Latest Grand Rounds

Emergiblogs hosts a Napoleon Dynamite themed Grand Rounds with a number of great entries, including these:

Another phenomenal entry from the Happy Hospitalist: Dr Nurse, The PA perspective, And Your Differential Diagnosis
(I could not resist excerpting more than normal from his entry, but you really must read the whole thing at his site):


Here's my opinion, most patients have no idea if you are a doctor, a nurse, or the lab tech. Walk in a room. Pretend you know what you are doing. Be nice. Talk to them a little. Let them tell you how Cuddles,their little Chihuahua, likes to lick the enamel off their teeth. When you walk out, I bet just about every patient would tell their spouse, "My what a nice doctor that was."
(..)
For medicine that involves the diagnosis and management of acute and chronic medical disease, there is only one type of doctor. Someone who has earned a doctorate degree in the study of medicine, not nursing. Someone who has gone on to train under the direction of medical doctors to learn their craft as defined by accredited institutions. Someone who has sat for and passed the requirements for certification as defined by the board of their medical specialty, the competency of which has been determined by other doctors who specialize in that field of training. That's what a doctor is. That's what the public expects when they get "a doctor"
(..)
Citing another PA: "My other concern is the use of the title, "Doctor". It is true that pharmacists, PT's, and others have moved to a doctoral degree. BUT, none of those professions outside of a psychologist, use the title "Doctor" when treating patients.....why you might ask?

Simple, it is confusing to the layperson, and downright fraudulent, ..."
(..)
Why? Because I don't define quality the way a NP or a DNP or a patient or the government will. I define it by characteristics that can't be measured in a randomized trial or tracked with outcomes data, but is at the same time, the most important aspect of independent patient care.

For me, that greatest determinant of quality care, which you won't find in any journal or on any government compare website, or in any patient satisfaction survey is the strength and quality of the differential diagnosis generated by that practitioner. Doctors are differential diagnosis generators. This is, by and far, the most important skill set a physician can offer their patient, something that cannot be learned in nursing level training or nursing level graduate school. It is what separates physicians from all other providers of independent care.

(..)
The only way you get that good is to know your differential diagnosis. And the only way you get to know your differential diagnosis is to learn it in a doctor level training program.

When you call yourself a doctor, you are portraying yourself as a master of the differential diagnosis. Your patients will not know otherwise. But I know that's what they deserve. And other doctors know that's what they deserve. Even you know that's what they deserve. Your job is not to put your signature on a protocol. Your goal is not to achieve 85% compliance with HgbA1c data gathering. Your job is not to get high satisfaction scores. Using these markers to define your quality is a slap in the face to your patients. Your patients deserve an extensive differential diagnosis, every time.
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Here is an interesting article from The Covert Rationing Blog on a study on colonoscopies performed without conscious sedation. The interesting find is not the percentage of patients who tolerated the procedure, but why the study was performed (hint: the author or the article, works in a VA Hospital)