“I’m tired all the time. I feel bloated, I am constipated, and can’t sleep. I have this pain in my side and I’ve run out of pain pills. I keep gaining weight and I diet and exercise. I am so depressed. I don’t have any libido. I’ve been to my other doctors and they haven’t helped me at all. Can you give me something to make me feel better?”
When I was in my Nurse Practitioner classes, I would have written a ten page paper just outlining the history questions I would have asked. I would have explored her diet including a diet recall of the last couple days. I would have asked about exactly what kind of exercise, how long, what intensity. We would have explored her social life, spirituality, culture, relationships, social supports, job, economic condition and her living conditions. I would have taken a complete medical history: surgeries, past problems, social history, family history, allergies, Then I would have explored all her presenting symptoms: duration, quality, intensity, alleviating and aggravating factors, and what she has already tried to help her symptoms.
Then I would have talked with the patient and asked her what her health goals were. We would have come up with mutual goals and I would have made a patient contract with her that outlines what she will do prior to seeing me again. And of course I would have some wonderful “reward” waiting for when she came back and had completed her goals. Using all that information, I would have come up with appropriate lab work and diagnostic testing.
It would have taken me about two days to design the “care plan” for my patient, get it typed up and sent to my professor. I would get it back in a couple days with red marks saying “you should have asked about her past sexual history and domestic abuse.”
So what happens now that I am in the “real world”? I ask a few questions like “are you having thoughts of hurting yourself or others?” I skim her medical record and say things like: “I see you missed your appointment for your pelvic ultrasound. Did you go to your counseling appointment with behavioral health?” Then I go through her medication list and take off the medications she has stopped taking.
Then I find myself saying those words I hate: “You will need to follow up with you primary care physician for the constipation and fatigue. I want you to go back to behavioral health and tell them that you are still feeling depressed and tell them you stopped taking your medications. I will schedule you to follow up with one of our MD’s after your pelvic ultrasound because I don’t do surgeries. You need to call your XYand Z providers who have given you your pain meds and ask them for refills, I won’t refill pain meds I haven’t prescribed.”
When I send her away, I can almost bet that she won’t follow up but will just find another provider to go to in a few more months. And I will be one of those long list of providers who have failed her.
I want to go back to school. And I want them to teach me how to help the complicated patients in the real world of managed care, overbooks and patients who are “non-compliant”.
When I was in my Nurse Practitioner classes, I would have written a ten page paper just outlining the history questions I would have asked. I would have explored her diet including a diet recall of the last couple days. I would have asked about exactly what kind of exercise, how long, what intensity. We would have explored her social life, spirituality, culture, relationships, social supports, job, economic condition and her living conditions. I would have taken a complete medical history: surgeries, past problems, social history, family history, allergies, Then I would have explored all her presenting symptoms: duration, quality, intensity, alleviating and aggravating factors, and what she has already tried to help her symptoms.
Then I would have talked with the patient and asked her what her health goals were. We would have come up with mutual goals and I would have made a patient contract with her that outlines what she will do prior to seeing me again. And of course I would have some wonderful “reward” waiting for when she came back and had completed her goals. Using all that information, I would have come up with appropriate lab work and diagnostic testing.
It would have taken me about two days to design the “care plan” for my patient, get it typed up and sent to my professor. I would get it back in a couple days with red marks saying “you should have asked about her past sexual history and domestic abuse.”
So what happens now that I am in the “real world”? I ask a few questions like “are you having thoughts of hurting yourself or others?” I skim her medical record and say things like: “I see you missed your appointment for your pelvic ultrasound. Did you go to your counseling appointment with behavioral health?” Then I go through her medication list and take off the medications she has stopped taking.
Then I find myself saying those words I hate: “You will need to follow up with you primary care physician for the constipation and fatigue. I want you to go back to behavioral health and tell them that you are still feeling depressed and tell them you stopped taking your medications. I will schedule you to follow up with one of our MD’s after your pelvic ultrasound because I don’t do surgeries. You need to call your XYand Z providers who have given you your pain meds and ask them for refills, I won’t refill pain meds I haven’t prescribed.”
When I send her away, I can almost bet that she won’t follow up but will just find another provider to go to in a few more months. And I will be one of those long list of providers who have failed her.
I want to go back to school. And I want them to teach me how to help the complicated patients in the real world of managed care, overbooks and patients who are “non-compliant”.
2 comments:
You can't. Sometimes no one can. Sometimes people can only save themselves...and some won't.
wow I disagree with the tone of that comment above. I just clicked here because I was so moved by what you wrote.
Intentions do matter. a lot.
Even when we cannot make a difference, even a small kindness helps.
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