Technology: A Virtual Preceptor
On my first day working the clinic alone, I saw 19 patients, half of
whom were primary care patients and the others a combination of family
planning, child health, and STDs. The nurses were amazed and very pleasantly
surprised. Given that the PA who was fired saw seven to eight patients a day,
and often left the clinic without notice, anyone would have been an
improvement.
The locum tenens MD who covered the clinic for 3 months and with
whom I worked for 5 weeks, built the practice back up from that point and I
hope to continue to increase the utilization of our services. I was told this
past Friday that I saw 23 patients, which surprised me since it seemed almost
effortless, and we finished well before noon in the morning and a bit after 4 in
the afternoon (clinic hours are 8-12, then 1-5).
In pondering the relative ease in dealing with the number and
variety of patients as a new grad, I realized that technology has created
virtual preceptors in the wealth of online resources available literally at my
fingertips. I invested in an iPad and UpToDate, the online resource used at
Duke, and cannot imagine how different my life would be without them!
I also have the Harriet Lane Handbook loaded for peds, a
dermatology app, apps for labs, heart murmurs, EKGs, a Spanish medical
dictionary with audio, the ICD-9 code website, the Medicaid and Walmart $4
formularies, the Medscape reference site, etc. Resources don't stand alone, of
course, and mean nothing without diagnostic and critical thinking skills, even
intuition, but are invaluable in helping to put pieces of a puzzle together.
In my first week working solo, with the help of sundry resources,
I diagnosed oral lichen planus in a patient and found that the painful nodule in
his neck may actually be due to salivary gland hypofunction, which, among other
conditions (stress, allergies, hep-C), can cause oral lichen planus. He was referred
to ENT.
Another patient, who has a 20 plus-year smoking history, presented
complaining of worsening dyspnea on exertion, recurrent episodes of shortness
of breath, chest congestion and productive cough that did not improve with two
courses of antibiotics prescribed by an outside provider. The albuterol inhaler
prescribed helped a little. My suspicion was probable COPD exacerbation, though
she had not been diagnosed with the condition. She was self-pay so I ordered
some basic labs, and her hematocrit was 53 (polycythemia) and her sodium was
high normal.
Per guidelines, I prescribed a steroid burst for symptomatic relief
and added Atrovent to her inhaler regimen along with spacers. I also referred
her to pulmonology, who agreed with my treatment plan, and were willing to
establish her as a patient with a $50 initial payment and a payment plan
thereafter. Imagine my sense of validation at reading the COPD
Status Report at the ADVANCE
for NPs & PAs website!
Many of my patients present with long-ignored health conditions
and many of the medical regimens are in dire need of overhaul. When a problem
is too complex for quick answers, I tell the patients that I'd like some time
to put a plan together, that I'll call them by the end of the day, and their
medicines, if any, will be called in to their respective pharmacies. I've not
had a patient yet who had an issue with this. By doing it this way, patients
don't have to wait any longer than they're already waiting (the eligibility
process in public health clinics is often the most time-consuming part of the
visit), and I have all the time I need to deliberate on the best treatment plan
for each patient. A win-win proposition.