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Archive for April, 2010


New classes start on Monday, Primary Care of Adults and Pediatric Primary Care. Last semester was such a marathon with three heavy classes, going to campus out-of-state for the skills labs for a week, and working, too. I finally have come down and am starting to think a little more clearly. I also realize I am suffering from CRS. (For those of you scratching your heads: Can’t Remember S**t.)

I visualize walking into an exam room with a patient and the parents waiting for me to do something useful for their little tot. The door closes behind me, and the realization hits that I have NO CLUE as to what to do. Pediatrics would have to be the first rotation. I have dealt mainly with older folks for most of my nursing career, and now being one myself, I can relate to their problems. Dealing with the little guys has not been an issue for me for YEARS. My own kids are in their 30’s for crying out loud.

So, groping in the crowded closets of my brain, I try to retrieve all the facts I have been busily stuffing in over the last 3 terms. The labels seem to have fallen off the little boxes. The information is in here somewhere, but seems inaccessible. This is WAY not good.

It never seemed hard to learn and remember things when I was younger, is it true that you can’t learn as easily when you are older? I am somewhat comforted by an article that reports it may take longer to learn new facts when you are older, but you are better at  processing the significance and using the information you learn than young people. Okay, that part is good. So, now the question is, what to do to help learn and remember what I need to.

An article in the Harvard Women’s Health Watch has ideas on how to improve memory for the older person. The first recommendation is to maintain health, Uncontrolled diabetes, hypertension, kidneys disease have all been shown to reduce cognitive function. Exercise is mentioned in this category. I am healthy and we try to ride bike most days for a half hour or more, so that is covered (though hot Florida summers will put a crimp in the bike riding).

Next they want you to keep the brain active by taking a course and learning something new. That definitely is covered and then some.

I like the next suggestion, to use all the senses. Odor is specifically mentioned. Evidently, if there is a pleasant odor while learning something new, you are better able to recall the new material even without the presence of the odor when recall is attempted. Half a dozen scented candles, please! In the bag.

They want you to think positive and not believe the myth that “old dogs can’t learn new tricks”. This old dog is definitely thinking positive. Becoming a nurse practitioner is a goal I have had for a long time, and had to delay for a while. Nothing is going to stop me now. Negative thinking is stinking thinking!

Next, we are not to over-strain the brain on unnecessary things. Like, get organized, dude. Use lists, electronics, designated key and glasses spots, and unclutter the desk. Well, that might not happen so fast. I am a firm believer in a cluttered desk being the sign of a great mind… Oh, you don’t buy that?… Sigh, okay, declutter the desk coming up.

Repetition, repetition, repetition. Say it out loud or write it down. Facts are easier to remember if repeated. And, the repetitions  need to be spaced out for better retention. Check.

Use mnemonics. You know, like RACE for fires: rescue, alarm, contain, evacuate. This has never been one of my favorite devices. I am more visual, pictures and hands on work better than a list of letters like that. We are all individuals and have to tailor things for our own use. 

Daniel Schacter, a Harvard psychology professor and researcher wrote a book called The Seven Sins of Memory: How the Mind Forgets and Remembers (Mariner Books, 2002). He describes common memory flaws, and the ones most common for older people are transience, absent-mindedness and blocking.

  • Transience is the losing of a new memory if it is not recalled. This reinforces the need for repetition in order to remember.
  • Absent-mindedness refers to forgetting because you didn’t pay attention in the first place. I guess that means no studying with the TV or radio on. Focus!
  • Blocking refers to that tip-of-the-tongue feeling, You know you know it, but can’t quite get it out. This is caused by a new similar memory blocking the retrieval. With a little persistence this can be over-ruled and the memory brought out.

Bottom line. I will have to work a little harder, set things up for study with a little more forethought, and repeat more than I did when younger. The good part is the fact that my judgement and understanding is better than it was years ago thanks to many experiences over the years. It’s all good. I’m ready for the next semester. Bring it on.

Thanks Harvard.

References:

Strauch, B., (2009). How to train the aging brain. New York Times December 29, 2009.

 Harvard Women’s Health Watch (HARV WOMENS HEALTH WATCH), 2010 Feb; 17(6): 1-3

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Dr. Keith Ablow, a psychiatrist on Fox news, has posted on his blog the worst diatribe I have read in a long time. Read it here: http://health.blogs.foxnews.com/2010/04/15/nurses-masquerading-as-doctors/

Okay, here is my response. I will do my best to keep it civil. Paragraph by paragraph.

