Outpatient Specialty Offices

[JBMmom, MSN, NP]

I'm finishing up my AGACNP program and during this last semester I have my first outpatient rotations. I've done a pulmonology, nephrology and vascular surgery rotation. I am surprised at the amount of "stay in your lane" medicine that I think I'm seeing. For instance, in the vascular surgery office they check a blood pressure for every patient coming in. The MD never looks at this reading. The other day the patient I was going to evaluate was 235/130, so I immediately found my precepting MD and told him. He was unimpressed. I asked the patient whether she has been taking her blood pressure medication, does she regularly check it at home, is she having vision changes, has she had any headaches, etc. I started passing along that assessment information to my preceptor and he very politely said that basically he doesn't care. He doesn't address high blood pressure with patients. Then I was in the ultrasound evaluation of another patient and they were clearly in afib based on the audible rhythm, and I palpated an irregular radial pulse. I asked the patient whether he had ever been diagnosed with an irregular heart rate before, and he said yes. I asked whether he sees a cardiologist or takes a blood thinner and he said no. My preceptor once again was very polite, but told me that I shouldn't have said anything because now the patient is going to tell their primary care doctor that the vascular surgery office said he has an irregular heart rate. The he's going to have to field calls from the primary asking for more information and he doesn't have it. He also said we don't have the equipment to determine afib, so we shouldn't be diagnosing but all I needed was to palpate his pulse (and I didn't diagnose him myself, I only asked whether he had ever been diagnosed with an irregular heart rate). 

I've been doing only inpatient to this point and I'm wondering whether some of my frustration is specific to my practice or is this a general practice in specialties? I know that not every doctor can address everything, but isn't it my responsibility to point out something potentially dangerous to the patient? If that patient is in afib, he already has numerous other comorbidities, shouldn't the possibility of a stroke be addressed? 

[LibraSunCNM, BSN, MSN, CNM]

I'm a CNM, not an NP, but I personally feel that yes, it is your responsibility to point out stroke-level blood pressures and concerning rhythms.  You're right, not every physician can solve every patient's every problem, but if he doesn't want to know the patients' blood pressures, he shouldn't be taking them.  This is so emblematic of the completely fragmented mess that is our healthcare system.  

[djmatte, ADN, MSN, RN, NP]

Not the norm in my experience in primary care.  Many times, I would have a patient show up from specialty stating their blood pressure was XXX/XX and they were informed to follow up with primary care.  For that high, I'm surprised they weren't recommended to go to the ED (but I believe you said this was an inpatient rotation?)  The specialty obviously wouldn't treat the patient, but they would at least be able to speak to what was documented and get the patient somewhere appropriate.  Some specialties won't even continue the appointment for the noted abnormalities.

[JBMmom, MSN, NP]

On 2/19/2021 at 11:13 AM, LibraSunCNM said:

This is so emblematic of the completely fragmented mess that is our healthcare system.

On 2/19/2021 at 11:58 AM, djmatte said:

The specialty obviously wouldn't treat the patient, but they would at least be able to speak to what was documented and get the patient somewhere appropriate. 

Thank you both. I totally agree that this is representative of what's wrong with the healthcare system. Another thing that happened was that I wrote a note and in the assessment I said the patient is morbidly obese with a BMI greater than 45. He said it had to be taken out because the patient will likely give him a bad review on-line if we call him morbidly obese. Which he is. 

And yes, part of reason the MD said he wasn't too interested in the BP is that medications related to blood pressure are not prescribed through his office. 

I think part of the problem is that this particular vascular surgeon gets a LOT of patients dumped as referrals when other doctors are out of ideas on what's wrong. So he is constantly being called by other providers. If he starts making referrals of his own, or recommending follow-ups, that's viewed, by him, as a potential source of more calls and follow-ups. I can see his point of view, in a way, but it's not how I'm comfortable practicing. 

