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First Year NP

Preparing for My First NP Job
June 1, 2015 1:01 PM by Fawn Workman

Well, it's been a long time since I have had the opportunity to write a blog. I've been busy with a shoulder surgery on my dominant side! Nothing like some slings, PT and lengthy recovery to make my transition into my first job- and move across state- nice and smooth.

Seriously, though, I have had excellent results so far with my shoulder. My physical therapist is a shoulder guru. I have newfound appreciation for what goes on in PT as I watch the other patients around the gym recover from sports injuries (as young as 6 years old), knee replacements, and a spattering of other things- like shoulders. Shoulder surgery hurts. The process for finding the right surgeon was frustrating and almost comical. I drove to four cities, saw four experts, and had four different opinions. No wonder patients can get confused. I was confused. Ortho is not my strong area...I need to find a way to continue to grow in my skill set.

So, now that my shoulder is almost fully recovered, and I'm driving and packing like crazy, I've had time to reflect on what looms ahead.

My first NP job.

Yes, finally, after 8 months since graduation, surgery, moving, ups and downs I am T-minus 1 month to start. I recently met my collaborating MD (required in my state) and I like him. I think we will work well together as I start out in a primary care office. Later this fall, my walk-in retail clinic will be open and operational.

Am I nervous? OH YEAH.

I expect several sleepless nights in my future. I'm concerned I've forgotten absolutely everything that I've learned in school - which ended 8 months ago!

Now, I know that can't be true. I was a good student. I know (knew?) most of the major national guidelines well. But the fear of making a mistake- messing up when there is no preceptor safety net- is real.

So, here's my plan: I'm going to do what I can, when I can, the best that I can, and I know I'm going to make mistakes. I pray none are major. I've seem new MDs go through a year or two of feeling their way and getting into the groove of things, so I'm sure that it will be a similar process for me. The knowledge will return from the deep recesses of my brain. I will have to ask for help. I will occasionally feel like a failure. But I know I won't stay one.

I feel like the AANP conference will be a great way to refresh my memory and keep up to date with guidelines. I've been to the last two, and had a great time. I strongly suggest it to any student who has the opportunity to go. I'm sure it will be just as valuable for my first year of practice as well. I think I will focus on what the most common things I will come across in my first year, rather than the previous years when I did a mix of common and specialty interest areas. I expect to get a knowledge and confidence boost, as well as a fun time out of the New Orleans conference! I'll see you there!

Rejections, Offers and Moving, Oh My!
April 7, 2015 12:05 PM by Fawn Workman
A lot has happened since my last blog entry. I've been on several interviews from the ocean to the hills, rural to bustling cities. Recruiters have ranged from being fantastic to unprofessional. Interviews: some have been like root canals and some really were fun! I've had some interviewers that were very easy to talk with and I could easily imagine myself working alongside them in collaboration. And I've had some that were a bit obnoxious, even downright rude! This absolutely amazed me. I’m very glad that I got to see their true colors in the interview process, and not after I began working there.

Rejections stink, but I’m thankful for them, too, because that means that I wasn't meant to be there in the first place- or at least not at this point in my career. A few of these places turned me down in a fantastic way, and told me how they thought I was really the type of person/NP they were looking for, except that I didn't have that E word. Yes, experience. (It’s a kind of a big deal). A different location in the company did offer me a position. I liked the people there, and I would love to work with a rural/underserved population at some point- not to mention the possibility of loan repayment. This is a company that I can see myself working for in the future, but not at first.
There were a few other offers that I turned down. 

Now, to tell you more about my new job! First, the recruiter was very helpful, and since it was across the state, she set up a hotel for two nights for me. It was nice- other than my fellowship interviews, no other company has offered to do this, despite most of them being a substantial drive for me. She also had a real estate agent come by and discuss the area with me. During the interview, everyone gave off a positive vibe. Something felt very right about this place, and I was fairly sure that I would be offered a position. Afterwards, I had some questions, and the recruiter answered them quickly and completely. I asked for the opportunity to meet providers in a similar retail clinic (part of a larger healthcare system) in another city, as this one is not yet built. I enjoyed talking to this NP, who was a new grad when he began in this setting as well. He enjoyed his work, felt well supported, and was fairly autonomous. Sounds good to me! The HR team called and made an acceptable offer that I took several days to consider before giving my yes.

