Traveling NP

My first week back in Virginia, I stayed at the Renaissance Marriott Hotel. It was a nice hotel on the water with city views. I actually ended up moving into a high-rise condo next door. I was initially not that interested in moving into the condo because I prefer living somewhere where I can park right in front of my home. However, once I toured the condo, it was an immediate yes. I am on the 23^rd floor and have views after views. The unit is also very spacious, sometimes I wonder if it’s a bit too spacious. But I guess I shouldn’t complain that my food pantry is meant for a family of 6.

The amenities are great too. There is a gym, pool, tennis court, pool table room, and walking trail on the water. There is a concierge and valet parking if desired.

Before moving into the condo, furniture was delivered and cable/internet was set up. I was able to pick up my keys on Friday after work. I moved in the following Saturday (the agency kept the hotel for me overnight).

I love sharing my current housing situation while on assignment, because many of my readers worry about living full time in a hotel or traveling with their family and not being accommodated. I just wanted to show that many times the housing arrangement exceeds expectations.

For the Fall I originally wanted to go back to the West Coast. Yet, I realized that I needed to be home several times for holidays, trips, and other festivities. So being on the west coast wouldn’t be ideal because of the distance.

The medical director from a site I used to work at in Virginia reached out to me asking if I could help in the fall. I originally was going to say no, because it was at a different clinic than I was at previously, so I wouldn’t even be able to see my old patients. When I thought about it more, I thought it was probably best that it was at a new clinic so I wouldn’t get attached to my patients again.

In addition, Virginia is a 2 hour flight from Miami and on the same time zone, making it pretty convenient to go home frequently. The site is also typically accepting of my time off – and knowing I would be taking almost 3.5 weeks off during that 3 month assignment, I figured it would be a good idea to work in Virginia after all.

I ended up doing a brief orientation again because it had been over 9 months since I worked with the company last. Fortunately, the EHR and work flow came back to me easily. On a positive note, the nursing staff and medical assistants at this clinic are all cordial and hard working. The patients are pleasant too. I do have to admit my first week was challenging emotionally. Although I knew some of the other providers from before (not well), I felt alone. Everyone I was previously close to was at the other clinic. I cheered up once I was able to meet up with everyone after work or on the weekend.

I know I have to give the new clinic a chance, and there is really nothing wrong with it. But obviously my old clinic has my heart since I was there for one year. I am still able to see how my old patients are doing when we have our monthly provider’s meeting. And I have even seen some of them around town :).

Side note: my first day working, the medical director already asked me to extend. Here we go again…..

After working in Maine and Ft. Lauderdale, FL, I went on a 2 week trip to South Africa. Direct flights from the US are about 18 hours. So my friend and I opted to stop in Brazil on the way to South Africa to break up the trip. The flight from Brazil to South Africa is only 8 hours.

We had an amazing time in Brazil. I was a bit nervous to go because I have heard stories about tourists being kidnapped and mugged. I wasn’t much of a target though since most Brazilians thought I was local. We stayed on Copacabana beach which was gorgeous with the mountain backdrops.

 

My favorite part was seeing Christ the Redeemer. I had seen the one in Peru previously, but the one in Rio de Janeiro is much bigger and more breath taking. I also enjoyed trying acai bowls for the first time (acai is native to Brazil).

 

After a few days we headed to Johannesburg, South Africa. It was interesting to watch my friend’s culture shock. There were a lot of Africans on the road, just hanging out, and moderate amounts of trash all over. To me it didn’t seem that bad in comparison to Haiti.

However, apparently Johannesburg isn’t the safest place in South Africa. There is a high unemployement rate (mostly from Northern Africans migrating south) and poverty. Unfortunately, we were told that tourists were often targeted in the city and were encouraged to avoid walking on our own.

In Johannesburg we went to the apartheid museum which I found interesting and learned a bit more about Nelson Mendela. It was interesting to see how much he is still beloved by his people.

The following few days we spent at Kruger National Park on a safari. It was fascinating being able to witness many animals in their natural habitats. I loved seeing a herd of elephants walking together with their baby elephants. I loved seeing the same elephants knock down trees to eat their roots.

Other animals we saw include baboons, hyenas, giraffes, zebras, lions, vultures, impalas, hippos, rhinos, buffalo etc. We stayed overnight in a bungalow which exceeded my expectations. There was a shower and even a heater in the room (it was cold at night). The lodging reserve also had a restaurant on site.

The last leg of our trip included Cape Town, South Africa. Cape Town blew me away. It was absolutely beautiful there! It reminded me of California, between the beaches and mountains, along with the cool weather and wineries. Some highlights were going to see the penguins at Boulder Beach and the views from Table Mountain.

The Southern Africans were very nice and polite. I appreciated that they didn’t try to take advantage of us (tourists and Americans) and wouldn’t expect/demand a tip. Everything was super cheap so we tried to be as generous as possible.

Overall I had a great experience on this trip! It’s crazy to think that I will already be back at work in a different location in a few days. I feel like I am still processing all of the amazing things I saw on the trip and recuperating from the jetlag.

Thanks for your feedback about sharing the Fairway Mortgage Nurse Practitioner loan program. Here is some more information about how they document income for 1099 independent contracts, which will apply to most traveling nurse practitioners.

As you might know, with conventional loans this can be a real challenge because if you don’t have a full two-year history, they consider you self-employed, and there’s virtually no way to get the loan done. The great thing about Fairway’s loan programs is they will allow a client to qualify based on 1099 income sometimes without any history at all. It depends on the employment contract, and how it’s worded, and if there’s some guarantees in there.

