Recently, I had a casual conversation with some nurse practitioner friends about an older adolescent I saw in clinic, and how my gut told me not to put her on methotrexate (MTX) because I wasn’t sure I believed her when she told me that she was not sexually active. I’m not going to get into all the details of the actual visit, but I instead want to focus on whether this was truly a judgment or a judgmental call on my part.
Why was it that I felt so strongly that this patient wasn’t telling me the truth about something so serious as her sexual activity even after I explained to her that certain medications such as MTX can cause birth defects or possibly fetal death? What was it about her, or me, that cued my skepticism?
As I have searched for a reasonable explanation of my decision, I have had to take a good, hard look at myself and introspectively ask, “What were you thinking?” What does it say about me that I didn’t trust my patient about this crucial information, and what potential damage might a decision like this have on our patient/provider relationship? Would she now start judging me for judging her?
When my rheumatology nursing colleagues asked me why I believed this patient was sexually active even though she denied it, I could only come up with one good answer—it was my nurse’s “Spidey sense.”
Now of course, there is nothing in any clinical guideline that says any clinician should use his/her intuition to make treatment decisions. Patient care does not occur in the context of a Marvel comic, and I am not Spiderman (though it would be nice). And yet, I clearly remember during this visit that I felt unusually confident in my decision not to prescribe MTX unless this patient agreed to birth control. In my gut, I was absolutely confident that I did the right thing at that moment.
Given time to reflect and rationalize my decision, I began by looking at what I know of adolescents. I spent more than 5 years working at a high school where I saw hundreds of teenagers in my office without the presence of their parents. I heard uncanny honesty from many of them regarding difficult issues and had many frank discussions about sexual activity. I am also very knowledgeable about the signs of high-risk behaviors among teens and vulnerable youth.
“Self-introspection can be a valuable tool to help us understand why we make certain decisions, both personally and professionally, and help us to better serve our patients in the long run.”
I thought about all of this when I reflected upon the factors that cued my “Spidey sense” in this case. Was it because this was a tall, pretty teenager who looked like she could have come from the pages of a fashion magazine? Was it because she looked like she was in her early 20s when in reality she was several years shy of turning 18? Was it because her general maturity level would make boys her age seem like middle schoolers? Was it because she was uncertain about attending prom because her father said he wasn’t sure he was going to let her go?
Combine all of this information and, to me at least, it screams “vulnerable teen.” And a vulnerable teen is someone who raises my fears. Fear of a young adult male thinking this patient is much older than she is. Fear that this patient will be flattered by the attention being paid to her and would put herself in a risky situation that could lead to a sexual relationship. Fear that this relationship would lead to the possibility of a sexually transmitted infection, pregnancy, or HIV, all risks highlighted in the clinical literature when teenaged girls date older men.1,2
Of course, none of my observations could be considered to be true risk factors. Instead, again based on my experience, I would consider them to be “soft signs,” akin to soft neurological signs. You know, those abstract signs that aren’t necessarily worrisome at the moment and would not help lead to a definitive diagnosis.
Based on my reflections of this patient, I am confident that my decision to withhold MTX wasn’t a judgmental decision but was indeed my nurse’s “Spidey sense” at work. There was something that simply didn’t feel right to me and triggered my need to protect this patient no matter the potential damage to our relationship. Maybe the fact that this patient had previously been lost to follow-up for almost a year and had rejected a suggestion of MTX during a flare played a role in my decision—it’s hard to say. In the moment of our visit, I couldn’t have easily put that feeling into words, but I rather remember the unidentifiable uneasiness I felt in the exam room. This was a patient who I felt needed my help and protection even if she couldn’t say so.
The situation with this patient continues to evolve. Fortunately, there are a number of other treatment options available to us that work just as well if not better than MTX in many patients. In our patients with RA for whom we are worried about the possibility of pregnancy, there is good data on the use of several nonbiologic and biologic therapies that can help control disease while presenting few fetal risks.
Were it not for my nursing colleagues, I likely would not have reflected—at least not to a significant degree—as to why I made the decisions I did with this patient. Self-introspection can be a valuable tool to help us understand why we make certain decisions, both personally and professionally, and help us to better serve our patients in the long run. So don’t be afraid to listen to your “Spidey sense” even when logic points you in a different direction—nursing intuition is sometimes the best tool in our treatment arsenal.
Cathy Patty-Resk, MSN, RN-BC, CPNP-PC is a certified pediatric nurse practitioner in the Division of Rheumatology at Children’s Hospital of Michigan in Detroit, MI, where she provides medical services to inpatient and outpatient pediatric rheumatology patients.
1. Manlove J, Moore K, Liechty J, Ikramullah E, Cottingham S. Sex between young teens and older individuals: a demographic portrait. Child Trends. September 2015.
2. Centers for Disease Control and Prevention. Teen pregnancy in the United States. Available at www.cdc.gov/teenpregnancy/about/index.htm. Accessed May 24, 2018.