An interesting way to look at convenient care is that it's a new brand of healthcare. The blog brandSTOKE posted about this concept recently in "Retail clinics vs. your doctor: it may come down to branding." The post very concisely explains the reasons for the fall of traditional practices that aren't stepping up to the new focus on patients' needs:

They are retail-based medical clinics — and your doctor doesn’t like them. The primary advantage of retail clinics (also known as walk-in clinics and convenient care clinics) is convenience. They accept walk-in appointments (no waiting for an opening at your doctor’s office) and they may be open late. They are often less expensive. You can fill usually fill a prescription on premises. Your doctor says retail clinics don’t provide the same quality of care. (Meanwhile, he or she may be losing patient visits to them.)

The post author explains that while a physician resisting the convenient care clinic claims only he or she has the quality that patients want, that isn't the case. There have been many studies now to prove convenient care clinics provide equal if not better quality. And because they're branding themselves as convenient and high quality, they're coming out on top. Providers that want to compete will have to brand themselves like convenient care clinics to keep their patient base.

This week I attended a forum in Philadelphia held by the Convenient Care Association (CCA). It was designed to address where convenient care is positioned now and where it's headed. In terms of presenters and panel participants, the cast was star-studded: Sandy Ryan, chief nurse practitioner officer for Take Care Health Systems, Web Golinkin, CEO of RediClinic, Tine Hansen-Turton, executive director of the CCA and Chip Phillips, former CEO of MinuteClinic, to name a few. There were about 160 attendees, and discussion was lively.

There was talk about the growth of the industry, not in numbers of clinics but in types of services. This brought up the question: Can we call this industry "retail healthcare" anymore? It seems that the moniker doesn't quite fit anymore, now that there are so many clinics in locations other than retail settings, such as primary care settings, hospitals and workplaces. There was what panelists called "Retail Clinics 1.0," meaning the first wave of clinics, and "Retail Clinics 2.0," the second wave of change that we're seeing happen now, with expanded services (weight management, asthma care, acne treatment, even diabetes management). The glue that binds all of these practices together is their focus on what the consumer wants - convenient, affordable healthcare. Patients are in the driver seat in this new healthcare vehicle.

The industry is thriving in a completely different way now, and consumers are going to continue to adopt the concept - who wouldn't want quality, convenient affordable healthcare? Also, as Chip Phillips noted, this flu season will put convenient care clinics on the map. And clinics are going to be hiring more and more NPs and will potentially be offering all sorts of incentives to do so. Will you be part of Retail Clinics 2.0?

Hey, convenient care NPs! Are you close to the Philadelphia area? Are you interested in getting engaged in the conversation about where retail healthcare is going? Is it expanding? Is it a dying fad? There's a free way to learn more: On October 26th, the Convenient Care Association is cohosting a forum to discuss issues and trends in the industry.

The "Convenient Care Clinics and Retail Healthcare: A Critical Innovation for Successful Healthcare Reform" forum will be held from 2 p.m. to 5 p.m. at the College of Physicians of Philadelphia with a reception following.

Panelists include leaders in the convenient care industry, such as Sandra Ryan, NP, chief nurse practitioner officer for Take Care Health Systems. To register, visit www.collegeofphysicians.org.Scroll to the bottom of the page and click on "calendar" for registration information.

During this last month we have been overrun with patients seeking flu shots and seeing patients with colds, strep throat and flu. I have seen some folks who are very ill and without doubt have influenza. But mainly I have seen the worried sick. People who have upper respiratory symptoms and know they are victims of "swine flu." One little boy who indeed did have influenza thought he was going to die because he had the "swine flu." Luckily his mom realized his fear and hopefully we were able to reassure him.

That has been a particularly bad effect of the worry about H1N1. Getting the vaccine is good; scaring children is not. I have not been to work in two days, so I don't know much about the distribution of the H1N1 vaccine in our clinics. I hope we find out if we are giving the injections at least a day before we start.

