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How To Eat An Elephant

Victor Czerkasij, DNP, FNP-C

Recently, a student following me at our clinic remarked on how quickly I could move through patients during the day. “You see about 60 people daily, and while it doesn’t seem like you are rushing them through, I don’t think I could ever do that. I am just too slow.”

I replied that I couldn’t see that many patients a day twenty years ago either! “What keeps you from moving faster with your clinic time?” I asked.

“Honestly,” she said, “I don’t know what I see. I don’t know if I am getting the right diagnosis. It could be so many other things. And if I think it’s the right diagnosis, which of all the treatments is the best? You seem so confident.”

Undoubtedly, healthcare, let alone dermatology, can be daunting in the early years. In fact, with the myriad of new medications for various disease states pouring out into the mix, understanding mechanism-of-actions, side effect profiles, drug contraindications, and more is truly like drinking from the proverbial firehose even for the older warhorses.

What’s an overwhelmed provider supposed to do? 

First, take the advice of how to eat an elephant: one bite at a time. I have a dedicated slot where I peruse through the most valuable articles from dermatology journals each week and thoughtfully highlight the facts I need to make intelligent assessments, diagnoses, and prescribing.

Second, don’t review what you already know: always hit your weakest spot. Remember that one patient that proved so difficult to care for? Thank them. They made you a better provider and you knew exactly what to do for the next dozen people with the same condition.

Third, don’t shy away from questions from patients and experienced colleagues. Even one suggestion can make for a revelation that turns your paradigm around. I still treasure the times the lightbulb went off for me in conversations.

Fourth, if someone asks you to share what you know unless you have crippling social anxiety, get up there and tell them what you learned. Explaining it to others puts it into concrete for yourself.

Finally, I still face challenges too. I have learned to slow down the moment there is a zebra and take a long breath and start to ferret out a solid history. An older gentleman was referred to me with a large reddish, tender nodule on the side of his right index finger. It had been treated alternately with many antibiotics for cellulitis and then oral steroids and even an attempt was made to drain it. Nothing was working. 

In my conversation, I asked the man about his hobbies. “Loves his roses,” his wife said, “But he just won’t wear gloves.”  The light went on from something I had once read. “Do you get stuck with thorns?” “Sure. In fact, I should mention that this finger gets stuck all the time.”

The diagnosis was sporotrichosis – I had just read about it. He received oral itraconazole from me and completely improved, and started listening to his wife.

Keep taking small bites every day and thank your challenging patients. You will improve with time and your patient numbers will slowly increase to where your confidence will also shine.

Skin Bones CME In-person Conferences

Wish you could network with like-minded colleagues for more insights like this? Meet and learn from nurse practitioners, physician assistants, and physicians from across the country at a Skin, Bones, Hearts & Private Parts CME Conference! At every event, the best of the medical community gathers to earn CME, network in an interactive and intimate group setting, obtain new perspectives in the medical field and gain knowledge from engaging speakers – in the fields of dermatology, orthopedics, cardiology and emergency medicine, women’s health, pain management and pharmacology, diabetes, ER, and mental health. On-Demand CME and Live Streaming CME are also available.