The Opposite of Tenebrific


A career in medicine is one that has many lures–the ability to touch lives,  fascinating medical phenomena, and the knowledge of the complexity that comprises the human body, among other things.  Yesterday, every single one of my patients reminded me again of why I became a PA.  One patient asked my advice on what to do about a lost love connection spanning over 20 years.  Another had such an intricate medical history, it had me stretching my brain for information I’d learned long ago in school.  One funny patient and I talked about our love of words, and I shared with him an app on my phone which gives me a new word to learn every morning. Every patient thanked me for being easy to talk to, and I was loathe to walk each of them to my door because I had enjoyed our visit so much.  It was a day sorely needed. Last week, the last patient of my day made me cry.

As anyone who knows me will tell you, making me cry is not actually difficult. I confess to a small sob while watching the movie Aladdin (which is a cartoon I know, but that Genie gets me every time).  aladdin genie

Someone else crying causes me to tear up.  Even writing a sentence about crying will cause what my son calls my “shiny eyes.” I’ve cried with patients numerous times, with a touching story or in shared grief. But this time, it was different.  I was crying tears of anger.  I am cursed with full-on waterworks if I’m extremely angry, which I would love to be able to control. It’s hard to be taken seriously if you’re wiping away tears while trying to make a point, and even harder to carry on a patient evaluation when you are doing everything you can to remain professional in the face of hostility.

This patient began our encounter angry before he had even met me because his appointment had been rescheduled with another provider. Where I work, I’m used to dealing with angry patients on an almost daily basis.  To some of them, solely on the basis of where I work, I am the face of all of the bureaucratic bean-counting, soul-sucking paper-shuffling nonsense that prevented them from seeking care in the first place. I am part of the system that denied them benefits, told them PTSD did not exist, and denied their right to be seen as a person, and not a number. So I understand the frustration and the anger that comes as part of the baggage of just getting to the appointment.  I understand that part of my job is to lift that burden of frustration, and make them feel like they are seen, and heard.

As patients, we come to our appointments carrying the invisible baggage of our history–the memory of an aunt who died on the operating table, medication reactions, a fear of bad news-“What if it’s cancer?” As providers, we know this, and try our best to gauge those worries and try to alleviate them if possible.   Sometimes though, the actions brought about by those fears and worries are inappropriate, and other times, even criminal.  Fears have been running high in our department because one of our sister facilities suffered a tragic shooting.  A patient shot and killed one of the providers at the hospital in El Paso.  He worked in the same type of department in which I work.   Meetings about safety measures, active shooter scenarios, and how to deal with violence in the workplace have been laced with tension-filled voices.  One of our police officers tried to help us dial back the emotions.  “Let’s not call it a panic button. I prefer the name duress alarm. We don’t want to have panic,” she said.  I’m not sure that changing the name makes a difference, though I do advocate for the power of words.

But the words I mean are those we use when dealing with patients.  As peace-loving as I try to be, I am not immune to the effects of violence. I trained in the city of Detroit and saw the ravages of drugs and violence on the faces and bodies of our patients, treated gunshot wounds and stab wounds, and saw families ripped apart by random acts of killing.   People argue that our patient population is more dangerous because as veterans,  our patients have all been trained on how to use weapons.  I argue that if anything, that makes us safer, because they were also trained in how to defend those in need, in how to stand and fight for those who could not or will not because of an oath to heal or religious convictions or even conscience alone.  I will defend our veterans as patients just as worthy of our compassion as any other patients, if not more, and not to be considered a source of fear.

Last Friday though, I was afraid, and if I were a superstitious type, might have seen the word of the day, “tenebrific,” as a portent, as it means producing darkness. My patient arrived upset, out of control, and angry with me and everyone else in his vicinity.  I stand a whopping 5 foot nothing, and so to me, everyone is tall.  This man though, stood a good foot taller than me, and weighed over 2 times what I weigh.  I tried every tactic I had ever used to deal with a difficult patient, but I could not connect with him.  The power of words failed me.  He kept standing up while I was attempting to gather his history, and the sight of this very large man gesticulating wildly between me and the door gave me a qualm every time he stood up.  Between his wife and I, we tried to calm him down, but nothing seemed to work.  He alternated between insulting me and denigrating the system, and I bit my tongue and tried to smile pleasantly until it reached the point that he started to use expletives.  I firmly told him that this kind of language was unnecessary.  At this point he demanded to see someone else because he thought I was “belligerent and argumentative.”