I personally do not have a choice in getting the seasonal flu shot or the H1N1 so when I am asked all I have to do is give the company line. I do have concerns about the use of the H1N1 vaccine but we have to depend on the CDC and the FDA for assurance that it is a good thing. And that is a very scary thing since both agencies have been wrong. Also there is a lot of money involved. And lastly there is my paranoia about vaccines and the government.

I know, rationally, that good people have studied and thought about this vaccine but I also know that some people will have bad side effects from the vaccine. This is a conundrum that most providers of healthcare are aware of and take into consideration every time we prescribe even acetaminophen. Medicine, while claiming to be science- and evidence-based, is just as much an art as a science. And art is often in the eye of the beholder. Every time someone comes to me for an opinion, help or just to be reassured, I try to keep that in mind.

On another note, I am not sure how every retail clinician works but I try to triage my patients. I will not see those who are too sick or who have illnesses that require more than my scope of care in a retail clinic can provide. Sometimes it can be hard to convince someone we are not set up to meet his or her needs. Just because we do sport physical exams and are very capable of doing complete history and physical exams does not mean we can provide what a regular provider's office can provide. Nor is it in our scope to diagnose and order antihypertension medications. There is a great difference between our "scope of practice" as a nurse practitioner and our scope of practice in a retail clinic. And if sometimes it is difficult for the public to understand, it can be hard for NPs to understand. I often wish for more clarity in knowing what to treat. There seems to be a difference between clinicians. I guess it's because we all are different and have different experiences. And if choose to refer some things others treat, it may be that I treat what others would refer. It can be confusing. As the field of convenient care develops, our scope will become clearer.

The theme for this month's post is ambiguity. We all live with it and deal with it. And I hope that there is always some ambiguity, otherwise things become rigid and leave no room for the art of medicine.

Wow, what a rush!  We started administering flu shots in our retail clinics Septemter 1^st, and have been extremely busy this season thus far, and it is not even really prime flu shot season yet.

I believe there are two reasons to explain the large numbers of patients looking for an early flu shot. The first is everyone has flu and influenza on their mind as H1N1 has started to consume my community: in the elementary, middle and high school students and in the universities. People are very concerned about this new strain of flu and with every "seasonal" flu shot I give I am requested for more information on "When are you going to have H1N1?" I answer their questions the best I can and try to advise them their place in the recommendation from ACIP.

The second reason is people are paying more attention to all types of flu this year and to the recommendations of the CDC. I have has more patients that are in the 20-40 year old range that are flu shot natives than ever, and I don't have to sell them like I have had to in the past. The other nice thing is people are getting the flu shots for those they love and live with and are learning the risks of the influenza, no matter what the strain!

I have yet to run into any patients thinking the flu shot I am giving them is for the "stomach flu," but of course the season is young. Hopefully people realize the difference and are seeking out the information they need to stay healthy this season.

Here's to round 2 of the flu shot season, H1N1!!!!

Since the beginning of the H1N1 (swine flu) pandemic, the public has relied on retail clinic practitioners to provide education, guidance, testing, assurance and treatment. The media is playing a vital role in keeping the public updated; however, I am not sure if this is helpful or harmful. The public is hearing with only half an ear, only listening when they hear about death by swine flu. Despite the CDC reports that states, "The majority of people who contract the virus experience the milder disease and recover without antiviral treatment or medical care. Of the more serious cases, more than half of hospitalized people had underlying health conditions or weak immune systems." People sometimes only hear "........Death ............swine flu." They cannot hear anything before or after these words. People are coming in or calling everyday with the belief that they or a loved one have the swine flu. I am being asked constantly, "When is the swine flu vaccine going to be available?" and "Will I be able to get one?"

