hubcaps

Jennicurn, feel free to PM me with questions.

Why would the PCP have a better overall view? We always update any changes with the patient (e.g. diagnoses and medication). I can easily argue that we can have better overall view because we understand how HIV/AIDS and their medication interfere with other medical issues and medications better than the PCP. I know of ID practices that manage all the primary care needs of their patients. My frustration with this conversation is that I am angry that this PCP was more concerned with the finances than with patient care. I completely understand the philosophy of the PCP being the gatekeeper. I am not trying to argue/defend why he shouldn't be the gatekeeper. My view is mixed. I can understand from both perspectives. My venting comes from my frustration that I was criticized for caring for my patient. My intentions were NEVER to overstep my bounds as a provider. I had no personal/financial gain. It is very hard as a new NP to be falsely accused. PLEASE understand that I am not trying to make a point of how referrals should be made. I only wanted to say that I was trying to provide the best care for my patient from my experience and training. I was very hurt by the fact that this PCP wanted to personally attack me. I can understand if I over step my bounds. However, his words and actions have only demonstrated self interest. One "mistake" from my part does not warrant his actions of refusing to give my group further referrals. Once again, this only happened ONCE. I can't help but feel bad that all of a sudden the census in one of our hospitals have dramatically dropped. I completely understand what you and Juan are saying, but I don't think it applies to this specific situation. I only brought up my point as an example of how some practices function, not as how things should be. I don't want to get into an argument of how thing should be done. There are different ways of practicing healthcare. This PCP did not want to talk to me. He went to my docs with false accusations of poaching patients. He did not say that ID should not be managing his neurological/pain needs. He said I was stealing his patients for my group. I could care less. I have NO financial incentive for make internal referrals. I wanted to express my frustration with our broken healthcare system. I wanted to express that it hurts to be falsely accused when I just wanted the best care for my patient. Remember, the ID docs in my group AGREE with my actions. My initial referral for neurology was the recommendation of one of my docs. Should I have called the PCP? Yes, that was another potential mistake that I made. The ID docs in my team alway tell me when I should communicate with the PCP. However, my docs did not think it was needed in this situation. I can understand the different philosophies of care.

Quick update. The PCP called one of my docs and he said he would no longer refer any of his patients to us. This was based on one patient. After reviewing the situation, my doc's agreed with what I did. They said they would have done the exact same thing. As I mentioned earlier, my decisions for referral were based on my expertise as an ID provider. My docs did not think I was overstepping my bounds. Myopathies and neuropathies can be related to HIV and their treatment. I wanted to rule out HIV related myopathies/neuropathies. Juan, I appreciate your response, but I somewhat disagree with your response. I don't think primaries should be addressing all referrals. In my experience, I've seen patients with chronic illnesses being managed primarily by their specialist. In my previous career as a peds CVICU/PICU RN, our kids with congenital heart defects were primarily managed by their cardiology team. They saw a pediatrician, but everything had to go through cardiology. I could say the same thing about our pulm, hem/onc, renal, etc. kiddos. Patients with chronic illnesses have unique needs that PCPs are not often aware of. In my opinion, the PCP is NOT always the gatekeeper. My manager said that unfortunately we have to cater more to the physicians than the patients. My original rant was with the politics and business of healthcare today, so Juan I think you missed my point.

Zenman, Thanks. Enjoying a nice glass of beer right now.

Thanks for the response Juan. I totally understand what you are saying. I just felt that the PCP was more focused on his self interest than the patient. He wasn't mad that I made the referrals, but rather that they were not part of his network. Also, I have taken care of many of his patients and this was the first time this had happened. How can you accuse me of poaching if it happened once? I'm very careful about over stepping my bounds. Our practice has many patients who ask for treatment that is outside of ID, and we always tell them to see their PCP. I felt that this situation was different because his pain was very likely related to his HIV. Also, the patient came to us. If I thought the pain was due to other causes (e.g. trauma), then I definitely would have told him to see his PCP. Should I have just told his PCP to make a referral to a neurologist? Maybe, but his group doesn't have ID and therefore very unlikely that the neurologist manage patients with HIV. Could I be wrong? Of course. But my group for sure has a neurologist that deals with HIV related symptoms. I did not want to delay treatment because this patient has a history of inconsistently taking his medications and as a result has developed significant resistance. I was afraid that he was going to stop taking his medications if his pain issue was not address. I would have a totally different reaction if the PCP was advocating for his patient rather than his own group. I know that I am a bit naive/idealistic (i.e. wanting to just care for patients and not caring about the business side). I'll admit that I made a mistake that I did not check the PCP's group/network, which is not easy given a 20 min time slot for my patients. FYI, googling the PCP reveals his own private practice, but not the larger network that he is part of.

