by Tilda Shalof
“It sounds like what a general practitioner does.”
“Yes, it is,” she says with her confident smile. “We share the same knowledge base and skill set, but we work differently. For what ails most people, a nurse practitioner is the right person. If you need open-heart surgery – that’s something else. You’ll understand more after today,” she promises. “Any more questions? Fire away.”
“Do you treat people of all ages?”
“Yup, from womb to tomb. We have a pediatric suite with an examining table that is a smiling turquoise dinosaur named Monty. We also treat teenagers, many ‘at-risk youth,’ who are dealing with addictions, poverty, homelessness, mental illness, and gender confusion.”
I wonder if the boy with the dog on the street corner knows about this place.
“Babies, too?”
“Yes. In fact, our first client was a baby. She was left on the doorstep on the day the clinic opened. The mother was never located but the father came forward to claim the baby. With lots of support, he is now raising her on his own.”
Kathryn has a down-home style, a beautiful smile that appears readily, and intelligent, twinkling eyes. She’s glamorous, too, dressed in black pants and a black-and-white blouse. (Black-and-white is her signature look.) She explains that she runs the clinic in a “nurse practitioner” way, always ensuring that ample time is booked for each patient so as to allow conversations to unfold and flow at their own pace.
“We never want to hurry people along. We’re not managers or business people, so we have a lot to learn, but we know what we want and I’ve set the bar high.”
They offer extended hours and off-hours services. Same-day access is important, so the office manager and receptionists always carve out time for walk-ins. This clinic is funded by the government and also by private businesses and philanthropic donations. As word is getting around town, the practice here is growing quickly. Kathryn has hired two NPs, with plans to hire more, two social workers, a dietician, and a pharmacist and two nurses. “At times, we are running on fumes, but we never turn anyone away. What helps make us so efficient is that our two RNs practise to their full scope.”
“Full-scope” practice is a hot-button issue. It boils down to the fact that nurses have been underutilized. We have a lot more skills than we think we do. For whatever reason, nurses have held ourselves back from working to the full scope of our practice.
I ask Kathryn to put it into terms I can picture.
“The RNs in this clinic do full physical exams.” She uses the fingers of both hands to list their other capabilities: “Pap smears, pelvic exams, cancer screening, well-baby visits, triage acute patients, counselling, health teaching, chronic disease management. Soon, RNs will be able to dispense and even prescribe certain medications. Our two RNs, Katy and Elena, will tell you more about that. The point is, they do everything that they have the skill, knowledge, and judgement to do. It expands what we can offer our clients.”
This clinic cares for people who have complex, often chronic, problems. Many have never used the health care system before and have “complicated lives,” as Kathryn puts it. They are dealing with poverty, addictions, mental health issues. “Primary care is a different way of thinking about health. It looks at everything – medication, diet, lifestyle to help improve health and prevent disease. We spend a lot of time with each person and we’re in it for the long haul, not just when they have a problem.”
The clients she will see today have all agreed to have me sit in on their appointments.
The first one, Oliver, walks in with a professorial manner. He’s a portly but distinguished-looking man in his mid-fifties, wearing a tweed blazer, carrying a thin briefcase, with an unlit pipe in his mouth and a cell phone wrapped in bits of torn newspaper and hanging from his neck by a piece of binder twine. Oliver is delighted to see Kathryn and to meet me. He even shakes my hand with a slight ceremonial bow.
Kathryn hones right in on her first concern. She tells Oliver that the lab found trace amounts of blood in his stool. She has ruled out active bleeding since his hemoglobin is normal and unchanged, and it could be a “false positive” for cancer, but to be sure, she wants him to have a colonoscopy. He recoils at her suggestion and folds his arms in protest. Over the top of her computer, level with his eyes, she looks at him squarely, unequivocally. “This test will offer you a huge reassurance or it will save your life.”
Kathryn turns to me. “I have caught many colon cancers. It’s always best to find pathologies as early as possible.”