First of all, we will see what is in the future regarding the health care reform, but there is, and has been, a shortage of primary care physicians, especially in poor or rural areas. Patients all over America and many other countries have long received primary care from Nurse Practitioners (NPs) who worked independently, or in collaboration with a physician, depending on the state in which the NP has her license and where they choose to work. This is nothing new. Many studies on the effectiveness, safety and patient satisfaction with NP care point to equal or better outcomes than physician care (I have the references if anyone wants them) in the specialities that the NPs practice in: pediatrics, family practice, adult, and geriatric, to name a few. NPs can and do provide excellent primary and specialized care.

The education includes pharmacotherapeutics, and have completed the requisite hours in order to be able to prescribe safely, and have the same CEU requirements as physicians. Each state has their own laws regarding  NP prescriptive privileges, but NPs write prescriptions in all states. Only 2 states do not allow NPs to prescribe controlled drugs such as cough medication, certain anti-diarrheals and pain medication. I, unfortunately live in one of them, Florida. Sixteen times a bill has been introduced and sixteen times shot down through the machinations of Florida Medical Association lobbyists, in spite of documented proof that NPs prescribe safely.  

As to the right to be called “Doctor”. Doctor is an honorific for someone who has reached a doctorate level of education in any field, Dr. Ablow confuses this with the role of physician. But to answer his objection, NPs don’t generally want to be called doctor, even if they have the Doctor of Nursing Practice degree (DNP). When I get it, I will still introduce myself by my name and title of Nurse Practitioner. In 2015, DNP will be the entry-level degree for nurse practitioner certification, and physicians will have to stop being so touchy about it, we are all there for the patients. It isn’t about ego trips, or shouldn’t be.  The minimum degree now is Master in Science of Nursing (MSN).

Obama care is an unknown entity so far, so calling it two-tiered care is just silly. I see no requirements that “poor” people can only see NPs and “rich” people get a “real” doctor. NPs are a resource for good primary care in a time of shortage of primary care MDs, and a great adjunct in the health care team as a whole. Many patients prefer the NP so money is not the issue. NPs are not trying to replace MDs.

Yes, medical school is rigorous and academically challenging, but so is nursing school. Getting into nursing school is tough, many schools have waiting lists of over two years. The average NP has had many years of education to get to where they are. I myself started as an EMT, then got a Nursing Diploma (3 years with many, many clinical hours), then  got a BSN, (3 years with more clinical), now I am enrolled in a MSN-FNP program (3 more years and 700 hours of clinical time). All in all, I will  have spent 10 years in school, and have 20 years of hands-on experience in nursing. I have worked in hospitals, home health, hospice and case management. I was top of my class every time I went to school, and have a 4.0 right now (and it was not easy!) I suspect most nurses who go the extra time and effort to be NPs are intelligent, hard-working, and driven to help patients. As to physicians having more “raw intellect” than the average nurse – aren’t we a tad arrogant, Dr. Ablow? I’ll match my IQ to yours any day and blow you out of the water.

What you are saying isn’t unpopular, it is untruthful in its insinuations. Suggesting nurse anesthetists (and advanced practice nurses in genreral) are second-rate is out-and-out ridiculous. Many rural hospitals don’t have anesthesiologists available, and would not be able to provide surgical and anesthesia services without CRNAs. Besides, anyone who works in the ER wears a mask and gown “just like the surgeon”, they aren’t hiding or masquerading, just doing their job, you moron. (Oops, sorry, not civil. Will be good…) You pay for anesthesia that is safe, and you get it. It is not relevant whether the one doing it is a nurse anesthetist or an anesthesiologist, they are both credentialed, licensed, and able to do the job equally well.

Also, please differentiate between nurses. I wouldn’t want a psychiatrist to decide if I had pneumonia or the flu, but I sure as hell would place myself in the capable hands of an NP. LPNs and RNs can’t do what you describe, but NPs can and do, and do it well.

