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.

In Memorium

It was a beautiful cool day much like this morning. I pulled into the parking spot recklessly. I was running late but if I hurried I might just make it. I grabbed my backpack and slammed the door shut without a second thought. And then my stomach sank. I heard the calm hum of the motor as I reached back for the door. Locked.

I felt the panic swell inside. My sixteen years of experience hadn't yet taught me how to deal with such things. Overwhelming embarrassment. How could I have locked the keys in the car with the motor still running? As I stood frozen trying to find a way out of the situation I heard footsteps behind me.

The women stood momentarily and gently placed her arm on my shoulder. A little bit of a predicament...huh? She had known me since birth. Her eldest child was my age. She was friends with my parents. And she had been kind enough to allow me to park at her house because I wasn't old enough to get a parking permit from my high school.

I remember her..... growing up. At that time we lived on the same block. Her smile was always comforting. Motherly. And her kitchen usually smelled of something good. Her son and I were best friends once. But time and distance had taken its tole. And now we only ran into each other occasionally.

But here we were again. I may have no longer been a child but I felt again like a five year old parked in her kitchen waiting for my mom to come pick me up. I was helpless. So she called the police to have my car door opened. And she made me hot chocolate while we waited. And she neither teased nor chided. As I left she offered to write a note for my teacher. But I relented. I had at least a little pride.

And over the next 15 years our paths crossed occasionally. Family events. My mom would update me on what was going on with them.

And I was busy with college, then medical school, then residency. I finished my training and returned to be a hospitalist at a local hospital. I was feeling young an important. Competent. Ready to tackle the world.

I had known that she was diagnosed with lung cancer. Never a smoker she was one of the unlucky ones. And I would stop into her room to chat when she was admitted for chemotherapy. We discussed her fears and anxieties. We talked about old times. Just a friendly visitor to pass the hours.

The last time she was admitted I made a point of visiting early. She was in the hospice program and was dying quickly. I knocked gently on the door and let myself in. I expected to find a room full of people but instead it was empty. Her family had stepped out briefly for a cup of coffee. She was resting quietly. Unconscious. Breathing deeply. She had a look that I recognized. The look of someone who was walking their lasts steps through life's unexpected maze. I knew she had hours at most.

So I sat quietly next to her bed and let her know that I was there. I spoke softly but leaned forward towards her. I told her that I was sorry for what she was going through. I told her that it was a pleasure knowing her. And then I said goodbye. I placed her hand in mine. Then I promised that I would always remember.

I left the room before the family returned. And she died later that day. Inexplicably I did not go to the funeral.

I run into her son every now and then. Our lives have taken such different paths but we still share history. Unlike the peolple he now meets today I knew his mom. And this means something.

I don't know why these thoughts came to me this morning as I got out of my car. Why such randomness pops into my head. But I am thankful for them nonetheless. And no matter what...

I will keep the promise I made that day...

I will always remember.

Jumped

We were young. Arrogant. Silly enough to believe that affluence had left a a chip on our shoulder. So we kept trying to knock it off. Or at least to appear that way. In reality we had as little common sense as street smarts. We weren't tough at all. We were just kids. Unschooled in life's bleak realities. Unaware of the danger that lurked around corners. But there were appearances to keep up. So we walked tall. Strutted even. But rarely dealt with the consequences.

I was nineteen. Inebriated. And home from college. My buddies and I had left the apartment at midnight for fast food. It was a quick walk. Ten minutes through empty downtown streets. We arrived just before closing. We scarfed down our burgers even though there was no particular rush. We loitered until they eventually kicked us out of the empty restaurant.

As we walked back we entered a particularly isolated area where lighting was sparse. My two buddies were carrying on as I listened closely. Behind me in the distance I could here a car screech to a stop. Then doors slammed as multiple feet hit the pavement. I crossed the street as my friends obliviously followed. I didn't dare turn around.

Then as I heard the footsteps gaining rapidly I zig-zagged back to the other side of the street. My friend at my side looked up towards me. Where the hell are you going?. But there was no time. The foot steps were coming too quickly. I broke into a sprint and turned only after putting a few hundred yards between us.

One of my friends was wise to what was happening and ran in the other direction. But our third buddy hadn't quite figured it out. I say "buddy" loosely because actually I barely knew the guy. I met him for the first time earlier that night.

