Traveling NP

It has been an easy transition to my new position working in a community health center in Northern California. Of course no place is perfect, but it is definitely a breath of fresh air in comparison to the facility I was working with in San Diego, CA.

The MA’s are pretty autonomous, they help assess which health screenings the patients have completed and are due for. They follow standard protocols to complete tests as indicated such as urine dipsticks and rapid strep tests. They gather and input family and social history.

The computer system we are using is NextGen. It’s an upgrade compared to Meditech but still part of the Flinstone era. There are a lot of clicks required to accomplish orders and adding of diagnoses. It can be a bit time consuming because your orders are all in different places instead of just having them all under the same “orders” tab (referrals, diagnostic tests, labs, medications etc.).

I started off on a slow schedule with 12 patients per day the first week. It ended up being really slow because there is a high no show rate. The second week I had 16 patients and found myself busy in a good and not overwhelming way. My only complaint is at one of the clinics I only have 1 patient room to use. Sometimes my patient is not ready until the time I am supposed to leave because other providers were using my room. This isn’t necessarily a huge deal when I have a low number of patients. But they will expect me to see 24 patients per day, and this will not physically be possible with just one patient room. I brought this to the attention of the clinic director – so we’ll see what happens.

They also only provide 15 min visits for all patients – including new patients and adult physicals. Once my schedule becomes busier, I foresee this as a problem. Luckily, any extra time spent seeing patients or documenting I can always add as overtime. This includes working through lunch and staying past my shift. I try to see this as a positive since the salary employees are often staying late and are not compensated for it.

All of the other physicians, nurse practitioners, and physician assistants are very friendly and helpful. They have welcomed me with open arms! The medical assistants are also nice and respectful. The patients are pleasant. There are not too many narcotic seekers, which is always a plus. It has been interesting working with a high Asian population for the first time. This includes Chinese, Vietnamese, Japanese, Indian etc. They often come with a family member to help translate but we also have providers that speak their native languages.

I don’t even have to do well woman visits/pap smears because each clinic has a Gynecologist or Woman’s Health Nurse Practitioner. I rarely have to see children because each clinic has two pediatricians. Procedures are rare since patients are usually directed to the “care today clinic” which is one of the facilities urgent care like clinics.

So far, so good. I will keep you posted!

As I am sure most of you know, housing in the Bay Area is extremely pricey. In fact, the housing budget for assignments in this area are usually doubled compared to other places.

I requested to live in the Marriott Residence Inn, which ended up being affordable compared to other housing options. This way, I wouldn’t have to worry about acquiring bed linen, pillows, kitchen utensils etc. since I have never needed them before. The hotel comes with a kitchen and supplies, which is very convenient for long-term housing.

I have been very pleased with my stay thus far. On the weekends I enjoy the free continental breakfast. On a sunny day I make sure to swim in their heated outdoor pool. I usually request housekeeping services once a week. It’s nice having someone clean up after you J

They gave me a first floor room adjacent to the parking lot so it is easy for me to go in and out. Not to mention that this hotel is pet friendly for all you dog lovers!

The best part is that after staying here for 3 months, I will have accumulated thousands of Marriott rewards points in which I can redeem in the future for free nights at any Marriott hotel. I will also become an elite member meaning I will always be offered free room upgrades and free breakfast at any Marriott property.

Below are some pictures of my studio at the Marriott Residence Inn.

I was fortunate that my next job didn’t have training available until the end of the following week. A lot of locum tenens nurses practitioners will take one to several weeks off in between assignments to recuperate. I usually just plan my vacations for the year ahead of time, not knowing what my schedule will look like. So I don’t take time off between assignments, since I already have scheduled vacation time during my assignments.

I had gone home to Miami, FL during the week of Easter because it was my brother’s birthday and my grandfather had just had back surgery. This was during my last few weeks in San Diego.

I was relieved I didn’t have to start working in the bay area the Monday after finishing my assignment in San Diego (which was a Friday). I slowly packed up my apartment during my last week of work. The following Saturday, I packed up my car with all of my belongings. I was surprised by how much I could fit in my car, especially knowing I had somehow accumulated a bunch of random things during my stay in San Diego.

I spent the weekend in Los Angeles with some friends. There are always new things to see in L.A. As we hung out by the beach and it was warm, I started wondering if I was making a mistake leaving southern California!

