Giving thanks.

NewFNP is often flippant and irreverent. She can, however, be ruminative as well and would like to take this time to note some of the things for which she is grateful. Only some of them will be flippant and irreverent.

1) Four consecutive days off for the Thanksgiving holiday. The Thanksgiving week is newFNP's favorite work week - it's three days!! Even newFNP can manage to smile for three days. OK, mostly. NewFNP is almost unsure how she will spend her Thanksgiving mini-break. She will not shop, although she loves to, but will just enjoy her time off and attempt to be mindful of just how fortunate she really is.

2) Literature. NewFNP loves to read. She intends to read a lot these next few days. She may shop, after all, but only to buy a highly recommended new book.

3) Friends. Friends who don't think she's a lame-o when she cries to them about love gone awry, who feed her well and ply her with good wine, who go on hikes with her, who laugh at her jokes and make her laugh in turn, and who just let newFNP know that she has a place in this world. NewFNP will be attending a potluck tomorrow. Some of the people are new to newFNP, others old. How lovely to spend a day eating potatoes and pie, and sharing one's life. And eating again.

4) Pie.

5) Family. NewFNP has had a lot of family time this year and a lot of fucking devastatingly sad changes. Her family has been through so much. NewFNP wishes she could be with them, but to do would mean breaking her longstanding prohibition against Thanksgiving holiday travel. She broke her self-imposed rule for Thanksgiving 2005 and believes that her ass might be extra-flat as a result of the fucking long drive.

6) Trouser jeans. Joe's Jeans, can you do no wrong? Your fits are amazing and your trouser jeans with patent leather trim on the pockets are divine. NewFNP is truly thankful for their flattering fit and reasonably lengthed inseam.

7) Paycheck. Without it, how would newFNP afford said fashionable Joe's Jeans?

8) Contact lenses. NewFNP suffers from extraordinarily poor vision. How would newFNP sport her perfectly over-sized Tom Ford lunettes de soleil if not for her contact lenses?

9) Retin-A. She has said it before and she'll say it again. NewFNP cannot extol its virtues enough. Why is not every 29-year old at their dermatologists demanding this prescription? Give up on the Creme de la Mer and get thee to thy derm!

10) Her readers. Seriously. Thank you for being interested in what newFNP has to say and for coming back for more.

Happy Thanksgiving.

Get me out of this thing!

NewFNP infrequently finds herself in the position of being a patient. Yet she found herself dialing the on-call physician for her practice last night, her wrist pain registering an 8 on a 10-point scale. She had fallen earlier in the day while hiking, thinking only her pride wounded, but as she palpated her very own anatomic snuff-box and brought a tear to her very own eye, she knew that something was woefully awry.

NewFNP patiently waited for Dr. On Call to call her back and was pleased when he did so promptly. NewFNP often feels a bit guilty when she is on call and attempting to do over-the-phone triage. It requires the patient to make a decision about their needs, to weigh the benefits of emergency room care over waiting for a clinic visit. Sometimes the answer is clear cut, others fall into the category of "art" rather than "science."

NewFNP's on call provider essentially told her that, yes, she needed an x-ray. No one wants to miss a scaphoid fracture, what with all its risk for avascular necrosis and non-union even when frigging treated! But did she need to go to the ED right then? NewFNP struggled with this.

For one, her ED co-pay is a Benjamin, whereas her office co-pay is a Hamilton.

NewFNP is all about the Hamiltons, baby.

For two, what was a trip to the ED really going to do? X-rays, maybe a splint. Was newFNP going to see a hand surgeon at 10PM on a Sunday? Was she going to get casted? No, she would be instructed to follow-up with the appropriate provider the next business day.

And finally, would newFNP be entirely truthful if she omitted the momentary thought of leaving work early in order to see her own primary care provider? She would not and newFNP is nothing if not honest. And fashionable. And stuck on this Sunday's NYT crossword puzzle.

In the end, newFNP decided that her x-ray could wait. But newFNP has years of education and practice under her belt and had the requisite knowledge to really weigh her options.

She was, however, unsure in her decision as she struggled to unhook her own brassiere prior to retiring. Can you imagine the panic - frantically struggling to unleash one's heaving bosoms from their support in order to repose without wires and cleavage? Agonizing. In the end, newFNP was able to shimmy her arms out, rotate her band around and unhook in front just like her 92-year old grandma does.

NewFNP is in great hopes that the humiliating extraction from her t-shirt bra will not be replicated in the upcoming weeks (months?) if newFNP is in a fucking spica cast. To her moderately-trained eye, the x-ray looked fine. To her internal med (handsome yet pleated pants wearing) doctor, the films were lovely. Now we wait for the radiologist to keenly examine newFNP's scaphoid and deliver the real diagnosis.

