[DaisyRN, ACNP]

Okay,
So... "only time can tell," right??

Well... "time" has brought me to a frustrating point in my new job. The things that I am frustrated about are things that I could not have really been warned about because no one has ever been in this position with my doc. Also, as a new NP you don't know to think about some of these things... so hopefully, these considerations will help you newbies in your quest for jobs.

For fun, we will refer to my supervising MD as "GD"...

Some background info:
a) After graduating in December, I started work for a cardiology clinic of 9 MDs (And I was the first MLP)
b) We use an EMR system for documentation AND billing
c) We just merged with a large corporation
d) I was hired primarily for a rural office with GD as the only MD that comes to that office, but it was understood (and in my contract) that I was hired for the WHOLE clinic/group of MDs
e) GD works at both the rural and not-as-rural offices, more so at the rural one... and then has patients/procedures at 3 area hospitals
f) There is another NP working for ONE cardiologist, strictly in the office setting (her preference)
g) GD has no spouse, sleeps on our office couch, and is a self-martyr
h) The medical director of the group was a clinical preceptor during school and LOVES me. I know that he will support any change I need and any problem I have.
i) GD is excellent at what she does, is a huge patient advocate, and puts her patients above all. And I mean... "ALL..." to the point that I think she uses her "patient involvement" as a crutch.

My frustration:
1. GD would rather see patients than do her documentation/BILLING
a. GD gripes about not making much money last year or having a life but she is a self-martyr and I made too many sacrifices in school to be making work-related sacrifices now
b. She pressed for our offices to get the EMR system and she does not utilize it. Instead, she just prints out a med list... jots down a few notes... and throws it in a folder for me to STRESS OUT over when I see the patient in a follow-up visit, when a PCP calls for consultation report, surgical clearance, etc. BECAUSE SHE didn't document in the EMR - she's a COMPUTER NERD! It's not a "speed" issue. All of the other doctors in the group are older than her, much less computer savvy and still manage to document and bill EACH patient AS THEY ARE SEEN. SHE HAS office visits and electronic notes incomplete since 2005!!!! Most are within the last 8-16 months, but still!! This is where her lost revenue is... stocked up in her office! She knows she needs to do the notes, but has been saying she needs to do them for MONTHS and hasn't done it. I am NOT about to do her documentation from God-knows when. No other self-respecting MLP would. Right??

2. GD was not ready for a mid-level provider
a. She swears that she knows better than anyone else the role of a midlevel... but she doesnt. During the mornings, while she's doing procedures (and I have been waiting on hospital privileges), I answer phone calls and handle "nursing duties." BULLCRAP. I should be seeing follow-ups, at least!
b. She will not "let go" of her patients... she says they are possessive of her... WRONGO! She is possessive of them!!
c. The documentation thing... someone cannot... in their right mind follow behind her and see patients. It ****** me off daily when I try to pull up a note to see what was done at the last visit and show nothing documented for >1 yr.
d. Her schedule... she does procedures in the morning 30 min away from our rural office and schedules patients 15 min apart starting at 1:00 thru 5:30-5:45. She's generally late, slow about seeing patients, doesnt document well, talks too much (inappropriately so), allows herself to get distracted (pulled out of the room, answering her cell for hospital calls), and doesn't see this as a problem. If she does, she may make a comment about "oh, I'm tired of staying late" or whatever... but doesn't EVER do anything about it. And we're stuck there until 7-8:00 pm... ROUTINELY! The office opens at 9.
e. Instead of being supportive and not worrying about me being a "competitor" she thinks that if I document better billing than her, it makes her look bad (DUH!!)
f. I am trying to build good habits and it is very difficult with her negative, poor-me, self-martyrdom, and "I don't give a crap about the rules" attitude
g. Plus, she has upset a lot of the community PCPs (that govern the local hospital) because she isolates herself

