Traveling NP

As my Virginia Beach assignment comes to an end I want to focus on the wins of this assignment. After my second month I started having to work 50+ hours a week in order to keep up with my growing patient panel. This left me exhausted and looking forward to the end of my time here. I don’t regret coming here for the following reasons below.

Here are some of my Virginia wins:

-Nice catching up with old friends and making new ones.

-Interesting visiting Thomas Jefferson’s estate after reading his biography.

-Having my parents come to visit.

-A patient made me home baked chocolate chip cookies. This was a thank you for catching a breast mass on her (she hadn’t had a PCP in decades), which ended up being bilateral breast cancer (treatable). So she was grateful.

-Having ~60 days with no patients in the hospital

-Advocating for patients to be placed in long term care that couldn’t take care of themselves anymore or getting their families more involved (had dozens of these patients).

-Meeting grumpy patients and by the end of the visit they had a smile on their face and were very thankful.

-Identifying when it’s time for a patient to go on hospice (non-cancer related) and them passing away shortly after comfortably at home.

-Having patients and staff ask me if I was opening up my own practice so they could follow me there.

The biggest win of all was showing hundreds of elderly patients that a nurse practitioner is just as competent as the physician they are used to seeing.

Feel free to comment with some of your recent wins while on assignment below!

I mentioned before that I wanted to come back to Virginia because I wanted to visit Thomas Jefferson’s estate. I am happy to say that it did not disappoint. It was amazing to get more insight into the life of such a brilliant man. I was also able to see where he is buried – next to his wife and daughter.

His home is in Monticello which is right outside of Charlottesville. Since this is only about 1 hour away from Shenandoah National Park, I went there to spend the weekend with my parents who were visiting. The views were beautiful since it was the peak of spring. I even forced my parents on a 1.5 mile hike which they enjoyed.

We also went to the Lurray Caverns. It ended up being more expansive than I had imagined.

Lastly, Virginia Beach is nice because it has a boardwalk you can walk or bike ride on. People often play music there and you can grab a bite to eat while listening to the waves. Being from Florida, I am biased to our beautiful beaches there, but the beach here is more than enough to relax in on a warm sunny day.

I think I have a little PTSD from working with the same company in Kentucky where the patients were just awful. Since then I am always apprehensive to meet a new patient (to me) and relieved when they are normal and kind.

I find this type of work more rewarding than my job in San Diego. Although working in San Diego was easier and I had more free time, I didn’t find the job to be too rewarding. I didn’t feel like I was making much of a difference. I think it’s because the patients were fairly stable and I didn’t see them more than once or twice.

This is in comparison to my job here, where all of my patients are 65 and older and very sick. I see them once a month or sometimes even weekly depending on how complex they are. I am able to develop relationships with them and their families. I am able to help them improve their health and witness them get better. I love when we get to the point of knowing each other that we can begin to joke around.

At the same time, since the patients are vastly sicker here, I barely have any free time at work. I often have to work through lunch or stay after hours to finish my work flow (medication refills, review lab results etc.). Luckily, I am paid overtime but I would rather have the free time and feel less mentally exhausted by the end of the day.

Unfortunately, the work life balance at this job isn’t good. The physicians often respond to phone messages or do medication refills even on their days off. They are usually still working even after I have left – and like I said I leave late.

Initially, I had a few patients that were upset about not having a “doctor”. The medical assistant would warn me about this and explain why the patient’s blood pressure is high. It didn’t bother me because I knew that they just had no idea what a nurse practitioner is. When I went in the room I introduced myself to them, listened to their concerns about seeing an NP vs MD, and explained the similarities and differences between each profession. By the end of the visit, they calmed down and their blood pressure went back to normal. They had no more concerns about seeing a nurse practitioner since they realized they still got everything they needed medically.

So far, I have had only one hiccup – which sadly happened during my first week. The referrals we place to specialists have to be approved by the medical director of the clinic for cost reasons. I placed a referral to neurology for a patient with a brain mass and swelling, and physical symptoms such as expressive dysphasia and hand tremors. The medical director asked to speak to me about the referral. He said he didn’t have enough information to approve it. He needed to know what I expected the neurologist to do for the patient.