Now, to get ready for the move and beginning a new career! Moving is tough- especially since there are a few extra things going on this month that will complicate it. My clinic won’t be built until July, so I most likely won’t begin work until June. I’m happy about this- it works well for a few important events between now and then. But I’m also a little bummed- I’m so ready to finally begin practicing, I can almost taste it.
Nervous? Kind of, but ready!
Career Decisions
February 2, 2015 5:08 PM by Fawn Workman
I'm currently taking a break from writing my thank you cards for four interviews this week. I interviewed the practices as much as they interviewed me; I intend to find the right place for me, where I am able to enjoy my daily work and grow as a professional.

The problem is, I had a good experience at many of my recent interviews, and I am looking forward to those coming up next week. The positions range from inpatient acute care to outpatient primary care, and from specialty to generalized fields. They offer different patient types, patient loads, schedules, benefits, work environments, and stress levels. "NP-topia!" my friend exclaimed. Indeed.

I may not be offered any of these positions. It can be a tough market out there for a new grad; I have friends from school that are still searching for their first position six months after graduating. Some are trying to find jobs by moving across the U.S. It is a huge decision for a family to move for the best position. Many new grad NPs resort to working as an RN, sometimes because the pay is better as an RN versus new grad NP.  I'm fortunate that I have the ability to move for the right position, but I'd be leaving a lot of friends and other comforts behind. Sometimes you have to let go and move on to something better.

Assuming I am offered more than one of these positions, how should I decide which to choose? I utilized a spreadsheet to decide on my NP program by making a list of all the options with their cost, GRE requirements, location, length of program, reputation, and personal factors. It came down to three: a nationally known university, a regionally known university, and a semi-unknown university (unless you are a NP or midwife). In the end, with prayer, I chose Frontier because it had a palpable heartbeat for patient care.

So, I guess it's time to make a similar spreadsheet. I'm going to include notes from my interview, including gut feelings. Those are so important. Additionally, other factors to consider include salary, location, work environment, patient type and load as well as special interests, work schedule, autonomy and collaboration among providers, orientation, respect and understanding of the NP role, contractual obligations and benefits (insurance, vacation, CMEs, sick time, retirement, etc). This is just a running start.

But how do I weigh each of these items? That is going to take some thought and prayer. Some require moving. Some require a varied schedule. Some are inherently more interesting, some more stressful. I have turned down a few positions already because I don't think they are a good fit for a new grad. Then, there's the issue of salary, because I have to face the facts that student loans are now due. The most rewarding jobs are not always the best paying ones. I will give a lot of thought and consideration for each of the contracts extended to me. Until that point, bring on the next interview!
Frustrations and Refreshments on the Job Hunt
January 20, 2015 8:58 AM by Fawn Workman
One night last week I applied to a position that said "FNP/ PA needed in Virginia- Family Practice! New Grads Welcome!" The next day I received a reply: they are no longer considering new grads. False advertising, huh? One recruiter for a large hospital system completely missed my appointment. And yet another hasn't returned my emails lately.

I've read a great article by Barton and Associates, which can be found here. This article discusses 5 key points (besides salary) that you should consider when you go into an interview. I firmly believe that the people you work with will make or break your day. You can have a terrible day, but work with people who are willing to jump in and help, or you can have a wonderful patient load, but work with nasty or condescending people. Finding the right group to work with is my goal- a team that recognizes and respects me as a growing NP and as a person. Reading this article changed my approach to finding my first position.

Up to this point, most of my recruiter conversations were over in 5 minutes, and it would go something like this: "This is a specialty or family practice position. The hours are "x." This next position is "x" and you would take call "x." Do you have any experience? Ok. I'll send these to the offices and they'll contact you if they are interested."

