08/24/10 Family Medicine

Today was the first day I was able to shadow a PA. The PA I shadowed has been in the field for many years and at her current office between 5 and 10 years. She started out with a BS in Chemistry and then worked as an oncology tech along with working in a laboratory. She works as a PA directly underneath a physician who specializes in geriatrics. There are other MDs and mid-level providers in the office, however, and she can end up seeing anyone’s patients at any time for any reason.

Most of this morning’s patients were follow-up patients. Two were acute add-ons. Many of the patients see her regularly, but at least one was seeing her because she was the first provider available.

I knew the PA from previous working experience, so we were able to dispense with the introductions and get right to the job at hand. The first thing she showed me was the electronic medical record (EMR) upon which she had two charts open for patients she had seen the previous day. She reminded me that, though the patient leaves the office with his/her plan of care, the documentation isn’t finished quite as quickly. Some of the documentation is done in the room while talking to the patient, at least enough to remind you when you sit down to finish the chart later. The rest of the documentation is often done during lunch, after the last patient of the day, or the next morning.

She told me that a provider trains his/her mind to remember what happened in the visit when it is time to finish documentation.

She had her schedule printed out before the day began and gave it a cursory glance to see what the day’s patients were coming in for. She could then look up past visits, if necessary, to remind her of the patient’s history and where she had left off with them. For the most part, when she entered the room with the patient, she was able to let the patient know that she remembered the last visit and what direction they were heading in.

I noticed that the patients really trusted the PA and wanted to know her opinions about everything related to their healthcare. One patient was schedule to see two MD specialists, but wanted to come back and see the PA to get her opinion on the matter before following the specialists’ advice. Another patient kept expressing her anxiety and stress due to her work situation. This patient seemed to want to talk about that a little more than she was able to during the office visit. The advice of the PA was important to both of these patients.

A 16 year old patient came in with a rash that her mother thought may be an allergic reaction to antibiotics she was taking. As the facts were investigated, it was found that the patient had been on the same antibiotic relatively recently with no side effects, plus the rash didn’t fit the typical allergic skin reaction pattern. She had, however, been swimming multiple days in the row, reusing the same damp swimsuit. In the end, the PA didn’t unnecessarily diagnose the patient with an allergy to a medication she may need in the future when there wasn’t conclusive evidence to do so.

Another of the acute patients was someone that I thought could have been treated over the phone if the PA had known the extent of the problems at the time. The patient had been seen for a similar problem in the past, had somewhat of a history actually. The patient had all the medications prescribed to her earlier in the year for a skin irritation but hadn’t needed to use the entire prescription. The patient didn’t have a new problem or need a new treatment plan, but just needed confirmation from a provider that it was OK to use the medication for what seemed to her to be a different incident. The PA was able to recognize the symptoms from earlier visits and recognize the medications from the EMR and assure the patient that it was appropriate to use them.

The last patient of the day told me she liked the PA because the PA was thorough. Right away, the PA started asking questions that didn’t seem to have to do with the chief complaints at hand. Through further probing, it was found that the chest discomfort and weakness the 38 year old patient was feeling was probably due to a new onset of hyperthyroid rather than any kind of cardiac problem, which she had been worried about. That patient had been good natured and making jokes, but deep down she was worried that her unhealthy lifestyle might be catching up to her. The PA was able to calm the fears significantly before the patient left.

I noticed that for every medical decision the PA made, there was another consideration that had to be followed up. For instance, when prescribing one medication to a patient, the PA then had to make sure to follow up with blood work afterward to check the liver. She also had to follow up with the prescription to make sure it didn’t cause a cough, which is the most common side-effect. No medical decision is an island. Medicine is an interconnected discipline and has to be practiced in that manner. That is often a challenge for an urgent care or emergency facility treating a patient they don’t know. The patient can be on other medications, have other allergies, and have other diagnoses that are going to affect medical decision making, however the provider doesn’t always have access to this information. In this regard, family medicine can be a little harder – you have to keep up with the patient’s entire medical history – but also a little easier because you have the medical history available when making decisions.

I realized a couple things from the experience I had today that I hadn’t thought of before. First, family medicine gives you a wide range of patient care opportunities. I like the thought of a challenge, as in the situations that present in an emergency department when someone’s life has to be saved and you might not know that much about the life before having to save it. Family medicine hints at this challenge with acute visits in a multi-provider practice. A patient you are unfamiliar with comes in to be seen for a problem you haven’t been following.

On the other hand, I like the thought of following up with the patient and seeing where my medical decisions brought them. Is the patient better off in the long run because of how I handled his/her care? Am I able to make the slight alterations in the care plan in each successive visit that ultimately lead to a healthy, enjoyable life for my patient?

Secondly, I was told that a provider trains his/her mind to remember what happened in the visit when it is time to finish documentation. I believe I would have the ability to see a patient at one point and document the visit later if necessary. Even now, hours after I have left the office, I can remember what the patients were seen for and how the PA treated them. Beyond the chief complaint and main reason for the visit, I remember many of the secondary diagnoses and other medications the patients were on that we saw today.

There were also some things from my shadowing experience today that I have further questions about. First, I understand the wisdom of looking at the schedule to know what to expect during your workday, however I wonder about planning the encounter before entering the room and the prejudices that come with it. From what I experienced the facts the patient gives, as they give them, influence the provider, but assumptions the provider researches before the visit can influence medical decision making before even talking to the patient. The patterns we see in healthcare can become ruts if we think that every patient with problem X can be treated the same or every patient with insurance Y abuses the system. It seems like it might be wise to mentally prepare oneself but be open-minded enough to not miss anything out of the ordinary.

Also, I think it is important for a PA, or any practitioner, to know the EMR well enough to be able to glean all the useful information from it. Healthcare may have been around a lot longer than the computer, but the computer can help in so many ways…if you know how to use it. Knowing how to access all the documents you want, and need, is key.

Lastly I’m concerned that some of the repetitiveness of the job might cause a provider to not fully listen to everything the patient is saying…and suggesting. I’d like to think that a PA is following up with a patient’s explicit and implicit anxieties instead of just focusing on prescribing a medication. There is an enormous link between a person’s mental well being and his/her physical well being, and that link works in both directions. If one is down, it can bring the other down. If one is up, it can bolster the other. Hopefully the practitioners of medicine aren’t just skimming the words coming out of the patient’s mouth for key terms and phrases, but are truly listening and taking into account everything the patient communicates to them. From just one morning in a family medicine office, one morning of listening to patients talking to a PA, I believe in a holistic approach to practicing medicine. This entire body of ours is inter-connected and it seems like it should be treated appropriately.

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