Friday, May 16, 2014

This just happened...

A real conversation with a medical professional:

MP:  "Hello, I'm your new Primary Care Nurse Practitioner, and I'll be standing in for Doctor Mogul.  What brings you here?"

Ann:  "I need refills of my Imitrex."

MP:  Looks down at sticky note on chart, "I'm supposed to talk to you about breast cancer. "  *flips through pages on the surprisingly thin chart*   "Um, let me see, breast cancer....breast cancer...oh, okay.  I see that you have Metastatic Breast Cancer.  How are you doing?"

Ann: "I'm doing okay, thanks."

MP: "Oh, okay, so you are stable or what?"

Ann: "Yep, I'm stable. The cancer is stable and has been for 9 months."

At this point, with her using the term stable, I figured she understood the situation.

MP:  "Did you have to do chemotherapy or radiation and how did that go?

Ann:  "Yes to both.  I'm still in treatment; it never ends when you have metastatic breast cancer."

MP:  "Oh, you are? Okay, good.  How are they monitoring you?  Are you having regular mammograms?"

Mammograms?  I am starting to rethink her understanding of my condition.

Ann:  "Well, um no, not mammograms.  I usually have a CT about every three months or so and a full-body PET every six, or when symptoms arise."

MP:  "Oh PET, oh okay, that's good.  You go see a cancer doctor regularly then?"

Ann:  "Yes, I go in for treatment every couple of weeks. Right now I'm just on Perjeta, Herceptin and Zometa."

MP:  "Alright, when was your last PAP?"

Ann:  *shrugs"

MP:  "When was your last visit to the gynecologist?"  She looks concerned. "Do you even have a gynecologist?"

Ann:  "No, I don't think I really need one."

MP:  "Oh, no,  you should have a PAP because it finds cancer cells early. If you want I can do a PAP right now."  She eagerly pats the exam table and looks at me, hope in her eyes.

Ann:  "Um, no thanks, I think they have found enough cancer cells. I mean, I do have metastatic cancer."  I now suspected she may not know what "metastatic" means in relation to breast cancer, and so I added, "You know, end-stage."

MP:  She spoke the words she wrote down out loud,  "Patient refuses PAP."

MP:  "Okay, colorectal health.  You haven't had a colonoscopy?  It's important to get a colonoscopy to find cancer early."

Ann:  "I've already found cancer. I get regular PETs which would find new cancer, I think. I don't need a colonoscopy to find more."

MP:  Clearly thinking I'm clueless, "No, everyone over the age of 50 should have one. It's very important for your long-term health.  A colonoscopy is where they take a lighted tube and check your colon for cancer...."

Long te...? Wait, my God, is she really going to explain what this procedure is to me?

Ann:  "I know what a colonoscopy is."

MP:  "Oh oh, okay you do. Good, good, then you know how important it is that you get one."  She sits, lab slip in hand, ready to write the order.

Ann:  "Let me ask you a question: If a person has metastatic breast cancer, is already undergoing cancer treatment and has been for the past five years, has regular PETs and CTs to monitor whether cancer has spread anywhere else in her body - why does she need a colonoscopy?  I already have end-stage cancer which I'm going to die from, so what would be the point of doing an invasive procedure like that to find more, and why do you think a PET isn't good enough?"

Like Hillary talking about Benghazi, I really wanted to know: "What difference, at this point, does it make?"

MP:  "Oh...oh...oh, I see.  Well, I'm sorry if I upset you or brought up negative thoughts."

Ann:  "..Sigh..."

Yes, my being upset is the problem here, not the fact that you are an early detection drone to the exclusion of all common sense.

You know what questions she didn't ask? Where my cancer spread.  She never asked me what chemos I'd been on.  She didn't even say, "Tell me the course of your breast cancer and what treatments you've done."  I'd have been happy to answer those questions and it might have made a difference in the discussion.

An accurate history seems important, even before common medical tests. Maybe if I had one small bone met that had been stable for a few years and was being treated by a hormonal drug, and didn't have all the PETs and scans and monitoring that I do, then some of these early detection screening tests such as a PAP wouldn't seem so off-kilter. But for me, with cancer in my liver and my abdomen inspected cell by cell on a regular basis, and, let's face it, having a pretty short lifespan, screening tests for new, early stage cancers seem completely unnecessary.

