Every Job Has Its Problems

As easy and stress free this job has been at the airport, of course it has its own set of problems.

When working for an occupational health clinic there can sometimes be some conflict between providers and the employer. The employer has this clinic to evaluate injured workers so that they can reduce costs by avoiding them from having to go to the ER or urgent care, and to have them be evaluated quickly so they can return to work. The goal is for them to get back to work as quickly as possible!

Thus, it is a big ‘no-no’ to recommend the patient go home without work. For instance, lets say a patient had a back injury from lifting heavy baggage, and shouldn’t continue to lift heavy baggage for the next few days. The employer would rather you provide the patient with work restrictions, including avoiding heavy lifting >10 lbs, walking and standing for up to 1 hour each shift etc. This way, the employee’s supervisor can find an alternative duty for that employee such as desk work or scanning bags etc. Of course they would rather have the patient at work doing something, than going home with partial pay for no work.

This is understandable, but as a nurse practitioner, my patient will always come first. There are times I do send my patients home unable to work. And a case manager from the employer would call me trying to find out why and insist I change my recommendations. These case managers are non-medical so I am rarely influenced by their comments.

Originally I didn’t think it was a big deal to receive their phone calls, but then they started to complain about the minutest things. In a world with so much chaos and injustice, I do not think these complaints are that serious. I would rather not waste 15 minutes of my day discussing these cases with the case managers.

There was one case where a worker twisted her back while moving a 70 lb bag, then accidentally fell and injured her back. She had trouble sitting during the exam but was comfortable with standing and walking. I put her on restrictions, which included no heavy lifting and “no sitting”. The case manager called me to ask why I put “no sitting”, just because the patient could not sit during the visit doesn’t mean I have to advise her NOT to sit. That didn’t make any sense. I kindly said I couldn’t advise someone to do something they are unable to do.

The case manager asked me if I thought the patient had not been sitting this entire time since being seen, like at home. I responded with: I am unsure as I have not seen the patient since the initial visit, but she is coming in tomorrow and I will surely re-evaluate her then. The case manager proceeded to tell me that I don’t seem to have a good understanding of restriction recommendations. I proceeded to tell her that she does not seem to have a good understanding of medical recommendations. She responded that she would escalate the request to the medical director.

My initial thinking was the patient is still able to work with restrictions, she is even able to stand and walk with no problem, which in my opinion is better than sitting for the employer. She was to follow up the next day, so unsure if changing the recommendations was a big deal for 1 day of work? Lastly, the case manager is non-medical so she doesn’t understand that some musculoskeletal injuries cause patients to find their “new” comfortable position. Whether it is sleeping in a sitting position or standing with a side bending position etc.

Too bad the dream job has its own share of headaches.
I do have a new founded respect for the fleet service crew. They often work every day and more than 8 hours per day, doing strenuous activities.

 

Travel Credit Cards

I just added a new page to my blog entitled “Travel Credit Cards“. You can find it on the home page next to scope of practice. The more I started traveling for a living, the more I realized having travel reward credit cards were worth it. Of course I make sure to pay off my balances at the end of each month to ensure I am not paying any interest or fees. Having these travel credit cards makes it easy to accumulate miles and points, and comes with plenty of benefits.

For example, one of my favorite cards, the Chase Sapphire Preferred credit card allows me to earn 2x points on dining and travel, provides primary car rental insurance, and baggage or trip delay reimbursement/protection. If your checked baggage is delayed more than 6 hours, the card will reimburse you  $100/day for purchases made of any essentials while waiting for your bag to arrive. I used this benefit before while going to one of my assignments. Although I made sure to pack essentials in my carry-on, once my luggage was delayed for more than 6 hours, I went on a mini shopping spree and purchased clothes and toiletries up to $100/day.

Currently this card is offering a 50,000 points bonus for signing up. It comes with an annual fee of $95 which is more than worth all of the perks. The sign up bonus alone can get you up over $1000+ worth of free travel. I personally used my bonus before to fly my brother and I to Hawaii, which saved us $1400 in flights. If you do not see a point in paying the annual fee after one year, you can always downgrade to a no-annual fee card afterwards.

