Category: Personal Experiences

My name is Kathy and I am a locum tenens nurse practitioner. Last year with my husband, I decided to leave Florida and start traveling. I was feeling burnt out at my previous job and wanted a change. My husband and I wanted to go to the West Coast and explore our beautiful country!

Originally we meant for Texas to be a half way point to our ultimate travel goal, California. We knew we wanted to visit either Austin or San Antonio, but didn’t know very much about them other than knowing they had good food and music. I took a job as a locum tenens provider working on Lackland Air Force Base in San Antonio.

San Antonio has been a blast! The people are friendly. The cost of living is cheaper than Florida. The food is AMAZING. If you love Mexican or BBQ, there will always be a great meal nearby. Our apartment is across the street from a farmers market, fantastic restaurants, and a culinary institute. There are a lot of outdoor activities- we love bike riding, running along the RiverWalk, and we have even hiked to see real dinosaur tracks! The museums have free admission once a week and many places have live bands.  Texas so far has been so much more than just working; we are experiencing a different culture and making new friends.

This past weekend we drove up to Waco to play disc golf, then spent the night in Austin and went to a brewery (named best in Texas, called Jester King) and a highly rated taco truck (called Veracruz). We also went to Ladybird Lake Park, famous for its running trail. On our way back we stopped at Bucees, the biggest gas station I have ever seen!

Regarding my current job, I am so happy this opportunity was available. Working with military service members is one of the most rewarding jobs you can have. Starting out can be difficult; you have to go through an extensive background check, lots of paperwork, and learn a lot about the military if you are not familiar with their customs and rules. Usually government contracts pay a little less than private clinics, they tend to ask for a longer commitment (my contract is 6 months, but could be up to a few years if I wanted), and the paperwork can be tedious.

For me, the positives outweigh the negatives. You don’t get burnt out here the way you do working in private practice or community health centers. I enjoy helping our military members get the care they need and deserve. At this job I have been able to help them in the process of retiring, doing physicals as they are leaving the military, and talk to them about their time in active duty. I have also gotten to learn about the different types of exams and health requirements for the service members. There is a great sense of teamwork with each department and if you need help someone is always willing to help you. In some cases you have the opportunity to fill in at other clinics and learn different skills. I have enjoyed it so much I plan to find my next assignment with the military or VA.

If you are thinking about taking a contract with the military, go for it! You will find that the patients are kind and appreciate your help. Management will not over work you, and everyone is a team player. I recommend traveling to San Antonio as well. Sometimes finding an assignment in bigger cities requires a little more patience, but it is worth it in the end to travel to a place you want to explore.

 

So far I have been having a love-hate relationship with this community health center in San Diego, CA.

PRO’S

• Being a walk-in provider 3 days out of the week, I only need to address one problem per patient, and they need to make an appointment with their PCP for the other problems. Ex: Patient came in for rash. They will be treated for their rash but need to make another appointment for their back pain.
• Part of the reason I wanted to indulge in locum tenens work was to broaden my experiences. Working with this population I have increased my experience treating patients with chronic Hepatitis C, sexually transmitted infections, transgendered communities, complex mental illnesses, chronic pain management, and abscesses needing I&D.
• I absolutely love all of the provider’s that work here. It is nice being in a setting with a diverse group of provider’s and they are always willing to help if needed. We share the same large private space to do our charting in between patients. So we are constantly consulting each other about patients, which I think benefits them in the long run.

 

CONS

• I miss following up with patients because it has always been the best part of primary care to me. Although most patients have a PCP, they are often just put with any provider based off of availability of appointments. I have noticed that any given patient has seen over one dozen different providers in one year (in the same facility).
• I miss my MA’s from Washington – quick, organized, able to prepare room well for procedures; being able to notify patients of lab results; serving as your advocate with scheduling etc.
• If your patient is a no show, they give you a walk-in patient. The problem is that if a patient is a no show at 1:30pm, the walk-in patient isn’t ready until 2pm, and by then your 1:50pm patient has already shown up. This ends up pushing back the schedule for the remainder of the day.
• Every visit is 20 minutes, even if your patient is a new patient with 30 problems or if a procedure needs to be done.

 

 

My first week working in San Diego was incredible! On my first day, I was glad to know that I had a full week of orientation like most facilities. During the first day, I was introduced to the directors of all the clinics and programs. The facility was larger than I thought, with over 14 clinics in the San Diego area.

It was nice seeing that they had programs similar to the community health center in Washington. For instance, they had referral specialists, behavioral health, and care coordinators. One cool thing they have that WA didn’t are health educators. These health educators meet with your diabetic patients to set goals for their diabetes and further education. They also meet with your other patients that have high needs such as children with developmental delays and their families etc.