But last week, I applied for a position and the new recruiter and I talked for half an hour. He had actually reviewed my CV and made notes. He complimented my strengths, asked about my philosophy of care, and what I wanted most in a position. I felt comfortable speaking with him because he actually seemed to want to make sure the position and I were well matched. He also conveyed an attitude that nurse practitioners are vital players in their healthcare organization.

I took a deep breath- I had found a page on their site that used the term ‘midlevel' provider. Should I say anything? I've said things to recruiters before, but often it was just brushed off. (I've educated quite a few recruiters this way). I said, "I know the position advertisement seems to convey respect for NPs, and what you are telling me does as well, but I wondered about this page I found on your website...."

His reply was akin to "Oh, no, we have to take care of that right away. Thank you so much for bringing that to my attention." It was such a breath of fresh air. I sent him the link, as well as the link to the AANP position statement on terms used to describe NPs. However, I thought he may have just said what I wanted to hear. The next day, though, he sent an email that stated the upper level management of the health system was very thankful that I brought this to light so they can fix it. I don't know if this will be my new job, but I can say I am happy to have found a place that seems to put their words into action!

The New Role: Family and Friends
January 5, 2015 10:28 AM by Fawn Workman
Happy New Year! I hope you had a great holiday season filled with the warmth and love of family and friends.

A few months ago, a physician friend told me that a prophet isn't accepted in his hometown. Basically, he meant that it would be hard transitioning from the role of nurse to nurse practitioner in the eyes of those who knew me as the former. I think this translates outside the medical community, too.

I have many family members and friends that are very happy for my new career as a Family Nurse Practitioner, but I find that many still don't know quite what it is I will be doing. Although I have this degree, I will always be their "little Fawnzie." And so, I know any advice I give will not carry the same weight as if I were not their family member at all.

"Aunt Louise, the symptoms you have are likely a UTI. Please call your physician and get seen- you may need an antibiotic to clear this up."  Two weeks later, Aunt Louise finally gets seen. "You know what Fawnzie? The doctor said I had a UTI and need antibiotics. How about that- I'm so glad I went to him. He knew exactly what to do." (Insert face-palm).

As a nurse, I think most of us are used to having people at any gathering ask us about some ailment. And it doesn't get any better when they find out that now you are an NP. "Can you look at this rash/ mole/ bulging knee/ tooth/ throat?" or "Do I really need this medicine?" But if I suggest that they need to get seen for something they have no desire to get seen for, then I am back to being ‘just Fawn'.

I am not dishing out advice or care- on the contrary! I've tried very hard to avoid this since early in school. I admit, in my naivety as a brand new NP student, I was honored when many friends and family said they wanted me to be their NP when I finished. Then I began to realize how slippery a slope that could be; there are several legal, ethical, and relationship reasons it is a bad idea.

Another aunt has recently been to an urgent care for the last three days for an abscess. Despite her hoping I would/could take care of it, I just can't and she understands. However, I can be there for her without being her provider.

No, once I start practicing I will not be professionally seeing family and friends- in or out of the office. I hope my friends and family know it is for both of our protection that I make them go through the hassle of seeing someone else, and they should establish a good relationship with a caring provider (NP/PA/MD/DO). And then, in their mind I can go back to being 'just Fawnzie.'

Well, until the next holiday gathering that is. "Pass the peas, Fawn. Could you look at this bunion?"

Merry Christmas and Happy Holidays
December 22, 2014 9:56 AM by Fawn Workman

The deadline for this blog snuck up on me. The last two weeks of my personal life have been very, very busy, and Christmas is just around the corner.

Since my last blog posting, I have found out that I was not accepted for the second fellowship position, either. This was very disappointing to me, as I felt the interview went well and I was a good match for them, too. But, there must be something else out there for me.

I have been a certified FNP for just a month now, and it feels so good to be done. With the craziness of my personal life this month, I have fallen behind on getting my license registration completed. I need to renew my nursing license this month, too, but there was a hang-up with the payment process and I have to wait. After that, I will need to jump through the hoops of the NPI and DEA. And insurance.

