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March 31, 2007

Other

Question from Richmond Hill, Georgia, USA:

Should our daughter's pediatric endocrinologist see her at every visit or is it okay to see just the nurse practitioner (NP)? What should we expect at regular visits beside blood work? The endocrinologist was in the office at our last visit, but we did not see him. No exam was performed (feet, neck, etc.), only blood work. My 11 year old daughter does have hypothyroidism along with her type 1 diabetes.

Answer:

It is certainly hard to comment regarding any specific patient without knowing overall how well she is doing, her last visits and patterns of visits, time of the most recent laboratory work, etc.

Having said that, I must qualify and add that many pediatric endocrinologists utilize NPs. The (wo)manpower shortage of pediatric endocrinologists essentially requires additional help to see all the patients. NPs are certified RNs who have had significantly more training in order to be able to practice rather autonomously. Nevertheless, they must work within a practice guideline set up by the physician.

In my own practice, my NP does see many patients routinely, but I try to make a practice that at least once yearly, especially for patients with diabetes, she review the patient with me and then I see the patient and family. At this “annual review,” we discuss appropriate screening for those conditions commonly associated with diabetes, which may include thyroid problems, celiac disease, cholesterol checks, urine protein checks, reminders about formal dilated eye exams, and sometimes others, depending on the clinical situation.

Other parts of your letter suggest your daughter is between ages six and 12. In general terms, children of this age who are on thyroid replacement for hypothyroidism, can probably get by with having the thyroid levels checked in the bloodstream about once yearly. Thyroid replacement is significantly impacted by weight and during the elementary school-aged years, weight changes are typically more subtle. Again, clinical judgment is important.

Personally, I think that the child with a chronic illness should be examined by a clinician at virtually every visit; the NP could/should do this. But, different practices feel that a diabetic child who is essentially doing well need not undergo the time and expense to do an exam each time. (Insurance companies code the “level of visit.” “NO” exam and no physician assessment is the lowest level (level 1) and lowest cost. The highest level, level 5, is pretty darn complete history and physical exam plus laboratory tests or x-rays to review). If the NP did not do an exam, you might want to be sure that your bill reflects this. You can discuss this with your doctors’ office manager or billing person so that appropriate adjustments can be made, if necessary.)

If all your doctor really wanted to see was the blood test, then other arrangements might be able to be made.

DS