The Privilege of Providing Primary Care
Hey, everyone, obviously, I'm obsessed with podcast. I listen to them while I do everything throughout my day. And that means I go through a lot of pike cast. So I'm always looking for new recommendation. So from time to time I'm going to be sharing with you some podcasts that I think you guys would also enjoy and one of those is lady parts all one word podcast. It is about women's health. We are living in a time of trying to be more educated about our health and this podcast really talks about the science behind women's health things like enemy dresses menstrual cycles. All that stuff that used to be kinda tab to talk about. Well, now, there's a podcast for that. And it's hosted by Indra who is very sweet. And it's really well produced so you can download lady parts anywhere that you are listening to you antidotes stories in medicine. Give them a listen, give them a share. I hope you enjoy it. Hey, everyone. Welcome to another week of antidotes stories in medicine. I had made some pretty big promises with having James from the flying snake coming back this week, and I had recorded that episode, but it seems like my Amager audio editing. Skills are really not up to the task of finishing that episode. So he is gonna come back and re record with me, also as I was listening to it. I realized that we had recorded the episode on a Friday night after I had given my notice at my old job ended ended up being a little bit tumultuous, and I had had some wine, and I listen to this recording. It was like, oh, I am so annoying. I don't wanna listen to me. So you probably don't wanna listen to me. It was just kind of a mess. Oh, the really good stories, and I really want you guys to hear them. But I also don't want you to murder me. So. We're going to save that for another time. So this week is going to be a really great nurse practitioner who is doing rural primary care, and we have heard incredible stories of rural medicine from alway round the world in Australia. And now we get to hear what it's like in rural America, and it's amazing to listen to the healthcare challenges that people face in all these different cultures where in Australia insurance, isn't problem. But for us here in America insurance is such a huge deal. It is such a mountain for us to overcome and for many people we can't overcome it. But as providers, we are always fighting that fight, and Jeff is a DMP. He is a doctor of nursing practice, and he is always advocating for his patients. And he's here to talk about what he does. But I I wanted to say thank you to. To several new reviews that we have gotten on ITN's. Thank you so much. That means so much people really loved rich and mirrors episode. I really appreciate everyone that has been sharing it. I know people tend to love the EMS episodes. I am going to try and get you some more awesome guests in the future. So please keep sharing it. So more people listen and decide that they wanna talk to me too. Okay. So this week. I'm really happy to have Jeff. Hi, jeff. Welcome to the podcast. Nice to be here. Thank you. So you have been N P for a while. How long have you been practicing about seven years? I graduated from a master's program in two thousand eleven and started practicing in a rural setting and in the mid west and did both family medicine and urgent care which kind of sucked my soul away. If you do urgent care for any length of time. You get tired of saying the same things over and over again. Yeah. After that, I moved up to a metropolitan area in worked in bariatric medicine in particular for bariatric surgical center. And I was there for a few months, and then an opportunity came up to move to an independent practice state and. A jump at that opportunity and the have not left. How do you like working in the independent practice state versus a supervised role? It's very different when I was doing family practice. My Claburn physician wouldn't do certain procedures procedures that I had been trained to do. So since that provider would not do them or would not permit me to do them. So that he could do them himself than generate the revenue they work our view credit for it kinda got frozen out of doing some things on the family practice side, the collaborating physician did not believe in medically manage weight loss. He thought it was a waste of time. And so we did zero medically manage weight loss. He left it at. It's a math question. Lower the calories in increase the calories out and everything will be fine. And as we know that's not that's an over simplification the changes there. Yeah. What kind of procedures would he not do if you don't mind me asking? Well in the urgent care setting come in. I'd have a patient with out diabetes with an ingrowing toenail that the had just driven that patient crazy to the point that they decided it eight o'clock at night they needed to have the dang thing. Remove well, they come in in an honestly, it's about a fifteen minute procedure, the longest part of the procedures getting nerve block to take especially if there's any inflamed tissue in there. So I put in the nerve block when on its ought to other patients came back spent the next seven minutes getting the nail off and all done. And then this was a Saturday evening. I think and come my next shift on a Tuesday got my knuckles rapped with a ruler. As hey, you're not going to be doing that anymore and urgent care setting. I don't do that here. So you don't get to do that in the urgent care. Just send them to