In addition to the growing fear, people are starting to believe that any new symptoms are the beginning of the swine flu. They are coming into the clinics demanding to be test for the swine flu or given a prescription for Tamiflu. It is important as healthcare providers that we do not give in to the fear of the public, and that we continue to deliver sound and evidence-based medical care. In addition, we must not become totally business-minded, conducting tests and writing prescriptions without significant symptoms. The CDC and media continue to warn the public about symptoms to make them aware but because of their panic state, they are not listening to these symptoms. The CDC states that signs of influenza A (H1N1) are flu-like, including fever, cough, headache, muscle and joint pain, sore throat and runny nose, and sometimes vomiting and diarrhea. I would like to share a few of my experiences with you.

Fearful parent:

I have a parent that came into the office and stated that he wanted to be tested for the swine flu because his daughter was seen yesterday at the pediatrician and diagnosed with swine flu. I asked did the physician perform a flu test, and he stated, "No, because he did not have time, but he treated her with Tamiflu and she is now doing better." When asked what his symptoms were, he stated that he did not have any symptoms. I explained to him that he only needed to be tested if he is having similar symptoms. Of course, you know what happened, in an instant he developed a runny nose, sneezing and felt he might have a fever. Although these are only the symptoms of allergic rhinitis, I realize that he is not going to be satisfied until he is tested. He also stated, "I do not want to pass on these symptoms to my job, if I do have the swine flu." I decided to relieve this man's fear and anxiety be performing a flu test. You and I both know the results, but I felt that testing this man was more beneficial, since he felt he was exposed, than not testing him. However, he did have symptoms of allergic rhinitis, and he was treated with antihistamines and Flonase. In addition, I provided education about the signs and symptoms of swine flu and when he should seek treatment, he left a well-informed man.

Just plain scared:

I had a woman who came to my office a few days after the swine flu pandemic was announced and she wanted to know if a mark on her face was swine flu. She had a marked that looked similar to a birthmark or hyperplasia of the skin. I asked her how long she had the mark.  She states, "About 5 years." I think this is an example of how much fear the swine flu has caused the public. I assured her that she did not have swine flu and recommended that she follow up with dermatology regarding the 5-year-old mark on her face. This woman was actually relieved to hear that the mark on her skin was prior to the onset of the swine flu and could not be related to the swine flu.

Panicky moms:

I cannot count the number of moms who bring their child to the clinic with a runny nose or cough with an onset of 1 or 2 days without fever or muscle aches for fear that the child has swine flu. I have to educate and assure these moms daily that their child does not have the swine flu. I do not test these children if they do not have a fever greater than 101, positive history of exposure, looks very ill, or complains of feeling very achy. Sure, testing these kids may be good for business, but it is not medically sound practice. It is essential that as practitioners, we only provide medically necessary treatment. We also must realize that we cannot test everyone that has a common cold or allergy, and that we must be careful not to waste resources that might be needed later. 

Protect myself and family

I have had persons come into the office and ask could I just give them a prescription for Tamiflu so that they can have it available, if needed. I took time to educate these people on the use of Tamiflu and the CDC guideline of only giving Tamiflu to persons who test positive for flu in order to prevent the virus resistance to the medication. I also explained to them that we must reserve the Tamiflu for those individuals who are at risk of dying from the swine flu. The CDC states, "Treatment with oseltamivir or zanamivir generally is recommended for persons with suspected or confirmed  influenza who are at higher risk for complications (children younger than 5 years old, adults 65 years and older, pregnant women, persons with certain chronic medical or immunosuppressive conditions, and persons younger than 19 years of age who are receiving long-term aspirin therapy)."

These examples are only a small sample of the types of inappropriate cases that I receive because of media coverage and fear of the swine flu. We must continue to give the public assurance and guide them as to when to seek medical treatment. The CDC states the following guidelines as when a person should seek medical care: "A person should seek medical care if they experience shortness of breath or difficulty breathing, or if a fever continues more than three days. For parents with a young child who is ill, seek medical care if a child has fast or labored breathing, continuing fever or convulsions (seizures)." However, I deviate from this guideline because I will test a child who looks extremely ill or listless or have a fever of greater than 101 regardless if it has been less than 3 days. CDC also states that "supportive care at home, such as resting, drinking plenty of fluids, and using a pain reliever for aches - is adequate for recovery in most cases." We must continue to educate and function within the CDC guidelines. If we try to please everyone by testing and administering medication at patients' requests, we will only feed into the fear development state. Retail healthcare NPs must help stop the swine flu madness.

