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Clinical Pearls

When you think of an oyster opening and producing a shiny pearl (or maybe you don’t, but imagine with me for a moment), let’s translate this beautiful event in nature to the gaining of bright idea or approach that you never would have considered that might be the perfect direction to head in the clinical picture of an individual you are caring for.

I have never looked up the actual “definition” of a clinical pearl or even the backstory behind it, but I do know that throughout my years of work, I have taken great pride to note (sometimes in my phone, sometimes on scraps of paper that I’ve saved and moved around my apartment, taking great care to not throw them away until I can place it in my “knowledge” book for when I start clinicals for my NP degree) the wisdom that providers I’ve worked with may not even know that they are sharing.

I had the privilege to work with (in my opinion, which means it must be true) an excellent Child/Adolescent psychiatrist (who is now enjoying a well-deserved and definitely earned retirement) throughout much of my time as a nurse. If my memory is serving me correctly, for the first few months of my training, we had a different provider as the attending provider, but everyone spoke very highly of the unit’s “actual” doctor and hoped he would be back soon. When I first met him, and probably for the first few months, I wasn’t sure what he thought of me. I’m kind of loud, definitely a direct communicator, and generally pretty confident in myself. He is highly intelligent and very experienced from years of work in various settings, but soft-spoken, and can appear serious at times. I grew to appreciate his approach with patients right away, having the chance to sit in while he rounded and listen to his style of interview, interaction, and intervention.

I started to work as a charge nurse very early in my time on the unit, and without any training, to no one’s fault but a sick call that resulted in none of the nurses scheduled for that shift being trained and me being nominated to steer the ship. Shortly after that first day, another sick call occurred, and I again was given the baton. My boss asked me if I desired any training and my response was, “am I doing anything wrong?” She laughed and said no, and I indicated I was comfortable continuing to wing it and do what I had observed others doing while developing my own style.

I asked that quiet, somewhat serious psychiatrist if he would consider writing me a letter of recommendation to attach to my application for grad school. I indicated I knew he was leaving on a vacation, and it wasn’t due any time soon, but I wanted to give him time to decide if he even wanted to do so. When he returned from his trip and provided me a copy of letter he had written, I was extremely grateful because it was so much more than just a standard “I recommend this person” type letter. It made me feel like the respect and admiration I had for his work and approach was somewhat reciprocated.

Being the not shy and confident person I was, and working in charge, I often had questions related to patient situations or parent phone calls that I was happy to make decisions on, but I could appreciate those that needed to be made by a doctor. In our work together over the years, as I moved through school, I started to hear the answers he would give in different scenarios and was able to glean many clinical pearls (that I have scattered throughout my notes app on my phone and yes, some are still on little pieces of paper in my apartment waiting my clinicals to start).

For example, how smart does this sound: “Naltrexone is worth considering since it reduces the reward/pleasure aspects modulated by endogenous opioids” for a patient who has chemical dependency issues. I can easily read that statement about the medication, and if it was being prescribed would feel comfortable calling a parent and explaining that the expected benefit of the medication would be that if a patient is using an opioid recreationally, the Naltrexone would reduce the reward/pleasure aspects the opioid drug produces in the brain. Would that have been a statement I ever would have come up with off the top of my head based on my knowledge of pharmacology? Not likely, at least not as a new provider. Consider that same medication, and one day during care rounds, a pearl about Naltrexone was shared that it was an effective medication for a patient who compulsively self-harmed and that patient had shared that the reason for their self-harm was that it did produce a reward/pleasure effect for the individual. This is something I’ve carried in my brain for many years. Does it mean I’m going to prescribe it to every patient I have that struggles with self-harm or urges to self-harm? No, however, it is a pearl I will keep for a patient that has been in therapy, who has learned coping skills, and that still struggles with self-harm that is described in a similar manner to the person who uses opioids chasing their high.

Probably the biggest knowledge I have gained is that silence can be therapeutic. It can be uncomfortable to sit with another individual during initial assessment and wait for an answer to a question asked. At times, the silence will lead to an answer, at times, it may require asking a different question, at times, it may lead to the need to simply converse about anything that might be of interest to the patient, and at times, it may lead to the need for simple observation instead of assessment. You generally can’t force answers that aren’t ready to be shared. I have gotten better at softening my approach, at projecting support with a quiet presence, and I definitely feel some of that is from observing it skillfully performed.

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