Once is never enough. Unless.....

If newFNP were to be flippant, she would counsel that if you have to acquire an STI, chlamydia is the way to go. Think about it, 1g of Azithromycin and, if you treat it early, you're likely good to go. This is in contrast to say, Lymphogranuloma venereum, which is, in fact, caused by C. trachomatis but appears to be much, much worse. Or ophthalmic gonorrhea in which your eye tries to kill itself by drowning itself in pus.

OK, enough of that fun mental image and back to chlamydia.

It's no big epidemiological secret that chlamydia is widespread in young sexually active people, much like their legs, newFNP presumes. NewFNP treats it on a fairly regular basis. In addition, she dispenses partner therapy in order to nip that drip in the bud.

So when newFNP diagnosed her new prenatal patient with chlamydia on her routine OB labs, she happily dispensed an extra gram of azithromycin for this young woman to give to her partner. She counseled pelvic rest for at least a week and instructed this woman to come back three weeks later for her routine OB physical and pap.

She returned, and guess what else did?

Where newFNP must have failed was in not dispensing an extra dose to treat her partner's partner. NewFNP will find out tomorrow when her patient returns for a second course of treatment and, perhaps, some frank discussion regarding the asshole who is re-infecting her.

A little help here, please.

NewFNP has been living in her major metropolitan area for over two years. She, for the majority of that time, has had a boyfriend. She has now been single for approximately four months. She has had not one date.

OK, sure, her dating life was theoretically complicated by the fact that she and her Punjabi ex-boyfriend were still living together, but that apparently would have made absolutely no difference whatsoever.

NewFNP was pondering her sad state of affairs when a young woman came to newFNP's clinic on Thursday, in need of some help with her lady business. You see, she had moved from Texas three weeks ago and now was having vaginal discomfort. Three weeks! That was all it took for this lady to get both a boyfriend and an STI.

Seriously folks, three weeks? Granted, newFNP would rather keep her downstairs free from the utter mess that she saw in this woman's vag, but for Pete's sake! Three. Frigging. Weeks.

There are many things that newFNP does not understand in this world. For instance, why does newFNP's front desk staff continually allow patients to be roomed without charts when they have appointments for follow-up? How does someone move from another fucking state and have an immediate, albeit undesirable, hook-up? Why is Designs Within Reach so named? How is a $3000 Le Corbusier cowhide lounge chair within reach? A little off topic, sure, but something about which newFNP has spent many hours considering.

In case any newFNP readers were curious as to the state in which newFNP lives, that state is celibacy and newFNP needs a change of venue!

Respect my authority!!

Prior to her current role, newFNP has never really been in a position of authority. Sure, she has been an authority on clear skin and flat-front pants for the fellows for some time now, but these things did not carry with them the burden of being feared, being disliked or being the target of shit-talking as a result of asserting her authority. Not even when then-studentFNP threw her law school pal's pleated pants across his apartment in fashion protest did her authority engender such strong responses.

NewFNP readily admits that she has an exceedingly low tolerance for incompetence and laziness. She values initiative and intelligence. She can see that these are her own values and can own her own shit, therapeutically speaking. This does, however, make her experience at work challenging at times.

But one would think that newFNP was in league with Pol Pot or Idi fucking Amin with the way the shit talking has been flying lately. NewFNP finds it bothersome.

When newFNP's MA asks her in which room she would like to see the prenatal patient and newFNP responds, "room 4" and then heads off to room 5 to see another patient, that is not yelling, nor is it saying that she no longer wants to see patients.

Likewise, when newFNP instructs the same MA to put one of the two 3PM adult physicals in with the other provider, that is neither yelling nor is it refusal to do one's job. It is a little something that newFNP likes to call "sharing the burden."

NewFNP's clinic manager and other MA basically just counseled newFNP to shrug it off. The exact words might have been "Fuck 'em."

NewFNP sort of agrees - who the fuck cares? Talking shit about one's boss is natural, healthy and fun! But newFNP is, in fact, no one's boss and she just wishes that they would all save the shit-talking for after 5PM.

This crap on a day when newFNP showed up bearing gift cards to thank staff for having Halloween spirit and dressing up! Lame.

Priorities

NewFNP is no Dr. Ruth, but she does pretty much accept that the most important body part in many a man's life is his penis. No big surprise there.

So when a 50-something year old guy presents to clinic with the chief complaint of the old johnson not working, newFNP is generally willing to help a dude out. She does, however, want to know why said johnson might be flying at half mast.

Thus, the history. Onset? Two weeks ago. Taking any meds? No. Any known health problems? No. Hmm, not much there. Glucose is normal. Chest pain? Maybe a little this morning, but none now. Next up, EKG.