I will begin with myself since I am a person in a society that generally considers "me" before anything else. And believe me I am a member of that society. There are many good things for me as a NP in a retail setting. Generally, our patients are not in life-threatening situations. Their physical problems are mainly minor and what I mainly do is a lot of just listening. Since I am good at this, I generally enjoy this part of seeing patients. I don't enjoy the people who come in with the attitude that I am being paid to give them an instant cure, generally an antibiotic. On my good days I am able to educate and satisfy them without the magic pill. I like the episodic nature of the business. In my last job, I had many chronically ill patients and while I learned to know them, I was often frustrated dealing with chronic issues. I have "frequent fliers" in the retail setting but for now, we don't deal in chronic care.

I like having days off during the week. I guess most nurses have learned to enjoy weekdays off, since nursing is generally not a Monday through Friday situation. I am having a lot of difficulty with the long hours. I am not as young as I used to be and when I work two 10-hour shifts back to back, I feel it. In a period of 48 hours, I am awake, driving and working at the minimum 24 of those hours. And when I have to stay late, as I have constantly had to do, I am eating, drinking and not sleeping 28 of those 48 hours. For me, it is an exhaustion problem. For my patients it could be a safely concern. I wonder how many automobile accidents occur with retail clinicians, and others, on day 2 of a two-day shift? Sounds like a good research idea. And of all my complaints, and I love to complain, this may be the one that forces me to another job search. I have come to dread leaving home when I know I have a marathon to endure.

I could continue on and on about me and I probably will since what I have to talk about next is my life as a nurse in a retail setting in the state of health care in the United States. For over 40 years now, I have been in the healthcare profession. And I don't count the years since I was four and I lived in the nursing home my mother owned. I know the state of healthcare as well as anyone does. I have lived it. And it is not a good or a fair state. Nothing in life is free and we all bear responsibility for ourselves. But, as human beings we have a responsibility to others as well. And I will not apologize or do the liberal dance-about, this is just my opinion. If you don't care about what happens to the sick, children and animals, in my book you don't deserve to be called a human being and certainly not an American.

In healthcare today we are schizophrenic in the old sense of the word. Split. One part of ourselves feels that each person has the responsibility to care for their own health needs and the other part refuses to let the sick child or the human being lying in the road stay there. Both are good and moral ideals. But because of this split, we all pay for poor healthcare at rising costs. And until we either care for all or don't care for those who can't pay, healthcare costs will continue to rise and healthcare will continue to be sick care. I don't know of anyone who will admit to letting a bleeding person without money (i.e. insurance) bleed to death. Societies, in the past, have allowed this, as well as beggars in the streets and animals sacrificed to angry gods. We call them barbarians or uncivilized. Funny how we judge others and can't see ourselves. End of sermon. I come by this honestly, since I graduated from Seminary and have been an ordained minister along the way. So what does this have to do with retail healthcare? In the three years I have worked there I have said and I am sure others say it: "I'm sorry, we don't take your insurance" or "Our price for a visit is X" and watch people walk away. Hopefully, these people have minor illnesses. But that does not mean much to a mother whose child is in pain and whose only hope for stopping her child's pain is either to give up about a weeks pay or sit all night in a hospital ER. It is not right, it is not fair and it is not civilized. And being in retail healthcare brings it home to me.