  • “How come no one in Congress would be able to tell you a story about that incredible nurse who diagnosed the rare condition in his or her child?” Because the idiots in Congress only listen to the lobbyists who give them lots of money, i.e. the AMA (which only represents 25% of physicians, by the way).
  • ” How come nurses either failed to be admitted to medical school or didn’t try? ” Because they wanted to be nurses. Nurses are closer to patients (in general, there are always exceptions to the rule,  my own MD is a good example), see them as whole people and not just a disease . I was working in the ER and was given D/C instructions for a patient after being seen by the medical person for hematemesis (bloody vomiting). The instructions consisted of a script for a PPI and a referral to a gastroenterologist. When I went in to discharge the patient, I saw he had fresh surgical scars on his wrists. I asked him about them and he explained he had carpal tunnel surgery three months ago. On questioning, it turns out he had been taking Motrin four times a day ever since. “The doctor didn’t tell me not to.” Further questioning of this 20 year-old determined he binge drank every weekend. The medical person never asked.  This situation wasn’t even rare or unusual and he didn’t catch it. In this case we needed to know the cause to be able to treat the problem and prevent reoccurrence, this is where NPs shine because of being a nurse.
  • “You think it’s because they thought nursing school would train them better to take care of patients? C’mon. It’s because nursing school is easier–as in, 10 times easier.” Since you never went to nursing school, you wouldn’t know, would  you? Don’t make assumptions about things you know nothing about. Nursing school is difficult, maybe not as crazy as medical school, but that does not make it less valuable. We go to nursing school because we like the nursing model of health care. We are advanced practice nurses, not mini-doctors.

Nurses don’t impersonate doctors (oops, physicians), they are their own entity; complimentary to physicians, not replacements.

Now a word to Dr. Ablow: Do you feel  threatened by NPs? What makes you so hostile? You are supposed to be a healer of the mind and emotional difficulties, yet you seem  beset by your own insecurities to lash out so. Perhaps you need a consultation with a psychiatric nurse practitioner, they are well-known for their good listening skills, understanding and compassion. 

Okay, I was fairly civil, for a Viking…Sigh, I hate it when I get mad, it never feels good afterwards.

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I have heard it said that an on-line program is not good enough to train someone as a professional medical care provider.

 I have a couple of issues with that thought. First of all, the word “training” reminds me of how you educate a dog, or reminds me of the very olden days when nurses had to stand when a physician entered the room, and “nursing training” consisted of slave labor at a hospital in order to get credentialed as a nurse and you had to wear dresses and a cute (NOT)  little cap at work.

 The following job description was given to floor nurses by a hospital in 1887:

In addition to caring for your 50 patients, each nurse will follow these regulations:

  1. Daily sweep and mop the floors of your ward, dust the patient’s furniture and window sills.
  2. Maintain an even temperature in your ward by bringing in a scuttle of coal for the day’s business.
  3. Light is important to observe the patient’s condition. Therefore, each day fill kerosene lamps, clean chimneys and trim wicks. Wash the windows once a week.
  4. The nurse’s notes are important in aiding the physician’s work. Make your pens carefully; you may whittle nibs to your individual taste.
  5. Each nurse on day duty will report every day at 7 a.m. and leave at 8 p.m. except on the Sabbath on which day you will be off from 12 noon to 2 p.m.
  6. Graduate nurses in good standing with the director of nurses will be given an evening off each week for courting purposes or two evenings a week if you go regularly to church.
  7. Each nurse should lay aside from each pay-day a goodly sum of her earnings for her benefits during her declining years so that she will not become a burden. For example, if you earn $30 a month you should set aside $15.
  8. Any nurse who smokes, uses liquor in any form, gets her hair done at a beauty shop, or frequents dance halls will give the director of nurses good reason to suspect her worth, intentions and integrity.
  9. The nurse who performs her labors and serves her patients and doctors without fault for five years will be given an increase of five cents a day, providing there are no hospital debts outstanding

Another hospital’s rules in 1939 (St. Giles, in London):

RULES FOR NURSES

walk at all times, only run in case of fire
stand when a senior member of staff enters
always open the door for the doctor
never overtake a senior member of staff on the stairs
no make up on duty
hair not to reach your collar
nails must be short
black stockings only when on duty and no runs in them
low heel shoes
on duty by 7.00 am
in bed by 10.30 pm

I prefer to think of my learning experiences as “education”, thank you very much.

So, about on-line versus brick and mortar, I have attended both kinds, pre- and post-graduate versions. It is my experience that what you get out of education is exactly what you put into it, and is also determined by what your goals are,as well as what your instructor’s goals are. Some people just want to “put in the time” to get that piece of paper with your name on it. Others want all A’s, and still others don’t care what the grade is as long as they pass. You know, “What do they call the person who was last in their medical class? Doctor.”