To help Oliver warm up to the idea, she offers a tip for the unpleasant preparation. “Choose the salty solution, not the sweet one. First, freeze your mouth with an ice cube. Have a glass of water ready. Throw the stuff back like a shooter, then down the water.”
They’ve been chatting casually for a few minutes, so when she gets up to take his blood pressure, there’s no chance of white-coat hypertension. “But,” she says, “if you’ve had even one cigarette in the previous hour, it will give a false elevation.”
“You know I quit smoking, Kathryn,” he says with a coy, unconvincing look.
But he walked in with a pipe in his mouth! Didn’t she notice that?
Oliver’s pressure continues to be high, and since it has been resistant to dietary changes, weight loss, and the medications she’s prescribed, Kathryn has decided to send him to a cardiologist, but she cautions him, “I’ve told you, Oliver. This cardiologist is very good, but he will only address your heart issues. Don’t expect more than that.”
“Thanks, I need the warning.”
Together they review his health risks. By using a chart, they discover that with Oliver’s medical profile, the odds of him having a cardiac event are very high. Oliver’s father died from heart disease, so heredity is also a factor.
Kathryn discloses something personal. “I’ll tell you both a secret. The reason that my passion for heart health is particularly heart-felt is that my father died from a cardiac arrest at the age of forty-seven.” I’m impressed by her willingness to be so frank and vulnerable.
“Heart health. We always talk about that, don’t we, Oliver? I’m on it. I want to bring your LDL down. A moderate amount of alcohol helps lower cholesterol, but I don’t want you to take this recommendation too far. Alcohol’s an issue, too, isn’t it?” She gives him a playful wink. “But one thing at a time.”
He looks overwhelmed and admits, “I am having trouble coming to terms with it all. But I am lucky. When I had a doctor, he’d only discuss one problem at a time. If there was a second problem I had to book another appointment. ‘No ticky, no washy.’ Kathryn has a job to do and so do I – to be a responsible patient and do what we decide I need to do. But” – he folds his hands and sits up straight – “I will not take the iron pills you’ve prescribed.”
“That’s fine, Oliver. I support that. We’ll do a complete review of your meds at our next visit.”
“Such a rigamarole.” He gives a resigned sigh. “I am coming to the realization I am not immortal. I am a gentleman with diabetes, lung problems, high blood pressure. But the iron pills are terrible. They gave me constipation. Very unpleasant. I will not take them.”
“I support that,” Kathryn repeats and moves on to bowel habits. “We live in a constipated society. Here’s what I do. Every morning, I sit on the toilet, whether I feel I have to go or not. This is how you train yourself to have a natural bowel movement first thing in the morning.” She turns to Oliver. “What are you doing about exercise?”
“I walk the cat.” He grins at her and Kathryn erupts in her unexpectedly boisterous laugh.
“Kathryn’s put me through the car wash.” Though he tries to act disgruntled, he’s anything but. “This is the best medical care I’ve ever received.” He shows us a graph he’s been keeping on his own of the past two months of daily blood pressure recordings and points to a row of peaks. “Here, I ran out of my beta blocker.”
“I’ll make sure to giv
e you a refill this time,” Kathryn promises.
Together Kathryn and Oliver look at a recent chest x-ray and review the results of his pulmonary function tests. Kathryn is waiting for a report from the nephrologist she sent him to because of his mildly elevated glomerular filtration rate, an early sign of kidney failure.
I’m beginning to connect the dots. Many of our critically ill patients in the ICU have one or more, or all, of these conditions, making their survival rates poor. What if you could get at them “before,” in the early stages of their disease, rather than “after,” when we treat them in the ICU and they are often at the end-stage of their health problems? Suddenly, the prospect of working on this side seems appealing, even exciting.
In between clients, Kathryn explains more. “When Oliver first came, I noticed precancerous lesions on his tongue. We got him to stop smoking.”
“But he walked in with a pipe,” I point out.
“It’s a prop!” And again, I get to hear that great big laugh explode from her, her body so compact and her demeanour so composed.
