Monday, May 12, 2008

On Nurse Practitioners and Physician Assistants

There is a nurse practitioner that works at my hospital. She is employed by the pulmonology group and helps run the intensive care. She is good. She is better then good...great even. She probably knows more then seventy five percent of the docs in the hospital. She is one of a kind. Hand trained by the pulmonologists she has spent every day in the hospital taking care of the sickest ICU patients. For years. Even so she is closely monitered by the attending staff and and each patient is seen by the covering physician daily. Sometimes it makes me wonder......It works for them.....could it work for us?

There is a primary care shortage in this country. No doubt about it. As access is getting more dificult there have been many cries to enahnce the responsibilities of physician extenders. After all if a a nurse practitioner can work in the ICU, A PA can work for the surgeons, why not staff primary care clinics with physician extenders. Afterall, compared to those specialities....primary care requires the least training....Doesn't it.

Maye.....maybe not.

Last week was a typical week. Maybe a little slow. But I took a look back at some of my interesting cases in the office to consider how a physician extender would have fared. None of these cases were particularly earth shattering, none of them were even life threating (at least for the most part). But they do highlight the way in which a primary care physician is trained. A training that actually is quite extensive.

Patient A was a young lady under a lot of stress. She recently had given birth and already was back at work. She was juggling a busy careeer, a busy family life, and quite a bit of stress. Starting the week before she came to see me she developed shortness of breadth. It was episodic. Lasted for 15 minutes at a time and was accompanied by dizziness and hand tingling. On further questioning she described the shortness of breadth as a strangling sensation around her neck which would cause her respiratory rate to go up and this would then be followed a few minutes later by dizziness and tingling.

At first I was convinced that she was having panic attacks. But her exam made me consider an alternate possibility. Her anterior neck was mildly tender. I ordered thyroid tests and an ultrasound. Thyroid functions were normal but the thyroid on ultrasound was heterogenous with some nodularity. The findings were consistant with thyroiditis. Likely the dizzines and hand tingling occured because the sensation of strangulation which caused her to hyperventilate. I prescribed first alleve and when that didn't work a medrol dose pack. She will see me monthly for repeat thyroid tests to make sure she doesn't become hypothyroid.

So how would a physician extender have done ont his one. Would the patient have been started on antianxiety medication? Would they have been sent for a head CT to work up dizziness? To a pulmonologist to work up dyspnea?

Patient B is a 50 year old Gym teacher with a sore calf. While teaching his students he demonstrated a sprinting technique and developed acute pain. It occured while pushing off the ground at the start of a sprint. He heard a pop and then developed sharp pain in the calf below his knee. Over the next day the calf became swollen and painful. He developed quite a bit of bruising and came to see me.

Based on the history I felt relatively certain the patient had developed an acute gastrocnemius tendon rupture. I examined him and sent him for a stat doppler to r/o DVT and also asses the tendon. Althought the tech told me he didn't see a rupture my suspicion was high so I called an orthopeadist for a curbside consult who confirmed my suspicions. Yes it was likely a ruputre, no the patient didn't need consultation. Yes the patient would likely recover with physical therapy only. Coincidentally the tech callled me back a few days later. He ammended his report. The ultrasound showed a free floating gastroc consistent with a tendon rupture.

Would a PA have caught this one? Would the patient have gotten and unnecesaryand costly orthopeadics consult or an MRI?

Lastly Patient C is a 65 year old female on dilaysis for end stage renal disease. While in dialysis her renal doctor noticed that she had a fever of 101. When the fever continued for multiple days she was sent to the ER for blood and urine cultures and a chest xray. They were all negative. The kidney docotor asked the patient to call me for an eval. The patients exam was completely normal ecxept.....she had anterior neck pain a few inches above a recently placed IJ dialysis catheter. It was mild pain and she had been told by the ER to use a heating pad. Given the fevers and otherwise normal exam I was worried there could be something more sinister going on. Ultrasound/Doppler revealed an acute DVT in the Right Internal Jugular vein and a chronic DVT in the LEft IJ. The patient was hospitalized and coumadinized.

