Today started out less happy than most days. I got a call from a patient who had a serious problem - a problem I had been worried about developing. Part of the problem was brought on by the medicine I gave to my patient. It was a known risk, one that I felt was outweighed by the benefits that were experienced. My patient agreed with that, until we both realized that the opposite was true. The natural adverse effect of the medicine was worse than either of us expected. No harm is done, it is all completely reversible. The patient will, in the end, be fine. But the hardship and emotional stress was more than expected, and I was a contributor to that. Chalk one up in the "Loss" column.
But later in the same day, I checked my inbox and found a magical piece of paper. It was a radiology study result that another patient and I had been waiting for for over a month; the patient had in fact been waiting for about the past 6 months for someone to make the diagnosis and get this magic piece of paper in their hand. And today I got it. The results of this test explained some very concerning and dangerous symptoms, and more than that offered hope of a cure of these symptoms. It was very good news and a long time coming. Chalk one up in the "Win" column.
This is life now. Wins, losses... Big wins, and big losses. But more than that, each win is a patient, each loss is someone I am responsible for. The gambles, the risk/benefit analyses I go through each day end up affecting someone else in a large way. This is not news to me, but this is the first time that I have had such a stark contrast in the same day. The gamble for one patient did not pay off, while the roll of the dice on a diagnostic test for another patient was completely successful. I am thankful that, to this point, I haven't had to gamble with someone's life. But I know that it is coming. And days like these make me one step more prepared. But it is still humbling, still intimidating, and incredibly challenging. I am just hoping that I stack up a whole bunch more wins than losses.
Tuesday, January 24, 2012
Tuesday, January 17, 2012
Candy, Toys, or Recess?
I have been thinking about these three things frequently since my emergency medicine rotation over a year ago. I may have commented on it at that time... I don't recall and don't want to sort through a host of old posts to find it. Suffice it to say that a wise preceptor of mine once told me that people who go to an ER or Urgent Care want one of three things: they either want candy (medicine), toys (protective equipment/braces/ace wraps, etc), or recess (time off from work/school). I spent my day today doing urgent care (aka minor care) and it was evident that the desire to receive one of these things is present in nearly everybody.
I had a patient today who basically came in because of cramps. As it turns out, the patient had not been drinking any water to speak of... at all. For days. But this simple explanation was not sufficient. This person was sick, according to relatives, and it had to be something worse than a water deficit. For almost everyone else, there was medicine or bracing or just a day or two off from work that helped them leave happy as clams. But for the one person who didn't get one of the three, there was little closure - little apparent relief given my assessment and treatment planning as well as the counseling on nutrition and hydration guidelines.
Several of my preceptors discussed with me the importance of "reassurance" as part of a treatment plan and counseling of my patients. This works well for a few patients, but mostly only those who schedule routine office visits and yearly exams on a regular basis. Reassurance for the "worried well" works fine in most cases... For those who are convinced that they are emergently or urgently sick, a little "reassurance" is much more difficult to make sufficient. At the same time, that should never keep us from trying.
I had a patient today who basically came in because of cramps. As it turns out, the patient had not been drinking any water to speak of... at all. For days. But this simple explanation was not sufficient. This person was sick, according to relatives, and it had to be something worse than a water deficit. For almost everyone else, there was medicine or bracing or just a day or two off from work that helped them leave happy as clams. But for the one person who didn't get one of the three, there was little closure - little apparent relief given my assessment and treatment planning as well as the counseling on nutrition and hydration guidelines.
Several of my preceptors discussed with me the importance of "reassurance" as part of a treatment plan and counseling of my patients. This works well for a few patients, but mostly only those who schedule routine office visits and yearly exams on a regular basis. Reassurance for the "worried well" works fine in most cases... For those who are convinced that they are emergently or urgently sick, a little "reassurance" is much more difficult to make sufficient. At the same time, that should never keep us from trying.
Thursday, January 12, 2012
Art
I know that I have talked about the art of medicine before. I have also talked about the lack of certainty that is ever present when practicing medicine. Endless study and research has gone into removing the uncertainty from medicine, but there is no way to do so completely. The human body is too complex, too poorly understood, for us to know 100% what the right decision is for every patient.
