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Posts Tagged ‘thoughts’


Well, it is happening. The clinic I work in will be closing its doors soon, partly due to money issues and partly because the physician is retiring, and I am back on the employment search train again. The sad part about this, though the PA I work with is going to try to take as many patients along to the next job (and mine will go with me), is how many physicians won’t take Medicaid anymore. It just doesn’t pay, and the loss of income on each patient, coupled with the impossibility of finding specialists to refer Medicaid patients to, and the restrictions on what we can and can’t order for them, it is not a viable option for a lot of physicians to take Medicaid. On the patients’ side, if they have share of cost, it is often so high, they can’t afford to get healthcare anyway. The whole thing just stinks.

The good news is that there are several options for me and I will not be jobless for long, if at all. The bad news is that things are so up in the air that I haven’t found a lot of emotional space to write in my blog recently, though I did get a new bike, well actually a recumbent trike. An arthritic girl’s best friend! And my dog’s favorite thing, too!

 

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One of the hardest things to do when starting a new job, is to get a handle on the office politics. The difficulty level is higher when there is a large group of physicians, other mid-levels and a large assortment of assistants and office personnel. Add some new services being set up and the mix gets a bit volatile.

I have never been a real political person, so I would have had a real problem with all of this only a few years ago. After the rigors of post-graduate education, and the “Project”, it seems that I have developed some new skills in dealing with the politics, and a higher level of personal confidence. So far, things are going relatively smoothly, and I am learning who the movers and shakers are, how to keep myself in the loop, who are my allies and which people I need to be careful around.

All in all, considering the amount of people in the practice and the sheer amount of patients seen and procedures done, this three-ring circus operates quite smoothly, and I am feeling more comfortable each day in my new role. We are settling into our new community, making new friends and enjoying the outdoor activities and beautiful surroundings we have here. There is a 43 mile long bicycle trail which runs past lakes, parks, and forest near by which we are enjoying each weekend. Life is good.

I need a new bicycle…

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I passed my final exam…..only the presentation of my project is left.

I suppose I will have to change the blog title soon to “Trials and Tribulations of a New NP”. I have found a position with a group of GI physicians, this ought to be interesting! It is not easy to find a position when you are a new grad, I was lucky to get more than one offer, of which this one worked out the best.

The cool part is, I get to hang out in the cushy doctor’s lounge in the hospital between patients. 🙂 If I have time to hang out that is… Will keep you all posted.

 

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Wow, I can’t believe it. I posted my clinical hours fron the last 2 weeks, and I get a response from my instructor:

You are officially done.

Really? Already? Have I really put in over 660 hours of clinical time? I am conflicted about this. Part of me says, “You don’t know shit” and another part of me says “Wow, cool, I have learned a lot. ”

I think I will stick with the second part, I did learn a lot.

It’s funny, when I  just looked back at what I wrote, the negative feeling was in the third person, and the positive in first. Goes to show that I really do believe in myself and a little voice by my ear is telling me the bad stuff. My heart knows the amazing amount of knowledge I have gained, and experience.

There must be a point in this observation. Don’t listen to that little voice in your ear, listen to the one inside.

 One interesting thing, I got to meet a real live alligator wrestler on my last day, he had a bad shoulder. Why am I not surprised? He did tell us that alligators were easier to wrestle when they weren’t hungry…

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Before I write my post, I have to express my sadness at the horrors that the people of Japan are facing. My prayers go out to them. No other words would be adequate…

Okay, my post about student nutrition. Every day I dutifully educate and counsel patients on diet and exercise to reduce weight, cholesterol levels and blood sugar. I feel like such a hypocrite.

 When the long clinical day is over, and I flop down on the sofa, the last thing I feel like doing is planning and cooking a nutritious meal, or riding my bicycle. I still have to spend at least an hour or so inputting the patient encounters into my log on the computer, respond to the weekly case study and look up and review some of the things I saw that day. By the time that is done, the brain and body are catatonic. My husband is not in any better shape. While he was unemployed for quite a long while, he was an angel, taking over the cooking and shopping. Now that he has a job, he is exhausted when he gets home. The job he has is very physical, and being in his late 50’s, it is tough on him.

