Continuing edu-vacation v.2010 part 1

NewFNP is so excited to be away from clinic for a week. Why is taking care of people so exhausting? (And rewarding, of course, but still exhausting!)

In the last week, the clinic was absolutely overloaded with patients, both in volume and acuity. A chief complaint of lab results twice revealed patients with GFRs in the teens. A chief complaint of staple removal revealed a young woman needing the staples removed from the incision in her wrist where she had tried to kill herself. Three likely cancers. One repeat teen pregnancy.

NewFNP is now lounging poolside, beverage at hand, chic new Pixie hairdo getting lots of compliments. She is at CME and she is recharging her batteries. She is somewhat concerned that her batteries need recharging after a mere four months back in full-time community health practice. She does, however, know that one thing that will always recharge newFNP's batteries, aside from J. Crew cashmere and coddington platform suede heels, is a (possibly) inadvertently hilarious comment at CME.

In discussing the newest ACOG pap screening guidelines, an OB/GYN and head of newFNP's state family planning program mentioned that one need never perform pap screening in a woman with a vaginal cuff after complete hysterectomy for non-malignant concerns. He then noted, "This one has been slow to penetrate into clinical practice."

Really? Really? Slow to penetrate, huh? As BostonFNP's dad once said, learning without laughter is like a day without sunshine. NewFNP's day was full of sunshine with that one.

Bring on the double entendres, the dorky medical jokes, and the alcoholic beverages. Because newFNP is on edu-vacation!

Punxsutawney newFNP

It has been just like Groundhog Day for newFNP. Stepping in the same puddle, getting annoyed by the same people and generally reliving the same thing day after day after day.

And then there was today, when newFNP literally hit her head against the wall while discussing yet another undesired change in her schedule.

Work. WTF. As newFNP's mom used to say, too bad we weren't born rich instead of so good looking.

The final countdown

NewFNP's CEO signed her final loan repayment form yesterday.  Her last full-time day is one week from today.

There is not one part of newFNP that is sad to be leaving full time practice at her clinic.  And that makes her very fucking sad.

Provider burnout is not new.  Articles have been written, schools talk about it, practitioners live it.  And for what?  There is a lot of talk about a broken health care system in every media outlet to which one chooses to listen.  But it's not just the Medicare reimbursement or the HMOs and PPOs that are broken.  

It's organizations like newFNP's clinic - where the average shelf-life of a provider is less than three years; where there is not one hour - hell, there's not one minute - of administrative time scheduled for providers; where there is no one to follow up on referrals to specialists; where there is not one registered nurse, not one LVN, not one CNA; where providers work through lunch every day; where lab results, correct phone numbers and vital signs aren't in charts; and where patients are double and triple booked.

NewFNP is partially to blame for her own burnout.   But, you know what, her clinic is responsible as well.  It doesn't seem too far fetched to make efforts to take care of one's employees.  NewFNP's senior management believes that providers are just there to see patients, and as many as possible each and every day, all the while fixing the errors of other staff members, filling out endless forms and attempting to care for the physical and, often times, emotional well-being of the patients.

It's too much.  NewFNP isn't sure if it's her - if her lack of personal fortitude is the problem, or if it's the dysfunctional environment in which she works.  She thinks that, given her degrees from top schools, it's the latter, but it's not in newFNP's nature to let herself off the hook that easily.  Perhaps it just means that she needs to choose her next practice site more wisely, if she ever goes back to full time practice.  Perhaps she needs to impact health outcomes from a more hands off venue.  

NewFNP thought that she would be working with the urban poor forever.  She sought out a free health clinic in the frigging ghetto.  And now she wants to get the hell away from it.  That is sad. 

One thing newFNP can say is that she learned a lot these past three years.  And she continues to learn every day.  And that is a really lovely thing about nursing and medicine.  But when it's time to go, it's time to go.

And it's time.

NewFNP is a jerk

NewFNP is reading an article about burnout and she sees herself in it far too frequently. 

She feels like an utter failure.  NewFNP hasn't really ever given up on something, but she is so relieved that she is giving up on her community health practice.  And she is so ashamed to feel such relief.  

But she is snapping at staff members (irritability) , she feels burdened by patients (frustration) and notices that she feels less compassion in the exam room at times (apathy), she dreads going to work (despair).  

In retrospect, she should have taken more vacation.  But she has coping mechanisms and she uses them.  They just don't work anymore (emotional exhaustion).   

To newFNP, that all screams failure and the cumulative effect is breaking newFNP's heart.  This is not how she wants to behave and feel.

Two more weeks.  Hope springs eternal for newFNP -- she hopes that when she is working part-time, she won't be such a huge asshole.  Can she just stay in bed for the first two days of her two-week vacation?  Can her friends and family gather at her bedside and bring her Lucky Charms?  Will a facial and a peel brighten her outlook?

NewFNP hopes so, because she wants the old newFNP back.

T minus 36 days

NewFNP is a broken frigging record.  She is burnt out.  No, she is charred.  She is unrecognizable.

She has, however, had some lovely encounters lately that have re-affirmed her love for nurse practitionering.  Her post-partum patient who was thrilled to introduce her newborn baby to newFNP, who had done the vast majority of her prenatal care, and who told newFNP that she wold help care for newFNP's baby when she finally got around to having one; the physical exam with a lovely woman who gave newFNP a big hug in the hallway and could be heard telling other staff members how happy she is with the care she receives at the clinic; the mom who entered the exam room so angry after having waited for hours to have her daughter's ear examined who left with questions answered and hope that her daughter's chronic condition will be solved; the overwhelmed patient for whom an IUD is a real life-saver.

She was so thankful to host nhFNP and nycPNP a couple of weeks ago and not only because of the crazy delicious tapas and wine!  Theses ladies graduated with newFNP three years ago.  Both are on their second jobs - various aspects of their respective first jobs having chewed them up and spit them out.  Both are happy and thriving in their new positions.  One even presented her work at a major conference recently.  

If newFNP were to present her work somewhere, it would be like an avant-garde show involving lots of crying while in the fetal position, some throwing up, and monkeys throwing loads of crap at her.  That is not how newFNP wants to have her work represented.  

NewFNP is struggling with the thought of leaving community health.  She takes a lot of pride in her work and she has a real love for her patients.  But the utter lack of a system is killing her.  Perhaps she will be able to maintain her sanity if she is only entrenched in the mire of her clinic part-time.  

And, just as importantly, she can't really leave full-time community health practice... whatever will she write about if she leaves entirely?!?!

Thirty-six work days until she can go.  Thirty-five if she gets a UTI or an otitis or something.  Nothing serious, of course.  Just something a little trip to the day spa would cure!

If you can't take the heat...

NewFNP is hot.  She is - sadly - not 'hot' in the new hair-do, flattering trousers, sassy flats sense of the word.  No, she is talking about the Holy shit! Who turned up the heat and why in the hell don't I have central AC kind of hot.

And newFNP is also frustrated.  This is not a good combination.

NewFNP is sending out a cry for help.  NewFNP does not like herself much of the time anymore when she is at work.  She is mean.  She hears the harsh tone of her voice and cringes.  She is endlessly frustrated by the half-assed work of the support staff.  Each and every day, she is correcting other people's mistakes and dealing with other staff members' shitty attitudes and disappointed by the lack of improvements in the system despite her efforts.  She hears that people have called her bossy, which is true, and a bitch, which has been true but is not something newFNP is in her outside clinic life.  NewFNP wants to not care about what people think, but she does.  And newFNP does not want to be a bitch.