Now, what I have learned about corporations providing for-profit healthcare? First, I have to say I have worked for corporations big and small, profit and nonprofit, religious and nonreligious. And in my opinion, some of the least ethical have been the religious and non-profit. So, I do not have anything against making money. And of all the institutions to come along, I think retail clinics are the most honest about the for-profit motive of their being. We talk about convenience and cost effectiveness and meeting the patients' needs. But we are up front that we cost money. What worries me is when a corporation in retail clinics mixes up the meaning of the word retail. By this I mean seeing retail as a definition not a setting. And as our prices rise to "meet the market" and our companies grow and the investors look for more profit and less investing, I am afraid of the consequences. I fear that our companies will go the way of many hospitals and forget about the health care in its effort to be more profitable. Yesterday, I cried with a lady who was sick with no insurance since her husband just lost his job. She didn't have the money to see me. I gave her the number for a free clinic and the health department of her county. She had already checked the Health Department out; no help. A stupid name for something with no help, health department, sure. I told her if the referral did not work out that the ER "had to see her." She tried to make ME feel better: "You have to be tough," "Things will get better." For 40 years things have gotten worse. When are they going to get better?

This seems like the longest blog I have written. And I think it is certainly the most personal. These are my concerns, my feelings and my frustrations. It is not all of what working in a retail setting is about. For a nurse/PA this can be a fulfilling and great career. And retail clinics are proving that we have a place in caring for people. If you are a research person, look at the studies that have been done so far. And look at our statistics. But in any endeavor there are conflicts and personalities, frustrations and paths to recognize and choose. These are my quirky personality's observations of a growing and changing entity in the context of a contentious period in healthcare. My liberal dance begins and ends here.

As a retail NP I work 12 hour shifts during the week and 8 hours if I work a weekend.  I can work two to three shifts per week, during the day, and still have a number of days off during the week for appointments, hobbies, going to my children's events, and just enjoying life. I have the option to work more weekend shifts or fewer, depending on my needs. All the NPs enjoy this flexible staffing that allows us to truly have a work–life balance. 

Many NPs choose to work as needed or part time, which is virtually unheard of in most primary care or specialty care office practices, but it's a wonderful option for NPs who enjoyed the flexibility of their nursing career without the nights or PM shifts. NPs who have children or might want to teach and practice also find the flexibility  wonderful. I know many of the NPs in retail started as a PRN employee because they wanted to "get their feet wet" and then loved it and went part time or full time; I did just that. Many of them stay PRN because they have another job with the 8–5 hours, but they really want to have the experience of working in the innovative environment that is retail health.

Retail health has made great strides in improving the access to health care, but has also worked hard to provide a very life-friendly work environment for NPs. Whatever you seek it is important to find a balance and working in retail has afforded me that opportunity!

While working in a retail clinic, I have identified the following tools as essential for building a successful, thriving clinic: word of mouth, positive perception and community awareness.

It is my experience that although company marketing is necessary, word of mouth is a valuable tool for growing a retail clinic. I have witnessed a large number of clients stating that they were referred by others, such as friends, schoolmates, pharmacy or school officials.

Word of mouth is referenced to the passing of information from person to person. According to Wikipedia, the term "word of mouth" marketing was formed in the mid 80's by an Australian company. I have heard clients state numerous times, "I have been coming to [the host] for many years and did not know you guys were here until my friend recommended that I come." In addition, I hear them stating that a coworker came yesterday and stated that you were able to treat them with no appointment. Word of mouth and first impressions are tools needed to build a successful, thriving retail clinic. Many of my school physical patients were referred by coaches, schools or another teammate. Often the child or parent would state, "I was referred by the school" or "Timmy told us he had his physical done here." Word of mouth is a major tool that I have seen actively working in building the retail clinic. I was referred by someone is becoming a common theme, in addition to "I had my physical here last year."

In addition, the perception of a clinic as being open, friendly, and available is also a factor in the success of a retail clinic. If people feel the clinic is open, friendly and accessible, this will enhance the clinic visits. Although on a factual basis the phrase "perception is reality" is untrue, based on society today this phase carries a lot of weight. We must build a perception that we have the client's best interest in mind instead of being just another medical service trying to make money.