[aok7, NP]

I am a NP in nephrology.  Refer to the PCP, it is easy.  I find problems all the time, and not fair to the specialty for which the patient has been referred that I go off direction.  If I am very concerned about a patient, to the ED.  They will get the broad look they deserve.  For example, a patient with report of "word finding" over past few weeks.  Followed-up (did NOT do own neurology act) and patient was treated for aneurysm for which surgery was done and the patient is grateful.  Fair to everyone involved, and best that I keep my nephrology focus.  I refer all the time, collaborate with other specialties.  If I start ordering meds or interventions (I used to be in internal medicine, trust me my mind goes seeing what I see), then who is going to follow-up and oversee what I have done.  I see resistant HTN (which I manage), and for every dx here there are five patients who are at higher risk due to polypharmacy and lack of basic management.

[Neuro Guy NP, DNP, PhD, APRN]

On 2/19/2021 at 11:01 AM, JBMmom said:

I'm finishing up my AGACNP program and during this last semester I have my first outpatient rotations. I've done a pulmonology, nephrology and vascular surgery rotation. I am surprised at the amount of "stay in your lane" medicine that I think I'm seeing. For instance, in the vascular surgery office they check a blood pressure for every patient coming in. The MD never looks at this reading. The other day the patient I was going to evaluate was 235/130, so I immediately found my precepting MD and told him. He was unimpressed. I asked the patient whether she has been taking her blood pressure medication, does she regularly check it at home, is she having vision changes, has she had any headaches, etc. I started passing along that assessment information to my preceptor and he very politely said that basically he doesn't care. He doesn't address high blood pressure with patients. Then I was in the ultrasound evaluation of another patient and they were clearly in afib based on the audible rhythm, and I palpated an irregular radial pulse. I asked the patient whether he had ever been diagnosed with an irregular heart rate before, and he said yes. I asked whether he sees a cardiologist or takes a blood thinner and he said no. My preceptor once again was very polite, but told me that I shouldn't have said anything because now the patient is going to tell their primary care doctor that the vascular surgery office said he has an irregular heart rate. The he's going to have to field calls from the primary asking for more information and he doesn't have it. He also said we don't have the equipment to determine afib, so we shouldn't be diagnosing but all I needed was to palpate his pulse (and I didn't diagnose him myself, I only asked whether he had ever been diagnosed with an irregular heart rate). 

I've been doing only inpatient to this point and I'm wondering whether some of my frustration is specific to my practice or is this a general practice in specialties? I know that not every doctor can address everything, but isn't it my responsibility to point out something potentially dangerous to the patient? If that patient is in afib, he already has numerous other comorbidities, shouldn't the possibility of a stroke be addressed? 

Sounds negligent to be honest. If you identify an abnormal finding, you need to intervene. That intervention does not necessarily need to be ordering a test or medication that is outside your specialty or comfort, but at least provide education, refer to PCP, or refer to the ED, and document that you did something, especially for something as urgent as SBP >/= 200 or identification of a new arrhythmia. This vascular surgeon needs to get it together.

What next? A patient with facial droop and slurred speech comes in and he shrugs it off and says not my problem? I'm not impressed. Besides, one would think that a vascular surgeon would be interested in the patient maintaining good BP control, etc. These things certainly contribute to their vascular disease after all........

[JBMmom, MSN, NP]

5 hours ago, Neuro Guy NP said:

Sounds negligent to be honest. If you identify an abnormal finding, you need to intervene.

Thank you for your feedback. I hope that since this patient was going to have a follow up visit with his PCP within a couple days of the office visit I saw him, that he will bring it up again since I mentioned it and he said he has had a previous diagnosis of irregular heart rate. For the blood pressure, the MD's response is that he often refers patients and then the reading at another office is 130/60 and he's getting calls asking how they evaluated the BP. He blames white coat syndrome. I don't know. Patients LOVE this vascular surgeon I'm working with, and I think he's very good in many respects, I've just been surprised by a couple things. I appreciate your time and thoughts. 

