In Practice: Reflections from NPs and PAs

Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.

 

I love practicing medicine. As a student, I devoured chapter after chapter of medical books. I listened to didactic lectures on repeat all the while envisioning myself bettering sick patients’ lives with treatments and curative procedures. The idea of this brought me a great sense of joy and excitement. In hindsight, I had been imagining the provider-patient relationship as very one-sided. I thought mostly of what my knowledge and skill set could do for my patient, but never really about the impact those patients would have on my life. I practice neurosurgery at a top-ranked, level I Trauma Ctr. in Boston, MA, which is arguably one of the best medical epicenters in the world. Anyone working here or in a similar environment has seen epic tragedies and miraculous saves, often in the same work day. I expected to be humbled by medicine and the techniques of practicing medicine, but I had no idea how much my patients and their reactions to these situations would shape the person that I have become. Not every experience was a positive or easy one, but each one changed me.  I have learned many lessons during my short time in practice and they have changed who I am, not only at work but in my personal life with my friends and family as well. I have taken these lessons and transformed them into 3 life rules that I follow like a religion. They keep me happy and balanced, and they minimize those burn-out moments, all of which will hopefully lead to a long career in medicine.

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LESSON #1: Get personal perspective and keep it.

I’m not perfect. Just last week I had a small meltdown after the fax machine destroyed the only copy I had of a patient’s medical record from Japan. I can’t lie; I came close to pushing the entire machine down the stairs. We’ve all been there, but quickly regaining personal perspective is invaluable. Did the fax machine burn down my house, transmit a life threatening disease, or cause me permanent disability? No? Great, then 5-6 deep breaths should do the trick. This approach has been an enormous stress reliever in my day-to-day life.

LESSON #2: Share your perspective with your patients (friends, family), but don’t forget to get theirs.

We see patterns in our practices and in the literature that help shape our perspective on things, including outcomes. I use ruptured intracranial aneurysms as an example. Approximately 50% of patients with ruptured aneurysms die prior to getting to the hospital. Of the 50% who make it to the hospital, 30% die despite our best efforts, 30% are significantly impaired requiring assistance with activities of daily living (ADLs), 30% have mild impairments but can still complete ADLs independently, and about 10% are discharged at their pre-rupture baseline. If you are in the “mild impairment” or “pre-rupture baseline” groups, from my perspective, you are incredibly lucky — lucky enough to consider purchasing a lottery ticket on the drive home. From the patient’s perspective, those mild impairments are life-changing, and we providers should not be so quick to dismiss that. I had a patient with a significant subarachnoid hemorrhage secondary to aneurysm rupture who nearly died twice in house. Eventually she recovered beautifully. Her cognition and memory returned to baseline, but she had some residual right hand clumsiness and a 4/5 manual muscle test of her upper extremity. From our standpoint, she was basically perfect, but for her, life had changed dramatically. She loved to cook, but due to the clumsiness she was unable to use a kitchen knife with the same precision. Things were just different now for her. Although I couldn’t change her outcome, I could be better about listening to and integrating her perspective into the plan. This lesson translates easily into conversations with friends and family. Be mindful that the skills and characteristics that make you a great provider/alpha team leader (firm tone, direct, evidence-based decision-making, demanding, and work-driven) may not translate easily into your personal life. I have learned to be open to suggestions and to go with the flow once in a while. If I start twitching from lack of control and organization (consequence of “going with the flow”), I refer back to LESSON #1.

LESSON #3: Don’t be the Lamplighter

The Lamplighter is a character from The Little Prince, a children’s book written for grownups, by Antoine de Saint-Exupery. The Lamplighter lives on a tiny planet and lights a street lamp every night and puts it out in the morning. The catch is that the planet is so small that it has 1440 sunsets daily, which means the Lamplighter is rapidly lighting and extinguishing the lamp all day long so that the plants and people on the planet never go without light. For a period of time, I was constantly putting out work fires, staying late because stuff “needed” to get done, and never taking time for myself and my personal life. I was so obsessed with doing my job well for my colleagues and my patients that, much like the Lamplighter, I never took time to relax.

Take some YOU time. We talk about it. We even preach it. We just rarely do it. Make time to do things that you enjoy with people that you enjoy, and when you’re doing them, take a little extra time to appreciate the subtle things. You truly never know when it could all change. Our patients and their families say things like, “I wish I had known I was going to have a stroke because I would have taken that trip to Rome with my spouse” or “I wish I could have told them that I loved them one more time.”

The work we do is important, but self-care is also important. Stop ending the calendar year with a bank full of vacation days. Use them. Go on a vacation. Sit on the couch and watch TV. Spend time with someone you love. It doesn’t really matter what you do – just take a break from the lamp lighting/extinguishing. I didn’t believe it until I tried it, but the hospital and our practice continued to run even when I took a vacation. I suspect yours will too.

I am a better person, and I have this profession and my patients to thank. I would love to hear lessons learned from other practicing PAs!