College student outgrows pediatrician, assigned to FNP who misses his life-threatening diagnosis

Corinthia Davidson-French shares the story of her son's missed diagnosis of aplastic anemia after multiple visits to an FNP at the local clinic. We also discuss racial disparities in the healthcare system, and what patients can do to advocate for their own medical care.

Learn more about becoming a bone marrow donor at: BeTheMatch.org.

Get the book! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/

Citations:
Goldberg GA, Jolly DM, Hosek S, Chu DS. Physician's extenders' performance in Air Force clinics. Med Care. 1981;19(9):951‐965. doi:10.1097/00005650-198109000-00007

Morrison F, Shubina M, Goldberg SI, Turchin A. Performance of primary care physicians and other providers on key process measures in the treatment of diabetes. Diabetes Care. 2013;36(5):1147‐1152. doi:10.2337/dc12-1382 

Kurtzman ET, Barnow BS. A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians' Patterns of Practice and Quality of Care in Health Centers. Med Care. 2017;55(6):615‐622. doi:10.1097/MLR.0000000000000689 

PhysiciansForPatientProtection.org

Transcript

Rebekah Bernard MD 0:08
Welcome to “Patients at Risk,” a discussion of the dangers that patients face when physicians are replaced by nonphysician practitioners. I’m your host, Dr. Rebekah Bernard, and the coauthor of the book “Patients at Risk: The rise of the nurse practitioner and physician assistant in health care,” and I’m joined on today’s show by a very special guest, Corinthia Davidson-French.  Corinthia, thank you so much for being with us.

Corinthia Davidson-French 0:32 
Thank you for having me.

Rebekah Bernard MD 0:34
Studies have shown nurse practitioners and physician assistants to be less aggressive than physicians in managing serious medical conditions and intervening when medically necessary.  Diagnosing and treating patients with life-threatening conditions, where the stakes are perhaps the highest, is a scenario in which the level of expertise really matters. While inappropriate medical intervention can be dangerous, non-intervention, or failure to act in a situation where medical treatment is necessary, may cost patients their lives. In fact, today’s guest faced this exact situation. Corinthia Davidson-French nearly lost her son when a nurse practitioner failed to properly diagnose his life-threatening medical condition. Corinthia, can you share your story with our listeners?

Corinthia Davidson-French 1:16
Yes, thank you. My son at the time was 24 years old and he developed the onset of swelling in his eyes, fatigue, diffuse rash so he called his doctor to make an appointment. The doctor happened to be a pediatric doctor, so they rescheduled him with a family nurse practitioner. The nurse practitioner looked at his eyes and referred him to an ophthalmologist. The ophthalmologist didn’t see anything – no problem - so he referred him back to the nurse practitioner.

He went back to the FNP, and during that time he had several visits with the nurse practitioner. There was no blood work done, there was no work up done. So, at that point, I was becoming very concerned because my son just didn’t he said he wasn’t feeling good. So, he reached out to me and when I got to his apartment, my heart dropped because he just looked terrible.

So, at that point, I just took my son to the emergency room because I was really concerned about his health. That’s when we end up going to UC Davis where we were told that he has very severe aplastic anemia which is a profound lack of blood in the body and it was heartbreaking to find out that this was going on with my son.

Rebekah Bernard MD 2:38  
And you wonder if maybe getting him diagnosed sooner might have spared him the suffering that he went through before he was diagnosed but it also may have made it easier for him to get the proper treatment. 

Corinthia Davidson-French 2:51
Oh absolutely, absolutely. If she had actually referred him to a primary doctor I felt that that would’ve actually helped him.

Rebekah Bernard MD 3:01
 It might have spared him suffering and he wouldn’t have had to wait until it was a drastic situation. So, just to recap. Your son was 24. He was seeing a pediatrician because he was healthy and he was just getting checkups and then he got sick. So he calls his pediatrician because that’s the usual person who takes care of him, but the office says, we don’t take care of kids that are over 21 and he’s 24. 

Corinthia Davidson-French
Right

Rebekah Bernard MD
So, we’re going to have you see instead of a physician we’re going to have you see a family nurse practitioner. Was that at the same clinic?

Corinthia Davidson-French 3:32
Yes it was.

Rebekah Bernard MD
So, he had a pediatrician who was a physician but instead of being offered an adult physician like an internal medicine doctor or family physician he was assigned basically with a nurse practitioner. 

Corinthia Davidson-French
Correct

Rebekah Bernard MD
 And so, he goes in and like you said, he was having some problems with his eyes. Can you describe a little bit more what the problem was?

