As a physician assistant (PA) for the past 20 years, I have asked a million questions. I have assessed, evaluated, diagnosed, and treated a whole lot of patients. It is, after all, what we do as PAs and nurse practitioners (NPs) and we are good at it.
We are good at considering what the worst things the presenting problem could be — coughs do not arise from the same cause, headaches may have different origins, and back pain can be a sign of a number of maladies. This is one of the reasons why the practice of medicine and advanced nursing is such an art, it requires extremely broad vision and thinking. While we sort out the zebras from the horses, however, we may miss some basic information about the patient such as their activities and behaviors.
One thing frequently missed by providers is adequately inquiring about quantities of over-the-counter (OTC) medications being taken by their patients. I recently had a patient who presented in pain and we were reviewing her medications. She noted a complex array of medications including “occasional acetaminophen.” I was feeling a little overwhelmed trying to process the information about her medications in the context of the vague symptoms she was describing. Almost as an afterthought, I asked how much acetaminophen she was taking. She noted that she had been taking 2 tablets (500 mg) 8 times per day for about a year. I almost did a double take and asked again to make sure I had heard her correctly. This would equal 8000 mg of acetaminophen daily, double the recommended safe maximum daily dose of 4000 mg.
I have seen the omission of a thorough OTC medication reconciliation, including nonsteroidal anti-inflammatory drugs (NSAIDs), both in my practice and the practice of others. Taking “a little ibuprofen here and there” can mean extremely different things to different patients. Often a patient’s description of their medication intake, and their perception of what is “a lot” or “a little,” is influenced by the context of their experiences including what their friends and family do and what they have heard. Although we may be tempted to move on when someone says “a little ibuprofen,” we may be missing some essential and key information.
An example of how the patient’s unique context skews their perceptions of their medication intake is a patient I worked with many years ago. I was inquiring about alcohol use, and the patient said they saw themselves as a moderate drinker and that they had a few drinks each day. It would have been easy to accept that information at face value and move on but I decided to probe further. It turned out that the patient was drinking between a pint (16 oz) and a fifth (25 oz) of vodka daily — clearly a concerning amount. When I talked to the patient more, it became clear that they believed this was normal drinking based on the behavior of their friends and family.
I work in addiction medicine at an opioid treatment program (OTP). An example of context influencing patient reporting is something I frequently encounter when I ask a patient about substance use. When asked “how much heroin are you using now?” they often reply: “I have stopped, I haven’t used for a long time now. I am really pleased!” Further inquiry reveals that they have not used heroin for 8 days; which may not seem like a long time, but 8 days is a long time for them to not use heroin.
These examples remind me of how important it is to slow down when taking medical and medication histories, particularly medication reconciliation, and to try not to make any assumptions that would make you miss vital information. I also am reminded not to forget other small stuff, such as providing brief smoking-cessation interventions when patients note they are a smoker.
I have found that a brief note in a friendly manner can have a big impact. For example, “thanks for that information that is helpful! So let’s see, you started smoking when you were 14, and now you’re 48, so you’ve smoked for about 34 years, is that correct?” Often, the patient will appear shocked that they have smoked for so long, and comment about how they find that disturbing. The data shows that brief smoking-cessation conversations are often skipped by busy providers.
We all want the best for our patients. I am finding that working to remember the small stuff greatly adds to my ability to help keep my patients safe and healthy.
Jim Anderson, PA-C, MPAS, DFAAPA, is a physician assistant working in addiction medicine in Seattle.