By: Alexandra Norcott, MD, second-year internal medicine resident at Yale-New Haven Hospital and member of the West Haven Veterans Affairs Center of Excellence in Primary Care Education (CoEPCE). She plans to pursue a career in general internal medicine with subpecialization in patient safety and quality improvement.
“On average, how much alcohol do you drink?” I questioned the sixty-three year-old veteran.
“About fifty beers a week,” Nate nonchalantly retorted. I noticed his cherry cheeks, accented by the red sailboats on his Hawaiian shirt.
“OK. For about how long?”
“About as long as I’ve been married—about thirty-nine years.” He ran his hand through his shoulder-length white hair.
“Have you ever tried to cut back? I’m really worried about your triglyceride level. It’s dangerously high and related to your drinking.”
“Sure!” He playfully chimed. “I’m not going to cut back though.” His eyes twinkled. “I’ll take all the pills you want, Doc, but I’m not going to cut back on my drinking or smoking. Non-negotiables.”
Ten minutes later, I sank into the wooden chair in front of my interprofessional precepting team, a team unique to our CoEPCE and designed to allow trainees with different clinical backgrounds to learn and work together to improve patient care. Dr. N, APRN Nancy Smith, one of our health psychology fellows named Charles, and a pharmacy resident named Madeline leaned in as I started.
“Nate is a 63 yo gentleman with coronary artery disease, poorly controlled diabetes, post-traumatic stress disorder, and heavy alcohol and tobacco use who is here for a routine visit.” I told them about Nate’s high fingersticks and alcohol use, reviewed his physical exam, and highlighted his A1c of nearly 10 and triglycerides of nearly 1,500.
“I think most of his issues stem from his drinking, but honestly I am doubtful I can change a thirty-nine-year-old habit,” I offered.
“Alex, do you think he would be willing to meet with me?”
“He seems preeeeeetty content with his drinking, Charles.”
“We could couch our meetings as opportunities to leave the house. He’d probably go for that. The appointment sheets just say he has an appointment in primary care. It looks like he hasn’t had any issues getting to his appointments.”
“It’s worth a shot, I guess.”
“I’ll come to the room with you. We can introduce health psych to him, and he’ll learn I’m not an ogre.” A warm handoff—one of the unique benefits of working together.
“We can also safely start gemfibrozil if we lower his rosuvastatin to 10mg,” added Madeline.
“Be sure to counsel him on the signs of pancreatitis and have Seth (one of our nurse practitioner fellows) follow up with him when you’re in the ICU next month,” Nancy reminded me.
One year later, Nate did exactly what he said he wouldn’t: He cut back. Surprisingly, he met with Charles throughout the year and reduced his drinking by 75%. His triglyceride level is the lowest it’s ever been (423), his A1c is 2 points lower, and he boasts more energy since losing twenty pounds. Moreover, he says his relationship with his wife has never been stronger.
I believe that the key to Nate’s success was that he had been moved to one of the interprofessional teams described in Meyer et al’s recent Academic Medicine article. While all these resources had been individually available at our hospital, having them in one place made them more accessible to Nate and more familiar to me. In less than one year, Nate accomplished things that he had not been able to do in thirty-nine. Nate is healthier and, more importantly, happier for it.
Prior to the CoEPCE, my exposure to clinicians with other training backgrounds was limited CNRAs in the operating room. I had never heard of a “health psychologist,” understood the role of a nurse practitioner, or thought to send my patient to pharmacy to aid with diabetes management. One year later, I involve these colleagues as often as I can and cannot imagine practicing outside of this model. By learning and working together, our patients are healthier and happier. As for Nate? He’s now conquering another “non-negotiable”: Smoking.
Author’s Note: The names have been changed to protect the identity of those described.