Corinthia Davidson-French 3:52
His eyes were extremely red. The pupil was kind of raised, like puffy. And he had some discharge coming from his eyes. At some point they started to get like a tea color -- it started to turn tan - it was not clear.

Rebekah Bernard MD 4:09
The whites of his eyes were not white. They were abnormal colored, and they were hurting him, too, right? They were swollen? But that wasn’t the only problem; he was also complaining fatigue.

Corinthia Davidson-French
Correct 

Rebekah Bernard MD
Was he having a fever, chills, anything else?

Corinthia Davidson-French
He was having chills and also a lot of nosebleeds

Rebekah Bernard MD
And nose bleeds? So, we’re not talking about just an eye problem we’re talking about an eye problem but also a constellation of other symptoms 

Corinthia Davidson-French
Correct 

Rebekah Bernard MD 4:40
So, unfortunately, the nurse practitioner didn’t realize that something systemic, something going on in his body. She focused on the eyes, and so she sent him to an ophthalmologist which is a medical doctor that specializes in the eyes. The eye doctor looked at his eyes and couldn’t find anything wrong with his eyes per se, and so sent him back to the nurse practitioner.

Corinthia Davidson-French 5:01
Exactly, and that’s exactly what happened. And it was a while in between because he had four follow-up appointments with her, and nothing was getting resolved.

Rebekah Bernard MD 5:13
So, he kept going back and saying, I’m not feeling better, I’m feeling worse, and then every time she didn’t do any blood work 

Corinthia Davidson-French
No

Rebekah Bernard MD
She didn’t do any other medical evaluation. Do you get the idea of what kind of instruction she might’ve given him, just to go home and rest or what did she suggest that he do about how he felt? 

Corinthia Davidson-French 5:32
She prescribed several eye medications. There were roughly 3 different eye medications he was prescribed and none of them was working. 

Rebekah Bernard MD 5:42
So really she kept focusing on the eyes, it seems like, even though he was having other symptoms.

Corinthia Davidson-French
Yes, and those other symptoms were so evident because he did address those – he mentioned how he felt sick – I mean fatigued- he mentioned how he had a lot of headaches and he’d been having these nose bleeds, but she insisted on trying to fix what was going on with his eyes. 

Rebekah Bernard MD 6:05
She just kind of got tunnel focused on that it sounds like. But what was really happening it turned out was something really, really serious which is called aplastic anemia and to explain that to our listeners, you did a great job of saying a profound loss of blood in the body, so I’m guessing his white blood cells were extremely low…?

Corinthia Davidson-French 6:25
All of them. His red blood cells, his white blood cells, his platelets. So basically, by the time we got to the emergency room he had to have a transfusion.

Rebekah Bernard MD 6:35
So, his bone marrow -- basically all blood in the body is produced by the bone marrow -- his bone marrow just stopped producing blood entirely. He was having nose bleeds because his platelet counts were so low he couldn’t clot – and he was fatigued because he had no iron, no red blood cells in his body enough to circulate to give him energy, and of course he had low white blood cells, so he was at high risk for infection. Thank goodness you went to check on him!

Corinthia Davidson-French 7:04
It was heartbreaking to see him and I was overwhelmed, and I was just so concerned that I would lose my child. 

Rebekah Bernard MD
 So you knew right away, like when you laid eyes on him, obviously you took him to the ER, but like what were your thoughts when you saw him?

Corinthia Davidson-French 7:17
It was scary. It was extremely scary He just did not look OK at all. My concern was just getting him to the emergency room to find out what is going on. I’m just so glad were able to get him there and that we were able to find somebody to actually address what was going on and we know now what was going on with him.

Rebekah Bernard MD 7:37
 Someone to make the proper diagnosis because someone wouldn’t think if a person just had some eye problems that they would actually have the serious disorder, but actually he had many more symptoms than just the eye problems it’s just that the practitioner really just kind of stopped thinking about other possible causes and just focused on one symptom, unfortunately. 

Corinthia Davidson-French
Correct. 

Rebekah Bernard MD 8:00
You got to the emergency room, they drew they did some basic blood and immediately it was pretty obvious that there was a serious problem health problem here. He got blood transfusions and I’m sure they called in a team of doctors, blood specialists, and started him on some treatment. And how is he doing now?

Corinthia Davidson-French 8:17
He’s doing well, thank you. He’s doing well. He has a really good oncologist who’s been very supportive and has him on a good regiment to stay healthy. He is still monitored, he’s being monitored by them.

Rebekah Bernard MD 08:30
 Did he have to get a bone marrow transplant?

Corinthia Davidson-French 8:32
Praise God, no. He’s on the list. OK that’s the most important thing he is on the list awaiting but right now he is currently in remission so I’m thankful with that.