me. Okay. So so interesting being said that the biggest difference is that if I'm trained to do it and comfortable doing it. I can manage the disease do the procedure whether it's exhibition ISD incision during like an abscess. Yup. Exactly. I can do those without. A physician telling me, no, I don't like doing those. So we're not going to be doing them in the setting right? The Dono nurse practitioners have to work under a physician's license as collaborating physician in some states, but not all states. So sometimes we can be completely independent. We can have our own practices. We can do whatever we want within the scope of our training in license. And that's where I work now, we can do that. And I touched on this before certain physicians groups and certain physicians don't like that they think it's a liability to them. They think it is bad for patient outcomes. Even though studies have shown repeatedly that that is not the case. And it's very frustrating when you're being supervised to no, you can't do something that you know, how to do or to go and do this work and be told ozone offering chart, even though they did not see the patient or in some states, like a nurse practitioner. We'll go see a patient for an admission to a nursing home. And then a physician has to go out within forty eight hours to see that patient. Want to redo basically the admission other that doesn't count. It's like there's a lot of weird rules with physician assistants have to always be supervised by physician nurse practitioners. Don't depending on the state. So it's a very controversial subject in medicine. Well in the practice. I work now is a rural health clinic and their two physicians that I work very closely with and to physician assistants and one other nurse practitioner. If I have a question, I absolutely go and speak to my physician colleagues, and they are happy to help. It's not like anybody ever practices in the vacuum yellow. Yeah. And that's the frustrating part about the Claburn practice agreements is very limiting to patients access to care. Right. And not even so far as clever practice, if you stop and think about what we have to go through to get a patient who needs diabetic shoes CMS regulations requires that the yes required that if physician be managing the patients diabetic care in order for the patient to receive diabetic shoes. The order has to come from a physician. So you end up with patients who need supplies desperately for gonna try and help them keep their toes if they've got wounds, and they can't get them. Right. The way we do it in our practice is if it's my patient and managing their disease, and we need to address foot issues. I will collaborate with the physician in the practice and together, we will be managing the diabetic care. I'll take primary responsibility for the day to day management, and then in the documentation, and I'll and I'll speak with the physician bout what my plans are. And in the documentation explained very clearly that the diabetic plan of care has been developed and agreed upon with the Claburn physician and. That physician will also sign that chart seat. You still have some small hoops to jump through. But it makes the experience much more difficult for the patient yet, and that comes into play to things like home care orders. So a physician has assign home healthcare orders for nurses, a nurse practitioner. Cannot or physician assistant and it's so frustrating because this patient has never seen the physician in my practice. They don't like the physician where I used to work. I changed my job. They don't know who that guy is. And I can't put in the order. I have to have them. Do it for me. It's it's frustrating to get them the services they need. And I'm not sure how we're able to do it because the physician doesn't always have to see face to face to sign off on it. They don't in our case the review the chart outside the order, the physician will co-sign the order certifying that my assessment is accurate in that they agree with the patient needs. We said it onto public health or to the home health agency. And they take it from there yet you fill the face based form, but she didn't signed by the physician that says the assessment was done by a NPA under their in their practice. It is all of this bureaucratic nonsense that we have to jump through. When I did all the work initially. It's just boggles my mind, and it's it's frustrating. I think patients understand it. And they appreciate our frustration with it Alex plane that a noted a giant pain in the took us for him that they have to come back in the case of shoes to have one face to face with the physician to evaluate. If I if the physician doesn't have time to come in to the room to do the exam on the feet while the patient is already there. You're actually adding more financial burden to already burdened healthcare system. Right. Yeah. Because they have another visit on their hands that they have to deal it yet. So I'm all about independent practice. Unfortunately, it's not a federal thing. So it stay stay in everything is caught up with it. But you work in a very very very different setting than where I have ever worked. I've always worked in very urban east coast settings. What is it like, I mean, you must have a lot of lot of different challenges. You. You learn how to practice a lot of clinical medicine. Explain what you mean by that. You may be used to having a patient that comes in. You know that you need to order this test this test this test for lab