Part 2: Enough is Enough

I think going back to Virginia and seeing some of my old patients, and how they were doing so well, supported my previous thoughts that the Florida market was not following the model. Our model is focusing on primary care and prevention to keep patients healthy, with less sick days (less days in the hospital), and living longer.

Here are some examples of how the model was not being followed:

Patients did not bring their medications to each visit. How are we supposed to perform medication reconciliation after a hospitalization? How do we monitor medication compliance? How do we reduce polypharmacy?

Hospital discharge appointments are ineffective. Patients are supposed to follow up with their PCP but the front desk keeps putting them with non-PCPs due to ‘availability’. The entire purpose of this appointment is to prevent them from going back to the hospital, who better to do that than their PCP that knows them well. Also, often there are no records from the hospital so we don’t even know what happened to them while they were there. Let’s just say the re-admission rates are high in this market.

Patients are being scheduled randomly. The entire model focuses on the PCP and patient relationship. Total hospitalization rates are high in this market because patients do not have an established relationship with their PCP. This means when they are sick they go straight to the hospital instead of notifying their PCP. Patients shouldn’t see a non-PCP unless it’s a walk-in or their PCP is on vacation.

HEDIS measures are not being done. As I have been seeing other PCP’s patients, I noticed that most of them do not have HEDIS measures done and it is the end of the year. Aren’t we supposed to be focusing on primary prevention, recommending mammograms, screening for depression, and starting them on a statin if they are diabetic etc?

Some other red flags: the social worker was asked if she could do a home visit on a suicidal patient and she said no. Apparently that was ok. Another instance was when I suspected a patient to have a DVT and approached his PCP, who recommended the patient go to the hospital. The patient declined going to the ER and I asked the PCP if he wanted to speak to the patient for a bit (since he had more of a relationship with the patient than I did), and the PCP said no. Apparently that was ok as well.

In response to the medical directors email, I wrote back to him with my concerns that we were not following the model but he never responded. I wasn’t surprised, since he never replies to any of our emails. Nor is he present to have an actual conversation with. I then realized that there was no leadership/management in this market, which is the primary root of the problem.

Part 1: Trouble in Paradise

Regarding my experiences working in the clinics in Tampa/Lakeland, Florida, I will be breaking it up into 4 parts.

Part 1 (this post): Trouble in Paradise

Part 2: Enough is Enough

Part 2: Why I Decided to Leave an Assignment

Part 3: How I became a Martyr


My initial reaction working in the Florida market (with the same company I worked with in Virginia) was “this seems easy”. The patients were not nearly as sick and complex as the patients in Virginia. This was due to many reasons such as socioeconomic status and lack/benefit of familial support.

Unfortunately, as the weeks went by, I realized how disorganized the clinics were. For instance, when I first stepped into the clinic I would only have 4-5 patients scheduled. By the time the day ended, I would have seen about 15 or so patients. This meant 10+ patients were either same day appointments or walk-ins.

For a clinic that is only a quarter of the size of the one in Virginia, there were way too many same-day appointments and walk-ins. In addition, after a patient is discharged from the hospital they are supposed to see their PCP within 4 days. Usually these are scheduled appointments. For some reason, almost every other day, there was a “walk-in hospital discharge”. This animated how disorganized the front desk was. They welcomed walk-ins for medication refills and same day appointments to obtain a pain management referral. All of these which are typically handled over the phone, via phone messages or referral requests.

I waited to see if things would improve. They did not. One day I had 15 patients scheduled (none that I was familiar with), and there were 8 walk-ins alone in the morning. I became extremely frustrated when the new (new to the clinic and me) patient I was going to see had to spend 30 minutes on the phone to update his insurance before he could be seen, and of course I was still expected to see him (late). Then with the walk-ins galore, none of the other PCPs had room in their schedule to see them, and I was expected to see them all. At one moment I had a new (late patient), a follow up patient (that I did not know), and 3 walk-in patients waiting for me. I felt like I was going to explode. Fortunately, I was able to ask one of the other PCPs for help when they had a no-show.

