Incognito at the Urgent Care

My husband, like every other doctor’s spouse, or maybe like all husbands, is the worst patient in the world. He was that way when I met him. Being married to me hasn’t changed him.

He’s resistant to medical care. 

After a few days of a particularly nasty cold, in the middle of the night, he starts coughing uncontrollably. He wakes me up and asks me to get my stethoscope. He’s unable to get out more than about two syllables without coughing.

I get the stethoscope. I detect nothing except some wheezing. I dig a cough suppressant out of the medicine cabinet. He takes it and goes back to sleep. When the alarm clock goes off, he turns it off and rolls over. 

I get up and go to the living room. I enjoy being up before everyone else. I use the quiet time to work on an article for my Substack. Hopefully you have already subscribed to it, but here’s the subscribe button in case you haven’t:

About an hour later, he texts me, “should I go to the clinic?” 

When Mister I-don’t-need-no-doctor asks about going to the clinic, you know it’s bad.

I respond, “No. Urgent care! You need a chest x-ray.”

One feature of being a doctor is that friends, family, and patients tell me horror stories of their encounters with the healthcare system. Doctors don’t usually experience these things themselves because, unsurprisingly, we get treated a bit differently. But there I was, incognito, at the urgent care center with my husband, who has a surname different from the one I use professionally. It’s an opportunity for me to see the kind of care regular patients get. I decide to stay undercover.  I’ve been a doctor in this area long enough that some nurses and doctors at area emergency rooms recognize me, but no one at this urgent care center recognizes me. 

The physician assistant barely notices the patient

A very young physician assistant enters the room and is briefed about her 65-year-old patient. He is reporting severe coughing, problems breathing, and severe lethargy. His condition began nearly a week ago with cold-like symptoms, then became bronchial with severe mucus secretion. 

She doesn’t bother to look at his throat. Or his ears. Or his nose. She listens to his lungs and heart, holding her stethoscope over his turtleneck. She’s unaware that he’s wearing a t-shirt under his turtleneck. She can hear wheezes, but any crackles could be clothing or lungs. Who can tell? 

She asks about shortness of breath. Many 65-year-old men cannot climb a flight of stairs without breathing heavily. This one still goes up short sections of stairs two at a time, and climbs the highest mountains in New Hampshire. He says he’s not experiencing shortness of breath, but he also says he’s too tired and weak to walk at his normal pace. I interject to tell her he was out cross-country skiing just a few days ago. 

Perhaps she has a great poker face. It’s easy to have a poker face when you’re wearing a surgical mask, which she was. But I cannot discern that she has figured out why I’m telling her this or, failing to understand somewhat of a non-sequitur, why she has no curiosity about why I’m telling her this. Maybe she’s thinking, “It’s another person who can’t stay on topic. I’m too busy for this today.” 

The point I intended to make was that we don’t know whether he’s short of breath because he has really good lung capacity. He’s so lethargic right now he’s not anywhere close to his limits. I sense I’ve failed to get this point across. 

My husband understands what I’m getting at and sees that the physician assistant is missing it. He tries to talk but just ends up coughing.

She orders a chest x-ray which comes back normal. 

I ask, “His symptoms are consistent with pertussis. Do you think he might have pertussis?” 

She replies, “Oh, no. That’s been practically eradicated here. There’s not been a case of it in years.” 

I mention that a nearby town reported an outbreak seven years ago. She responds with silence and that poker face again.

She prescribes a five-day course of steroids.

When we get to the car I tell my husband, “if you get a survey from them, give it to me. I have a thing or two to say.”

The thing that gets me the most is just how incurious she was about her patient. She barely looked at him and was uninterested in learning about what his normal condition was in comparison with his sick condition. At 65, patients can be as vigorous as the average thirty-something, or they can be unable to walk to the bathroom.

The physician assistant is not interested in diseases either 

But it also bothers me about how incurious she was about disease. Pertussis is not practically eradicated. According to the CDC, there were 35,000 cases in the US in 2024, and 51 of those were in New Hampshire. While I can forgive her for not knowing that pertussis is still very much an active disease, I cannot forgive her lack of interest. 

Every once in a while, I come across a fact that I cannot believe that I got to this point in my medical career without knowing. This happens to everyone. It’s her reaction to this sort of thing that bothered me. Maybe she thought that I was telling her an “alternative fact.” Sometimes, a patient will declare something to me as a fact, but it’s a “fact” that I highly doubt, although I cannot say for sure it is not the case. When this happens to me, I become curious. I tell the patient something like, “I am pretty sure I learned that pertussis was practically eradicated in med school, but maybe something has changed. I’m going to make a note to look that up later or maybe we can just have a quick internet search here. Thank you.” 

If the physician assistant had expressed this curiosity, I would have said, 

Cold-like illness for a week, followed by an unrelenting cough that lasts weeks or longer. It hasn’t made him vomit after coughing. Post tussive vomitting is highly suggestive of pertussis, but not required for the diagnosis. People with pertussis don’t usually wheeze, but they can. There is a characteristic cough (many coughs followed by a single desperate huge inhale), but people who have been vaccinated for pertussis don’t always get the characteristic cough. 

And had she shown real curiosity, I would have disclosed,

I missed a case of pertussis once. I don’t feel too bad because I caught and treated the patient’s GI bleed during the same visit. I even considered pertussis because it was during an outbreak, but I decided against it. He ended up getting the diagnosis from the emergency room the next week. 

The treatment seems to help somewhat

It’s been a week since that urgent care visit. Not only is my husband still sick, now my daughter and I are sick, too, coming down ill on the same day, with the same symptoms. We don’t seem to be as bad as he is, but that’s typical. His immune system is prone to overreacting. Although I don’t have a name for what’s making us all sick, I’m pretty sure we’ll be able to shake it off. 

What I’m not sure about is the physician assistant.  I am sad that she missed an opportunity to do some medical reasoning. I worry that if she goes through her career like she went through her visit with my husband, she will miss important diagnoses, and equally important, she will miss why medicine is a worthwhile intellectual pursuit. Her professional life will be less rich and satisfying than it could be. She doesn’t seem to have been taught to take joy in the particular activity that is medical reasoning and she’s too busy now to learn it. We are all churning through patients so quickly that she likely does not have time to sit around and show off her diagnostic skills to her co-workers or marvel with them at the crazy things patients say sometimes.

We are burning our young medical practitioners out because we are overwhelming them with work in an increasingly dysfunctional healthcare system. We are also failing to teach them to appreciate the beauty of medical decision-making. Getting the patient better is, of course, the point, but understanding as much as possible about what is going on is part of what makes being a human medical practitioner more meaningful than being a diagnostic jukebox.