I felt like Dr. House in clinic today. Bear with me.

[3catwoman3]

11. Being a primary health care provider...

...provider is like the box of chocolates from the Forest Gump movie - when you walk into an exam room, you never know what you are going to get.

I work in a private pediatric practice, as the only nurse practitioner among 9 docs. We see patients from birth thru college, which requires quite a broad knowledge base. Happily for us, unlike your situation, Aristus, we seldom have patients at risk of dying. Those who are in those sad circumstances are generally under the care of subspecialists for a hematology-oncology diagnosis or degenerative neuro disorder

That said, we do see quite a number of patients with multiple concerns - some real, some imagined, some simple, some complex. Visits are scheduled every 20 minutes, which is adequate for a straight forward problem like an earache or sore throat. I cannot begin to count the number of times an appointment will be made for something that sounds simple when you see the stated reason on the schedule, only to walk in and find that the parent/patient has thought of at least 3 other "issues," usually presented with the, "By the way, as long as we're here..." phrase. Or, they make an appointment for one child, and then ask if you would please take a "quick peek" at the 2 siblings they brought along, hoping you will do it for free. "It'll only take a second." Nothing only takes a second, if you are going to do it well.

Just yesterday afternoon, I went in to see a 17 yr old girl, whose mom had made an appointment for the stated reason of 'cold symptoms.' The young lady was 17, and by herself, with mom planning to show up a bit later. The patient got there late. I walked in, and was presented with the following list entitles "my issues":

1. losing hair
2. losing weight
3. sore throat
4. diaphragm hurts when she takes a deep breath
5. IT band problem for a few months
6. 2 episodes of numbness and tingling in her legs
7. elbow sensitivity
8. long term problem with a knee that required surgery a while back - no record from her orthopedist
9. nausea for over a year
10. lump in right breast
11. lump in left armpit
12. often feels cold

WTF!!! The alleged cold symptoms weren't even on her list.

With that many problems, you can't even take a decent history in 20 minutes, let alone perform a decent exam and devise a plan. No freaking way. We dealt with problems 1, 2, 10, 11 and 12 with orders for thyroid levels, and ultrasounds of the lumps, both of which were small and and had classic benign characteristics. She already had an appointment scheduled in 2 weeks with a chiropractor for the knee problem. I suggested she also tell that person about the elbow, IT band and numbness concerns, and offered her the contact information for our favorite orthopedic specialist should she not be satisfied with the chiropractor. Her GI complaints were evaluated quite thoroughly by one of my colleagues last summer. Probably time for her to go to a GI specialist.

I probably spent at least 40 minutes with her. For some mysterious reason, this type of patient usually has an appointment late on a Friday afternoon, when we are often running behind because that is just how things go on Fridays in a pediatric office - everybody want to come in on Friday to get something their kid has had all week fixed right now, because there is a game/party/ dance performance/ family gathering, etc on Saturday.

Once I got home, I spent about an hour documenting this encounter in the electronic medical record. I find EMRs very cumbersome and time consuming - it takes at least as long to document what I do as it does to do what I do, and I routinely take home 1-2 hours of record keeping at the end of what can be 9-10 hours at the office. I still, for the most part, enjoy the interactions with families, and the challenge of helping parents learn what they need to know to take safe and confident care of their children, but I thoroughly detest the electronic documentation and how it has changed how we do our jobs - more secretary than clinician much of the time.

I have been a nurse practitioner for almost 40 years. I used to think I would dread retirement. Since the advent of EMR, I am now looking forward to it.