The above issues occurred on a daily basis. I was only able to take a 15 minute lunch at the most, would leave 1-2 hours late each day, and always with a headache.

I approached the center manager requesting that I have blocks be placed on my schedule that will give me room to see the walk-ins, instead of having a full schedule with patients that belong to other PCPs. This is pretty much what we did when I worked in Virginia. She told me to just communicate with my front desk person about how I wanted my schedule to look like.

Thus, I looked at my schedule for the following day, a Friday (aka tons of walk-ins), and saw I had a full schedule like usual. I chose about 4 patients that could be rescheduled for a routine follow up with their own PCPs (it’s not like their PCP was on vacation), leaving me with room to see walk-ins. As my front desk person was calling patients to reschedule them, the center manager overheard and made her stop.

The following day the Medical Director of the clinics emailed all of us Nurse Practitioners (yup just the NPs) with this nasty email:

“Each of u should desist from telling the front desk how to schedule ur patients. They cannot arrange your schedules based on what you tell them. Your schedules are set by me and are based on the needs of the patients and markets.
At present the market needs are such that your schedules will remain as they are.”

The other nurse practitioners were upset, as was I, since they too started confronting the front desk about their schedules. Remember from my previous post “The NP Perspective” that we were all being abused.

I chose not to respond at that time because it was the Friday before I was going to Virginia for the holiday party, and figured I would just deal with this later.

My Apartment on Assignment in Florida

Upon starting my assignment in Florida, I opted to stay in a hotel for the first 1-2 weeks and an apartment for the remainder of the assignment. The first couple of weeks at the hotel gave me the opportunity to check out a few apartment options in person before having to settle on one. A bonus was that these extra stays at the hotel enabled me to renew my platinum status with Marriott for the upcoming year!

I had two main options to choose from, one apartment was close to work but small and outdated. The other apartment was about 15 minutes from work but modern and expansive. I was spoiled living 5 minutes away from my job while staying at the hotel. In the end, I decided to go with the newer apartment that was 15 minutes from work.

I was baffled by the price because the apartment was double the size of my apartment in Virginia, more modern, but 25% less pricey. It was booked through traveler’s haven. They furnished the apartment and provided all necessary items, such at kitchenware, towels, bed linen – even a vacuum! They also set up the cable and Internet prior to me moving in.

Here are some pictures below. I am enjoying living in Florida again as it is much more “new” and “brighter” looking than other states.

The Kitchen was pretty spacious!

This pantry is even bigger than the one in my house!

The dining set was nicely placed and even place settings were put on the table.

The family/living room had more space than I even knew what to do with!

Above is my a partial view of my bedroom. Below is a partial view of my huge bathroom.

I wanted to share my living arrangements again because I still get questions about what to expect when traveling as a locum tenens nurse practitioner.

The NP Perspective

I think I took for granted how well the clinic in Virginia treated me in general. Working in their Florida clinic, I noticed they didn’t treat nurse practitioners as well. For example, nurse practitioners should only be seeing about 12-15 patients per day with this complex geriatric population. However, the nurse practitioners here were scheduled about 20 patients per day. Often seeing more patient than even the physicians.

Those of us without a patient panel, are not allotted the usual 40 min patients for “new” patients (new to us but not new to the clinic). When we are unfamiliar with a patient we can easily take 10 minutes just for chart review. So with only a 20 minute appointment, that leaves us a mere 10 min to address a patient with over a dozen disorders, while also working on health maintenance. Remember this practice is all about having good patient outcomes. Thus, having a brief 10 min visit with a complex patient doesn’t equal good outcomes.

We have approached the front desk requesting they provide us with the allotted time for these new patients, but it’s like speaking to deaf ears. I like to be thorough and even though I have 20 minute appointments for new patients, I usually go beyond this time. The problem is, the front desk books back to back patients, so if I go beyond the allotted time then that means my next patients are waiting forever. In order to be efficient, I often have to catch up on my documentation at the end of the day, or skip a lunch. This isn’t what I signed up for…..

