Ending of a Yearlong Assignment

The end of my yearlong assignment in Virginia was bittersweet. When I finally accepted that I needed to move on, I was reminded of one of the best parts of locum tenens – looking forward to the end. The things that used to bother me before didn’t bother me anymore. If the medical assistants were short staffed and took forever to bring my patient back, I no longer cared. The demanding or pessimistic patient that normally frustrates me, no longer impacted me.

It was tough to say good-bye to my patients. For some reason the majority of them were in a good mood during my last visit with them. For example, one of them randomly said: “You are really great. I’ve never had anyone explain things to me the way that you do.” This made it hard to tell her I was leaving. During a follow up with another patient, he said: “Man, you are the best! You remember everything about me and follow up on things from last visit. You review notes from my specialist before I see you. You don’t just fix everything with a pill. You explain things thoroughly and find natural ways for me to improve.” After telling him that I was leaving, he nearly caused a scene.

Many of the patients were extremely disappointed, some even cried (both men and women). I re-focused them to realizing that most importantly their health had improved significantly over the past year, and they know what to do to continue on that path. I also reassured them that since I would be working in their Florida clinic, I would be able to check on them from time to time and perhaps even see them again in the future.

I think I became too attached to the patients, but with our healthcare model, it was hard not to. The patients came every month or even more frequently, some I spoke to via phone on a weekly basis. I knew their husbands and wives pretty well too. Our goal is to keep our patients out of the hospital, and the only way I knew how to do that was to develop trust and bond with them.

My last day was extremely sad. I had never cried so much in my life. Not only was I going to miss my patients but I was going to miss my co-workers too. Our clinic is big with about 50 employees, more than half of them I was really close to. Any time one of the physicians or medical assistants would mention they were sad I was leaving, I would break down and cry. I was even super close to the Medical Director, who honestly acted like my guardian angel while I was there. It was weird knowing I wouldn’t be seeing them on a daily basis anymore. On the bright side, the Medical Director promised to fly me up for their annual holiday party and we agreed I could always come back in the future to help out when I wanted to.

The clinic surprised me with a sweet party. Everyone went around in a circle and said some nice words about me. The Center Manager told me he was so glad that I came because I brought a new uplifting energy to the clinic and between the other PCPs. The clinic also surprised with me with this beautiful gift:

I never knew leaving a job would be this hard! Yet, I am so grateful for my experiences there over the past year, and will continue to cherish the relationships I have built. I am looking forward to my next adventure and will try not to stay at one place as long again.

Philadelphia Trip

During one of holiday weekends, I went to Philadelphia to visit for the first time. It was a 5-hour drive but I opted for the 1 hour flight instead.

I had a fantastic time in Philly! It was pretty diverse and there was so much to do. I visited tons of museums, including looking at my favorite artists.

My visit also reminded me of why it is so great to be an American! I toured the independence hall and the liberty bell. It’s crazy to think that our forefathers had the courage to rebel against Great Britain, the most powerful country in the world at that time. It’s even more amazing to think that the 13 original colonies all united together to fight for their beliefs.

Why I Decided Not To Go Perm

My previous post demonstrated all of the good reasons I should become permanent at my current assignment. I’ll now explain why I chose not to go that route.

I actually spent a few days leaning towards going permanent. There are two main reasons that I chose not to. The first reason is that I received my extension bonus and realized after taxes I was only going to take half of it home. This reminded me that one of the main reasons I love working in locum tenens, is that I can alternate between being a W2 employee and being a 1099 contractor. This allows me to deduct more taxes at the end of the year.

I am currently working as a W2 employee and was reminded that I needed to work the remaining 3 months of the year as a 1099 contractor, or else I would be paying $60k in taxes at the end of the year! As much as I love my current job, I don’t think any job is worth working just for your income to go to uncle sam.

The idea of becoming a partner at the clinic initially sparked my interest. I compared my current salary and benefits with those I would earn if I were to become a partner. An experienced nurse practitioner at my job confided in me her current salary, and just by being a traveler I was making $20k more than her. In addition, by being a partner, after the initial raise and the quarterly bonuses, this would equate to an extra $20k. I calculated the cost of my living arrangements for the past year and recognized that my job had paid $20k over the past year for my rent, furniture rental, cable/internet, and electricity.