3. I feel like the "rural" office and GD are holding me back from full potential
a. The rural office does not have nuclear testing, our own lab, or other ancillary services that I can readily get reimbursed for. The other NP functioning in other office billed for $32K in Feb alone and will get $10K of that as salary/incentives. I should have the same opportunities.
b. GD can make up for this loss with her procedures and duties in the other office, where as I cannot. But, she gets a larger percentage of the bonuses I am eligible for... so you'd expect her to be more supportive. Right?
(BONUS STRUCTURE EXAMPLE: NP billed for $32K in Feb. Take out minimal overhead and NP monthly salary... what's left over is divvied up 70/30 at the end of the quarter. MD takes 70, NP take 30. Longer NP with larger corporation, bigger NP percentage becomes and smaller MD percentage.) I was told by the CEO himself that within the second 6 months of being there, my salary would become "meaningless." WOOHOO!
c. GD is concerned about me making her look bad if my documentation and billing practices are better than hers
d. Over the next couple of weeks, I will be spending time with the other NP and other partners in the group (which by the way, GD is NOT a partner), and GD did not think that I should do that. She wants to control me all by herself.
e. When I met with the CEO about my contract, she was upset because I did not ASK HER PERMISSION to go talk with him (she didn't tell me... she told the office mgr who told me). I think she was worried about what I was going to tell him!! In this meeting, by the way... I told him that I was getting to a point of utter frustration where I wanted to leave if it didn't improve. And I love what I am doing... but she's gotta improve for me to stay!

OKAY... so, there are probably more bits and pieces of the story... but I'm tired of thinking about it. I just don't think it was fair for a new NP to be put in such a pile of crap... however, I can't really blame anyone because nobody knew it was so bad. I don't know how to help her. I don't have the experience and I don't think it should be MY responsibility to "change" her... because I don't know that she will ever change. I just want to go to work... and be done... and come home. I know that healthcare is a 24/7 business, but my family has to come first. Then work.

I feel stuck. There are not many NP positions, let alone ACNP positions around this area... but there is enough need in the entire group for me to keep a job. I just don't think my current position is right for me. At least not right now.

[emtneel]

Daisy, I'm sooo sorry you are going through that crap. But try not to let her intimidate you or turn you into a bad NP with bad practices. (bad charting, etc..)
I would just say "I am protecting my license and lawsuits" if she comments again.
And r/t the nursing duties, shoot if you have a salary and they want to waste their money having you do nursing duties.. then.. easy money...
I read somewhere on here, maybe from David Carpenter? that your first job is just that, your first job, and if after 1 year they aren't treating you right, not giving you what you are worth you can say okay bye, thanks for the training.

Nobody can tell you what to do, but I hope it gets better for you!

How long have you been working? I graduated in Dec. too, and still trying to find a job.. (actually might end up moving to Texas, saw that's where you are from)

Definitely doesn't sound like someplace to stay forever...

Neelia

[traumaRUs]

Hi Daisy -I've followed your posts for awhile now. I remember how happy you were with this practice. However, I agree that you some change in order for you to be happy. I work in a large (15 MD, 5 mid-level) nephrology practice. I am fortunate in that they have had MLPs (both PAs and NPs) for 8 years now. However, I personally like to work with some MDs versus some others. Here are some suggestions:

1. If you think this is salvageable with this MD, ask for a sit-down meeting with a mediator and be honest, non-accusatory and very blunt about what you need in order to make this workable.

2. Ask for expanded duties with other MDs in the practice in order for you to stay busy but also to expand their knowledge of you. You might find an MD that you would like to work with more.

3. Is there anything in your contract that says you are assigned to a specific MD? I work for the entire practice but have my own duties and interact with many of the MDs.

4. As to doing nursing duties, in the beginning of your career this is not a good thing. If you are not keeping busy with APN duties, they might rethink their needs of you.

5. Do you have a networking organization in your area for MLPs? In IL we have the IL Society of APNs which has frequent networking opportunities. It is always nice to find out what other practices are doing.

6. I would also point out to your physician that you are on the same team - if you look good, so does she.

7. In the end, if after a year the situation doesn't get better, start looking for another position.

Daisy - I'm sorry that you are so frustrated with this. I feel your pain. It was very hard for me to let go of the RN mentality and think like an APN. I am normally pretty assertive but find some of my work-related angst difficult at best. Keep at it - it does get better.

[core0]

I'll post more a little later. However, a couple of points:
1. You stated that the Medical director likes you but they put you in a very untenable situation. It may be that they were hoping that having an efficent NP that documents well and actually bills would show her how they want to practice. While I understand the concept, I will tell you that this rarely works. Generally the physicians that you describe are this way for a reason.
2. They may be putting you in the office with the intention of firing the physician later and having you take the patient load. While this may work, in a specialty office you have to be concerned about how this looks to your referring physicians.