Moreover, when a patient calls requesting a same day appointment due to an acute issue, the front desk will tell them “your doctor is full so you’ll just have to see a nurse practitioner”. The way they say this implicates that you can’t see your PCP but you’ll see the next best thing. I think it would be better if they said “your PCP’s schedule is full so you may have to see another provider.”

Another odd thing is instead of calling us by our first or last name (Sophia vs Ms. Khawly), they call us Nurse Khawly… It’s weird because I wasn’t even called that when I worked in a hospital or school setting as an RN or LPN.

The patients also have a poor attitude towards nurse practitioners. Sometimes they will straight up tell us “I haven’t seen a doctor the whole time I have been here. I saw John last time and now I am seeing you”. As if it’s such a bad thing…

I have been trying to get the other nurse practitioners to stand up for themselves as well, but it recently caused some out lash by the medical director.

Will this experience encourage me or deter me from accepting a permanent traveling gig from this company? Only time will tell…..

Anyone experience poor treatment in a work setting as a nurse practitioner vs the physicians?



Locum Tenens Blogs – December 2017

Happy Holidays everyone! Here are some interesting articles and finds from around the web this month about working in locum tenens.

. has a non-profit website which connects providers with medical missions abroad. You just select which dates you are available and which country you want to go to and it will list various global volunteer opportunities. This year honored a nurse practitioner for her time volunteering in Guatemala over the past 18 years. Read her story here.


Certifications for Nurse Practitioners: How to Increase Your Job Opportunities

Certifications for Nurse Practitioners can make your resume stand out, increase your job opportunities, and even boost your salary.


4 Tips for a Smooth Transition to Locum Tenens Work

A locum who works in ambulatory primary care settings shares four basic tips to help you get started with locum tenens jobs.


Is Telehealth Personal? Exploring Telemedicine Efficiency and Patient Care 

Because the technology is fairly new, patients unfamiliar with telemedicine may not fully trust it. This article illustrates two providers perspectives about telemedicine efficiency and patient care.


ZDoggMD and Barton Talk Burnout:

Check out this video with Dr. Zubin Damania, also known as ZDoggMD, for a recent episode of “Incident Report.” Let’s beat professional burnout in healthcare together!



Trip to Virginia

One reason why I am considering going perm with this company is because they have always treated me well as a whole. In fact, I was invited to the annual holiday party in Virginia where I was working previously. They offered to fly me up for the week of the party and have me help train a nurse practitioner that just started there.

Of course I agreed to go and had an absolutely wonderful time! It was actually a surprise, so the other PCPs I had become close to were shocked to see me. The other clinical staff were really happy and said “it’s like having my friend back.” I was also fortunate to see some of my old patients that were ecstatic to see me.

When I walked in the room they shouted for joy and said they thought they saw a ghost. A few of them also said “this is the best Christmas gift ever.” One of my favorite patients (are we not supposed to have favorites?) with pancreatic cancer had undergone the whipple procedure right before I left Virginia. When I saw him this week he told me he was cancer free!

The holiday party was on an enclosed yacht in the harbor. It was fun catching up with everyone, taking pictures at the photo booth, and watching the “Doctor’s Dance Off” performance. I had so much fun but it was hard saying bye a second time. I thought to myself, how lucky am I to have a job that will fly me up here to reminisce!

Nurse Practitioner Week

This year Nurse Practitioner Week fell on November 12-18th 2017. I hope your organizations made you feel appreciated during your special week. I have partnered up with Barton Associates to share some great articles and interviews from some of our fellow nurse practitioners. Enjoy!

Happy NP Week! NPs of the Past, Present, and Future Speak Out [VIDEO]

In the featured NP Week video, these professionals let us know what they’re most proud of and what they’re most looking forward to. Check it out!

My Locum Tenens Story: Meet John A., NP

John A. is a locum tenens nurse practitioner (NP) from Ohio. After working several permanent roles that weren’t a good fit for him, John says his locum tenens experience simply “fell into place.” Here’s what he had to say about how going locum has affected his passion for healthcare.

