April 14th, 2017
Is There an NP on Board?
It was a moment I’d anticipated for nearly 7 years — not with excitement, but with dread. Two weeks ago, I boarded a plane, having won the lottery known as the standby list. Due to heavy wind, all flights were departing from a single runway and because of delays, the airline had thrown in a complimentary cocktail. Things seemed to be going smoothly. Then just before starting our descent, a female passenger fainted onto the floor of the aisle next to my seat.
As I jumped up to help, I had a few thoughts:
- Thank God I only had one drink.
- I’m on vacation – but here’s one more patient literally dropped at my feet.
- Oh shoot – it’s actually happening.
You see, I’ve had anxiety about just such a situation since 2006. One time, I was flying to a meeting in California with three outstanding physician colleagues when the pilot asked for medical assistance. They handled the emergency beautifully, of course. Since then, I’ve thought about my lack of emergency experience whenever I’m on a plane. Multiple times I’ve joked that if a fellow passenger is in need of diabetes education or has strep throat or any number of primary care complaints, I’ve got this under control. But a medical emergency at 30,000 feet? What could I contribute?
Turns out, more than I thought. First of all, my training of nearly a decade allowed me to remain calm and focused. My daily work and my international aid experience reinforced an ability to complete an assessment using the tools I have at my disposal, thereby garnering a lot of information. And the ability to quickly develop a differential diagnosis came in more handy than I ever thought it would – thanks to my teachers and preceptors! As medical emergencies go, this one was mild. It seemed a case of vasovagal syncope – the patient didn’t have a head injury and was awake within seconds. She had a pulse, a normal neuro exam (thanks to the makers of the iPhone for that flashlight), and appeared a reliable historian who knew her medical history. Not to mention, we were close to our destination and on the ground in no time.
After the adrenaline slowed, I started unpacking the experience and reflected on how it felt. The flight attendants were great teammates – getting what I needed almost as soon as I asked. And the patient behaved the same way – responsive and grateful, without questioning my decisions or experience. I was in charge completely even though I was doubting myself. Why did this feel different from my daily work?
As a nurse practitioner, I’m used to defending my practice. I explain my role to patients, which I am happy to do – some don’t know what an NP does; some have never seen one before. I consider it an opportunity for education and discussion. I’ve also had patients question an evidence-based plan of care, wondering if my credentials equipped me to make the decision alone or if we needed to check in with a physician. Again, I don’t take this personally – I can see it as a place to better understand a patient’s concern or a chance to explain something more clearly. Other conversations are less pleasant; one patient’s family member recently accused me of wearing my badge flipped over to hide my status as a non-physician and asked for a doctor, though he had confirmed the appointment with an NP earlier that day. This, also, I can understand – patients simply want what is best or most comfortable, while they may feel unwell, stressed or scared. I can empathize and do my best to reassure them. I can also involve physician colleagues for reassurance and often do.
What has been more troubling to me is observing similar reactions from healthcare colleagues. Last year, a physician testified before the Massachusetts legislature that nurse practitioners “aren’t even trained to diagnose ear infections” – an allegation without basis in reality. Physicians within my hospital have asked to speak to a doctor in my office about a patient of mine – either not understanding that an NP could be the primary care provider, or that speaking to the provider who had actually delivered the care would be best for the patient (even if they didn’t have the “better” credentials). Several physicians have weighed in on blogs here at In Practice with sharp comments like, and forgive me for paraphrasing, “PAs don’t practice medicine” or “everyone wants to be a doctor with only 6 years of college.” In fact, we are practicing and my graduate degree (much like yours) is simply not equal to a few extra years of “college.”
I have worked collegially with physicians across my career. I am educated on my role and scope of practice, and I don’t hope to practice outside of my license. Nor do I have any illusions that I can know everything or will never need help. I am aware of my strengths and I work collaboratively with physicians and other colleagues as needed. I have often seen that this is a two-way street. An intelligent and well-respected physician colleague often asks me questions about women’s health, in which she had minimal training and I have more experience as a family medicine practitioner.
I wonder; if there had been a doctor on that plane, would my skills or contribution have been questioned? What if that doctor was one with minimal experience in the chief complaint – say, a psychiatrist or an orthopedist? Would there have been a recognition that although I have different letters after my name, I may have been better suited to care for this patient? If there had been an EMT, an ICU nurse, or an ER doctor on the plane, I would have stepped aside without ego, in the best interest of the patient. To that end, I hope we as providers can begin to treat all situations as opportunities to work together as colleagues without unfairly judging each other’s credentials.