The Value of a Truly Good Doctor..Or Is This a Doctor? An Argument for PAs
Denver Health is one of those sprawling campuses that take up multiple city blocks. There several free parking facilities (an endangered species, if there ever was one), and after parking, it’s easy to get lost trying to find your building.
Which is what happened to me yesterday when I took off for my neurology appointment armed with only my Google map, leaving the office and location on my kitchen island.
Sigh. I hate getting old.
In this case it was for a neurology appointment. For the life of me, as a kind doctor was squiring me around in search of my building, I couldn’t think of the word “neurology.” This is one of the reason I’m seeing someone. After twenty cracks to the coconut, I am dealing with near-daily migraines, and all the effects of post-concussion syndrome. I had been referred to this office for Botox injections, about which I had deep misgivings. The two VA neurologists I’d met with some months ago insisted that this was my last resort.
The check in area was jammed, the computers were having glitches. When it came my turn, the receptionist had difficulty checking me in because my VA card doesn’t have a group number. Such issues give front line employees endless headaches as their systems aren’t set up for anything that doesn’t fall within certain parameters. I waited, reading stories on my phone while the women finally found a way to check me in. I wasn’t expecting much.
The last time I was at Denver Health was in 1972. During a wild night of partying the night of July 4th, I had leapt out a first story window at the Kappa Sigma house at the University of Denver campus- mind you I was stone cold sober, but terrified- when the frat boys began spraying the inside of the building with hoses. I fell into the window well, my foot went through a small glass window and I severed my Achilles’ tendon like soft butter. That earned me a trip to this campus for a repair job. It was a hack job but I could walk. I still have a big, fat, ugly scar on my ankle.
This campus then, as now, serves a very broad population, and then, as now, a great many of us couldn’t pay. So after being referred here for neurology care, I wasn’t expecting much, as I might in a very expensive specialty clinic.
I needn’t have worried. In fact, the common misperception that a very expensive specialty clinic would result in better care probably costs us that very thing: better care.
After a surprisingly brief wait I was ushered into an exam room. Then Brandon walked in.
Brandon’s a Physician’s Assistant. PAs are becoming vastly more common these days, as there is an expected 72% increase in PAs through 2025 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3151188/). One advantage is that they’re cheaper and can be graduated faster than primary care physicians. Some 65% are female. I’ve dealt with PAs before and almost every single time I’ve found them to be as well-informed and far less arrogant than doctors, which makes them vastly easier to work with.
After having been informed in no uncertain terms that I would have to have Botox injections- and let’s make this clear, that’s thirty one injections, about every two months, from now on- to solve my twenty migraines a month, working with Brandon was a joy.
First of all, Brandon asked me a whole different set of investigative questions. We spent a good bit of time tracking migraine patterns and behaviors. We explored multiple options, especially since I’d made it clear that I wasn’t willing to use additional pharmaceuticals. The only pill that works is Imitrex, and with twenty migraines a month or so, taking that many sets me up for a stroke. I want to stop using it completely.
What set Brandon apart from the neurologists was his knowledge of herbal and alternative remedies. These weren’t even discussed or offered by the doctors. In this way, Brandon is far more of a shaman, informed by Western medicine, than those specialists who end up with blinders on because their only options become pills and procedures.
Brandon and I ended up spending more than an hour together, which is nearly unheard-of in today’s push-’em-through system. By the time we were done, not only had Brandon helped me identify what my headache pattern indicated, but he also had identified two non-drug therapies that I could try without embarking on a lifetime of hundreds if not thousands of injections in my neck, head and face.
In fact, once I learned that the Botox protocol involved 31 injections, I was out. Especially since I do adventure travel, and am gone for months at a time. This isn’t a reasonable expectation. Besides, I HATE needles. And, having done my due diligence on Botox, I wasn’t a fan of having botulism injected near my cranium, which already has plenty of its own issues. Brandon had other options to try, including a TENS unit which I already own, and a single shot to calm the irritation around my sub-occipital nerve, which is where my headaches originate. Now that’s reasonable. This was a vastly more targeted approach which took into account not only my aversion to needles but also the fact that I simply don’t trust Botox. The potential side effects are awful.