Bottom line, at dinner time, we look at each other blankly, wishing that a cook would miraculously appear to feed us. So, in general this is the nursing student dinner hit parade:

  • Pizza: the guy at the local pizza shop recognizes Randy’s voice now and can take our order before we even say what we want. It is always the same, thinking up new and exciting pizza combinations is beyond our mental capacities. I suspect our house is programmed into the delivery guy’s GPS as a favorite.
  • Chinese food: again, the guy recognizes us, and also knows our order by heart
  • Omelet: It takes exactly 7.5 minutes to make an omelet with cheese and toast
  • Grilled cheese and soup: This takes about 13 minutes, so we need to be more ambitious for this one.
  • Healthy Choice or Kashi box dinners: These come in when we are feeling guilty about too much crap food and the clothes aren’t fitting so well.  One or two nights of this has us back on the phone ordering pizza.
  • Fast food: I can say we are proud of ourselves in that we almost never eat fast food, partly because it is so disgustingly bad for us and partly because we have to drive pretty far to get it.
  • Publix hoagie: If I have even a tiny bit of energy on the way home, I will sometimes stop and pick up a large Italian hoagie which we share.
  • Rotisserie chicken and macaroni and cheese: otherwise known as death by cholesterol and salt. Now this is not the boxed macaroni and cheese, that is WAY too much trouble, I mean the dish of nice, creamy frozen mac that you heat up in the oven. We can make this combo last a couple of days. If we are really ambitious, there will be a salad with this.

Here is hoping that we survive the nutritional deficits until I graduate. Then, I will have the time and energy to enjoy cooking again. My cookbooks and cooking magazines will get dusted off, and the kitchen will smell of baking and spices again. I will have to see if I can locate my bicycle under all the stuff in the garage.

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Everyone should have a primary care physician or nurse practitioner.  Primary care is vital and basic in our health care delivery system. It is the foundation of good health care; the gate-keeper that makes sure you are getting the proper and most effective/efficient/economically sound health care. Right? Oh, you didn’t realize that? Did you think that your primary care provider was just a back up plan of last resort because s/he is JUST a family doctor?

Primary means first.

Now that I am in the last six months of my nurse practitioner program, friends and family keep asking me for medical advice. I guess this is something that health care providers get used to, this requesting of advice with the most rudimentary of information, 99% of the time without any exam at all, and often over the phone. It pays to be very careful. I also notice that many of the requests start with the “patient’s” opinion of what is wrong and what they should do, and they are only seeking confirmation for their diagnosis and treatment plan.

Example: the wife of an elderly friend calls up and tells me that her husband woke up “in a pool of blood”. In the background I hear him say “It was only a little bit, don’t exaggerate” and she asks me if they should go to the urologist. I ask where the blood came from and she told me she wasn’t sure if it was from the penis or someplace else. “It came from my ass” I hear in the background. “Well, I think we should go to the urologist in case it was your prostate”. After determining that the bleeding had currently stopped, I suggested that they get an appointment with their primary care physician. “You don’t think I should go to the urologist, or how about the surgeon that did his colonoscopy, maybe he has cancer?” she asks.  It takes a little while to convince her that the family doctor was the place to go. That he would be able to determine what the problem was and if a specialist was even needed. She finally agreed. It turned out to be a hemorrhoid.

The thing about specialists is, they specialize. Go to a gastro-enterologist with chest pain and he will look for an ulcer, a cardiologist looks for heart disease, a psychiatrist will look for panic attack. Specialty practices generally aren’t the place to go to for an initial diagnosis. Okay, if you are having crushing chest pain, or have a bone sticking out after you fall down, or you have vomited so much you are passing out, go to the emergency room. That is a specialty you can go to for an emergency. As I have stated previously, a sore throat or infected big toe are not emergencies. This is where the primary care provider fits in.

Another friend has had a history of triple bypass. He kept having chest pains after and popped nitro and aspirin like candy. It just didn’t seem to be helping. He kept going back to his cardiologist, had test after test, year after year. Everything seemed fine when he had his cardiac tests, but the chest pain continued. I finally asked him one day to describe when where how, etc. of the chest pain. It was when he was moving around, he couldn’t do anything without getting chest pain.

Okay, when exactly.

In the morning when he tried to wash dishes after breakfast (nice guy, huh? Washing the dishes).

Any other time?

When he took his walk after lunch.

Hmmm. After meals. Okay, did he have any  other symptoms with his chest pain, sweating, dizziness, shortness of breath?

No, just a terrible burning pain in the middle of his chest. Oh, and feeling really tired.

Do you ever get it at night?

Well, yes, when laying down in bed watching TV after dinner.

Are you seeing the point yet? It turns out he had a hiatal hernia. I talked them into going to the primary care doctor for a workup and he was diagnosed, properly, with the hiatal hernia. He was tired because the nitro was dropping his blood pressure and the aspirin was also contributing to the stomach pain. It had nothing to do with his heart. A prescription for a PPI and he is in the pink (literally, his color is so much better, not pale anymore). No chest pains, no more fatigue, exercising without a problem…

So: the moral of the story is, don’t try to diagnose yourself. Let the primary care provider do it.

