Part 4: How I became a “Martyr”

Just one week after I left, I already heard from the other nurse practitioners that things were changing for the better. There was an announcement that all walk-ins and hospital discharges are supposed to be seen by their PCPs. If only that had been implemented while I was there, it would have prevented a whole lot of problems.

There is a new nurse practitioner there, in which this is her first job practicing as an NP. I had told the CMO that they were scheduling her with way too many patients and that no one is available for her to ask questions. (Note: she worked at the other clinic from me, not mine, otherwise I would have helped her). She told me that after I left, the Medical Director told her that she was seeing too many patients, and they were going to start giving her 30 minutes per patient. He also told her that if she had any questions she could ask any of the doctors including him.

Lastly, another major announcement is that the Medical Director will actually be stepping down and there will be a new Medical Director taking his place within the next 3 months.

Although I would have preferred to avoid the recent past turmoil, I am glad that by me speaking up for my peers and myself, circumstances are improving for them. Sometimes you have to sacrifice yourself in order to help others.

As far as working with this company again in the future, it is definitely a possibility. I think it was insinuated that I would not be taking the permanent traveling gig at this time. Considering the Tampa/Lakeland market was mainly for me to make sure other markets were just as great as the Virginia one, but it clearly didn’t work out. Nonetheless, the CMO clearly took my concerns seriously and did not waste any time to implement change. He has my utmost respect and I hope to work with him again in the future.

Part 3: Why I Decided to Leave an Assignment

T’was the Friday before Christmas. I had the usual full schedule and there were plenty of walk-ins. It was 11:30 am, lunch started at 12:00 pm and I had 2 patients waiting for me. This is when I was asked if I would see a ‘walk-in hospital discharge.’ Remember from my previous posts that these are supposed to be schedule appointments but became ‘walk-ins’ on a regular basis.

I responded with “no I cannot see the patient because I already have 2 patients here and unless she has an urgent issue the patient should be scheduled for a hospital discharge appointment.”

The next thing I know, the patient was checked-in under my name. I was told that the front desk “lead” said I HAD to see the patient because we cannot turn away any walk-ins. I proceeded by approaching the front desk “lead”. I told him “I already said I could not see the patient. So I am not sure why she is checked in under my name.” He responded with “she is a walk-in hospital discharge, so she has to be seen.” I said “these should be scheduled appointments. Regardless I cannot see her as I already have two patients here, but maybe someone else can.”

I went to lunch late anyways, and when I returned the Medical Director was waiting for me. He pulled me aside and pretty much said to me:

“I was told you turned away a walk-in hospital discharge. You know we do not turn away walk-ins, not here and not in Virginia. You have upset a lot of people here. I think you should take the rest of the day off and think hard if this is a place you want to return to.”

Like the great leader that he is, he didn’t even bother asking for my side of the story. I didn’t “turn a walk-in away”. I just said I could not see the patient, and they should have asked someone else, but they did not.

I was happy to leave early to be honest because I was able to drive down to Miami in the day-time (for Christmas). As the company is based out of Miami, I decided to use the time I was home to speak with the Chief Medical Officer. I told him about all of my concerns (not following the model and us nurse practitioners being mistreated) at the Tampa/Lakeland market, and what had happened the week prior. He said he would like for me to meet with the Medical Director and “hash things out” by giving him my perspective. I told the CMO that I had already tried approaching the Medical Director about my concerns prior to the incident last week, but he ignored me, as he ignores all of us. The CMO then said he would try to address my concerns himself.

When I returned to work after Christmas, I decided it wasn’t a place I wanted to remain at. As much as I enjoyed working with some of the other PCPs and my supportive staff, I was only there for the model. And since the model wasn’t being followed, nor was management receptive to any suggestions, I knew it was time to go. I notified my recruiter about everything that had happened and told her to find out when was the earliest date I could leave.

I originally still had another month of that assignment, but the Medical Director agreed to let me leave at the end of that week. Like always, it was bittersweet saying bye to everyone. However, most of them understood why I was leaving and agreed that since I have the luxury to do so, there was no point in me staying there longer. I am hopeful that things will improve within the next year, and maybe at that point I can return.

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?

 

 

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!

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.

South America

My most recent international trip was to South America. I went to Colombia, Argentina, and Chile. I was originally supposed to go to Brazil as well but my visa didn’t make it in time.


My first stop was in Buenos Aires, Argentina. The first day I was there, I witnessed the person next to me get his Iphone stolen from him right out of his hands. This was definitely eye opening since I thought Argentina would be the safest place in South America. My favorite part of Argentina was watching a tango show one evening.

After a few days I went to Santiago, Chile. Ironically, it had been the last place I was looking forward to going to but ended up liking it the most. I think the combination of being in a big city with snow capped mountains and awesome seafood did the trick! The weather was a bit cold but I enjoyed being outside with the awesome scenery.

To end the trip, I went to Cartagena, Colombia, which is a small town on the coast. The people were very friendly and hard workers. No one begged for money, but everyone was hustling and trying to sell you something. I had a lot of fun and enjoyed visiting Castillo San Felipe de Barajas, which is a super-fort built long ago by the Spanish.

This was my second time in South America (I had gone to Peru a few years ago). As always, I enjoyed learning about the local culture and trying new things. I hope to get back down there to visit Brazil once my visa comes through.