You’d Make a Great NP
A nurse practitioner talks about a resident and a complicated patient
I worked with a patient, 84 or 86 years old, with some dementia but still living alone despite multiple medical problems. She had chronic renal insufficiency, hypertension, diabetes, gout, and also was on anticoagulants. She couldn’t keep her meds straight. This patient needed a team, and I had to put the team together. The PCP became very involved. She wanted to see the patient frequently and not expect me to do all the hard work. I also had to see the patient frequently, and in-between visits I would report to the resident or the attending. I also ended up seeing the patient at home because it was difficult for the patient to come in. The resident then asked me if she could accompany me on a home visit and I thought sure, between the two of us it should be quick visit.
Not so. Not when the resident spent over an hour looking through photo albums. At first I think the patient was really shocked that the doctor was at all interested in these things. The patient had been to nursing school and had pictures of her graduation on the wall. The physician asked questions about her school, nursing jobs, her marriage, her family life and what brought her to Charlottesville. This patient discovered her doctor really cared. The doctor wanted to know about the patient’s day-”What do you do when you wake up, and let’s go to the kitchen and show me what’s in your fridge”-but it wasn’t threatening in any way. She kept telling the patient, “I just what to know what makes your day go by and what makes you tick.”
Afterwards I told the doctor, “If you weren’t a doctor you would make a great nurse practitioner.”
I think we kept her out of the hospital. I know this seems like enabling but the patient lives on my way into work so I pick her up every once in awhile and take her to see her nephrologist because she had so much trouble just figuring out how to get through the medical system. Unfortunately she did end up in a nursing home. Her dementia ended up so bad that she was found down a couple of times and ended up taking too much of her medication even though it was in a med box.
The patient relationship for me was very rewarding, the patient was just absolutely lovely and she appreciated every time I came over. She really, really didn’t want to be in a nursing home, so that is why all this work went into this. She loved her little apartment and her neighbors. I would love to be able to dedicate this much time to all my patients who need me, but I know that is not really appropriate. This was kind of the ultimate nurse practitioner experience, the right patient, the right resident, involved attendings, and as a team the opportunity to prevent a lot of bad things.
Recently I looked up a complicated patient, thinking, “Why isn’t the resident asking me for help? This patient has so many demands, has home health and has maybe 8 different real medical problems or issues all the time.” It turns out this doctor sees him every other week, and I think, “Oh my gosh, how do they do that?”