One of the ways to portray this image is client referral and education. Retail clinics are unable to treat every client that visits the clinic because of our limitations concerning retail scope of services, but I have had many return visits from people that I had given referral information to because the original visit was for something that was out of my scope of service. We should not be afraid to refer clients to other practices if we are unable to provide a particular service or the person needs more extensive care than can be provided in retail clinic setting. Because these clients see that I have their best interest in mind, they often return for other visits. I always explain to them why it is best that I refer them, and I give them a brochure of the services that I am able to provide. I have had many return visits from clients I was unable to see because of limit scope of service. These clients often return stating, "I was here last month, and you were unable to see me regarding my hypertension medication but I knew that I could come see you regarding my sinuses."

Creating community awareness is another method to increase the client visits in retail clinics. If the public is not aware of the services that retail clinic provide or not aware of the location of the clinic, then they would be unable to take advantage of these services. I still have many clients referred by school coaches and the host pharmacy that were coming to the host retail and unaware of the clinic. The building of awareness in the community in which your clinic resides is important. I believe this makes a big difference in the number of clients seen in retail clinics. I do not discount the fact that other clinics or competition in the area may also affect the number of clients.

In conclusion, the public perception of the clinic being active and the services of the Practitioner are key ingredients for a retail clinic in addition to community exposure and clients' word of mouth. These tools I feel are very important factors in the survival of a retail clinic.

A common problem that I am encountering is no parent or guardian present on sign in. Sometimes the child presents with someone who is not their guardian or with no one at all. I sometimes have to remind parents that even though their child is bigger than they are and can drive they are still minors if they are under 18. As a parent it makes sense to me that if my child were under 18 I would need to be there for a physical exam and to give the appropriate health history information.

So often parents will say they can't come in because they work.  I remind them that they have the opportunity to come in after work or on the weekend when we are also open. There is the option of the telephone consent but I am not comfortable with that.

I prefer that the parent be present to give me important health information about the participant. The parent or guardian is really our most important resource for this information in this setting. They also need to be present for any part of the exam that the child may be nervous about. We often pick up abnormalities that make it necessary to stop the exam and refer the child for further evaluation. The parent should be present for that as well. It is also important for them to receive the same information we give our patients regarding safety and health while playing sports.

We can offer these physicals with convenience but at the same time keep our athletes' health and safety in the forefront.  As nurse practitioners a large part of our role is to advocate for our patients, especially the ones who cannot always speak for themselves.

I don't know about others but when I hear how bad healthcare will become under a public plan, I get insulted. There are lazy people and there are dumb people and unethical people, unfortunately, already in healthcare. But just because the government is a payer, all of the sudden, the majority of us who are ethical, smart and not so lazy will suddenly change? That is insulting and not true. Maybe everything a person wants will not be covered. So what, everything I want my insurance to cover doesn't always work out now. My hope is that with corporate revenue not being the bottom line, patient care can be what it is all about. Funny to say, seeing as how I work in a retail clinic, but I hope "retail" says more about our location than just profit. Not that I don't want my company and others to be viable and make a profit. I want to keep my job. But just adding another source of revenue with a public option doesn't seem bad.

I have wondered how we would function with a public option. I don't think it would be very different from how it works now, at least for the next few years. If our companies choose to be a provider and if the public option chooses to use retail clinics, I think it would add much to healthcare reform and especially to healthcare cost reduction. Our business should increase when people, who had once had no insurance, would options other than ERs. And as these people come to have medical homes, there is more room for preventive care. Preventive and wellness care is something I think we will have to offer working with a person's medical home. As our scope of practice expands, I think the healthcare system will see more savings. At least that is my hope. One of the reasons I do this is I want to be part of the solutions to the mess we call a healthcare system.

So that is what I think will happen if we do have health insurance reform and a public option. How this committee to oversee Medicare works will be interesting. I believe in following evidenced-based guidelines, however, I truly believe we need to treat our patients not the tests or the guidelines. And a lot of how much these guidelines work will be determined by how much room we have to be clinician-chefs and not just cooks following recipes.