But for now, I am just getting through Christmas, and enjoying time with friends and family. Who knows where I will be next year, or what I will be doing. I may not have the opportunity to take this kind of time with loved ones in the future. I need to consider family and down time as I continue to look for a new job. From a NP networking group on Facebook, I see a myriad of work schedules- some 8-5, some 4 or 5 days a week, some with lots of call and some with no call. The situation is as varied as the NP. I question my negotiating skills for salary (which seems rather low in my area), work life and benefits as a new NP. And yet I know that, given the right environment, I will soon be a productive and effective NP, I think the odds are stacked against me for having much say in the matter. That doesn't mean I won't try.

I have considered working for a Federally Qualified Health Center (FQHC) in order to apply to the National Health Service Corps Loan Repayment Program. The other day, I opened up my mail to see my final loan amount. I felt a bit dizzy after that. When the stars stopped spinning around my head, I realized I need to figure out something very soon. So, just after Christmas the massive hunt for a new job, a great job, begins. While I would love to stay in my current city, and I could make it off of what I hear the going salary for a new NP is here, I am open to moving somewhere else within the region. I also will have to weigh the pros and cons of having a higher salary that can pay of the loans faster versus a potential job with a lower salary at a FQHC that I MAY be able to get a loan repayment down the road.

There's a lot to think about. Here's to happy job hunting! And a Merry Christmas and Happy Holidays to each of you and your loved ones!

The Waiting Game
December 8, 2014 1:54 PM by Fawn Workman

December 2nd. It is currently 2:20 pm, one day after when we were told we would find out who got into the second fellowship I applied to and interviewed for. The date changed at least once - at first we were told we would know by the Monday before Thanksgiving, and then it was changed to December 1st. This is the fellowship I interviewed for the day before I took (and passed!) my boards.

I called and was told that the secretary is still making calls. I don't know what to think. The day has slipped by, and I'm trying to not let my mind wander back to whether I made it or not. I reason that maybe they are going in alphabetical order, and I am at the end. But deep down I think that I didn't make the cut.

What if I did get in? It would be less pay than a new grad NP, but a great experience: living in a new city, learning new procedures and intensive experiential learning sessions - just up my alley. Although I learned a lot in graduate school, I want to learn more deeply in real life.

And what if I didn't get it? My friend Alicia texted, "Then that means there is something better for you out there."

Another person who interviewed the same day for the same track texted me at 5:30 pm. He got in. Still, no call for me. I congratulated him. "Thanks. Hope it works out," he said. "Me too," I thought.

December 3rd. 1:30 pm. I called and reached another one of the secretaries. I remember she commented my essay was great. I asked when we would know, and she said that the letters would be sent out this week. "So, if we got a call, we were accepted; and if we get a letter, we were not accepted?" I asked. "Yes, that's correct," she replied.


I really thought this interview went well, and I liked the people and the area. I was really excited about the possibility of a fellowship. I wonder if it is something about me, something I said, or did, or didn't do.

Rejection hurts. I web-searched a list of famous people who failed or were rejected time and time again early in their careers. The list includes Sir Isaac Newtown, Walt Disney, Lucille Ball, Winston Churchill, Thomas Edison, Van Gogh, Dr Seuss, Steven Spielberg and many more. They didn't find their calling, or didn't have others see in them what they knew deep down, but they never stopped. They pushed on.

I know that there are only so many available openings for a position. There is a chance I'm on the wait list, but the waiting game is over. At least now I know, and can move on. My former instructors and preceptors have faith in me and my abilities. I have several areas of interest that I will continue to seek. There are many bright possibilities in my future, and like my friends and family say, "something better is headed your way!"

Boards & A Second Interview
November 24, 2014 12:04 PM by Fawn Workman

I'm not sure how to describe my experience of taking national boards. Maybe I should just explain. This is by no means my endorsement of my methods. For one thing, I'd recommend more study time.

