Fighting for independence: NPs vs. the 50 states

The Pennsylvania legislators have finally seemed to get on board with nearly half of our 50 states to break the cumbersome bonds of collaborative agreements.  Right now, nurse practitioners are being forced to practice under a two-physician contract agreement in order to give routine care to Pennsylvanians who desperately need medical care.

This desperation stems from two things.  First, the health care system has been and continues to be in a state of shambles.  Second, and most urgent, is the little-known fact that the nearly 11,000 nationally certified nurse practitioners in Pennsylvania are being held to a decades (decades!) old law that requires NPs to “collaborate” with not one, but two physicians in order to practice.  There are about 38,000 active physicians in Pennsylvania (General Assembly of the Commonwealth of Pennsylvania, 2015, p. 11).  Many physicians do not want to be bothered with the cumbersome paperwork slowly, ever so slowly processed by the Pennsylvania Board of Nursing.  Although the website states two weeks, it is more like two months to process.

Worse yet are physicians who never step foot into an NP-led practice, typically in rural areas, but they are named as collaborators.  And the NPs pay on average $5,000 annually each to those physicians just for a signature.  It’s like being held hostage but never getting the resolution.

Should one of those “collaborative” physicians retire, fall terribly ill (think stroke), or die, the nurse practitioner must stop practicing.  I personally know an NP who owned her own clinic in a rural area and did house calls when one of her collaborative physicians had a stroke and retired.  No warning. It just happened.  And until she found another doctor to agree to sign on, she had to close her practice.  Three weeks.  Closed.  Patients had no care for three weeks. Tell me, after over 15 years of practicing, how is that fair?  Will her mortgage company cut her a break?  Her light and power company?  No.  Not any more than that Commonwealth of Pennsylvania.

Fortunately, the legislators of the great Commonwealth of Pennsylvania have passed SB717 and now it will head to the House of Representatives.  The Pennsylvania Coalition of Nurse Practitioners (2017) states, “Senate Bill 717 and House Bill 765 would end this costly, arbitrary and outdated mandate and make Pennsylvania a full practice authority state.”

Already, 21 other states plus the District of Columbia have granted full practice authority to their NPs.  However, Pennsylvanians in rural and underserved areas may soon be able to rejoice as NPs who have completed an unprecedented three-year “training period” and 3,600 hours under the aforementioned collaboration agreement would be able to apply to work independently.  (One can only imagine how many months it will take the PA Board of Nursing to process the flood of applications).

It is maddening, as a doctoral-prepared NP, that I should have to work with two physician collaborators.  If the Pennsylvania branch of the American Medical Association, who has fought this break in antiquated wink-wink boys’ club tradition was so concerned about the health of Pennsylvanians they would have jumped in to break the collaboration and made physicians available via a hotline to support what they call “mid-level” practitioners.  Instead millions have been wasted on both sides and years have gone by while tragically underserved Pennsylvanians, my neighbors, people I know and have heard of via word of mouth, have suffered with no access to care.  No. Access.  To.  A.  Medical.  Doctor.  Or.  NP.

There are plenty of patients who prefer a board certified physician.  And I have learned under and alongside wickedly intelligent physicians to whom I will always be grateful.  But there are also patients who love NPs and welcome our prevention as well as treatment modality.  There is enough room for everybody.  We should respect each other. Stop throwing verbal stones.  However, aside from that, get rid of the collaboration agreement.  And once that is done, fix this new, upcoming law because even when it is passed, Pennsylvania’s collaboration will remain the most antiquated in the entire 50 states.  And that, my dear friends, is unacceptable.



Sinus infection? Allergy? Cold?

One of the most often seen complaints in primary care is the basket of nasal stuffing/dripping with headache.  Some patients come in, absolutely certain it’s “another sinus infection because I get them all the time.”  Others are sure it’s “the same allergies I get all the time.”  And yet the final category are those who are certain the cold will kill them, likely before the end of the day.  Each of these unfortunate souls can find it hard to keep up with the mad-paced electronic-super charged society we live in. Many wait until they can no longer take it.  Others rush in after just a mere few hours of symptoms.

