Category: Personal Experiences

After I decided to leave the assignment in Tampa, FL early, I was planning on just taking a vacation. However, one of my recruiters insisted he had the perfect assignment for me. It would only be 3 weeks long (covering an FMLA) and would consist of working with a migrant community of mostly Hispanics and Haitians. Since I speak some Spanish and Haitian Creole, I figured why not.

The agency had already submitted 10 candidates that the site was reviewing. My recruiter was confident that I still had a chance because of my work experience and language skills. They selected me as one of the top 3 candidates and proceeded with a phone interview. It seemed like a good place to work, so when they offered me the job I said yes.

The site was about 2 hours from my home in Miami, FL so I was provided with a hotel during the weekdays, and I went home during the weekend. I was reimbursed for daily mileage to work and mileage home each weekend. Since I had a long commute, the site even allowed me to leave 1 hour early each day (paid for full shift) to make up for it.

This is a community medical center, one of the goods ones as I portrayed in my previous post. Since it was a brief assignment, I didn’t expect an extensive training. My first day, I completed the mandatory OSHA/HIPPA etc. training during the morning. In the afternoon, I was introduced to the EHR system. The funny thing is they originally offered me a scribe. Meaning, I wouldn’t have to document, there would be someone following me and documenting my encounter with the patient. I thought, wow that’s neat. Some of the providers here have scribes, if they aren’t comfortable or too slow with the EHR. That’s a nice gesture to support their PCPs.

I told the manager that I didn’t need a scribe, as I am used to jumping into places and learning the systems quickly.

They used Athena EHR which was straightforward, and by the next day I was already pretty competent. They also had an IT person on site available to me in case I needed any assistance.

I really enjoyed working at this community medical center. I had two medical assistants, which meant I never had to wait or look for help. The patients were pleasant, not as demanding as the previous practice I was at. My schedule was fair – I averaged about 12-14 patients per day (of course there were no shows).

Another funny thing is that everyone was so impressed. They were surprised how quick I was, and told me that the patients were used to waiting 2-3 hours to be seen. They were also amazed by how quickly I learned how to use the EHR system. I have been used to working with such a complex elderly population over the past 1.5 years that these average patients seemed so ‘basic’ to me.

I forgot how easy it is to manage a 40 year old patient with just hypertension and hyperlipidemia versus managing an 82 year old patient with hypertension, hyperlipidemia, diabetes, heart failure, angina, arthritis, hepatitis C, cancer, depression, insomnia, obesity, glaucoma, kidney disease. No joke!

The only challenge for me at this site was getting accustomed to the diagnostic coding and billing sections again. I had been working in a ‘managed care’ setting over the past 1.5 years so the diagnostic coding is much different. For instance, at this community medical center I had to make sure I specified physical exam with or without abnormal findings, normal or abnormal BMI (and which value). In comparison to the managed care setting, we didn’t use those diagnoses much. We mostly focused on HCC codes, which are codes that can bill at a higher rate and represent how sick our patient is. So if a patient was overweight, it didn’t matter as much as if a patient was morbidly obese, if that makes sense (billing wise, not medically).

Like anything though, the more you start to do something again the more it becomes familiar. It was the same with doing well child check ups. I was so used to treating complex geriatric patients that I had to do a few well child exams before I was confident in them again.

In conclusion, this assignment deserves an A+. On my last day, the CEO came all the way to our clinic just to meet me and tell me “I have heard such great things about you!” He came prepared to make me a permanent offer, but I told him (in a nice way) not to even bother J. He told me they would love to have me again when there is another need. I definitely wouldn’t mind helping them again. I hope other sites can take a lesson from this one – PCPs like to be appreciated!

 

 

Whenever I meet other nurse practitioners or physicians on assignment, they’ll talk about their prior experience working in a Federally Qualified Health Center (FQHC)/community health centers.

They will tell stories about seeing over 30 patients a day, being mistreated and unappreciated, and places that are really disorganized. As a traveling nurse practitioner, I have already worked at 5 different FQHCs. And guess what, they aren’t all bad!

When I tell the other providers that there are actually some really great FQHCs out there, they look at me in shock. I do agree that most of them are pretty awful because “it’s all about the numbers”. However, I have come across 2 so far that are incredible!

For those of you that have been following me since the beginning, you may recall my first assignment out of Florida. This was a FQHC in Washington State that was extremely organized and well-run. Patient per day ratios were fair, about 14-18 patients per day. They allotted 30 minutes for new patient appointments. There were standard protocols in place that allowed medical assistants to help PCPs with immunizations, acute rapid testing, and even health screenings. PCPs were given admin time, 1 day a week where they could catch up on medication refills and paperwork.

After my awful experience working in Tampa, Florida, I ended up taking a brief assignment in a FQHC in south Florida. I felt spoiled having 2 medical assistants just for me, and seeing a fair 14-16 patients per day. The EHR was straightforward and there was an IT person on-site daily to help if needed. If there was an issue, such as having too many physicals scheduled in one day, the staff quickly corrected this without push-back. Leadership was amazing too. The center manager and medical director made themselves available and constantly offered positive feedback.

It’s such a wonderful feeling to look forward to going to work and being enabled to provide the appropriate care you strive for. So don’t be afraid of traveling as a nurse practitioner. Sure you may stumble upon some awful assignments, but most of them you can handle for the brief 3 months. If there is one you do not feel comfortable staying at any longer, you can just leave. Although there are some bad assignments, there are definitely plenty of great places too.

 

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.

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.

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.

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.

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.

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?

 

 

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!

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?