Wednesday, December 19, 2007

What's in a name? A really long post, that's what

Today's post comes to us courtesy of the Reader Mailbag, where a sharp and doubtless lovely person named Barb writes:

OK, so I've got a question for you.

Is there a "proper" form of address for a PA? or is it an individual preference?

I ask because at my husband's neurologist's office the ratio of time spent with the PA to time spent with the doctor is running roughly 25 to 1 in the PA's favor. Calling her by her first name seems somehow not quite right, (too casual and familiar, I think); but calling her Ms {lastname} feels off-kilter, too.

Ahh, yes, Barb, one of the eternal questions of PA-dom. This is just one more way in which the pioneers of the field... how do I say this kindly... kinda screwed us (without meaning to, of course).

The best answer is that it's an individual preference, and if it were me, I'd just go ahead and ask your PA how she feels about it. It could be a non-issue, or you could prompt the kind of long-winded discussion I'm about to launch into. I agree, that using "Ms. ______" in the context feels weird, as though you're talking to a grade-school teacher or you're entertaining a guest in the parlor for tea.

Within the PA profession, there are some even sillier ways to try and be formal, there are ways to just ignore the difference between an MD and a PA, and then there's the first name thing. There's no perfect answer. In my experience, most of the time fellow practitioners of all levels use first names with one another, and patients call everybody "doctor" whether they are one or not.

In the small town where I shadowed a PA for 8 or 10 weeks, everybody in town was on a first-name basis anyway, so those PAs used the trusty first name basis. One guy explained that the weirdest part about practicing medicine in the same small town where you grew up was the collision of the social roles -- guys he had played football with now needed yearly prostate checks; their wives, some of whom he had dated in those high-school days and some of whom had turned him down flat, needed Pap smears. And come to mention it, so did some of their moms. So the small-town factor was bigger than the problem of what to call people.

Even so, I couldn't help noticing that with the MDs, many of the townsfolk seemed reassured by the ability to use the title "Doctor" in speaking with them, probably for the sense of decorum and legitimacy it imparts. After all, when you're in the exam room getting that super-personal exam, I imagine it's easier if you can think of those gloved hands as belonging to "doctor" somebody, rather than "good ol' Bill, the kid who really loved tater tots, and peed his pants in third grade*."

The really nervous patients called the PAs "doctor" too, out of a sense that they basically do the same job. And for all that's about 99% true, it's still incumbent on the PA to gently say, "actually, no, I'm not a doctor. I have a [Master's / Bachelor's / Whatever] degree in Medicine, not a doctorate. So just call me _______, okay?" And I've heard a few versions of that speech, in many settings. After a few years out of school, PAs seem to settle into a mode where they will give it their best shot, and if a patient insists on saying "doctor" anyway, correcting every usage doesn't seem to help.

From its conception, the PA role was always meant to dispense with that kind of formality and social hierarchy. It was the Sixties, after all, and there was a legitimate need to question all the stuff that had built up over the years, around the idea of doctor-hood. No doubt there are situations and people even today, around which rather a lot of that not so desirable, paternalistic, know-it-all identity has built up. On the other side of the coin, fewer of today's patients listen to what somebody says just because they have extra letters after their name... for better and for worse.

PAs were meant to be different in several ways, and that lack of entitlement was one of them. The profession grew in part out of wartime experiences that proved to the grander institution of capital-M Medicine that a competent, hardworking man or woman could be trusted with serious medical stuff even though they'd had less of the advanced hard-sciences-style training -- as long there was a solid foundation in how to think about and how to perform the component tasks of medicine, and as long as the conditions were right. Meaning, if help is available from some Captain not so far away, you can trust a Lieutenant to patch somebody up M*A*S*H style, or treat all the runny noses on base. As a matter of fact, the PA can be trusted to treat 3,000 runny noses and STILL catch that one brain tumor, with the right training. And so that's the training we get.

But for all that, in the planning stages it was decided that we should never really try to cross over into that special, ill-defined, highfalutin' area that marks where official doctor-hood starts. Some of it is politics, of course. Some is a return to the good ol' accessible "country doc" spirit of the earlier 20th century (and Star Trek), and some is a look forward to a more competency-based way of thinking, where a person's title means less than their skills. Over the years this has played out in good ways and bad.

We saw a video in one of our classes last term, demonstrating some ethical dilemmas and providing a point of departure for some really good discussions. One thing everybody commented on was the way the people in white coats were calling one another "PA Smith" and "PA Jones," as in, "I see here in your chart that you spoke to PA Jones about this." Our instructors assured us that we would not have to act like gigantic dorks and call one another "PA" anything. It turns out that's how it's done in the military, bless their hearts, but after all that's an environment where titles give important information and everybody has one. Calling somebody by a first name there might be an embarrassing breach of protocol.

And lastly, I was really fascinated by something I noticed back in my job at the County ER: as the Emergency Med residents got farther and farther in their training, they seemed to appreciate the PAs more and more. The way this manifested sometimes was that the senior residents, the ones about to graduate and go out into the world to become attendings, would be talking with patients and refer to the PAs as "doctor [lastname]." I found this to be pretty weird, but eventually caught on that it was the same kind of shorthand that patients use, where the word "doctor" doesn't mean "person who has completed a terminal degree that's beyond what other fields might consider a grad program," it means "person who completed a program sufficient to allow that person to provide medical care," and even more than that it means "person who provides medical care."

Which is all pretty cool, I suppose, because it means that in some places, the idea of competency over credentials is becoming the reality. And that's nice. But I specifically didn't want to be, and don't want to be, a doctor. So I will be correcting people, both patients and colleagues, at least once.

Hope that answers the question, Barb. Thanks for reading!