I bring up these cases because they are examples of the wide and varied nature of a primary care physician's job. My ability to recognize and treat these problems comes from years of studying, training, working in hospitals, and overall experiance. I fear that physician extenders will not have as deep experiance. They will not have spent long hours in hospitals like we did in residency. They will never have been confronted by do or die situations in which vital decisions have to be made in the middle of the night without anyone around to help. Becoming a physician has been a life long process. I still have soo much to learn. I read vorasciously, I learn from each patient. I discuss cases with specialists daily. Yet even I often feel humbled by the vast sea of knowledge necessary to treat my patient's appropriately.

If you were really going to go through all the trouble and training necessary to be good at primary care....why the heck would you become a physician extender. Why would you accept a lower sallery for all this hard work?

The simple answer is you wouldn't. You get what you pay for my get what you pay for!

Wednesday, May 7, 2008

On Defying Death

The man sitting in front of me was in a wheel chair. He had lungs riddled with cancer. He had a neurodegenerative disorder that took away his ability to walk and left him unable to speak. He was in his eighties. And he was dying.

But his wife and three children who gathered in my office that day had no interest in discussing such things. I tried to talk aboutt hospice. I tried to work in the idea of palliative care. But they interruprted me. Each one in turn. They had there own story to tell. A story that had nothing to do with illness. A story of life. The life of their beloved family member. And how it changed the world.

At the age of eighteen the man sitting in front of me proposed to his wife. He was fresh out of basic training and on his way to fighting in World War II. He had just a few days before he shipped out. They had been dating for only a few months but he was desperate to know that she wouldn't forget him when he was gone. The wedding was set for after his return.

Little did she know that two years later a uniformed officer would come to his parent's door and give them awful news. He was dead. Shot down while flying a mission over Japan. He was the only person in the plane. He had died honorably protecting his country.

She was devastated. His family was devastated. And they mourned his passing. Such a young wonderful man killed in the prime of his life. She didn't have the heart to date anyone else. She just couldn't get over her loss. And this was good....because a few years later he would show up at her door.....unexpectedly alive.

His time in the war was both difficult and exciting. He had always dreamed of being a fighter pilot. He was brave and well trained. He flew countless missions unscathed. But on the last of these missions he hit a patch of bad luck. Blindsided by the enemy he was caught unawares. A sitting duck. He only had a moment before impact. And briefly he saw his life flash before him.

The next thing he could remember was falling. Still strapped into his plane. Turning rapidly in sickening circles. The centrifigul force on his body was almost unbearable. And then he passed out. It is estimated that he must of fell at least 30,000 feet. No one knows for sure.

The next thing he remembered was waking up to find the barrel of a gun in his face. Japanese soldiers above him were arguing in a threatening tone. The tongue was foriegn but he couldn't miss the underlying meaning. They were going to shoot him. Right there on the ground. His leg was tucked beneath him and the bones on his right had punctured the skin and were sticking out.

Years later he would return to the sight of that fateful day. Long after the war had been settled. He would come face to face with his previous captors. And through an interpretor they would tell him the truth about their arguement that day. One of them was going to kill him. But the other soldiers stepped in. They felt it was somehow unnatural to wantonly kill this man who had survived such a fall.

So the Japanese soldiers used some cloth and tree branches to make a stretcher. And they walked days to the nearest prisioner camp. And deposited there prisoner with the rest of the other POW's.

Once again luck seem to come his way. Not only was his open leg fracture not infected but also one of his fellow POW's was a surgeon. The head soldier in charge of the prisoners felt uncharacteristicallty kind and supplied the surgeon with some basic instruments. The operation was a success. And a year later he was as good as new.

Although many of his fellow POW's died, he survived his two years of captivitiy. Was it becuase the Japanes soldiers feared him because he had survived such a fall? Was it that he didn't have the heart to give up after all he had gone through? Or was it the thought of returning to his beloved fiancee that kept him going? We all know what he would say if he could still talk!