None of these remedies, including a host of other options including dry needling and herbs, were even mentioned by the doctors.
Here’s my point. Brandon, who is in his thirties, is immensely likeable and a great listener. He’s also a problem-solver extraordinaire. Armed with plenty of good training as well as a full quiver of alternatives to traditional medicine, his world view is much broader in terms of offering options to explore. That makes his advice very powerful. While Brandon doesn’t have the extensive training a neurologist has, what he does have is the freedom to explore a host of other options ranging from the aforementioned TENS unit as well as massage, meditation, stretching and supplements. I heard nothing of this from any neurologist I’ve seen, and given my headache record (beginning in 1974), I’ve seen my share.
Given that he has more leeway to advise his patients — and by this I mean that he’s not limiting himself strictly to pharma or procedural outcomes — Brandon is able to negotiate a series of protocols that allow me to pick, choose and commit to programs that I am both comfortable with and confident about. When I walked out I had an 81/2 by 11" sheet full of recommendations ranging from supplements to OTC machines. This puts my care right into my hands, where it belongs. I walked out of his office educated, and enthusiastic about getting my migraines under control and being able to either vastly reduce or fully stop using Imitrex. I’m jazzed, not only because I had an excellent experience with Brandon, but also because I am armed with options and know I have a health partner. I rarely, if ever, feel that I have this with traditional doctors.
Not all of us are comfortable, or even very well-informed, about a PA’s job.
According to a national survey last year by the American Academy of Family Physicians, 72 percent of Americans prefer physicians for information related to their medical care, viewing them as more knowledgeable and experienced. https://www.nytimes.com/2014/08/03/education/edlife/the-physician-assistant-will-see-you.html
This tells me that we still have a long way to go. For my part, I vastly prefer working with someone who listens, educates, challenges my assumptions, and expects to work with me rather than dictate to me what I should do, as though I were a clueless kid. Brandon got it right away that I’m committed to wellness without pharmaceuticals if at all possible. What makes him different from most other specialty health care doctors is his combination of questioning and careful listening. Doctors aren’t rewarded financially for spending more time. However doing so prevents misdiagnoses, and it also allows your PA to get a real bead on what’s wrong- which might not be at all what you think.
My Veteran’s Administration primary care provider or PCP is a nurse practitioner. She’s also a jock, a marathoner. I chose her because first, she’s a woman, and second, she’s an athlete like I am. These combine to create a different level of conversation and cooperation about my health care. I don’t encounter the condescension so common among older doctors whose god complex or ties to pharma corporations make them at best, useless, and worse, very dangerous. She gets my commitment to wellness and prevention, and she fights with and for me to obtain it.
In a system where good healthcare is hard to find, Brandon, and those like him, are gems. I am far less worried about his non-physician status than the quality of care, his ability to help me suss out and identify the problem, then offer me a wide range of options that include alternative options that keep toxic meds out of my body. That’s the road to wellness, and vibrant health.
That’s what a healthy healthcare system provides. For my part, I’m moving away from doctors and more towards PAs and NPs. Largely unencumbered by professional arrogance and righteousness, many, if not most, do what doctors used to do: doctor.
Credentials are nice. Results are nicer. Patient prejudice about credentials might prevent a great many of us from receiving superb care. I vastly prefer collaborating with an NP or a PA to keep me well as opposed to having an impatient doctor dictate treatment that solves symptoms but doesn’t address the source. The latter takes time.
If we want quality of life given the time we have, which is remarkably limited, we need quality care. Increasingly, as PAs and NPs take over more and more responsibilities in our healthcare system, this might be a shift in the right direction, especially if Brandon is a prime example.
Got a PA instead of a doc? Give them a chance. You might just be reminded of what real doctoring should look like.