I passed a predictor exam about a year ago. After passing my school's comps, I listened to review courses CDs as I drove, and spent some time in my review and quiz books. But I didn't do a live review course, or spend several weeks studying. I signed up to take boards several weeks before I finally received my authorization to test (ATT). There were some good available dates in my city. I waited a week, then I searched for my city's availability again, and all of a sudden, there was nothing that worked for me. I searched other nearby cities, and available dates started to disappear like crazy.

Out of desperation, I looked at the distant city where my next (second) job interview would be in two days. There was a date available, the day after my big interview. So I took another predictor exam, and I passed with a good margin. I felt fairly confident, so I signed up to test.

And so began the marathon of studying.

My interview went well, I think (and I hope they think so too!). I enjoyed the process much more than my first job interview. Perhaps that comes from just being my first interview as an NP. This organization had very nice people, their Advanced Practice Providers initiative was innovative and encouraged NPs to work at the fullest scope of their practice. I felt very comfortable there, despite the following things: 1) Having boards looming over me the very next day, and 2) Being in the middle of a big interview, and 3) During a break, I checked my email and found out I didn't get the job from the first interview. I thank God for giving me such peace through everything that happened that day.

The next day, I arrived at Prometric early and a bit anxious. I immediately wrote down all sorts of things I might have a hard time remembering. Then I went to start the test... and my mouse didn't work. I was re-set up on another computer. Some questions were really, really tough. But a well-known review course leader told me "don't expect the test questions to look like anything you've ever seen." And she was right. I kept as calm as I could, and tried to consider each question carefully. I felt mentally beat up by the end. After reviewing about 20 of the ones I flagged, something in me just said ok, you've either got this or you don't. So I hit enter.

And I waited.

The next screen was a survey - are you kidding me? All I really wanted was to know if I passed or failed! I did the survey anyway. Then it came up: preliminary results show you have PASSED. Passed!!!! Oh, happy day!

Celebrating NP Week!
November 10, 2014 1:16 PM by Fawn Workman

Nurse Practitioner Week is November 9-15, 2014 and as of 2014, there are more than 192,000 NPs in the US. That's up from 140,000 in 2010 - a huge jump that is expected to rise to 244,000 by 2025!

Since I first entered my master's NP program, I have been involved with my local chapter of the Virginia Council of Nurse Practitioners. I have had so many positive experiences with this fine group of NP leaders! Their support and encouragement have really helped my transition from RN to NP student to new NP. While I love being a small part of the AANP at the national level, and the Virginia Council of Nurse Practitioners at the state level, it is this local chapter environment that is so very important to me. Through this organization I have learned about legislation that may affect NP practice, advocacy, changes in billing and coding, new drugs/ drug updates, local treatment options for certain conditions, and the list goes on.

Every year, we participate in NP Week. Usually we have one of the local governments sign a proclamation of NP Week, and we always have some sort of community involvement - in years past it has been collecting books for underserved kids and highlighting our free clinic NP volunteers. This year, we plan to raise money for local cancer patients' needs.

Awareness and change starts locally and grows. There are a hundred small ways you can be proactive in celebrating NP Week! You don't have to do anything huge (no bullhorns and clashing cymbals required!), so here are a few small ways you can join in the fun.

  1. First, thank an NP who helped get you where you are today!
  2. Display some NP facts in your reception area.
  3. Send a letter or press release to the PR person or CEO of your organization, highlighting some of the specific ways you and your NP colleagues are making a difference in your workplace and community (see the AANP [2014c] tool kit).
  4. Perhaps you can meet up with your local NP association and team together on a project to highlight NP week or volunteering in your community.
  5. Call your legislators, let them know it is NP Week, and thank them for their support on some recent matter that positively affects your practice and patient care.
  6. Social media is a great tool too, and remember to always use professional common sense and etiquette when sharing!

So, how are YOU celebrating NP Week?