It was about a 6 hour drive from LA to San Francisco. I did not drive on the pacific highway because I had already explored it when I did an assignment in Monterey. I just wanted to get to San Francisco as quickly as possible. I am glad I never did an assignment in the Central Valley of California because it is pretty deserted. There were times I was afraid I wouldn’t be able to find a gas station. Other times it smelled like manure as I passed by farms with tons of cows – more cows I had ever seen in one place in my life!

Upon arrival to San Francisco, I thought to myself – wow it’s cold! I automatically started to miss San Diego a lot. I spent the next couple of days exploring San Francisco and Napa Valley with some friends. Seeing the Golden Gate Bridge again still gives me that breathless moment. The wine was incredibly good! I had a great time but found myself remembering why I always preferred Southern California to Northern California.

San Francisco was foggy for the first half of the day, and when the sun finally came out, it was accompanied with a lot of cold wind. Some nights I had trouble sleeping because I was so cold!

This assignment is 3 months long, but between all of my vacations, I will only really be working 2 months. I figured I could put up with anything at this point, but will really have to consider the location of my next assignment when the time comes. In the mean time, I am super excited about all of the cool places I will be exploring near by: the Redwood Forest, Lake Tahoe, Sacramento, Napa Valley, Silicone valley etc.

As usual, it didn’t hit me that I was actually leaving San Diego until my last day.

It was bittersweet because I was genuinely going to miss all of the great people I met, but was also looking forward to starting a new adventure.

The two main clinics I was at each through me a good-bye party. My main clinic made theirs a surprise and the charge nurse even sent me a beautiful bouquet of flowers. She is so thoughtful!

All of the providers hugged me good-bye, and asked if I really had to go. Yet, they were very excited for me to move on to the San Francisco Bay area.

Some patients said they wanted to make an appointment with me next week, or that they wanted to bring in their children to see me next month for a physical. I did not have the heart to tell them I wouldn’t be there. I also heard after I left that some patients came in expecting to see me, and when they learned I wasn’t there they caused a scene.

The tough part about doing locum tenens will always be leaving behind my peers, co-workers, and patients I have developed a bond with. It is good to know that I can always go back if I want to.

After San Diego, I wanted to make my way up to Northern/Central California. I wanted to be somewhere in the bay area or near Sacramento. I have previously visited San Francisco but have never been to Sacramento. I mostly wanted to situate myself close to Lake Tahoe, so I could easily drive there for a nice summer weekend.

I knew I didn’t want to overwhelm myself again as I did with my search in Southern California, by having over 20 options. I just stuck with 3 agencies this time to help with my search.

My main search criteria were:

-Working with an agency that pays 1099 (vs W2): the reason is because California already takes out a high amount of state income tax, and I had already done my due diligence in San Diego working with a W2 company. I needed to balance out my sole proprietor/self employed income with my employee/employed income for tax purposes.

-Location: I wasn’t too picky about the city; I just wanted to be within 1 hour from San Francisco or Sacramento (or both).

After interviewing with a handful of clinics, I decided to choose based on the clinic I preferred over location. Since I had a great location with my last assignment (San Diego) but did not enjoy the clinic itself, my main goal was to work with a clinic that was well-run and the medical assistant’s were very autonomous.

I ended up choosing a community health center in the Bay area, between San Francisco and Sacramento. Per my conversations with the directors of the clinics, each provider has two medical assistants, and they can be as autonomous as the provider wants them to be.

I am grateful that the facility has also pre-approved my requested vacation time for two trips I will be taking during the assignment. My assignment is 3 months long, but after deducting my vacations days, I will only really be working there for 2 months.

I was able to take 1 week off for a mini vacation with friends. We decided to go to Guatemala since it could be a quick fun trip. I had a good time, minus the fact that once again by baggage was delayed.

My friends and I joked that I should purchase some traditional Guatemalan clothing in the mean time. I didn’t get my luggage until the day before the trip ended. Funny thing is that my gut kept telling me to bring a carry-on, since I had a feeling my luggage would be delayed. However, since I already had my baggage delayed twice within the past 4 months, I thought I couldn’t possibly have such bad luck in which I would lose my baggage again. I guess since I travel more than the average person, my probability of having baggage delayed is higher than others.

I definitely learned my lesson and will bring a carryon to every trip in the future. I couldn’t even be upset about not having my things, as uncomfortable as it was, because the Guatemalan people barely have anything at all so I was fortunate I had “things” I could miss.

Guatemala was a mixture of Costa Rica and Peru. Although Costa Rica is more beautiful – landscape wise, Guatemala also had an abundance of volcanoes. It reminded me of Peru because the locals wore traditional clothing that was similar to the indigenous people. Guatemala is different because their ruins are from mayan influence.