My hands shook and my heart was pounding as I escorted him to the appointment desk to be rescheduled, and then I returned to my office and promptly burst into tears. I was angry and upset, mostly at my inability to control the situation and at the fact that I had not been able to get him to see beyond me as the face of an organization, to see me as someone who cared about his well-being, and at myself for feeling intimidated by a patient.

I believe strongly that all patients deserve good health care, the best that I can provide if possible.  To come to a point where I could not do so, made me realize that as providers we also have the right to be treated with dignity.  When we in good conscience have done all we can to do right by our patient, we also deserve to be seen and heard. We deserve, as our patients do, to work in a place where we should not fear for our lives for doing our jobs.  My heart goes out to those in El Paso, and especially the family of the man who was killed trying his best to help others.

Today I am thankful for work which allows me to be present in the lives of others in the midst of their pain and suffering. I pray for the strength to continue to be the opposite of tenebrific as much as possible.  And I am grateful for all of the wonderful patients I’ve met along this journey.

I would love to hear any of your stories of how you’ve either dealt with a difficult person or tactics on how to keep the tears from flowing when you don’t want them to.  I hope and pray that you have someone taking care of you with whom you can laugh and cry. Let them know you appreciate them if you do.  They might really need to hear it today.

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Do What You Love: Top 7 Things You Never Knew About Physician Assistants


Growing up, my dream list of future occupations was varied: Supreme Court justice, Shirley Temple stand-in, crime-fighting assassin/journalist, astronaut, and finally, Nobel Prize-winning brain researcher. Alas, Sandra Day O’Connor took my seat, Shirley Temple grew up, being Catholic put the nix on the whole killing people gig (even if you only kill the bad ones, the Church frowns upon that–see Commandment #6), my 5 foot even height makes me too short to be an astronaut, and no matter how much I loved studying the brain, I found I really dislike research. However, I was blessed to work with stroke patients in my research work, and it turns out, I love people. So in 2003, I became a physician assistant (PA).

If you know any PAs, this is a logical conclusion. As a whole, PAs love people–helping them, taking care of them, and making a difference in their lives. I had never heard of the PA profession until shortly before I applied to PA school, when I met one while working with a surgeon who did not particularly like people (but that’s a story for another blog post).  That PA was, and is, a paragon of compassion and competence. She said and did all the things I had always associated with physicians, and her patients loved her and asked for her by name. Not by doctor but by Jennifer, because as she said, “If I cared about titles, I wouldn’t have become a PA.” Inspired by her quiet example, I researched the profession (all that time in research wasn’t wasted), and was astonished by what I learned.

1. PAs have been taking care of Americans since around the time of the Vietnam War.  The first PA class graduated October 6, 1967 from Duke University. In fact, PA training was based on the fast-track model of training doctors in World War II because of the health care shortage at that time, and the fantastic Navy corpsmen and their wealth of knowledge from the Vietnam War–necessity being the mother of invention and all. And in a time of civil unrest, one of the examples Dr. Eugene Stead used for the PA-physician team model was a white physician and his African American assistant, Henry Lee “Buddy” Treadwell, who capably managed the clinic while the physician was out of town, and whom “the richest man in town would rather have. . . sew him up than [the physician] because he can do it better. . .” as quoted by said physician.  As a female Asian American PA, I can’t think of any better testament to the founder of our profession than that he was progressive enough to recognize quality health care and not care who was delivering it, in a time when Jim Crow laws still existed.

2. PAs work collaboratively with physicians and other members of the medical team to provide quality health care in all fields of medicine. Yes, all.

3. PAs can write prescriptions for what ails you. And when there is no prescription, you can count on us to listen and be present, and fight like hell for you. I mean, advocate strongly for you.