Kathryn tells me how she became an NP. She used to be a law clerk on Bay Street, doing sexy deals and living a glamorous life. At the age of thirty-five, she became terribly ill. “I had a raging fever and went into liver failure. My stool turned white, my urine was black as Coca-Cola. It was acute mononucleosis. When I recovered, I decided to become a nurse, but when I graduated I knew the hospital wasn’t for me. I need sleep.”
Kathryn worked in public health at a computer job, but one long weekend in May at a pool party, a friend suggested she’d make a good nurse practitioner. “I had no idea what it involved, but I called. Unbelievably, on a long-weekend Monday, someone answered.” Kathryn makes a telephone of her fingers and talks into her palm, the receiver. “They’d just had a cancellation, so there was a spot for me. ‘I think I’m in,’ I said to my friends. It was meant to be. Call it divine intervention.”
As we wait for her next client Kathryn explains that “360” is not just the street number. It’s meant to indicate that this is a full-service facility. She likes the message it sends about turning people’s lives around. Most of all, it pays homage to our Aboriginal population, to whom the circle symbolizes returning home, wholeness. The chief of a local tribe performed a smudge ceremony at the clinic’s opening ceremony.
Kathryn introduces her next patient. “Meet Meg, our poster child for the 360.”
It’s hard to believe Meg was once a heroin addict. She looks robustly healthy, radiantly happy. I would have guessed Meg is around fifty, but not so. “I’m pushing sixty-five,” she reveals. “When I was using, I looked eighty. Now, I get enough sleep. I take vitamins. I come here. I’m dealing with my problems.”
“We got you off cigarettes, didn’t we?” Kathryn prompts.
Meg nods. “I want to be here for my grandchildren. I’ve cut out alcohol, improved my diet.”
“What about exercise? Can we do anything about that?” Kathryn asks. “Your blood pressure is still high at 178 over 90 today.” She decides to increase the dose of Meg’s anti-hypertension medication and explains the importance of one of her other medications. “Statins. They’re our best weapon against cholesterol buildup. No one is going to have elevated cholesterol on my watch.”
Meg looks over at Kathryn affectionately. “I trust her. She’s changed my life, just knowing she’s in my corner.”
“Trust. It’s the only way to develop a partnership.” Kathryn smiles at Meg.
Her story of recovery is inspiring.
“When I was using, I lied, stole, cheated, conned. I worked the streets for drugs and I needed the drugs to work the streets. I thought I’d never be able to crawl out of that hell. Somehow I got to this clinic and met Kathryn. She gave me the message, I believe in you. You can beat this thing and I will help you in any way I can. When someone like her says that to you, you feel maybe there’s a chance. I came from Vancouver’s Eastside, the worst drug haven in the country. Now, I have a future, the respect of my family. I can hold my head up. I don’t go to support sessions because people there have a ‘poor me’ mentality. I don’t want to hear garbage talk. It’s not how long you’ve been abstinent, but the quality of your sobriety. I’d rather be with someone who’s been clean a few months but has a good attitude than someone who’s been clean a few years and gripes all the time.”
Meg still takes methadone, to keep her off heroin. She’s happy to teach me about the drug, as I know nothing about it. “It’s a synthetic heroin. It’s mixed in orange juice in a controlled dose so you can’t overdose. That way, your veins don’t get wrecked and you don’t get hepatitis. If you’re not clean you have to come into the clinic to get it every day and that’s a horrible place. After awhile, I got ‘carries’ to take home, which was more convenient for me.”
Meg had been using heroin to obliterate the memory of a childhood trauma.
“But I can’t tell you about it.” She closes her eyes for a moment. “It still affects me. I ache inside. Bad stuff happened. The other day, I saw someone on the street scrounging for butts. Not long ago, that was me. I was the one going through garbage cans looking for something to eat or smoke.”
Sometimes, there really are happy endings.
After Meg, Sean strides in with confidence, in a black leather jacket and tight jeans. He’s a bit rough around the edges, but handsome in a tough, rugged sort of way. He has a shoulder injury, but seems to forget about that when he gets to what he really came to tell me.
