Some More Thoughts On Physician Extenders

I made the mistake here of posting on my thoughts of PA's and Nurse practitioners. Predictably I received a number of not so happy comments. Most of them came from people who had googled phrases such as "physician opinions of nurse practitioners" and fortuitously landed on my blog. I can understand their venom. And maybe I deserve it. Maybe I am a little defensive. A little jealous even.

I mean.... why did I spend so much time and money learning how to be a primary care practitioner? Why did I endure medical school and residency? Why didn't I take the faster route? I could have become a PA or Nurse Practitioner with much less training. I wouldn't have had to spend nearly as much on education. And I would still be able to take care of people and pretty much fill the same role I do today. Right?

I mean you can understand that. Why I would be a little bitter. I guess I do have a jealousy problem. But its not the training or the cost of education that gets me. It something else completely.....

You see I find practicing primary care inexpressibly difficult. Every day I struggle endlessly to balance physiology and psychology, ordinary and uncommon, health and illness. And most days I feel like I do a miserable job. Many nights I sit up worrying that I made the wrong decisions.

I can chart the maturity process of my education. It started early. My first patient.....during gross anatomy. I watched as my cohorts were crass and cocky. How they made fun of the cadavers. In retrospect we were sublimating to protect ourselves. And then we dissected the genitals. And emotionally I fell down. I faced a very sad and scary reality. This was a person that I was cutting open. A human being who had willingly donated their secrets to me.

And then there was medical school. When every patient was a room number or a disease. Until you realized they were people. People who had lives and family. And that was tragic.

Next came residency. After hours of being on call. When no matter what you did your patients got more and more sick anyway. And then there was the day when you sit next to a patient and hold their hand. And watch them die and accept that sometimes even when you can't help by being a physician you can help by being a human being.

With time my attitude towards knowledge also changed. From thinking I knew nothing...to thinking I knew everything....to learning my limitations.

And my knowledge. From anatomy and physiology to disease. To use my senses to evaluate a patient. The visual....the smells...the sounds. To learn to become quiet and listen to myself. To pay attention to what each patient evoked inside and use that to help guide judgement. Seeing sickness over and over again until one could recognize it by the most subtle clues in a half awake state after working 24 hours in a row. Until the gravity of illness was not only a series of lab results and exam signs but an innate feeling that pinches you in the chest before death rears its ugly head.

And overtime I got better. My diagnostic acumen improved. I was better able to wade through the morass of anger, denial, oversimplification, and the useless complexity of the human condition to feel a small level of competence. To appropriately recognize the chest pain that smacked of imminent coronary disaster and direct to the ER as well as comforting the chest pain from anxiety and starting appropriate meds.

But everyday I learn something new. Everyday I return to the literature. Everyday I confront my own inadequacies to imperfectly perform this task that has become my life work. A task that leaves me in awe and humble.

And everyday I wonder if my training has been enough....and I probably will till the day I retire.

So yes I am jealousof you....of anyone who feels that they can do my job with less training. I bow my head to the PA's and Nurse Practitioners who are vying to take my job. I find being a primary care practitioner extremely difficult and wish I could be smart enough to arrive at your level of expertise...

so quickly.