Rebekah Bernard MD 8:46
  Let’s take a second to put out a plea to everyone out there. If there’s any chance that you can go on the bone marrow registry list, it is so important. There are patients across the country that are desperately waiting for bone marrow transplants. Corinthia, do you know much about how someone would get on the list for that?

Corinthia Davidson-French 9:05
Yes. There is a registry that’s out there, it’s called “Be The Match” and most importantly I would like to share with everyone that many minorities have a difficult time finding that match. So, it’s very helpful and beneficial if they go out and at least be tested. They do go through a screening process. They want to make sure that the person who is going to be a donor meets the criteria. However, it is important for minorities especially, but everyone. But I do want to say that minorities are the ones that often have a difficult time finding that match.

Rebekah Bernard MD 9:41
It’s so true and you know, people are scared of the idea of donating bone marrow, but I have to tell you -- I haven’t done it myself but I’ve known many people who have and a good friend of mine did it and she told me it’s not that bad.  They numb you up – and just because you go on the list does it mean that you’re necessarily going to get called to donate bone marrow -- I mean that’s going to be just a minority of people might actually be called up that they are needed. First of all, there’s nothing even worry about about getting screened I think they just do a cheek swab don’t they?

Corinthia Davidson-French 10:13
 Yes they do. That’s the new process - very easy, very simple, no needles. They do the testing and they let you know if you will be a candidate. 

Rebekah Bernard MD 10:24
If they call you up of course they would explain to you how the donation happens which is usually a small injection of numbing medication and then that using a special needle they remove some bone marrow usually it’s from your hip and and it’s done very minimally painful and you could save somebody’s life. So, everyone, but especially people of color, really your bone marrow is desperately needed so please consider looking into at least getting your name on the registry list to potentially be a bone marrow donor because you could save a life. 

So, thank God your son didn’t actually need that and I’m so glad that he’s doing well and you know, speaking of people of color and minorities, we talked about how there’s more of a need for bone marrow but also there’s more challenges in healthcare in general for people of color. We know that COVID19 has certainly showed us that if not many other aspects of health, there’s a lot of bias that happens. One of the things that we point out in our book is that when we use algorithms which is when you just go down a checklist where you try to make a treatment for a patient without actually looking at them as an individual, you’re more likely to make mistakes and you’re more likely to be biased against people of color and so that’s one of our concerns when it comes to practitioners who are trained under an algorithm type model, that there is more propensity for that to happen.

Have you as seen any other evidence of racial disparities or what would you advise to other people of color when they’re navigating the healthcare system?

Corinthia Davidson-French 12:01
 I would say definitely make sure you educate yourself.  Make sure you get the information you need. You have the opportunity to be really be invested in your health, so I think it’s important that you do the research, look it up, ask a lot of questions about who is going to be caring for you. Also, the resources that are available. So, I say, look into it, ask questions, invest in your health.  Find out about what programs -- find out the training in those facilities – where you are going -- just like where my son went was a clinic, and the clinic was in a low economic area so therefore, most of the patients are not aware what are the requirements or what is the training of the person in that facility, how much training do they have; so I say it’s very important to invest.

Rebekah Bernard MD
You’re so right. I had my first job out of my residency was at a federally qualified health center which is a type of clinic designation for people that are not of a high social economic means and these clinics get a lot of federal funding but they also charge patients and they take insurance and Medicare and things like that too. But one of the things that I learned when I worked there was that they have a certain ratio in order to receive federal funding, they have to hire -- especially if they’re in a rural area --they have to hire a certain proportion of nurse practitioners and physician assistants to physicians. I worked in a rural area and I remember we were really busy, the patients were very complicated, and so I asked the administration, can we try to get another physician to help us? And I was told we can’t. We have to hire another NP or PA, because if we don’t, we will lose our funding. That was something that was established in 1977 with the Rural Health Clinic Act, a federal governmental policy that continues today. So, people that are utilizing these health clinics they may not have an option because they may find the only healthcare practitioner at that clinic or the majority of them might be non-physician practitioners. So, you need to know that, and if you have a simple problem maybe that would be OK. But if you have a complicated problem or if you’re like Corinthia’s son who is not getting better and keeps going back, that’s a time when you need to ask is there a physician that can see me and help you investigate this a little more to find out why I’m not getting better. 

Corinthia Davidson-French 14:29
Correct, most definitely, and it’s important that patients speak up. It’s also important that if you have a doctor and they transfer you or schedule you with the nurse practitioner you have the right to say, I want to see a doctor. As a patient you should also make sure that your voice is being heard. 