4. PAs not only work in all branches of medicine, they can be found in a variety of settings. We don’t just deliver health care in hospitals, operating rooms, and private practices, we also teach at universities, work in prisons, practice in schools (not the same thing, no matter what you might recall about middle school), perform research (I suppose someone has to), lecture around the world, serve our country in the military and in the White House, own our own practices (in some states), publish in medical journals, care for nursing home residents, and work in industry. The sky is the limit in terms of opportunities available for PAs–literally. I’m still trying to figure out how to work the astronaut angle–first astronaut PA anyone?

5. PAs have to bring similar prerequisites for medical school to the table when applying to PA school, and to be competitive they usually need 2-3 years of healthcare experience to even be considered. My dual degrees in biology and neuropsychology from the University of Michigan were not sufficient. I had to go back and take more classes than I needed for a medical school application, just to be able to apply to PA school. Suffice it to say, I would have taken those classes in medical school if I had gone, but PA school expects you to come loaded for bear so you can be out practicing medicine upon graduation. The time I spent in the healthcare field before PA school was helpful in navigating through the intensive onslaught of information during PA school, and has made me a better PA now that I’m practicing because I had already worked as part of a healthcare delivery team prior to becoming a PA.  The PA who has helped clean patients in nursing homes before PA school knows to be on the lookout for decubitus ulcers from first-hand experience, just like the PA who was a paramedic before PA school is acutely aware of the possibility of tension pneumothorax in a patient with blunt chest trauma from an MVA.

6. PAs can be found practicing medicine internationally. Besides those serving in the military for the United States, the PA concept has spread to Canada, the United Kingdom, the Netherlands, Ghana and South Africa. The Russian feldsher was a forerunner to the physician assistant profession dating back to the 17th and 18th century and introduced by Peter the Great to the Russian military in the setting of a physician shortage–not a new problem as you can see. PAs also work in disaster relief and with medical mission groups across the entire world, and many PA schools offer international rotations. One of the best experiences I had in PA school was going on a medical mission to Honduras. Nothing makes you more grateful or humble than knowing that patients have walked miles carrying their shoes just to see a medical provider in order to show up wearing their best clothes. Seeing ingenious providers treat patients in a clinic without reliable electricity inspired me to be more aware of how I allocate our health care dollars, and to hone my physical exam/diagnostic skills.

7. PAs are required to have both national certification and state licensure, and must recertify every 10 years by passing a national exam covering the following areas of medicine: surgery, pediatrics, cardiology, pulmonology, orthopedics, dermatology, psychiatry, neurology, infectious disease, hematology, genitourinary, gastroenterology, endocrinology, and otolaryngology (see #2 above).  In addition, we must remain up to date by earning 100 continuing medical education credit hours every 2 years. So even though patients ask us frequently when we are going to finish our schooling and become physicians, the answer is never, because we will never stop learning and we love being PAs.

National PA Week starts today. Even though I never did win a Nobel Prize, travel to outer space, or learn to dance like Shirley Temple, I am blessed to do what I love. Being a PA has been a more rewarding career than I ever dreamed possible. I am thankful for all the patients who have allowed me the privilege of caring for them, listening to their life stories, and sharing their journeys. I am humbled by the incredible trust they place in my hands, and strive like all in the medical field, to be worthy of it.

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Be Not Afraid


This past Sunday, like too many Sundays, we walk into Mass late, yet again.  We scoot into the section where we always sit, because us humans, we are creatures of habit, near dear friends with their five children, one a baby boy just learning to talk.  I try to focus on the readings, but in the back of my head is running the list of things that must be done before the alarm clock rings Monday morning. I scan the doors, waiting for my husband coming straight off his shift to join us.  I am praying today for patience and for guidance.  You see a few weeks ago, my husband told me he was thinking about joining the SWAT team.  Yes, that SWAT team, the one you see on TV facing off the bad people, running towards trouble.

