As you are going through your Physician Assistant program you get inundated with this huge amount of info. Every minute of every class is jam-packed with information that you will be expected to know when you graduate. Not just so you can pass a certification exam, but so you don’t kill somebody when you finally start working as a full-fledged Physician Assistant. At some point in time when all this knowledge is being packed into that head of yours, you are going to wonder; “Will I remember all this? Will it all stick?” Hell, you might even be so brazen to ask your professors those very same questions. (I did.) I asked my professors, fellow students, preceptors, my wide, the school librarian, my parents, and anybody else I thought might give me some glimmer of hope that all this stuff I was learning was not just flying out as fast as it was being flown in. As it turns out the answer I received from everyone was essentially the same. “Trust yourself, when the time comes the information you need will be there for you.” I swear it felt like I was asking Master Yoda about this. I mean what is this “trust yourself” crap. C’mon people, I turned to you for advice about a very serious concern I have over my ability to consume, digest, process, and then regurgitate enormous amounts of information that will become essential to my ability to keep someone alive and you give me this sh!+ about “Trust yourself, it will be there for you”. What kind of half a$$ answer is that?
Well, as it turns out, it is the right kind of half a$$ answer. These people weren’t just feeding me some Freudian BS to make me feel better. They were actually right, for the most part anyway. As you get out in the real world and start working on your own, it’s amazing how things you spent time studied just come out when you need it. I am always a little surprised when I recall some arcane bit of knowledge about a problem or drug just when I need it. (Proof that I am not as thick headed as some of my high school teachers asserted. Stuff does stick in there. Kiss my A$$ Mrs. Glaze.) Sorry about that, got carried away.
As I was saying, the folks that I was grilling about my questionable memory prowess were only partially right. The information you need to perform well as a Physician Assistant is tucked away all nice and neat in your head, and it will be retrievable most of the time when you need it. Yes, I said most of the time. I am sorry to be the one to break this to you, but at some time in your career you are going to either not remember something that you damn well know you should be remembering or just not know what the hell is going on with a patient. It happens, believe me; it happens. The question is, how are you going to deal with it? You are sitting in the room with a patient working up some old lady’s sore throat and she breaks out with “How does my Sjogren’s syndrome affect the enamel of my teeth when I drink too much orange Kool-Aid and the temperature is below 72 °F during a full moon after swimming all day in public pool?”
WTF!!! HOLY SH!+, IS THIS PATIENT F’N SERIOUS?
Answer; yes, they are serious. So what do you do? How do you deal with this patient’s question? Well, if you are really good you will tell them that the enamel on the teeth will only be affected by Sjogren’s when drinking grape Kool-Aid and the temperature is above 72 °F during a half moon and swimming in a private pool. (OK, I made that up). The point is that this patient is expecting an answer to the question and you are not going to have a clue how to give them one. How to deal with the scenario of “not knowing” will not be covered in school. Why should it, your school is extremely confident they taught you everything there is to know about being a Physician Assistant. (FAT CHANCE OF THAT!)
So, back to the patient with Sjogrens. What do you do? How to you give her an answer that does not make you seem like an incompetent baboon in a lab coat? To be fair, this particular patient’s question would be extremely difficult to answer since I made it up and I wanted it to be off the wall to illustrate the point that these kinds of patients with these types of questions will show up in your office.
Generally I like to be as honest as possible with my patients about my skill set and areas of medicine that I am more proficient in. I want my patients to understand that I am more interested in their health than trying to be the “Big Shot” Physician Assistant. If I truly have no clue what they are talking about, I will tell them that “I don’t know” what is going on. I make sure to address the fact that they are concerned about the problem they are having, no matter how crazy it may sound to me. Then I work hard to find them a specialist that can better help them with that particular problem. (More often than not, this includes Psych)
There are times when I just don’t want to throw in the towel and tell the patient “I don’t know.” These circumstances are extremely situational and a bit rare for me. Not because I know everything about everything, but because (as I said earlier) I tend to be quite honest with my patients about what limitations I have as a health care provider. I have expended a lot of time and energy developing a solid relationship with my patients and I don’t want to jeopardize that relationship by trying to pretend to be something I am not or pretending to know something I do not.
One situation that comes up occasionally that will cause me to want to buy some time before I admit to “not knowing” is when the patient just does not make any sense. Not that I can’t comprehend what they are saying or that they don’t speak English, but not making sense in the clinical realm. The complaints, symptoms, and exam just don’t fit together the way that I would expect.