Often times they can do just an employment or offer letter for a 1099 or independent contractor. You don’t even need your first paycheck stub. Now if you’re already on the job, no problem. They have solutions for that as well. If you’re an independent contractor, you’ve run into some challenges getting financing, or you anticipate you might run into challenges, I welcome you to contact them through their website at: https://nursepractitionerhomeloans.com/ for more info.

As many of you know, I despise when the term ‘mid-level’ is used to describe us nurse practitioners. When I correct people that use that term, sometimes they ask what title I would prefer to be called. I tell them to just call me what I am, a nurse practitioner. I don’t know why there is even a word at all to group nurse practitioners and physician assistants together. Does it really save that much time instead of saying both titles? Not to mention that nurse practitioners and physician assistants are very different, with a different model of care.

I like the word ‘provider’ since we can interchangeably use it in PCP. PCP originally stood for primary care physician, but these days a lot of places use it to mean primary care provider. Another term that I have heard been used before is ‘clinician’. Although this title is not often used, I like it a lot. It represents what we really are, clinical experts. However, my issue is that is doesn’t encompass the fact that nursing is both a science and an art.

I don’t know why we even have to be grouped with physicians or physician assistants in the first place. As nurse practitioners become more popular, I prefer when organizations or patients just specify who they see. I like when patients say “I saw the nurse practitioner in the ER” or when clinic managers say “we are proud of what our physicians, nurse practitioners, and physician assistants have been doing.”

What are your thoughts? Is there a preferable way you like to be called?

With that being said, I really liked this article called “Don’t Call Me a Mid-Level Provider!”

After Maine, I ended up covering a clinic in Ft. Lauderdale, FL for one week. The physician is a family friend and he asked me to let him know when I was available to provide coverage for one week, so that he could go on vacation. This way he wouldn’t have to close down his clinic, and there would be a provider present to see patients and provide medication refills etc.

Since we wouldn’t be going through an agency (lucky him), I charged him a higher hourly rate than I usually am paid through the agency. At first, he was looking to pay a lower rate than I was charging. He only wanted to pay $60/hour which is what permanent nurse practitioners make in the area.

However, I told him through an agency he would normally have to pay double that, since they are filling a demand and it is pretty costly. I was only charging him $90/h since we weren’t going through an agency, but realistically there is a premium for locum nurse practitioners. This is because I can easily learn the EHR (electronic health record) they are using in a matter of minutes and wouldn’t need a thorough orientation to provide coverage for one week. A non-locums provider, wouldn’t be able to jump into a new environment and start seeing patients within the first hour, as I am.

Eventually he agreed to my rate and I made sure to draft up a contract which stated the requested dates and hours to be worked, and the hourly pay. I also made sure that he added me onto his malpractice coverage. Since I wasn’t going through an agency, I had to be sure I was protecting myself – family friend or not.

Covering his clinic was pretty straight forward. His practice used Practice Fusion EHR which I was familiar with. The patient load was fair, about 12-15 patients per day. The majority of the patient population were Haitian, so it was fun practicing my Haitian Creole and French.

I realized how different the Haitian population is in comparison to their neighboring Hispanics. Hispanic patients typically come with a list of complaints and want to take as many medications as possible. Haitian patients seemed to be more shy and won’t tell you if something is bothering them unless you ask them directly. They aren’t interested in taking medications or even accepting that they are “sick”. This can be a bad thing because it seemed that a lot of them had complex chronic illnesses that could have been treated better early on, had the patient been compliant or honest.

I had forgotten how South Florida clinics sometimes run on Caribbean time. Meaning, patients often showed up 30-45 minutes late to their appointment but were still expected to be seen (by both staff and patient). In addition, they didn’t mind waiting an hour to be seen by the provider. Obviously, in more Americanized clinics, patients are considered no shows if they are more than 10 minutes late. And it’s all about lowering “wait times”.

I had a good experience covering the clinic for one week. I was a bit nervous at first since it was the first time I was doing this without the help or guidance of an agency. But everything worked out well. I suppose my 4 years of being a traveling nurse practitioner paid off.

My only issue was after completing the assignment, the physician of the clinic provided me with some unnecessary feedback. It was mostly just nit picking of my documentation. He told me I should describe how my patients look better (such as tall, obese, Caucasian, black). He said if a patient is anemic I should specify mild or severe (even though I listed the hemoglobin level under the diagnosis).

I tried not to let this feedback bother me because he clearly has never had a locums before. Everyone documents differently, and I consider myself to document thoroughly considering I have a nursing background. But of course, every provider has their own way of documenting and he can’t expect everyone to do it the way he wants it to be done.

Had his feedback been specific to patient management, such as “perhaps use this medication next time” or “refer this patient for a cardiology evaluation”, that would have been a different story. I welcome any criticism when it is beneficial.

Anyways, I just wanted to share my story providing coverage on my own. Maybe once you have enough experience as a traveling nurse practitioner, you can start providing coverage on your own too. Keep in mind, I didn’t need any housing or travel since the clinic was in my home area. So, there are definitely some benefits to working through an agency versus on your own, but that comes at a cost. Those benefits include completing credentialing, facilitating orientation, arranging and covering housing and travel, providing liability insurance etc. The main benefit of working without an agency will be increased pay.

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.