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San Diego is even better than I remembered! The weather is perfect. All of the different scenery is beautiful. It is so diverse. And there are sooo many young people here! I guess I had been in Florida for too long haha.

I was given a 3-day orientation and EHR training since I haven’t worked here in 5 years. The EHR is the same which is pretty straightforward. I was given one afternoon to shadow another provider. I am pretty sure I had a couple of days shadowing last time, but maybe it is reduced due to covid. It’s not a big deal to me, but there was a locums physician that was doing orientation with me. She seemed to need more shadowing than that, especially since she hasn’t worked here before.

I was given a ramp up schedule, which is a mixture of office visits and phone visits. I like this particular clinic a lot, more than my main one last time. My patients are mostly Spanish speaking which is nice. They have been very pleasant so far. The medical assistants at my clinic are really helpful and friendly. The PCPs are as well. The last patient of the morning is scheduled 1 hour before lunch and the last patient of the day is scheduled 1 hour before the end of the day.

This is great because if you are running behind you have that extra time to catch up and finish notes. The no-show rate is pretty high, but there is often a walk-in waiting to be seen during a slot where you have a no show. This is fine since it is usually for a direct reason or something quick like medication refills. I also like that patients are required to check in 15 minutes before their actual appointment. So no late patients are accepted.

I was a bit nervous about seeing pediatric patients again, but the EHR made it easy by having guiding well child exam templates and immunization records. It’s actually been pretty fun working with that population again.

The community health centers have so many resources for their patients which is excellent. They have a transgendered clinic, mental health center, registered dieticians available, and HIV services. There is a lot of social support for the patients.

The most challenging thing for me has been deciphering between normal cold symptoms and covid19. We always encourage patients to get tested, but sometimes their covid test is negative – and they continue to have symptoms. So you have to decide if it is a false negative for covid or if you should treat them for other disorders. Also, since California is the hot spot for covid right now, we try to deter patients with covid like symptoms from coming to the clinic at all. This can be challenging when a patient has a history of asthma and you would love to be able to listen to their lungs but administration wants us to encourage them to utilize the ER if they do not get better.

Fortunately, I was able to get my first covid vaccine on my second day here. That was fast. Had I waited to get it at home in Florida, it would have probably taken forever. My only reaction was arm pain that lasted a few days.

I am really loving my time here and wish I could stay forever! Too bad I am a nomad and it is too far from my family in Miami. They are still getting adjusted to the time difference and continue to call me at 5 am or while I am at work. It’s too early for me to decide if I want to extend. You get a better feel for a place after working there for 1 month.

San Diego is probably my favorite city in the USA. I absolutely love it here. I worked here about 5 years ago and have always wanted to return. When I worked here before, I worked at a community health center between 3 different clinics. I liked working at 2 out of the 3 clinics. However, the clinic I hated was my main one (where I was at most days of the week). I didn’t like the leadership there and was always overwhelmed with the quantity of patients.

The opportunity for me to return to work with the same community health center was ideal this time. This is because I would be able to only work at one clinic, instead of floating around. I prefer this because when the clinics are large, it’s difficult to remember everyone’s names and where everything is when you are working there for just 3 months. It’s easier to get overwhelmed when you are not comfortable.

The usual patient per day volume is 20 patients per day per provider. I prefer to see closer to 16 patients per day. Due to covid, they converted some of their scheduled patients to phone visits. The phone visits are quick so this made me more comfortable with accepting to see 20 patients per day.

Before accepting the San Diego position, I was also asked to help out at my previous job in Virginia. They wanted me to start in January as well. I ultimately decided to move forward with the San Diego position for 2 main reasons. I needed to work at a family health center to gain more experience working in pediatrics. I had been working with only adults for the last 18 months. If I didn’t work with children soon, I would eventually lose both my skills and credentialing to be able to work with all ages.

The second reason is that it is obviously too cold for me in Virginia from January-March. I did work there during that time frame once, and it even snowed. Fortunately, they understood that I needed to gain some pediatric experience, and asked me if I could help out once I am done in April. I told them I would let them know once I started my new job in January.

I would love to go back to Virginia because I have a lot of friends there and it’s a quick plane ride from home. But I wanted to see what it was like to work with all ages again. Would I love it so much that I would want to continue working with pediatrics again? Would it be way easier than working with my usual complex geriatric population?

I was a bit nervous to start the job in San Diego because of my previous challenges. I am not a fan of the limited scope of medical assistants here. Such as not being able to swab for strep or flu. Yet, it has been 5 years since I worked here. Since then I have worked at 15 other places, including years of challenging geriatric work. I was curious to see if the job would be “simple” to me compared to other places I have worked.