I support the ANA's stand on reform and I am writing to both my representatives in the Congress and the Senate. I think, it is probably a waste to write my senators. They have never voted for anything I support and I doubt they ever will. I just like to keep them aware that one person is working to get them out of office.

Again, what do we have to fear? Right now we have insurance company bureaucrats telling us what to do in order to keep their profits. Isn't it time for a health care system more concerned about care than profit?

I had the opportunity to attend the Retail Clinician Education Conference in Orlando, Fla. this week August 3rd-5th. I did not attend the conference last year and was very excited to attend this year.  

The presentations at the conference covered a broad range of topics in clinical education including dermatology, asthma, OTC cough and cold treatments, and vaccinations. An introduction to homeopathy and dietary supplements was a very nice addition to what we traditionally have in clinical education. The seminars I thought were most intriguing included the presentation on health policy in which members of the CCA presented great information on the past couple of years and battles and legislation that has impacted the retail clinics.   

The CCA or Convenient Care Association was established in 2006 when retail was in it's infancy and there were only 150 clinics. Now with over 1200 clinics the role of the CCA will be even more important. The CCA delineates their focus as 1) establishing quality care standards 2) providing industry education and 3) addressing common policy and practice challenges. The CCA is made up of an executive board and an advisory board, and they have a number of secondary committees.   

Many of the members of the CCA were in attendance at the conference and it was a real treat to hear from them and share their passion for the industry.  Hearing about all the proactive legislative interventions that the CCA has been involved in around the country was very reaffirming that NPs are making headway, there are people who are behind what NPs stand for and what we are trying to do in healthcare today. Healthcare reform was discussed by Barbara Safriet, JD, LLM, Associated Dean for Academic Affairs and Lecturer in Law (retired), Yale Law School. Her perspective was refreshing and shared by many of us in health care today.  What is going on today is not true health care reform, rather insurance reform. There is a lot of work to do. 

The good news is NPs are making a difference every day and we are getting the support we need to continue to make policy changes that positively affect the way NPs practice, which in turns impact the way we care for patients, the aspect we are most concerned about. 

The word "rude" in the dictionary means lack refinement, cultural, or elegance. Another definition that I found on the Internet is "an impolite action, contrary to the usual rules observed in society, committed by one person against another." I think this is the best definition to describe the people I am talking about in this post. The behavior of these poeple can be considered against the present customer in the office or against the nurse practitioner.

For a lack of a better word, I would like to talk about rude customers in retail health. I have noticed that this behavior is not limited to any particular race, ethnicity group, or nationality, but it does seem to happen with males more often than females. This behavior is not necessarily connected to any meticulous situation or circumstance. Dealing with rude customers is a challenge for me in the retail health field.

I will start with an example of what I mean by "rude." I am sitting in my office taking care of a customer. The sign next to the door states, "with a patient" and the window is clear; therefore, my action and the customer's presence can be seen by everyone. On the table next to the sign-in log is a sign that states, "Please sign in, take a seat, and I will be with you shortly."

A patient bangs on the window immediately after signing in and yells, "How long will you be before I can be seen?" I actually saw the person walk up to the table and sign his name on the board. Now do not get me wrong, if a patient has been waiting for 5 or 10 minutes and wanted to know how much longer that is a different issue. What bothers me the most is that if this person went to his doctor's office, he would not walk up to the office and demand to know how long before the doctor will see him.

I will tell you how I handle this situation. Being the professional that I am, I counted to ten, took a deep breath, kept myself calm, smiled, and point to the sign that says "with a patient" and continued to take care of the current client. What was most disturbing is that he actually got an attitude and walked off talking under his breath. I thought respect for others was taught early. However, this particular patient did return an hour later and we both acted as if the previous incident never occurred.

