1. Byrd, Stephanie DNP, APRN, FNP-BC


An inexperienced NP pushes past her self-doubt to ask the hard questions.


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Nurse practitioner students are taught to take thorough histories, carefully consider differential diagnoses, and perform detailed physical exams. Then they graduate and face the reality of clinical practice. Schedules are busy, patients are often double-booked, distractions are plentiful, and time pressures can impede good patient care. At the start of my career, I understood that the path to making the correct diagnosis was challenging, but I didn't anticipate the many twists, turns, and roadblocks ahead. At times, I was tempted to take the quickest route, but I learned from a memorable early encounter that this wasn't necessarily best.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Janet Hamlin.

I was green, still honing my skills, and working under the constraints of 20-minute visits in a busy family practice. I saw J. on my schedule, a 38-year-old woman with a chief complaint of "medication refill." Quickly reviewing her record, I saw that a physician in my group had diagnosed her with rectal bleeding secondary to hemorrhoids just a few months before. Two weeks later, she'd returned for a follow-up and a second physician confirmed her diagnosis. She noted improvement with the cream and sent her on her way.


Everything seemed straightforward, and I was happy to have an "easy" patient on my busy morning schedule as I grabbed the chart and knocked on the door. A pleasant voice told me to come in, and inside I found a smiling, heavyset woman dressed in a red-striped knit top and jeans. She had her baby girl with her who, to our luck, was sleeping soundly in her carrier. I introduced myself and asked how I could help her.


J. described her diagnosis of hemorrhoids following her recent pregnancy. The prescribed cream was helping, but she was out and needed a refill. She'd seen an occasional spot of blood on the tissue, but said she wasn't worried. I thought her previous diagnosis and treatment plan made sense, and I was tempted to go ahead and refill the prescription. But I knew I needed to get a good history and do a physical exam for myself.


I asked J. more questions. She said she'd had loose stools for several months, beginning even before her initial visit for hemorrhoids, and thought she was having flare-ups of irritable bowel syndrome. She reported no other symptoms or risk factors for malignancy. Time was ticking, and I debated skipping the dreaded rectal exam, but I knew I needed to proceed. Having confirmed the existence of hemorrhoids, I immediately questioned my choice to put her through all this for refill of a cream that was working. I asked her to get dressed and left the room to consider my options.


Although hemorrhoids were the likely source of her bleeding, her change in bowel habits was concerning. I pondered the costs and risks of further testing and considered recent research on the negative consequences of incidental findings. I recalled a patient who almost died from a bowel perforation from a colonoscopy. I didn't want to overreact, but I knew what I needed to do.


When I walked back into the room to tell J. my concerns, she was still smiling. I told her that cancer was unlikely, but we just needed to rule it out. After reviewing the risks with J., I ordered a complete blood count (CBC) and a colonoscopy.


The CBC returned normal later that afternoon. Another negative. Learning this, I became even more worried that I was overreacting and putting my patient at undue risk. One week later, I had my bag on my shoulder and my hand on the door to head home after a busy day when my nurse called out that Dr. N. was on the phone. I needed to get home, and I didn't know Dr. N., but I walked back in and took the call. Dr. N. told me that he'd performed J.'s colonoscopy and found a "huge cancerous mass" in her colon. He told me it was a good catch. I felt sick. I put my bag down and called J.


J. had already received the news and was in good spirits. She was grateful that the cancer was found and planned to stay positive. I never saw her again, and I don't know if finding the cancer when we did led to a better outcome for her or not, but the lesson of her case stuck with me: never cut corners. I learned to always consider differentials, not to assume, and to do a thorough history and physical for myself. I learned not to overlook the can't-afford-to-miss diagnoses, and to explore abnormal findings. I learned that unpleasant exams and procedures are sometimes necessary. I also learned that close follow-up care and "call-if" recommendations can be crucial.


Adhering to best practices amid competing priorities and time pressures can be challenging. I am thankful for the lessons I learned while caring for J. I share this story with my students in the hope that they will know the importance of not cutting corners.