This is where it gets interesting. It's not so often that one catches a guy in the middle of an M.I. but one might think to delve further into this possibility when one's EKG shows both ST elevation and T-wave inversion. When newFNP brought up this likely scenario, her patient noted that he had, in fact, been diagnosed with an M.I. a mere three days ago in the emergency department. He received some medications, but wasn't taking them because he didn't trust the doctors there.

Didn't think to bring that up, did you pal?

Well, buddy, newFNP won't be bringing your penis up with a Viagra prescription since you are actively infarcting. Now, take an aspirin and high-tail it back to the ED, would ya?

Maybe we should all take a lesson from Harlequin romance novels and embrace the notion that if you take care of the heart, my friend, generally the penis will follow.

Unless, that is, you've decroded its blood supply with Gatorade, tortillas and Sugar Babies.

Trichtillomaniac, maniac on the floor!

NewFNP has few compulsions. Yes, she likes to keep her eyebrows groomed. True, she flosses regularly. OK sure, she wishes that she was more of a compulsive exerciser, but who amongst us could resist the lure of Harold & Kumar Go To White Castle arriving via Netflix? NewFNP is not made of steel!

What newFNP does not do is pull her own hair out. Figuratively speaking, sure, during a tough clinic day. But literally? Friends, newFNP quite frankly spends too much on highlights to just toss these tresses aside!

NewFNP would have never suspected her first trichotillomaniac this week. Please bear in mind that it is Tuesday and that newFNP works in family practice, not psych. Anyway, this woman only pulls out her eyelashes. Holy crap, that has got to hurt! NewFNP's patient was less concerned with the pain, however, than she was with the mounting costs of false eyelashes. She felt despair because, as she said, her natural lashes were much more lush than the falsies. She felt embarrassed that she could not stop pulling them out. She never even mentioned pain, although newFNP is wincing at the thought of pulling out her own eyelashes. Fuck. No. NewFNP grimaces when one lash gets a little cattywompus and has to be realigned.

The second trichotillomaniac has been a patient in newFNP's practice for as long as newFNP has been there. Today, she told newFNP that she has been pulling out the hair on her scalp for years and has now begun to yank out her armpit hair. Now, newFNP has waxed her own axillae and knows that experience to be somewhat unpleasant. But to take each hair out individually? No, no sir. No can do.

This patient has beautiful braids and has them styled in a fashion which successfully hides her compulsion. But move them aside and hello patchy alopecia!

Now, newFNP's family practice curriculum did not really cover trichotillomania. NewFNP only really knows about it because there was a random treatment center in the town where she completed her undergrad education and she felt compelled to learn what in the hell the place treated! What newFNP didn't know then is that some trichotillomaniacs eat their pulled hair. These folks can develop trichobezoars, or hair casts, in their stomachs and intestines.

Go ahead and put that on your differential for abdominal pain.

Natural mood enhancement

NewFNP did not go to nursing school to have days like this. There are some days when one just wants to be a researcher. Or a bank teller. Today was one such day.

For starters, how do all of the depressed patients know to come on the same day? When they go to the ED for headache and back pain, does the attending tell them to head to newFNP's clinic at 8:30 on a frigging Monday morning? If depression is contagious, that may explain why newFNP was in a pissy mood after her first three patients. It wasn't just newFNP who got bum-rushed with neurovegetative complaints today. Nope, two of us had multiple patients in need of what newFNP charts as 'supportive encouragement' with a side order of SSRI.

Then, one of newFNP's few patients who are circling the drain came in after having been discharged from the hospital yet again. In health age, this gent is at least three times his chronological age, putting him at about 163 health-years-old. The most fucked up things is, despite test after test and hospitalization and after hospitalization, newFNP isn't entirely certain why. This is partly because he is so unaware of what his doctors and nurses in the hospital are doing and is, thus, unable to share any info with newFNP. It is, however, in large part due to the fact that newFNP has never received any documentation regarding his inpatient care.

What newFNP knew today was that his BP was a troublesome 56/36. That is on the low side for him, but - astoundingly - is not out of his range of normal. The highest newFNP has even seen him is around 80/50. He's got a touch of the old renal failure and truly variable glucose. Addison's? Perhaps, but newFNP has never been able to get an ACTH on him, nor has she been able to get his hospital records.

Now, newFNP has sent him to the ED once to rule out Addisonian crisis and a second time when he was hypotensive and having syncopal episodes at the vital signs station. Today, he was rather perky aside from complaints of dizziness. NewFNP had him drink about 32 ounces of water in 30 minutes and then rechecked his BP. It was 70/50. He felt better. NewFNP's big treatment for this guy today was none other than water.

Take that, big pharm! Water saved the day.

