Last year, still new on the job as a nurse practitioner, I had a phone conversation with a patient's husband I will never forget.
He said, "This CT scan will cost us $730 out of pocket. My wife is feeling better after the shots you gave her. Are you SURE we need to do this today?"
I looked around desperately for someone to tell me what to do. No one did. Had this room always been so Hot?
I tried to sound confident. "Based on her lab results, I really do think she should have the scan done. I think there's a good chance she might have appendicitis."
Truthfully, I had never seen a patient with appendicitis before. She might be my first, and $730 were hanging over my head.
No one warned me about this kind of thing in school--the pressure of trying to keep costs down while also trying to keep my patients alive.
She had appendicitis.
Exactly one week later, I had the opposite conversation with a patient. He had similar pain but looked much less sick than appendicitis lady, and his labs were perfectly normal. I consulted with another doctor, and then told him he probably didn't need to do the CT scan (he also had a high-deductible plan and faced high costs for it).
"I'm already at the hospital and prepped. The pain is worse. If it's OK, I'd like to go ahead and have the scan done."
He had appendicitis too.
Thank GOODNESS he followed his instincts instead of mine.
Sometimes my job freaks me out.
One thing that is difficult for a new healthcare provider is to find the balance between thinking every patient is on the brink of death and thinking everyone is perfectly fine.
Most people with abdominal pain don't have appendicitis, most kids with coughs don't even need antibiotics, more sore throats are not strep throat than are, and most chest pain is not a heart attack.
BUT some chest pain IS a heart attack, and truthfully the only way to know (depending on symptoms), is to run the appropriate tests.
I've only seen one patient having a heart attack so far, surprisingly (out of a dozen or so that I've sent to the ER to be checked), and it wasn't the guy that showed up with crushing chest pain that radiated down his left arm, who looked sweaty and a little out of breath.
No, it was the lady that showed up with one complaint: excess burping. I'm serious.
Sometimes my job FREAKS ME OUT.
Although the majority of what I see is upper respiratory illnesses (sinus infections, coughs, ear infections, and sore throats), I'm often surprised at the variety of what comes through the door.
I have told 2 girls they were pregnant.
I diagnosed someone with type 1 diabetes.
I have pulled an ear bud out of someone's ear, a popcorn kernel from a toddler's nose, and sticks too large to be called splinters from arms and feet.
I have seen quite a variety of broken bones, treated migraines, backaches, stomach aches, rashes, pink eye, burns, eye injuries, abscesses, STDs, and on and on and on.
I have sutured eyebrows and shins, chins and fingers, knees and bottoms of feet. Sometimes I suture under perfect textbook circumstances, and sometimes I just really wish someone else would come in and rescue me from my job. The most miserable I've ever been at work was suturing the bottom of a toddler's foot while his dad held him. It was a bad angle to work from, he kept kicking his leg, and I bent 3 needles trying to get that thick skin pulled together. Zero fun. Maybe negative fun.
Some of my interactions with patients are funny. Like the time a fully-grown, obviously athletic man was terrified of getting swabbed for strep throat. ("How far back do you have to put that thing?") Every time I came near him with my swab he dodged me. I told him to hold still. "I'm trying!...Please don't tell the nurses out there about this..."
Some of my interactions are heart-warming. Kids that are SO excited if I let them listen with my stethoscope, or that try to comfort their siblings when sick or scared. Grandparents that light up when I ask about their grandkids. Patients that come in terrified of a procedure that leave saying, "That wasn't so bad."
There have been diagnostic wins, such as finding whooping cough or mono, suspecting aspiration pneumonia or urosepsis and being right about it, or basically any time I figure out what someone's rash is.
There have also been diagnostic FAILS, which are inevitable but discouraging. I have sent patients to the ER thinking they had something serious going on which turned out to be something minor. Something I could have treated, saving them an ER visit. Sometimes I think someone has appendicitis and they don't. Sometimes I treat people for an illness and they don't get better.
Sometimes I just have NO IDEA WHAT'S WRONG. This is just as discouraging for me as it is for my patients.
Sometimes I go to bed at night worried about patients I've seen that day. I question whether or not I did enough for them. Sometimes they even find their way into my prayers. Inevitably the kids are the ones I worry about the most. I recognize the look of worry on their parents' faces as the same look on MY face when MY kids are sick, even with all my training.
More than a year and a half into this business, the misdiagnoses and treatment failures remain deeply disheartening, but I've also learned that they continue to happen even to seasoned providers. Turns out none of us will ever know everything. But we all keep learning. All the same, I'm sure the wonderful, truly kind doctors I work with tire of my incessant, "rookie" questions.
But at least they're less incessant than they used to be.
I'm making progress.