My “Travel Credit Cards” page will list a few of my favorite credit cards and why. If interested, please use my referral link to ensure that we both get bonus points for you signing up! I also wouldn’t mind helping you figure out how to use your bonus points for travel, when the time comes. If there becomes enough of an interest, I will start regularly posting best ways to earn and redeem points.

Check out the new page: http://travelingnp.com/?page_id=1129

Occupational Health Clinic

I accepted an assignment in Miami, FL for one month because Hurricane Irma did some minor damages to my house. I needed time down there to make repairs. Fortunately, there was an assignment available that was brief and was from a 1099 agency (which is what I needed).

I was excited to begin this new assignment because it was an occupational health clinic for a major airline. It was something different in comparison to the chronic disease management I had been used to this past year. I was initially a bit nervous to start because it was the first occupational health site I have worked in. Fortunately, things transpired well.

The clinic is located in Miami International Airport. I made sure that I would be reimbursed for parking because parking fees are $17/day. Since the site didn’t have to pay for lodging, they were ok with paying for mileage and parking.

It has been an interesting experience so far. I mostly see on-site work related injuries such as musculoskeletal injuries, clogged ears, and lacerations. I sometimes see minor acute episodes that need to be treated quickly so the employees can return to work.
Examples of these are UTI, cold symptoms, rash, STDs etc.

The workload is relaxed, I mostly see about 4 patients a shift, on a busy day I see up to 8. The patients are gregarious and appreciative! The staff is friendly, and there is always another provider working with me. The center manager is nice and flexible; she even allowed me to change my work hours to accommodate me so I wouldn’t have to be stuck in Miami traffic.

It’s a really great gig, and I hope others are fortunate to find an assignment like this when they want to return home for a short period of time. If I were on the brink of retirement I would stay at this job permanently. Since I am young, I still need adventure and a challenge so will continue to work as a locum tenens nurse practitioner.

The clinic I worked for in Virginia called me this week to find out when I will start working at their Florida clinics. After working at this stress-free job, I am somewhat reluctant to jump back in to care for such a complex population.

 

Choosing Between Multiple Assignments

Sometimes when searching for your next assignment, you can end up with more than one offer on your lap. I personally like having multiple offers so I can choose the best one. However, I am sort of a commitment-phobe so when I have multiple offers, I end up overwhelming myself and have a hard time choosing. How should we choose between multiple assignments?

When looking for an assignment, I mentally note what my priority is at the moment. Do I HAVE to be in Florida because winter is coming? Is a HIGH pay rate important this time so I can save up for a major purchase? Am I physically drained from my last job and need a lighter work load? It’s important to evaluate what you value most in your next assignment because it will facilitate the decision making process.

My needs often vary. Sometimes I care more about the location so I am willing to take a lower pay, other times I sacrifice the location I want to work in because I do not feel like seeing 30 patients a day.

During my most recent assignment search, I ended up with several options:

1. Brief local assignment in my home base – Miami, FL. Pay lower than usual. Light patient load.

2. Brief assignment in California, in a rural setting. Pay was my usual rate. Fair patient load.

3. 3 month assignment in North Carolina, major city. Pay was my usual rate. Moderate-heavy patient load, and I would be the sole provider at the clinic.

4. Transitioning with my previous site (in Virginia) to work in their clinic in Florida (not in Miami). Same pay. Same load as before.

How did I end up choosing number 1? I think it is easier to narrow down your choice through the process of elimination. I knew I wasn’t ready for #4 because I needed a break from working at this type of setting with very complex geriatric patients. Thus, I eliminated #4 as an option. I originally thought it would be neat to go back to California for a short period of time to catch up with some friends. When I began researching flights from Virginia (where I was at that time), I realized it would take 13 hours of flying for me to reach that rural destination. I didn’t think a 3-week gig was worth the amount of flying time it takes to get to Europe or the Middle East. Thus, I also eliminated #2 as an option.

Finally, I was left with option #1 and #3. Option #1 was safe, I could just go home for a bit, which is never a bad idea. #3 was more exciting because I could live in a new state. I had traveled to North Carolina before and really liked it. Eventually, I decided to go with #1.