NewFNP left work today feeling as though she had really helped no one. It was a horrible feeling. Thankfully, newFNP's city is enjoying unseasonably warm weather - the kind of weather that makes an evening walk while listening to one's iPod cure a rotten day in the clinic, proving newFNP's rule that a little physical activity really improves one's mood.

Let's hope this weather holds on a bit longer.

Exam room 6, ready for seating

NewFNP hasn't commented on obesity lately, but she cared for a patient who got her thinking. This patient has a BMI over 60. Although newFNP is no Mavis Beacon, BMI >60 is no typo. This patient came in for various complaints, including abdominal pain. Let's just call newFNP's exam "limited by habitus."

This patient also noted lesions in her skin folds. NewFNP has treated fungal intertrigo in this patient before, but has not seen her in well over a year. Perhaps if she would have, newFNP might have stopped the awful maceration to this patient's thighs, pannus and buttocks. NewFNP hasn't been doing weights lately and it showed as her arm was shaking in an effort to hold back the pannus in order to examine the extent of the damage.

And can newFNP say it once again, ladies? If your BMI is over 60, your lady parts are also going to be fat. And when those lady parts get fat, the picture is oh-so not pretty. And when you have macerated abdominal, thigh and groin-adjacent skin, it is, quite frankly, time to hang up the bikini underpants and find peace with the big cotton grandma bloomers.

Seriously.

But what really struck newFNP is how demoralizing it must be for this patient to come to the clinic, to have newFNP struggle to hold back her obese belly and to have newFNP counsel her on the merits of the grandma panty. How she must feel some amount of shame every day regarding her weight. How every activity must be a struggle for her. As horrifying as the physical effects of obesity are, the emotional effects must be comparably devastating. NewFNP felt a combination of honor and horror when this patient asked her if she would do her pap. On the one hand, she must have felt respected and cared for by newFNP. On the other hand, that is going to be one hell of a pelvic exam.

**********

When newFNP was in public health school, she had this frigging awful narcissistic professor who informed the students about her success as a physician, model, poet and basketball player, ad nauseam. She also took away our break, probably because she knew that we would talk vicious shit about her, not only to read us her crappy poetry, but also to make us exercise. We hated her for it. This was, after all, public health school. The majority of us had already had our morning workouts before we came to her piece of shit class. NewFNP isn't saying that she is going to adopt this as a practice, but that she must admit that she has considered finding a far less offensive way to encourage physical activity in the waiting room. After all, the patients may be sitting there for hours.

Perhaps newFNP's clinic should buy buzzers a la Cheesecake Factory. The patients can then go exercise and we can buzz them when their exam room is available!

Yuck Mouth

Two thousand and seven has been, quite frankly, a real drag for newFNP.

To recap, a truly beloved family member died, newFNP and her formerly live-in Punjabi now ex-boyfriend broke up, and a mere one week later newFNP was in a serious car accident from which she walked away without a scratch - so, a bad and a good there. Then, one of newFNP's BFF's moved to South frigging Africa to do public health. Ugh. In sum, a shithole of a year to date.

And now newFNP has to have a fucking root canal tomorrow morning.

Son. Of. A. Bitch. Seriously, there are not enough swear words in the universe to express newFNP's distaste for her current situation. And if there is one thing that newFNP knows, it is motherfucking swear words.

NewFNP's insurance covers a portion of this horrific and utterly undesired procedure, but leaves newFNP to cover upwards of $600 of the cost herself. Really, Dental HMO? That is coverage? No wonder tons of poor people are walking around with mouths that look like jack-o-lanterns from just yanking those decayed fuckers out.

NewFNP has known for quite some time that community dental health is utterly lacking, but it seems as though dental care for the insured leaves a lot to be desired as well. Even The New York Times took this on today in this article noting how dentists are faring well, although many teeth in the heads of Americans are not. NewFNP's clinics is one of the rare free clinics around that offers dental care - free dental care. One shudders upon seeing the lines and is astounded by the number of emergencies who are seen on a daily basis.

As much as newFNP enjoys a day off, she would rather be opening huge abscesses and taking cockroaches out of ears than sitting in a fancy endodontist's office trying to figure out how she, a relatively well paid person, is going to pay for this.

No wonder newFNP's patients are so sick by the time they get to newFNP's clinic.

Say what???

NewFNP must be a monkey's uncle, hell must have frozen over and pigs must be flying because the brain-trust at newFNP's clinic did not can the mooning LVN.

Nope, the flashing was just a "joke that went too far."

Yeah, too far over her bare ass. And, please, let's all just overlook the fact that she denied it all, just flat out lied. Strong character. Good choice to keep this one.

Seriously, what do people have to do to get fired? NewFNP could hypothesize that flashing one's va-jay-jay might do it? On the other hand, maybe not - there is another provider who pretty frequently rocks the camel-toe and shows a significant amount of cleavage and she's been there longer than has newFNP.

Maybe the administration figures that patients will continue to frequent the clinic of they know that there is a chance for a free peep show.

Seriously people, what the hell?

Now boarding

There are several ways in which patients can endear themselves to newFNP.

For instance, they might express heartfelt thanks for the care they've received. They might tell newFNP how young she looks when, in fact, she is not.

Most endearing of all, they might be funny as shit in the exam room.

NewFNP's first patient of the day hit the ball out of the park when she did all three and started newFNP's first post-move work day off right!

Now, newFNP knows that it is through the magic of Nars that she looked so youthful this morning. Who the fuck wouldn't look youthful with a fresh sweeping of Sin blush across the apples of one's cheeks? However, beyond her welcome flattery, this patient was truly grateful for the care she received and expressed her gratitude freely.

It was not, however, the flattery or the gratitude which endeared this patient so profoundly to newFNP. No, it was the fact that she was the funniest historian newFNP has encountered, hands down.

This patient, a woman in her fifties, came in with a chief complaint of vaginal discharge - already one can appreciate the potential for humor in the face of a not-so-humorous condition if you are the patient. This discharge, according to newFNP's patient, had "set her back." NewFNP had never heard that turn of phrase in this context before. She is more familiar with its use in the context of something along the lines of "That new Miu Miu purse set newFNP back a car payment!" So, when evaluated in that context, newFNP understood that the discharge was significant.

NewFNP's patient went on to give newFNP details of the discharge, such as the fact that it was malodorous enough to warrant "a hell of a scrub" before coming to the clinic. In addition, it was copious enough to require the use of feminine protection.

Now, newFNP's patient had a hysterectomy some years ago and, as a result, was unfamiliar with the decades-old advances in pantyliner technology. She stated that she had purchased some pantyliners but, upon running out, could not afford another box and borrowed some pantyliners from her daughter.

"Those damn things look like an airplane! I ain't never seen a pantyliner like that - it had wings!"

Superfluous information? Sure. Welcome? Fuck yeah.

Wings.

Full moon

NewFNP's clinic has rapid staff turnover. Now, there are some staff members who have been there for years and years, but it is not uncommon for people to not last through the 30-day probation period.

The most speedy exit came from an MA who just didn't show up to work her third day. No phone call, no 'nice to have known ya!' - she just didn't come back.

Then we had an LVN who single-handedly emotionally dismantled our MA staff by starting rumors and spreading gossip. He was let go after several wildly inappropriate comments in the presence of the interim COO after about two months of employment.

And finally, the current employee termination. Our most recently former LVN began working ten days ago. She was lazy, said 'shit' in front of a patient on one occasion and engaged in useless banter with the MA's. That kind of behavior, while bothersome to newFNP, does not get you fired from newFNP's clinic.

But do you know what will get you fired? Mooning three other staff members in the hallway during a busy clinic day.

A few years ago, newFNP and her girl gang were returning to our grad school's home town after having attending one of the most well-attended political marches in recent history. We were driving alongside a van caravan, each van filled with eight undergraduate-aged guys who appeared to be jocks. Four of the front man-van riders mooned the gents in the rear van. NewFNP's car honked and the guys were clearly embarrassed to have flashed five lovely ladies. But these are just the people who should be mooning - 19-year old guys.

Not a 30-something LVN. At work. When work is not a strip club. Sure, pink undies are nice but newFNP and her staff do not need to see them.

Don't let the door hit you on your currently covered ass on your way out!

Advice

NewFNP is here to tell you that there are simple ways in which to ensure that your visit to your doctor, nurse practitioner, midwife or physician assistant runs smoothly. NewFNP is not able to say whether these tips extend to the more holistic professions, let's say one's acupuncturist or colon hydrotherapist, but she is sure that some of them will be applicable.

1) Schedule your appointment early in the morning. This is helpful for a variety of reasons. First, your provider will likely be on time or only marginally behind. Second, it is easy to be compassionate at 8:30 in the morning - that is, of course, if your provider is compassionate to begin with as newFNP likes to fancy herself. Like it or not, even the best provider wants to go home on time so avoid the 4:30 appointment slot unless you only need a Retin-A refill and have absolutely no complaints whatsoever.

2) Avoid using a harsh tone with the front desk staff and saying things such as "You all are fucking retards!" or "I am fucking pissed!" or even "This is bullshit!" That kind of language will not help your case and may earn you the title of "difficult patient." Let's face it, shall we, if you are throwing the F-bomb at a receptionist, you are a difficult patient and your clinician will know that you were rude to her staff. In practices other than newFNP's, this type of behavior might just get you escorted out the door and fired from the practice. But, no, not in newFNP's clinic. Bring on the verbal abuse! We'll see you anyway. Of course, newFNP does not assume that her readers would engage in such behavior, but offers this advice merely to file away as an FYI.

3) Smile when your provider enters the room. NewFNP tries to smile at every patient in order to tip the encounter in the direction of "pleasant" rather than "emotionally draining." A little smile, like a little hot sex or Comito Mojitos, goes a long way in making one's day more enjoyable.

Happy 5768, Jewish Style

Shana Tova, newFNP readers!

Nothing has been very exciting in newFNP's world, except that she did go to a yoga class this week with her friend CDCMPH and got her ass kicked. Jump back into plank? No thank you. NewFNP will step into plank and will pretend that she and her pal are not the only yogis who are sweating like wild boars!

Clinically speaking, newFNP has been recently plagued with the mind-numbing "same old-same old." The potentially interesting cases have not followed up and, thus, newFNP is in the midst of several clinical cliff-hangers. Does the seven year-old with B-cups rivaling those of that 'High School Musical' nude-internet-picture-girl merely drink too much hormonally-ridden milk or is she in the dangerous clutches of McCune-Albright syndrome? NewFNP would love to tell you, but this young lady has not returned for further evaluation. NewFNP hopes that she has followed up on her endocrine referral.

What newFNP has noticed of late is that she is spending an inordinate amount of time educating her patients on something that she herself has taken for granted for years, no - decades: the medication refill. NewFNP expects that when she gets her Retin-A prescription, it will damn well come with a year's supply of clear skin and wrinkle prevention, all with a simple automated phone call to her friendly neighborhood pharmacy. To newFNP's patients, most of whom hail from countries where over-the-counter meds are the norm, the concept is foreign. "What?!?" they say with raised brows, incredulous that they could have more than one month's worth of hydrochlorothiazide! Ah, yes, newFNP explains. All you have to do is call. Then newFNP reviews why it is important to, therefore, use the same pharmacy for all prescriptions. This interaction takes significantly longer than one might assume.

NewFNP is a joker, but she is not joking about this. Patient after patient, newFNP must review the concept of a refill. Swear to God. No fucking joke.

The other thing which newFNP finds striking is the all-too-common answer to a question posed by newFNP during each and every well-child visit: What kind of milk do you drink at home? To newFNP, it is as relevant as the presence of smoke alarms, medication allergies, asthma and if there is a frigging TV in the three year-old's bedroom.

And how do the vast majority of newFNP's patient's answer?

"De galón."

Oh, no shit? You get your milk from a gallon container? As opposed to, say, drinking directly from the teats of the many cows freely roaming the streets of newFNP's urban metropolis! What the fuck? NewFNP is not sure if she is missing something in the translation, but, in writing this, allows that she could simply ask if the 50-pound toddler is still drinking whole milk.

But shit, where's the fun in that?

"De galón." L'chaim!!

Welcome back, my ass!

The rough thing about attending a posh CME in a serene location is that one tends to forget the reality of everyday work life in the ghetto. In case you had forgotten, allow newFNP to refresh your memory: it sucks.

NewFNP is right back in the thick of it: leaving an hour late, attempting to correct the fact that she had seven patients scheduled in the three o'clock hour today and dodging bullets fired by the ever-critical and sorely lacking in introspection OB-GYN. Hey sister, when you point one finger at newFNP, there are four pointing at yourself, you ho-bag.

NewFNP returned from her conference ready to take on the world. Well, the world has dealt newFNP a real shit-storm. So much so that newFNP has begun to question whether she really is doing well for her patients.

The OB/GYN is quick to point out the cazillions of flaws she sees in the care that newFNP and the other prenatal providers have delivered, yet this provider sees an average of 10 patients per clinical day. She is not at all hesitant to allow other providers to see the remaining patients on her schedule as she delves into every detail of her patients' care. NewFNP truly makes every effort to address all pertinent aspects of medical care as well as engaging the patient about social issues, but newFNP has a 30-patient schedule and, therefore, misses things sometimes. Does this make newFNP a bad, incompetent or inadequate provider? Is the OB/GYN right in just giving a big "F-you" to the rest of us while she assesses for every fucking hangnail that may trigger preterm labor, birth anomalies and the omnipresent threat of legal action?

Another new physician pointed out that newFNP's clinic is "killing" our patients because we cannot start diabetic patients on insulin if their A1C's are over 8.5 or 9. The reason newFNP is unable to do so is that a very small number of patients can afford blood glucose monitoring supplies. The new provider didn't mean it as a judgment, but rather as a statement of fact. However, newFNP feels acutely aware that she is between the proverbial rock and hard place. NewFNP can either slowly kill them with the ravages of hyperglycemia or quickly kill them with the rapid action of hypoglycemia. Talk about choosing between the bat and the belt! What a fucked up world we live in. Perhaps there is a program that would supply all of newFNP's DM patients with testing supplies and syringes, but newFNP doesn't have even five minutes in her day to research this.

NewFNP is uncertain what to do. She is at her two-year anniversary at her clinic. NewFNP is community health and had planned on staying at this clinic indefinitely. But how in the fuck can newFNP put up with all of this?

On the positive side, everyone loves newFNP's new hair-do - even the fashionable gay guy so newFNP knows that she is looking hot! Watch out!

And she's back...

New FNP learned quite a bit while she was at her CME. However, the most striking thing that newFNP learned is that her patients will likely not benefit from a fucking shred of what they should be receiving.

For instance, the lovely and brilliant physician who lead the Obesity 2007 chat couldn't stress enough the importance of a nutritionist. Yes, indeed. However, let's just say that hiring a nutritionist is not on newFNP's clinic's short-list. Very low calorie diet? In newFNP's clinic, we call that 'food insecurity' as no one ever self-restricts to 800 kcal/day. NewFNP was thrilled to have it made public that a BMI of 26 has a positive effect on mortality. Ah, NHANES, God bless ya! NewFNP already knows that a little extra cushion is her natural set point, but she is stoked to know that science is getting on board with the voluptuous lady. Interestingly, this speaker did spend a fair amount of time on discussion of how fitness truly helps in preventing mortality. If your BMI is 31 but you are a walking-fool (45 minutes/day while talking), you're actually not in that bad of shape. However, if the only exercise you go is extending your left arm though your auto-roll-down car window to reach for your double bacon piece of shit burger, then - yes - you are on the train track to an MI.

And the fertility lecture. Fascinating, especially when newFNP has had two thirty-something friends struggle with it. Practical in newFNP's urban free health clinic? Uh, no. Interesting to learn that laying supine with the knees up for twenty post-coital minutes is advised if attempting pregnancy. NewFNP suspects that adopting such a position might lead to a 'round two' which goes against the tenet of QOD action for best baby-making.

NewFNP learned a lot about bisphosphonates. However, newFNP has succeeded in getting a single patient a bone mineral density scan. NewFNP would love to help the ladies spare the hip fracture - hell, who wouldn't! But newFNP is reluctant to just start adding Actonel to the water supply.

One great overall experience that newFNP had was to see that her practice was already mirroring a lot of what these experts were recommending. Hallelujah! And she is doing procedures which many of the physicians in attendance don't do, such as IUC (new phrase - apparently IUD is out of vogue) insertions. Why would anyone want to do less? Sure, newFNP would want to do fewer prostate exams but newFNP wishes that she could, for example, be doing biopsies for her patients. Because frankly, if newFNP's clinic isn't providing the care, it's unlikely that newFNP's patients will receive specialist care.

There are, however, things that newFNP would like to do more of, such as starting patients on insulin. However, newFNP's patients don't have glucose monitors so one shan't prescribe a hypoglycemic without appropriate monitoring! This conference recommended starting patients on insulin when they have an A1C greater than 8.5. Holy fuck - newFNP rarely sees a patient with an A1C that low, at least when they initiate care with us. A1C of 15.4, sure. Of 17.2 - rarely but not unheard of. When newFNP gets an A1c into single digits on oral hypoglycemics, she is quite thankful.

Mostly what newFNP learned is that she loves to take bike-rides through one of her state's most beautiful areas, amongst trees and rivers and a huge, glorious lake. NewFNP learned that perhaps her huge urban area is not where she will be for the rest of her life, that perhaps she will need a mid-point between the luxuries of urban life and the natural beauty which is too few and far between in her city.

CME Update

When attending a CME, all of the answers seem so obvious.

Duh, the lesion in slide is melanoma. Ray Charles could see that!

Clinical practice, however, is not so tidy. Especially family practice. Being a generalist is tough. In the eyes of the patient, one is expected to know it all, be it funky dermatological lesion, West Nile Virus or lumbago. However, in clinical practice, patients give horrible histories and, in newFNP's practice, this issue is significantly exacerbated by the ole language issue. In clinical practice, newFNP doesn't have the luxury of having convenient multiple choice answers from which to choose her differential diagnoses.

NewFNP will, at some point, share some of the more illuminating information gleaned from the conference, but in the mean time, can she just say that she enjoyed so thoroughly her 12-mile scenic bike ride with BostonFNP and her younger sister RooSF? NewFNP is leading a life of leisure! Post-conference and gym yesterday, we all hit the pool where newFNP donned some very now Tom Ford sunglasses, slathered herself in SPF, and read The NewYorker. She topped her evening off with not one, but two margaritas and a crab tostada.

NewFNP loves her CME. It's not just all the leisure either. NewFNP feels inspired yet again to be an excellent clinician and is in touch with her inner nerd as she basks in the glow of the Power Point slides.

Ahhhh..... Continuing Medical Edu-vacation. Just what the nurse practitioner ordered!

Life imitating art

Does everyone remember when Aidan and Carrie broke up? At the end of the break-up episode, Carrie had her wild, curly mane and, at the opening of the next episode, it was transformed into a chic, short-ish curly-bob. New hair, new life.

NewFNP. New hair-do. Soon to be new apartment with new couch (thank the heavens for Crate & Barrel). Still with old job but without old boyfriend.

And, in the midst of it all, newFNP was actually thankful to have her crazy job, her NP student and her intellectual stimulation. How do people go through break-ups if they have some mindless job in which they can ruminate and sift through the remains of the relationship? It's not often that newFNP is thankful that she has nary a minute to re-apply lip gloss or take a sip of filtered water, but she has been very thankful for her hectic schedule this past month.

Even more so than that, newFNP has been thankful that her career actually means something to her patients.

This past week, newFNP had the pleasure of working with Dr. G. Dr. G. is newFNP's age and went to med school a mere block away from newFNP's nursing school. Yes, newFNP and Dr. G. have probably walked the same hospital floors but never knew each other until practicing community health on the other side of the country. Dr. G. mentioned to newFNP that one of the things -in a very long list, of course - that makes her a good provider is that she truly cares for her patients, that she listens, that she asks them questions about their lives. During this time of major personal change, it was nice to get that validation from a co-worker.

It was just as nice when a patient's fasting glucose dropped from the mid-300's to the low-mid 100's after newFNP stopped his oral hypoglycemics and started him on an all-insulin regimen. Most of newFNP's patient cannot afford glucometers and supplies, so newFNP hasn't had the opportunity to do this transition very often. Nonetheless, even though he is technically a Type 2 diabetic, newFNP believed that his pancreas had thrown in the towel. There isn't enough metformin in the world to help this guy out. Furthermore, this patient was an exception in that he had glucose monitoring supplies, so newFNP wrote out a detailed baseline NPH insulin regimen with instructions for regular insulin sliding-scale coverage. She was so proud of herself and her patient when his glucose started to stabilize.

Now, newFNP knows that this one day of control may be an anomaly. However, to get props from a co-worker and to achieve something akin to medical success constitutes one hell of a week for newFNP.

Just wait until those fuckers see newFNP's fierce new hair-do. They'll have to wait a week, though, because newFNP and BostonFNP are hitting up the vacation CME in a fun-filled resort town.

As BostonFNP's dad once told us, learning without laughter is like a day without sunshine. NewFNP cannot wait to have both at her Continuing Medical Edu-vacation.

Continuing education

Jeez! Where has newFNP been?

NewFNP's student finished her month at the clinic and claimed to learn a lot from newFNP. Ah, shaping young minds - what an inspiration. It helps when the student is brand new and literally everything is a learning experience.

All in all, newFNP was glad that her student got to see just how community health practice is.

For instance, one day newFNP asked her student to leave a half hour early so she would be spared the experience of observing newFNP rail on the manager for overbooking appointments at the end of the day. Certainly not community health's finest hour, but an integral part of newFNP's clinical experience.

Another day, newFNP was giving a little nutrition education to the parent of an obese three year old which included advising her to avoid giving her kid candy, to which this parent responded, "Oh, I don't give him candy - just lollipops." Bingo. When newFNP explained that lollipops are, in fact, a form of candy, the mother was astounded. "They are?," she asked, wide-eyed and as sincere as could be. You just can't pay for that kind of education. Truly, how many people with whom newFNP's student is in contact fail to grasp that a lollipop is candy? Are there some marketing geniuses at the super mercado who are selling lollipops in the produce section, convincing slow parents that a cherry-flavored lollipop is one in the quest for five fruits/veggies per day?

NewFNP had her patient doing paps, cleaning out cerumen, listening to hearts and lungs - whatever she could get her to do. NewFNP really loved doing the teaching, but realized that she was completely disorganized in the process. As newFNP's student has just finished her accelerated RN year and has yet to do her health assessment class, newFNP felt a little unsure as to how to help her along. At any rate, newFNP thinks that her student will be ahead of the pack when she starts her master's clinicals next year and that she herself will be better organized when the next student comes along.

And, for newFNP, it was really meaningful to help to support someone in their learning and in their development into an NP. So thanks to newFNP's alma mater and to her student for making an otherwise crappy July 2007 something meaningful.