Frank Drackman

    I don’t know about you, but they taught us how to diagnose things at my medical school, lets see…
    1: “Common Things are Common”
    2: “When you here Hoofbeats…can’t remember the rest,cause it was an Internist who said this one…
    3: “This could be a case of PsuedoPsuedoHyperparathyroidism!!!” another internist, and it wasn’t.
    4:”X-ray everything that hurts” that one actually is true, NOT said by an internist.
    5: “Hold your breath while your intubating, that way you’ll know when your patients getting hypoxic” umm isn’t that what the Pulse Ox is for??? And who wants a hypoxic doc takin care of em? OK, this one was said by a Gas Passer, but he used to be an Internist…

    Frank

  • http://dinosaurmusings.wordpress.com/ #1 Dinosaur

    @Maggie:

    Everyone keeps throwing OB back at me whenever this topic comes up, and FWIW that’s a red herring. I happen to agree that midwives provide better care for uncomplicated pregnancies (even complicated ones), and that’s who I chose for my own deliveries (including twins the first time around!) I would be thrilled if obstetric care in this country came to mirror that in the UK and elsewhere, with 85% of it provided by CNMs with OB backup as necessary.

    As for NPs referring when they don’t know what’s wrong, the problem is more one of not knowing what they don’t know. That’s where the arrogance of ignorance can become downright dangerous.

    Regarding NPs and controlled substances, it wasn’t pain meds she was dispensing like candy; it was ritalin, adderal, and fen-phen, leaving me to pick up the pieces when the excrement hit the ventilation and everyone needed echocardiograms. In hindsight, I suspect it was simply a case of having encountered a bad apple.

    I continue to believe that the appropriate scope of practice for allied health professionals is the care of healthy people. Let NPs and PAs do well-baby, well-child, and well-woman exams til the cows come home. When you’re sick, you need a doctor.

  • Dr. J

    The idea of easy cases and easy diagnoses is misguided. There certainly are simple cases and patients who are easy to treat, but separating the complex from the easy is far from simple. IT is especially important to remember that the patient will sometimes think they have a simple problem but really have something far more serious.
    Within the last week I’ve had the following cases in my emergency room.
    #1
    CC: They put me on penicillin for strep throat but I am allergic, can I have azithromycin?
    Outcome: I’m sorry to tell you, you have lymphoma.
    #2
    CC: I fell at bingo and cut my arm, stitch it up quick so I can make it back for the last couple of cards!
    Outcome: You have an aspirin overdose sir, you might need dialysis.
    Both of these cases were fairly straight-forward diagnostically once I’d listened to the history and examined the patients, but both were far more complex than they, the patients, were expecting. Both took a lot longer than the patients expected, and both patients were suprised when I had them gown up for a physical exam (‘I just need a new Rx!!’). The idea that super-accessible quick care trumps good care is just silly. Sure most of these patients would be picked up eventually on one of their repeat super-quick visits, but that really misses the point in my opinion….

    • Tricia

      I don’t think it’s silly. Nurses, PAs and doctors are not the first tier of care in this country or anywhere else. It’s the patient (or his mother!)

      We make diagnoses ourselves every time we get sick or our children do. If the diagnosis we hit upon isn’t that serious, we take a wait and see attitude and don’t even allow medical professionals to flex their diagnostician muscle.

      I’ll agree that when I’m sick and have no idea what could be wrong, I want to see a doctor, but when everyone around me has strep and my throat hurts, I really don’t care who swabs my throat and writes the prescription.

  • http://www.registerednursern.com/ Sarah

    I agree with most of your points.

    I have found that primary doctors generally aren’t as good as more specialized doctors. As you said, many Nurse Practitioners are also lacking on good diagnostic tools.

    I think it all comes down to deterioration of the medical field like you said.

  • AmyT

    Why is it that no one stops to ask “why do doctors spend less time with patients and have poorer diagnostic skills than they did in the past?” It is not because they are inherently less caring or more lazy. Medical schools are filled with some of the most intellegent, driven, and dedicated people we have in the U.S. The great majority of these go into medicine egar to help people and have a vision to make a difference in the world. However, they are congradulated at the end of all their years of hard work and training with a VERY broken medical system. Financial pressures from declining reimbursement and sky-rocketing over-head put such time constraints on physicians that it is impossible to be the kind of doctor they were trained to be. PLEASE, just let us practice medicine and get rid of all the other BS and we will be the SUPER Docs that everyone is looking for.

  • http://soonerorlaterbook.com Damiano de Sano Iocovozzi MSN FNP CNS

    Thanks for the article. Let’s not play the same tired game of “Doctor=Good; Nurse=Bad.” I have been a nurse practitioner, clinical nurse specialist and college instructor for 23 years, never had a law suit and never a major complaint. In 2015 all nurse practitioners will have the PhD after their names and can call themselves “Doctor.” Patients are not confused by this as they call their dentists, pharmacists and shrinks “Doctor.” The literature is not full of horror stories about NPs, in fact, the numbers of lawsuits is insignificant. I don’t know why many patients prefer us for their care. I think both professions need to look at how better to serve the needs of our patients without oneupmanship and a “good care-bad care” attitude.

    Sincerely,
    Damiano de Sano Iocovozzi, MSN FNP CNS

    • gc

      How important is it to get a diagnosis right? I have heard PAs and NPs say that they are as good, or at least 95% as good as a doctor. So if you see 100 patients in 2 days, every two days there are 5 patients who are misdiagnosed or mistreated- or maybe die as a result of the wrong treatment. Is 95% good enough?

      Unfortunately most primary doctors are very poor at making a diagnosis. So therefore, if you are often wrong, it is easy for someone with little training (2 years?) to be also often wrong.

      Primary care needs to get better at what it used to do. Take a patient with a headache. Or take someone who has abdominal pain. What does a primary doctor do? Order imaging studies, have the radiologist tell you what is wrong, and take credit for a diagnosis. I would wager that the majority of nurse practitioners and doctors have no idea the difference between the exams. Do you order a x ray, CT, MRI, nuclear medicine?

      • jsmith

        Rest assured that med students learn the difference between these listed imaging exams in excruciating detail very early in their first days on the wards as third-year med students.
        If they don’t, their professors will quickly make mincemeat out of them–as well they should.

    • Anonymous

      The oneupmanship is not coming from the established medical profession – the physician, but from groups lobbying for equal practice rights without equivalent training. Also, no one is arguing that midlevel providers provide “bad care”, but simply stating that it is not equivalent care.

    • Primary Care Internist

      to imply that the PhD for NPs is about anything other than deception is an absurd lie.

      When someone goes to the dentist to get their cavity filled, calling them “doctor” is very clear.

      But if someone is sick, admitted to a hospital and being addressed by someone in a long white coat calling themselves “doctor” don’t you think they’re entitled to know explicitly whether that is a PhD/NP or an MD?

      Walking into a hospital these days, every nurse “manager” (what the heck do they do, anyway?), respiratory therapist, and even some physical/occupational therapists wear a stethoscope and a long white coat. I think the push for Ph.D.s for NPs is purely for the purpose of deceiving patients.

      One simple rule I tell MY patients: When you’re reading an advertisement, or even reading someone’s nametag, if it says “Dr. so-and-so” chances are that they are NOT a physician. Most physicians would read as “so-and-so, M.D.”

  • Kira B, ARNP, ACNP

    I am very saddened to read the opinions of this author. As an Acute Care NP trained in the management of acutely and critically ill patients, I find my physician colleagues invaluable. I value their input and knowledge, and recognize that my training has not been as thorough as theirs in some areas. However, in our practice, both physicians and midlevels practice mutual respect. Our physicians recognize our years of bedside nursing and experience in dealing with people, as well as the skills that we have gleaned, not only from years of nursing, but in ongoing education and professional development. In return, we not only respect their position, but their training, knowledge, and clinical expertise to guide us in difficult situations. Our group has now developed an outstanding hospitalist practice, in fact, the largest in our state. Our patients and referring physicians choose us out of choice, not obligation, as we are an independent group.

    I am dishearted to see, on both physician and NP sides of the aisle, the continual need to belittle each other’s professions. I’m sure our patients suffer the most.

    I’m sorry that the author feels that NP’s refer too much… Perhaps it’s because those NPs recognize their own limitations of practice, and are willing to ask for help when they need it from more experienced providers. In addition, do not make the mistake of calling our practice “cookbook” medicine. While we may use protocols to guide our practice, our years of experience and intuition serve us well in making informed and educated decisions regarding the diagnosis and treatment of our patients.