I hope you have found a local NP organization to become a part of- and if not, find yours today! The AANP (2014a) can help you find your regional and state organizations. Here's a link to get you started: http://www.aanp.org/about-aanp/regions

Here's a great resource for sharing NP week with the public and your organization! http://www.aanp.org/all-about-nps/np-week


American Association of Nurse Practitioners (2014a). About AANP- Regions. Retrieved from http://www.aanp.org/about-aanp/regions.

American Association of Nurse Practitioners (2014b). Historical timeline. Retrieved from http://www.aanp.org/all-about-nps/historical-timeline.

American Association of Nurse Practitioners (2014c). NP week. Retrieved from http://www.aanp.org/all-about-nps/np-week

Just Breathe
October 31, 2014 3:55 PM by Fawn Workman

I'm Fawn Workman and I am a brand new MSN graduate. I'm so new that I'm still waiting for a test date for my FNP boards! I'm glad you have come to read about my thoughts and musings on my first year as an NP.

Since April, I have logged several thousand miles driving for clinical in another state while living with family members. I've also flown to Nashville for the AANP conference, to Kentucky for my school's diversity weekend and to Oregon for an externship at the Indian Health Service. I am really thankful I had these awesome opportunities, but all this busyness can create unseen muscle tension.

I once watched a Physical Therapist demonstrate the relaxation of muscles with simple deep ‘belly' diaphragmatic breathing while the participant was hooked to a machine. It was amazing to see the release of so much tension with a few deep breaths.

So I decided to splurge and take a graduation celebration trip to Hawaii.

Ahhh... It was so nice to just breathe, to sit back with one of my BFFs and take in the warm, soft sand between my toes, smell the salty air of the most beautiful ocean, to just relax and have fun. I thought about sacrificing some of my school materials to the volcano, but unfortunately there aren't any active volcanoes on Oahu.

I didn't want to leave Hawaii. After about 16 hours of air travel (seated near every misbehaving child or crying baby), reality - with all its to-do lists - waited for me on that tarmac. Plus a few extra surprises.

Maybe all that yoga and Lamaze breathing works, after all...

I graduate this weekend. When I walk across that stage, everything I have worked for these many years culminates in that moment: all the blood, sweat, tears, friendships, heartaches and triumphs of the past three years. I want to run up to my friends and shout, "We did it!" It will be awesome to hug mentors and instructors. I hope my family enjoys the weekend and see all the things I want them to experience in a short amount of time. After getting back this weekend from the six-hour trip, I will immediately have my first NP interview. (YAY!) But, no stress, right?

What was that I said about breathing? Oh, yes, Fawn. Don't forget to breathe! Be thankful, pray, and enjoy every bit of this weekend-every crazy, wonderful, exciting moment of it. Inhale, and exhale. And smile!

So, tell me, how do you relax? Are you a student just trying to make it through the next paper, or a new NP trying to make it through the next day? Remember, every day is a gift. Hug someone you love, have a cup of tea and breathe! And maybe get a massage too! ;)

And Then There Were None
September 22, 2014 12:41 PM by Katrin Moskowitz

One year ago I was offered the wonderful opportunity to blog for ADVANCE for NPs & PAs. I was unsure if I would be able to provide any words that would be beneficial to the community, as I was having a hard time even thinking of myself as a practitioner. One year later, many things have changed.

I enjoy going to work every single day. The challenges and learning opportunities continue to occur on a daily basis and I feel that my knowledge base is ever expanding. Over time, I have built relationships with new co-workers and have discovered how to delegate, consult and make decisions. There are many areas that I would like to continue to develop, including EKG interpretation, x-ray interpretation and complex wound repair.

The patients have been very receptive to my new role and have been a pleasure to work with. I continue to love working with the various age groups throughout the day, as it keeps my mind fresh and adaptable. Are there interesting patients along the way that make you think on your feet, or just shake your head? Sure, but in the end, they leave you with a better understanding and an increased point of view.

