Archive for September, 2010

Scary Stories for a Primary Care Provider

Thursday, September 23rd, 2010

You know what scares me in my job as a nurse practitioner?  You’d probably think it is a missed diagnosis, a treatment failure, or a drug-drug interaction.  You’d probably think malpractice liability and obscure diagnoses with unusual presenting symptoms would keep me up at night.  Oh, these things are stressful, certainly, but they don’t scare me.What really frightens me is the number of middle-aged, middle-income adults I examine; find an acute or chronic illness in, and who then inform me that they are unable to afford the care they need.  There is a steady parade of people in these circumstances.  What scares me is that there are more of them and that there are ever-higher wage-earners now falling into the “don’t bother with the prescription unless I can afford it” category of patient.Every day on my job I meet patients who need something expensive and make do with something else.  The first line therapy for diabetes is inexpensive, but the recommended second-line oral medications for diabetes are over $100 per month, each.  So that patient gets last decade’s technology.  It is treatment, but not the best practice.  Arthritis sufferers cannot afford maintenance medications. Asthmatics cannot afford an inhaled steroid.  Heart attack survivors cannot afford the currently recommended regimen of drugs to prevent another heart attack.  Seizure patients can’t afford new antiepileptic medications, and instead must take 25 year-old medications with serious side-effects.What am I doing with so many patients like the ones I describe?  I am an occupational health nurse practitioner clearing people for new jobs.  I find newly discovered diseases several times per day, and almost never does the perspective new-hire have a primary care provider.  They have no job, no money, no health insurance, no access to indigent care in the county where I practice.  All they have is…  And my empathy.  And my conscience.  And my band-aid-dispensing solutions to a gaping social problem in our country.  It’s a grave situation (pun intended).  I am the nurse practitioner performing employment physicals who must change his hat to primary care provider several times each day because the need is so compelling, and the system is so broken.Yet, willing as I am, the system itself conspires against me.  I am restricted by really stupid Florida laws in my professional practice.  I could do so much more if the handcuffs which prevent me from doing my job were removed.  Being in the exam room, with the door closed, facing a person who has been unemployed for a year, and watching his or her smile of pride at a new job dissolve into tears as they learn they have a chronic illness which makes him or her unable to start the job, and no way to care for themselves, is what scares me.  It scares me that my expertise, empathy, and conscience are all they’ve got, but the cracks keep widening.  It scares me that there is no social-engineered solution, and I am completely left to devise my own.