Overall its a tough situation. I would frame any issues not in terms of utilization or even pay, but in terms of training or understanding the medical practice there. Suggest rotating with other physicians. Especially in the hospital. Depending on your hospital you can see the patients with the physician as long as you don't write notes and orders. Maybe you can use your morning as a learning experience.

Good luck

David Carpenter, PA-C

[dhigbee]

Wow, Daisy, sounds really frustrating. The only thing I could add to the excellent points made here, is that I don't think you're going to be able to change GD. She is practicing the way she is because she wants to practice that way. With you as the newbie, you're pretty much stuck with working around her, and getting the best experience you can, considering the circumstances. I expect that could sound discouraging, but at least it takes away any stress you might feel to "fix" her. I also don't think that management expects you to solve all her practice problems.

I wouldn't stick with this job forever, unless circumstances change. Get the experience, and then get something better.

Dana

[core0]

Originally Posted by DaisyRN

Okay,
So... "only time can tell," right??

Well... "time" has brought me to a frustrating point in my new job. The things that I am frustrated about are things that I could not have really been warned about because no one has ever been in this position with my doc. Also, as a new NP you don't know to think about some of these things... so hopefully, these considerations will help you newbies in your quest for jobs.

For fun, we will refer to my supervising MD as "GD"...

Some background info:
a) After graduating in December, I started work for a cardiology clinic of 9 MDs (And I was the first MLP)
b) We use an EMR system for documentation AND billing
c) We just merged with a large corporation
d) I was hired primarily for a rural office with GD as the only MD that comes to that office, but it was understood (and in my contract) that I was hired for the WHOLE clinic/group of MDs
e) GD works at both the rural and not-as-rural offices, more so at the rural one... and then has patients/procedures at 3 area hospitals
f) There is another NP working for ONE cardiologist, strictly in the office setting (her preference)
g) GD has no spouse, sleeps on our office couch, and is a self-martyr
h) The medical director of the group was a clinical preceptor during school and LOVES me. I know that he will support any change I need and any problem I have.
i) GD is excellent at what she does, is a huge patient advocate, and puts her patients above all. And I mean... "ALL..." to the point that I think she uses her "patient involvement" as a crutch.

My frustration:
1. GD would rather see patients than do her documentation/BILLING
a. GD gripes about not making much money last year or having a life but she is a self-martyr and I made too many sacrifices in school to be making work-related sacrifices now
b. She pressed for our offices to get the EMR system and she does not utilize it. Instead, she just prints out a med list... jots down a few notes... and throws it in a folder for me to STRESS OUT over when I see the patient in a follow-up visit, when a PCP calls for consultation report, surgical clearance, etc. BECAUSE SHE didn't document in the EMR - she's a COMPUTER NERD! It's not a "speed" issue. All of the other doctors in the group are older than her, much less computer savvy and still manage to document and bill EACH patient AS THEY ARE SEEN. SHE HAS office visits and electronic notes incomplete since 2005!!!! Most are within the last 8-16 months, but still!! This is where her lost revenue is... stocked up in her office! She knows she needs to do the notes, but has been saying she needs to do them for MONTHS and hasn't done it. I am NOT about to do her documentation from God-knows when. No other self-respecting MLP would. Right??

I think that you need to separate this out. There are really two issues here. One that impacts you and one that only peripherally impacts you. The billing issue is not really your problem. If she is not a partner I am surprised that the practice has let it fester for so long. That represents lost money to them not to you. Let them figure that one out. The documentation is a bigger problem. It is a patient care issue and a liability issue. If you do not have good notes to work on then you are putting your license in danger. If you think that its wise then try confronting her. Otherwise work it up the chain of command.

2. GD was not ready for a mid-level provider
a. She swears that she knows better than anyone else the role of a midlevel... but she doesnt. During the mornings, while she's doing procedures (and I have been waiting on hospital privileges), I answer phone calls and handle "nursing duties." BULLCRAP. I should be seeing follow-ups, at least!
b. She will not "let go" of her patients... she says they are possessive of her... WRONGO! She is possessive of them!!
c. The documentation thing... someone cannot... in their right mind follow behind her and see patients. It ****** me off daily when I try to pull up a note to see what was done at the last visit and show nothing documented for >1 yr.
d. Her schedule... she does procedures in the morning 30 min away from our rural office and schedules patients 15 min apart starting at 1:00 thru 5:30-5:45. She's generally late, slow about seeing patients, doesnt document well, talks too much (inappropriately so), allows herself to get distracted (pulled out of the room, answering her cell for hospital calls), and doesn't see this as a problem. If she does, she may make a comment about "oh, I'm tired of staying late" or whatever... but doesn't EVER do anything about it. And we're stuck there until 7-8:00 pm... ROUTINELY! The office opens at 9.
e. Instead of being supportive and not worrying about me being a "competitor" she thinks that if I document better billing than her, it makes her look bad (DUH!!)
f. I am trying to build good habits and it is very difficult with her negative, poor-me, self-martyrdom, and "I don't give a crap about the rules" attitude
g. Plus, she has upset a lot of the community PCPs (that govern the local hospital) because she isolates herself