I told him I disagreed as I provided more than enough information, and since I was not a neurologist I didn’t know what they would do. I also told him I wasn’t a new provider and knew what to include in my referral notes. I had never had an issue with my referrals in the past 5 years that I have worked for this company.

He still kept going on and on about what he needed to approve the referral. I was so mad that I just walked away as he continued to talk. I went to see another patient and when I came back his demeanor had changed. He told me that I was doing such a great job and had already noticed an improvement in the patient numbers; and that he was so grateful I was here.

I don’t think I even responded – just stared, because I was dumbfounded. I thought to myself ‘yes you better suck up to me because you need my help’. One of the physicians had retired earlier than expected so the physician that would be taking that panel wouldn’t start until the end of summer. Thus, they were grateful to have me cover the 3-month gap. The funny thing is that medical director had shadowed me when he was a resident my first time working for this company 5 years ago. So, I really didn’t care for his feedback.

He ended up approving the referral – if he hadn’t that would have been a big lawsuit waiting to happen. I just want to do what I enjoy which is seeing patients and not be bothered with trivial things. If he bothers me again I may decide to discuss the matter with the chief medical officer. She told me to let her know if I came across any issues.

For some reason there aren’t many short-term apartments available currently, even though Virginia Beach is a military town. The options the agency sent me were either 30 min each way from the clinic or had wall unit a/c (it gets really hot here in the summer).

So, I was put in a Courtyard Marriott hotel. I thought it would be for only 1-2 weeks until they found me something. I even searched myself and no short-term units were available close to work. After living in a hotel with just a minifridge and a microwave for one month, I was finally transferred to a hotel with a kitchenette. I didn’t complain too much because the hotel was 5 minutes from my job.

I am currently staying at a Hilton Home2Suites 10 minutes from work. It has a full-size kitchen minus an oven. Apparently, the Marriott Residence Inn hotels were out of budget.

It’s funny because I sort of forgot what it was like to live in a hotel for a long period of time. It’s actually not that bad because they offer breakfast and someone cleans my room. I even have an extra bed for guests.

Another bonus is that all of these stays are contributing to my elite status qualification, and I am earning thousands of points that I can use for leisure travel.

After the first week where I had the incident of the medical director micromanaging me, things went smoothly. I think the medical director realized I know what I am doing because he hasn’t bothered me since. In fact, he is constantly thanking me for my help and letting me know that I could stay as long as I want to.

The other PCPs are really nice too, they see their own walk-ins and even offer to see the walk-in that the nurse asks me to see. I only had one bad afternoon out of my entire first month. I had a packed schedule and was surprised to have a new patient show up at the end of the day with only a 20 min slot. Typically, our new patients are scheduled for 40 minutes, in reality they are at the clinic for 2 hours between the visit with me and all of the work up testing.

At that moment I felt very overwhelmed because I already had 4 patients in the clinic (some brought early due to transportation), and one of them was already a new patient. I asked the front desk how come the new patient was scheduled only 20 minutes and they said the clinic manager had approved it. Of course, the clinic manager wasn’t there for me to confront, so I told them they would have to reschedule the patient. Apparently one of the other PCPs had an opening so they transferred the patient to her.

The following day I couldn’t wait to ask the clinic manager why he thought it would be a good idea to schedule a new patient with me in only 20 minutes, especially since all of the patients are new to me and I can’t be efficient as I could be had I known these patients for months or years.

Before I even had the chance to approach the clinic manager, he came up to me and apologized for scheduling that new patient incorrectly and not talking to me about it beforehand. I was grateful for his apology and I took the opportunity to tell him I needed the last slot of my schedule blocked. As my patient panel is rapidly growing, I am beginning to become overwhelmed and need that time to return phone messages to patients I do not know (since I am covering for the newly retired PCP).

He said ok but later came to tell me that if he blocked the lost slot of the day, he would have to remove the block before lunch (that all of the providers including me have), in order for me to meet the expected amount of patients per day seen.

I told him that in my contract I have it listed that I am only supposed to see up to 16 patients per day – not the 18-21 patients per day that the full time PCPs are required to see. Considering I am a temporary PCP, this is the number I am comfortable seeing since the patients are complex geriatrics and I am only there briefly.