I continue to progress in my Doctorate of Nursing Practice program at Frontier Nursing University. It has been a challenge, but one that has been accomplished in baby steps. If I had to choose again, I am not sure that I would have jumped on board in the program so soon after graduating from the FNP program. There is a lot to be said about gaining clinical experience in order to choose a capstone project that one is passionate about. The faculty has been supportive and has provided positive criticism in order to develop myself as a doctoral student.

The greatest lessons I have learned over the past year are to be open to change, adaptable and continue to be compassionate. Challenges will always arise; embrace them, solve them, and learn from them. Do not be afraid to ask for help whether from fellow practitioners or support staff. Love what you do, if you do not, then don't do it. Last but not least, I have learned that I need to take care of myself. Heading back to the gym and adjusting my nutrition has made me feel that I can be proactive and speak to my patients from personal experience. Do not ask a patient to do what you are not willing to do yourself.

Thank you for allowing me to share my journey. Buckle up and pave your own way, be ready for bumps in the road and most importantly: Enjoy the scenery!

A Wolf in Sheep's Clothing
September 8, 2014 10:54 AM by Katrin Moskowitz

My experiences with patients have been very positive since I have come into practice. Most are able to communicate their complaints effectively and some may even tell you exactly what antibiotic they want, or what they believe their diagnosis to be. On occasion they may ask for things that are clinically inappropriate and at times may make my eyebrows rise.

In the state of Connecticut, nurse practitioners are able to prescribe schedule three medications. This can be a double-edged sword. In the setting of urgent and emergency care, there tends to be more prescribing of controlled medication that occurs due to the nature illness and injuries. I consider myself an appropriate prescriber, but have to make sure that I listen to that "inner voice" when situations and circumstances do not add up. As prescribers in CT, we also have an online database that we can utilize to see how many controlled medications a patient has been filling. This has been very helpful in order to verify or disprove my suspicions.

I will be honest: I do not like when patients openly lie to me or try to pull a fast one. Who does? Just recently I had a patient who truly tested my patience.

She was a 50-year-old female who came into urgent care as a self pay patient for back pain. She stated to the medical assistant that she tried to get into her PCP that morning, but that they were full and would not prescribe anything unless he was physically seen by a provider. She was due to start physical therapy the following week and did make an appt with her PCP in 2 weeks. The MA asked that I look her up in the database as she was acting suspiciously. She had had several months of narcotic pain medication prescriptions, but had a documented case of a severe staph infection that required multiple skin grafts. I went in to evaluate her and diagnosis her with back pain with sciatica. The patient was told that in no way would she be prescribed long term pain medication in this setting and I would prescribe her medication to last through the weekend (her visit was on a Friday). I also wrote a letter to her PCP stating that I saw her and the plan of care and the need for them to follow up with her. The next day she calls asking if I would increase the dosage of her pain medication and she was told no. I was off for the weekend and she ended up coming back and telling another prescriber the pain medication was too strong and that she needed a different lower strength narcotic. The per diem prescriber changed her prescription. On Monday she came in again asking for a "less strong" pain medication. Unfortunately for her, I was back and knew what she was attempting. I brought her into the room and told her that she needed to follow up with her PCP and that she would no longer receive controlled medications from this facility again due to her dishonesty. In her last ditch attempt she asked me if I could "give her a few Tylenol # 3" to get her through.

I was angry - really angry - and needed to remove myself from the room. Maybe I am still naïve and think that patients all have good intentions, but these patients make me rethink this notion. I know that I need to keep myself neutral as not every patient ends up being a wolf in sheep's clothing.

Those little things
August 25, 2014 12:53 PM by Katrin Moskowitz

There are days in practice that the hours go by without you realizing it. Patients are in and out quickly, you work hard to complete your charting and tasks become second nature. Then, certain patients come in and make you smile with the things that they say, the mannerisms they exhibit or the way they look at you. Children are the most honest, and how they see the world is eye-opening.