So today, I was accused of "poaching" patients by a PCP. Here's some background information. I'm an ID NP and we were referred by this PCP for a pt that needed HIV care. I've been co-managing this pt with one of the docs in my practice. We started this pt on a new drug cocktail and after a few weeks he developed neuropathy/myopathies. So I referred him to a neurologist that is part of my medical practice, who has experience with HIV related neuropathies. This patient continued to complain of pain and our ID nurse gave him a pain referral. The patient eventually goes to the ED for worsening pain and I did the initial consult. I briefly introduced myself to the PCP and said that it was nice to finally meet him. He did no say much except that he would like to talk to one of the docs in my practice that day. I said that one of them would be rounding in the hospital the next day, but he said he had to talk to them that day. This made me feel very uncomfortable. If he had a question about the patient, then I would attempt to address it and if not I would have called/texted one of the docs. So today, he ends up talking to one of my docs and said that I was poaching his patients. He said that referrals should be made to members of his group and not my group. That was not my intent. I have no financial interest with internal referrals. Also,my patient was asking me for care that was presumed to be related to his HIV. I wasn't trying to manage healthcare needs that was unrelated to his HIV. It frustrates me that my intent was to get my patient the best care and to be accused of selfish gains. I really want to confront this doc, but it's best not to rock the boat. Do I just avoid him and defer all communication with him to my docs? The politics of private healthcare is really wearing me down, which is all new to me. My RN experience was at a large teaching institution, and my NP clinicals were in underserved areas, mostly supported by grants and fundraising. I just want to take care of my patients! Thanks for letting me vent.

It is great that you are seeking advice from various sources because you'll get so many different responses. Everyone process death/grieves differently so there is no easy answer to how you should process this. I think the previous responses are great. My advice is to be aware of your own boundaries and learn where to stand with various situations. At times you may cross them but the risk may be worth it. Some of my friends have relationships with families years after their child's death, but it is part of the healing process of the the family and the RN. Knowing myself, I can't do that, but I am so grateful that there are nurses like them.

No you are not... at least right now. I am a FNP and I care for both inpatient and outpatient. If you want to do ED, FNP may be the way to go because you are trained in both peds and adults. Most ED positions that I came across wanted FNPs. However, in the long run this may change. The hospital that I was at as a RN will only hire acute care NPs for inpatient care. This change probably won't happen for a long time. Community hospitals depend heavily on NPs and there are not enough acute care programs to meet the demand.

Very wrong. What I am about to say is from my experience and observations. My sister is a ped rheumatologists. I was in nursing school when she was in med school and I was a new nurse when she was a resident. Her training and experience is completely different from a family practice doc. I have also worked with many peds residence so I know their experiences. Family practice docs do not go through all the peds specialties and if they do it is very brief. The depth of knowledge and experience of a pediatrician vs a family practice doc in peds is vastly different. I probably have more knowledge from being a PICU RN than a family practice doc in managing kids with chronic issues. In my opinion, for a well child or simple illness, there's little to no difference. However, for complex illnesses a PNP or pediatrician would be better. There are exceptions, which are typically based on experience.

Going a back to the original question, I would say go for a PNP program. I get asked this question a lot from my friends because I was a PICU RN and I am now a FNP. If you have no interest in caring for adults don't do FNP. Don't do it because the market is better. You don't want a job that you'll hate. FNP positions are heavily adult focused. I did FNP because I like both adults and peds. I do terribly miss taking care of kids (I see them once in a blue moon). You will get more extensive training in peds by doing PNP. The school I went to is highly ranked in FNP and PNP and my FNP program did not go into as much depth as the PNP program. I learned well child and basic sick visits. My PNP friends learned about chronic care issues and some acute/in patient care. If you do PNP, you'll have more peds options. I know one of the childrens hospitals near me will hire new grad PNPs, but only FNPs if they've worked in their hospital for a few years (I forgot the exact number).

I started as a new RN in the PICU. If it is what you want to do then just start off in the PICU. I've trained many new nurses and nurses transferring to the PICU. I've had the most difficulty from nurses who came from a general peds floor or med/surg. They may have time management skills, but they have a skewed sense of urgency and don't prioritize things well. I'm not saying all of them are like this. I've worked with some amazing nurses that came from very low acuity units. I personally don't believe that gen peds/med surg is a stepping stone to ICU. I think the units are very different. I sometimes had difficulty when I floated to gen peds. Priorities are very different for those patients and you can be just as busy and often times more busy.

Congrats! Not only does it feel good to pass, but also to realize that you don't have to take any more of these types of tests. Good luck with being a NP.

Thanks Juan. I never thought of that and it makes a lot of sense.

I agree with zenman. I wouldn't do any more practice exams/questions. If you haven't done so, look at why you may have gotten the questions wrong (e.g. weakness in certain areas, misread questions/answers, etc.). Rest is super important so that you can think clearly. The test is relatively short, but your brain will be in high gear the whole time. If you have a good grasp of the Fitzgerald material, I think you should be fine. I thought she went into greater depth than the questions on the AANP. Good luck!

Here's a little background on myself. I'm a new grad and I just started a new job with ID. Initially, I'll be seeing patients in the clinic, but the group wants me to eventually see patients in the hospital. I was hired because I had the mix of my FNP education and ICU RN experience. I was wondering if anyone here is a FNP that does inpatient care. Are you planning on getting your ACNP degree/certification? I know the trend is to move away from using FNPs in the hospital. The hospital where I had previously worked as a RN no longer accepts primary care NPs for inpatient care. Does it even matter (with the exception of looking for a new job)?