NewFNP spends so much time looking for unfiled labs, asking her MA to find unfiled labs and doing laps around the poorly designed clinic in an attempt to find her MA in order to ask her to find unfiled labs that she could probably see an extra 1-2 patients per day if this one issue were to be solved.  She is fed up with the growing piles and piles of unfiled charts on the floor of the file room while the clinic staff sits and chats about whatever crap it is that they talk about.  She is frustrated that the very young and very overwhelmed clinic manager is impotent when it comes to actually managing the clinic and the staff.

As an aside, there are many reasons that drive the resistance against change in newFNP's clinic.  When newFNP eventually leaves, she'll share them with you and it will make your heads roll.  But the infrastructure is so unique that it would be a dead give-away if anyone in the know was to stumble upon the blog.

So what to do, what to do?  NewFNP doesn't want to leave, but she doesn't want to be a bitch and she doesn't want to be frustrated.  

Her CV looks pretty slick.  Will her local major university -- and her alma mater -- think so too?  Because newFNP submitted it in an act of sheer desperation.  She is looking for options.  And a pension.  And a salary increase.  But to leave would mean giving up what brings newFNP joy - caring for her patients.  

A conundrum indeed.

Thankfully, newFNP has the Death Cab concert, her super-duper friend from South Africa visiting and not one but two grad school pals visiting this week.  She'll be too busy with her real life to worry about her work life.

NewFNP's fantasy letter of resignation

Forgive the lapse into first person.

*******************

Dear Medical Director and Other Pertinent Senior Managers,

It is with absolute joy that I, newFNP, submit to you my letter of resignation.  Hooray!  To quote a decreasingly relevant but still important songstress, "Holiday-ay [oh yeah, oh yeah], celebray-ate [come on, let's celebrate]!"

I see that you are scratching your heads wondering why I, newFNP, may be leaving.  Is it the unreasonable workload, you may be asking?  It is not.  Is it the lack of support staff in the clinic? Not that either.  Is it the incessant drama?  Alas, I have grown immune to it.  Is it the working through lunch almost every day?  No, in fact, I, newFNP, think of that as part of my calorie restriction plan!  

Is it the fact that, despite our mutual agreement that adults with chronic diseases should have thirty minutes allotted for physicals, they continue to have fifteen minutes and I, newFNP, am expected to take good care of them in that time frame?  Ditto for new prenatals and IUD insertions.  No, I have begrudgingly accepted that I must see another patient faster in order to have a longer time with the more demanding patients.  I, newFNP, am a natural-born problem solver!  

Is it the fact that I, newFNP, earn $15,000 less per annum than the provider who referred the patient with the markedly enlarged prostate to nephrology?  I know, I know, I am not supposed to know the salaries of other providers but - guess what?  I do, and that still is not the reason I, newFNP, am leaving.  Is it the fact that, despite having brought concerns to you all several times, only to have you nod empathically and promise to address these aforementioned concerns, you do nothing?  Amazingly, no.  

As you can see, I, newFNP, am willing to put up with a shitload of crapola because I am a schmuck and committed to community health!  So you can go ahead and pile this dump-truck of crap on me and I, newFNP will stay!  I do not expect that you will thank me, only that I will receive my bi-weekly paycheck.  I must admit that you have unfailingly delivered in this!  I wonder if you laugh when you see how many hours I, newFNP, have worked for the amount of money you pay me?  Not that it matters.  As I have already noted, I am not leaving over paltry concerns such as salary.

No, I am leaving because you continue to fuck up my schedule.  That's right.  After almost three years of employment, you continue to change my day off and have appeared to have settled on Tuesday.  Well guess what?  No thank you, Sirs and Madams.  I understand that so-and-so has school and so-and-so has another job and so-and-so never works Saturdays.  Because I, newFNP, have demonstrated flexibility in the past, I see that you saw fit to take advantage of that yet again.  Why should I ever have doubted you?  You are a consistent bunch, after all!  Consistent in screwing up my schedule!

No hard feelings, eh?  

Taking this job and shoving it, fondly of course.

