Category Archives: Nurse Practitioner

Health Care Culture

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I usually find a way to fit in a new job pretty quickly. Years of working as a locum tenens makes fitting in a survival skill.  I am surprised that I am feeling a little more guarded than usual. A friend of mine would call it “well defended”.

So much of healthcare is cultural. In some places every one handles colds in one way ( everyone gets a ton of medications) and in some places, we recommend tea, honey and rest.  In the first weeks I am in a new place, there are always folks who misunderstand my “style”.   With some patients I have to WORK really hard to convince them that I am really on their side.

Then, there is the whole culture of handling urgent issues.  Some places have protocols- anyone has a blood pressure greater than 180/90 gets the 911 treatment, no matter what the provider thinks is right.  Some place rarely send anyone to the ER and try to handle everything possible in the clinic.  Today was one of those days of explaining that I know what I want to do with this young patient, but I need to know how this clinic handles things. Labs/imaging and then to ER, or just skip it all and send to ER. Direct admit? What goes with her? Do I print the note, or write a new one on a script?

Some clinics work as a team, while some are just people in the same building without much interaction. Some folks are much more serious, some laugh and goof off all day between patients.  I am trying to find out where I will fit in this new place.  I feel “stressed out” trying to adjust. I am trying so hard not to be too much of me. I am working this time on having unspoken thoughts.

But, somehow it ends up like this…

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( I am also trying to let go of wanting things to be perfect- like blogging.  )

Crying

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I was reading over on Kevin, MD about a photo that was captured by a paramedic. (http://www.kevinmd.com/blog/2015/03/why-did-this-image-of-a-crying-doctor-go-viral-heres-why.html )  The photo shows a young doctor crying over the death of a patient.  The photo has generated quite a lot of internet buzz.  Should healthcare providers cry? Does crying make us unprofessional? Are we supposed be detached? What kind of person is able to remain emotionally detached doing what it is that we do?

I am not sure if it is a nurse thing or not. I cry.  I cry in front of patients. I cry with patients. I cry with families. My last cry was happy tears while hugging a patient who had been told that the diagnosis of “metz” to his lungs was a mistake and he was going to be just fine.  Yes, I cried with him when he got the original bad news.

I cry because I genuinely care deeply. It makes me a good provider for the most part. It makes me sit up reading every thing I can find that might help.  Sometimes, there is nothing I can do but care about the other person.  Sometimes that is the most important thing.  Being human.

I laugh with patients. I joke with them.  I encourage. I tease. Sometimes, I am the ice princess.  But that is rare.  The emotions I don’t share are angry ones. At least, I try not to let it show that I would like to dump a glass of ice water on the head of a patient that is yelling at me or insulting me.  So, there are limits to being fully expressed.

It makes me sad to read about physicians being expected to “suck it up”.  I imagine all that compartmentalizing is crazy making and it may be one of the reasons that physicians have such a high suicide rate.  I don’t know why their training is so harsh.  I don’t think it makes them “better” as health care providers.  Their crazy high divorce and suicide rate should let them know it isn’t good for their health.

Do you remember Rosie Perez in White Men Can’t Jump? I love the part where she was trying to explain that she didn’t want the boyfriend to get up and get her a drink of water when she said she was thirsty.  She could get it herself.  She wanted him to just understand or care. She wanted him to say ” I too, have been thirsty”.  Sometimes, our patients don’t want a pill or advice. Sometimes, they just want someone to say: “Yeah, parenting a teen was so hard for me too”.

I hope that more physicians are talking about the “disconnect” from emotions. I hope that they start encouraging each other to talk about their feelings long before they consider suicide.  I think of all the young residents that I knew while working in that huge hospital.  It breaks my heart to think that they will feel so isolated from the rest of the world that they think that sedation or suicide is the only way to cope.

One of the physician blogs that I follow is “Behind the White Coat  beats a real human heart”.   We all need to keep that in mind, don’t you think?

These boots are made for walkin’

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These boots are made for walkin’

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It is that time again. Time to move on to my next clinic. I have worked locum for about 7 years now. This means that I have had to learn to make friends fairly quickly.  Making friends with co-workers and forming attachments to patients is one of the things that makes saying good bye so difficult.  Good byes have become easier over time.

These next 3 days in this clinic will go by quickly as I struggle to tie up all those loose ends in the charts.  It means that I may not get to see the outcomes of a few of the “zebras” that wandered into the clinic in what seemed like a herd. It means I will not be working with the amazing Nurse Practitioner and the brilliant Physician Assistant, two of the brightest guys I know.  I have learned so much from them and can’t help feeling that I have so much more to learn.

