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.

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LocumTenens.com has a non-profit website MedicalMissions.org 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 MedicalMissions.org 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.

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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]

https://www.bartonassociates.com/blog/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

https://www.bartonassociates.com/blog/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

https://www.bartonassociates.com/blog/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

https://www.bartonassociates.com/blog/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

https://www.bartonassociates.com/blog/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

https://www.bartonassociates.com/blog/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.

Working in Tampa, Florida

After taking a brief break from the geriatric facility in Virginia, I agreed to help them out at some of their clinics in Tampa, Florida. Being in Florida during this time fall/winter is especially beautiful because it’s not too hot and not too cold. The drive up here from Miami was about 4 hours.

My first day at the new center was okay. I sort of knew what to expect since I had worked at their centers before. Upon arrival, everyone was gregarious and it was nice to see an LPN that I knew from Virginia. She had transferred to that market a few months prior.

I initially was a bit sad because it felt strange to work in a familiar setting with completely different people. The Medical Director was friendly but he didn’t nurture me the way the previous one did. The center manager was welcoming but wasn’t prepared with my laptop, new ID, and lab coats the way the previous one had been. I think I took for granted that the Virginia clinic treated us for lunch almost every day!

I thought I would jump in and start seeing patients, but I spent the majority of the morning on the phone with IT trying to set up my login and computer etc. I also called a few of my patients from Virginia to check in on them. They were extremely happy to hear from me and mentioned that they felt neglected from the clinic since I left.

Originally, the Tampa clinic wanted me to help out 3 months ago when they were short staffed. It seems like since then they have recruited A LOT of PCPs. So I sort of wondered why I was there and if I was even needed anymore. I felt like I should be at the clinic in Virginia, but knew I couldn’t go back there yet.

By the end of the day, I tried to keep a positive mindset. The clinic was new so it wasn’t nearly as busy as the ones in Virginia. Therefore, at least it was unlikely I would feel overwhelmed some days like I did in Virginia. In addition, I was mostly going to be helping with walk-ins and overflow for the PCPs. This meant I wasn’t going to have my own panel the way I did in Virginia. This was a good thing because I wouldn’t have as much responsibility or have to work overtime as I did before. The only bad thing is that I wouldn’t be able to develop relationships with the patients. But considering I spent a year in Virginia, I am glad it turned out this way because at least I can put in my 2-3 months and move on without feeling guilty.

Locum Tenens Blog – November 2017

Welcome to this month’s blog post sharing some great reads from around the web!

 

How Locum Tenens NPs Can Redefine Work-Life Balance

I love the above article from TinkBird because I often get messages from other Nurse Practitioners that are burnt out and wondering if locum tenens would be the answer for them. Fortunately, the answer is Yes! Read the article above to find out why.

 

Barton Associate’s had a lot of interesting articles too:

5 Qualities a Recruiter Looks for in a Locum Tenens Candidate: This provided some good insight into what will make a recruiter more interested in working with you and open up more opportunities to finding the perfect assignment.

Finding Volunteering Opportunities As a Locum on the Road: I actually used to be REALLY involved in volunteer work and started thinking about how I wanted to get back into that realm again. I was happy to stumble upon this resource guide to help me start volunteering while I am on new assignments.

 

Forbes had an article about the increase in Advanced Practice Nurse pay. Great read to see how nurse practitioners and other advanced practice nurses are starting to be compensated appropriately.

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.