What's up, Sicko?

NewFNP and her Punjabi boyfriend hit the theater and checked out the new Michael Moore film, Sicko. NewFNP is hesitant to call it a documentary as it certainly was envisioned to do more than increase knowledge, but it certainly was not created solely to entertain its audience and therefore falls outside newNFP's definition of a movie.

Like the NYer, newFNP wishes that Sicko would have dealt more with the faults of insurance coverage and with how many Americans actually support universal health care rather than on some of the theatrics, but newFNP is a one-trick pony in this arena and her documentary about the subject would be boring as shit and would have had lots of swears and no one would want to watch it. Moore's film, on the other hand, showcased two very compelling stories about regular working folk who had HMO coverage and who died as a result of red tape and cheap, cheap, cheap decision makers who denied necessary care.

NewFNP is not wholly opposed to the idea of an HMO - an insurance designed in response to the over-consumption of medical care and the ordering of excessive tests in the fee-for-service system. However, who cannot deny that it is fucking rotten to have rewards for flat out denying care. And emergencies are emergencies - people need to get to the closest ED, not the closest in-network ED.

Shit, newFNP could make billions if she were just more of an asshole. She denies care on a daily basis just so that she can selfishly leave clinic on time instead of taking a walk-in pap test, but she never denies someone care, even at 5PM, if they really need it. So maybe newFNP couldn't make such bank after all. Damn, newFNP just shattered her own dreams of riches in the course of two sentences!

NewFNP dealt with her own "denial" moment today when an administrator at the clinic told her that she couldn't refer a patient to a partnering organization for post-partum depression because this organization wasn't a part of the right collaborative. What the fuck? There is exactly one resource in newFNP's area for uninsured women with post-partum depression and newFNP used it. No, this normally very with-it administrator was adamant that the patient wait and go through the referral process. Referral to where? The fucking Hubble Space Station? Disneyland? Buckingham Palace? The hospital that let a patient die on the floor of the emergency room?

NewFNP knows that universal health care isn't "the" answer, but it sure as hell seems like a better solution to what we have now and, call newFNP a leftie, but it seems like the ethically right thing to do. A wealthy nation should care for its people, should protect the health of the nation at the individual level as well as the community level, and should acknowledge that people cannot be productive members of society if they are unwell. For Pete's sake, newFNP is less productive if she has a fucking pimple! Imagine if she had pink eye! Or diabetes, hypertension and dyslipidemia.

So, anyway, after you all see Knocked Up, see Sicko. They both have to do with health care, in a way, so maybe you can get your popcorn reimbursed and call the time spent "continuing education."

Ah ah ah - stop right there

NewFNP has been slacking because all that has been occurring in her clinic is drama, drama, drama. It is exhausting. Save the drama for you mama is right!

Anyway, clinical telenovelas aside, newFNP's clinic has instituted this "new" practice policy of addressing just one concern per visit. It's not revolutionary, it's just that some of us (read: newFNP) have a difficult time adhering to it.

In newFNP's clinic, it takes about 3 weeks to get an appointment so newFNP can understand why a patient may want to kill you for saying that they need to schedule yet another appointment, for which they must arrive on time and subsequently wait 30-90 minutes to get seen. Would it kill newFNP to look in your ear when you're truly there for your pap results? Unlikely. Will you assume that this willingness to overlook the rules extends to each and every clinical visit? Definitely. Honestly, someone else needs to be the bad guy. There needs to be a triage nurse or some type of signage up in every room letting patients know that it's 1 - not 3, not 5 - concern per visit. No, no signage. All of newFNP's patients ignore the 'turn your cell phone off' sign, as well as the 'shoes off if you're diabetic' sign. No, newFNP's appointment needs a triage nurse that pins the real concern down.

And for the love of all that is holy, what is newFNP to do when her 50 year old patient with normal lab results tells her that his lower back is hurting? Should she even begin to ask about it? Should she punch him in the gut and ask, "Any less pain in the back now?" Seriously, once newFNP hears a complaint, she feels a little compelled to address it. What if his prostate is the size of a Buick? What if he has the horrifyingly freaky cauda equina syndrome? NewFNP would assume that over the counter Tylenol, even extra-strength, wouldn't touch that motherfucker!

NewFNP printed an article from the current issue of Family Practice Management entitled "How to Manage the Difficult Patient." It's pretty helpful and reminds newFNP that, no matter what, she should not be another problem on the already exhaustive chief complaint list.