-newFNP

*******************

NewFNP is clear that she cannot say this to her supervisors, but she is unsure why they are so unfailingly unrealistic.  Is it wrong to hate them?  NewFNP thinks not.  Is it, after all, the natural order of things.

Tuesdays off?  Didn't we already go through this with the last inept scheduler?  

NewFNP is nothing but a hater tonight.  Not even a delicious homemade meal of sesame-encrusted seared ahi with organic broccoli and rosemary fingerling potatoes could extinguish her fiery distaste of her clinic and its retarded scheduling.  

Introspection

NewFNP has recently begun to wonder more and more -- is she part of the solution or part of the problem?

NewFNP is type A to the nth degree, she is a stubborn Capricorn and she is addicted to having things done correctly, generally on the first try.  She is unfailingly punctual.  She expects that the people with whom she works will get their jobs done correctly so that her job is easier.   

Perhaps these personality traits are more suited to, oh let's say, dictator than to that of an FNP in a community health clinic.  While newFNP knows that her expectations oftentimes exceed the ability of her support staff and sometimes of other clinical staff, during a busy clinical day in which newFNP is correcting the mistakes or oversights or laziness of others, she cannot help but to grow frustrated.

NewFNP is so used to having things screwed up that she perpetually dreads and anticipates the mistake du jour.  

For instance, last Friday, three providers were scheduled, two were working and zero patients were cancelled until newFNP had a fit of apoplecty in front of the clinic manager and scheduler.* Today, one of newFNP's clinical colleagues left early and newFNP was overly sensitive to ensuring that the front desk staff was aware of her departure and would allow for a reduction in patients as a result of having one less provider.  NewFNP is so sensitive to foolishly booked schedules that she was unable to see her way through the management of two physicals scheduled at the same time - mom and baby - who arrived an hour late and wanted to be seen together.  Though not an unreasonable request, it seems more unreasonable when A) the one month old boy's father was present and B) the pair were an hour late.

NewFNP is confused.  She has autonomy in her practice, the physicians do not see her as incompetent or "less than" because she chose to be a nurse rather than a doctor, she has decent benefits and a reasonable salary, although that last point is negotiable.  

But is newFNP doing any good when she feels like she is walking into the DMZ as she crosses her clinic's threshold?  Do other providers have to remind themselves to smile?  Is her frustration causing her circulating cortisol level to rise to the point where newFNP will be rendered infertile and laden with belly fat?  Will she need therapy, IVF and relacore?

Is it worth it?  Is this just what it is, what it always will be?

In writing this, newFNP thinks back to this morning when she arrived at her desk to find a sweet coffee cup, wrapped in paper towel - a gift from a patient.  So lovely and sweet.  Is newFNP an asshole for thinking of leaving these sweet patients, frustrating though they and the practice may be?  

NewFNP is holding out for the four-day workweek.  Rumors have been circulating that the clinics may open for extended hours.  Three days off each week might be the ticket.  Hiking, movies, yoga, hair-dos, shopping, cooking.  That may just turn over a new, happy leaf in newFNP. 

* Alas, not the first time.

Buh-bye.

NewFNP walked out of work today.

Monday was the twentieth anniversary of the death of newFNP's mom.  NewFNP is not old enough to have passed this anniversary, but it came and went nonetheless.  NewFNP was feeling pretty sad about it and had a heartbreaking conversation with her younger brother in which mom's favorite flavor of ice cream was hypothesized about, but remained unidentified.  It seems more significant when the person is gone.

Well, nothing takes the sting out of that miserable piece of crap day than to get an e-mail noting that one will be working every frigging Saturday in February.  NewFNP feels compelled to remind everyone that Saturday clinic now begins at a soul-crushing 7:30 AM.  NewFNP promptly replied to this e-mail assault, employing words such as 'unacceptable' and 'disheartening' and 'go fuck yourself.'  OK, that last one was not verbatim but newFNP likes to think that she conveyed the sentiment in a very genteel fashion.

