Tuesday, February 17, 2009

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.

Sunday, February 8, 2009

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.

Monday, February 2, 2009


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: