New NP Blues

[malapata]

Hi everyone, I am a recently graduated NP. I started my first job about 3 months ago at a specialty and primary care outpatient clinic. There are only three providers at the clinic including myself, one of whom is not always at the clinic the days I am. I'm reaching out to the allnurses community because I wanted to vent/express concern or frustration over not having a mentor or someone who is guiding me in my learning as a new practitioner. Our clinic is not extremely busy but when I see primary care patients I feel lost. I use online resources such as Uptodate and other clinical guidelines but it is cumbersome and time consuming. For example, I had a patient come in with possible UTI the other day and I struggled figuring out how to properly rule it out. Luckily, I have a lot of time to spend with these patients but I don't know if I'm learning good practice by having to figure things out on my own without the help of a mentor or seasoned provider. I worry I will create bad habits as a self-learner. I do compile information on a drive that use as a reference but I feel there might be other ways I could be conducting my examination or other secondary diagnoses I could be considering that I don't think of due to my lack of experience and expertise. These are things I feel a good mentor might help to nurture in me...

Has anyone every felt this way as a new NP? What did you do? How did you get through it? Does anyone know of any resources for new grads who are struggling? Any other comments/experiences welcome!! Thanks!

[evolvingrn, BSN, RN]

ok, you get my drift. np education is too lax and not formulated correctly at most institutions.

My program had very high standards ..... In the didactic classes you had to have an 87 percent average on tests only. My program was online and some of the courses required our tests be proctored which I found I scored similarly to the non-proctored tests ( it's hard to cheat with higher level reasoning when it's timed) My first clinic course 10 % did not move on.

[evolvingrn, BSN, RN]

Being a good NP necessitates being autodidactic. Reread physiology and pathology, review assessments, learn what your assessments including labs and rads are actually picking up, and start learning the ins and outs of common complaints. Pick a couple meds for each indication that you like and run with it.

To give you my path in psychiatry, NP training mostly made me an APA expert. So then I had to actually learn enough about physiology, neurobiology, neuroscience (are these distinct fields to anyone else), pharmacology particularly -kinetics and -dynamics, psychopharmacology, psychopathology, memorizing a good chunk of the DSM, and becoming generally better acquainted with neurology (neurocog, PD, HA, Sz.), endocrinology (mostly thy, adren, and DM) and sleep medicine. I do try to be somewhat abreast of primary care mostly because I think all of us should be aware of the interplay of life's sicknesses and injuries with our respective populations.

Some things I still am grossly uninformed about are CT and MRI interpretation, although I never see any images, and EEGs.

I think being a fnp is a whole different ball of wax than most specialties. I have a good handle on patho and guidelines the sheer variety of what we see is what makes it challenging.

Certain conditions get triaged where I work. And I love it because I can prep/ research ahead ..... Sometimes once I talk to them I waaaaay overthought it.

I think it comes with time. Low back pain, depression/ anxiety, IBS, utis, bppv, sinus, Eustachian tube dysfunction, cough, and eczema..... This I am finding is my bread and butter.... Yesterday I had several "multiple repeat" conditions and it was awesome to have my flow.

In the 2 months I have been working I have 40 hours ceu from uptodate [emoji23][emoji23][emoji23]

[PG2018]

lol all those big words they tend to dodge in any nursing curriculum. I talked to one of my friends who is in an online np program. she states they don't have tests.... ever.

They write papers and do discussion posts.

Let me repeat that

they write papers and do discussion posts

one more time

they write papers and do discussion posts

ok, you get my drift. np education is too lax and not formulated correctly at most institutions.

I know. I feel like I got a M.A. in nurse studies. Where is the science in master of science in nursing?

[PG2018]

I think being a fnp is a whole different ball of wax than most specialties. I have a good handle on patho and guidelines the sheer variety of what we see is what makes it challenging.

Certain conditions get triaged where I work. And I love it because I can prep/ research ahead ..... Sometimes once I talk to them I waaaaay overthought it.

I think it comes with time. Low back pain, depression/ anxiety, IBS, utis, bppv, sinus, Eustachian tube dysfunction, cough, and eczema..... This I am finding is my bread and butter.... Yesterday I had several "multiple repeat" conditions and it was awesome to have my flow.

In the 2 months I have been working I have 40 hours ceu from uptodate [emoji23][emoji23][emoji23]

I'm not so sure it's really that different. If anything, you're done more disservice than the rest of it. But you're right, you get probably 25 different complaints in your field to "know." Anything you can't workup you can refer out, lol.

Me, for example, I could skate by in psych. Plenty of NPs and physicians do. There really is no organ system to master so one can work somewhat effectively off matching meds to DSM diagnoses. I'm not that guy and strive for parity. If the material was at some point presented to a psychiatrist in either medical school or reaidency, I'm eventually going to cover it on my own sans surg, OB, and gynecology which I care nothing about. I guess I need to get someone to donate their body to me and keep in a freezer so I can dissect it in my downtime.