So how do I figure out what is really wrong with the patient?  Above all else, listening to the patient’s story as to what their symptoms are and how it unfolded offers much guidance.  For instance, a patient who felt fine and then “suddenly” felt like they were “hit by a Mack truck” are more likely to be suffering from a viral illness of some sort.  Colds, you know, the ones which make you look like Rudolf the red-nosed reindeer and cause a sharp spike in Kleenex stock, are viral.  They don’t need antibiotics to cure.  In fact, so sorry all of you who want an antibiotic for every sniffle, antibiotics will do no good for a cold or viral illness.  None.  Zero. However, if a patient pushes, sometimes I will give in after I tell them they will still get better in about 7-10 days because that is about how long most viral illnesses last.

Other markers of the cold/allergies/infection are ones I see when I examine you.  I really do like to check your ears, nose, and throat.  Your ears could have wax build up or fluid behind your eardrum.  Both can be painful.  Both can seem rather abrupt. But the treatment is very different.  Your nose is a wonderful clue box as I call it.  Oh the things the inside of your nose tell me!  And your throat is a lovely indicator of allergy (the back of your throat looks kind of like a cobblestone street) or some other nasty things I may need to address.  I’ve found strep throat  by sight and I’ve also found folks who have just eaten something bready like a bagel of which remnants can look remarkably like white pustules back there.  (You might want to brush your teeth and don’t eat anything before you come in to see me).

While you’re there, I like to see how your blood pressure is doing.  Today’s American diet has led to blood pressure problems at very young age.  It’s no longer just for those over 40.

And very often, folks like to tell me about what’s going on in their life.  Most of all, they need to vent to someone who won’t tell others.  And who will listen.  And who will care.  Because I truly do care about my patients.  I care about their families.  And I like patients to show me a quick snapshot of their pets.  It’s something to bond over.

The next time you get sick, remember to tell your practitioner about how quickly or slowly you fell ill.  Tell us about how long you’ve been sick.  And know your symptoms.  If the answer to every question is “yes”, I’m often suspect the patient wants a quick antibiotic because a lot of the questions I ask do not apply to every cold/viral/allergy illness across the board.

And by the way, I like patients who look things up on Google.  Why not?  Sometimes when I am incredibly busy, they often have an idea as to what is going on and will be sure to tell me about those symptoms so I can verify with a few more questions and a good physical exam.

Allergy season: Which product? When to take?

Oh allergy season is upon us.  If you haven’t already started an allergy pill, hurry on up down to the Piggly Wiggly and pick up a bottle, box, or carton.  Today.  To-day.  I know the ads show allergy sufferers dancing through fields of hay fever and snuggling next to Fluffy the super-furry long-haired white cat.  Apparently, the drug companies want you to believe their allergy medication works “in as little as 30 minutes”.

Okay, people, here’s the truth.  If you want the best allergy coverage, start taking allergy medication about two weeks before your allergy season begins.  Spring allergies?  Then start no later than March 1st.  Late summer?  Start July 1st.  Fall?  Start September 1st.  Now remember my disclaimer, my comments are not meant for everyone and not intended to replace the advice of your health care provider.  However, in general, it takes about two weeks for allergy medication to seat itself in your system and cover most of the symptoms.  You know, the runny nose, watery eyes, itchy ears, and throat.  While you can get relief quickly, full coverage relief is best achieved after two weeks.  That means heavenly 24 hour relief.

Here’s a pearl I’ve learned which may or may not apply to you.  For indoor allergies, I’ve found Claritin works fairly well.  Yes, it will work on outdoor allergies, too.  But it sure does seem to cover indoor pretty well.  And, yes, the store brand is fine for most people although some patients don’t do as well with the binding ingredients.  You will have to decide that for yourself.  For outdoor allergies, Zyrtec covers fairly well.  For most people, taking allergy medication at night is a pretty good idea because it can make you tired.  Relief from allergies and a good night’s rest.  Not bad.  Allegra is also a good alternative.  Patients ask about the stuff behind the counter, for example, Claritin-D.  The D is a decongestant.  In general, most people do not need it.  It is not very often, in fact, that the decongestant is necessary except in short-term periods.

If your ears are feeling “clogged” and popping or clicking, it’s often because they are not clearing properly.  It is often on the heels of a cold or allergy-related.  I’ll talk about that in my next post.  It’s something you can buy at the pharmacy as well.  So stay tuned….