You seem to have identified the problem. The real issue is that GD is not only not ready (or will ever be ready for an NPP) but isn't really cut out to be in a multi physician practice. You have identified several warning signs. They are unlikely to get better.

3. I feel like the "rural" office and GD are holding me back from full potential
a. The rural office does not have nuclear testing, our own lab, or other ancillary services that I can readily get reimbursed for. The other NP functioning in other office billed for $32K in Feb alone and will get $10K of that as salary/incentives. I should have the same opportunities.
b. GD can make up for this loss with her procedures and duties in the other office, where as I cannot. But, she gets a larger percentage of the bonuses I am eligible for... so you'd expect her to be more supportive. Right?
(BONUS STRUCTURE EXAMPLE: NP billed for $32K in Feb. Take out minimal overhead and NP monthly salary... what's left over is divvied up 70/30 at the end of the quarter. MD takes 70, NP take 30. Longer NP with larger corporation, bigger NP percentage becomes and smaller MD percentage.) I was told by the CEO himself that within the second 6 months of being there, my salary would become "meaningless." WOOHOO!
c. GD is concerned about me making her look bad if my documentation and billing practices are better than hers
d. Over the next couple of weeks, I will be spending time with the other NP and other partners in the group (which by the way, GD is NOT a partner), and GD did not think that I should do that. She wants to control me all by herself.
e. When I met with the CEO about my contract, she was upset because I did not ASK HER PERMISSION to go talk with him (she didn't tell me... she told the office mgr who told me). I think she was worried about what I was going to tell him!! In this meeting, by the way... I told him that I was getting to a point of utter frustration where I wanted to leave if it didn't improve. And I love what I am doing... but she's gotta improve for me to stay!

OKAY... so, there are probably more bits and pieces of the story... but I'm tired of thinking about it. I just don't think it was fair for a new NP to be put in such a pile of crap... however, I can't really blame anyone because nobody knew it was so bad. I don't know how to help her. I don't have the experience and I don't think it should be MY responsibility to "change" her... because I don't know that she will ever change. I just want to go to work... and be done... and come home. I know that healthcare is a 24/7 business, but my family has to come first. Then work.

I feel stuck. There are not many NP positions, let alone ACNP positions around this area... but there is enough need in the entire group for me to keep a job. I just don't think my current position is right for me. At least not right now.

I think that you have analyzed it admirably. However, there is an analysis peace that is missing. Why did you end up in the situation that you are in. This also points to a basic failing in the company at upper management level. The first failing is to continue to employ a non-partner with these work habits. The second is to put you in the position. Either they didn't understand what the situation was, didn't understand the situation that they were putting you in, or did understand and are have some other motivation. Any of these choices shows bad management decision making.

I think that you definitely need to talk to management and get some straight answers.

I would also worry less about money (as long as the base salary is OK) and more about developing your skills. To be really honest the type of numbers that you are talking about are simply not sustainable for most practices. In the case of one NPP they generally get hidden in the clutter of the general practice expenses. However, once that number gets multiplied the amount gets to be noticeable. For a PA the numbers that you are taking about would be in the top 1-2% of cardiology PAs. Those PAs are generally working more than 70 hours per week.

In my mind the biggest problem is that the company turned you loose without formal education plan with a physician that doesn't seem too interested in education. My advice would be to insist on a formal education (and collaboration) plan that would detail the pace at which you take up this process.