The ten commandments of primary care:

  • Thou shall have no other doctors before your primary care provider.
  • Thou shall not use the internet to diagnose thyself.
  • Thou shall not call them at 4:45 PM on Friday because the itchy rash you got from poison ivy 3 days ago didn’t go away yet and you want something now.
  • Thou shall not expect them to know by osmosis which other doctors you have seen and what medicine they gave you, and what you are being treated for. It is better to let her/him refer you to specialists, that way s/he knows what is going on and has a handle on your overall healthcare, and gets the records from the other physicians.
  • Thou shall not use them as a last resort, remember they are primary care.
  • Thou shall honor the annual physical and attend regularly.
  • Thou shall not forget that each medical problem you have affects all the others, the primary care provider is the one that keeps the show moving in the right direction and directs the traffic.
  • Thou shall not steal your primary care provider’s time by asking them to diagnose and treat you over the phone (okay, I am guilty of this one sometimes) You would never ask this of your cardiologist, would you?
  • Thou shall not go to the emergency room to do what your primary care provider is perfectly capable of doing, such as sewing up a small laceration, treating a stomach virus, splinting a sprained ankle, etc.
  • Thou shall remember you have a relationship with your family physician/nurse practitioner. They know you and your history, they follow up with you, they care for you on a long-term basis. Use that relationship to manage your health care in the best manner possible.

I just wish the insurance companies and the government realized the importance of primary care and reimbursed accordingly. Specialists are important, but primary care is more valuable in the general scheme of things: prevention, health maintenance, health screening, counseling and 98% of the health care the average person needs.

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I am at the half-way point of my Adult Practicum term. The midterm exam is due this week, I’ll take it on Wednesday. Friday will be my first day of clinicals at my doctor’s practice for the second half of Adult Practicum. It should interesting. My greatest complaint about my previous two preceptors is that they didn’t tell me enough.W hen I saw my doctor last week, he said he has been accused  of telling people how to build the watch when asked what time it was. That works for me!

Seeing the patients that came to the health department for their primary care was definitely “interesting”. Coming from a background with high work ethic and a belief in the value of your health and the need to do everything to maintain it, mostly to be able to keep the ability to work and be productive, it was a shock to see what was considered  important by some of the patients I saw. Their values differed from mine in several major respects.

  • For them: 1) if Medicaid pays for it, I want it. If it isn’t paid for, I don’t. 2) If it doesn’t make me uncomfortable, it isn’t important. 3) Whatever I can use to go on disability is good, even if I am a big, strong, young man and my only disability is a bum knee from basketball. 4) Why bother with prevention if you can just fix things afterwards.
  • In my world it goes 1) I will find a way to pay for it as healthcare is important 2) What ever it takes to prevent future problems or treat current ones gets done, I need to keep healthy and active so I can work and do what needs  done. 3) Disability is the last thing I would ever want, I will find a way to work and stay independent until the last possible second (so bad that I can’t get out of bed, well, even then you can use a phone or computer) 4) An ounce of prevention is worth a pound of cure.

A woman came in whose main complaint was a sore in her armpit. When the nurse took her blood pressure, it was 210/102, approaching stroke city…then the patient admitted to having some pain in her chest. “But that is not why I came in, I want you to deal with the sore under my arm!” All through the ECG she complained about the armpit thing. Thank goodness there wasn’t an ischemic event going on (heart attack), though the ECG showed LVH (enlarged heart, probably related to the ridiculously high BP).

We reviewed her BP meds, changed the doses a bit to better address the BP issue, tried to educate her a bit on the risks of heart attack and stroke, etc. Not interested, “Just take care of that thing in my armpit!”. Okay, we drained the small abscess that had formed  from a folliculitis related to shaving her armpits. Then she was happy.

I have to wonder if a large part of the higher rates of stroke, heart disease, diabetes, uncontrolled hypertension, etc. in the “underprivileged” is a result of noncompliance with treatment plans, or simply not caring enough to take care of their own health. The care is there and available, but if you don’t use the care available or follow the treatment plan, you will not be healthy or get better.

I have seen several patients with genital warts, lots of genital warts and big ones. Personally, one teensy little bump would send me straight to the doctor’s office in a screaming panic (not that I would put myself in the position of it being possible to get such a disease if I had anything to do with it). I can not conceive of letting things go the way some of these patients did. When the treatment is finished (which is painful, as it basically consists of burning them off with acid) I sit and chat with them a bit, educating them on prevention, etc. Not a single one of them used condoms. They knew about condoms, they knew about safe sex, but it didn’t seem important to them. I asked some of them “So, you want to be a daddy?” The answer of course was usually “no”, or “not now”. I asked if the girl they were having sex with was the one they wanted to be the mother of their children. The answer to that was always “no”. They know that sex=possibility of babies, but when it comes to their own personal selves, “I wasn’t thinking about that.”  The universal attitude seems to be: fix it if it happens when it comes to diseases, and for some of the girls Plan B or abortion as contraception. Thank goodness, there are a lot of girls that take advantage of the free contraception offered by the health department.

The concept of being responsible for the results of your own actions doesn’t seem to be a big value these days. Or as the young people say: “Whatever.”

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