Public Health and Pediatrics

Measles and the nurse practitioner: A tale for our times...

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. 

Dr. K

Cell phone ban while driving: We can do much better!

Striking a dubious blow for public health safety everywhere, the National Transportation Safety Board released a controversial statement on December 13, 2011, wherein it recommended banning all cell phone use by automobile drivers.  This call comes in spite of evidence showing that these sorts of bans may not reduce the numbers of accidents on our highways.  DrRich, in a posting on this topic, noted in his tongue-in-cheek fashion that the NTSB should propose even more bans on behaviors that accompany driving.  This was also noted in a posting on the Hot Air blog as well.  One of the points they all seem to be making is that distracted drivers have always been on our highways and will continue to be so, despite the banning of any particular behavior.  In this vein, I would like to propose to the NTSB some driving behaviors for their banning consideration:

• Singing loudly (and harmonizing) to Air Supply while driving.  Granted, this behavior was more in vogue 30 years or so ago, but was and probably could still be a hazard on the road in that over-50 crowd. 
• Necking and petting while driving.  I realize the antiquated verbiage used here, but many an accident may have been caused by distracted teenagers well on their first forays into this behavioral distraction.  Besides, it would cut down on the possibility of these folks reproducing and begetting the next generation of distracted drivers.
• Letting your miniature Chihuahua sit on your shoulder while you drive.  (Though this does provide the opportunity for this sort of yappy dog to accidentally fly out the window…)  On second thought, this ban might be a wash.
• Fathers yelling at their kids on a long vacation trip.  Said dad reaching behind him to the kids in the back seat:  “DON’T MAKE ME GO BACK THERE AND TELL YOU WHERE YOU CAN HEAR!!!”  Ah, good times.  But distracting nonetheless.

I’m sure there are more behaviors we can all think of to ban in addition to cell phones.  It just remains to be seen what will be the next villain in the government’s quest for perfect, distraction free driving.  Thinking?  Breathing?   

Dr. K  

How to see patients in three easy steps: First, go to nursing school...

In previous posts I have vacillated between frank pessimism and hopeful optimism regarding the future of physicians in the field of primary care medicine.  An incident occurred yesterday that has my thinking careening towards the pessimistic side again.  A friend of mine finished nursing school a couple of years ago and has been working as a registered nurse at an Indian Health Services facility since.  As seems to be the typical career path for a nurse these days, he has decided to become a nurse practitioner and will commence with his online coursework soon.  This will take about a year and then he will embark on a year’s worth of clinicals.  After that, a freshly minted advanced practice nurse will start seeing patients (likely without physician oversight as this is not required in the state of Arizona). 

A couple of thoughts come to mind.  First, what was I thinking of when I went into primary care pediatrics 20 years ago???  Second, why did I spend all that money for 4 years of medical school when others now receive a less comprehensive education in less than half the time and yet still go out and see patients?  One year of clinicals?  Why do our family docs spend the last two years in medical school and 3 years in a residency program honing their clinical skills when 1 year hanging out with a doc or an advanced practice nurse somewhere for 1,000 hours qualifies one to do pretty much the same thing?

Either this doctoring thing is easier than we have been led to believe or our society is in for a rude awakening somewhere down the road.  If it is indeed the former, then entire generations of medical educations might have been for naught.  We could have been using the wrong model for decades.  If the latter, then somehow a reckoning will have to occur after a series of disasters and a realignment of thinking could result in the waning of the nurse practitioner revolution.  A third possibility exists however-that doctoring truly isn’t that easy but the powers that be will continue to push the idea of alternative “providers” so as to be able to provide a cheaper form of healthcare to the masses, with an indifferent attitude towards the eventual outcomes. 

Which will it be?  I’m not sure, but I wish my friend well in his new endeavor.  I’m thinking there will be more of his kind in the future and less of mine… 

Dr. K