work to continue with planet care. So you order the test than the patient other weights in your office, or or weights at home, and you get the results you call the patient and the patient disposition is whatever's appropriate based on those results, I may not have results for twenty four hours in which case, you're doing exactly and evaluating all those although signs and symptoms of the patient to make the decision. Yes. This person needs to be evaluated by a surgeon today, this patient can wait until tomorrow this patient needs to hit head to emergency department. So they can be transported to a tertiary care facility or more definitive care. Facility in our case. We have a loose affiliation with a state university with a medical school attached. And if we've got a extraordinarily sick patient. They've gotta go up there. We don't perform surgery in our hospital. So if a patient comes in with a suspected appendicitis our plan of care is very different will start the lab work. We'll get the C T will give them down to the emergency department. Simply so they can be transported by ambulance to tertiary facility. And some cases we'll call the ambulance in have the ambulance. Come straight char clinic in pick them up from the clinic that saves them an emergency charge and for us. It helps the clinic out because we're all build under the same tax ID number Medicare and insurance companies will pay for one date of service on that tax ID number at a twenty four hour period. Unless there is a completely separate. And distinct service, so we pay attention to our exam and learn how to trust hunches. And sometimes we're wrong. We've sent somebody on that. We didn't need to send on. But for the most part, we don't see people being under treated how far away is your major medical center, that's has surgical capabilities via normal vehicle. One hour ten minutes. We've got lifelike capability, and they can be in the air in on our pad in about thirty minutes from the time. The call goes out. Do you have a lot of Medicare and Medicaid patients? I would say probably sixty percent of our practice is a government based insurance. Whether it's Medicare Medicaid. Wow, we all have issues wherever we practice. Whether it's a rural setting urban setting with patients having financial access to care, and that is probably. The biggest challenge where I practice versus where you may practice in an urban setting have a lot more opportunities for for commercial insurance to be accessible, the income and appointment opportunities in our area are very few primarily agricultural or industrial and the insurance programs offered by these companies are often cost prohibitive. So we'll have we learned how to access the medications are services that are needed that don't cost significant amounts of money. One of my favorite sites that use with patients is needy meds dot org. It has every patient assistance program available for every medication users. The you go to the site you input. The name of the medication, and it will pull up the options for the fire. Suitable assistance. Whether they've got a co pay card all of those things in these resources to help patients another limitation on care that we have is access to specialty. We'll have outreach clinic that comes down. We have a psychiatrist that comes down. She just doubled her availability. And is now available twice a month in our facility. It may be a four month. Wait to see neurology. Nephrology? Oh my God. And so you're doing a lot of patient management between the time you recognize the need and the time they can get in. Now that being said we can kind of back door it and make a call to the facility and speak with the provider and see if they can squeeze the patient in a little bit sooner grease the wheels as it were. And in some cases, we absolutely do that. But otherwise, they're waiting for two three or four months to see a specialist. Derm specialty. We there's a clinic in the area that. Right now is taking zero new patients because they're weightless is about six months out. It's just not available, and you mentioned the jobs of the people in the area. Those are jobs that are very taxing on the body and under health. I imagine there's probably a lot of Ortho and just lifestyle induced injury illness. I'll have patients come in. That have told me what their veterinary has told them to do for an injury or an illness that I then need to care for. And you have to be careful because these are friends and neighbors, you don't really wanna step on step heart on people's toes. But I have suggested on more than one occasion that may be veterinary care and human care should stay little bit separated. You know for general injury stabilization the principles are the same. When you're talking medications. Maybe you don't want to be injected with the cows antibiotic, maybe not just just a suggestion. Oh, you get all sorts of great stories. Yeah. About what's going to work, and what's not gonna work and what somebody down the street told them, but they weren't sure that they could believe him because the something that happened ten years ago, it here everything how is the health literacy there, can you ask that a little bit more specifically because there's there's a really broad. Topic? Yeah. So do you find that patients are fairly educated when it comes to the conversations you're having about their healthcare needs. Or is this a lot of like, you know, you shouldn't be drinking this much soda, or is it this is more educated population. They're