Foremost, I needed to be home to oversee some repairs on my house after Hurricane Irma. Although the pay was lower than usual, it was something I was able to overlook because the patient load was light, and the assignment period brief. I eliminated #3 as an option additionally because it is not ideal for me to be the sole provider at a really busy clinic.

I always think it’s good to have multiple options for your next assignment, so in case one falls through you can have a backup. Yet, it can be a challenging process to choose one assignment
from multiple great offers. How have you chosen between multiple assignment offers in the past?

 

Maintaining Multiple State Licenses

I currently have 5 active state licenses. Many of you have asked how I am able to manage having multiple licenses (for cost and time reasons). I usually work on obtaining about 2 new states licenses every 6 months.

I actually allow some state licenses to expire. There are state licenses that expire after one year (which can be annoying). Some people may think it’s a bad idea due to all the work that went into getting them in the first place. But the truth is, reactivating licenses is pretty easy.

I allowed my California licenses to expire. Yes, the same licenses that took more than 4 months to obtain. The fees are costly though, since you have to renew 3 licenses. I think having a California license is always a good idea because there are plenty of jobs there. I had one agency I worked with prior renew the licenses for me. It was a piece of cake. The agency’s licensing team did all of the work and paid for my renewal fees. I just had to sign a form agreeing to work with them initially with the new license.

In case I end up working with a different agency in California, I would just have them pay back the other agency for that license. It’s no big deal. Not to mention the renewal process only took 2 weeks!

I had also allowed my Texas licenses to expire. The same agency renewed the Texas licenses for me. It was nice having the licensing team work with me because they would call the board of nursing to follow up on my application. This process also only took 2 weeks!

I allowed my Washington state license to expire. Washington is really far from Miami, so I didn’t see myself going back there anytime soon.

Lastly, I always renew my Florida license because that’s my home state and initial license upon examination.

Some people may have more trouble managing their multiple licenses than me. I recommend having some agencies invest in applying for or renewing licenses for you. It facilitates the process and covers the costs upfront.

 

Back in the Game


After working at one assignment for the past year, I had to get back in the groove of working in locums again. I was used to working with the most amazing recruiter, which made me have high expectations for all other recruiters.

My priority for my next assignment was for it to be a 1099 job. I had worked most of the year with a W2 agency and had also paid tons of taxes to Uncle Sam. I needed to work with a 1099 agency to allow me to have more tax deductions at the end of the year. Unfortunately, this meant that I couldn’t continue working with my favorite recruiter for my next assignment.

My experiences so far have been a bit rocky. Prior to presenting me to an assignment, I felt like this one recruiter/account manager put me on the spot as if it was an official interview. He asked me “what is special about you, that would make me want to present you to my site”? I was appalled because I know I am great, but I didn’t feel as if I needed to explain to him the reasons why. Because the reality is that by me working with this site, I would be providing him with his income. This is a type of question I wouldn’t mind answering someone interviewing me from the site, but not the agency….

Another recruiter called me SEVEN times in one day! I kid you not. If this were a relationship I would have broken it off long ago! Another one of my pet peeves is when I am not scheduled for a phone interview with a site, but the site will just randomly call me. I think it is more professional when you provide your recruiter with good interview times, and then they confirm the time the site will be calling you. Instead, I had a site call me during the mid-afternoon while I was at work. Then we were playing phone tag for the rest of the week.

I decided to accept a brief assignment with a new agency I haven’t worked with before. The credentialing process hasn’t been the smoothest. For instance, I was told by my recruiter to go to a lab site and request a urine drug test (without an order). Usually the agency provides me with a confirmation form for the urine drug test and I just bring in that paper to my scheduled appointment. I called the lab site prior just in case and they told me I needed to register for the urine drug test prior. I informed my recruiter, and she gave me a number to register for the test. When I called, they said the place of employment had to register me. -_-

The issue was resolved but sometimes it boggles my mind because don’t these people deal with this on a regular basis?

Another credentialing contact person requested I sign the protocol with my supervising physician. She only sent me the last page to sign via email. I had to let her know that I would not sign a protocol without seeing the complete set. Also, the board of nursing requires the original protocol with original blue signatures. Typically the agency will fed-ex me the protocol to sign and send back to them via fed-ex. So just printing the protocol and scanning it back to them wouldn’t make it official.

