Tag Archives: Nurse Practitioner

Health Care Culture

Standard

woman-fitting-in

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…

ballet

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

Guidelines-schmidelines

Standard
Guidelines-schmidelines

In a few days I will start a new job in a new place. The focus in this clinic is patient wellness. Visits are 30 minutes. The people that I have met so far are amazing and we seem to be on the same page regarding patient care.

But

I am wondering if  guidelines are imposed in the same way they are by private insurance companies. Those crazy, meaningless guidelines that had the folks in charge of that non-sense talking to me about my “numbers”.  I need to put the overweight 18 year old girl on a Statin because her lipids are a little high. I tried explaining that there is really no benefit to that and only risk. If I remember, the number needed to treat was 2418 and the number needed to harm was 10-20.  It was explained to me that their reimbursement is based on the surrogate markers being at where the guideline de jour says it should be. The physician and the bean counter both told me that my concerns for the patient were good, but they get docked somehow if they miss the “Star” measures.

Why I didn’t  put that teen on an antidepressant if they had PHQ-9 that was worrisome. I quoted studies right and left and tried to explain the risks of psychiatric medications, but more importantly, the lack of evidence to support their effectiveness but  It looks like I am not treating “depression”.  I say, of course, I am just not with drugs. I don’t think she has a Prozac deficiency . She is sad and she should be sad given the current situation. I am working to find a counselor that takes her stupid insurance. I have appointments with her regularly, sometimes more often than you would like.

Guidelines? Which ones? The ones that say we need to do a DRE and PSA on every male over 50 ish. Oh, snap! All those exams and labs didn’t do a damn thing to improve the mortality rate.  Women who are sexually active or (was it when they reached menarche?), should have a PAP.  Oh, never mind. That caused a lot more harm than good, now didn’t it? Let’s get those A1Cs below 6.5 even if the patient feels horrible. The blood pressures in seniors ? Let’s get those down so low that they have no quality of life, or maybe with a little orthostatic hypertension they will fall and break a hip.

When I imagine the folks writing guidelines, I always get this image in my mind of Yul Brenner saying ” So let it be written, so let it be done.”  Or maybe the writers of guidelines are more like the Great and Powerful Oz.   I know that I don’t believe much of what they say anymore.  I want to direct my attention to the person in front of me and not their surrogate markers.

My vocation calls me to look into the eyes of the person in front of me and figure out together what they want to do about their health.  Most of the time those markers have little to do with what will decrease the chances of having something “bad” happen. We all know that. Well, those of us who work with people know that.  The folks that write many of those guidelines may have never interacted with an actual patient. Certainly, those “Star” measures don’t reflect good healthcare don’t reflect good patient care anymore than patient satisfaction scores do.

When you start a new job-what is important to you? Money? Culture? Philosophy?