Once I made up my mind that I wanted to go to San Diego instead, I dreaded having to tell my recruiter that I was no longer moving forward with the Kaiser job. If any of you have backed out of an assignment before, you know how recruiters can get nasty real quick. I remember one of my friends telling me that his recruiter threatened him with a lawsuit even though he backed out more than 30 days prior (his contract stated he can cancel an assignment with a 30-day notice).

The truth it, I knew my recruiter/agency couldn’t do anything to me since I never actually signed a contract. Part of me still wanted to work with Kaiser eventually, just to see what it’s like. So instead of cancelling completely, I asked if my assignment could be postponed until April.

Of course, my recruiter was over dramatic. He said I was leaving Kaiser with ultimately no providers, since they were counting on me to start. He must have forgotten that he told me he had placed 2 other providers at Kaiser to start right before me. He made it seem that the clinic was going to be without any providers. My interviewer there told me they have over 100 providers at any given time.

My recruiter said he didn’t know how Kaiser would take this and maybe they would put be on a black list. I laughed at that because I was almost done with credentialing with them (which takes 60 days), so I knew they wouldn’t mind the convenience of having me in the future.

He also asked me if I was sure I could get another job in January on such short notice. He seemed very doubtful. I laughed at that too. At this point in my career, I have worked in over 20 different practices, so my connections are endless. Not to mention I already had another job secured.

I was glad when that conversation was over. A few days later he let me know that Kaiser said it was actually fine for me to start with them in April. But he needed to know if I was 100% committed. I told him I would let him know in January after I start my new assignment. April was months away.

He clearly didn’t like that response because he sent me a long message saying how they can’t wait that long – and how I need to hold my commitment to that start date – and if I don’t start in April after all then it will damage my name with them and also their relationship with the site too. Blah Blah Blah.

I did not answer because at that time I was focusing on meeting my newborn niece, the upcoming holidays, and my assignment in San Diego. I didn’t appreciate the way he was “threatening” me, and the fact that he sent me the same message AGAIN on Christmas eve with a “merry Christmas” at the end. -_-

My first week in San Diego, I was obviously busy with orientation and adjusting to my new job. That didn’t stop him from blowing up my phone every single day. Multiple missed calls, voice messages, text messages, emails, and even his co-workers were calling me daily! I was so furious because I had already told him I would let him know once I started my new job. One thing at a time….

But since he couldn’t respect my decision and continued to “harass me”, I texted him on Friday to let him know my answer for starting at Kaiser in April was “No Thank you”. He couldn’t even accept that decision either, he responded with all of the reasons why I should work with Kaiser after all.

The truth is, I do want to work at Kaiser. But I am extremely turned off by his lack of professionalism and is not someone I would ever want to work again with in the future.

Have any of you had a similar experience when backing out of an assignment?

Besides the weather, there were multiple factors that were deterring me away from the job in Northern California. I wrote a recent post about the California AB5 bill, which doesn’t allow nurse practitioners to work in California as a sole proprietor. This job with Kaiser was with a different agency than I normally work for, although I have worked with them in the past. Part of my desire to work with them was to get some 1099 work for the 2021 year.

I usually work with Comp Health for the majority of my assignments, which pays me as a W2 employee. I like to have at least a little bit of 1099 work each year to help reduce my overall taxes.

However, due to the AB5 bill, the agency had just notified me that they would have to pay me as a W2 employee while working in California. This meant they had to offer me benefits such as health insurance and a 401k, but if I accepted the benefits, I would be given a decreased hourly pay. I thought to myself, than I would rather just work with Comp Health to get my usual benefits and usual higher pay.

In addition, I was also drawn to this particular job because they were offering a $3500/mo housing stipend. I had found a furnished apartment that was going to cost me $2000/mo, so was planning on pocketing the extra $1500/mo. But since I was now going to be an employee for them, they could no longer give me a stipend. They could only reimburse my cost of housing.

At this point I knew I wanted to take a job with Comp Health in San Diego instead. I had already interviewed with the job in San Diego twice in 2020 but hadn’t moved forward with them for covid related reasons. The first reason was when covid just started, I decided to extend at my current assignment to wait things out. And the second time was because I had the opportunity to work in Florida which was closer to home.

Stay tuned for part III!

Working during the months of January – March, my options are quite limited since I hate being in cold weather. I usually try to be in Florida or California during this time.