Another example: A patient walked up to the closed door with a sign that says "with a patient," swung the door open, and began to engage in a conversation with no regards to the person I am presently taking care of. How rude is this?

I politely said, "Sorry, but I am taking care of another customer at this time, I will be with you shortly." He glanced over at my present customer and continued to tell me his problems. I had to ask him twice to please close the door and sign in to be seen. 

What is missing? Are these cases of lack of respect for the nurse practitioners or are people in today's society just rude? I continue to get similar cases each week, and I am trying to determine if this rudeness is related to a personal defect or a lack of respect for the profession. The question remains, why must I police grown adults daily? Why do they not behave with respect and courtesy?  Are there other NPs out there feeling my pain?

I attended all 5 days of the AANP national conference in Nashville; I really had an interesting time.  I met many NPs from all over the United States. 

I cannot comprehend how very many different roles that NPs are filling. Every possible field of medicine was covered from neuro to OB, trauma to psych, family practice to ER. What really surprises me is the number of specialty roles NPs fill. I listened to a speaker who is running a clinic in a maximum-security prison and not just doing infirmary care but adult family practice, internal medicine and nursing home type care then throwing in hospice too all within the confines of a prison. I was really interested in the palliative care hospital programs. This is one way that NPs will get noticed and will make an NP's value apparent to the big hospital systems if managed correctly. What about those who are first assists in surgery, being billed thru the hospital or physician or even more impressive being their own boss and contracting themselves out to surgeons. There were NPs who are managing ICUs and really performing intense critical care skills inserting lines and trachs and all I can think is, "Amazing!"

Quick clinics, urgent cares and the ERs are showing the community that NPs are fully capable of meeting their needs. 

Then there are the pioneers who have the guts and drive to hang their own shingle and practice as they see a need, dancing to their own beat.

This only confirms what we have been hearing all along, that an NP is able to perform in any environment given the training and the desire.

I was surprised that all of these roles are so very different from each other. It made me really think, "Do NPs really have anything in common?" I talked to so many NPs my head was swimming but it brought me to this article and...

I found that one thing we all seem to share.

The worry and concern we have for our patients. The need to care for them. The craziness of trying to figure out how to make health care affordable to our clients.

The bottom line is that no matter what field we practice in, we remain true to our first calling: that of nurse. A nurse is responsible for the treatment, safety and recovery of acutely or chronically ill or injured people, health maintenance of the healthy, and treatment of life-threatening emergencies in a wide range of health care settings. Now we just go a litle farther in our quest of helping those around us with our ability, skills, experience and knowledge bringing more to our patients. It really makes me proud to say I am a nurse practitioner.

The other day a patient presented for evaluation with left arm and chest pain. She was immediately sent to the emergency department. There have been many instances when patients have presented with that same complaint and other acute emergencies like abdominal pain, severe headache or severe cellulitis, to name a few (they were also referred to the ED). We also have patients requesting medication refills for their chronic conditions; many have been out of them for a long time.

I appreciate the confidence these patients have in us. We could take care of them in the correct setting of course. But, as we know, presenting in an office setting of any type with these inappropriate conditions can be potentially detrimental to patients' health.

I believe that most people are aware that we are here for nonurgent episodic care. But now in this time of high unemployment and no health coverage, people are desperate and not always thinking clearly about their best health interests. For example, they hope that we can look at them and tell them they are not having a heart attack.

Some of the stories people convey about their circumstances will tear your heart out. They've been out of work for a long time, or they've just lost their house. It takes a lot of talking and convincing to persuade some of them to go to the emergency room or urgent care. We keep lists of local health departments, physicians, local indigent clinics, etc. We also try to keep a working knowledge of other types of programs available for people who are underinsured or have no insurance at all. For example, we have a program in Georgia called Breast Test and More for women 40 years old and over who are uninsured which enables them to get their pap and mammogram at reduced or no cost to them.

Educating people about the things we can do in this setting is a very important part of our job. Educating people about how to access appropriate care is a vital part of our job and one of the things we do best.