Traveling NP

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!

Back in September 2020 I had a patient come in to the clinic with a sore in his mouth. He obviously had to pull down his mask for me to look inside his mouth. The next day the patient decompensated and ended up in the hospital – positive for covid.

About 5 days later I developed a severe headache and extreme fatigue. I decided to get tested for covid but my results came back negative. Although I was sick, since my covid test was negative, I was still expected to work. I remember being so tired after work that I would just collapse in bed and sleep until the following morning.

I ended up being sick for 2 weeks and the last week developing no taste and no smell. Obviously these are classic covid symptoms, and I have never been sick for an entire 2 weeks in my life.

I shared this experience with my family and friends to let them know that there is such a thing as getting a false negative when it comes to covid testing. So even if they have a false negative test but were exposed to someone with covid, they should continue to quarantine. Unfortunately, as an essential worker I didn’t have that luxury. My clinic and I are lucky that I didn’t infect anyone else.

This experience infuriated me a bit. I was frustrated that I was doing my part in social distancing, but my patients weren’t. Some of those patients told me how they would still go to restaurants, even though they were 70 years old or older. And as a result they were putting me and others at risk.

I was also frustrated that even though I was sick I still had to work. Of course, the timing of me getting sick was inconvenient. Three out of the four other PCPs were already out for FMLA or PTO reasons.

On the bright side, I had such a mild symptoms and no breathing issues. I am grateful I was able to recover and that I didn’t infect anyone else. I am also grateful that I was able to get the covid vaccine during my second day of work in San Diego. My only reaction was that I had arm soreness for a few days, similar to the tetanus shot.

Have any of you gotten covid from work?

One reason I don’t like working in California much is because they have such a high rate of state income tax. With my income range, I have to pay 9.3% in state income taxes. This is especially annoying when my residential state is Florida. Depending on the state, I can often get some of those state incomes taxes back when I file my taxes.

To avoid having to pay 9.3% of my income in CA state income taxes, I have devised a plan. I decided to front load my 401k and max it out during the 3 months I will be working in California. This means I will be contributing 50% of my income to my 401k each week. I will be able to max out the 19,500 allotted contributions by the time I finish my assignment here.

So instead of having to pay $300 of taxes to the state of CA each week, I only have to pay: $70. I won’t owe more state income taxes at tax time because technically my overall taxable income while working in California is the total amount after my 401k contributions.

Obviously, this hack comes at a cost. Since I am contributing 50% of my income to my 401k, my paycheck will be significantly lower than usual. Fortunately, my costs are low and I can still afford to live off of this lower take home pay.

Have you ever tried such a hack before?

1. San Diego Zoo

I am not a big zoo person but the zoo in San Diego is one of the largest in the USA. It is definitely my favorite zoo. They even have a section with over a dozen koalas (you know most zoos only have one koala).

2. Mission Beach/ Pacific Beach

This is my favorite place to hang out in San Diego. They have a boardwalk which is fun for biking, skating, walking or running. They have a small theme park on the boardwalk as well. You can hang out at the beach, play volleyball, surf, or go kayaking on the bay. There are many restaurants to grab a bite to eat.

3. Sunset Cliffs

Beautiful site to watch the sunset or even to participate in yoga classes in the morning. Plenty of people have picnics here.

4. La Jolla

La Jolla Cove is an underwater marine park. La Jolla Shores Park is where you can visit to see a large amount of seals sunbathing at any given time.

5. Gaslamp District

Great area downtown for night life. They have tons of bars and restaurants. They often have festivals there too and hidden piano bars.

6. Seaport Village

Check out the famous kissing statue (the unconditional surrender) and the USS Midway Museum. You can even rent an individual speed vote to tour the area.

7. Balboa Park

Beautiful park with lots of gardens, Spanish architecture, and bike/walking paths.

8. Coronado Island

Gorgeous views of the city and has its own beach which is less crowded than MB/PB. Famous for its Coronado Bridge which is a lot of fun driving on when you have a convertible!

9. Torrey Pines

State Natural Reserve for hiking, bird watching, looking at wild life, and exotic plants. They have their own beach too.

10. Old Town

This is the first European settlement in California. Now it’s more of a tourist sport for adobe homes and Mexican restaurants.

Since the clinic I am working at is in a different location than where I was working previously, I decided to live in a different area. Last time I lived in Mission Beach. 

This time I decided to live in Ocean Beach/Point Loma area. This area is different from Mission Beach because it is less of a party scene and more laid back and hilly. It’s a 20 minute commute to work. I could have chosen to live closer to work but I always prefer to live near water when possible. Plus 20 minutes without traffic isn’t bad. I love being able to walk to the sunset cliffs on weekends.

I ended up getting a furnished 2 bedroom apartment. This is a great feature because I have an extra bedroom for visiting guests. Most importantly I have a heater, which is nice for those cold nights.  

Below are some pictures of my new place! 

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!