just kind of receivable or both both types. I would say in the area where I practice the high school. Graduation rate is probably somewhere between forty and seventy percent. Okay. A lot of folks don't finish high school and get a GED. And so in our training, as you know for taught to teach to the level of our patient. Yeah. And so I start with a six to seventh grade eighth grade explanation, and if they start to look bored like like, I'm speaking way below them up that. People are somewhat educated about their health. But they don't see the value. Oftentimes in preventative medicine that what we're doing today is going to help them five years. Ten years down the road using aspirin in primary prevention there is no immediate benefit to that. That benefit we've seen studies that show that benefit really doesn't come for five to ten years with routine use at the aspirin. So you're telling somebody to take a medication that sometimes irritates their stomach that they're not getting any relief from and we can tell them Esperance the miracle drug it couldn't reduce your risk for certain cancers, it reduces the risks Roque in heart attack. It helps with some platelet. In addition that doesn't mean anything to them. It's not the same thing is they came in with the bacterial infection requiring antibiotic treatment they're gonna take this pill. They're gonna take it for this. Length of time, and they will get better to value of primary prevention, I think is lost. Because this is such a I don't say an indigent community, but you have such limited access to financial resources that they guard them precious -ly when you think it in there's one grocery store in the area where I work. So you've got a bit of a food desert. Anyway, you've got major act. I don't wanna say major city, but a smaller city within forty five minutes to an hour in any direction with different access to groceries. But a lot of people that wanna make that drive or can't afford to make that drive or have to find a ride to get there. There's no there's we got a message. The other day that Uber is just now available. It's a big deal because these folks who had no no way to get to a store. Get in for care now can say, hey, get an Uber. We do a lot of home monitoring in patient reported homeowners just because you have to meet them where they are. And in your documentation, you're telling them or you're stating I would like to see this patient back in two weeks. If the patient is unable to attend the visit or find transportation than I requested that the patient call in with an update on their blood pressure or their mood. Whatever it whatever it may be you have to meet them where they are. It is such a contrast to what I do. It's it's really incredible. I work in a very very wealthy population. You said oh, financial hardships are everywhere. It's the clinic that I had been at that was not the case. No one woman will be retiring about the new shingles vaccine, and she already had the other one. When I was like, well, I'm not sure what your insurance coverage will be for this vaccine, but it's opposed to be better at preventing shingles. And better at preventing poster Pedic rouser, the nerve pain, you can get. So the CDC does recommend even though you've already been vaccinated. You should get it. However, you've already had the vaccine if it's not covered by insurance. I would say don't bother you're covered, you know, until you do get coverage. She goes, well, whatever out is Pat pocket. And I was like oh my God. Like this. That's where I work. I mean, if you say go get a blood pressure cuff and go get a gym membership. They'll go get a personal trainer. Like, it's mind boggling and there's concierge services for things because they want the best. It's crazy. It's really grieving a I have a lot of a lot of people who advised to go walk around the grocery store just because they can't afford it. Gym membership, and it's cold outside when it's zero degrees. Twenty degrees. Wendy, people don't really want to exercise outside if they want to exercise at all. And a lot of folks will say, well, I work hard at work. That's my exercise. I fall back on. Well, that's just bonus. I tell people YouTube yoga, I love YouTube yoga, you can do it for twenty minutes. You can do it in your house in your bedroom. And no one's judging you if you follow over, and it can really help with that back pain in all his other stuff. It's free. Well, and you get patients who are used to having a pill for everything that problem. We do have. In in opioids in particular have been. Beating the dead horse. It's it's in the news everywhere. But in these communities is also a source of revenue for patients. I've gotten to the point where if I have a patient who's on routine. Opioids they're going to get your drug screen every time if you're managing diabetes. Are you not going to get an eighty one c are you not gonna get a micro human every year? Are you are you not going to check their renal function? The same thing I'm monitoring the treatment that's being provided and the number of patients who get upset about. That is surprising. He and that's a whole other show. I'm going to do a show on the opioid problem having worked in addiction and then worked in EMS to it's. Yeah, it's a whole 'nother show. So any cases in particular, the kind of stuck out as being, you know, either particularly challenging or particularly rewarding in that challenging environment. It, of course, will hip a compliance. Everything has been generalized