On the other hand, I am doing a happy dance to get away from that one physician he who will not be named.  The squeezy feeling I get in my heart when I see I am following one of “his” patients will ease up. Rolling my eyes at  3 years of cut and paste notes leaving me with NO clue what is going on with the patient since every note for 3 years states they are here for hospital follow-up 5 days ago. Bye, Felicia.

I am looking forward to the new place. I have spoken with the medical director a few times and I have met so many of the admin folks and everyone seems great. I no longer feel the need to try to make myself sound like the person that they want. I have learned that it is best to be myself from the beginning. I am outspoken when it comes to my philosophy of healthcare and if we are not a good fit, better to know that right away. So far this place sounds wonderful ( except for the commuting).

The new job is closer to home. I will be sleeping in my own bed every night. I will have time to wear my gardening boots and my hiking boots this summer. Time to read under the grove of trees in my hammock with walls made of sunflowers.  But tonight? Organizing and packing so I can leave right after work on Thursday.

Zebra Hunter

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Zebra Hunter

zebraI am admittedly a Zebra Hunter.  In my defense, I worked acute care pediatrics in world famous children’s hospital when nearly all 300 of the kids were zebras of some sort. If not, they were more easily cared for in the community hospitals. For the years I worked there, I was surrounded by the most brilliant minds, amazing caregivers trying to puzzle out the most complex children. I had no idea that it was possible for so many chromosomes to be off just a little.

Everyday things were life threatening. Sinus infections and ear infections somehow had turned into empyema of the brain.  The rarest cancers, the most complicated neuro surgeries.  Once when Infectious disease and neuro surgery looked at images together, the neuro surgeon picked up that baby to RUN him to surgery.

So, when I first saw kids in the community with an ear infection or sinus infection, I would want to make sure it wasn’t going to be more serious.  Are those bruises on that toddler ” non accidental trauma.”?  In the hospital, everything was figured out immediately- it was like magic- Any image, MRI, MRA, or weird lab was just done almost immediately. Work ups were quick, often intense, but things were figured out before the child went home.

The “real world” isn’t like that at all. It is full of mostly horses. Sometimes some pretty fancy horses, but mostly mundane. Except for the past few weeks, when I have learned more about endocrine that I had no idea that I didn’t know. I am weirdly excited about it all. I mean, it is fascinating when it is something so unusual.

I think I find the weird stuff in part because I worry about missing something. I also tend to listen to patients.  I like to hear their stories. I like to try to put the pieces of the puzzle together.  I am endlessly curious about everything.

What is so very interesting these past few weeks is that these are things that one would think would be noticed long before I meet the patient. I don’t know how someone else didn’t think it odd that the 40 year old patient with palpitations was so weirdly bendy. Not yoga bendy but something unusual, that makes me ask if they can touch the floor with their palms, encircle their wrist with pinky and thumb, touch their thumb to their wrist. Can I see your palate?  Yeah, no one every asked or looked.

I am not a physician, so I didn’t have much exposure to radiology in school. Well, actually NONE. So I don’t just read the radiology report “impression” I read the whole report. I look up words. I pull out one of my radiology texts. I read, read, read. I question. I want the answers. I need the answers, so next time I will know. More times than I can count, what I read in the “Impression” doesn’t completely match what is in the body of the report. This is probably a reflection of those dreaded “pre clicks” on computer programs. I ask about that nodule or cyst mentioned.

These past few weeks I have been in the middle of a whole herd of Zebras!  Strange lung stuff that we are still working out. Pheochromocytoma in that “anxious” patient.  Some things that are so unusual that HIPPA’s ears will perk up if I think it too loud, but really, really strange endocrine stuff that is fascinating.

The term Zebra Hunter isn’t a compliment really. It would be more of insult, if I didn’t nearly always get that Zebra. As often as I might say that I long for less interesting practice,  I find the hunt makes me look forward to getting to work.  It is like turning the pages in a mystery novel. This next week, the pieces of at least 5 very odd cases will come together.

Snitches Get Stitches- Protecting the Guilty

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For weeks, I have been conflicted about talking about a situation in my work world. I am not sure what the “right” thing to do is. No, that is a lie. I know right from wrong, damnit and what is going on is wrong.  I worry about big scary words like slander and liable.  I know that my vocation calls me to protect my patient from harm. Sometimes, that harm is another health care provider.

On the other hand, we all have this not quite unspoken code of keeping our mouths shut when we are all aware of another health care provider who is dangerous.  We talk among ourselves. We roll our eyes. We call someone to the computer and say- “Did you see this?”.  We ask each other how that person gets away with this. Of course, that is as far as it goes, right?