So just to review, becoming a permanent employee could possibly push me back $20k. Even if it didn’t, becoming a partner wasn’t even worth it because I was already receiving the financial benefit through my covered housing costs alone.

The other main reason I decided not to go permanent is because the longer I stay at my assignment, the more drama I began to notice. I observed that the working environment isn’t always quite fair. Some physicians have an easier case load than others, while the most hard working physicians often go unnoticed. I also had some issues with a couple of my medical assistants, where they get too comfortable with you that they think they don’t need to do their job. I had been working in locums for so long, that I had forgotten about the annoying bureaucratic issues of working at a permanent job.

I asked a handful of people for advice; most people told me that if I liked my job then I should consider staying. I never saw myself settling down in Virginia, but wondered if the job was worth it. We do spend the majority of our time at work. And it would just be a year or two, and I am pretty sure my job would still allow me to travel abroad all of the time.

My sister who knows me best was the only person that told me not to stay permanently and to continue being a traveler. She told me not to think about the patients because they come and go. She told me that I am living the best kind of life being able to travel and have constant new experiences, as well as tons of freedom. She told me that I am still young and should think a bit more selfishly.

That pretty much sums up the main reasons I decided not to stay permanently. What do you guys think? Did I make the right decision?

How I Almost Went Perm

When I realized I only had 1 more month left of my year long assignment, I found myself becoming sad. I was close to my co-workers and I truly cared about the 250+ patients in my panel. I began to wonder if I could see myself working anywhere else.

I mentioned to one of the physicians that it was bittersweet that the end was near. She replied that I should consider becoming permanent. She told me that I wouldn’t have to stay there forever, but could commit to 1 or 2 years. I laughed because I never even thought a permanent job would be an option for me.

Yet, I started to ponder over the idea of staying there permanently. The clinic wanted me to help them open one of their new clinics in Florida afterwards. I thought about how I would have to start all over. I would have to get to know 250+ patients from scratch, in comparison to already knowing my current patient panel pretty well. The most challenging time at my job were the first 6-9 months becoming familiar with the patients and helping them become stable. Afterwards, my patients improved so much, that their frequent visits with me became a breeze.

My patient outcomes were really good, that I could have easily become on track for partner status. Becoming a partner with the firm meant an automatic raise, quarterly bonuses, and some other perks such as an easier referral process.

Although there was a permanent physician starting right after my assignment was ending, I knew me staying would really help the clinic. I could continue to carry my current patient panel, while the new physician accepted all of the new patients. Our clinic was growing very quickly, about 50 new patients per month, and there was no provider for them to go to. Nurse practitioners at my site have a panel of about 250 patients, where as the physicians have a panel of 400 patients.

This meant that I could continue with my current panel since I was already maxed out. I wouldn’t even have to take any new patients. Or the physician gave me the idea that if I agreed to stay permanently, I could discuss with the medical director that I would stay with the possibility of giving a handful of my most complex patients to one of the partner physicians. Since those partner physicians have been there for years, their panel should be really stable since they have a long-term relationship with their patients, and could afford to acquire a few more complex patients to their panel.

This all sounded pretty great, but my next posting will be about the reasons why I did not choose to stay permanently.

Questions from Readers – September

Each month I will include a blog entry answering some of the most common questions I get from readers about locum tenens as a nurse practitioner. Feel free to comment any questions you have or email me at travelingNP.com@gmail.com.

 

  • I have worked at a permanent job for over 10 years. I am now interested in trying out locum tenens, but I am a bit worried about the transition. You always seem so confident so was wondering if you had any tips for us newbies?

 

This is an example of a pretty common question I get from my readers. I think any major step in life can be a bit nerve wrecking; this includes buying a house or getting married. Nothing in life is guaranteed but if you want to start a new adventure, travel to new places, and build yourself professionally; working in locum tenens can be a great option!

Here are a few tips of I have for those of you initially starting a career as a locum tenens nurse practitioner:

-Stay open minded, especially with your first assignment. Your first assignment will be a learning curve, so don’t think you HAVE to go to the best place on earth. (I have seen a lot of you act on this advice, which is great).

