Practicing Where the Action Is

Our new Nurse Practitioner stopped in my doorway the other day to update me on a patient’s progress. It was a difficult case we had talked about before, with several complications, twists and turns in his case history.

I reflected about how similar that case was to one of my own, where she had been involved enough to know the dilemma – in both these cases, why neurosurgeons sometimes turn down patients with far-gone tissue damage and risk for poor outcomes.

“You know, in just one year here”, she said, “I have seen so much more and learned so much more than my classmates. None of them work in big cities or anything, but they’re all closer to specialists in towns that seem less remote than here.”

“I know”, I answered. “Sometimes it feels a little heroic to be the only resource a patient has or is willing or able to use. So many of my patients have major diseases and don’t want to go 20 miles down the road to Caribou or 35 to Presque Isle. And now endocrinology is gone, rheumatology almost not available, with even Bangor short staffed, and on and on.”

“People think primary care is just simple stuff”, she said. “But it isn’t at all when you practice in rural Maine.”

Thinking back over my career I certainly agree. As it happened, the very same day I saw a patient I once puzzled about and found a rare diagnosis in: a fifty-something man with undiagnosed fairly rapidly progressive shortness of breath seemed to have weaker breath sounds on the left side of his chest. His left lung looked different on X-ray, almost as if it was starting to shrivel up. His CTA showed agenesis of his left pulmonary artery. Only in rural America does the family doctor make that kind of diagnosis.

The Man With the Shrinking Lung

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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