I might have pre-cancerous cells in my cervix?  So freaking what?

I expect my primary care doctor's office to either know these tests aren't necessary for me, or tell me why I'm wrong.  Why, when the house is burning down, is it important to turn the light off when you leave?

"Ask about breast cancer" on a sticky note is how the doctor guided her and that lady needed a lot more guiding than a single sticky note can provide.  She was so focused on the early detection line of thinking  that she was unable to change mental course when that was no longer a reasonable possibility.  She didn't ask the right questions, she spoke like I was ignorant, she didn't hear what I was telling her and at the end, she assumed I was upset by thoughts of my disease rather than the truth - her lack of insight.

Unfortunately, as more people need healthcare, more nurse practitioners are standing in for doctors, and talented as many may be,  they do not have the training or education that a doctor has.  Primary Care will soon be exactly like calling first line tech support, where you have to go through that required checklist no matter what you say the problem is.

"Hello tech support, I'm calling because my printer is smoking."

"First unplug the router, turn off your computer, plug in the router, turn your computer on...."

Based on the advice of this NP, a person less vested in the understanding of their own disease than I am and who is used to doing what medical people tell them would today be spread-eagle in the stirrups of an OB-GYN's office or worse,  butt-up, anesthetized, on the table of a GI doc.

Welcome to the future of medicine.

Turn the lights out before you leave.




28 comments:

  1. Oh my word! I cannot believe this- what a story! This part: "you are an early detection drone to the exclusion of all common sense." In so many areas people follow rules and protocol to the exclusion of common sense. Often common sense supercedes the need to follow the "rules". I am so sorry you had to go through that. Idiots.

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  2. I hope you get to ask for a different nurse practitioner? At least a different post-it note? Good lord. But as always, you managed to make a grueling experience quite funny.

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  3. Great analogy to first line tech support.

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  4. I think you should send her a copy of your blog post! Seriously she needs to get a clue.

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  5. Please ask for a different nurse practitioner and tell your primary care, his office staff, whoever you can get to listen, WHY!
    But, it was pretty funny.
    I had a lab tech once who was unsatisfied with the available veins who kept demanding I remove my lymphedema sleeve so she could try that arm. Maybe she and your nurse practioner are related.
    Elizabeth J.

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  6. I normally love NP's! I bet it was her inexperience that had her seeming so ignorant. I love this statement: "Why, when the house is burning down, is it important to turn the light off when you leave"! The next time an intern ask me how long it's been since I've had a breast exam, I'm going to answer with that! Best of luck to you!

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  7. Unfortunately, as more people need healthcare, more nurse practitioners are standing in for doctors, and talented as many may be, they do not have the training or education that a doctor has.

    This. You hit the nail on the head, Anne. Don't ever settle for a mid-level in place of a physician. Yes, you may run into physicians you don't like and have to look further, but every physician you encounter has had the background education and depth of training that a mid-level will never have.

    NPs and PAs are NOT physicians. They should not pretend to be. They do a wonderful job within the parameters of their education, but they are not sufficiently educated to be, and should not be, independent practitioners.

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  8. Hi Ann,

    Been reading your blog for a long time but this is my first time posting. This post really struck a cord with me.

    I am an RN training to be a Pediatric Nurse Practitioner and hoping to practice in oncology as an NP, as I have as an RN. I myself continue to struggle with the role of the NP and where it fits in the health care system. This story is extremely upsetting and I cringed thinking of that NP's poor judgment, insight and bedside manner.

    I as well wonder if NPs are adequately trained. They are clouted as a "cost saving measure" but if they are doing the same jobs as a physician (which many are) should they not get paid as one? Are NPs simply underpaid and undertrained physician wannabes? Interestingly enough, at least at my program, much of our training does come from physicians.

    But still, I hope that your bad experience has not soured you to all NPs. I went into this program with the best of intentions (because I loved being a nurse for kids with cancer and wanted to have a further role in their care) and I like to think that most RNs who pursue this path do as well. The skill of the nurse you have describes is embarrassing for a nurse let alone one with advanced skills.