But there he was alone. Surrounded by three tall men who were starting to grab at him. Give me your money...give me your money. They kept yelling but he didn't respond. His genteel upbringing and sheltered existence were crashing in around him. He stared blankly with the look of a lost puppy dog.

As I slowly walked back towards the group I felt none of the toughness I had tried so hard to portray at my suburban high school with my suburban friends. I was just a typical rich snot head. Inexperienced and weak! Wearing a beat up brown leather bomber jacket hoping that others would think that I too was gritty and tough and bruised but durable on the inside.

Wordlessly I pushed my way into the center of the fray as the men grabbed my jacket. I clipped there arms under my shoulder and broke my friend loose. The shortest of the bunch reached into his coat pocket and held his hand in place. I have a gun...Don't make me use it....give me all your money. My buddy had awoken from his reverie and I pushed him towards freedom. Yah...well if you have a gun pull it out and I'll give you everything!.

No gun appeared. I wrestled myself free and we all ran to safety. There wasn't any pursuit.

As we returned to the apartment and rejoined the rest of our group my two friends told a tall tale barely resembling what had actually occured. They left out the fact that our three pursuers weighed in total about 200 pounds and that they were likely cracked up and harmless. They forgot to mention that at precisely the most important moment they both froze.

But I didn't correct them. After all was I any better. Hadn't I struggled with the same chip on my shoulder? Let them have there moment.

Maybe toughness was overrated. Maybe what I was really looking for all those years was something that is much more important. Something that I'm still struggling with today:

Wisdom.

It wasn't a time when I new the difference between sick and well. For God sakes I was only nineteen. But the feel of Alex holding onto my arm for dear life made me age quickly. And feel frightened. But unfortunately no more wise

I had gotten the phone call thirty minutes earlier. His fraternity brother saying it was an emergency. To come quick. When I arrived I found Alex. Panicked. Holding his chest. His face was flushed. And he kept on saying over and over again....I'm going to die...I'm going to die.

His roommate sauntered over to me casually with a stupid grin on his face and handed me his car keys. We're all too fucked up! Can you take him to the ER. He then disappeared with the rest of his fraternity brothers into their rooms. And I, towering over Alex, gently tried to coax him off the ground and towards the car parked in the driveway.

His eyes were blood shot. His gait unsteady. His breath smelled of alcohol.

None of this was missed by the nurse checking him in at the front desk. So what did he take...heroine, shrooms, LSD? The truth is I didn't know. And Alex wasn't going to confess. The nurse absentmindedly took his vitals and gestured for us to sit in the waiting room.

Alex began to panic. He grabbed his chest and moaned. He told me his heart was racing. The holding area was empty but a few remaining stragglers visibly distanced themselves from our seats. And so we waited...and waited...and waited until someone came to get Alex and told me to stay behind.

A few minutes later a Doctor beckoned me to come to Alex's bedside. He was agitated and the doctor felt that a familiar face would calm him down. I held his hand as an EKG and blood tests all came back normal.

Eventually Alex calmed down enough to return home. The Doctor gave me instructions and wished us well. As I was leaving he looked over his shoulder...So what are you guys studying anyway? My head slumped forward as my answer came out almost a whisper: Premed.

And now years later I often wonder what happened to Alex. Did he ever become a doctor? And what drug had he taken that day anyway? With the experience of years I realize that Alex wasn't that sick at all. Just scared, inebriated.

And I try to be a little easier on people......

especially in their moments of frailty.

Primary Care

In the winter
Of my discontent
The welfare line forms
Outside the office

And I
The phony banker
Dispense phony treatment
Like monopoly
Money

In exchange
For the incoherent mass
Of unsatisfying
Nonsensical
Symptoms

Fatigue
Light headedness
Numbness and tingling
And then
You

Abdominal pain
Without vagaries
The belly jumps
With my slightest
Touch

A keeper
IV's
A CT
Antibiotics

Satisfaction...
However
Ultimately eludes me
On the eaves
Of the Scalpel's
Sharp Tongue


From the chapbook Primary Care, The Lives You Touch Publications

Does A Good EMR Erase Some Of The Benfits Of Hospitalists?

Although I don't personally use hospitalists I am a supporter. To internists who don't want to leave the office they are indispensable. In today's fast paced ever changing health care scene hospitalists are a bastion of stability and bring excellent care to almost any system.