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I had this patient not too long ago that came in because she was getting cold (common problem for the ladies). Ok, no problem. Review of her medical history is unremarkable. So I go in and start talking to her about the situation and was stunned by what she had to say. I have only laughed out loud twice in a room at a patient during my career as a Physician Assistant and this was one of them. She stated that she was getting cold hands and cold feet several times a month. These episodes would last anywhere from 30 minutes to 2 hours. When I asked her if she has noticed any particular pattern in these feelings of having cold hands and cold feet she said yes. (good, time to get to the bottom of this mess) She said that the feelings come every time she goes to Wal-Marts. (Yes, I do know Wal-Mart does not have an “s” at the end. This patient apparently did not.) I was a little confused by this and asked her exactly what it was about Wal-Marts that made her have cold sensations in the hands and feet. She informed me that every time she went to Wal-Marts and walked by the frozen section she would get cold. I am not joking at all when I tell you that I was frozen in my tracks. (Enjoy the pun) I just stared at the lady for what seemed like 15 minutes. I asked her, just to make sure I understood correctly, “So you get cold hands and feet every time you go to Wal-Marts and you walk by the frozen section?” She said “Yes.” (Please notice that I have not laughed at her yet.) She further explained that if she avoids the frozen section, she will not get cold. Up to this point in time in the visit, I am still with the lady. It makes perfect sense to me that walking by the frozen foods section of the grocery store can make people cold. So I decide to just roll with it. I suggested that she keep a sweater in her car to put on when she needs to go to the frozen section of the grocery store. She then informed me that it had nothing to do with the frozen section; it was Wal-Marts that made her cold. She could go to Kroger, Skaggs, Target, Tom Thumb, or any other store and never have the problem. Only when she went to Wal-Marts frozen section did she get cold hands and feet. (Not laughing yet.) To clarify I asked her, “So you are getting cold only at Wal-Marts when you are in the frozen section of the grocery store?” Her reply, “Oh no. Not in the store. I get cold at the house.” (What kind of sh!+ has this lady been smoking?) Me, “So you do not get cold hands and feet from Wal-Marts frozen section?” Her, “Oh, it is from Wal-Marts alright. Just that I get cold after I get home from there. My hands and feet get real, real, real cold after I come home from shopping at Wal-Marts. Exactly 2 hours after I leave the frozen section my hands and feet get all cold and tingly.” Me, “Are you saying that this only happens 2 hours after you leave Wal-Marts? And only if you go to the frozen section?” Her response, “Yes.” (Please note the excellent control of emotions and calm demeanor I maintained during this exchange because up to this point I have NOT LAUGHED YET!)
This is the type of situation I am talking about when I tell you a patient does not make sense. Like I said, I understand the words; it just does not make any clinical sense. So what would you do with a lady like this? (Outside of hoping she wins a Darwin award) What would you do to try and help her? Is there any help for her? When faced with a patient like this I have the ultimate tool to both buy some time an make sure you look good to the patient. Please take some time to get your pen and paper so you can write this down. I will wait for you to get them.
Okay, got the pen and paper?
The definitive thing to do when you are just not sure what the hell else to do is a two-step process.
Step one: Run labs. That’s right, run some f’n labs. Run as many labs as you can think of. I’m talking CBC, CMP, lipid panel, UA, TSH, hormone panel, EKG, Cortisol, Prolactin, and anything else you like.
Step two: (this is the most important step) Pray! That’s right, pray. Pray to Jesus, Buddha, Krishna, Allah, or whatever deity is your personal favorite. After hitting the favorite, send prayers out to the others just to be safe. Pray as much as you can that something, anything, will be wrong with the labs. It could be slightly elevated creatinine kinase, B-12 complex a little low, lipids a bit elevated, protein in the urine. Just anything.
It is very rare for me to not find something “abnormal” in labs on just about every patient in my clinic. Most often these findings are not truly significant clinically; they are simple ancillary findings of no real value. However, with a patient like the one I described above, it can be just the ticket you need to find something, anything, wrong. I’m not saying it is the right thing to do. Running all these labs then hope and pray that something pops up that you can pin the patient’s problems on, I’m just saying that it’s done.
Oh, I forgot to tell you what the patient did that eventually made me laugh in her face. (I truly felt bad about that.) She was explaining in detail her condition with the cold hands and feet. I advised her that we should run a complete set of labs. (Step one.) She was actually not interested in having any lab-work done or having any particular type of treatment. This got me even more confused than I already was. What she said next made me laugh like crazy bad. The kind of laugh you get when you replay a video of your kids doing something really funny. I mean eyes watering laugh. She told me that she did not need any treatment. She was just there to get some documentation about her problem. (Wait for it) “Documentation? What kind of documentation?” She wanted me to fill out some paperwork. (Almost there) “Paperwork?” Yea, paperwork so that she could file for states assistance. “I don’t follow you. What kind of states assistance?” She needed the forms completed so she could apply to have states assistance for home care needs. She wanted me to say (Here it comes) she had a medical condition so that she could get a home health aide to do her grocery shopping for her. (AHHH, HA! HAHAHAHA! HOHAHOHA! HAHAHAHAHA! Literally LOL.) Can you believe the balls on this lady? She wanted me to sign off on this crap. No f’n way. I was calm, except for the laughing. She actually asked me while I was laughing, “So, can you do it?” Short answer, “HELL NO!”
I’m not saying you will ever run into a patient like this one, but I guarantee you that at some time in your career you will run into a situation that you are just not sure about. As long as it is safe and not going to cause harm to your patient, you can always run labs to hopefully find an organic cause of the problem. Labs will almost always have some “abnormals”. The question is can those “abnormals” be used to explain your patient’s problems. I know we “don’t treat labs, we treat people.” In a case like this treating the labs is treating the people. Labs in this situation are like the hail mary of football plays. Just toss something up high and far, hoping to come up with some points on the score board.