    Thanks for sharing, you've given me lots to think about as I pursue this degree.

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    1. I would not say I'm soured on NPs. I have seen another in that same office who is compassionate and if he doesn't understand what metastatic breast cancer means, he hides it well.

      But I typically refuse to see PAs as doctors. I am okay with seeing them when I have no issues, when I only need a refill and insurance requires my body in the doctors office (as yesterday). I'll see them for follow up after I've had a doctor appointment and treatment, with no issues to report. If I have a problem to discuss or something I want diagnosed, nothing less than a doctor will do for me and I now request that when I make an appointment.

      I cannot tell you how to do your job but I think it is important that you make clear that you are not a doctor. Most patients are not like me, and many don't distinguish between the various jobs out there They see a white coat or stethoscope or scrubs and even if you say you are a PA, they will assume it's fancy word for another kind of doctor. I would explain your role.

      And as for pay, you don't have college, med school, residency, etc etc and no, you shouldn't be paid the same. They are likely taking the risk of what happens too. They are turning themselves into consultants but they are still the trained ones. A factory worker doesn't earn what a factory manager with a business degree does, even if the factory worker does the real work.

      Sadly, doctors are turning their practices into factories, with them as managers, and it's sad for them thinking any body can do what they can. Funny thing is I thought my PCP liked seeing patients - I started with him at the beginning of his career. But apparently, he prefers overseeing other people now. *shrug* If I still needed him for anything but refills that would bother me and I'd change practices but at this point, it is unimportant.

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    2. Hi Ann,

      I am a little confused by your response and perhaps you misunderstood my post. My point was that as an NP in training, I myself have confusion with where this role is going and what it's place is in the health care system. When I said: " Are NPs simply underpaid and undertrained physician wannabes?" I only meant that if NPs are expected to work the exact same as a doctor, then what is their purpose?? Is it ethical to make someone do the same work with less pay and less education?

      Regarding your comment about my role as an NP and not a doctor, I would NEVER lead a patient to believe that I am a physician. Part of my professional accountability is to ensure that the patient understands the limitation of my role. Yes, some patients get confused, but that is no different than them confusing me as an RN for a medical resident. Has happened many times before and I would never intentionally mislead a patient.

      As for education, becoming an NP IS a faster route than becoming an MD, I can't disagree with that. But it still requires a bachelors degree to become an RN, 2-3 years of work experience, and a Masters degree in nursing with an NP specialty. In fact, it is now becoming mandatory that nurses complete a doctorate to become an NP (doctor of nursing practice or DNP). As I said, much of our training does come from physicians. Does it leave us prepared in the same was as a physician who completed medical school, residency and fellowship? Absolutely not.

      But I'm pretty sure it's a pre-requisite, at least at my school, to know the definition of "metastatic."

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    3. I guess the whole profession is trying to figure out how this will shake out. But I'm sure you'll be good at it when you are employed. Hey, you are here reading the other side of things, that can only mean you care, right? :)

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  9. Thanks for writing this! I know my sister in law was distressed by questions on a form when she went for a follow up mammogram after having a breast remove.

    She was already scared that she may have new cancer in her remaining breast then to be asked difficult questions not pertaning to her situation was distressing. Maybe forms can be made for first time patients and other for those who have been diagnosed previously.

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  10. This incident had nothing to do with the training or education of the NP.... but it had everything to do with the idiocy of a supposedly highly trained & highly educated physician leaving a STUPID note on a Stage IV cancer patient's chart that merely reads "Ask about breast cancer". What an ass.... as most physicians are! A patient as yourself, Ann, whose history is 10 miles long, can't expect any NP to be up-to-speed on your entire condition in the 15 seconds she's standing outside your exam room door, thumbing through your chart before walking in. If I would have been the NP, I would have simply said: "Your physician has a note here, requesting I ask you about your breast cancer. What is the update you would like me to tell him?" And that would have been the end of it. She was trying to be thorough & it sounds like she zigged where she should have zagged. I think the first mistake she made was agreeing to working as a NP for your idiot physician to begin with!

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    1. I cannot agree with this at all. Maybe the note was stupid, but she searched my chart, found that I had "metastatic breast cancer" and proceeded along behaving like it was early stage. She didn't understand what the term metastatic meant, plain and simple.