and nothing terribly specific my first day on the job at a facility in this stuck with me. I saw a patient for depression asked all the right questions. Received all the right answers. No suicidality. No cause for immediate referral to emergency psychiatric care which in and of itself is challenging. Patient discharge from the clinic to home, I came back to work cited started that this facility late in the week came back to work at the beginning of the week and the. Director of emergency services. Tapped me and asked me if I had heard about this patient and kind of cocked my head and said, no I hadn't seen anything what's going on. Well, apparently this patient head called their significant other about two hours after the visit and head made some statements that indicated that the patient was planning on harming themselves and then went through with it. Oh my God. In it stuck with me because it fell into that same realm as your show with the guys from just just some podcasts. There are there are three kinds of patients. There's the type that no matter. What you do? They're going to get better. No matter what you do. They're not gonna make it. And then the third type is the type that we have the opportunity to intervene in make their life better. I love managing diabetes. I realized that may wind me up for some psychiatric. Evaluation. But I I love the challenge. And I love personalization of care is available and many of my patient. Success stories are are centered around diabetic management patients who have never seen in a one c less than ten in six months there at goal, and it's just by changing the conversation and getting the buy in and explaining that, this is why in often I get the the responsible. Nobody's ever told me that. And it's unfortunate. We see a lot of concussions. There was one kiddo in particular who I saw for their fourth concussion and. Yeah, older teenager or younger kid or in their teenagers. Okay. And because oftentimes the only way out of their financial environments were talking cities with. Population's less than three thousand people. Yeah. I'm sure sports are huge. That's their ticket out. There's ticket to college. And you take that away in that kid is now stuck in a job where they may not be able to get any further than where their parents got. They're able to get that far at all. So being able to get somebody the help that they need and prevent further injury in particular to that child was extremely rewarding. I was proud to have a coach tell his players that they were not to come to my office for concussion evaluations because I would sit them and we would follow the protocol. We would follow state law on concussion management the best turnaround from that is their athletic trainer. Physical therapist would tell every parent. Don't listen to what he says send them here. They're gonna get the care. They need. Oh, screw that. Coach. There were there were words exchanged women wants. But it's the little things a patient who had been on opioids for I wanna say greater than ten years came back and saw me within the last six months and is completely opioid free. Wow. Feels better van have ever felt. And it's just because people kept throwing pills and the patient heard heard the discussion it got the information explaining this is what's happening to your body. This is why you feel like this. You can feel better, and it it was a long lean, but that's a huge huge. Big success plot, substance abuse, problems in our area and limited resources for care. Those heartbreaking stories where when you have a patient. Come in that starts off tell you how desperately they want to quit drinking and you're having the same conversation month in month out and there's. A meeting close. There's not a an affordable treatment center close their insurance doesn't cover treatment. It's just it's those kinds of stories are heartbreaking. Do you ever? Do anything in office like, you know, now trek zone or Campbell or virtual AA meetings or anything like that. We don't really have that ability and our office. There's also some mistrust about telemedicine in our area. They don't they're a lot of patients that don't feel like it's the receiving real care. They're just talking to some stranger on the TV that being said if when I see patients who are on high doses of opioids, they get a prescription for Narcan and our state does not require prescription to receive Narcan from pharmacy, which is great. And so we have those conversations we talk about the dangers, and what to do if your wife or your husband stops, breathing or is not responsive. This is what you need to do. It's such a the substance use in areas such a part of socialization than kinda the middle aged and young adult generations. That's their outlet. The older generation I'm finding there are fewer people that continue with alcohol use reviews, I'll hear a lot of a used to. But boy assured needed to stop interesting. There's a lot of you know, Peewit addiction in the northeast and alcohol abuse. It was funny in Iraq way that we really didn't see any men in phetamine, I'm gonna guess that there's probably a lot of meth outright. You are. There is a lot of methamphetamine out where we are. And again, we're in a unique position as nurse practitioners to meet people where they are. And I don't think that that's always the case with many physicians learning how to stop in put on the brakes and take the extra time. And of course, I'm making a generalization there, plenty of physicians who do stop