First year as an NP: type-casting??

IsabelK · Mar 20, 2016

Just a question: Why are you so hung up on primary care as the only way you want to work as an NP especially since you are an adult-gero NP? Frankly, I don't see how working in an LTC would hamper your ability to go back to an office eventually if you want. I worked in acute care my first 19 months out, then an office where I did consulting and primary care. Now I work full-time in a LTC and do the day to day primary care/chronic condition management. I also see people on an acute basis. Lots of flexibility about how I structure my day. I could go back to an office...have had a few offers, but why? I make a good salary, can decide on a moment to moment basis who needs me right then, and don't spend hours and hours charting at the end of the day. I see an average of 4 - 6 people per day.

The best part: because I am responsible for taking care of all the chronic and acute conditions that come up in my panel of residents, I've learned a lot about things that I never expected to. They still go out to specialists as needed and there are attendings who see each individual on a 60 day cycle, but on a day to day basis, it's all me. I even found out that diagnosis codes and lab work is a lot of fun.

MegRyanGirl · Mar 21, 2016

I am not sure I would call it "hung up on primary care." :-) I was trained to be a Primary Care NP. I was not trained to be an Acute Care NP nor do I enjoy doing acute care. I want to be in an office practice because I enjoy it. My question was whether it would be a problem getting back into an office practice after doing LTC, which you answered, so I thank you for that. :-)

Personally, I would be bored if I saw only 4-6 patients a day, but the job I am being presented with gives me the freedom to see as many patients as I want, so that should not be an issue.

Trauma Columnist · Mar 21, 2016

I have several friends who see LTC pts and many round on a lot more pts than 4-6 but that may be the norm and expectation in her area.

I think just like any office job, your job is what you make of it to a large extent. However, I agree if there aren't enough pts at your office, then the writing is on the wall that you will need to look elsewhere.

Are you able to relocate?

IsabelK · Mar 22, 2016

Some people do see way more than 4 - 6 people a day but the company I work for has a model that has no more than about 100 residents on a panel because I see them every month. I am not doing acute care. I do primary care or skilled care, but this is not a hospital. I treat the same conditions I treated in primary care the same way I did in primary care. I just get more time. And I'm never bored between rounds, acute issues that crop up, family meetings, and all the paperwork that goes with it.

Trauma Columnist · Mar 22, 2016

Good for you Isabel.

MegRyanGirl · Mar 24, 2016

I was leaning towards taking the LTC NP job after reading these comments, but now I feel a bit differently after shadowing an NP at one of their facilities the other day.

I was taught that NPs are not assistants to MDs and we are not there to be supervised. At least not in the State I practice in. We have to have a collaborative agreement, not supervision, and we can order whatever we want including narcotics as we see fit. But the NP I shadowed at this LTC said we can't just do whatever we see fit. If I want to treat one way and the MD wants to treat another way, we have to go by what the MD says. And that NPs don't own patients. We share them with the primary MDs, and we assist in their care of their patients. So the MD has the ultimate say when it comes to patient care. I am starting to think this might not be the situation I want, since it would not allow me to practice to the full extent that I am trained.

When I was in my previous NP position in an outpatient primary care office, I didn't have to ask for permissions on anything from an MD, nor did I have to check in to make sure that an MD agreed with something. If I saw the patient, I could do whatever I wanted that was reasonable practice. I could ask a question to an MD if I was unsure of something, but no one kept tabs on me. Well, I am sure they did, but no one said anything about how I practiced. But in this LTC, it was explained to me that I have to notify the primary MD what I did or was planning on doing on a daily basis or several times a day. Granted this is just in the beginning until I establish a relationship with the MD. Once the MD trusts me I don't have to update as much, but still the MD has to be made aware of a lot of stuff. So in a sense, I feel like the position I am being offered is just a glorified RN position. Agree? Disagree? What is your LTC setup like? I really wanted this position to be the one but I'm feeling disappointed. :-(

sailornurse · Mar 26, 2016

My friend worked orthopedics for her first NP job then had difficulty when she wanted to return to primary care in family practice, 3 clinics turned her down, one wanted to do a trial period for 2-3 months. She did get hired in the ER. She admits she forgot a lot such as women's health & pediatrics.

IsabelK · Mar 26, 2016

In my job I do let the MDs know when something major has changed, primarily because I need them to sign some paperwork like the DNR/DNI stuff (NYS still isn't letting NPs sign them). Otherwise I do my own thing and rarely have any issues with the attendings. The medical director loves having me there because I don't do any short term rehab, only long term care and the MDs are only in once a week each (sometimes less often). I spend so much time with the LTC folks that I've kept people out of hospitals, improved health status, gotten people off sliding scale insulin, had in-depth care planning conversations with residents and families. I think some of what you're looking at is facility based. In most of the facilities I worked at the NPs all worked independently and rarely had issues with the MDs not liking what they did.

sadiemae1123 · Mar 26, 2016

Before you turn down the job, you might ask to meet with any of the physicians who would be supervising you. If both of you are on the same page in terms of practice standards and management techniques, then the supervision issue might not be as big of a deal as it initially sounds.

I work in a restricted practice state in a psych hospital. When I first started as a new grad,100% of my charts were reviewed weekly for my first 6 months. It felt intrusive at first, but now that we have worked together for a while there is an element of trust that I will bring any questions to him about a treatment.

MegRyanGirl · Mar 27, 2016

I actually met with the Medical Director for the facility they are hiring. There was not enough time to go over practice standards or management techniques, but he expressed some frustration with the facility like the staff nurses not having good assessment skills and getting after hour calls over stupid stuff when it's not nothing urgent. I forgot to mention that the LTC has on call duties as well! :-( He did sound like he wanted me to call or email him at least in the beginning to update him on a daily basis.

My previous job also went over my notes the first 3 months and I did find it a little intrusive but I didn't care so much cause I knew I was new and that they wanted to make sure I wasn't doing anything funny. I would rather have my charts reviewed than having to call/write the MD every day and update him on everything. That's just extra work and annoying.

sadiemae1123 · Mar 27, 2016

It sounds like they're not very good at selling the upsides to working at that facility. I wouldn't discount working at a LTC facility completely, though. Like others have said, you really would be doing a lot of primary care in terms of chronic disease management, referrals, etc. You just need to make sure you find one that's the right fit.

Try to focus on what you want from the job in terms of patient census, types of disease management, support staff, expected workload, administrative duties, autonomy, available resources, and compensation. If you're working someplace where you are well treated, well respected, and well supported then inpatient vs outpatient and acute vs chronic disease management may seem less important.