A Guide to the NP Wheel: Nurse Practitioner Scope of Practice Laws

To celebrate National NP Week, Barton Associates fully updated their Nurse Practitioner Scope of Practice Laws Wheel with the latest state laws so you can quickly navigate NP scope of practice in your state with a fun, interactive guide!

How NPs and PAs Can Avoid Stagnant Salaries: 6 Strategies

Sometimes hard work doesn’t equate to a big reward. You will likely reach a point in your career wherein you have to maneuver a little bit in order to shake out of a stagnant salary, especially as an NP or PA. This article discusses a few things you can do to avoid merely an inflation-adjusted wage.

“I Want to See a Real Doctor”: How to Talk to Patients Who Question Your Abilities As an NP or PA

Patient management can be difficult, especially when one questions your medical expertise and advice. Here are some tips for NPs and PAs for how to respond, from a PA who has been there.

7 Tips to Help NPs Prepare for Telehealth Roles

As a nurse practitioner, chances are good you provide care in rural and other underserved communities — a population with a lot to gain from the accessibility and cost-effectiveness of telemedicine. How can you best prepare for a telehealth role? Here are some tips.

An Offer I Can or Cannot Refuse?

As a quick summary, I spent the past year working in Virginia for a geriatric clinic that follows a preventative care model. I am currently working in Florida for the same clinic, as they have clinics in multiple states and continue to expand.

My previous post animated part of a discussion I had with the Chief Medical Officer of the company, in regards to nurse practitioners. The main purpose of the conversation though, was for the CMO to see what my goals were and if the company could hire me as their internal locums/traveler.

I alluded to having a similar conversation previously with their Chief Financial Officer. And how I told him that I wanted to continue with my current agency for now, until I had a better grasp of the various markets.

The CMO told me that he definitely sees the value in having an internal locums, especially as they continue to grow. He said he would love to invest in me to develop into a leadership role eventually. Meaning I would either oversee a larger traveling team in the future, or even manage all other nurse practitioners in the market. He said as a contractor it wouldn’t make sense for him to invest in me, so that is one of the main reasons he wants me to become directly employed with the company.

He asked me what I was currently being paid and told me he could increase that. (Side note, I already get paid significantly more than the permanent nurse practitioners, even those with 20 years of experience, since I am a traveler). He said he could also offer me a sign on bonus and yearly bonuses as well. The company would of course cover all of my travel, lodging and licensing fees. He said they would also provide me with a weekly dining stipend, and cover flights whenever I wanted to go home in the middle of an assignment.

In addition, I would have the same benefits as the other employees such as 401K, health insurance, CME allowance, and PTO. The company would also guarantee me with a yearly schedule where I am in a different location every 3 months or less.

After the CMO made all of these offers, I think he was surprised to hear me say “we’ll see”. Financially he was offering me a whole lot, but my priority has always been freedom and flexibility. Although I would continue being a traveler, I would be restricted to practicing in locations the company has clinics in. On the bright side, they are continuing to expand and are opening up new centers in several different states by mid next year.

At the end of our meeting, we agreed to allow me some time to feel out the new center I was in and to think things through. We set up an appointment to meet again next month.

I am extremely grateful for the offers he made me, and especially for the fact that he sees something in me that would make him want to invest in me as a leader. I would be honored to manage and help other travelers and nurse practitioners.

It honestly seems like an unbelievable opportunity for me to grow in an incredible company. My main hesitation is how much flexibility will I have? Will I still be able to take time off in between or during assignments to travel abroad? Perhaps I could negotiate this in my contract. The average PCP has about 4 weeks of PTO but I will definitely need more than that even if it’s unpaid. Will I still be able to leave an assignment early if I absolutely hate the place (whether it’s the people or location)? Maybe I can have them agree that if I don’t like a center I can give a 30-day notice the same way I do with my agency.

On the plus side, they will give me a schedule so I can actually plan where I will be in advance for once. Am I ready for a commitment? I guess worse comes to worse I can always quit and become a regular locum tenens nurse practitioner again J

I would love to know your thoughts! Should I go for it???