do take that kind of time. Absolutely. But it's been my experience that it's more often that physician is in and out. Out and doesn't stop to talk. If I see patients with dentition problems. I don't jump out and ask hey, are you using methamphetamine because access to dental care dental insurance in our area is is scarce. Right. The I don't know what it's like where you are water is not fluorinated where we are because people are afraid of the chemicals that are being put in the water, and no mount of public education changes are seems to change the underlying mistrust. Well, it's I'm not surprised in. It's it's this thing we learn about when you go through school, and you you see a little bit in the urban areas. But it is it's not something ideal that keep saying that again, and it is something that I feel like we have created kind of as a medical community wearing the white coat. The I know more than you talking down to patients, it's a culture that the providers have created. Did just talking at the patient Hauer. How your agency not better are you eating sweets as opposed to, you know, tell me what your meal looks like tell me what your day looks like did, you know, that rice is a carbohydrate because people don't know that like things like that. And how this affects your blood sugar and how fiber plays a role, and I think you can do this in like kinda being cheerleader. All these things that the conversation that you mentioned not everyone has one of my favorite lines that I tell patients is corn and potatoes do not belong on the same plate. Is a vegetable what do you mean? And then you hear about shepherd's pie. And you just have to you just have to laugh at that point. It's cheap. It's cheap food. And that's the problem is to eat healthy costs money. And when that is a matter of if that's the difference between keeping the lights on or the heat on. They're going to go with what works best for them. Right. And meeting people where they are is a huge part of what I think we do very well as nurse practitioners. I have an earned doctorate introduce myself as Dr and my next sentences. I'm a nurse practitioner. Please call me by my first name and immediately set that stage that I am at this exact same place that they are better. I am no worse. We're in the same spot. And I think we do that as a general rule. Nurse practitioners because that's what we've been doing most of our career when we've practices, nurses, or in your case when you practice emergency medicine, we use our first names to help create an immediate bond with the patient. There's nothing that in for lack of a better term intimate about being invited to use a first name, and that puts people at ease in in such an interesting way. It does end I've had patients it always happens at the end of the visit especially like, the older generation usually is older nails. They'll say, okay, you're Christine, and your nurse practitioner. Should I still call you doctor? You're not a doctor, but and they get really uncomfortable. But should I call you miss or what like what do I call you? I wanna respect you. But Christine seems to informal on. I say, no, please, call me Christine. I want you to call me by my first name because. I'm here to help you in to be your ally in this, and we're gonna work through things together. And I want you to use my first name, and I'm gonna use your first name because I want that relationship. I want that good relationship. They feel like they're disrespecting me. Like, no, I'm a nurse practitioner. You call us by our first names. I think it's always really horrible when they do that. When patients realize that we can identify with them. It changes it changes the dialog completely. They will tell us things that they would never tell anybody else in love those moments that patients start talking this. I've never told anybody this. I can't believe I'm telling you this said, well, you're in a good spot. And then we moved from there. But it builds a level of trust that is invaluable and that patient provider relationship, you need it. 'cause how are you going to be forward? Anything else is unique about your job or just that really strikes? You about what you do that you find really rewarding the appreciation. I think the most rewarding thing for me is the appreciation that the community in patients have for the services we provide we had a reasonably dangerous coating of. Vice overnight Monday into Tuesday, I had patients that called in canceled on Tuesday morning because of the weather, and then would ask to be put back to my nurse. So they could ask my nurse. If I made it in, okay? In it made us both chuckled. But you real- it really forces you to look at the impact you have on somebody's life at how important you are to them even without being family. They tell you things that they wouldn't tell their family, and they trust us with things that they wouldn't wouldn't trust anybody else with as that old adage there to people you never lie to your doctor and your lawyer. Yeah. It's so true. I said I'm changing jobs, and I have never been so flattered as I have been. I'm not even allowed to tell people where I'm going, and they said, that's okay. I'll look you up. I'll Google you. Multiple people have said they're following me. And it's I have never been so touched in my life. Is so humbly I changed jobs in November and move to a smaller community than had been practicing before. And so far, I think I've seen about a third of my practice has has made the transition. Wow, that's