I am submitting this post as a means to get some things off my chest, as well as simultaneously get some insight and advice from other NPs in primary care.
I am currently 18 months in to my 24 month contract at my first primary care NP job. I graduated with my FNP degree in the fall of 2021, passed boards in the Spring of 2022, and began my current contract in June of 2022. I have been a nurse for 13 years and prior to my current job, I worked as an RN in various ICU/PCU settings, mostly cardiology.
The clinic is a small, privately owned practice owned by 2 MDs and one pharmacist. The pharmacist being the main owner/manager. The company consists of 3 clinics, all of which have a pharmacy attached. I float between 2 of the 3 clinics. In addition to seeing patients of all ages for their primary care needs, we also see patients for urgent care needs. This happens, because the clinics are WALK-IN only. I do not have my own panel of patients. If I see a patient and request that they follow up, they don't make an appointment for that, they just come back in the requested timeframe and see whoever is working that day. This in and of itself causes a lot of issues, but it's the least of my worries.
There are several rules, or "policies" that the pharmacist owner upholds that I do not agree with (including the walk-in model for primary care pts). He will not take anyone's clinical knowledge, critical thinking, education, or experience into consideration when discussing these rules.
One rule is that all patients have a urine dipstick done for every visit, does not matter why they are there. Then, if there are any abnormalities on this UA (despite the patient's subjective complaints/symptoms, chronic conditions or lack therof), a urine PCR is sent to the lab, and this order is submitted by a medical assistant with the supervising physican's signature. This leads to some patients getting treated for asymptomatic bacteriuria (which is very rarely indicated) by some of the other providers that I work with. While the order does not have my name on it, the clinical note, which does have my name and signature on it, shows "urine pcr" in the plan.
Another rule is that we are not allowed, under any circumstance, to prescribed medications for more that 90 days. Not allowed to give any refills, doesn't matter what the medication is, what it's for, how stable the patient is, how well tolerated the medication is, or how long the patient has been on the medication. He wants them coming in for a visit with the provider every 3 months no matter what. I will get a text from him if I give a refill past the 90 days telling me that I am not allowed to do that. This leads to many patients running out of medications, having very high BP or poorly controlled HLD and returning when they're able, usually well past the 3 month mark. I realize that this is appropriate in certain situations, but not EVERY medication needs follow up every 3 months.
Something else that goes on is that there are 2 ultrasound techs, who work for an outside company, that hang out in the clinic throughout the day. They will wait for patients to arrive, look at their charts and their chief complaint, pluck them from the waiting room, and perform different ultrasound tests on them without a proper provider's order or real indication. I've had to interpret echocardiograms, abdominal US, thyroid US for patients who were told "this is what we do on all the patients." There is never a realistic indication for doing the test. They also call patients from home and tell them to come in for these tests. This leaves the patient's scared and confused. When I asked my bosses, why this was being done, they stated, "this helps keep food on the table for the ultrasound technicians." In my opinion, this is insurance fraud....
Patients also have to return to the clinic for a full visit with the provider in order to get blood test's interpreted and addressed, we are not allowed to call them and tell them anything over the phone, even if it's something harmful or dangerous such as an STD. Granted, most of the time I do not have the resources or time to check results (don't have an inbox) or call because of the walk-in model. I see a very large volume of patients over time, and a lot of patients each day (30-35 pts per day). But sometimes I come across something concerning, I am not allowed to call and inform them of their results or the plan moving forward.
I realize that the reasons for all of these "polices" is for business or financial reasons, but I guess this is what upsets me the most. I was taught to be a COST-EFFECTIVE provider, which I take very seriously. Performing unnecessary tests is NOT cost-effective. The population we serve are uninsured, or on medicare/medicaid, many are non-english speaking patients with low income/education levels and limited transportation. I went into this field to help these people, but don't feel I can do this in my current position.
I am wondering if anyone else has experienced anything similar with management. I feel stuck, because my contract doesn't end for 6 more months, but I also feel like my license could be at risk. When I've voiced that specific concern to my bosses, they say that they will cover the costs of any court cases or lawsuits, if it happens. I am shocked an appalled by this answer. My contract requires that I pay back A LOT of money if I break it prior to the 2 year mark. I feel very burnt out and not even 2 years into this role. I really do love what I'm doing, but feel as though I can not practice to the best of my ability in my current situation. IF any one can relate or has any advice or insight, I would greatly appreciate it. Also wondering if these things are standard in similar clinics.
Thank you for reading my extremely long-winded post.