Job Search & Networking

This week I attended a national conference for nurse practitioners (NCNP 2017).  The original intent was to learn the newest guidelines on common ailments I encounter in primary care practice. However, with recent events, I found myself in need of networking to see about locating a new employer.  Here’s what I found…

Being outright honest about why I parted ways with my previous employer was refreshing to both parties.  I did not bash the folks I used to work for.  Instead, I quickly noted our disagreement and stated I enjoyed working for the previous company and would miss them but things did not work out as I had hoped.  It was truthful and heartfelt.  Speaking negatively about a previous employer, even when, by many accounts is could have been justified, would have been poor form.  It is not in my character.  My grandfather used to tell me the only two things people can’t take away from you are your character and your education.  He was right then and that statement continues to hold true today.

Another thing I found was that the nurse practitioners I met from around the country were engaged in refreshing their knowledge. They enjoyed networking with others regardless of geographic origin as much as I did.  I’ve picked up a few words in another language which has been fun, too.  It is apparent the days in which health care providers earn their license and then practice the same way year after year until they retire some decades later are gone. NPs are vested in their patients’ health and wellness.  That entails constant refresher courses as guidelines for every major and minor disease, ailment, and injury change faster than they can be printed.

It’s been the type of week which reinforces why I became a nurse practitioner.  I have met other NPs who also strive to do the best they can to do right by their patients.  I’ve also picked up clinical pearls, those tid bits of information which successfully guide medical decisions to help my patients recover or cope with medical illnesses.

When I return home tomorrow, I will get on the plane as a better NP, have more friends, and maybe, just maybe, a new job in the pipeline.  I sure do hope so.

If no job materializes, I know God will have the right job waiting at the right time just for me.  It’s kind of like a prescription for medication, follow the right  steps and then wait and in time things will work out just fine.


Those who are supposed to care

Sometimes we as health care practitioners (HCPs)are the ones who are ill or injured.  When that occurs, we generally believe the other HCPs around us, and particularly, those whom we work so hard for, will treat us with caring respect. For some HCPs, especially some employers, that is simply not going to happen regardless of the nature of the injury.  Large facility employers have adequate policies in force to protect both the employer from lollygaggers and the employee from heartless owners who purposefully disregard obvious painful, debilitating injuries.  Smaller places of practical care often  have policies which evolve spontaneously, usually to the benefit of the employer.  It is not until times of such disability that employers reveal what type of wizard is truly behind the curtain.

In the course of our employed lives, which accounts for roughly 70% of our time on this earth, realizing that our employer is not the wonderful, caring being we had believed them to be.  The slow realization that the previously beloved employer is focused only on money production can be agonizing.

After much thought, two end products should result when the employees care more about each other than the employer could ever claim in front of the Almighty.  First, the injured practitioner should give swift, adequate, professional notice.  Save yourself.  In order to be the best NP one can be, it is an absolute necessity to care for oneself and about oneself.  Working for any practice that only treats employees well when those employees are, um, well, is like continuing to date someone after they have shown themselves to be untrustworthy.  Save yourself.

The second end result should be to evaluate future employers more carefully.  Weigh smaller versus larger practices.  Ask about written policy handbooks.  And what to expect if policies are overhauled.  Are employees grandfathered?  It is important to know.  Save yourself from jumping too fast. 70% can be a long, long time.

Sadly, finding out how an employer treats injured employees is often something we understand after the process has started.  Worse is that this has to be written about at all.  Our society has become so completely romanticized with the PC of everything that it is difficult to understand how any employer can be so callous as to watch an employee physically suffer day after day and then verbally and policy-driven attack them.

However, if you are genuinely kind, truly and authentically kind to co-workers and patients, rest assured those fine people will be tremendously supportive right through to the last-minute of the last day.  And that, my friends, is why being honest and kind triumphs over hardened money-driven hearts every single time.

Save someone else this season

Oh the flu season is upon us.  And it’s hitting the east coast like a ’72 Chevy Nova tearing across the county line to get to the all night diner before it closes.  If you’re young and healthy and one of those who don’t mind feeling like you got trampled by a herd of cattle, that’s your business.