Surprisingly the food in Guatemala was good too! I like that they pretty much use avocado/guacamole in plenty of their dishes. A strange thing is that they had a lot of café’s that served French crepes. It was a delightful surprise because crepes are my favorite!

Once again, thanks to being a traveling Nurse Practitioner, my schedule is flexible and I can easily make it on trips abroad.

Lake Atitlan with 4 out of 30+ volcanoes in Guatemala!

Antigua, Guatemala – small historic spanish town.

There are so many external factors that influence workflow for a locum tenens nurse practitioner. In some clinics I am able to see 25-30 patients without feeling stressed. In other clinics, I can barely see 18-20 patients without feeling overwhelmed.

What factors influence work flow?

• Clinic policy for late arrivals. One clinic I worked with had a 15 minute rule. Meaning, if a patient is scheduled to be seen at 4:00 pm, they have until 4:15 pm to show up for their appointment before they are marked as a no show. No shows then have to reschedule their appointments. This inspired patients to be on time for their appointments.

In another clinic, patients were scheduled 15 minutes before their actual appointment. So if they were scheduled for the 1:30 pm appointment, they had to check in by 1:15 pm or they were considered late. Once they were late, the provider was asked if the patient needed to be rescheduled or if they should wait for a “no show” and be placed as a walk –in appointment (replacing the “no show” appointment). Patients typically learn their lesson the first time they are late, because they will either not be seen or will have to wait a couple of hours to take a “no show” spot.

• Desktop vs Laptop for charting. I think it is ideal for providers to have a laptop for charting, in which they can bring with them to the patient’s room. On the other hand, a lot of clinics have their providers use desktop computers. There is a desktop computer in the provider’s office, and a different one in the patient’s room.

When using a laptop, you can easily start documenting before, during, and after seeing the patient (while staying logged in). You can quickly put in orders with the patient or while stepping out of the room. I find that having to log in and out of a computer upon each patient visit and upon each order can be tedious and time consuming when using desktop computers.

• Patient room locations. I have taken for granted having my own office and my patient rooms directly adjacent to it. In some clinics they have providers share a common work station/office. In this case, it is impossible to have provider rooms as close as possible to the office. Some days my patient rooms were easily a couple of hallways away from the office. This became time consuming, as I constantly had to walk back and forth between my office and the patient’s room. Some patients require care in which you need to step out of the room to look for something or call someone, thus you need to be in and out between their room and your office.

• Medical assistant level of autonomy. As I have mentioned previously, some clinics I have worked with have very independent MA’s. They gather past medical history; follow standard protocols to order and test for strep, flu, or UTIs; assess and order vaccinations per schedule; order screening exams as needed such as mammograms, colonoscopies, and diabetic retinal imaging exams; perform diabetic foot exams; have the patients undress for well woman exams or STD screenings; etc.

These little tasks can easily accumulate and become time consuming. By MA’s helping facilitate the process of gathering information and ordering recommended exams, it helps save us time and allows us to focus on other primary care needs.

I have worked in places before where the MA’s were not well trained. So when I went in to see a patient for a well woman exam, the patient was not undressed, nor were the pap smear materials ready for me to use. Once I had a patient that came in for wound care, but the previous dressing was not removed, nor were there wound care items easily accessible for me to use.

Unfortunately, those delays in the preparation of the patient cost me plenty of time. Anyone working in healthcare knows that time is precious, and any set back can push back the entire schedule.

As usual, time has flown by and I only have a few more weeks left in San Diego. It is bittersweet because I sincerely LOVE San Diego – but I am ready to work in a different facility.

I was asked to extend my current assignment by another 3-6 months. Unfortunately, the amazing weekends do not make up for the weekdays full of stress and anxiety. So I decided that I would just move on like usual.

I love that San Diego is so diverse. I love that it is a big city that is not overcrowded and there is not a crazy amount of traffic. I love the different coast lines; from the beaches to the cliffs to the bays. I love the food – my favorite restaurant is Chocolat! I enjoy the night time life at Gaslamp district. I absolutely love bike riding on the boardwalk where I live, with a nice cool breeze hitting me. I have also gotten used to seeing seals everywhere I go.

In a perfect world, I would take the community health center from Washington State and put it in San Diego, where I would be the happiest employee ever!

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Below is a picture of the sunset cliffs in Ocean Beach, SD (looks like Cabo, Mexico).

My sister came to visit and we had a blast bike riding:


Skyline view of San Diego at night time:

La Jolla Cove with tons of seals sunbathing: