Wednesday, May 23, 2007

Relationship issues

When you work with someone every day, you have a relationship with them - like it or not. NewFNP is very picky about her relationships, although she has made some questionable decisions in the past. Let's just say that newFNP is a wiser woman for them!

She is now in a relationship with a new OB/GYN at work. This OB/GYN has been in our clinic for a little under a month. NewFNP was out last week so the relationship is still a fledgling one. This relationship, however, is very unlike the honeymoon phase in other relationships during which all you want to do is make out, eat dinner and make out again. NewFNP thinks that under non-clinical circumstances, she and this OB/GYN may be friendly. Under work circumstances, newFNP is ready to snap.

In newFNP's clinic, the prenatal population cannot support a full time provider. On the other hand, the uncontrolled diabetics, depressed patients and kids with URI's provide a never-fucking-ending stream of work for newFNP while the OB/GYN leisurely sees her 10 patients per day. This pace leaves OB/GYN plenty of time to point out the flaws in care she sees in the charts, the flaws with our clinic's MA's and the flaws in systemic issues, and man alive, does she ever take advantage of all this free time. Unfortunately, the maelstrom is all directed toward newFNP while she is in the midst of charting, writing letters, filling out forms, helping MAs, etc.

Does OB/GYN think that newFNP has a fucking shred of control over any of this? Patient care notwithstanding, newFNP believes it safe to say that any input she may have into overall administrative issues is placed directly into the "whatever" file. NewFNP may exude the cool professionalism of upper management, but in her clinic, she is nothing but a worker bee.

OB/GYN's complaints struck a chord when she noted that a prenatal patient disclosed that her husband had been beating her throughout her pregnancy and it hadn't been addressed and it's our responsibility, yada yada yada. NewFNP looked through the chart. This patient had been screened for IPV at every visit, admitted to it once and was sent to the appropriate resource. Does OB/GYN want newFNP and the other providers, all of whom see full patient loads, to go Guantanamo-style on the patients in order to get information from them? NewFNP wants OB/GYN to work for a month before she starts pointing out all of our flaws. And even then, she should learn a little tact or keep her trap shut.

As newFNP was walking out the door, OB/GYN asked her to contact a patient for her. NewFNP encouraged her to ask our LVN to do that as he would be in the clinic a full hour after newFNP left. No, OB/GYN left it for newFNP. Unacceptable, but newFNP was too pissy to deal with it in an appropriate manner.

NewFNP is admittedly a little low on emotional reserves this week as her cousin died last Monday. But even when newFNP is at full reserve, she takes it very personally when other providers point out what they deem mismanagement when it is done in a mean-spirited fashion. NewFNP isn't even responsible for some of the visits about which OB/GYN is complaining, but she still takes it personally. All of the providers in newFNP's clinic strive to deliver care that rivals private practice standards given our resources. NewFNP is open to teaching and constructive criticism, but assholery will not be tolerated.

Thursday, May 10, 2007

Is that a twinkie in your pocket?

It is a hard fact of practice that there will be a time in a clinician's life when he or she will be confronted with an erect penis. NewFNP is not talking about after work; she is referring to on-the-clock erections.

In newFNP's experience, these awkward moments tend to occur with teenage boys who will pitch a tent upon sensing a sideways glance at the penis. There appear to be two schools of thought regarding the acknowledgement this experience. School one says, "Hey, let's all normalize the exam erection for the patient and tell them not to be embarrassed - it happens all the time." School two says fuck that. Sure it's embarrassing for the patient and awkward for the provider, but saying "Oh, it appears that you have an erection. Don't worry, newFNP sees millions of erect penises every day!" might be mortifying. NewFNP belongs to school two. That is why she leaves the genital exam for last on her erection-prone male patients.

In general, newFNP really feels sorry for her male patients who have an itchy trigger penis. She knows that they know that they have an erection at an inappropriate time. She knows that they are uncomfortable and assumes that they might like to sink into a crack in the floor. As such, newFNP simply finishes her exam, states that everything appears normal (as long as everything does appear normal) and invites her patient to get dressed after she excuses herself. She returns to a fully-dressed and fully flaccid patient to conduct any education.

As newFNP stated, she generally feels sympathy for these guys. However, there is an exception to that rule.