To me, education is about acquiring knowledge and experience, the grade doesn’t necessarily reflect the amount of knowledge you obtained. Whether the course you take is on-line or in a class room is not relevant. The hands-on experience is pretty much the same either way, in my experience. Classroom programs have a lab in the building, on-line programs require you to come to the campus at least twice to attend lab sessions, intense week-long sessions to get the hands on skills of assessment and procedures.

Clinical hours are the same either way. There is a required number of hours you must put in under the eye of an experienced nurse practitioner in a clinic or private practice setting.

The main difference is how the classroom time is handled.

  • School room classes last an hour or two, two to three times a week. There is some discussion, but generally you listen to a lecture, take notes and go home. You spend time reading, studying and writing papers to turn in, and take tests in the classroom. All in all, say 8 hours a week per class, or so. 
  • In the online version, class expectations are posted which include papers, group projects and the dreaded “discussions”. Imagine having a “conversation” about the subject of your current course, and every word out of your mouth has to be backed up by current research or peer-reviewed journal articles. Questions can be asked to the instructor, but everyone in the group sees the question, and invariably a class mate will jump in with an answer covered by three journal articles and personal correspondence with Clara Barton. Expectations are very high, and the research time is daunting, but you do learn stuff. You still have the papers to write, group projects, and tests. The tests are open book, which sounds great until you have the three tomes (book is not a big enough word) in front of you, and notes, and a limited amount of time to answer the questions. I also think the question are probably a little more convoluted in an open book test. End result, it’s more like 10-12 hours a week per class.

So, is brick and mortar better than online? I don’t think so. Classroom time is more fun, interaction with classmates is great (or not, depending on the classmate), the discussions are easier. You also have more time to actually sit down and study. But you have to drive to school. I think on-line programs seem more in-depth, but leave you less actual reading time (which I miss), and carpal tunnel syndrome is not far off. Also, Facebook and little games, the news and email are tempting to digress to (or blogs). Then again, you have Internet at your fingertips which is great for research, and the school library is in your own home to boot. But then, there are the dreaded “computer problems”.

The type of program  you choose to get your education is not as important as how seriously you take it, and how hard you work at it. After all, the school is really only there to tell you what you need to know, it is up to you to actually learn it.

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So, finally, a break! Three weeks of no classes. Whew, this last semester was a bear.

Notice I am still sitting at my computer, can’t break away. So I decided it was time to have a little fun. I am going to share with you my twelve favorite medical words, except one will be a fake. It will either be a made-up word, or the definition will be made up. Good luck trying to figure it out. The ones who get it right will win a FABULOUS PRIZE! (Knowing that you are very smart! That is a fabulous prize,  is it not?)

1. Infundibulum: the little stalk your pituitary gland sits on.

2. Poikilocytosis: having blood cells that have little pointy things sticking out

3. Acephaly: the condition of being brainless, (a requirement for being a member of Congress)

4. Echoencepholography: using bouncing sounds inside your head to see how your brain works (anybody home home home?) 

5. Amaxoapraxia: inability to drive (Dad, I’m sorry, but you are suffering from amaxoapraxia, I’ll have to take your car keys)

6. Biperforate: what a vampire does to your neck

7. Dentoliva: having olives stuck in your teeth after having a Greek salad

8. Glossodyniotropism: enjoying sticking your tongue where it doesn’t belong

9. Eupnia: normal breathing (they need a word for this?)

10. Myokymia: that little twitch in your eyelid when you are tired

11. Myokrismus: a creaking muscle 

12. Lordosis: no, it doesn’t mean you take the Lord’s name in vain too often, it means you butt sticks out because your lower back is too curvy.

The thing about medical terminology, it is designed to be mysterious, unpronouncable (say glomerulonephritis three times real fast) and to make the medical people sound really smart. A medical person won’t say “You don’t have any teeth”, it has to be adentulous. The hay fever  is coryza. Creaky knees have crepitus, that is where decrepit comes from.

I have to say, that those three years of Latin in high school are now paying off.

Just as an FYI. If a doctor is going to do anything with -ectomy after it, they are going to cut something off, -otomy means they are going to poke holes in you,  -oscopy means they are going to stick a tube in some orifice that you don’t want it in to take a peak at your insides. A disease ending in -itis means you have an infection or inflammation, -osis is a problem without an infection.

I almost forgot another favorite word: borborygmi: the sound your stomach makes.

I think I will go read a non-medical book on the patio now.

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