When I met my husband he was studying to be a pilot, and when he told me he was thinking about joining the military, I point-blank told him I would stop seeing him.  Not because I don’t respect and honor our military, especially now that in my work I directly serve veterans, but I knew myself.  I knew that the fear that I felt already everyday would be overwhelming.  I could not bear the thought of lying in bed at night worrying about him.   I said it calmly, as a statement, not a threat, then logically persuaded him to continue with his schooling, because I am not a reactor.   My oldest is the same.  We never tear into presents, always taking the time to admire the wrapping and read the card, then carefully going to the seams and pulling off the tape.  Before starting anything, I have to look at all the angles, deduce all the potential ramifications of what could happen if something went wrong.  Though I am a joyful person, I live my life by knowing what the worst-case scenario could be. I have been motivated by fear and the avoidance of danger all of my life.  When my parents left me in charge of a grandmother who could not really speak English and 3 younger siblings, my goal was always to keep them safe.  I took real-life stories from the newspaper and Reader’s Digest as lessons on how to avoid tragedies, incorporating them into my arsenal of weapons to keep fear at bay.

And so, when he very off-handedly mentioned while we driving to the store that he was interested in training for a spot on the SWAT team, I didn’t react.  I didn’t yell or cry.  He reminded me of an incident in which a police officer had recently been shot, and how her life was saved just because a paramedic firefighter like himself had been nearby.  You see, although firefighters and paramedics are standing by in scenes of emergencies like with what happened at Sandyhook Elementary, first they have to wait until the scene is secure, deemed safe by our brave police officers who although they have some medical training, are not medics.  He would be wearing SWAT gear, of course, covered in armor.  “If I were there,” he said, and my heart skipped a beat imagining this, “We could get to people sooner, and be there immediately if a police officer is hurt.  It would make a real difference.” I know this.  I know how minutes, even seconds count when your life’s blood is pouring out on the ground.  It is part of our training as physician assistants, sayings like “Time is muscle” as in the heart muscle, or “time is brain” as with stroke patients, are just part of our vernacular.  I understand this, and he knows it.

I look at my watch.  He is late, and unlike days where I am working, he can’t call me while I’m in church.  My girlfriend’s husband gets up to take his youngest daughter to the restroom, and the baby boy begins to call “Da da”  repeatedly.  Everyone glances over, and smiles, even me.  Father Charles begins his homily and I feel like he is speaking directly to me.  “Be not afraid,” he says.  He speaks of climbing our mountain, the same mountain I referred to a few days ago in my blog post High Desert.  His words fill me, pushing back the fear.   For some people, church is the desert, or a quiet place where they can meditate.  I am not one of those people.  I miss church if I am not there at least on Sundays.  I feel like something is missing if I am unable to attend.  Days like this when the Gospel and the community to which I belong lift me out of the mires of fear and ordinary life are part of why I am here.  I need this connection, this reminder to get out of my head, to stop carrying around this burden by myself.  None of us is alone, not truly.

Here is the difference between now and when we first met.  I am the one who suggested he investigate becoming a firefighter.  It sounds counter-intuitive, doesn’t it? That I would suggest he spend the rest of his life going into dangerous situations, when I prevented him from doing it so many years ago just doesn’t fit.  But knowing him, I knew that this man I jokingly referred to as the Boy Scout, would love this work.  That his steady hands in an emergency, knowledge of all things mechanical and construction-related, and his aptitude for medicine would serve him well.  This is what you do when you love someone.  You don’t hold them back from what they are meant to do.  No matter what it does to you.

Communion arrives, and he is still not here.  I stop scanning the doors, knowing he will not come this late.  When I see him later, I will smile and tell him about how well the baby is talking now, and about our friends who asked about him. I will be able to tell him and mean it this time, that I will support him no matter what he decides to do.

He was still speaking when suddenly a bright cloud covered them with shadow, and suddenly from the cloud there came a voice which said, ‘This is my Son, my Beloved; he enjoys my favour. Listen to him.’ When they heard this, the disciples fell on their faces, overcome with fear. But Jesus came up and touched them, saying, ‘Stand up, do not be afraid.’  And when they raised their eyes they saw no one but Jesus.” Matthew 17: 5-8

Today I am thankful for our police officers, all the firefighters, our military and for all of those who make our world safer by running towards danger.