At my previous practice they had bad luck several years ago when they hired a PA. We worked together to develop a plan. The first part was to follow all of the physicians for several days and see how they did things. The second part was to develop a list of presenting symptoms that they and I were comfortable with me seeing. The CEO listed the top 20 presenting symptoms and we developed a list. For GI, we started with well patient screening visits and rectal bleed. Those were the only conditions that could be put on my schedule. Every month or so we re-evaluated and added more conditions. Despite the schedulers best efforts some slipped through so the CRC screen really was dysphagia. This gave me more experience when I added conditions. By the end of six months I was seeing 90% of their top 20 conditions. By the end of the first year, I was seeing whatever walked in the office. We were both very pleased with the stepwise approach and used it as a template for the next 3 PAs that were hired. I'm not sure how well that would work for Cardiology but I would suggest a similar sort of approach.

The other thing with that particular practice is that the physicians liked to teach. We would meet each month with one of the physicians and go over a particular area of medicine (either symptoms or disease processes). This was very helpful not only in understanding the symptom or disease but also how the physicians think about the disease process.

Working in a specialty practice you can develop your own practice style in the clinic. This is the advantage of working with multiple physicians. You can pick and choose the best of multiple practice styles. The hospital tends to be a little different and requires the NPP to develop a very plastic practice style. You essentially have to anticipate what the physician would do and do the same thing. It requires a close working relationship with the physician but also an understanding of their internal dynamics.

In my opinion the reason that practices and NPPs fail each other is:
1. Failure to communicate
2. Different/Unrealistic expectations
3. Inability of the practice to allow the NPP to flourish.

Sounds like you have all three. Time to fix it.

Good Luck

David Carpenter, PA-C

[traumaRUs]

David you bring up a very valid point. When I joined this nephrology practice, I had a very set schedule of didactic classes taught by various MDs in the practice. I also had some observational time at each hospital with one of the MDs as well as time in surgery with one of our surgeons. My entire orientation was approx 4 months. It was only at this point that I was seeing patients on my own.

[DaisyRN, ACNP]

Neelia,
Thanks for your comments. It is just all together a bad situation... yesterday, she went to my "supporter" the Medical Director to complain that I am too slow because "I INSIST ON DOCUMENTING EACH PATIENT AS I SEE THEM." Can you say self-incriminating????????

The Medical Director about fell out (from the office supervisor's report)! He told the office super that I am doing "EXACTLY WHAT I AM SUPPOSE TO DO." The super informed him of GD's means of "documentation" and he got very red faced, leaned back in his chair, and was speechless (aka ticked.)

As for the nursing duties... I see your point, but as a new NP... I want to be building on my skills and have already lost a great deal of my confidence from the time I was finishing my last clinical rotation with the medical director to now. What I have heard and now appreciate is that you have to be ONE or THE OTHER. The transition from RN to NP is difficult anyway, but when you are put in a situation where you are held back from successful transition... it makes it seemingly impossible.

And I have been working for this group for 3 months now! I should have already gone through this "learning phase" with all the other partners, etc. The medical director said that he views me as just getting started, since I have truly only been certified 1 month. That, I feel, is 1 month lost. I guess later is better than never.

Originally Posted by emtneel

Daisy, I'm sooo sorry you are going through that crap. But try not to let her intimidate you or turn you into a bad NP with bad practices. (bad charting, etc..)
I would just say "I am protecting my license and lawsuits" if she comments again.
And r/t the nursing duties, shoot if you have a salary and they want to waste their money having you do nursing duties.. then.. easy money...
I read somewhere on here, maybe from David Carpenter? that your first job is just that, your first job, and if after 1 year they aren't treating you right, not giving you what you are worth you can say okay bye, thanks for the training.

Nobody can tell you what to do, but I hope it gets better for you!

How long have you been working? I graduated in Dec. too, and still trying to find a job.. (actually might end up moving to Texas, saw that's where you are from)

Definitely doesn't sound like someplace to stay forever...

Neelia

[DaisyRN, ACNP]

Originally Posted by traumaRUs

Hi Daisy -I've followed your posts for awhile now. I remember how happy you were with this practice. However, I agree that you some change in order for you to be happy. I work in a large (15 MD, 5 mid-level) nephrology practice. I am fortunate in that they have had MLPs (both PAs and NPs) for 8 years now. However, I personally like to work with some MDs versus some others. Here are some suggestions:

1. If you think this is salvageable with this MD, ask for a sit-down meeting with a mediator and be honest, non-accusatory and very blunt about what you need in order to make this workable.


This is not a bad idea... and the key word is "mediator." GD has made herself unapproachable. I feel like I am constantly walking on eggshells with this woman. To me, as my supervising physician, she should be setting a better example... not only with regards for her clinical practice/organization, but also her communication with me. I constantly feel like I am pulling teeth to get her to answer my questions.