NewFNP is, quite frankly, sick of men telling her how they have a girlfriend but have other partners and do not use condoms with any of them. In newFNP's mind, this is wrong on several levels - infidelity, potential exposure to communicable disease, being a slimy bastard. When newFNP's skeevy 32-year old patient told her how difficult it was to control himself when he had a few beers and started dancing with and kissing other women, she thought about rolling her eyes and calling him a prick, but she decided against that intervention. Instead, she educated about risk reduction, mutual monogamy and encouraged him to be a man of his word.

So imagine her suprise when, after being more judgmental than usual, newFNP's pervy patient had an erection during his exam. NewFNP's gag reflex was triggered. Should newFNP have done a gen-probe rather than a urine GC/CT? Who knows. She didn't, mostly because she had no desire to touch the man's genitals after assessing for testicular masses, of which there were none.

Keep it holstered, dude. NewFNP feels no sympathy for womanizing, dishonest, boner-having 32-year olds. Gross. Clearly he was not lying about being unable to control himself.

NewFNP needs hazard pay sometimes. Please, cough your TB in newFNP's direction but keep your erection out of her face. Ugh.

Wednesday, May 02, 2007


How could newFNP have forgotten to encourage all new NP's to ask their potential employer about the number of patients you are expected to see per day?!?

See, this is why newFNP needs lists.

A new MD in our practice told me that at her former employer, Planned Parenthood, the providers saw 50-60 patients per day. Can you imagine? NewFNP just about had a stroke when she heard that. Not all of those patients need exams, but nonetheless, that is a lot of vaginas in one day.

Tuesday, May 01, 2007


NewFNP likes to think that one day - one fine, sweet, sunny day - she will leave her current practice and enter into a world where practice isn't so, how might newFNP put this, fucked. When considering this throughout her workday, newFNP finds herself thinking that she should remember certain aspects of her current practice that are troublesome and should write them down in order to wean out practices that may continue to vex newFNP.

Given that graduation is right around the corner, newFNP thought that she would share some of these ideas with her readers. Now, when newFNP graduated almost two years ago, she felt as though she should pay someone just to hire her. That feeling lasted for all of three days of work and newFNP strongly recommends against feeling that very way.

Take heed, new grads. You will work your ass off.

Thus, point one. Research your salary. NewFNP's starting salary was reasonable, but she negotiated a big increase her second year based on internet research. In newFNP's clinic, the NP's see as many patients as the MD's and newFNP works damn hard. She, therefore, has no problem asking for big salary bumps.

Point two. Salary isn't everything. NewFNP is obsessed with saving for her retirement. 401k baby. Does your company match? Huge! Free money. Do they actually have a retirement plan because that would be spectacular!

Point three. Time off. Holy crap, will you ever need time off. So how much do you get? When newFNP begins her third year with her clinic, she will start to have three weeks of vacation per year, plus one week of CME allowance plus four personal days. It is newFNP's intention to use every single one of those days. NewFNP loves time off.

Point four. On call time. Will you be expected to have it? Is it paid? How frequently are you on call? Is there a service? What is the average call volume? Oh, how newFNP loathes her on call time.

Point five. Malpractice insurance. You need one with a tail.

Point six. Actual practice policies. Are late patients allowed in? NewFNP saw two physicals two hours late today. The receptionist did write the helpful note "patient filling up the paperwork" on the superbill, as though we are a Chevron station. When her 3:00 physical appointment showed up at 4:00, she told the manager that this was unacceptable. He basically told her to shove it. These are the types of policies that make newFNP crazy.

Point seven. Walk-ins. Is there time built into the schedule or do they just get squeezed in? In newFNP's clinic, they are squeezed in which is just a lousy system.

Point eight. Help. Who is available to you? Do you have access to databases like Cochran or Up-to-date? These are helpful. NewFNP's clinic doesn't have them.

Point nine. Licensing. Does your clinic reimburse you? They should because your DEA number and your licensing fees add up. They should also pay for CME's and the good conferences aren't so cheap. For instance, this summer newFNP is having a CME vay-cay in a relaxing location with one of her BFF's from grad school, BostonFNP. The conference is $600, the hotel is $1000. See, staying smart is pricey! Hanging out with your pal, learning and then lounging - priceless.

NewFNP is certain that she will think of more points during her days, but this is a good start. NewFNP is looking forward to taking her own advice!