My Name is Not Lenny


Dear Mr. O’ Reilly,

My name is not Lenny.  I did not graduate from a community college, and even if I had, my master’s degree in physician assistant studies more than qualifies me to take care of you and the veterans that I serve.  Your off-hand comment about not wanting to be cared for by someone who is not a physician is revealing.  Perhaps you arrive on the set of your show, and perform all of the duties necessary to get on the air from running the microphones and cameras to making sure that your guests have water to drink, but that is not how it works in medicine.  We operate as a team. Your show has highlighted the shortcomings of our health care system, so perhaps that is why you have not discussed the quality care provided by physician assistants.  I would implore you to educate yourself and thus help to educate America about what physician assistants are doing and can do to bridge the health care provider gap that is present now, and that research shows will continue into the foreseeable future.  Saying that PAs are akin to “Lenny, who just came out of the community college” grossly misrepresents my education and the quality medicine PAs practice in every medical setting and specialty in America. The misleading information in your show does a great disservice to the millions of viewers who trust the information and opinions you provide.

What you need to know is that the majority of today’s PAs are educated through intense, graduate-level medical programs wherein we are trained to diagnose, treat and prescribe. In contrast to your comment, 94 percent of PAs hold bachelor’s, master’s or higher degrees. We are often trained right alongside physicians in medical schools, academic medical centers and residencies. These programs are modeled on the medical school curriculum with a combination of classroom instruction and a minimum of 2,000 hours of clinical rotations. That means I share diagnostic and therapeutic reasoning with physicians. PAs are nationally certified and licensed to practice medicine and prescribe medication in all 50 states, the District of Columbia and all U.S. territories with the exception of Puerto Rico. PAs are authorized by the State Medical Boards to practice medicine, meaning I can perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, assist in surgery, perform procedures, provide patient education and counseling, and make rounds in hospitals and nursing homes among many other medical services.

I have to admit that I do not watch your show, other than the March 4, 2014 broadcast in which you stated that “If I want a strep throat diagnosis, I don’t want Lenny. . .,” in references to clinics that are staffed by physician assistants and nurse practitioners.  Mr. O’ Reilly, can you please clarify your statement as to why the care received from a physician assistant or nurse practitioner, although good enough for  millions of Americans, is not good enough for you?  I took my son today to an urgent care clinic for what I knew to be otitis media, and he was seen by a nurse practitioner who provided excellent, compassionate care.  My children receive all of their routine care from a physician assistant who specializes in pediatrics.  I did not go out of my way to choose them as these were the providers chosen by my insurance, but given the choice I would pick both again.  This is the reality of medicine in America today, and I and many patients, especially those living in rural, under-served areas are grateful for my fellow physician assistants and nurse practitioners.  Physician assistants are increasing access to high-quality healthcare. We know better than anyone that our health care system is broken, but instead of making disparaging remarks about the people doing the work, we just roll up our sleeves and do everything we can to make sure that we take care of everyone who walks through our doors.  Please join us in our fight to make our medical system better by highlighting what works, including the 95,000+ physician assistants working in hospitals, clinics, and nursing homes. I look forward to your response.

Sincerely,

Nguyen

To everyone following my blog along this Lenten journey, I hope you know that I write only about those topics which inspire me and which I hope will inspire you.  For my gratitude journal, I am blessed to have found my life’s calling as a physician assistant, and I love what I do every day.  What I try not to do is participate in discussions that denigrate others or are polarizing, and I am thankful for the opportunity to live in a country where it is still permissible to freely voice our opinions, but when misinformation which is harmful is disseminated, I have a hard time not speaking up.  Please take this as fair warning that this may happen again 🙂 .  I welcome any comments you may have about your experiences with PAs, and am aware that there are bad eggs among us, just like with any profession.  Also, please feel free to tell me how you are doing with what you have given up as we blaze on. I am still working on that fear of failure, but have to admit it is getting a little easier with each blog post.  Please pray for a speedy recovery for my  little guy and his bilateral ear infections.  He is sleeping now, as we all should be.

I am providing a link to the clip of the show solely for the purposes of accuracy:

http://www.billoreilly.com/video?chartID=610&footer=true#play

If you are a physician assistant and would also like to respond to Mr. O’Reilly, please check out this link from the American Academy of Physician Assistants (the italicized parts of my letter were copied from a template provided on this link). I could not, of course, resist adding my own touches:

http://www.pasconnect.org/lenny-from-community-college-how-to-respond-to-oreilly-factor-misinformation/