In Practice: Reflections from NPs and PAs

Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.

I consider myself a fan of sports in general, but of baseball in particular.  I grew up in a small town near Cape Cod, and I had no chance of escaping a fervent love for America’s pastime.  My sister was the only girl on her T-ball team, my dad played church softball, and being born in Massachusetts, I watched endless Red Sox games from a tender age (I had no choice, really; there was only one TV in the Donahue household). To top it all off, we became a host family for college baseball talent playing in the Cape Cod Baseball League when I was about five, ensuring a seasonal parade of older brothers to teach me the rules of baseball over the course of my childhood summers.

One of the first and most basic of the rules was that each batter gets three strikes before their turn at bat is up.  Recently, I’ve started to notice a trend in patient care that has left me to wonder — can I get more than one pitch in this game before I’m sent back to the dugout?

Everyone in healthcare is aware we are in the thick of flu season. Four months ago, we started sending emails and posting signs in practices asking patients to remember to get vaccinated, reminding them that they were protecting not only their own health but also that of the more vulnerable patients, family members, or coworkers around them.  And yet, one after another, patients in the office have patently refused the vaccine from the first mention — citing an experience of developing an illness after their last flu vaccine.  It may have been last year or ten years ago.  It may have been a headache, a fever, a runny nose, vomiting, diarrhea (some symptoms not even associated with the flu!) or a combination of complaints.  Despite all of the data, knowledge, and discussion I can present — the flu vaccine has no live ingredients! the timing was probably a coincidence! a real allergic reaction looks radically different from this! — I might as well have started the game on the disabled list.  The vaccine’s only gotten one strike, and I’m out.

A few weeks ago, I was out to dinner with a close friend and her mother, both of whom I’ve known for years.  My friend’s father had a sudden, serious illness requiring hospitalization a few years prior — long story short, it was complicated, involving multiple sequelae and considerations for his future treatment.  When seeing a physician assistant in the emergency room following his acute illness, my friend’s mother questioned whether or not the treatment recommendation was the best choice for her husband’s care.  The attending whose second opinion she sought agreed that the treatment may be detrimental and chose to implement another option.  After sharing this with me at dinner, she expressed her fear of dealing with anyone but attending physicians going forward.  I didn’t say anything at the time, empathizing with her, understanding that managing family illness is difficult and scary.  But underneath I was thinking, don’t throw the baby out with the bathwater here, there are providers who aren’t attendings who can provide excellent care.  One of them may even be that particular PA who simply did not have all of the information to make the best choice at that particular juncture.  A coach doesn’t bench a player after one bad at bat, and batters typically perform better as they learn more about the pitcher, or in this case, the patient.

Of course, as a provider, I realize there are many times where the first strike is all you have — surgery comes to mind.  I also understand that one of these things is just a game, and the other is very much real life.  But in healthcare, thousands of decisions are debated, communicated, and implemented every day, and not every one of them is high-stakes.  When we’ve swung at a single bad pitch, we may still deserve our full at bat.  In order to convince patients, I think we need to point to evidence and invest time to establish trusting relationships — raising our “stats” in their eyes and hopefully showing them that we’ve still got a home run left in us.