[malapata]

Thanks, sauce! That is good advice.

[malapata]

Sadly we have no protocol book and I get no feedback from anyone. I really wish I had either one of those things or both. The physician who practices with us is so busy that it's really hard to sit down with him. When I do get the chance I feel very rushed (not that he is rude or mean, he is very nice).

[Penguins10, MSN, RN, NP]

I think that your experiences are not unusual as a new grad in a primary care setting. The fact that you are concerned is healthy. Your use of appropriate resources and seeking advice show good insight and desire to learn that will serve you well. Good for you!

It sounds like you were done a disservice by your program, which is apparently common. Your employer doesn't seem to have done a tremendous job with orientation either, which is also pretty common. Primary care is tough because it's you and your patient in a room and everyone else is usually in a hurry. I recently switched to outpatient primary care and I am finding it a bit isolating compared to my previous IM/nephrology job where I got a lot more cross-talk with other providers.

Depending on your co-workers and the work culture you could see if someone would be willing to do 30 minutes of didactic time or talk through some cases with you each week. As someone else mentioned it seems like you should be getting some supervision/feedback from somewhere in the first few months at least.

In terms of day to day patient care always ask "is this something dangerous?" This is a difficult question, because not everything that's dangerous is obvious and you won't know about somethings that are dangerous, making them hard to recognize. Nevertheless, it's a good place to start. Look at the patient, do they look ill (like need to be admitted ill). Look at vital signs, are they abnormal? If they are you need to figure out why (which may just mean asking, "is your BP always in the 90s? Oh, it is, and you feel fine and take no medications that are causing that, great."). Be wary of anything that is new or old, but getting worse.

I agree with everyone else that self-learning is normal and effective. At this point I have diagnosed a number of things that I had only read about until they turned up in front of me.

Be wary of drug interactions, renal/hepatic/geriatric/pediatric dose adjustments are all easy to overlook. Look up everything you are prescribing at the time you are prescribing it. You'll feel better and you'll learn a lot. Uptodate has good articles on adverse effects for a lot of med classes (it's a downer to start your patient with epilepsy on ciprofloxacin, buproprion, and tramadol all on the same day, and those kind of disease specific problems are endless and impossible to know right away). You don't have to know everything about all medications, just focus on the ones you are using regularly (and look up anything you don't use regularly, that's another high risk situation).

Give patients clear instructions about what you expect to happen and what they should do if it doesn't. "I think you have a sore throat due to a strep infection. I expect that you should start to improve over the next 48 hours. If you do not get better call me so we can think about this some more. I don't think any of this will happen but if you have voice changes, difficulty swallowing, neck or tongue swelling, or problems breathing then you need to go to the emergency department."

There are lots of great resources out there. Pick one or two and get very familiar with them rather than collecting tons that you never get around to reading.

Picking something symptom based is a good move I think. I find I learn best by starting with a chief complaint, learning the differential, then learning managment/patho etc for those conditions over time.

Pocket Primary Care (Kiefer and Chong ed) is fairly comprehensive, yet focused, and will give you a framework for what needs to happen with a particular complaint. The format takes a little getting used to, but I find it very usable.

Symptom to Diagnosis (Stern and Cifu) provides good coverage of how to approach diagnosis of common adult problems. There is less detail about management, but they are really helpful in framing how to think about different problems and how to organize your differential.

The Common Symptom Guide is older, but has a chief complaint focused format and helps you think through key questions at various levels (hx, pe, meds, fhx) to help narrow your differential.

Diagnosis is hard, there are a lot of ways to screw up. Knowing what some of them are is useful (at least I hope it is). Patrick Crosskerry's "The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them" is a nice, readable introduction.

Primary Care Rap is a great CME podcast (EMRAP is another product of their's, it's emergency medicine focused, but a lot of that information is transferable to primary care I found when I subscribed). It's a bit pricey, but not terrible.

EMBasic is a free podcast for emergency medicine learners, but again, he takes a given chief complaint and givens you a framework for thinking about it. I think I work with a similar patient population to yours and I have folks come in with stuff that really should have gone to the ED (PE, late STEMI, extensive cellulitis) so it's important to be aware of the dangerous ddx items, even if you only address them via hx and pe, that's often fine, but you have to think about them in order to diagnose them.

Louisville Lectures posts IM residency education on a broad range of topics. It's free and overall the quality is very good.

There are a lot of other good podcasts and resources out there. Google Free Open Access Medical Education.

Sorry, that got really long. Your experience sounds like normal stuff (which is unfortunate, but not your fault). Try to find someone locally to work with you, keep looking stuff up, find some additional resources. Try to give yourself space to be new. In a few more months you will likely be surprised by how much progress you've made. Good luck!

[malapata]

Penguins10, wow thank you for all of the advice and encouragement! It means so much to me! I will definitely look into the resources you mentioned. THANK YOU!

[malapata]

Does anyone out there have a lab interpretation book or other resource they really like?