There is a physician who is routinely seeing 70 patients in 5 hours. We joke that on the evening he works later, the whole waiting room looks like a scene from the Walking Dead.  I found myself humming the Leper’s song from Jesus Christ Super Star.  They are all there for Norco, Xanax, and Soma as a cocktail along with more other drugs that I can count. We know this is wrong.  We worry. We whisper. No one says anything to him though.

Yesterday, I shared clinic hours with him. In my defense, I was in and out of rooms too, and doing some much needed catching up on four inch stack of labs and images. I was working as hard as I could to stay on task and focused. Once, I walked into the common nursing area and heard folks talking about “not responding right” and he was standing the doorway and I assume this is his patient and he is a physician who has this handled. I went back to office/charting area a few doors away.  In the hallway I heard someone say something about an ambulance and again, assumed he was taking care of his patient and had called the ambulance. I was only mildly concerned because I had worked in clinics where it is just protocol to call 911 for things as minor as elevated blood pressure. I briefly wondered if one of the COPD patients was having a very hard time.

I went back to the nurses station area to get some forms as ambulance was arriving, the physician wasn’t in sight, so I assumed he was in the room with the patient. I had called 911 in other clinics and stayed with the unstable patient until care is turned over to the paramedics.

But no. Later, several assistants came in the providers charting area and asked me if I knew what happened. The physician walked into the room, the elderly female patient seemed groggy to him. He came out after a minute and told the assistants- “She won’t answer my questions” and said something like she had probably taken too many medications. He gave no orders, no concerns and moved on to the next patient. It took a few minutes for the assistants to figure out to go in the room and check, and they found her nodding out and barely responsive. One got a blood sugar of less than 30 and called the ambulance. On their own because he was ignoring the whole situation.  They didn’t come to me, because HE is the DOCTOR.  He continued seeing all his patients and ignoring the whole scene and the patient who became completely unresponsive before the ambulance arrived.

I find this out after the ambulance has gone.  We are all not as shocked as we pretend to be. We know he is horrible. We know he doesn’t examine patients. We know. We talk. We DO nothing.

I came in this morning and looked for a trusted colleague and he told me he had just heard the whole story. I told him, I am not staying silent. I am going to the clinic director.  We each spoke with her today.  I doubt anything will happen. Not for her lack of trying, but he is a powerful person in this community.  This is not the first or even second time I have been to a clinic that is so scary.

I am scared for his patients.  When I see them and update the problem and medication list, explain that some medications are not safe to be taken together or shouldn’t be taken with their condition, or that they need some tests and I do a physical exam, they tell me that it is the first time someone has touched them or examined them in 3,5, or 7 years.  I am quiet.  I don’t criticize other providers.  I think I am a coward.

Who are we protecting when we stay silent? Are we protecting the other provider? Are we trying to protect the patient? Are we protecting ourselves?

I am the locums. I am the outsider. I was raised that tattling is the worst thing you can do. No one likes a tattletale. “Snitches get stitches”. “Not my circus, not my monkeys”

What do you tell yourself when you protect the dangerous provider with your silence? We all know these “bad apples”, don’t we?  Have you confronted them personally? Do you think administration will handle this?  What do you do? I really want to know.

Dear Dr. Crankypants

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I follow the Kevin MD blog because the blogs and guest blogs  present the human side of health care. Every so often the debate of the role of nurse practitioners comes up.  Mostly, these conversations are pleasant, but there is one physician that is so angry that nurse practitioners are allowed to practice at all. It may be that he has reasonable concerns, but the tone is so hateful and insulting.  His posts always boil down to the same points. Nurse practitioners are poorly trained and do not have the ability to diagnose anything because they lack the education that physicians receive in medical school. He says we order too many tests and consult too many specialists. The vitriol of his comments always takes me by surprise.

I really do try to understand his fears about us, but what I just can’t understand is the hatefulness of his tone. There is clearly so much emotion behind those comments. He talks a lot about how superior medical school is to nursing school.  It certainly is much longer and much more focused on the what I think of as the bits and pieces of people and not as much focused on the whole person. I don’t know for certain because I have never been to medical school.  In my mind, medical school is about microbiology, organic chemistry, pathophysiology and the other sciences.  I had those classes too, but I am certain not as advanced. I do think medical school is probably harder, and certainly longer. I am not sure it is the hard science classes that it make someone a better health care provider. He says we lack the ability to deal with complex situations. This is true sometimes. This is also true of physician primary care providers.

