Every now and then something happens that lets me opine on two of my pet issues at the same time. As the director of a county public health department, I just received a phone call from a laboratory manager in town who was concerned about a possible measles exposure to her staff. It seems a 6 year old patient was seen by a nurse practitioner today in her office with the complaint of a rash and a sore throat. There was strep throat going around the household and the kid did indeed have exudates on his tonsils and had a positive strep test. There was no evidence of any cough, conjunctivitis, coryza, recent travel or exposure to measles. He also had a florid rash that was scarlatiniform in appearance. Slam dunk case, right?
Not so fast, my friends!
It seems that this kid had never received any immunizations so the nurse practitioner was “concerned” about measles and sent him to the local lab to have measles titers drawn. Given the history sent over with the patient and the fact that there were 3 other patients in the lab drawing area, including an expecting mother, the lab manager was concerned about possible exposure. I called and talked to the nurse practitioner, eliciting much of the above past medical history from her. She did promptly inform me that the patient didn’t have Koplik’s spots…
Now the $64,000 question is this: which is more likely to make physicians pull their hair out? The mother who doesn’t immunize her kids thereby leading a nurse practitioner to wander away from the obvious clinical diagnosis of streptococcal pharyngitis with the typical accompanying rash into the wilderness of a phantom measles case that will require unnecessary medical expenditures just to rule it out? Or the nurse practitioner who doesn’t have the clinical acumen to diagnose a typical strep case without resorting to further laboratory testing to allay fears of missing that incredibly unlikely zebra that doesn’t even have the clinical appearance with which the patient presented?
No wonder our health care costs are rising. No wonder I am concerned about the quality of care from a new breed of “providers” that faces us in the future. No wonder I fear for the children who don’t receive even basic health care because of parental beliefs. It’s a brave new world out there, folks. I hope you get used to it.