Working back in Florida is always an eye opener. I am working at a private family practice with my supervising physician, covering a maternity leave. At this clinic in particular, nurse practitioners and physician assistants are expected to forward their clinical notes to their supervising physician to sign off on at the end of each day. Supposedly its to get a higher reimbursement rate from the health insurance plans.
This is definitely a first. I remember working in California (another state with restrictions for nurse practitioners), in which the practices there often required the supervising physician to review 25% of the nurse practitioners charts for the first month. I was fine with that because it seemed fair, being a new employee at the practice and all. However, having to send ALL of my charts to my supervising physician EVERYDAY is a bit ridiculous.
It feels weird having someone “monitor” my work. Fortunately,
my supervising physician here is pretty great. He doesn’t criticize my work,
considering every provider practices differently. Instead, he will give
me an update on worrisome patients or a thumbs up when imaging matched my
diagnosis (such as pneumonia or gallstones).
In addition to forwarding my clinical notes, the supervising
physician is the only one that reviews lab results and imaging. Initially, I
thought ‘great, less work for me’. But now I am finding it a bit of a
nuissance because I don’t know what’s going on with the patients I am caring
for. This practice isn’t what I am used to, where the physician has his own patients
and the nurse practitioner has her own patients. Instead they just manage the
same patient panel together. So technically the patients belong to the
physician and the nurse practitioner is helping the physician care for his patients.
That is why there is so much oversight here.
Of course, I am not a fan of this. Especially since I have
worked in so many states with independent practice for nurse practitioners. I
almost forgot what it felt like to be constrained like this.
As I said previously, luckily my supervising physician treats me as an equal. He will encourage teaching moments but will say “I am not sure if you already know this or not” without assuming I don’t. He also tells me almost everyday “you are doing a great job and I am glad you are here.” I prefer this generalization versus him telling me “good job with that case” because the latter implies that he is surprised or not expecting a nurse practitioner to give good care.
On the other hand, sometimes he disagrees with my follow up timeline or my choice of medication. I try not to get worked up about it because I know each clinician practices differently. And he doesn’t disagree in a “matter of fact” way but is more inquisitive as to what led to my decision based on my vast experience. I have also observed that he really cares a lot about his patients, so I don’t take it personally when he wants to change my plan of care. It’s a testament to his practice when patients travel from out of state to continue following up with him.
Initially, it really bothered me that I wasn’t practicing “independently”. That prior to completing a note I always second guessed myself to make sure my supervising physician wouldn’t have any feedback. I slowly became accustomed to it and I am fine with it since it’s only on a temporary basis. I have even started consulting my supervising physician a bit more since they are technically his patients.
This practice is interesting because it is my first time working in a private family practice where the majority of patients are part of the working population and are very well education. This means most of them have co-pays and rigid schedules. So if they come to you with cold symptoms and paid $20 for their copay, they aren’t happy when you tell them they don’t need an antibiotic. I feel like the demand for antibiotics here is the equivalent of the demand for opioids in low income populations. The patients are looking for a quick fix so they can get back to their jobs or practicing for the next marathon.
I remember a fellow traveler telling me she worked in a private family practice last summer and didn’t enjoy it as much as working with disadvantaged populations. I understand what she means now. This population isn’t as sick as what I am accustomed too. That means less of a challenge and therefore, less of an impact.
In general, I don’t have much to complain about, my day goes smoothly and the majority of the patients are pleasant. In fact, I typically finish an hour early and get paid for the full day. I just wanted to share some interesting observations as always.
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