Hitting a wall, I hope it gets better fast

  1. I've been an NP for 1.5 years, but I've only been seeing patients at my new job for about 5 months, I work mon-fri seeing Rheumatology and Arthritis patients, and on the weekends I work ER/Fast track, I'm seeing a good number of patients and charting w/o worry in the ER, however, I'm struggling in my clinic during the week, and week before last, I hit a wall, angry, exhausted, tired, sleepy, nauseated.

    I was/am getting overwhelmed, I opened my own clinic (within our facility) seeing patients on my own in March of this year, after a few months training with some of the Rheumatologists for a few months prior to that, and initially I was doing ok, seeing mostly knee/shoulder pain w/lots of steroid injections, as our office had a contract Rheumatologist with over 40yr experience seeing all of the harder Rheumatology patients, she abruptly left the office and I have been seeing her patients now as well as seeing new Rheum consults all with very little Rheumatology training or back up and it's taking a toll on me, as I'm spending hours reading/charting and trying to figure out what the patients correct diagnosis is, and if you've worked Rheum, the difference between diagnosis is minute, I've been studying/charting until 10pm at night and I'm getting to be angry and grumpy, exhausted.

    Luckily, this past week, I've been back to mostly injections, gout treatment, fibromyalgia, etc, easy stuff, so I"m out on time, but I'm still quick to anger now, kinda punchy, I dunno, it's a mixture of fatigue and self doubt coupled with a little resentment, I suppose, I've received a tiny fraction of the training that the Rheumatologists receive and I make less than most of the RN's that I work with (VHA system).

    The Rheumatologist Fellows are MD's, graduated medical school, residency, etc, and they get 3 full years of Rheumatology Fellowship with an Attending that staffs with them on each patient and aren't out on their own until the 3 years are up, they train in the main hospital branch.

    I'm down at the satellite branch and I got 3 months of how to do injections, with a little on the fly Rheum training and I'm seeing patients on my own, with very little help when I have questions, and it's just a little overwhelming, a great opportunity to sink or swim, but I spend hours reviewing everything, with the hopes that I'm not missing too much, but week before last week, I just couldn't go any further and honestly if last week had been like the previous 4 weeks of nothing but new consults to the Rheumatology service, I don't think I would have made it to the end of the week, I'm trying to get them to remember, that I'm not a Rheumatologist!

    What do you do when you hit a wall? Literally I sleep a few hours, dream about diagnosis, dream about patient RVU's, and then I wake up and go back to work, now everyone looks like a joint, I don't see people, I see knee's, hands (dip, pip, mcp, cmc), ugh........If I had a life, a wife or girlfriend I wouldn't be able to keep up, as it is, it's just me, so I plug away.

    Some days I think that I should just take an RN job in the clinic, it'd be <$5000/yr pay cut, and literally all I would have to do is to take the patient vitals, chart that, put them back into the waiting room and that's it, the provider goes and gets the patients, assesses, diagnosis, treats and injects them, calls with lab results, sends lab/xray results via mail, and more often than not, I have to clean the room between patients myself, this is the main reason that the contract MD quit, she was paid per patient and with having to do all of the work herself, she wasn't able to see enough patients to make it worth the effort. We only have 5 providers in our division, used to be 7, they lost 2 NP's last year, I replaced both, and 2 MD's have quit in the year as well.

    As I look at the clock, it's 1:30am, I have to stop rambling, I need to wake up in 5 hours and get ready for work! Sorry for the long rant and whining, I'm just so frustrated lately and I don't know how to make things better.
  2. Visit Tony1790 profile page

    About Tony1790, BSN, MSN, RN, APRN, NP

    Joined: May '06; Posts: 207; Likes: 118
    FNP-BC; from US
    Specialty: Arthritis/Rheumatology

    7 Comments

  3. by   Jules A
    Quote from Tony1790
    I dunno, it's a mixture of fatigue and self doubt coupled with a little resentment, I suppose, I've received a tiny fraction of the training that the Rheumatologists receive and I make less than most of the RN's that I work with (VHA system).
    The Rheumatologist Fellows are MD's, graduated medical school, residency, etc, and they get 3 full years of Rheumatology Fellowship with an Attending that staffs with them on each patient and aren't out on their own until the 3 years are up, they train in the main hospital branch.
    You are wise to recognize the fatigue and attempt to do something about it before you crash and burn. If you want things to change you are going to have to set some immediate and firm boundaries both for your patients, your license and your sanity.

    You should immediately review the patients on your docket and have the ones who are too complicated for you to reasonably care for as an intake removed and reassigned to a rheumatologist, not your problem where they find one. Either they sold you a bill of goods or you have accepted a position that is above your skill set and training regardless you need to put a stop to it before a disaster happens.

    I get the VA system however accepting a high responsibility job for low pay doesn't make sense to me but the good news is that is something you can change either by insisting on appropriate compensation or finding another job.

