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of Nurse Practitioners (2017) states, “Senate Bill 717 and House Bill 765 would end this costly, arbitrary and outdated mandate and make Pennsylvania a full practice authority state.”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.

 

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.