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The Art of Medicine

When a cold is a cold

Katers, Laura A. MCHS, MS, PA-C

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Journal of the American Academy of Physician Assistants: January 2020 - Volume 33 - Issue 1 - p 58
doi: 10.1097/01.JAA.0000615512.30796.10
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The advice I give to new grads engaged in their first job search is to find an employer who supports the process of onboarding (time to learn what is needed before flying solo). I started my own career as a primary care provider with an organization that gave first-time clinicians an hour with each patient for the first 6 months. I used every minute to examine each patient from head to toe, build rapport, and ensure I got everything right. My white coat was so clean it hurt the eyes. No matter how confident, skilled in a past life, or smart I felt I was, there is only ONE first day as a medical provider. And I had to get through it.

I did well with only a few hiccups. I prescribed polyethylene glycol to an 18-month-old with constipation, but not the dropper/kid kind. I'd accidently written for the “adult version”—GoLYTELY, basically a gallon of salt water used for colonoscopy prep. The pharmacist called and, after a brief clarifying discussion, couldn't stop laughing. A second patient had new-onset diabetes, and my second prescription ever was for metformin. I completed homework on metformin, memorized its uses, adverse reactions, and initial dosages for my boards. Still, all that knowledge suddenly disappeared and I wondered aloud if someone could overdose on metformin. Was I about to cause irreparable harm? There was a sprained ankle (no problem there as I've had many), an STI screen for gonorrhea/chlamydia, and a patient asking to start an SSRI (in my wheelhouse of behavioral medicine and the most comfortable visit of the day). Six hours, six patients—with the last one the most challenging by far.

A 23-year-old man with 3 days of nasal congestion, sneezing, slight fever, sore throat, mild cough, and fatigue. An easy slam dunk on my first upper respiratory tract infection (URI). We discussed the timeline and course of symptoms of the common cold and the best home remedies. Antibiotics weren't warranted as I didn't suspect a bacterial infection.

I headed toward the door with a smile, white coat still perfect, ready to finish my chart notes for the day, sign out, and celebrate. Then the internal chatter began. Did I miss something? I'd used up only 11 of my 60 minutes, and the what ifs began to gather like wind in a hurricane. I spun around and asked the patient to sit down, catching him off guard, and then I possibly terrified him with a barrage of new questions. Recent travel outside the country? Contact with homeless individuals or recent time spent in jail? Any recent exposure to someone with tuberculosis? Occupation? History of vaccinations, childhood illnesses, night sweats, high fever, green or red phlegm, was the cough only 3 days or 3 weeks, chest pain with breathing, dyspnea, tachypnea, nocturnal cough, wheezing, recurrent chest infections, coughing up phlegm every morning for more than 3 months of the year, history of family cancer ... what was his oxygen saturation while walking and at rest?

It was the most thorough history taking of my life. He exhibited no red flags, but still. I asked a senior provider to assess him, just in case. At this clinic, each new clinician—whether a physician assistant, physician, or NP—chose a senior provider as a mentor. The mentoring relationship was to provide feedback and provide opportunities to discuss new or difficult cases with clinic time of 2 hours set aside each month. This time would be extremely invaluable during those first 2 years, as my level of certainty increased while my appointment times dropped to 30 minutes and then to the standard American Primary Care Provider (burnout) allotment of 15 minutes. I chose my mentor, a physician, specifically because of her rapport with patients. No matter how complicated the complaint(s), she always addressed the patient's most pressing concerns and never seemed rushed. She was the provider I wanted to be.

She performed her own 5 minutes of history taking and a thorough physical examination and easily came up with the same diagnosis—a URI or common cold. Even so, my fear of screwing up on the first day of my new career, the “fake it till you make it” mantra I could never quite adopt, the unyielding imposter syndrome that follows many new medical providers into their first role—all these had me follow up with this patient in a week. Of course, my mentor was right, which meant I was right. The patient was fully recovered. No TB. No cancer. Imposter syndrome still intact but with a few small victories, no one hurt, and my next shift of seven new patients only hours away, I went straight home and went to bed. On to live to a second day.

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