      I wouldn't expect any physician or anybody to be up on my condition - my file is as long as a Michener book. But I do expect anybody who is in place of a doctor to know what metastatic breast cancer means, and apparently, that's what my doctor expected too.

      And, your question would have left me puzzled. What update would I like to tell him? I don't really have updates for him, he doesn't treat me for cancer, I am there to get my headache meds. The update about how the SBRT is working, the update about the next PET I'm scheduled for, the update about what chemo I'll do next, the update about my new pain...what? I told her my current treatment....and it flew by her like I was speaking Spanish. I probably would have countered with, "Well, what do you want to know?" Which wouldn't have worked because SHE DIDN'T KNOW WHAT METASTATIC BREAST CANCER MEANT.

      If she did, the very first question would have been, "Where did it spread?" As a million "idiot" doctors have asked me on hearing the news.

      Sorry, the only idiot here was the NP. I stand by that.

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    2. "A patient as yourself, Ann, whose history is 10 miles long, can't expect any NP to be up-to-speed on your entire condition in the 15 seconds she's standing outside your exam room door, thumbing through your chart before walking in. "

      What????? Let me tell you something, I do expect an NP, an RN or a MD to spend more than 15 seconds thumbing through my chart. If you don't want to take the time to do your job properly, get out of healthcare. You could kill somebody because you don't read the chart.

      Ann, your posts often produce a reaction in me. This time it's anger. What an absurd experience you had.

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    3. And, if it's true that this NP really doesn't know what metastatic breast cancer means, then how in the world did she ever graduate?

      I think most likely she has a script in her head about breast cancer and couldn't deviate from it because she didn't know what to say because she doesn't have a script for anything other than "awareness"

      Either way, this is extremely scary.

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  11. Welcome to 'It's all about the money' Healthcare! It has worked to catch up with the rest of society.

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  12. She is a clueless twit. Call your PCPs office and tell the doctor his np needs a bit more training....

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  13. I agree with the suggestions to tell the MD and the office manager about your experience with this NP. What an idiot. I'm so sorry you had that happen-- that would shake me up badly!

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  14. Oh My God Ann, I simply cannot believe the insensitivity and rudeness of the NP. At the very least, she should have been focused in on what you had to say. I'm so sorry. I actually had to threaten a Physicians Assistant with the Medical Board because she informed me I was clearly uneducated and ridiculous in asking what she considered to be invasive questions about my mother's care. I exploded all over her with a great deal of energy and I think she wet her pants, which gave me a little satisfaction. I'm so amazed at how you kept your calm. I might have gone for a primal scream!

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  15. Seriously clueless. It sounds like she didn't learn anything from your encounter so someone needs to educate her. Sometimes the script does not freaking apply! "currently under the care of an oncologist" and "every three weeks" should have been big freaking clues. And It sounds like getting stuck in the script completely derailed her from finding out what that office *could* have helped with. What was the appointment for?

    And yeah I've seen two absolutely wonderful NP's , people who were up on their medicine and very good listeners. There are some great ones out there but clearly you got a dud!

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  16. This is really sad, but it's reality. Although there are many good doctors out there, the money matters a lot in any industry and that kind of changes the quality of service that we receive from these doctors.

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  17. OMG! What an airhead. The future of healthcare is quite frightening

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  18. This seems to me, and I hope it is, like an anomaly. The NPs I've seen we're highly trained, had doctorate degrees, etc. I also have to disagree with the person above who said most physicians are idiots. If that's her impression, she must not have chosen her health care providers very carefully.

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  19. Here is what also probably happened. Doctors and clinics are now being tracked on how often they have certain tests performed and this is now being reported not only to insurance co's and the govt but to the public.. Their compensation is tied to it as well.

    She was trying to check off a box that you clearly should have been exempt from. I am so sorry that happened to you and so glad that you were aware enough to be able to say no.. and hopefully based on your feed-back another women won't go through the same experience.

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    1. oops left off my twitter name @cascadia

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  20. Scary…yes I too have encountered idiocy in the medical world that is suppose to be saving my life!!

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  21. I think you your hunch was right - she didn't understand the term "metastatic" but didn't want to admit it.

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