[Neuro Guy NP, DNP, PhD, APRN]

3 hours ago, JBMmom said:

Thank you for your feedback. I hope that since this patient was going to have a follow up visit with his PCP within a couple days of the office visit I saw him, that he will bring it up again since I mentioned it and he said he has had a previous diagnosis of irregular heart rate. For the blood pressure, the MD's response is that he often refers patients and then the reading at another office is 130/60 and he's getting calls asking how they evaluated the BP. He blames white coat syndrome. I don't know. Patients LOVE this vascular surgeon I'm working with, and I think he's very good in many respects, I've just been surprised by a couple things. I appreciate your time and thoughts. 

No problem. Big caveat that this is arm chair review of the situation, but just keep your eyes peeled and see how things go.

[DowntheRiver]

I'm a RN working in Oncology and I've seen my docs do both. We had one doc who absolutely would not address other issues, such as BP, and would send them to ER if critical or to PCP. We'd also hold their treatment that day, so usually patients were motivated to get it corrected. My other doc would treat BP while they were doing their cancer treatments but would not refill after they finished. The patients would then call us and beg us for refills when we instructed them to follow-up with PCP, Cardiology, etc. Our docs would also prescribe meds while the patient was in the hospital but on discharge would direct them to follow-up with PCP, Endocrinology, etc. We had one patient who had diabetes and refused to go anywhere else, saying that we had refilled their insulin twice, why couldn't we keep doing it? We repeatedly told this patient that and documented that the patient needed to follow-up with Endo and PCP but the patient refused. The patient stated they didn't have time. The patient got management and corporate involved and guess what - it got refilled. The patient really needed to see Endo though because it was poorly managed. It still baffles me that a patient had time to to go up the chain of command but not to see a specialist. You already have cancer, why wouldn't you want to work on the rest of your health problems?

It's like a double edged sword - damned if you do, damned if you don't. 

[TheMoonisMyLantern, ADN, LPN, RN]

I'm not an NP. However, most providers I've worked with would at the very least assess to make sure the patient wasn't in immediate danger and then refer to the appropriate service. I've also worked with providers that were squeamish at the thought of taking on more than their 6 inches of the body they specialize in. Given our litigious society I can appreciate that. I've had the situation occur where an issue with a patient arises and the attending is pointing fingers at another specialty and they're pointing fingers at another and so on and so forth and interventions get delayed due to the confusion of who is "responsible". I've also experienced this first hand as a patient, I had a problem arise that needed to be managed and my providers were kind of treating me like a hot potato. It was very frustrating, expensive, and for a period of time my quality of life was significantly effected until a provider finally decided it was within their purview to address. 

If I were a provider and I discovered a problem unrelated to their visit or the service I were providing, at the very least to do right by the patient, I would have to ensure they received proper follow up particularly if the matter were urgent. Ultimately you can only do so much legally and ethically, but I think it would be hard to just flat out ignore a significant abnormal finding that needed some sort of remedy or follow up.

[BCgradnurse, MSN, RN, NP]

I'm an NP working in outpatient Asthma, Allergy, and Immunology and I certainly do notate any abnormalities "outside my lane" and refer back to PCP, or ER if appropriate.  A lot of what I see crosses over into Derm, Rheumatology, ENT, etc, and I will collaborate with these other specialties as needed.  I think it's negligent to ignore significant abnormalities.  All the providers in my practice do the same.

[sleepwalker, MSN, NP]

Sounds like he's going with "plausible deniability"...if he doesn't know about it then it's not his problem

Problem with that train of thought is that it's documented in the medical record and as a provider it's your job to review the medical record...so you either ignored the documentation or you are lazy or you're incompetent or  all 3. Neither choice bodes well in a court of law if that pt had had a CVA, MI, etc. and the lawyer blows up your EMR 5x it's normal size (with the BP highlighted) and asks why nothing was said to the pt when you were aware (or should have been) that the BP was at a dangerous level.

Someone with that high of a BP should have been assessed for related symptoms, advised of the condition and any s/s that would warrant a visit to the ER...if no emergent ER visit is warranted then the pt should have been advised to follow up with their PCP immediately. Of course, all assessment and information provided to the pt should be documented in the medical record.