Archive for February, 2011

Everyone should have a primary care physician or nurse practitioner.  Primary care is vital and basic in our health care delivery system. It is the foundation of good health care; the gate-keeper that makes sure you are getting the proper and most effective/efficient/economically sound health care. Right? Oh, you didn’t realize that? Did you think that your primary care provider was just a back up plan of last resort because s/he is JUST a family doctor?

Primary means first.

Now that I am in the last six months of my nurse practitioner program, friends and family keep asking me for medical advice. I guess this is something that health care providers get used to, this requesting of advice with the most rudimentary of information, 99% of the time without any exam at all, and often over the phone. It pays to be very careful. I also notice that many of the requests start with the “patient’s” opinion of what is wrong and what they should do, and they are only seeking confirmation for their diagnosis and treatment plan.

Example: the wife of an elderly friend calls up and tells me that her husband woke up “in a pool of blood”. In the background I hear him say “It was only a little bit, don’t exaggerate” and she asks me if they should go to the urologist. I ask where the blood came from and she told me she wasn’t sure if it was from the penis or someplace else. “It came from my ass” I hear in the background. “Well, I think we should go to the urologist in case it was your prostate”. After determining that the bleeding had currently stopped, I suggested that they get an appointment with their primary care physician. “You don’t think I should go to the urologist, or how about the surgeon that did his colonoscopy, maybe he has cancer?” she asks.  It takes a little while to convince her that the family doctor was the place to go. That he would be able to determine what the problem was and if a specialist was even needed. She finally agreed. It turned out to be a hemorrhoid.

The thing about specialists is, they specialize. Go to a gastro-enterologist with chest pain and he will look for an ulcer, a cardiologist looks for heart disease, a psychiatrist will look for panic attack. Specialty practices generally aren’t the place to go to for an initial diagnosis. Okay, if you are having crushing chest pain, or have a bone sticking out after you fall down, or you have vomited so much you are passing out, go to the emergency room. That is a specialty you can go to for an emergency. As I have stated previously, a sore throat or infected big toe are not emergencies. This is where the primary care provider fits in.

Another friend has had a history of triple bypass. He kept having chest pains after and popped nitro and aspirin like candy. It just didn’t seem to be helping. He kept going back to his cardiologist, had test after test, year after year. Everything seemed fine when he had his cardiac tests, but the chest pain continued. I finally asked him one day to describe when where how, etc. of the chest pain. It was when he was moving around, he couldn’t do anything without getting chest pain.

Okay, when exactly.

In the morning when he tried to wash dishes after breakfast (nice guy, huh? Washing the dishes).

Any other time?

When he took his walk after lunch.

Hmmm. After meals. Okay, did he have any  other symptoms with his chest pain, sweating, dizziness, shortness of breath?

No, just a terrible burning pain in the middle of his chest. Oh, and feeling really tired.

Do you ever get it at night?

Well, yes, when laying down in bed watching TV after dinner.

Are you seeing the point yet? It turns out he had a hiatal hernia. I talked them into going to the primary care doctor for a workup and he was diagnosed, properly, with the hiatal hernia. He was tired because the nitro was dropping his blood pressure and the aspirin was also contributing to the stomach pain. It had nothing to do with his heart. A prescription for a PPI and he is in the pink (literally, his color is so much better, not pale anymore). No chest pains, no more fatigue, exercising without a problem…

So: the moral of the story is, don’t try to diagnose yourself. Let the primary care provider do it.

The ten commandments of primary care:

  • Thou shall have no other doctors before your primary care provider.
  • Thou shall not use the internet to diagnose thyself.
  • Thou shall not call them at 4:45 PM on Friday because the itchy rash you got from poison ivy 3 days ago didn’t go away yet and you want something now.
  • Thou shall not expect them to know by osmosis which other doctors you have seen and what medicine they gave you, and what you are being treated for. It is better to let her/him refer you to specialists, that way s/he knows what is going on and has a handle on your overall healthcare, and gets the records from the other physicians.
  • Thou shall not use them as a last resort, remember they are primary care.
  • Thou shall honor the annual physical and attend regularly.
  • Thou shall not forget that each medical problem you have affects all the others, the primary care provider is the one that keeps the show moving in the right direction and directs the traffic.
  • Thou shall not steal your primary care provider’s time by asking them to diagnose and treat you over the phone (okay, I am guilty of this one sometimes) You would never ask this of your cardiologist, would you?
  • Thou shall not go to the emergency room to do what your primary care provider is perfectly capable of doing, such as sewing up a small laceration, treating a stomach virus, splinting a sprained ankle, etc.
  • Thou shall remember you have a relationship with your family physician/nurse practitioner. They know you and your history, they follow up with you, they care for you on a long-term basis. Use that relationship to manage your health care in the best manner possible.

I just wish the insurance companies and the government realized the importance of primary care and reimbursed accordingly. Specialists are important, but primary care is more valuable in the general scheme of things: prevention, health maintenance, health screening, counseling and 98% of the health care the average person needs.


Read Full Post »

I am at the half-way point of my Adult Practicum term. The midterm exam is due this week, I’ll take it on Wednesday. Friday will be my first day of clinicals at my doctor’s practice for the second half of Adult Practicum. It should interesting. My greatest complaint about my previous two preceptors is that they didn’t tell me enough.W hen I saw my doctor last week, he said he has been accused  of telling people how to build the watch when asked what time it was. That works for me!