In November, I was presented an opportunity to work with Kaiser Permanente in one of their Northern California clinics. I was really interested in this offer because Kaiser is supposed to be the “mecca” of healthcare. They use EPIC EHR which is supposed to be the best – ironically, I haven’t yet come across it after working with over 15 different electronic healthcare systems.

I even spoke to a provider that was working there and they told me how much they loved it. She told me there are tons of specialists that work there so you can always get a curbside consult when needed. The orientation and training process are very thorough as well.

My main hesitancy was that credentialing takes 60 days. That meant I had to make up my mind as soon as possible. And if you recall my ‘FOMO’ post, I hate committing early on. I also wasn’t thrilled about the location. I prefer to be in Southern California. It is more my vibe and less cold. Plus, I know more people there.

When I finally decided to move forward with the assignment, I let my recruiter know that my CA licenses and DEA were going to expire at the end of the year. Thus, I needed them to cover the costs of renewal. I was surprised when the recruiter made it seem like I was crazy for asking for this. He told me these things aren’t typically covered.

I said for sure state licenses that are used for the job are usually covered. I knew that particular agency usually doesn’t cover the cost of the DEA since it’s $700+, but they had paid for it for me in the past. He tried to negotiate with me, saying if they covered the cost of the CA RN license can I cover the cost of the NP one. Obviously, I said no. I am no rookie here…

In the end they ended up agreeing to cover the cost of all CA licenses and my DEA. When they sent me the contract, of course there was no mention about paying for my licenses. I did not sign the contract. I sent it back to them requesting that information be added to the contract. I know from experience not to take a recruiter’s word for anything. Everything must be in the contract!

In the meantime, I started credentialing so that my start date wouldn’t be delayed. Fast forward to a couple of weeks before my start date, and I still hadn’t received my contract. I hadn’t mentioned anything to my recruiter because I knew without a contract I still had the opportunity to back out last minute.

So when a “cold front” hit Florida for a few days, I knew I wasn’t cut out for winter in Northern California afterall. I checked the weather there and saw it was in the 30’s and 40’s. I then checked the weather in Southern California and it was in the 50’s and 60’s – more my style. Luckily I knew had another option in Southern California.

Stay tuned for part II!

FOMO stands for “fear of missing out”. Usually people use this expression when they missed out on a trip or a reunion with friends etc.

As a traveling nurse practitioner, I sometimes have FOMO when it comes to choosing my next assignment. For instance, some sites have a credentialing process that takes 2-3 months. I try to avoid these jobs because I don’t like committing to an assignment too early.

Locums jobs are usually available last minute. Typically, there wont be a job posting until about 1 month before the assignment start date. This is why I am not a fan of committing to a job 2-3 months in advance. What if a better job comes along? Maybe something in a better city or a job that pays better. What if I need to be closer to home?

I know most people would like to be committed to multiple assignments in advance so they won’t have to worry about it last minute. I guess I have been doing locums for so long that I am the opposite. I like to decide on my next assignment within a few weeks of the start date. When I commit to a job well in advance, I often start second guessing it.

I even have FOMO when extending an assignment! Often, I am asked to extend during the first month of my 3-month assignment. I usually tell them I will let them know closer to the end. Of course the site wants to know sooner than later to see if they need to hire someone else. But I need to decide last minute to see what my needs and desires are at that time.

The only time I don’t mind committing to a job super early is when I have a bunch of vacations/trips planned. That way I know where I will be prior or during the trip so I can book my flights instead of assuming I will be flying from Miami.

Any other traveling nurse practitioners with FOMO out there?

Instead of focusing on the covid pandemic, the American Medical Association (AMA) has been advocating for #StopScopeCreep. The AMA has been calling for limits on the autonomy of NPs and PAs, and for years has been working against legislation that allows NPs to practice independently. Their argument is that Nurse Practitioners do not have adequate training to work independently. They support this by saying Nurse Practitioners have less clinical hours during graduate school than physicians have during their training and residency.

I think the AMA forgets that most NPs have experience as nurses prior to practicing as an NP. Our first 1-2 years working as an NP is technically a residency as we adjust from being in the classroom to implementing what we have learned. In addition, most independent practice states only allow nurse practitioners to become autonomous providers once they have several years of experience under a supervising physician.

It is disappointing that the AMA is using this challenging time to blast social media with misinformation about other healthcare professionals. I am not sure why they are so threatened by nurse practitioners. Physicians will always be the expert in medicine, and nurse practitioners are filling in gaps in the healthcare system.