Rebekah Bernard MD 14:49
 It’s so important and it’s so funny Corinthia, because you would think, like, well, doctors have special privileges because we’re doctors and we should treat each other all a certain way, but I have heard so many doctors tell me that they made an appointment with a specialist – say they are a family doctor like me – they go to see a specialist and they get there and there’s a nurse practitioner or PA. And this is a doctor! So, imagine if they treat doctors - who you would think would know better and give a fight -how are they going to treat the average person that doesn’t know that?  So, I think the squeaky wheel gets the oil and like you said, you have to ask for it. And then if you show up and they just replace -- you  made an appointment with the doctor and they put you in with a nonphysician -- then you really, you know, I don’t want to say raise a stink, but you kind of need to, because this is your health care, this is your life on the line and yeah, you might have to rattle a few cages and say this is not OK.

You’re going to pay the same thing that’s the other thing that most of the time people don’t realize; you don’t pay less necessarily to see a nurse practitioner or physician assistant often you pay the exact same thing, the same co-pay, the same office visit charge, so why is it OK to get lesser quality or lesser trained person if you’re paying the same amount of money?

Corinthia Davidson-French 16:02
Absolutely I definitely agree with you on that one, and a lot of patients don’t realize that. Patients need to be really mindful and know that they have those rights, to see a physician. I really think it’s important. 

Rebekah Bernard MD 16:14
 Corinthia, did you know anything about this stuff before this all happened to your son?  Like, had you even heard differences between the different professions?

Corinthia Davidson-French 16:22
No. This has been an experience, and this is been very educational for myself because no, I didn’t. And it’s just from my son’s own health crisis is what I learned and understood the importance and the difference between the two, and I will say I was not aware of it. But I have people in my life who are able to also educate me and help me understand the differences. I really feel fortunate that I have somebody and that’s why I say for patients, it is important, if you have that person allow them to give you the information, embrace that information because it is very important. That’s how I learned.

Rebekah Bernard MD 17:04
Especially because if you don’t have someone in your life who can explain to you what the difference is, you might just turn on the TV and you might see a TV commercial that says ‘we choose NP‘s’ and there’s a whole campaign that tries to tell patients that nurse practitioners are just as good as physicians, they have they have the same outcomes as doctor. And the same thing for physician assistants - they have a slogan called ‘your PA can.’ So, if you’re just a regular person and you’re not in the healthcare world and you turn on the TV or you open up the newspaper and you see this big article and you just say wow, OK, well, a nurse practitioner and a PA, they’re the same as a doctor, they’re just as good as a doctor. You call your doctors’ office and they say oh, we’re gonna put you in with the nurse practitioner, we’re gonna put you in with the PA because the doctors busy, let’s say. And you just go, OK, no problem, because you don’t know.

That’s why I want to thank you so much for telling this story because I know it’s not easy to remember what a tragedy this could’ve been if things had not turned out differently but it’s so important to speak out and to explain to people that no, there is a difference. That’s not to say that nurse practitioners and physician assistants aren’t be good care providers and can’t be an important part of the healthcare system but if you have a serious health problem then you should be seen by a physician because a physician is the person that has the highest level of education and the most years of training so that they don’t miss something like your son’s aplastic anemia that is life-threatening.

Corinthia Davidson-French 18:32
Correct, absolutely. And I say for all patients it is very important to make sure they ask a lot of questions, make sure they look into the background and make sure, let’s say, if they are scheduled with a doctor that it is not switched on you and you have that right to say, “Well, I want to see a physician.”

Rebekah Bernard MD 18:54
 Never be afraid to ask for a second opinion, and that goes for doctors too. If you’re seeing a doctor and you’re not comfortable with the care or you aren’t getting the answers that you need or you’re not getting better, then it is always appropriate and it’s perfectly fine. Any reasonable doctor, nurse practitioner, or PA is not going to be upset or angry or offended if you ask for a second opinion or to see a specialist because it is your health on the line and if you don’t advocate for yourself, then who will?

Corinthia Davidson-French 19:21
Absolutely, absolutely .

Rebekah Bernard MD
Unless you have a good mama like Corinthia that comes to your house and says, uh-uh, this is not OK. That’s what we all really need, right?

Corinthia Davidson-French
Yes

Rebekah Bernard MD 19:34
I want to thank you so, so very much for joining me, for telling your story and I also want to encourage all of our listeners out there that if you’d like to learn more about this topic we have much more information in the book that I co-wrote with my co-author Niran Al-Agba, it’s called “Patients at risk: the rise of the nurse practitioner and physician assistant in healthcare” it’s available on Amazon and a Barnes & Noble and please stay tune to our podcast Patients at Risk and subscribe to our YouTube channel and we will see you at the next show.

Corinthia Davidson-French 20:06
Thank you.