NewFNP's COO earnestly apologized and promised that he would change her schedule and that she would be working only two Saturdays, as per newFNP's agreement.

At three o'clock today and after seeing 20-something patients, newFNP received an e-mail reflecting the change.  Lo and behold, newFNP had a paltry one Saturday off and, friends, it was not the one she had specifically requested.  She attempted to broach the topic with her COO, but he was late for a meeting.

So newFNP left her patients in her exam rooms, donned her Tom Ford sunglasses and walked out, frustrated and feeling powerless.  

Granted, she only walked around the block, but she could have kept on walkin' if not for the risk of bodily harm via drive by shooting and of credit harm via student loan default.

But instead, she went back, did a couple of exams and then solved the problem.  

The huge drag is that it didn't even need to be a problem.  Dr. Dual-Ivy-League-Degrees offered to work one of newFNP's Saturdays.   The Real Dr. Mc Dreamy is working part time and she offered to pick up another Saturday.  All that really needed to occur was a little communication.

NewFNP is certain that poor communication is a problem in many community health clinics.  But newFNP is sick of it.  She is committed to community health, she is willing to be flexible, she has no intention of leaving.  Is senior management trying to force her out?  

Community health clinics have a hard enough time keeping providers.  NewFNP doesn't need a clothing allowance, but she does need to be treated with courtesy.

She'll probably need a Xanax when the March schedule comes out.

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.

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!

Happy Holidays

NewFNP would like to institute a rule firmly stating that her schedule the week before Christmas and, equally as importantly, newFNP's birthday can accomodate only well visits and patients who would like to sit and chat about ways to keep healthy throughout this holiday season.

Patients who should bypass the tiny community health clinic and go straight to the emergency room include those who are a) new to the practice and b) 80 years old and c) having chest pain and dizziness and d) apparently carrying a right-sided heart the size of a Plymouth around in their chest as evidenced by ekg tracings. Shame on newFNP for forgetting to share that this gentleman also had inverted t-waves. At least the decision to send a chap like that to the ED is an easy one.

Similarly easy in the "A/P" department is a woman who is being seen for itchy eyes and has a blood pressure of 150/110 who casually notes that she has been snacking on ice for the past year or so and whose hemoglobin was an eye-popping 3.4. Note: blood should not be pink and watery. Merry Christmas and Happy Hanukkah - you're getting a blood transfusion! Hell, maybe even two!

As for newFNP, she has five consecutive days off and she frankly needs it. Burnout, baby, burnout. Five days should provide newFNP with a fresh outlook and, considering the season, perhaps some new fashions with which to create a vibrant return to the 'hood.

What to do, what to do

As many of you know, newFNP has been experiencing distress at her place of employment as of late. This distress led newFNP to forward her CV to two of her public health type colleagues who are, as they say, connected.

And now newFNP has a job interview at the Cadillac of community health clinics.

Here is the conundrum. There is never a *good* time to change jobs. There are times that are worse than others. For example, newFNP has a three-week vacation planned in February. Is it a bad thing to say, "Oh, and BTW, I'm going to need to take February off. Problem with that?" NewFNP thinks that is not ideal. Secondly, newFNP let her CPR certification lapse. Fucking hell because now newFNP has to sit in that MF-ing course all over again. Double fucking hell because it looks flat out bad to let such a thing lapse when applying for new employment. Thirdly, newFNP's clinic just lost a provider - no big shock. This does, however, cause extra stress on the existing staff.

Finally, newFNP really likes and respects the MD with whom she works. NewFNP will need to excuse herself from work for a half-day to attend said interview. NewFNP wants to tell her MD, but doesn't want her MD to think she is a big ship-jumping a-hole. Ay ay ay. And newFNP is not even sure that she wants to leave her fucked up community health clinic for a more posh community health clinic. This posh clinic is at least 15 minutes further from newFNP's new apartment and, in newFNP's city, that could be a real problem.

NewFNP has about 10.5 hours to figure this all out.