Many of my readers have shared some of their frustrations when starting locum tenens, and unfortunately a lot of them are due to their recruiter/agency. I was so used to working with some great recruiters and agencies, I almost forgot how bad others could be. Alas, I had to continue working with this agency because the assignment they offered really matched my current needs. I was a bit disappointed that my recruiter didn’t ask me how everything went after my first day of the assignment. It was something I was used to when working with other recruiters, and I think it’s a nice gesture.

After writing this, I am going to send my favorite recruiter some flowers as a big Thank You for Being Awesome! This pretty much sums up why I often advise my readers to reach out to me personally, to recommend specific agencies and recruiters, because they are not all created equally.

Ending of a Yearlong Assignment

The end of my yearlong assignment in Virginia was bittersweet. When I finally accepted that I needed to move on, I was reminded of one of the best parts of locum tenens – looking forward to the end. The things that used to bother me before didn’t bother me anymore. If the medical assistants were short staffed and took forever to bring my patient back, I no longer cared. The demanding or pessimistic patient that normally frustrates me, no longer impacted me.

It was tough to say good-bye to my patients. For some reason the majority of them were in a good mood during my last visit with them. For example, one of them randomly said: “You are really great. I’ve never had anyone explain things to me the way that you do.” This made it hard to tell her I was leaving. During a follow up with another patient, he said: “Man, you are the best! You remember everything about me and follow up on things from last visit. You review notes from my specialist before I see you. You don’t just fix everything with a pill. You explain things thoroughly and find natural ways for me to improve.” After telling him that I was leaving, he nearly caused a scene.

Many of the patients were extremely disappointed, some even cried (both men and women). I re-focused them to realizing that most importantly their health had improved significantly over the past year, and they know what to do to continue on that path. I also reassured them that since I would be working in their Florida clinic, I would be able to check on them from time to time and perhaps even see them again in the future.

I think I became too attached to the patients, but with our healthcare model, it was hard not to. The patients came every month or even more frequently, some I spoke to via phone on a weekly basis. I knew their husbands and wives pretty well too. Our goal is to keep our patients out of the hospital, and the only way I knew how to do that was to develop trust and bond with them.

My last day was extremely sad. I had never cried so much in my life. Not only was I going to miss my patients but I was going to miss my co-workers too. Our clinic is big with about 50 employees, more than half of them I was really close to. Any time one of the physicians or medical assistants would mention they were sad I was leaving, I would break down and cry. I was even super close to the Medical Director, who honestly acted like my guardian angel while I was there. It was weird knowing I wouldn’t be seeing them on a daily basis anymore. On the bright side, the Medical Director promised to fly me up for their annual holiday party and we agreed I could always come back in the future to help out when I wanted to.

The clinic surprised me with a sweet party. Everyone went around in a circle and said some nice words about me. The Center Manager told me he was so glad that I came because I brought a new uplifting energy to the clinic and between the other PCPs. The clinic also surprised with me with this beautiful gift:

I never knew leaving a job would be this hard! Yet, I am so grateful for my experiences there over the past year, and will continue to cherish the relationships I have built. I am looking forward to my next adventure and will try not to stay at one place as long again.

Philadelphia

During one of holiday weekends, I went to Philadelphia to visit for the first time. It was a 5-hour drive but I opted for the 1 hour flight instead.

I had a fantastic time in Philly! It was pretty diverse and there was so much to do. I visited tons of museums, including looking at my favorite artists.

My visit also reminded me of why it is so great to be an American! I toured the independence hall and the liberty bell. It’s crazy to think that our forefathers had the courage to rebel against Great Britain, the most powerful country in the world at that time. It’s even more amazing to think that the 13 original colonies all united together to fight for their beliefs.

Why I Decided Not To Go Perm

My previous post demonstrated all of the good reasons I should become permanent at my current assignment. I’ll now explain why I chose not to go that route.

