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Interview with Sophia Khawly – The Traveling Nurse Practitioner

I did an interview with LeaderStat, a locum tenens agency, last month. You can find the article by clicking the link above. I have also added this agency to the agency tab on my home page. They are a smaller agency but the benefit of that is you will have more of a personable experience and reasonable pay. Feel free to contact me for a direct recruiter recommendation.

 

4 Doctors and Nurses Share How They Pack for Missions Around the World

This luggage website illustrated some packing tips for medical providers traveling around the world. My tips are mainly for traveling nurse practitioners working a 3 month gig. Check out the link above for some recommendations, and feel free to browse Mighty Goods for baggage pieces.

This is something I never thought much of until recently. When I finished my first travel assignment, I remember receiving a survey that asked about my experience working with the site, working with the agency, and my housing. I soon learned that the agency also sent a similar survey to the site to evaluate their experience working with me. I think this is a nice feature because it lets the agency know if they should continue utilizing both the site and locum tenens provider.

During one of my assignments in Florida, I remember the first week the agency sent a survey to the site to ask how I was doing so far. I thought it was strange since my recruiter never even called me to see how the job was.

At the end of the assignment I was expecting a follow up survey but received none. I was surprised and also thought it necessary since I did have some constructive feedback to give. Although it may seem minute, the agency that didn’t send the survey didn’t rub me the right way. I didn’t have the personable experience I was used to getting from my favorite agencies/recruiters.

Honestly, since they never sent me a survey to evaluate the site, I felt like they cared more about keeping their business with the site than whether or not I had a good experience working there. After this, when I had the option to accept a job from them vs another agency, I went with the other agency.

Look out for those surveys and they may give you a glimpse of how much you are valued in that company.

Since the opioid epidemic is nationwide, even as locum tenens nurse practitioners, we may have to participate in this battle. I have been asked several times if there is a specific approach I take when it comes to refilling opioids during an assignment.
I’ll start by saying every provider has a different approach to prescribing controlled substances. Some are lenient while others do not prescribe it at all. I would say I have more of a moderate approach. I do refill opioids to an extent, as long as I have enough supporting documentation, and I feel the patient needs it. I also try to wean down a patient when appropriate.

For example, let’s say a patient comes in with chronic low back pain and is requesting refill for 120 tablets of oxycodone. Before going in the room I look for several documentation. Is there a controlled substance agreement in the chart? When was the last urine drug screen? Is there imaging in the chart to support this complaint? If there is no controlled substance agreement, I make sure to obtain one during that visit. I will also go ahead and order a urine drug screen. Some patients have tested positive for cocaine or other drugs, in which I let them know that I will no longer be refilling their pain medications.

If there is no imaging, I will go ahead and order that. Sometimes I am only comfortable with providing a 2 week refill while waiting for the proper workup. I will also check the PMP or controlled substance database of the state to find out when the last time the patient filled the medication. I will also check to see if the patient clinic hops to obtain narcotic prescriptions (which would be a red flag, and I would not refill for them).
During the visit I make sure to document pain level, location of pain, and failed treatments. Have they tried physical therapy? Have they tried joint injections? Have they tried non-narcotic medications? It’s one thing for a patient to say they have tried it and it didn’t help vs seeing on their chart that they did try alternative treatment and it did not lead to improvement. Most of the time, if I refill narcotics for a patient, they need to be proactively trying alternative measures. This can be specialist consults, surgery consults, acupuncture, physical therapy, injections etc.

When possible, I will refer to pain management. Especially for patients on stronger opioids like fentanyl patches, morphine, and high doses of oxycodone. However, in some areas, pain management access is limited so unfortunately, we will have to manage these patients ourselves.

I have found that if you are willing to work with a patient, the more receptive they will be. So for the patient requesting oxycodone #120 tablets, I would let them know I am not comfortable prescribing such a high amount due to risk of overdose. I would compromise to prescribing 90 tablets after they meet the requirements above, with the goal of weaning them off completely. Some patients are okay with the change because I guess it’s better than nothing, while others can become visibly upset.

This is why it is so important to have the controlled substance agreement in place. As soon as a patient becomes verbally or physically aggressive, they are breaking the contract, and you no longer need to refill pain medications for that patient.

Some other things to keep in mind are that I never initially prescribe opioids for patients. Meaning I will only refill, but not start anyone on them. In addition, I never refill opioids during a patient’s initial visit to the clinic.

No site has the right to force your prescribe opioids, but I often find that they will ask me my approach during the phone interview. If you think you will just go to a clinic and not refill any narcotics, and send them all to pain management – think again. In an ideal world it would be great, but as mentioned before, some areas have limited access to pain management, so you would have to figure out a plan for the patients you are treating. By no means am I encouraging you to follow this practice of refilling pain medication, but I just wanted to share with those of you interested, how I approach the opioid epidemic.

 

A benefit of working through an agency for a locum tenens position is malpractice insurance. In some states, such as Florida, it is mandatory for nurse practitioners to carry liability insurance. Even if it’s not mandatory, it is something locum tenens nurse practitioners should all desire to have. Since working in locum tenens is fast paced and you aren’t as familiar with a patient as their primary care provider, this leaves room for more risk.

Once I begin an assignment, I always ask for a copy of my malpractice insurance (provided by the agency or site). Then I make sure to update my CAQH profile with the liability insurance information. The reason for this is because when you accept a new assignment; sometimes the site will need all of your previous liability insurance information for credentialing. They need to verify that you do not have any current or previous claims.

Sometimes it’s annoying having to provide copies of a dozen different malpractice insurance policies. But having them already saved in a work file makes it convenient to find when needed.
I am sometimes asked if I carry my own malpractice insurance in addition to the ones provided by the agencies. The answer is no. I don’t see a need to spend a few extra thousand dollars for something I already have. Also, keep in mind the liability insurance provided is often for the entire year and not just the length of your assignment. For any specific questions about your liability insurance through the agency, be sure to clarify with your recruiter.

As I consider which states I plan on obtaining new licenses in, I am thinking about only getting licenses in states that allow independent practice for nurse practitioners. Here are the reasons why:

1. Respect: No one is calling me a ‘mid-level’. In states where nurse practitioners can practice autonomously, we are seen equally to physicians. When we are seen at an equal playing field, no one is using that term (mid-level), I despise. When I worked in Washington State before, a state that supports full practice authority for nurse practitioners, I felt respected.

2. Licensing process is easier: States that require nurse practitioners to have protocols in place or a supervising physician make the licensing process more difficult. Sometimes I have to provide a protocol before they even grant me my nurse practitioner license, which is ridiculous. Other times I have to show proof that I prescribed medications at a previous job, or obtain a letter from my supervising physician.

3. Freedom: In independent practice states I’ll be able to order home health and sign orders for my patients in need. I’ll be able to prescribe all kinds of medications without the pharmacist requesting the name of the physician I work under. I’ll be able to spend less time wondering if that’s something I am authorized to do and assume it is.

4. Better pay: States that value nurse practitioners have already progressed to allowing full practice authority. As a result, these states will typically pay nurse practitioners well. This is because other states use the term ‘mid-level’ to explain why nurse practitioners aren’t paid as well as their peers (physicians), even when doing the same work.

Some states that are considered to be independent practice states for nurse practitioners may have different stipulations. For instance, working in Washington was the ideal full practice autonomy state to work in. On the other hand, although Maine is also an independent practice state, the licensing process was still a bit tedious. I had to have a previous supervising physician confirm that I was supervised over 2 years or more, prior to them giving me an independent license. In addition, some home health agencies do not allow nurse practitioners to authorize home health orders, which I find strange. So keep in mind that the 23 states with nurse practitioner practice autonomy are not all equal.

I am so glad I chose to spend the summer in Maine. I went on a coastal road trip with a friend that visited me up here. We stopped in several cute towns on the coast of Maine, and wandered to many lighthouses on the way.

My favorite town was Camden. It was so endearing with nice views of the harbor and boats. I was able to try a Maine delicacy: lobster roll. I can’t say I am a big fan.

I really enjoyed visiting all of the lighthouses. The Pemaquid Point lighthouse had stunning views and they even allow you to go inside, all the way to the top.

We also stopped by this famous lighthouse from the Forrest Gump movie. It was even nicer in real life.

My preferred lighthouse is in Portland, Maine. It is located in the Cape Elizabeth area at Fort Williams Park. It is beautiful and I liked how families gathered there to enjoy the weekend.

A highlight of my time in Maine would definitely have to be going to Acadia National Park. There were many hiking paths, awesome views from mountain peaks, and beaches. The day I went, it was a bit cool so the beach was covered in fog. It looked like what I always expected Cape Cod to look like.

Additionally, Jordan pound was spectacular at Acadia. You can even enjoy lunch or coffee at the Jordon Pond House restaurant while enjoying natural views.

On a side note, I love being in New England because you are so close to the other states. I was able to take weekend trips visiting a friend in Boston, and exploring New Hampshire and Vermont.

My only wish is that I could remain here for fall. However, since snow fall starts as early as November I will not be extending.

There is so much provider support at my current job in Maine. It just makes our lives easier. For instance, there is an RN that handles the medication refills as long as it meets protocol (recent labs, recent appointment etc.).  When requesting a controlled substance refill, the medical assistant will copy and paste the most recent PMP report on the phone message. PMP is what we use here to look up where and when the patient last filled a controlled substance prescription.  How convenient that this information is automatically provided for you instead of having to spend precious minutes signing in and looking up the patient yourself?!

Like many states, Maine has an issue with the opioid epidemic and even patients forging prescriptions. Thus, they use a system called ‘imprivata’, which all providers must enroll in. Controlled substance prescriptions must be submitted electronically. After submitting the prescription electronically, the imprivata system pops up in which the provider must sign into. After signing in, the provider must then check her imprivata phone app and approve the prescription from there. It may seem a bit tedious but it’s a pretty quick process and at least it ensures that you are the only one prescribing controlled substances. Patients are unable to forge or change a prescription, and no one in the office is able to refill a controlled substance without your permission.

The front desk staff also handles all of the referrals. They make the providers lives easy by proposing referrals for patients. This means if a patient called requesting a referral to an eye doctor, the front desk staff will put in the referral and diagnosis, then send the proposed order to us, in which we just have to sign off on.  The RN also handles triage, so providers aren’t bombarded with ‘tick bite’ visits or patients with cold symptoms that just started today.

The only negative interesting finding I have surveyed does not have to do with the clinic staff. It has to do with the patient population. It appears that developmental delays in pediatric patients here is very prominent. Most places I have worked, you will find a developmental delay in about 1 out of 100 children. Here it seems that every other child that comes in for a physical has a developmental delay. I am assuming it has to do with the low level of education here and high use of alcohol and drugs during pregnancy and infancy.

These are just some observations I thought would be interesting to share with you all.

“I have been searching for my first traveling position for months now but so far, no luck. Did it take you this long to find your first assignment?”

Yes, I always let my readers know that the first travel assignment is the trickiest to find. Imagine how many people reach out to recruiters on a daily basis with an interest to travel but without follow through. It is expected that you will reach out to your recruiter on a weekly basis to follow up on possible assignments. They prefer you call them to let them know how serious you are instead of just sending an email.

I always recommend that as a first time traveler to go ahead and apply for 2 states licenses to make yourself more accessible to sites. If you have been waiting around for 3-4 months without a job lead and have not applied for any new state licenses then that is problem #1.

If you do have other state licenses but still have been struggling to find something, the next questions to ask yourself is – am I in contact with enough agencies/recruiters? To open more job options I suggest you are credentialed with at least 5 agencies so that you can be presented to more jobs.

If you have been presented to several jobs but no sites have accepted you, consider reviewing your CV and making it more attractive. Also, prepare for the phone interview a bit more and ask the right questions to make it seem you are very interested.

Lastly, if the first three steps are taken care of then I suggest you become more open minded. Maybe you envisioned yourself taking your first assignment out on the beach. Realistically, these assignments go fast so you may have to be more willing to go where the jobs are. Let your recruiters know that you are open, and they will pass more jobs by you.

Realistically, some traveling nurse practitioners may be presented to a dozen sites before something matches up well. Do not be discouraged, as some assignments do fall through. Just be sure to work on yourself and make you more appealing to the sites.

 

Normally when I am going on an assignment, I will opt to receive mileage for travel and either drive or ship my car to the destination. This time I didn’t want to bring my car up because the lease will be ending mid-assignment. I am considering not getting another car once I return my current one, because it doesn’t make much sense to have one as a traveling nurse practitioner. As much as I love my current car and bringing as much stuff as can fit in the car, driving long distances seems less and less attractive to me.

So instead of asking for mileage, I had the site provide me with a flight and rental car. If I decide not to get another car after I return my current one, I will just continue to obtain rental cars for work. When I am home, I can always borrow my parents’ car since they live abroad, or even rent one if I will be there for a short period of time.

I realized taking a flight to Maine was going to limit how much of my belongings I could bring. I was a bit stressed during the packing phase because I hadn’t taken the flight option since my Washington assignment several years ago. It ended up working out, as I like to pretend I am a minimalist.

When I picked up my rental car, I was hoping I wouldn’t end up with a compact hatchback. Fortunately, the rental car agency upgraded me to a small sport SUV. Since I would be renting it for 3 months, they gave me the newest car they had so that it wouldn’t need any maintenance.

Prior to coming I looked at my housing options. Being 1 hour north of Portland, Maine, I didn’t see any apartment options. I began to be nervous when all I could find were cabins in the woods for rent. Being a city girl, this wasn’t going to work for me. I talked to my recruiter about it and she let me know that the site had actually rented out a house for me and sent me some pictures which seemed fine.

The house turned out to be pretty big for just me. It is 2 bedrooms and 1 bath with an entire basement downstairs, and an entire finished attic upstairs. It also has a big screened in front porch and a detached 2 car garage. The house came completely furnished, with all essentials, from bed linen to dishes. The best part of the house is it’s across the street from the clinic so I can actually walk to work!

An added bonus is that they allow employees to use their brand new cardiac rehab gym at the hospital (which is across the street from me) after hours. So I often have the gym to myself when I go after work.

As I mentioned previously, searching for my next assignment I wanted to go somewhere up North that is normally cold but would be pleasant over the summer. I also needed to go somewhere with a quick licensing turn around. Thus, I ended up in Maine!

Originally it seemed like a random place to go, but after researching activities to do, Maine appeared to be an ideal place. I wanted to be somewhere that I could be outdoors and enjoy both weather and nature. Maine is perfect for that, as there are tons of hiking trails. It is a nice mixture of coastal beach town meets mountain life.

I have been here for a few weeks so far and I feel like I have reincarnated into Henry David Thoreau (who is from Maine by the way). I feel peaceful and harmonious with myself, work, and all of life.

I am working for a clinic owned by a local hospital, covering a maternity leave. It has been a truly positive experience. Everyone is so laid back here – the supervisors, the medical assistants, nurses, physicians, and even the patients. It’s nice working somewhere where patients don’t feel entitled and staff is extremely friendly.

My patient volume per day is light. I see between 8-14 patients per day. The majority of the patients are pediatrics so I do a ton of well child exams. These are pretty easy since the nurses handle the immunization schedules and I just verify the accuracy. I do have some adult patients but they are straightforward. Even the patients that my medical assistant warns me are “complex” or “nuts” are pretty basic. Sometimes I reminisce about my complex geriatric patients in Virginia. I miss them and the challenge. Yet, this zen life is too good to give up!

Each of the physicians and nurse practitioners have one day off a week for admin time. To be fair, the clinic is giving me one half day off a week, paid! I obviously don’t have any admin work to do, so I just get paid to go home at lunch time and spend the remainder of the day lounging around. Some days I use my free time to go on a nice hike…while getting paid. Yes people, these jobs exist.

The only issue in the work setting is the EHR. They use Cerner which most nurses would know belongs in an in-patient environment. It’s not user friendly, is redundant, and complex. All of the other providers and staff loathe it. It’s not as bad as Meditech but it’s a close call. Had I been seeing a patient every 15 minutes, I may have gone insane. But since my schedule is light, I have enough down time to maneuver the system.

Another great thing is that the coding here seems to be laid-back as well. I am used to having to change ‘well child exam’ to ‘well child exam with abnormal findings” (when there is something wrong) and linking diabetes to all other complications (neuropathies, chronic kidney disease, hyperlipidemia etc). Here, Cerner doesn’t give you all of those coding options so the coders have protocols to update the charts for us. This a big relief for us providers, considering how time consuming the billing/coding aspect of documentation can be.

I am so happy with my decision to come here, and I am looking forward to exploring the region!