To put it simply....hospitalists give efficient, timely care, in a cost effective manner. In fact it has been this cost efficiency (as well as the benefits to PCP's) that has been trumpeted as the battle cry to advance hospitalist programs.

But as time goes by the data are starting to illustrate that maybe the cost savings aren't as great as we once thought. That doesn't negate the force of the movement. After all there are other efficiencies besides economic. But it does make you wonder. Can a good EMR level the playing field a little bit.

For instance. In my current hospital system we use a highly effective EMR called EPIC. Using this system I round early in the morning. When I arrive at my office I open up the EMR from the Internet. As I am doing my morning paperwork I also scan vitals and labs right as they come back from the laboratory. As the day progresses the regular commotion begins. Between seeing outpatients I review xrays, consultant notes, and even discharge patients right from the comfort of my office.

It is safe to say I am more in touch with what is going on with my patients throughout the day then I ever was previously...even as a hospitalist. Even though I may be deluged with outpatients, I only have a few people in house at a time so it is easy to keep on top of them.

I don't know for sure but I suspect my length of stay and cost of care data is right on par with our hospitalists.

As an outpatient primary care doctor I feel more connected to my inpatients then ever. And I wouldn't have it any other way!

Sitting In a Trendy Bar in LA

Sitting in a trendy bar in LA I find myself out of my element. My eyes wander to the tables adjacent. The room sways with the music as the beautiful people inhabit their space. And then out of the corner of my eye I catch a glimpse of two men embracing. Young. One then reaches his arm around the other putting him in a mock headlock. And instantaneously the image transports me back to a week earlier...

I'm rushing to the emergency room from my office. I have a thirty minute break between patients. The buildings are connected. I try to sort out what I am gong to say to the family I'm running to meet. Their mother has just died unexpectedly in the nursing home. She was deathly ill but that won't make it any easier. I feel a twinge of guilt as if I could have done anything differently.

I enter the hospital from a side door and start down the long passage that eventually leads to the main entrance and the ER. My eyes forward I almost crash right into the women in the white coat. She is standing at the intersection between hallways. Holding a hand up towards me she is speaking in harsh loud sentences. Her head is turned towards the bisecting hallway. "Okay...okay...they have a bed for us move him forward..." a bead of sweat falls from her forehead.

Next five large security guards stumble forward into view. They are struggling to carry a thrashing figure. They each have a limb wrapped squarely between large arms. The fifth has the patient's head in his hands and is holding it for dear life in a headlock. They are all obviously fatigued already. The man in front responds, "okay...we have to hurry...we can't take it much longer".

And just as quickly as it has come the commotion disappears. Later as I walk through ER I see the attending and nurses scurrying to the exam room with syringes. Ready to sedate on command. The security guards are loitering at the nursing station. Each grasping a cup of water. And I, distracted by the scene, still am not sure what I am going to say to the family as I pass through the main area and head towards the crisis room.

The men in the bar are now sitting. They toast eachother with their newly delivered drinks. And I let go of that day in the ER. It all seems so far away now....

sitting in a trendy bar in LA.

Another Holiday

As the snow gently drops onto my windshield it is quickly whisked away by the wipers. It's another holiday. 5:30 AM. And I'm in the car on the way to the hospital. I've worked them all. Holidays, birthdays, anniversaries. I've missed countless family events. I generally leave the house before the children awake. Occasionally I return after they are sleeping. And when I'm not working...I'm constantly thinking. Mulling over a patient....a disease. Agonizingly trying to grasp the ephemeral. The missed diagnosis..the hidden clue. My wife rolls her eyes when she asks a question and I fail to respond. My head in a cloud I'm lost in the ether, desperately clinging to fleeting thoughts. So why do I do it. Why be a physician?

I am not a religious man. I have never read the bible. When times get tough I do not pray. But I have a sense of what must make it so gratifying. The husbands gentleness as he helps his wife onto the examining table. The ward secretary who sneaks into the hospital room to hold the patient's hand because there is no one to sit with him while he dies. The countless acts of beauty and kindness that occur behind closed doors when we are all at our worst. This....this is as close as I get to feeling God's presence.

This is the mistress that whispers in my ear early in the morning and forces me to get up. To leave my family on a holiday. To drive a half an hour in the snow to the hospital. To practice the craft that I have been taught. A craft which invites me into the most intimate moments of others lives. And gives me the unique possibility to help.

No matter how bad it gets there will always be doctors.....

There will always be doctors!