    I truly hope that each profession will stop using the media to beat each other up, and learn to work together for the continual advancement of the best healthcare system in the world.

  • Jimmy Peanut

    As a pharmacist, I see only the treatment end of the medical spectrum and I’m not qualified to comment on the diagnostic skills of any practioner. However, I do tend to see more errors, particularly more serious drug interactions, with prescriptions from NPs that MDs. And when I talk to prescribers to correct one of these serious errors, MDs tend to understand the reasoning behind my objections more quickly and make more appropriate corrections (without prodding and suggestions). This isn’t a blanket statement; some NPs are amazing and some MDs are lacking, but by percentage I definitely catch more errors from NPs.

  • jim

    Advocate for a more free market health care system! Let the patients decide who they want to see. I would never see a nurse over a physician but that is my decision. My neighbor may feel otherwise, and that’s alright because that is his decision. Competition is never a bad thing.

  • AmyT

    For most of these tasks, many primary care doctors are actually ‘over-qualified.’” …

    This is absurd. I am a Family Medicine MD, graduated in the top 10% of my medical school class, a member of Alpha Omega Alpha, and was chief resident during residency. I consider myself well trained and at least above average intelligence. However, I still go to work every day and am in awe of the things about medicine that I still do not know. I think this is the difference between MDs and NP/PA’s….we know enough to know there is a tremendous amount that we do NOT know and even the seemingly simple medical problems can be VERY complicated. It amazes me how so many NP/PAs feel that they can do 95% of my job with less than half the knowledge and very little training. And the trend for many nurses to get their NP/PA degrees online, is doing nothing to legitimize your field.

  • Anonymous Veterinarian

    >>we know enough to know there is a tremendous amount that we do NOT know and even the seemingly simple medical problems can be VERY complicated>>

    Oh, this is very true. Ask any veterinarian who has dealt with physician and nurse clients which group is more likely to cause harm by delaying treatment or even treating inappropriately prior to calling the veterinarian. Nurses as a group (though I have some excellent nurse clients, and I’ve met a few clueless physicians) are far more difficult to convince of the need for appropriate diagnostics. Nurses as a group are far more likely to argue when I attempt to clarify misconceptions (“I do not know what an abdominal incision in a human looks like three days post-op, but let’s talk about treating that bite wound on your animal’s torso.”) The difference in training is obvious to me, much as I enjoy many of my nurse clients.

    For myself, for routine, well-patient care, I’d consider seeing a NP. For a problem, I’d much prefer to start with a high-quality family physician.

  • MB

    Physicians have open the door for midlevels to practice medicine. If I called my doctor today with an urgent need, I would be offered one with a nurse practitioner. If a nurse practitioner’s diagnostic skills aren’t as good as a doctor’s, then doctors are negligent in partnering with nurse practitioners for their sick patients.

  • jsmith

    I supervise a NP; I’m looking at her in her office across the hall as I type this. She is just as good as I am at strep throat and ear infections and UTIs, and I am happy to have her see those pts. But every day she consults with me on a couple or a few pts–fine, I’m happy to help her, it’s part of my job. If I were not there, some of those easy (to me) pts would wind up as subspecialty consults. Also, she is not as good at chest pain, abdominal pain, acute shortness of breath or acute on chronic renal failure. I see those pts. They get better and more timely care from me. Unfortunately, these types of pts walk in the door in random order. Every practicing internist or FP knows this fact, even if others don’t.
    NPs should be supervised by MDs, period. Much safer for the pts, and, frankly, safer for the NPs.

    • http://www.arnp.blogspot.com Jennifer Scott ARNP, FNP-BC

      I think that instead of looking at your fellow medical professional across the hall and noting what she lacks, why don’t you pull her into your office and tell her where she can focus in order to make her a better provider of care. We are not meant to be “just for the coughs and sniffles” and some of us are great diagnosticians. I know my limitations and am not afraid to consult my collaborating MD and sometimes I even teach him a thing or two. It’s about the give and take in a partnership. If you don’t let her know that you find her skills lower than you would like, you are doing her a disservice.

  • Laurie

    “They get better and more timely care from me.”