2. Ask for expanded duties with other MDs in the practice in order for you to stay busy but also to expand their knowledge of you. You might find an MD that you would like to work with more.


I have done this and it was a HIT! The office supervisor and medical director and CEO feel this is a great idea... and I am still doing this. HOWEVER... GD does NOT approve. She has told the office super that she "questions my loyalty to the rural clinic." Bah. Humbug. I've never put myself first in hardly any situation, but I don't feel like I have a choice here... Business is business and I have got to do what's best for me, my career, and my family. Why doesn't she get this?


3. Is there anything in your contract that says you are assigned to a specific MD? I work for the entire practice but have my own duties and interact with many of the MDs.


NO! THANK GOD! My contract is currently being reworked since the merger and on the draft I have, there are all 9 MDs listed as supervising MDs. I'm very thankful for that because of this very situation I am in!


4. As to doing nursing duties, in the beginning of your career this is not a good thing. If you are not keeping busy with APN duties, they might rethink their needs of you.


You bring up a very valid point! When I met with the CEO, he incenuated this... and I assured him, I was doing MY best to be a NP, but it is a constant struggle between what SHE wants me to do and what I know that I NEED to do.


5. Do you have a networking organization in your area for MLPs? In IL we have the IL Society of APNs which has frequent networking opportunities. It is always nice to find out what other practices are doing.


Yes we have a local organization actually... and the other cardiology NP is actually the president. I have been talking with her and her response is, "You need to get out of there."


6. I would also point out to your physician that you are on the same team - if you look good, so does she.


Good idea... I have tried to express this to her, but she still perceives me as "trying to look BETTER than her."


7. In the end, if after a year the situation doesn't get better, start looking for another position.

Daisy - I'm sorry that you are so frustrated with this. I feel your pain. It was very hard for me to let go of the RN mentality and think like an APN. I am normally pretty assertive but find some of my work-related angst difficult at best. Keep at it - it does get better.

Well, read my response to Neelia here... I'm trying to change gears, but I feel like I'm up against a really hard wall and struggling to break through it. I truly want to succeed. I am driven, motivated, and eager to carry out my role...

I've got to get to work (I am with the other cardio NP today), but I will respond to the others later. I do appreciate all of your comments and suggestions... I never expected things to be this bad. And I don't think anyone did.

Just a brief comment to David... the partners were not aware of the situation because GD isolated herself from them and would NOT allow them to help her. From the supervisor: the partners do not like conflict and didn't want to mess with her because she was not really negatively affecting their practice (that they saw), except when she wouldn't read echos or document her device procedures on their patients. And the two office admins wanted to handle GD's situation and become more involved in the rural office, but none of the partners would back them because they didn't have the influence?? to make the change. But now that we are with the larger corporation, the CEO made it very clear that anyone who gives his company a bad name, or doesn't do their job will be OUT. He is not going to take her crap... so it may be that at the end of my 30 days to see if it gets better, she may not be around anyway. (Can't remember if I told ya'll this or not... The CEO asked me to give him 30 days to see if things improve. If not, I will be doing something else for the group. And I know that he and the medical director have already been discussing my role with the group and its potential changes.)



Thanks again! Pray that my tummy aches go away soon!! *haha*

[emtneel]

Daisy,

Sorry, i guess you can't really read sarcasm online--> re the nursing duties!
(I interviewed at one job, at a GREAT children's hospital in ft.worth, i REALLY liked the person who interviewed me, as well as the people who worked there, they even let me go in with a patient and see how things work,... but the job itself.. I just really don't know why they even need NPs for. It was pre-op screening/H&Ps.. no dx,tx,management, only write for a few pain meds for pre-op).. I would really like to work there, but don't think it would be challenging, and also seemed more "nursing" duties.. one thing that bothered me was that the interviewer said the Doc's/Anesthiologist had been seeing the mid-levels as "nurse-extenders" and they were trying to change that role to be "physician extenders"
I personally don't like either one of those terms (I'm not all gung-ho about independent practice either) In ACNP you might be more of a physician extender, but in private practice often the NPs and MDs each have their own set of pts. okay..

anyways, I hope things work out for you (we just need to survive the 1st year right??)
I pray that maybe they will figure out a different place for you, and you won't have to deal with GD anymore.
keep us updated!!
Neelia