However, before you even know you’re sick,  you can infect others.  That means  your time at work, the trip to the grocery store, and the local convenience store can be costly to ten or twenty of your community members.  If they are young and healthy, great.  You can all watch Netflix and take Instagram your misery in unison.  But if they are very young or very old or have poor immune systems (think those fighting cancer or breathing problems), the flu can be downright deadly.  D E A D L Y.  As a previous hospital floor nurse, I’ve seen it.  And it is pitiful to see the families come in to visit their loved one.  Over and over they say, “But I just saw them.  They were fine“.  That’s how fast and furious the flu hits.  How horrible it can be.  How uncaring and non-selective it always is.

The idea of vaccinations is driven by something called “herd immunity”.  Just like that herd of cattle that ran roughshod over folks in your town already, the herd can also surround and protect those same folks as well.  If enough people get vaccinated, the herd is effectively “immunized” or protected against, in this case, the flu.  That means the community  is less likely to suffer the huge flu epidemics we hear about on the news which cause us to say, “Well, I hope I don’t get it.”  So don’t get it.  Get the flu vaccine instead.  If it is the injection (a rather small needle unless you are a total and complete woos), it is NOT a live vaccine.  You cannot get the flu from the flu vaccine.  You CAN get a reaction which makes you feel sick which is GOOD.  It is your immune system building resistance to the flu virus so that if your body sees that virus again it will smack it down like a Tennessee Lady Vol defending the net.

Please get the flu shot.  You can get it all the way through until April.  Just like you can get the flu through April.  Look around at your family.  The babies.  Toddlers.  Grandmas and Grandpas.  Protect them.  Protect other community members’ babies.  Grandmas who make the best birthday cake frosting ever.  Think about others.  The world sure is a lot bigger than just you.  And you can’t get the flu from the flu shot.  No matter how much you say otherwise.



Those left behind…still

Today was my house call day…or half day.  I wish it were a full day.  Or a whole day.  Or a few days of my week.  I love my home visits.  My patients are largely the forgotten ones.  The ones who spent hours under the sun as children, playing in cops and robbers in the dirt, their mommas calling when the lights came on, years raising kids (older, forgotten versions of themselves), and now they have shrunk down into brittle memories of their parents.  They can’t get to the office and most don’t have family to shuttle them into our office.  They have outlived their “people”.  So they have me.

The first house was to what could clearly be something right out of a Hollywood haunted house movie set.  Dilapidated two-story.  White paint worn off the wood decades earlier.  Second story windows boarded up.  Front porch screens torn.  Sometimes Cecil answers the door. Sometimes not.  I pick my way across the broken floorboards and stray-not-so-stray cats and carefully sit at his table so we can chat about what ails him.  He is forgetful and usually refers to me as “that nurse”.  I know he’s secretly happy to see me.  I’m pretty much all he has these days.

The next house is a brother/sister team who have more ailments than I have time to list.  And some of them painful.  Their house smells like something illegal.  I ignore it and take my migraine medication as soon as I get back in my car, leaving the window half-open so my other patients don’t finger me.  Narcotic medications are so tightly regulated, they can’t get them from their specialists.  This is what happens when too many prescriptions were written then narcotics were getting into the hands of the wrong people and then legislators had their usual knee-jerk reactions.  Patients who were good, honest people now suffer.  They can’t make it in to pick up a monthly prescription.  Nor can they drive every thirty days to their pharmacy.  Because they can’t drive anymore.  A neighbor checks on them once in a while and they get meals on wheels.  It would be an ethical violation for me to prescribe and pick up their narcotics.  Of course, not unless something happened.  But in this day and age, who wants to risk their whole life and license?  So as long as I don’t see it, I don’t say it.  No harm, no foul and they are not in writhing pain.

The third and fourth houses are much of the same.  These are the forgotten people.  The invisible ones.  The houses we all drive by, the ones which look almost vacant but not quite.  We wonder who lives there from time to time as we zoom by on our way to work, to run errands, to pick up our kids.  What I wonder is, what do those next door neighbors think?  What do they wonder?  Do they wonder enough to drop by?  To clip the bushes?  To cut the lawn on a regular basis?  Not ask, hoping for a polite turn down, but just get up on a Saturday and just do.  Who brings them food?  Who takes care of them when they outlive their family?  Close friends?

They don’t all go to nursing homes.  Or to live with families.  Or drop dead the moment they have ceased to be able to care for themselves.  No.  They are forgotten.  Forgotten too much, too often.



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