    I spent two years being cared for by midlevels for what seemed like a complications from a common cold. The only time my doctor had time for me was during a physical, and she never saw me when I didn’t feel well, only relied on the notes of the nurse practitioner.

    After research at WebMD, thanks to Dr. Enright, I referred myself to a specialist. I wonder if I would have received a more timely diagnosis if my primary care doctor had been involved with my care? I don’t waste time in primary care anymore.

  • imdoc

    Maggie, you are right that doctors are overtrained to do “primary care” by your definition, because you are equating it with being a triage nurse. We are not and don’t want to be triage nurses.

  • Sharon Dietrich

    It is indeed sad but true that diagnostic acumen based largely on history and physical is a dying art. Some of this loss is due to the push for “productivity”, some is due to technology(new and wonderful tests and imaging studies), some due to training, some due to laziness because of the availability of technological help, and some due to patient demands for tests.

    However, I must disagree with Dr. Hornstein regarding Nurse Practitioners and Physician Assistants. My experience has been almost always positive. I find the mid-levels I work with to be well trained, appropriate, and quite functional and helpful in a busy clinic. They, however, may be falling prey to the same pressures that plague doctors, as listed above.

    I would also like to say that patient care coordinator is a very appropriate role for Primary Care Docs, and often can be incorporated into an office visit, and is also a learning experience at times, if one gets a good consult note back from the specialist!! It is simply a reality that specialty care is more and more necessary for our aging population with multiple medical problems. Helping our patients benefit from specialty care, providing appropriate referrals to specialists, and making sure that their health maintenance and well-being gets addressed can be a satisfying part of what we do.

    Sharon Dietrich

  • Nancy C.

    In less than a year I had 4 surgeries by 2 very skilled surgeons. A hip and knee replacement by my orthopedic surgeon and a 2 cervical fusions by my neurosurgeon. Both of these learned gentlemen told me I had very soft bones. I questioned them both about it, asking if this was something I needed to follow up on or do something about. Both told me no. I assumed I probably had osteoporosis and that I’d discuss it with my primary care physician when I was well enough. The remarks kept bothering me and as I sat there during recovery from the fusion surgery, a commercial for a well known osteoporosis medication came on TV. It mentioned brittle bones. I thought, but I have soft bones, osteoporosis is not what I have. I typed the words “soft bones” into Google and the first entry that popped up was “osteomalacia, vitamin D deficiency”. After reading the article, I was surprised it didn’t have my picture beside it. I had an appointment with the FNP who works with my neurologist who treats my migraines the next week. The minute I mentioned this to her she asked several more questions, then sent me straight to the lab and for a bone scan. She and I were correct. I had D levels so low they were not detectable. My bone scan showed osteopenia and osteoporosis. Neither of my surgeons even seemed to care about even doing the lab work to find out what might be causing those soft bones. Thank goodness my FNP did. And thank goodness I had the good sense to keep searching for a solution myself!

  • Ron Crossno

    Having come to this thread somewhat late, I am struck that no one has pointed out that medicine actually has three (not two) distinct parts. Besides diagnosis and treatment, there is also prognosis, which clearly is given even less emphasis than diagnosis.

    As a hospice & palliative medicine specialist, I am repeatedly flabbergasted by how rarely anyone has ever had a conversation with their patients (often long-standing patients) regarding how their condition (i.e. diagnosis) is going to affect them in coming weeks, months, or years.

    When it comes to life-threatening or life-limiting conditions, such conversations are even rarer. Physicians and nurses alike have had very limited training in this regard.

    Traditionally, both diagnosis and prognosis have been considered within the scope of practice for medicine and not nursing, which is part of the reason that legally only physicians can certify a patient as terminal for purposes of accessing the Medicare Hospice Benefit.

    Practically, I have seen more nurses than doctors who can both recognize and communicate effectively regarding a patient’s terminal status.

  • Anonymous

    I agree with you Dr. Hornstein that too few MD/PAs/NPs truly know how to diagnose, becaause we don’t take the necessary time.  Another part of the problem is that we don’t allow our intuitive gut tell us that we’re in over our head and we need some additional help, our pride/ego tends to get in the way.  That’s why I find the team approach to be the best, and this is modeled in the patient centered medical home.  -sharon bahrych, pac, mph