I was happy to see the American Academy of Nurse Practitioners (AANP) publicly defend nurse practitioners and asked the AMA to discontinue the #StopScopeCreep campaign. If you aren’t already, try to support the AANP by becoming a member. We need to unite as nurse practitioners to prevent the AMA from continuing to dispraise us.

For more information, click the link below to read the statement from the AANP in response to the #StopScopeCreep campaign.

Joint Statement on the Scope of Nurse Practitioners

Last year I had a couple of posts about a new nurse practitioner in Chicago that I was mentoring. I thought it would be nice to give an update on how she is doing since then.

In my previous posts I animated how the new nurse practitioner had a lot to learn and didn’t have much support from the physicians in her clinic. Since then she has registered in multiple boot camp courses to build upon her medical knowledge. She also studied for a few hours every day after work.

Besides asking me questions from afar, there were a couple of new physicians at her clinic that she was able to form good relationships with and go to them if she had any questions. As a result, her support network has improved.

She has been practicing at that clinic for over one year now and has come a long way. I am happy to report that she has excelled even beyond her fellow peers.

In her clinic of 4 providers, she has the top patient satisfaction scores and the top patient outcomes. This means she has been the most successful in keeping her patients out of the hospital and healthy.

I have also noticed her clinical knowledge has improved, along with her confidence. She doesn’t come to me as much with questions, and if she does, she typically already knows the correct answer.

I am proud to say she has graduated from her role as a novice nurse practitioner. I think it’s so important for new nurse practitioners to continue learning their first year working and find a mentor to guide them. 

It has been a while since I made a post based off a question from a reader. I had an interesting question from a reader the other day that I get quite often, so I figured it was time to share it.

Do you have consistent work as a traveling nurse practitioner?

It seems a lot of nurse practitioners are worried about having consistent employment prior to taking the plunge as a traveling nurse practitioner.

The answer to the above question is – yes. I have consistent work because I have formed relationships with recruiters in multiple agencies. When I am ready to start searching for my next assignment (usually 1 month prior to my current assignment ending), I will reach out to my recruiters. I let them know when I am available and what I am looking for. This allows them to keep me in mind when something opens up that meets my needs.

By having these relationships, the recruiters are constantly reaching out to me when they have new gigs. I try not to ignore them, and will let them know if I am currently not available or not interested.

I think the other important aspect is that I have at least 5 active state licenses at any given time. This makes me a good candidate for job prospects, as most clients aren’t willing to wait for you to become licensed.

As I stated above, I do have consistent work being a locum nurse practitioner. In fact, there are often many options from me to choose from at any given time. It also helps when you have been traveling for a while, because previous sites may often request you to come back. I like to use these as my back up options unless I am excited to return.

The reality is you have to be flexible. If you are only open to working in a certain city vs being open to working in the general state, then your options will be limited. In addition, sometimes the start date may be delayed a week due to credentialing or licensing so you should make sure you always have a financial buffer.

I have found that newbies are concerned about consistent work but once they start working as a traveling nurse practitioner, they realize their take home pay is more than their full-time job. As a result, they recognize that they actually don’t need to work 52 weeks out of the year. And enjoy taking time off to be with family/friends or travel abroad.

This year went by incredibly fast. I guess because most things that happen were halted by Covid such as traveling and celebrating holidays.

Finishing up my assignment in Florida, I interviewed for several assignments in California. I was looking for an assignment for November-January. Since it would be cold during those months, my options were limited. I had 3 offers from CA jobs that actually seemed great. However, I ended up turning them down because in the end I decided I just wanted to be home for the remainder of the year.

November is my birthday month and Thanksgiving. Even though I knew we wouldn’t have our usual 50-person thanksgiving dinner, I still wanted to be home to celebrate those occasions with family and friends. I had an incredible birthday, so I am glad I made the decision to be home for it.

Besides Christmas and New Year’s Eve in December, my older sister got married and my younger sister had her first baby. Thus, I had a lot of (positive) family things going on, and didn’t think it was worth traveling back and forth from California at least 10 times within 2 months.

After finishing my Florida assignment, I wasn’t burned out so I actually wanted to continue working. But after talking it out with people I am close to, I realized that I want to retire early so I can spend time with the people I care about. So why wait until I retire to do those things?

I was worried I would get bored with 2 months off, but between all of the holidays and festivities I was pretty busy. I even picked up a few per diem shifts helping out the Ft. Lauderdale, FL clinic I worked at previously 1 or 2 years ago.

I had a great end of 2020 and am looking forward to what 2021 has to offer. Happy holidays everyone!