-Work with multiple agencies. To increase your probability of finding the right assignment, you are going to have to work with more than one agency. Yes this means tedious paperwork, but it pays off in the end. You can also compare benefits and choose which one you prefer. (Example: working W2 vs 1099, living in a hotel vs having an apartment).

-Always look for your next assignment. After working the first month of your current assignment, you should already be thinking about where you are going next. Should you be working on obtaining another license? Start looking at states you are interested in to see if there are job options there that meet your needs. The last month at your current assignment is crucial, as that’s when most jobs will open up (last minute). You can easily have your next assignment secured 1 to 4 weeks in advance.

 

South America – Vacation

My most recent international trip was to South America. I went to Colombia, Argentina, and Chile. I was originally supposed to go to Brazil as well but my visa didn’t make it in time.


My first stop was in Buenos Aires, Argentina. The first day I was there, I witnessed the person next to me get his Iphone stolen from him right out of his hands. This was definitely eye opening since I thought Argentina would be the safest place in South America. My favorite part of Argentina was watching a tango show one evening.

After a few days I went to Santiago, Chile. Ironically, it had been the last place I was looking forward to going to but ended up liking it the most. I think the combination of being in a big city with snow capped mountains and awesome seafood did the trick! The weather was a bit cold but I enjoyed being outside with the awesome scenery.

To end the trip, I went to Cartagena, Colombia, which is a small town on the coast. The people were very friendly and hard workers. No one begged for money, but everyone was hustling and trying to sell you something. I had a lot of fun and enjoyed visiting Castillo San Felipe de Barajas, which is a super-fort built long ago by the Spanish.

This was my second time in South America (I had gone to Peru a few years ago). As always, I enjoyed learning about the local culture and trying new things. I hope to get back down there to visit Brazil once my visa comes through.

Powerball Winner Quits Job At Hospital – Here’s What Nurses Would Do

Check out this article from nurse.org about the recent Powerball Jackpot winner quitting her job at the hospital. I was asked to give my thoughts on what I would do if I won $750 million dollars, displayed in that article. Would you quit your job if you won $750 million dollars?

Locums Make Stronger Nurse Practitioners

There is a new nurse practitioner that was recently hired at my current site. Watching her find her place during her first year of working as a nurse practitioner, reminded me how working as a locum tenens nurse practitioner has made me a stronger health care provider.

Working in various clinical settings and with different populations, we are constantly learning something new. Something new that we can apply to our future practice. I have gained some skill sets such as doing incision and drainages, joint injections, and skin biopsies. With much experience, I have also improved my differential diagnoses, and prescribing methods. I can think outside the box and see my patient holistically.

Being one of the first nurse practitioners to work at my current site, I could see that the new nurse practitioner did not have the support system she needed, being a new grad. Sometimes she would see my patients as walk-ins. I noticed she would give solumedrol IM injection for acute pain. In another instance, she saw my patient as a hospital discharge and failed to document that a chest xray done in the hospital incidentally noted a lung mass, which needed surveillance in 6 months.

I used these examples as teachable moments. For example: avoid solumedrol unless the patient has respiratory symptoms, especially in my diabetic patients. Read hospital records thoroughly and as nurses we are usually more thorough with our documentation in comparison to our peers. And how overlooking a diagnostic finding could lead to malpractice.

I also addressed my concern with the Medical Director. Virginia is not a full practice authority state. Thus, the new NP has a supervising physician. Besides being a name on a piece of paper, I believe the new NP definitely needed closer supervision. Even as an experienced nurse practitioner, some states I travel to may require physicians to review 5% of my charts or the first few dozen notes. The Medical Director assured me that the new NP’s supervising physician will play a closer role.

Most importantly, it is important to promote an encouraging vibe in the workplace setting. Luckily, after discussing some of my patients and concerns with the new NP, she started to ask me questions she was unsure about instead of proceeding with a wrong decision. For instance, she had a diabetic patient that could not tolerate metformin due to chronic kidney disease stage 4, and was unsure if she should add glimepiride to the patient’s plane of care, whom was already on glipizide. I discussed with her that the patient should not be on both due to increased risk of hypoglycemia, but as the patient was on a low dose of glipizide, she can titrate up.