    Quote from Tony1790
    I'm trying to get them to remember, that I'm not a Rheumatologist!
    But unfortunately you "opened my own clinic" and therefore have represented yourself as being able to work in this role. I wish you the best and thank you for posting, this is an excellent learning opportunity for many of us. Employers will hire you to do anything you sign up for often at a bargain basement rate. It is up to us, and our schools lol, to acknowledge our experience, training and limitations.
    Best wishes, please keep us posted.
  4. by   traumaRUs
    Some thoughts:

    1. Cut back on the weekend job - you are going going going without any break. Take some time for yourself.
    2. Agree with Jules - turf the pts that you don't feel comfortable with.
    3. You've been a provider for a short period of time. If you want to make it in this business, you have to have boundaries (again thanks Jules).
  5. by   Tony1790
    Quote from Jules A
    Either they sold you a bill of goods or you have accepted a position that is above your skill set and training regardless you need to put a stop to it before a disaster happens.
    Yes, it was supposed to be mainly injections, gout and Fibro, which is easy cheesy, but as my clinic has the most openings, it acts as the pressure relief valve for the clinic, in order to meet the CID, clinically indicated date, in order to meet the timelines for consults. Part of the problem, is that the schedulers are scheduling theses patients into my clinic, even though the MD clearly states in the consult triage, that the patient should be seen by a Rheum MD, but they schedule them into my clinic in any regards.

    To be fair, I am doing a good job on assessing and diagnosing the patients, it's just taking me hours and hours to do it and taking a toll on my psyche, but it's a great opportunity to learn, it's just stressing me out!

    Thanks again, I shouldn't whine, and as far as the Pay, it's a product of the VA system, there is no negotiation with the VA. I'm just keeping my head down until I get a couple of years of experience under my belt, hopefully I'll make it long term :-)
  6. by   Oldmahubbard
    All this sounds like worse case scenario of what can happen to an NP, and what's worse, you aren't even making any money.

    In my opinion you need to have some type of urgent meeting with someone who can do something about it, before a real disaster occurs.

    About a decade ago, I was in private practice with a physician. One day, our office manager observed that we had not been reimbursed by Blue Cross for my visits.

    60% of our business was Blue Cross, so it was a major issue.

    The office manager called and she was told that some NP had apparently made a major blunder, and that the company was re evaluating NP reimbursement.

    A couple of months later, we did finally get paid, but don't let that be you.
  7. by   Jules A
    Quote from Tony1790
    Part of the problem, is that the schedulers are scheduling theses patients into my clinic, even though the MD clearly states in the consult triage, that the patient should be seen by a Rheum MD, but they schedule them into my clinic in any regards.
    Huge red flag if you are taking on patients knowing they were recommended for a higher level of care.

    Quote from Tony1790
    To be fair, I am doing a good job on assessing and diagnosing the patients, it's just taking me hours and hours to do it and taking a toll on my psyche, but it's a great opportunity to learn, it's just stressing me out!
    To be fair if you are saying you are taking on patients that you don't have the training to care for extra hours at night isn't acceptable to ensure you aren't missing critical points or are providing adequate care. I appreciate your moxie and I'm not trying to bash you just shed light on a few items that will likely set you up for problems. You have said you are overwhelmed so possibly not seeing the entire picture at the present time. If you really want to work in rheum hook up with a decent size physician's group to get the training, support and compensation you deserve.

    Its all well and good until someone loses an eye and they start to examine care provided. This sounds like a bad situation on more than one level.
  8. by   Tony1790
    Quote from Jules A
    Huge red flag if you are taking on patients knowing they were recommended for a higher level of care.

    To be fair if you are saying you are taking on patients that you don't have the training to care for extra hours at night isn't acceptable to ensure you aren't missing critical points or are providing adequate care. I appreciate your moxie and I'm not trying to bash you just shed light on a few items that will likely set you up for problems. You have said you are overwhelmed so possibly not seeing the entire picture at the present time. If you really want to work in rheum hook up with a decent size physician's group to get the training, support and compensation you deserve.

    Its all well and good until someone loses an eye and they start to examine care provided. This sounds like a bad situation on more than one level.
    I appreciate your view point and to be honest, maybe my whining in a public forum, isn't appropriate, which I will now stop. I am working to resolve the problem, and thankfully Rheum is a chronic problem and not usually life and death, essentially with the new consult I'm just getting an HPI, doing an examination and ordering baseline Rheum labs and xrays, and then I'm suggesting a multitude of differential diagnosis, where I'm reaching for the eject handle is, I'm then scheduling the patient to come back for the 2nd visit with the MD, so gathering an HPI & doing an exam is well within my NP role. The MD then see's the patient, reviews the labs, films that I ordered, agrees or disagrees with my diagnosis and either keeps the patient in their panel or puts them back into my panel on a co-managed basis, this is the model of many Rheum offices, the NP seeing the less involved cases and even then co-managing them, which is where I'm going.

    Thankfully, the pool of the departed MD's panel is drying up, I'm seeing and rescheduling them, updating her plan, re-assessing the patient and rescheduling for follow up with another provider, so really no worries.

    Thanks all for allowing me to whine, but I will now stop :-)
  9. by   JellyDonut
    I have worked in a specialty for several years now and I often work on my own. However, I always have specialist who know way more than me to check in with if I am unsure or I need more of an expert opinion. I cannot imagine treating patients without support with only a fe months training. I can't see that being a safe environment and you could be opening yourself to liability.

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