Outpatient Specialty Offices

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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? 

Specializes in OB.
2 hours ago, sleepwalker said:

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. 

100%

Specializes in New Critical care NP, Critical care, Med-surg, LTC.
On 3/3/2021 at 10:15 AM, sleepwalker said:

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

So, as I mentioned, I went in and starting asking questions like did the patient have any vision changes, weakness, numbness or tingling, difficulty with speech, etc. She did say she had missed her BP meds that morning and hasn't been taking them regularly. The blood pressure isn't documented anywhere in the patient's chart, this office is still partially EMR/paper chart. They write the BP on a sheet that gets shredded when the patient leaves. There's no record that it happened. And for something like the afib, there's no record of that anywhere either because I heard/palpated it, but it's not charted anywhere. Since the MD doesn't listen to anyone's heart/lungs it would normally not be noted either. 

I'm always a little sad to see what the "real world" is like. As @TheMoonisMyLantern mentioned, things like this could really lead to patient's not getting the best care. And if they're not informed about their health, they wouldn't even know to follow up on these things. And now that I'm done, I don't think anyone in the office will mention heart rhythms again. Oh well. 

Specializes in OB.
37 minutes ago, JBMmom said:

They write the BP on a sheet that gets shredded when the patient leaves. There's no record that it happened. And for something like the afib, there's no record of that anywhere either because I heard/palpated it, but it's not charted anywhere. Since the MD doesn't listen to anyone's heart/lungs it would normally not be noted either. 

Well that's a hot, hot mess.

 "Damned if you do, damned if you don't." I find myself repeating this mantra over and over. We are expected to be doormats for our patients to walk all over. Patients know how to play the game... escalate the complaint until they get what they want. 

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