“When I used to have a problem, I’d go to the ED. I only came to this clinic to get a prescription refill, but she” – he points at Kathryn, pretending to accuse her – “wanted to do more. I want my wife to come, too, but she says she’ll only go to a doctor. ‘Why?’ I ask. I get everything I need here. What I like about this place is that they’re not bossy. I don’t like anyone telling me what to do. But I have stopped buying my smokes from the reserve, even though they’re cheaper, because Kathryn told me they’re full of poison.”
“Many of the toxins in cigarettes are the same as the ones in lawn pesticides, rat poison, lighter fluid, and rocket fuel, and yet we voluntarily inhale them into our precious bodies?” Kathryn asks. “Sean, you tell me when you want to stop smoking altogether. We’ll be waiting to help you when you’re ready.”
“I’ll let you know.”
“I’ll support you wherever you’re at with it.” She turns to a new subject. “Okay, how about sex? How long’s it been?”
Sean has erectile dysfunction, and Kathryn has told him that can be an early sign of heart disease. The arteries in the penis are the smallest in the body so they’re the first to clog up, preventing an erection. Smoking and alcohol can decrease function, too. Kathryn hands him a pack of drug samples. “Try these and enjoy. If your erection lasts for more than three hours, go to the emergency department.”
“Just like they say on TV. So, what do they do for that? Send me to the head nurse?”
Kathryn turns to me. “I always talk to my clients about sex. They usually don’t raise the topic themselves but it’s an important human need. Elders especially crave touch, being hugged. For some patients, I actually prescribe sex.”
“What’s the recommended dosage?” I joke. She laughs with me, but she’s serious about the therapeutic benefits of sexual health, listing its cardio benefits, endorphin production, and depression-boosting effects related to right prefrontal cortex stimulation.
She returns to Sean. “Is there anything else I can help you with today?”
“How to survive without hockey.” He looks glum. There’s been an NHL strike and there’s no sign of resolution.
“Sorry, can’t help you with that,” she says cheerfully, obviously not a hockey fan.
“Well, I still have shoulder pain but I go to physio and try to keep a stiff upper lip,” he says, then mutters under his breath, “Let’s hope something gets stiff.”
Kathryn moves on. “How about booze?”
“Not much. I’ve cut back. I drink it for the buzz, not the taste.”
“What about a change to light beer? Make an agreement with yourself, not me.”
“The treatment I get here is excellent,” Sean tells me as he stands up to leave. “I feel the people here are genuinely concerned for my well-being. There’s no bullshit. From day one I had trust in this place. I’m never rushed and I never have to wait. Honestly, I think Kathryn cares more about me than I do. They gotta clone her.”
As we wait for the next client, Kathyn notes, “We often have late arrivals or no-shows. Not everyone can organize life like we do.” She points at our smartphones and daily organizers.
Jade walks in tentatively. She is thin with a sallow complexion and looks frail, but summons impressive vehemence to express her anger at Kathryn.
“Why didn’t you refill my pain meds? When they weren’t with my other meds, I had a panic attack. My body was vibrating. It put me in a dark place. How could you do this to me?” Her fists are clenched at her sides and her eyes are blazing with rage.
“The medication you are asking for is not the norm for what you describe as depression and fibromyalgia.”
“You made my condition worse because you wouldn’t order my pain meds. I had to go to two doctors to get what I need. I didn’t want to get into such a bad state that I’d end up having to go to the hospital.”
Kathryn sits calmly. “I’m sorry I can’t give you what you want –”
“But there are doctors out there who will. Why won’t you?”
“Oxycodone is not the drug you need, and it has side effects, as you know. These may not be the answers that you want to hear, but –”
“But some doctors do have the answers! I’ve tried the antidepressants, pain patches. Nothing works except the oxys. I can’t seem to get across to you the urgency of my situation.”
“It’s not in your best interest to order that medication,” Kathryn says kindly but firmly.