Meeting with the Chief Medical Officer

In between completing my assignment in Virginia and starting the one in Tampa, Florida (with the same company), I sent the CMO of the company a letter about my experiences working in Virginia. I had met him several times before and thought it would be a good way to share my experience at each clinic, both good and bad.

He was appreciative of my feedback and requested a meeting with me to see what my goals are and how the company could expand an internal traveling PCP program.

As our conversation began, I could tell how new the concept of having nurse practitioners was to the CMO. When he elaborated about the collaborative agreement between nurse practitioners and physicians, he also stated that there is a wide spectrum on preparation of nurse practitioners. He said that they have observed there can be some amazing, knowledgeable, and competent nurse practitioners; but on the other hand there can also be some inexperienced, insecure, and non-proficient nurse practitioners. Personally I agree, but it’s the same thing in any profession.

The CMO continued to ask me what was the perception of nurse practitioners from the patient’s point of view. He asked how my previous patients handled having a nurse practitioner as a PCP. I told him that the concept of nurse practitioners is something new to a lot of people, especially the elderly population. Many times they do not know what a nurse practitioner is, yet once they see that we practice similarly to physicians at a holistic level, they are fine with it. I told him that of course there are patients who automatically say they do not want to see a nurse practitioner and feel as if they need to be seen by a physician. He asked me, in my experience, what percentage of patients would I say did not want to see the nurse practitioner? I responded with 5% of patients or less. Perhaps other people’s experiences vary from mine.

I found his questions to be intriguing because like I said before, the concept of nurse practitioners is so new, even to a big shot CMO like him.

I updated the other nurse practitioners at my clinic on our conversation. I emphasized the fact that only WE can be our own advocates. That we have to speak up for ourselves when either management or patients try to suppress us. For instance, any time a recruiter or manager calls a nurse practitioner a “mid-level provider”, I make sure to correct them.

In addition, when a patient calls to be seen by their PCP the day of, the front desk will tell them “Your doctor doesn’t have an openings, but you can see the nurse practitioner.” I personally don’t like the way it is said, because it insinuates that the nurse practitioner is the next best thing, and not as good. So I am trying to encourage the front desk to say instead “We can accommodate you today but you will unlikely be seen by your PCP, and may have to be seen by another provider.”

Besides being our own advocate, I think as nurse practitioners, we need to have confidence. Sometimes I hear nurse practitioners turn down a job because they are afraid they are not well trained or competent enough for the position. Of course anything new is scary, but as long as you put in the effort and the time, I feel like you can excel in anything. Physicians will look up things they are not familiar with; we can do the same without being embarrassed by it.

In my next post I will elaborate on the second major part of my conversation with the CMO.

How Treating Others Well Pays Off

Remember I mentioned I couldn’t work with my favorite recruiter at the Occupational Health Clinic because I needed a 1099 job? Fortunately, going back to this geriatric clinic meant I could go back to my favorite recruiter as well!

As promised on my previous post, I sent her some flowers and she called me in tears! I think it is extremely important to make incredible people feel appreciated. J

When I asked for my new agreement with the Tampa clinic, I noticed that the pay rate was $2/h more than I was making previously. I honestly thought it was an accident because no one mentioned anything to me and I hadn’t even asked for a raise. I asked my recruiter and she said ‘I always try to get you the best rate, and even though it doesn’t always work, this time it did!”

I was really surprised and grateful! Sure $2/h doesn’t sound like much but over 3 months it’s an extra $1000.

Perhaps some of you are wondering why I didn’t ask for an incentive to work at another market for the same company. To be honest, the company has always treated me really well and I almost consider them to be family. For instance, they gave me a $5000 bonus just for extending another 3 months. When I worked 10 hours of overtime a week, they never questioned me about it. They house me in expensive hotels (such as the Westin) and don’t mind flying me home every 1-3 months. They even randomly give me gift cards occasionally for no reason (such as Starbucks and Walmart).

Although they need me more than I need them, it’s good for me to have an option in multiple states that I can consider at any time. They are also an amazing company that I would probably work for the day I decide to go permanent (if that day ever comes).

They also agreed to fly me up to Virginia for the annual holiday party, which is sweet and more for me than for them.