Penguins10

Hello, I am licensed as an NP in DC and adding a second NP certification. I am trying to determine if I need to apply for an additional license to cover the second certification. I have not been able to get a response from BON and wondered if anyone had any experience with this in DC?

Same here. I don’t have to look up as many things now as my first year, but I frequently look stuff up in the room or tell people I am going to go look something up if I want to check a book. Especially if we’re talking drug doses. If anything I think people appreciate being taken seriously and getting cautious/thoughtful care.

Sorry, missed that part in my response. You're probably correct about sending identifiers to people not involved in care.

Why does the fact that patients have paid for unlimited access preclude a productivity metric? They need to be seen and if you don’t someone else will have to I imagine? Are you involved in advertising/recruiting patients? If not how does your work influence number of new patients? What about quality measures? Either disease control or some kind of performance metric that you aren’t dependent on someone else for (e.g percentage of patient calls returned in same business day). Satisfaction could be option too but I imagine in a concierge model that will have to stay high or things will fall apart quickly.

If it’s a G suite email product Google will sign a business associate agreement so with that and appropriate encryption in place this could be a compliant system.

Had similar questions as a new grad, now think FPA makes sense. The NP model has been around since the 1960s and tested extensively. I have not seen a study showing NP care is unsafe (happy to see if someone has one), if someone disagrees then do the research and show it. How does someone reading my progress notes days or weeks after I see a patient provide “supervision”? If I’m such a threat to public health how can you rely on my version of a patient encounter to evaluate my care? As a professional I need to know when to ask for help whether I’m working as an RN, an RN with NP license, PT, MD, JD.... Current supervision requirements are almost always a facade and essentially about asserting physician control as a professional guild. I am happy to critique NP education, but I don’t think requiring nominal physician supervision helps patients, nurses, or physicians.

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!

I did volunteer and career fire/EMS before nursing school, which was useful background, then worked in sub-acute care, primary care, and emergency medicine as an RN prior to taking an IM/nephrology job as a new NP. I work in primary care now. Whatever setting you work in will provide some transferable skills, so there's no point in being dogmatic. However, an ED job is ideal in a lot of ways, you will take care of patients with a wide variety of concerns, you can watch the way those concerns are evaluated, you can see the disposition (who needs to be admitted), and you should definitely start to learn sick/not sick which is obviously extremely valuable in any future work role. Primary care can provide similar breadth of exposure, it depends a bit what your role is and how much the folks you work with are willing to teach. But, like I said, pay attention (read about patients, think about why you're doing what you're doing, do continuing education, ask questions of patients and providers as it is appropriate) wherever you are and you'll learn things that are useful in the future (and be better at what you're doing at the time!).

I like Diagnosaurus DDx. It is easy to use and helps to broaden my thinking. In addition to ddx for symptoms it provides ddx for various lab abnormalities which is helpful. I downloaded DDx Teacher. I haven't used it much, but I like the concept and hope to spend some more time with it in the future.

trauma: Our office manager claims we'll get a raise, but, because of how our billing is organized, I'm not sure that the hospital system will think we're all necessary. It'll be interesting to see how it shakes out. I like the fact that we do IM as well as nephrology, but, just as you point out, I'm realizing that doing good quality primary care in the midst of dialysis rounds is pretty tricky. I saw a job with a local university system recently, it looked like they saw their dialysis patients in clinic on non-dialysis days for primary care type issues. I'm sure that is beneficial from a billing perspective, but it would also allow more focus on those issues too. swimming: Wow! I'm jealous, I didn't have any prior dialysis exposure, besides taking care of dialysis patients in the ED, so there was a lot to learn. Prior experience would definitely help to smooth your transition. I think my experience in terms of compensation was similar to everyone else. I took a straight salary position and most of the work I do is billed through the MDs I work for, I think in the future I may pay more to finding a position where I am generating RVUs. I'm finding that administration people don't value work that doesn't produce billing, which is a problem to the extent that they evaluate your value to the organization.

Wow, you guys are in big groups and it is interesting to see the ratio of MDs to NP/PAs. We have three nephrologists and four NP/PAs. One MD does CMR each month and does PD/HHD clinics. We see in-center hemo patients the other weeks and trouble shoot acute issues with home patients. We have talked about starting CKD education group visits, but that seems to have fallen by the wayside. Interesting to think about mineral/bone/stone clinic, would be cool to have specific time to think about those issues. We are doing inpatient work the rest of the time. Our situation is the same as Trauma in that we are doing split/shared inpatient visits and billing under the MD. This has been ok, we save them time and they are a private group, so if they're happy we're employed. In the near future we will be transitioning to a hospital employed arrangement and I expect will need to find ways to bill more. In terms of how much you're taking on I, I guess it depends on what you need to do (effectiveness of support staff, just dialysis vs primary care and dialysis, etc), what kind of previous experience you have, how much orientation you had/have. Are you the first NP the group has worked with, that can be tricky to figure out if they aren't sure what to do with you?

Thanks for the replies, it's interesting to hear how others work! We have folks at three clinics. One is about 35 miles away, one is about 25 miles, and the other is in the same town as our office. We see about 155 people in 3.75 days (we spend the other 1.25 days seeing acute visits in the office). Fortunately, we don't have to drive between different clinics on the same day. I'm in the relatively snowless mid-Atlantic, so weather isn't too much of an issue. We're lucky in that we do dedicated inpatient and dialysis weeks, it would be tough to try to do both at the same time I think. Trauma, I enjoyed your article on ESRD patient's in primary care.

For those of you rounding on chronic hemodialysis patients, how many patients are you seeing per hour (or whatever other patient to time ratio you want to use)? Thanks!

Hi llg, Thanks for your thoughtful response, that gives me plenty to think through. Is fundability something to consider when weighing areas of interest at this stage or should I just assume that if I can find faculty doing work related to my area of interest that represents adequate funding sources? Thank you!

Thanks everyone! It is helpful to hear multiple perspectives.