I actually spent a few days leaning towards going permanent. There are two main reasons that I chose not to. The first reason is that I received my extension bonus and realized after taxes I was only going to take half of it home. This reminded me that one of the main reasons I love working in locum tenens, is that I can alternate between being a W2 employee and being a 1099 contractor. This allows me to deduct more taxes at the end of the year.

I am currently working as a W2 employee and was reminded that I needed to work the remaining 3 months of the year as a 1099 contractor, or else I would be paying $60k in taxes at the end of the year! As much as I love my current job, I don’t think any job is worth working just for your income to go to uncle sam.

The idea of becoming a partner at the clinic initially sparked my interest. I compared my current salary and benefits with those I would earn if I were to become a partner. An experienced nurse practitioner at my job confided in me her current salary, and just by being a traveler I was making $20k more than her. In addition, by being a partner, after the initial raise and the quarterly bonuses, this would equate to an extra $20k. I calculated the cost of my living arrangements for the past year and recognized that my job had paid $20k over the past year for my rent, furniture rental, cable/internet, and electricity.

So just to review, becoming a permanent employee could possibly push me back $20k. Even if it didn’t, becoming a partner wasn’t even worth it because I was already receiving the financial benefit through my covered housing costs alone.

The other main reason I decided not to go permanent is because the longer I stay at my assignment, the more drama I began to notice. I observed that the working environment isn’t always quite fair. Some physicians have an easier case load than others, while the most hard working physicians often go unnoticed. I also had some issues with a couple of my medical assistants, where they get too comfortable with you that they think they don’t need to do their job. I had been working in locums for so long, that I had forgotten about the annoying bureaucratic issues of working at a permanent job.

I asked a handful of people for advice; most people told me that if I liked my job then I should consider staying. I never saw myself settling down in Virginia, but wondered if the job was worth it. We do spend the majority of our time at work. And it would just be a year or two, and I am pretty sure my job would still allow me to travel abroad all of the time.

My sister who knows me best was the only person that told me not to stay permanently and to continue being a traveler. She told me not to think about the patients because they come and go. She told me that I am living the best kind of life being able to travel and have constant new experiences, as well as tons of freedom. She told me that I am still young and should think a bit more selfishly.

That pretty much sums up the main reasons I decided not to stay permanently. What do you guys think? Did I make the right decision?

How I Almost Went Perm

When I realized I only had 1 more month left of my year long assignment, I found myself becoming sad. I was close to my co-workers and I truly cared about the 250+ patients in my panel. I began to wonder if I could see myself working anywhere else.

I mentioned to one of the physicians that it was bittersweet that the end was near. She replied that I should consider becoming permanent. She told me that I wouldn’t have to stay there forever, but could commit to 1 or 2 years. I laughed because I never even thought a permanent job would be an option for me.

Yet, I started to ponder over the idea of staying there permanently. The clinic wanted me to help them open one of their new clinics in Florida afterwards. I thought about how I would have to start all over. I would have to get to know 250+ patients from scratch, in comparison to already knowing my current patient panel pretty well. The most challenging time at my job were the first 6-9 months becoming familiar with the patients and helping them become stable. Afterwards, my patients improved so much, that their frequent visits with me became a breeze.

My patient outcomes were really good, that I could have easily become on track for partner status. Becoming a partner with the firm meant an automatic raise, quarterly bonuses, and some other perks such as an easier referral process.

Although there was a permanent physician starting right after my assignment was ending, I knew me staying would really help the clinic. I could continue to carry my current patient panel, while the new physician accepted all of the new patients. Our clinic was growing very quickly, about 50 new patients per month, and there was no provider for them to go to. Nurse practitioners at my site have a panel of about 250 patients, where as the physicians have a panel of 400 patients.

This meant that I could continue with my current panel since I was already maxed out. I wouldn’t even have to take any new patients. Or the physician gave me the idea that if I agreed to stay permanently, I could discuss with the medical director that I would stay with the possibility of giving a handful of my most complex patients to one of the partner physicians. Since those partner physicians have been there for years, their panel should be really stable since they have a long-term relationship with their patients, and could afford to acquire a few more complex patients to their panel.

This all sounded pretty great, but my next posting will be about the reasons why I did not choose to stay permanently.