This week I learned about volcanoes, silly sticks that cause toe injuries and worries about "ouchies." In the world of urgent care and the ER, children often are most afraid of things that will cause them pain. I have been very fortunate that I have never (I am knocking on wood at this moment) to now have to swaddle or restrain any child prior to suturing. I will give most of the credit to the wonderful medication LET, however I also would like to give some credit to my approach with the smallest of patients.

Recently I have found that asking what the patient is most afraid of helps to get that fear directly out of the way. Of course, this can be applied to the older children and adults of this world, as well. I have also found that kids are often frightened by my suture tray and all of the scary, shiny instruments it contains. I now compare myself to Bob the Builder. I tell the kids that while Bob fixes things, I fix people, and that I would be coming in with my people-fixer tools. Because I often have extra hemostats that I end up not using, my little patients get to hold a pair to see what they feel like.

The relationship that I build with the kids rubs off on the anxious parents, and often the whole family leaves not only fixed, but happy and relieved that their visit was much less traumatic than anyone had anticipated. The visit often ends with a nice sticker (and a sigh of relief from me).           

A patient said to me today, "You don't just hear me, you actually listen." This makes my heart feel good all around.

It's Not Always About the Medicine
August 12, 2014 8:44 AM by Katrin Moskowitz
From August 3-8, I went away to Boy Scout Camp to work as the nurse for the week. This is the first year we have been involved in the organization with my six year old son and the first year that we decided to send him away to resident camp. The mom in me decided that there was no better way to be watchful than to be on the same property as him, but to give him space to grow and learn amongst his peers.

As a professional, it took me out of the hustle and bustle of electronic records, x-ray machines and telephones. It took me into nature, amongst hundreds of excited children, and back to tender loving care, Band-Aids and high fives. It reminded me that no matter where you are in medicine, it is not always about that. It is being holistic, knowing where your patient is coming from and how to make them feel better right in that moment. As a person, it has allowed me to be calm, creative and centered.

This too ends and the real world of medicine awaits me yet again. But I return refreshed and more understanding for individuals. I hope that the kids and adults alike enjoyed their time here at camp, and if they had to come visit me, at least left with a smile.

I reminisced at the fact that almost a year ago I was finishing my clinicals and was on my way to starting a new, exciting career. It is truly hard to believe that time has gone by so quickly but am excited to find out what year two has in store for me. There are definite professional hopes that I have, and I believe that you truly can never stop learning.

The kids at camp taught me how to be a caring provider while showing me the joys of GAGA ball, whittling, songs and dance, and outdoor life. Thank you, Camp Workoeman!! Do not ever doubt yourself; remember where you have come from and where you can go with your profession as an APRN. If you are on the journey of getting there, keep going, don't stop and never look back!



NP's Orders
July 28, 2014 10:53 AM by Katrin Moskowitz

There are not many things that frustrate me in my clinical practice. Most patients are open, receptive and leave shaking their heads in agreement to your plan of care. What happens once they leave your office is often unknown. You hope that they venture directly to the pharmacy, take their medications as prescribed and their health improves.

What I am occasionally finding is that my hope of 100% patient compliance is just a dream that I have comprised in my own mind. As a new practitioner, I really focus on patient education: informing them of the expected course of illness, how to take the medications, possible side effects of those medications and, of course, things to be concerned about.

In our urgent care, we encourage patients to come back for rechecks for common procedures such as suture placements and incision and drainages - we want to make sure things are improving as expected.  I am amazed at how many patients decide that they do not need to start their prescribed medications because they thought that "things will get better on their own." This in turn leads to worsening conditions, longer recoveries and frustrations on both the patients' and practitioners' parts. Is there an answer to this commonplace problem? Maybe I should be more firm when going over prescriptions, repeating the importance of taking medications as prescribed.

My hours in primary care, as limited as they are, have been quite successful. All of my patients who have come in have completed their blood work and have made improvements with lifestyle changes and follow ups. I enjoy showing patients how they can make simple changes that can last them a lifetime. I know our instructors said we may not be able to change the world but I hope to at least impact one person at a time. My success streak in primary care may be short-lived but I will enjoy it while it lasts.



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