It is not our duty to judge new nurse practitioners, as we all started somewhere. Even physicians can admit their first year working in medicine is challenging. Yet, many people are still unfamiliar with the role of a nurse practitioner. Which is why I believe it is crucial we make sure we provide competent care. This can be done by trying your foot in locum tenens to make you a stronger nurse practitioner, and to make sure we continue to mentor novice NP’s.

Appreciated

 

I just posted about my final extension at my current site. Moreover, I wanted to share some kind words that were said to me during the final weeks of my previous extension.

“You have changed the way I see locum tenens.” The Medical Director told me this when asking for my final extension. She said she was previously apprehensive about hiring locum tenens providers but now sees it can work with the right fit. They even hired 2 locum tenens physicians after I started to help with a maternity leave and walk-ins at some of the other clinics.

“In my eyes you are a physician. There are some nurse practitioners that work better than some physicians, and you are one of them.” The physician lead at my clinic mentioned this to me as her eyes filled with tears just thinking of the possibility of me leaving. I will always be a nurse at heart but it is nice to be appreciated by a physician and for them to recognize the benefits of having nurse practitioners at their clinics.

After telling my patient his Diabetic A1c improved from 17% to 8% in only 3 months he said: “That is thanks to you. I appreciate you looking out for me, going above and beyond and doing more things for me than most doctors.”

I sent one of my new patients, whom was completely healthy and on no medications for a routine colonoscopy. The colonoscopy was positive for colon cancer and imaging confirmed an additional renal cancer. Luckily he was able to undergo a partial colectomy and nephrectomy and recuperated really well. After seeing him post-op, he said to me: “Thank you! I wouldn’t be alive here today if it wasn’t for you!”

I thought it would be nice to shares these kind words. It is easy to get burnt out in medicine, but if you remember why you got into the healthcare field in the first place, it should keep you motivated. As a PCP we are constantly hearing ‘complaints’ all day. “My back hurts; I have difficulty breathing; I have no energy” etc. So hearing words of appreciation really makes our day J

Final Extension

Although I initially enjoyed my current assignment, after extending 3 times (for a total of 9 months), I knew it was time for a change. I needed a change in scenery both state-wise and job-wise.

The site asked if I was interested in another extension. I kindly declined and told them I was ready for a change. They hired a physician to take over my patient panel and would like for me to stay an extra 3 months to help transition my panel over to the new physician.

The Medical Director set up a meeting with me titled “What Can We Do to Keep You Longer?” She wanted to respect my wishes to move on but also to make me feel like I was appreciated. She offered me her first and second born children as a joke. She even offered me to house-sit while she went on vacation (she has a beautiful home on the lake with kayaks and jet skis etc.).

Although I knew I was ready to leave, I spent several weeks with an inner turmoil contemplating what I should do. There are normally 4 PCP’s in my clinic, one of them was approaching maternity leave, while another one was having surgery in the upcoming weeks. I felt guilty knowing 1 PCP would be all-alone in the clinic if I were to leave. When 1 PCP is out, it’s manageable. When 2 PCP’s are out it’s a disaster. Think about the walk-ins, phone messages, medication refills, reading of PT/INRs, and paperwork that needs to be completed.

I also thought about my patient panel. When I had taken over for their previous PCP, the patients had been pretty neglected for a few months since their previous PCP had gone on sick leave. I thought about the connections I had formed with these patients since they come to the clinic at least on a monthly basis. I thought about how far these patients had come after first meeting them. The uncontrolled hypertensions now well controlled, improved diabetic A1cs, resolved heart failures, controlled depression, weaning them off their opioid dependencies, and encouraging health screenings to help with early detection of newly diagnosed cancers.

My patience and level of contentment were starting to decline, as I became blasé with this routine lifestyle. The cure to this was to move onto another assignment. But for the reasons above I knew that I had to stay. Another 3 months wouldn’t kill anyone right?

In return for my final extension the site offered me a $5000 bonus. This is equivalent to an extra $10/h over 3 months. They also agreed that I did not have to continue seeing new patients, and can focus on my current patient panel since they are already very complex. The agency I work for offered me an extra round trip flight home and proactive licensing in other states.

The site is hoping when I am doing with this final extension, that I will help them open their new clinics in Florida.