And so the war ended and he was rescud and delivered home to the utter surprise of his family and his beloved. He was married quickly and had three sons. He went back to school and earned his PhD and became a scientist.

He did some of the initial pioneering work with electron microscopy and taught medical school. His work led to advances in almost all fields of science and medicine. His children who looked up to their father became doctors and scientists. Without a a doubt millions of lives were affected by what seemed like such small events. Surviving a long fall, a decision not to shoot, a fellow POW with surgical skills.

And as the youngest son finished I could tell that the family had said all they wanted to say. We talked for a while longer. I gave them the phone number for our local hospice and sat for a few moments quietly.

As I got up to leave the room I took the gentleman's hand and offered all that I had left to offer. I cleared my throat....

"I will never forget what you and your family have showed me.....that even for men of science and medicine as us....we must always take a moment to wonder about the beauty and mystery of life".

Out of the corner of my eye I could see his children and wife nod amongst themselves happily.

Even now their father....husband.....veteran....fall survivor.....prisoner of war...scientist.....and teacher....

still had a few lessons left.

He died a few days later. home.

Monday, May 5, 2008

On Discussing Death

I don't know when it happened. The day that I realized that I had certain abilities. A premonition...a feeling....about when my patients were about to die. It happened slowly. But as time goes on I have become more aware. The way people look....the things that they say....the disease processes that they suffer from. Somehow it all comes together and I know. Sometimes its hours, sometimes it days, and sometimes weeks. And I tell them...for better or worse. How could I not?

I remember the first time. It was when I was in residency. My grandmother was in her nineties and had dementia. Over months she had become progressively ill. She had seen her doctor and was diagnosed with cancer. My mother called me the week before to tell me that things weren't going well. She wasn't in pain but she had lost her interest in doing things. I was in the middle of my second year of residency and was on an easy rotation. No weekends...I was well rested and happy. I had warned my residency director that a family member was sick and that I may have to take some time off.

The next time I heard from my mother was a Thursday night. She was sitting in my Grandmother's room. As I strained to listen I could here her breath in the background. Each breadth was long and deep followed by a pause. I remember the certainty in my voice as relayed instructions...."Mom she's got less then a day. It's time to call every one and tell them to come tonight....she doesn't have long."

My mother got on the phone and called her sister....who booked a flight from New York. I jumped in the car and started the 6 hour drive home. I promised my family that I would drive safely and take my time. The last thing they wanted was to have me get in a car accident on the way home. It took awhile but I made it in time.

As I walked into my Grandmother's room a crowd had gathered. Children and granchildren...we were all there. In fact I was the last. I walked directly to my grandmothers bed and took her into my arms. She was unconscious.....her breadthing shallow. I placed my lips gently to her ear and whispered..... "grandma I'm here, we're all can go now". I gently rested her back on the pillow.

I walked over to the windows and opened the curtains. The sun gently made its way into the room bringing much needed light. As we waited I grabbed the rickety tape recorder that was lying on the table next to the bed. We put in her favorite tape.....the soundtrack to an old movie...I believe it was My Fair Lady. And then she left us. Such a quiet ending for such a lively and rambunctious women. A survivor of the great depression. Her mother died of influenza. Her father, an alcaholic, abandoned her in an orphanage which became her home till adulthood. Yet she endured....even today she endures.

So I often explain to patients that physicians don't like to prognosticate on when a patient is going to die. I tell them that every physician has a story about telling someone that they are going to die in a few days and then having them live much longer. And then I tell them that I am not that kind of physician. And I tell them that even though there oncologist/pulmonologist/cardiologist won't give them a prediction that I will not hide my opinion.

Some say that this is not fair. That somehoew by telling someone they are going to die I am in some way hastening the event. Or that I am squelching their hope.

To them I reply that I can't argue that they are wrong. But in my opinion I prepare my patients for life. I prepare them for aging, and for surgery. And yes....sometimes I even prepare them for death.

Wouldn't you want that kind of dignified treatment from your physician?