huge. I keep trying to come up with funnier stories. Honestly, I I don't have. I I I was thinking of them a couple of weeks ago that oh I should talk about that. And but they're just people always want to tell stories. I don't know what it is. This is not a comedy podcast. No, it is not. I don't know. Why everyone is like, oh, I wanna tell funny stories, and I'm like have you not been listening? This is a very depressing. To finish the story about the patient that that committed suicide, and I won't say the rest of it because it's there will be too much. That's dentist. The first patient. I had seen at that clinic and called the patient called their spouse and said, I'm gonna be dead by the time you get home. And there's nothing you can do to stop it. Oh, my God in you know, you ask you ask all the questions. You you go through the arts are you actively suicidal? You have a plan. What stops you from wanting to harm yourself? You know, all this questions, you get all the right answers. And then first thing in the morning after report because we hospital rounds before clinic. Hey, did you hear about fast forward two and a half years? The very last patient. I saw that clinic was their spouse. Oh my God. That was an apparently had been struggling the whole time. Time. And that was probably the hardest. Visit I've ever had. Oh, God it just knowing that that was that was who that was. And there were there for mood shape. No. You're not you're not now, you're not. So but. It's it's just amazing. What people will put themselves through. No. You had seen day. I shared that. At the end of the visit had do you might ask do you mind? If we keep this in because other something I actually wanted to share with you after you tell the story that's very similar. How did that go? Horribly uncomfortable. The patient told me about their spouse. And once I realized who the patient's spouse was and why they were there. I understood. More about what what was going on and disclosed that I had taken care of the patient spouse. And there was just silence in you know, you talk about. Therapeutic silences, I don't know that that was therapeutic. But neither one of us really knew what to say. In after I swear it was ten minutes. But I'm sure it was about thirty seconds. The patient said, you know. That threatened over and over and over again. None of us ever thought that the patient would go through with it. Oh my God. And. Coming home and seeing that and knowing that the patient, head had an appointment and. Was sent home. I was the patient is Thomas patient said that. Dismantle how it goes the atmosphere said. I was angry with you. For a very long time. And. After having met you in senior for this. Visit for again, a mental health problem. There wasn't anything. Anybody could have done. And he. The patient. Said thank you for the time. Oh my God. Because. The patient gut in headed understanding of what the visit had to have been like because it's the it's the same format you use for mental health visits when people have depression, and it's the same type of documentation, you're asking the same questions in you are trying to reach in probe and with this person not being with their spouse at the time of the visit that was unknown quantity. Right. And it wasn't until the end of the visit that I figured out who this person was in disclose. So there this person got an unvarnished view of the care that had been provided his spouse. So yeah, it was it was very challenging. Not something I would ever want to repeat. No, I would imagine. On any level. But. That whole being confronted that being said, you have your you have your huge successes that. Child under under ten days of age that my after evaluating this is what I see this is this is what I think is going on. If you see if you see nasal flaring, if you see retractions if you see gasping at all don't come here. Call an ambulance and go to the hospital later that evening the child e compensated is I was afraid or as we know. 'cause when they dicamba sate they're fine until they're not they're really not fine and the kid did amazingly. Well, and it was just two minutes of education as a small community that were gets around, you know, one of the nicest bad problems to have as people can't get into see you for four weeks. So I just keep opening more schedule spots. When you were telling the story of of that patient. I was reminded that. So actually sorry. So on Friday was my last date is clinic I took a little bit time. I took a week off and Saturday morning. I woke up to a text message from my old office manager that patients, and I'm going to be vague a patient that I saw very regularly was involved in a murder suicide, and my patient was the victim another regular patient committed the murder, and of course, it's a family practice. So, you know, the family of the victims, and I even knew the cops that were there. And then we found out based on the news reports I had seen the the real victim. You know in my office, maybe two days before I remember. She was difficult stick and while the full bottom was trying to stick her. I was asking her trying to structure so was like what are you doing this week? What are your plans? And what are you doing? You know, just how. You talked to somebody Weller I take an extra time just to talk to her because I knew she was really scared about it and treating for infection, and she probably didn't even finish the antibiotics 'cause she was martyred, and it was like. Oh my God. What if we had given that