Seeing the patients that came to the health department for their primary care was definitely “interesting”. Coming from a background with high work ethic and a belief in the value of your health and the need to do everything to maintain it, mostly to be able to keep the ability to work and be productive, it was a shock to see what was considered  important by some of the patients I saw. Their values differed from mine in several major respects.

  • For them: 1) if Medicaid pays for it, I want it. If it isn’t paid for, I don’t. 2) If it doesn’t make me uncomfortable, it isn’t important. 3) Whatever I can use to go on disability is good, even if I am a big, strong, young man and my only disability is a bum knee from basketball. 4) Why bother with prevention if you can just fix things afterwards.
  • In my world it goes 1) I will find a way to pay for it as healthcare is important 2) What ever it takes to prevent future problems or treat current ones gets done, I need to keep healthy and active so I can work and do what needs  done. 3) Disability is the last thing I would ever want, I will find a way to work and stay independent until the last possible second (so bad that I can’t get out of bed, well, even then you can use a phone or computer) 4) An ounce of prevention is worth a pound of cure.

A woman came in whose main complaint was a sore in her armpit. When the nurse took her blood pressure, it was 210/102, approaching stroke city…then the patient admitted to having some pain in her chest. “But that is not why I came in, I want you to deal with the sore under my arm!” All through the ECG she complained about the armpit thing. Thank goodness there wasn’t an ischemic event going on (heart attack), though the ECG showed LVH (enlarged heart, probably related to the ridiculously high BP).

We reviewed her BP meds, changed the doses a bit to better address the BP issue, tried to educate her a bit on the risks of heart attack and stroke, etc. Not interested, “Just take care of that thing in my armpit!”. Okay, we drained the small abscess that had formed  from a folliculitis related to shaving her armpits. Then she was happy.

I have to wonder if a large part of the higher rates of stroke, heart disease, diabetes, uncontrolled hypertension, etc. in the “underprivileged” is a result of noncompliance with treatment plans, or simply not caring enough to take care of their own health. The care is there and available, but if you don’t use the care available or follow the treatment plan, you will not be healthy or get better.

I have seen several patients with genital warts, lots of genital warts and big ones. Personally, one teensy little bump would send me straight to the doctor’s office in a screaming panic (not that I would put myself in the position of it being possible to get such a disease if I had anything to do with it). I can not conceive of letting things go the way some of these patients did. When the treatment is finished (which is painful, as it basically consists of burning them off with acid) I sit and chat with them a bit, educating them on prevention, etc. Not a single one of them used condoms. They knew about condoms, they knew about safe sex, but it didn’t seem important to them. I asked some of them “So, you want to be a daddy?” The answer of course was usually “no”, or “not now”. I asked if the girl they were having sex with was the one they wanted to be the mother of their children. The answer to that was always “no”. They know that sex=possibility of babies, but when it comes to their own personal selves, “I wasn’t thinking about that.”  The universal attitude seems to be: fix it if it happens when it comes to diseases, and for some of the girls Plan B or abortion as contraception. Thank goodness, there are a lot of girls that take advantage of the free contraception offered by the health department.

The concept of being responsible for the results of your own actions doesn’t seem to be a big value these days. Or as the young people say: “Whatever.”

Read Full Post »

Knowing that I can say I graduate this year is very liberating. There is light at the end of the tunnel. The weight of all this is not quite so heavy, though I still feel a bit stretched thin. I decided to take today off.

Yesterday I posted the case study response, logged my patients for the week and sent in the time sheet for the clinical hours. Today, I decided to give my brain a much-needed rest. Of course, I fell into the trap of responding to “Bob” who commented negatively on the “Nurses masqurading as doctors” post. Oh, well, at least I didn’t get steamed up about it. There will be “Bobs” forever. The good news is, I surround myself with positive people who see the value in NPs, who are great clinicians and willing to share their pearls instead of assuming I am too “logic-impaired” to understand.

Life is good. I am learning every day. The book knowledge is turning into actual experience, the “oh crap, what do I do” moments are getting fewer and far between. I have helped people, have gotten lots of thank you’s and “good luck in school” from patients. My years of nursing experience have been augmented by new skills and knowledge, it’s all cool. I know I will never know it all, and learning will continue until the day I retire (hopefully around the time I turn 90).

So today will be spent hanging sheets on the line out in the beautiful sunny day we are having (there is nothing like fresh wind-blown sheets on the bed), watching a movie, sitting outside with a book, a cup of hot tea and watching the birds, hugging my long-suffering husband, having friends over for dinner, and just generally doing nothing related to healthcare.

Tomorrow I will study some more. Still sorting out the million birth control options and diabetes management which seem to be the top two things at the health department clinic…

Read Full Post »

It’s time to collaborate— not compete—with NPs

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy?

First, because it’s the reality. In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:

 • Nurses should practice to the full extent of their education and training.

• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

 • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training. Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate diff erences in practice, explore opportunities for collaboration, and develop diverse models of care.

 Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our eff ectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition. As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisionin g the future of health care.

From an editorial by Jeff Susman, MD. Editor-in-Chief of the Journal of Family Practice

Here is a link to the article: It’s time to collaborate

Read Full Post »