When I find myself in a situation in primary care that is very complex and sense that those thundering hooves belong to a zebra,  I am not prideful. I ask a physician if one is available. It is rare that they know the answer immediately. Mostly, when I say that I have a patient with these symptoms, and I thought it was this diagnosis and I tried a, b, c but they are not getting better- am I missing something? The answer I mostly get? Refer them to the specialist. So my physician colleagues in primary care don’t have all the answers either. I think experience with zebras makes the biggest difference.

He often says we are not smart enough to have been accepted into medical school. I am a couple standard deviations to the right on that damn bell curve. If I wanted to be a physician, I would be. I don’t want to be one. I don’t want to be a dentist or a physician. I like working with physicians most of the time. Some of them are wicked smart. Some of them give me nightmares. Physicians and Nurse Practitioners vary in their skills. In the best practices, we compliment each other wonderfully.

Sometimes I have stayed hours after work trying to clean up the messes that happen with that physician that sees 70 patients in a five hours. I have also been blessed to be mentored by one of the most brilliant minds in primary care- a virtual Dr. House but with a down home country charm. I think that there isn’t a typical provider. We all vary in our skills and our interests. I don’t see this as a competition in the way that you seem to see this.

I have also seen disrespect on both sides of this debate. I have heard from many Nurse Practitioners who quote all those studies on how patients prefer nurse practitioners over physicians for primary care. I think patients prefer someone who listens to them and who spends time with them. Early in this profession we were given longer visits and were able to focus on our strong patient education skills. Those days are gone. I am often dropped into a primary or internal medicine practice with the same short time slot for complex patients as my physician colleagues are. I imagine those numbers will level out  as we are all pressed to manage complex patients in 10-15 minute visit.

I have heard nurse practitioners complain about the patriarchal “medical” model as if it were completely archaic. Yet,when I was a floor nurse I was blessed to work in a teaching hospital where everyone focused on the whole patient. It was their mission-to make man whole. It was rare to find a physician that wasn’t educated using a more holistic model that focused on health, education, nutrition, exercise and spirituality. None of those stereo types held true. We worked as a respectful team to focus on helping our patients. I respect the role that each of us plays in health care. I am aware of the differences in our education and our skills. I have no desire to practice outside of my scope of practice.

So, Dr. Crankypants, I am so sorry this is hard for you. I think I can understand how unfair it must seem to you that you struggled for so many years in medical school, internship, residency, fellowship and when you entered practice so sleep deprived and drowning in debt only to find yourself shoulder to shoulder with a nurse practitioner managing that same “non-compliant” patient with diabetes. I guess what I don’t understand is why you don’t enjoy the opportunity to teach- to help fill in those gaps where needed. Sometimes I can teach you that the “non compliant” patient isn’t using the insulin because they are afraid of needles and I can help with that. I can teach you that Mary doesn’t need more medication when her blood pressure is out of control, she needs you to know that her husband left her, her son has been arrested and she is working two jobs to make ends meet and forgets to take her medication. I taught her 3 great ways to remember, downloaded that relaxing song “Weightless” to her smart phone and that blood pressure is just fine now.

Dr. Crankypants, you are putting yourself at a much higher risk of an adverse cardio vascular event carrying on with all that anger and resentment. We aren’t going away. Your own health would be improved by finding ways to accept that this is the way healthcare is heading and do what you can to make things enjoyable at work. You could set up in-services at your workplace to decrease what you perceive are unnecessary referrals and diagnostic studies. The sheer number of your posts on this topic leads me to believe that you have an expertise in this area. I want to learn everything that I can. I promise I would buy your book or read your journal submission on this topic. You could offer a podcast or a iTunes University course on when to consult. You could be an editor on UpToDate because Gawd knows I rely on that data base ( as do many physicians) to guide my decision making. You tell us often how that classes on embryology and advanced chemistry make you a better provider and that my empty little head cannot comprehend a fraction of what you know about the workings of the human at the cellular level. You could write a medical sciences for Dummies book! I would read that. Well, no, I probably wouldn’t because I haven’t needed to consult one my dust gathering science text books even once since I started practice.

Some nurse practitioners should not be able to practice independently. Neither should some physicians. Most of us of pretty good at what we do even when it is so hard and overwhelming working in the front line trenches. We need to stop the bickering and work in collaboration.  We need to find solutions to the problems we are all struggling with in healthcare. In the words of Rodney King : … Please, we can get along here. We all can get along. I mean, we’re all stuck here for a while. Let’s try to work it out. Let’s try to beat it. Let’s try to beat it. Let’s try to work it out.