I was introduced to their EHR system, which was internally created. It seemed pretty straightforward to use (nothing like Meditech). It has order templates created based on the diagnosis, which is pretty neat. For example, if your diagnosis is hyperlipidemia, the order template will have the most common orders used for this diagnosis. Then you can check those orders instead of having to search for them one by one. Orders on this template include commonly used labs, referrals, medications, imaging, and patient education documents.

Another great thing about the San Diego community health center is that providers are not required to do billing or coding for the visit. There is an entire separate team that handles that. Although I do not typically mind doing the billing, it is another thing off our plate. After a provider enters all of the orders and problems, the patient is discharged to the medical assistant, in which they provide an “after visit summary”. This summary includes their diagnoses for the visit, new medications ordered, their vital signs, and any other information you wanted to add to it such as notes saying “don’t forget to drink plenty of fluids!” If you choose to order patient education documents, these are printed along with the after visit summary.

Each EHR note is in a SOAP format, in which you can drag diagnoses, orders, medications, and lab results into your SOAP note from the orders page. There is also a smart phrase section which you can store commonly used phrases. I created some phrases to include all of the ROS and Physical Exam components. I would just need to edit what is abnormal after inputting these phrases onto my SOAP note.

Similar to WA their EHR has a ‘decision aids’ tab. When the patient comes for their visit, the aids tab will tell you if they are due for a pap smear, colonoscopy, flu vaccine, HbA1c testing etc. It will even tell you the ASCVD risk factor of the patient. This tool can help you decide if a patient should be placed on a Statin for mild hyperlipidemia or not. Unfortunately, unlike WA, medical assistants do not order immunizations or rapid strep/flu testing on their own. In fact, providers even have to swab tonsils/nasal turbinates ourselves. Unlike WA, medical assistants and nurses are unable to provide lab results over the phone. Meaning I would have to call patients myself or have them make follow up appointments, which are not always a good idea since they many be unable to get an appointment in sooner than 4 weeks.

For the remainder of the week I shadowed multiple providers in various settings. It was actually pretty neat to shadow a Pediatrician, Family Nurse Practitioner, and a Physician’s Assistant. I thought about the community health center in WA, and how nice it would be if they had a pediatrician there. In comparison, the physicians appeared to be very intelligent, and I grasped that our nursing background truly enables nurse practitioners to think outside the box.

Everyone is really nice and helpful. I think it is pretty neat that lab coats are left in the clinic at the end of the week for them to be sent out for dry cleaning. The clinic is also trying to increase patient portal access. I think this is the future of medicine because it allows patients to obtain their lab results (so they can bring with them to other consultations), has patient education material based off of their problems list, and they can even submit messages to the providers (such as I need medication refills or I forgot if I was suppose to take this in the morning or at night).

Looking at my schedule for the upcoming weeks, the facility is definitely starting me off slowly. My first week I will only see 8 patients per day (PPD). The following week 12 PPD, then 16 PPD, and then finally the 20 PPD I will be seeing for the remainder of my assignment. The 20 PPD is definitely doable because each patient has a 20 min time slot and the no-show rate for the clinic is 30%.

I am actually going to be working at 3 of their clinics each week. At one clinic I will be the walk-in provider. It appears to be nice because the patients only get to have one problem addressed during this type of visit. Each clinic is different, especially because San Diego is pretty diverse, so one clinic will have a heavy Hispanic population, while another clinic has mostly Arabic patients.

Of course I was bored after the first couple of days of shadowing. So I ended up seeing a few patients under the other providers’ schedule. My first patient was deaf and had a translator with him. It was pretty neat and I was glad I was able to take my time with him.

Did the community health center in San Diego surpass my expectations? Absolutely! Is it better than the one in Washington? No, but it is pretty close! I am looking forward to working here for the next few months.

 

After my horrible experience in Monterey, CA I was nervous about my next assignment in San Diego, CA. I wondered to myself if California was just another Florida. I wondered if there was any other facility out there as good as the one in Washington.

When I arrived in San Diego and moved into my new studio apartment, most of my fears vanished. I was in disbelief that I was going to be living on the beach for the next 3 months! Since San Diego is a large metropolitan area, there were many housing options available to me.

The housing coordinator for my agency was initially going to find me an apartment to do a short-term lease, and furnish the apartment. A friend of mine suggested living in a home hosted by airbnb. I found some great options but a lot of them were already booked out for the next several months.

I found a beach studio that was listed at $100/night. This would be $3000/month aka over budget. My agency did not specify my housing budget, but based off of my housing in Washington, I figured they were looking to spend around $2000/month. My friend suggested I contact the owner because a lot of times the owners are willing to give you a discount since I would be staying there for a long period of time (they wouldn’t have to worry about finding someone in between short stays).

Luckily, the owner told me he was willing to give it to me for $1800/month! This was mainly because winter in San Diego is low season, so he wouldn’t really be making a high profit until the summer anyway. I notified my housing coordinator and they worked with the airbnb owner to set up my stay.

I was thrilled to live steps from the beach! I am living on Mission Beach near the boardwalk and shops. It’s nice being walking distance to activities and restaurants. Plus having a beach parallel to the boardwalk with 60 degree weather is great motivation for getting some exercise in!

On the bright side of my experience in Monterey, CA, I was very appreciative for my recruiter and other agency team members. When I told them about my experience at the clinic, they quickly apologized and admitted that it was their first time working with the site so they had no idea. They told me they would speak to their contact at the site about my complaints so that other providers they send in the future can have a better experience. They worked to get me the overtime that I deserved, and my recruiter checked in with me almost every day.

Although my experience with the site was grotesque, I had a great experience with the agency. They truly spoiled me by putting me in a Marriott on the weekends where I could be in more of an urban setting, and even enabled me to be reimbursed for the gas used with my rental car.

They were helpful and patient with my complaints between my travel nightmare and clinic disaster.

I am fortunate we discussed the “30 days notice” clause in the contract, because I was supposed to return to that facility the following month. Yet, as I am sure you can infer from this post, there is NO WAY I am ever going back there!

My only issue with the agency is that I was told I would be compensated for working on New Year’s Eve with holiday pay. Unfortunately, with everything going on, I did not get that in writing. So of course when I received my paycheck, there was no sign of holiday pay, and the agency acted like they never told me that. I partially blame myself for not sticking to my # 1 rule which is “get everything in writing”! I secondly blame the agency, and I do not plan on working with them in the future. At the end of the day, it always comes down to the pay and what you were initially promised.

In addition, I had awesome friends that came down to visit me during the weekend of New Year’s. We had a good time exploring the area, going to the Monterey aquarium, and eating some fresh seafood.

I knew I had been spoiled in Washington but I didn’t realize how much until I began my next assignment in California. This was a hospital affiliated clinic near Monterey, CA. It should have been a red flag to me when the orientation process was only 1-2 hours, and my EHR training was 45 minutes long. To be fair my assignment was only 2 weeks long.

On my first day, I met another locum tenens nurse practitioner that had been working there for one month. She told me she usually has to stay about 3 hours after her shift to catch up on documentation. She told me she didn’t charge overtime or tell the front desk not to overbook her schedule.

My first thought was that she was nuts not to charge over time and to stay all of those extra hours after her shift. One of the perks of working locum tenens is – NOT having to work more than 40 hours per week. I also assumed that she was the reason why she stayed late and it would not happen to me.

Boy was I wrong. Right away I noticed that they booked patients every 10-15 minutes, even if they were new patients, needed procedures done, or had a lot of complex illnesses. Not to mention, the EHR system they use is the oldest version of Meditech possible. Meaning it was not at all user-friendly, and I would have rathered done paper charting (which I hate), it was that bad.

I normally like to do my charting with the patient in the room. However, this EHR system was sooooo slow and complex, it was too much of a burden to use while the patient was present. I do not like having my patients wait too long so I typically get them in and out. I found myself seeing the patient and doing my charting afterwards.

Just because the patient left the room/clinic didn’t mean I was done with them. Unfortunately, if the staff saw an empty room, they put a patient in it, whether they were originally scheduled or not. Meanwhile, my charting started to accumulate and I could quickly see why the other locums nurse practitioner was staying after hours to chart.

I am definitely not a push over, so as soon as I saw my charting was going to accumulate, I demanded for 1 hour of charting time at the end of the morning and evening shift. This helped ease the burden, but I had to make sure I at least wrote a little in the HPI and plan so I would not confuse the patients.

Moreover, I noticed that I would have walk-in patients without even being asked. This meant that although I had a 10 am patient and 10:15 am patient, I suddenly also had a 10:10 am patient. I made it clear that I needed to be asked before placing walk-in patients on my schedule. Does it make sense to fit in an uncontrolled diabetic in my tight schedule? No. Yet, some patients came in for the flu vaccine or depo-provera injection, so these types of walk-ins would be fine since they are quick and easy.

For the first time in my life, I hated my job! I began having symptoms that a lot of people I know have before going to work each day. For example, I couldn’t sleep well at night; I had stomachaches the mornings before working; I felt so exhausted by the end of the day I did not even want to eat. I thought of all the people who go to work every day and hate their jobs. I was grateful that this was only a brief and temporary assignment, and I sucked it up for the two weeks I was there.

I believe the main problem stemmed from the facility being unorganized. Since I wasn’t trained properly, having to figure out internal processes made my days longer than they should have been.

The front desk staff aren’t trained well enough on triaging patients and scheduling them. There was confusion even between the nurses and medical assistants, in which they told me I was responsible for doing all wound care (a nurse’s job)….. I wasted time ordering flu vaccines for patients, compared to many places I have worked at previously will have the MA/RN order and administer the immunization, with me just signing off on the note.

Of course the horrible EHR system contributed to the disaster. Since the affiliated hospital owned these clinics, you would think I would be able to see why the patient went to the emergency room the other day (that was not the case). The electronic prescribing was always lagging that pharmacies continuously told patients they hadn’t receive the prescriptions, and in return patients were constantly calling the clinic.

During my interview, I was told I would be seeing 20 patients per day, which is pretty average. I found myself actually seeing 30-36 patients a day. I wouldn’t call that safe, and honestly if I hadn’t hustled my butt off, I would have probably ended up staying 3 hours after my shift every day like the other provider.

In between seeing 30+ patients per day, walk-ins, and charting on an ancient computer system, I was also expected to review the provider I was covering’s messages. These messages included medication refill requests, lab results, imaging results, specialty consultations, and general patient messages.

On my last day I saw the other locum tenens nurse practitioner. I told her I saw what she was talking about but she should know that it’s not her fault. The way the clinic is set up, it is causing her to be stressed out and overworked. I told her she should definitely talk to her recruiter about it and charge for over time. I told her that by her not saying anything, the facility will continue to abuse and overwork providers.

The weekend after Christmas, I left Miami, FL to travel to Monterey, CA for my next assignment. I woke up that morning at 4 am to make my 7 am flight. Once I reached the terminal, I discovered my flight was delayed. This meant that I would be missing my connecting flight in Phoenix, AZ. Unfortunately, it was after the holidays so the majority of flights were all booked. Therefore, I was placed on stand-by on the next flight out from Phoenix.

My 7 am flight became a 9 am flight that took 4.5 hours to Phoenix. Then I found myself waiting 5 hours before being able to board the next flight out. I wasn’t able to find out if there was room for me on that flight until everyone had boarded the plane. Luckily, there was space for me, however the plane was too small to accommodate my carry-on luggage. Thus, I was forced to check in my carry-on luggage.

After a 2 hour flight, I finally arrived to Monterey 7 hours after I was supposed to based off of my flight itinerary. To make matters worse, neither my checked in baggage or carry-on made it to the airport. Apparently, there was not enough room in the small plane to accommodate all of the passengers luggage, and they had to leave half of them behind.

I waited in my 3^rd long customer service line of the day, and was told my luggage would likely be on the next flight in. With my luck, that next flight was cancelled. The last flight of the day was arriving at midnight. I forced myself to stay awake, although at that point I had been awake for 23 hours already, in order to get my suitcases. I checked the American airlines baggage app that said my luggage was checked into this arriving flight.

I waited for my luggage at baggage claim, and was beyond furious when they still were not there! While in line for the 4^th time that day, I found myself exhausted and on the verge of losing my mind. Turns out they had indeed put my luggage onto the plane, but had to remove them due to space, once again. The agent said the luggage would likely come the following day.

I was supposed to start my new assignment the next day, so through the advice of a friend, I went to Walmart to find some alternative clothing. I was wearing leggings and a long casual shirt, which wouldn’t have been appropriate at the clinic. Unfortunately, Walmart had absolutely nothing. The following morning I woke up at 5 am to call my recruiter who works on the East coast, and explained my situation.

After being awake the previous day for 25 hours straight, then sleeping only 3 hours the next night, I felt like a zombie. My recruiter notified the site and they told me to take care of my luggage situation and clothing, and to come in later that afternoon. I went to Target as soon as it opened but found nothing. Then I went to Ross that was next door and still nothing. I even went to the mall to look for appropriate attire. I think part of the reason I had difficulty finding appropriate clothes at the mall was because it was 35 degrees outside and I was freezing, since I only had a light sweater on me. The other reason is since I felt and looked like a zombie, I thought no attire looked good.

Not to mention, each time I checked for the status of my baggage, it seemed that every flight coming out of Phoenix that morning and afternoon was getting cancelled. I was so grateful when my recruiter and site contact agreed that I should just start working the following day.

My luggage finally arrived at 7pm that night and I was relaxed enough that I could sleep well.

Things I learned from this experience include refusing to check-in my carryon luggage in the future; or using a small duffle bag as my personal item to keep a change of clothes inside; or flying to larger airports instead of smaller ones even if I have to drive a couple of hours (because smaller airports also mean smaller planes).