guy better mental health treatment that did this? What about this mother? You know? And I know we couldn't have I didn't see that guy often that did it. But it's because it was a domestic violence situation. It's just like. Oh, God in primary care. You have these relationships. And when I first when I first decided that I was going to be a nurse. I had always planned on doing emergency nursing. I don't know if it was drown rush, or what it wasn't until I got into nursing school and had the opportunity at the very very end of the bachelor's program. You have the externships or basically, it's an intensive you're on one unit assigned with one one nurse. And this is your final clinical experience, and you do that for X number of hours, and I opted for an ER and realized I hated it. Because I didn't get a connection, and that's the that's the piece. I love about family medicine is the connection you get to make with people. And you know, you can you can get in the room, and they can call you every name in the book 'cause they're ticked off at what you what you're telling them and have and need to tell them they need to hear the best feelings when they go out and schedule their follow. Visit yet just they've just spent ten minutes telling you how big able Yar and then scheduled the two week follow up because they recognize that what we're doing is for their best interest and not ours. You know, we've all got the stories in heck we've all been there ourselves. And I think when we use our own experiences to some extent when we're carrying our patient. It makes a big difference in the buyin that you can get. Yeah. When you show that you're caring. Yeah. It's it's so easy. In the nice thing about the physician colleagues that I have there. They are absolutely willing to help talk through things when there's a tough case. A what could I have done different or what should I have done different? And absolutely we'll talk through it, and how sometimes earth things that could have done different. And sometimes there is nothing different nothing else to do. Well, again, not a county podcast, but to end on a little bit of a lighter note, what is one of the one of the best compliment you've ever received from patient or. What's one of the nicest things was interested? You. I don't know that I could pick out one thing in particular for for me, the nicest the nicest thing experience that I get is I moved from I moved from my regional practice when I moved to the general area where I practice now. I have patients who are returning to my care that I hadn't seen in three or four years because I'm close again close enough for them to drive allocations. I've got several patients that will drive hour and a half to come in those those are my are my I feel good moments in my feel good stories. It's not necessarily about helping somebody who has done who has gotten from their a c down to goal or blood pressure has been at goal or or the change in their health and the gratitude there. Yes, that's rewarding in it's great to hear that. But I think the biggest. Implement. We get as providers is our patients come back to us or I keep I will hear things in the community. You know, if I seeing patient from the for the first time, they say, I will ask. So how did you end up finding us? And well, so and so told me that they see in their cousin sees in. Moms that you might know what you're doing. And so I should take a listen and my media responses while you can't trust everything you hear. They they tend to take that pretty well. Well, I think that's a that's a happier note to end. Well, thank you so much for taking the time to talk to me. It's always great to talk more about were medicine and primary care. Primary care. I think it's shit on a lot people realize what we do in that you have to know a little bit about everything in the you're really kind of the the center of everyone's medical care, especially now in certain types of medicine are so accessible for people in certain areas. They kind of forget about their primary care provider in how important it can be so agree. But clearly that is not the case for your patients have. I wouldn't trade what I do for anything. I would miss being in primary care and they're their times. I joked that I keep the application for a non healthcare related field filled out in my desk. Just just for after this really really crappy days. But at the end of the day, I wouldn't trade what I do that all and I don't think most of us would now it just means too much. You can't leave your patients. They find you do. Good, better indifferent. They will find you. So thank you. Everybody for listening. If you have been enjoying antidotes stories in medicine, please share us on social media or you can reach out to us as well. So follow us on Facebook at antidotes stories in venison podcast. You can join the the Facebook group which is into stories in medicine group. Follow us on Twitter, antidotes pod. My Twitter is Christine. The N P Instagram is antidotes podcast. And of course, thank you to Peter Hopkins for our custom using you can always mean Email at answer with podcast g mail dot com. If you just have any comments or you wanna be on the show as well. Jeff reached out to me. That's how he got on the show, and it's great people from all over the country all over the world. And I just I love hearing everyone in hearing your unique story. So please truly reach out. I I love you know, hearing what everyone does. So thank you guys. Again. I. With another episode.