It truly is an art. I will briefly share an experience from a few weeks ago that illustrates this - again, please pardon the vague references, but I want to protect confidentiality. So, a young woman comes to me with signs of a relatively common problem that is quite serious. I followed all the scientific evidence to diagnose the condition with laboratory tests - but none confirmed the diagnosis. Because of her prior history, I referred her to a specialist she'd been seeing so that he and I could get her referred to another specialist ASAP. They screened her for the same condition I screened her for and did not find any evidence for it. The other specialist didn't find anything either. Basically, as a last resort, a risky procedure was done with what seemed like little evidence - and all of her symptoms resolved. She'd had the condition we were worried about the entire time, but had none of the standard manifestations of the condition.
I shrugged my shoulders and threw my hands up in the air when I heard that she'd had what we were worried about all along. She had only one sign, and though the books say that someone with this condition should have laboratory findings to confirm the diagnosis, she did not. My question was, "How am I supposed to make the right diagnosis and save lives when they don't exhibit the signs they're supposed to? Don't they read the books?" I know, of course, that uncertainty is inherent in the job. That this is an art, and that sometimes I have to follow paths that are not spelled out 100%. This is why I enjoy the job, but it is also something that makes the job quite frustrating and at times remarkably scary. All in a days work, I suppose.
It truly is an art. I will briefly share an experience from a few weeks ago that illustrates this - again, please pardon the vague references, but I want to protect confidentiality. So, a young woman comes to me with signs of a relatively common problem that is quite serious. I followed all the scientific evidence to diagnose the condition with laboratory tests - but none confirmed the diagnosis. Because of her prior history, I referred her to a specialist she'd been seeing so that he and I could get her referred to another specialist ASAP. They screened her for the same condition I screened her for and did not find any evidence for it. The other specialist didn't find anything either. Basically, as a last resort, a risky procedure was done with what seemed like little evidence - and all of her symptoms resolved. She'd had the condition we were worried about the entire time, but had none of the standard manifestations of the condition.
I shrugged my shoulders and threw my hands up in the air when I heard that she'd had what we were worried about all along. She had only one sign, and though the books say that someone with this condition should have laboratory findings to confirm the diagnosis, she did not. My question was, "How am I supposed to make the right diagnosis and save lives when they don't exhibit the signs they're supposed to? Don't they read the books?" I know, of course, that uncertainty is inherent in the job. That this is an art, and that sometimes I have to follow paths that are not spelled out 100%. This is why I enjoy the job, but it is also something that makes the job quite frustrating and at times remarkably scary. All in a days work, I suppose.
Wednesday, January 4, 2012
Absence
It has been quite some time since my last post. In the intervening time, a lot has changed.
The major change is that I am going to be moving to a new job. I got a phone call out of the blue about five weeks ago with an excellent proposal. The new position will have me seeing more patients weekly, but working fewer hours. I will be moving from government medicine to private practice. I will be working in a larger practice with many excellent MDs, DOs and NPs around me. Interestingly, I will be the only PA in the practice. I am a bit intimidated by this fact - what will it mean for the future? Will the group transition away from PAs in favor of NPs? Why did they pick a PA in the first place? I am grateful for the opportunity and I believe it will be an excellent one - there is already some talk about working with the local emergency room and there may be opportunities to work in surgery as well.
I deeply regret leaving my current clinic - the need for providers is very great. But with this move I am putting my family first. I feel good about that.
The major change is that I am going to be moving to a new job. I got a phone call out of the blue about five weeks ago with an excellent proposal. The new position will have me seeing more patients weekly, but working fewer hours. I will be moving from government medicine to private practice. I will be working in a larger practice with many excellent MDs, DOs and NPs around me. Interestingly, I will be the only PA in the practice. I am a bit intimidated by this fact - what will it mean for the future? Will the group transition away from PAs in favor of NPs? Why did they pick a PA in the first place? I am grateful for the opportunity and I believe it will be an excellent one - there is already some talk about working with the local emergency room and there may be opportunities to work in surgery as well.
I deeply regret leaving my current clinic - the need for providers is very great. But with this move I am putting my family first. I feel good about that.
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