He said “oh sorry I had no idea!” and I told him it’s fine that usually I have more blocks on my schedule, but I am trying to be flexible since I know there are a lot of patients that need to be seen. But at the same time, I need him to work with me to make sure I don’t get burnt out and am not working too much overtime. It’s funny because I have been working with them on and off for the past 5 years, so I make sure to get everything I need listed in my contract before starting the assignment, to cover all bases.

At the end of the month I won an award for having no patients in the hospital during my first 4 weeks there. Out of 22 PCPs in the market it was just me and another nurse practitioner that got this award. Go figure. It’s about time they got a taste of what I am made of.

I pretty much moved out of San Diego, spent a few days in Birmingham, AL (where my sister lives), spent a few days in Miami (home), and started my new assignment in Virginia Beach all within 1 week.

I immediately regretted my decision to only take 1 week off between assignments. However, I knew that the position in Virginia Beach was desperate for me to start since one of their physicians had retired abruptly.

Flights have been cheap lately – my flight from San Diego to Miami was only $125 one way. Yet, for some reason the flights from Miami to Virginia Beach were ridiculous for the date I needed – about $500 one way. Most of them had layovers and the total flight time was about 10 hours. So, I opted for the only non-stop flight which was at 7 am and a total of 2.5 hours of flight time. I also regretted this decision when I had to wake up at 4:30 am that morning to make my flight on time.

Even though my agency knew about this assignment since January (I started in April), they still hadn’t found me an apartment. Thus, I had to stay at a hotel the first 1-2 weeks. I usually like to stay at a residence inn Marriott but these were apparently over budget. I settled for a Towneplace Suites Marriott since it was still a Marriott and had a kitchenette. When I went to check it, turns out it is no longer a Marriott chain. It was now an Extended Stay hotel. My room smelled horrible and the a/c barely worked. I was too tired to request a different hotel. I quickly showered and was disgusted by the towels which were more like rags from a car wash and lint from the towel would stick to me. I was additionally grossed out when I noticed how unclean the room was, with random hairs everywhere and dirty tables etc.

I sent an email to my recruiter telling her I would need to be moved to a different hotel the following day.

My first day in the clinic I was still tired from the previous day and annoyed that I wasn’t in a comfortable housing situation. However, the clinic staff made up for it. They were so nice, by decorating my desk and giving me flowers upon my arrival. Everyone made sure I was comfortable and reassured me to let them know if I needed anything.

Once I met everyone and completed meetings with leadership, I was disappointed to find out that my EHR login wasn’t working. I spent hours on the phone with IT getting everything re-set up. I hadn’t worked with this company for 5 months, and in a different state so they had to get everything transferred over. Not sure why this wasn’t done prior to my start date. I was grateful I didn’t have any patients until the afternoon. By then my EHR access was working but no e-prescribe. So once again I was back on the phone with IT.

During lunch, my agency had moved me to another hotel. It didn’t have a kitchenette, just a mini fridge and microwave. But I was desperate and figured I could survive like that for just 1-2 weeks. I was moved to a Courtyard Marriott. I am very happy with the change – nothing beats having a place you feel safe and can relax in after work. Also, as a Marriott Titanium Member, I was given a $10/day credit to use at the café or snack bar.

My second day at work I was able to see a few other people I knew from my time working in Virginia before, which was nice. I started seeing a full day of patients. Some of the patients were distressed when they found out their PCP retired, but luckily I was able to calm them down and they felt better once they realized they would still be taken care of until their new PCP starts over the summer.

At the end of the day, I received a surprise delivery of an Edible Arrangement and bag of flavored popcorn. It was a gift from the medical director welcoming me back to Virginia. I thought that was incredibly sweet! They keep hinting that they really want me to stay longer. It’s way too early for me to make that decision.

So far the specific clinic I am working at is nice. The other providers are friendly and check in with me to make sure I am doing ok. And they don’t expect me to see all of the walk-ins (which has been a problem in similar clinics elsewhere). The clinic is reluctant to overwhelm me, that I had to encourage them to give me more patients and to send me medication refill requests for the retired physicians patient panel.

Even though things started a bit rocky, I am happy to say I am looking forward to my assignment here!

The last time I worked in Virginia was already over 2 years ago. When they had initially told me they needed help back in December, I was looking forward to going back. It’s always nice to catch up with old friends and co-workers there.

Also, I have since read a book about Thomas Jefferson and would like to visit his estate in Charlottesville, VA, as corny as that sounds.

However, now that I have recently worked in a regular family practice in San Diego, I was a bit reluctant to return to the Virginia job. Virginia is the first place I had worked for this geriatric outpatient practice I have worked with on and off over the past 5 years.

Going back there meant going back to working with a complex and sick elderly population. Being completely responsible for their hospitalizations and ER visits. And having to manage their 30+ plus disorders without placing many specialty referrals as was the model of the company.

On the other hand, I was looking forward to creating relationships with patients again. Seeing relatively young and healthy patients in family practice clinics doesn’t allow for forming much of a relationship. This is because they come just once a year for a physical or if they need something. Versus elderly patients come to our clinic every month or even more often if necessary.

When I had the call with the medical director prior to me returning to Virginia, she said “everyone is so excited to have you back!” So, I knew I had to move forward with the assignment. The medical director there is new but I have heard good things about her. I am hoping my time there is flawless. As noted in my previous blog posts, there tends to be some type of drama when I work at these geriatric clinics. At least it will be spring time there, so can enjoy the outdoors.

I am writing this towards the end of my assignment in San Diego. I’ve had a really good experience. San Diego itself is still a majestic place. The work side has been pretty straightforward and “easy” considering the complex geriatric patients I typically work with.  

The other PCPs here told me how impressed they are with me. That I surprisingly just jumped into the new role and rarely have any questions for them. They said typically new providers have tons of questions. I reassured them that it was likely because I already worked here before, albeit 5 years ago.

Some of the physicians are within a year out of residency, so they come to me with medical questions or to see if I agree with their plan of care. This has been quite flattering.

I have enjoyed getting experience in things I don’t see often in geriatrics such as sexually transmitted diseases, identifying developmental delays in children, and reassuring young adults that their abdominal pain of 3 months is not appendicitis.

Interestingly in California I noticed a lot of patients try to get short-term disability through their PCP for medical reasons. It must be a California thing because I am filling out disability forms on a weekly basis. This is in contrast to working in other states. Some reasons for short term disability include status post stroke, fracture, or cancer. I believe the state provides them with financial benefits.

It’s gotten to the point though that no one wants to work. For instance, I had a patient with diabetes ask for short term disability. He said it’s because sometimes he doesn’t take his insulin properly and his sugar drops. I told him there are millions of people with diabetes in the country, so if every one of them was on disability we wouldn’t have a work force. And of course, he needs to start taking his insulin properly.

One of the other PCPs told me she had a patient request short term disability for a low back cyst they had removed over a year ago… The short-term disability request has become the new narcotic refill request. Where patients start crying and put on a show if you decline authorizing them for short term disability.

I had a patient that I gave one week off for abdominal pain, who showed up one month later saying her job fired her because she never went back to work, and now I had to fill out HR paperwork stating she was out for medical reasons. I told her I felt like I was being taken advantage of because I only gave her 1 week off, and if she was in so much abdominal pain as she claimed, she would have completed the imaging and lab tests I had ordered by now. So, she started crying and saying she was so depressed etc. which of course she never mentioned previously. That’s probably been the only part of my job I haven’t enjoyed.

I usually see 20-22 patients per day, a mixture of them being phone visits. I often finish early and in between patients, I even read a book which I am able to finish in about one week.

They asked me to extend here for another 3 months. That would have been great except I already committed to working in Virginia in the spring. I wouldn’t want to back out of the Virginia job because I’ve had a good relationship with that company for the past 5 years. However, I wouldn’t mind returning to this specific clinic if the need arises again in the future. 

On my last day, the clinic staff spoiled me with breakfast – bagels and donuts for everyone. My medical assistants gave me some going away gifts. And my fellow Doctors and Nurse Practitioners treated me out for lunch. I thought that was so sweet and started to feel a bit sad about leaving. It’s amazing how you can develop relationships with people in such a short time. They are crossing their fingers that I come back!

I had a patient that came in the other day for a routine follow up. She hadn’t been to the clinic in about 6 months. She had over 20 diagnoses in her medical record. One of them being Diabetes Mellitus type 2. She was overdue for blood work, her diabetic foot exam and annual eye exam. She also told me her insurance was no longer covering byetta, so needed a different medication prescribed.

She then told me she needed medication refills, some were not even on her medication list. She also needed a referral to orthopedic to get a hip injection. She was also feeling depressed and wanted to try a new medication. She was interested in getting therapy so I placed a referral to our mental health department as well.

She said she called her insurance and they told her acupuncture was covered so would like a referral to them for her multiple joint pain.

At the end of the visit, she said she forgot to mention she also needed a referral to neurology for her headaches. She wanted to try botox.

I told her I had already placed orders for her labs, did a thorough physical exam, placed referrals for her eye exam, orthopedic, mental health, and acupuncture; in addition to refilling her medications, changing byetta, and trying something new for depression.

I thought it would be best to hold off on the neurology referral until a later date. She seemed disappointed but I told her that perhaps her headaches were due to her depression and may improve with medication for mood disorder, and that acupuncture may help with her headaches as well.

It got me thinking about the fact that primary care providers always wish they had more time with their patients. 15-20 minute visits is often not enough to treat a complex patient. After I was done with this specific visit, I asked the other providers if they would have preferred to have an hour with this patient to cover all bases, or just to have her come back more frequently such as monthly (she doesn’t have to pay a copay).

Interestingly, they all said they would prefer the longer 1 hour visit. I used to have that same perspective, but after working at the geriatric clinic for several years, I have realized that frequent visits are more effective in providing good patient outcomes.

For instance, it’s not ideal to have a patient try more than one new medication at a visit. This is because if they have side effects, you wouldn’t know exactly which medication was causing it. Additionally, such as in the above visit, when patients request multiple referrals, it can become overwhelming. Most of the time, when a patient has more than one referral, they are unlikely to go to all the specialist visits without you reminding them at a later visit.

In one visit with a complex patient, I can easily adjust their blood pressure medication, review their lab results, refer them to nephrology, order compression stockings for their leg swelling, and encourage them to quit smoking. After the visit, the patient often forgets the summary of the visit, no matter how many times you repeat it to them. Thus, they will forget to pick up their new blood pressure medication from the pharmacy, and are unaware they need to follow up with referrals to get their nephrology appointment scheduled or find out where they can pick up their compression stockings.

This is why I think it is best for each visit to be focused. That way you have ample amount of time to evaluate a disorder and the patient can be more proactive in their care.

Once I explained this to the other providers, they all seemed to agree that frequent targeted visits may be more effective after all.

I know patients are often looking for a quick fix, but the reality in healthcare is that the body is so intertwined that one problem can cause other problems to occur. There is no point in giving a pill for every single symptom. That is why it is important to treat one thing at a time and perhaps you won’t even need to treat the other problem at a later date. 

Would you prefer to see patients more frequently or have longer but more rare visits with them?

One of my friends asked me when my last trip abroad was. They were surprised when I said the end of 2019. I didn’t travel internationally throughout 2020 due to covid. It was the first time in over 12 years that I hadn’t traveled abroad.

I know plenty of people that still traveled to the Caribbean or Mexico even during covid restrictions. I chose not to for various reasons. Of course, I didn’t want to get covid and spread it to others. But most of all, I didn’t want to be stuck anywhere abroad.

Some countries closed their borders with a short notice and cancelled all flights. I didn’t want to be stuck in another country without any way home.

As I mentioned in a previous post, I did get covid from a patient and my symptoms were mild. But who’s to say I couldn’t get it again and have even worse symptoms the second time around. Thus, I didn’t want to have to quarantine for 10-14 days away from home.

Now that I am vaccinated and covid rates seem to be improving in the USA, I am considering traveling again. I am hoping I can plan to go somewhere internationally in late summer or early fall. I may travel somewhere close to the USA such as the Caribbean or Central America first and see how that goes, before planning to go somewhere further away.

Surprisingly I didn’t have travel withdrawals in 2020. I think it’s because I had already been to over 40 countries and still had memories there to reflect upon.

Have any of you traveling abroad since covid? I can’t wait for my next trip!