* There is no story about any of the nice practitioners in that town peeing themselves. At least, not as far as I know.

Thursday, December 13, 2007

I also knew this season of "Heroes" would be lame

Here's me, in October of last year:

" pal, future Golden Globe-winning screenwriter (and eventual Hollywood Squares center square) Diablo Cody..."

Here's today's news:

"Besides Cody's screenplay nomination, "Juno" was nominated for best comedy or musical. Star Ellen Page, who portrays a precocious 16-year-old who decides to give up her baby to a yuppie couple, was nominated for best actress in a comedy or musical."

Yes, yes. Those chickens don't hatch until January 13. Duly noted. I'm just saying, is all.

Hollywood Squares 2025 will be rated TV-14, for adult situations, suggestive dialogue, and fantasy violence.

Monday, December 10, 2007

Fairly Legal

I'm not sure if you're aware of the state of the medical Blogosphere, but in the past year or so, there has been a spate of closures of medical-type blogs. To be sure, there are some shining examples of ways in which working health-care types can enlighten, opine, and entertain. Many are a great read, some are intellectually and/or politically challenging -- but I guess it's an endeavor that is not without risk. In these waters, there be sharks. Arrrr.

When I started this little experiment, I was sure to make mention of HIPAA, the medical privacy law, as it applies to blog postings. I'm aware of where the rough outlines of appropriateness start to blur even more than usual... and in fact, I'm one of the few people I know who has actually read the text of the thing. Even so, when it comes to guidance, there's really nothing concrete, and nothing a poor student could call reliable. Because nobody really knows. Like so much of law, once you get into it a little, it's more a conversation than an edict from on high.

No, I'm not closing down the blog. I'm just long-windedly saying that people act like HIPAA provides a clear, bright line, when it really doesn't. The best a guy can do is to keep the conversation going. So, when I started school last summer, I had a conversation.

The handbook for my school seems pretty up-to-date, when it comes to real-world questions. There's a policy about the finer points of how and when alcohol may be served at school events, for example. I am expressly forbidden to use not just school computers but also school bandwidth to download pornography (or, presumably, to upload it). Care is taken to let me know that the use of the school's name and logo is controlled, and there's a procedure to follow, when it comes to getting a possible class t-shirt design approved.

Yet it says nothing about blogs.

My opinion, based on my interpretation of the law, is that writing here is a part of my learning process. It's a tool I use to reflect on the ideas and experiences that will make up the foundation of my training and eventually, my practice. So if I'm doing well, writing here is part of a system that is getting good results. If I'm struggling, the blog might represent a means by which I can identify and address problems I'm having with my own learning process.

As I've said before here, losing out on academic or professional standing because I keep a blog would be mortifying, not least because I like to think of such conflicts as avoidable. I am still (relatively) young and naive as I write this.

So, in the first week or two of classes, I sat down and spoke with the director of my program. I told him that this blog exists. I explained that thematically, it's about the story of how I got from where I was to where I am now. I mentioned that a handful of interested parties, most of them family and friends I talk to in the real world, keep tabs on it, in a loose way. I said that I can't expect it to be totally anonymous, but I make an effort to at least obscure details, and explained to him a few of the minimum things involved in my process for doing that.

He said it's cool. As long as I don't mention individuals by name, and I don't specify the name of the school or be too very detailed about its location, he sees no problem.

So... have no fear that I'm jeopardizing my present or my future. If you've got questions about what "studying medicine on fast-forward" is like, or about the deal with the PA world, give me a shout. It's nice that a core group tries to keep tabs on me this way, and it's always fun when unexpected people pop up, having followed me from more interesting places.

I'll try not to be so terribly cheese-sandwich-ey, but then again the definition of a blog is personal writing that is interesting... to the person writing.

I have a break coming up soon. This could be a good time for me to perk this place the heck up.

Sunday, December 02, 2007

In The House

So, we have a new class this term. It's called "Clinical Decision-making." And it is AWESOME.

I am practicing (and hopefully, perfecting) the art of differential diagnosis. You know how on House, about 30 to 60% of any episode is sitting around and thinking about "what it might be?" That's what this class is. Naturally, I frickin' LOVE IT. (And yes, I have already whispered "it's lupus!" to the person sitting next to me.)

It's like being a Cheers fan, and having a class where you're asked to drink beer and insult each other. Or being into Miami Vice, and taking a course where you use the door of your Ferrari as cover in a gun battle where for some reason nobody's wearing socks.

The class happens each week, over a couple of days. On the day of the class, we have to write up our first impressions, and what our next steps would be. That night, the Web portal for the class shows us what the lab results and images and whatnot tell us. If we asked the right things, we can assume we now have those answers, and those go into a write-up that's due the next day. It's really fun, and exactly the kind of thing that I learn from. Back in EMT training, I killed one such hypothetical patient, and still remember those lessons. So far this term, no imaginary sick people have cacked it on my watch. Knock on wood.

So far, I have correctly recognized a Congestive Heart Failure case and a heart attack. Nice to know I can make 2 and 2 equal 4, I'd say. I was too conservative with the CHF'er, and wanted to wait for some labs to come back before getting some meds going. I was sure to say "STOP FUCKING SMOKING," though maybe not in those exact words. For the heart attack, it was presented a little cleverly, such that not everyone in the class saw it as what it was. My treatment plan was maybe a little too cute: it went, "1: CALL 911. 2. Do everything else in the ambulance and/or in the ER." I did go on and explain what 3-7 would be, but only grudgingly.

I also could have done more to treat the irritating chest pain the patient was suffering. Sorry, fake patient. Next time I'll give you some morphine for your ride in the fast boxy truck.