Hg free for you & me

At newFNP's clinic, Fridays are reserved for pediatrics and, more specifically, for well child checks. *Well* child. Physicals and vaccines. Sure, newFNP will treat your child's ezcema during the WCC. She, however, cannot solve your daughter's super-fucked up life in 15 minutes. NewFNP can generally survive one train-wreck on Fridays. But four? Well, four is just too damn many. Especially afternoon train wrecks. Isn't there some type of screening tool the front desk staff can utilize in order to schedule all of the emotionally exhaustive patients in the morning? Doubtful, given that newFNP continues to struggle with labels missing from a fair number of her charts.

NewFNP's first afternoon patient was a 15-year old girl, absoultely ridden with sour-puss attitude, who had missed school for a month because the pills she was taking for her abdominal pain made her sleepy. What was she taking? Lunesta? Oh, the attitude. NewFNP knows that she must have been somewhat like this girl oh-so-many years ago and it pained her to see that she may have been such an asshole. NewFNP generally likes teenagers, but she was considering advising this patient to go screw herself. NewFNP rose above the temptation, however. A smart move all in all.

Then newFNP had the walk-in depressed patient with the very chatty grandmother. Her patient was a very sweet young man and his grandmother was very concerned. However, newFNP does not need the anecdotes regarding the patient's anxious sister, grandma's 'nerves' and dad's relationship issues during the already tight walk-in schedule.

Then there were the sisters with the mercury exposure. Too much tilefish? Broken thermometer? Nope. In newFNP's mind, this is the epitome of a ghetto exposure story.

These sisters attended a baby shower in a house located next to a junk yard. Some kids were playing with a bottle filled with silver liquid that they found in the junk yard. Opened up the bottle and - voila! Millions of little silver balls! Please kids, please... don't play in junk yards. NewFNP doesn't even like to go to Ross, so there is no fucking way that she is going to a junk yard. Anyway, word got out that the house was subsequently quarantined as a result of the exposure so newFNP needed to evaluate the kids.

The only problem was that newFNP didn't learn about frigging mercury exposure in school. She just learned not to eat mackerel. So, off to the CDC website for some guidance. In short - assess for respiratory complications, draw their blood and do a urine, preferably a 24-hour urine but a spot urine will do in a pinch. Call the health department. Done, done and done.

Oh but wait, what do you do if one of the mercury kids had scooped up some of the pretty, shiny toxin and taken it to school, where she then threw it away? Well, then you call the haz-mat team and everyone gets an early summer vacation.

NewFNP thought that she was finished with the heavy metal when she received a call from our friendly neighborhood laboratory draw station. The attendant had the requisition forms from newFNP's patients, but apparently their mother and a whole other family was there to get their labs checked as well. NewFNP's patients truly do not know how the health care system works and newFNP spends an inordinate amount of time explaining things such as what it means to have refills on prescriptions and why patients need appointments. Now this poor lab worker was stuck doing the explaining as to why you can't just walk into a lab and order tests yourself.

Oh, community health. The hits just keep on comin!

NewFNP did, however, feel very proud of herself for acting as a public health practitioner today. Sure, all she did was call the toxics epidemiology department, but she sure felt good about doing it. It made newFNP realize how much providing individual health makes her miss public health. One day.... one day.

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.

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.

Addendum

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.

Checklist

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!

Va-va-va.... hey, wait a minute

As of late, newFNP has been using her spare time in between patients to help the higher-ups at work compile data for a new program application. As such, she has learned many statistics about the area in which she works. For instance, she works in the area that has the highest all-cause mortality in her county of residence. The area has the highest rates of uninsured adults and children in the county. The majority of the residents in her clinic service area speak a language other than English at home. Only a quarter of the residents have graduated from high school. The average income is in the low 20,000's.

All this to say that the patients who newFNP serves are poor and largely disenfranchised. No shit, right? They're waiting 2 hours for a 15-minute appointment at a free clinic after all.

Generally, when newFNP is conducting a health history during a physical, the past surgical history that she elicits include cholecystectomies, BTL's, hysterectomies and traumatic injury repairs. It is rare, exceedingly rare, that newFNP has a patient who has had breast implants, a tummy tuck and a face lift - all conducted in the US. Any plastic surgeries that newFNP's patients may have had are generally conducted in Mexico.

So let's see... breast augmentation. What does that even run a person? Thankfully, newFNP will never have to know! But she thinks that it is in the neighborhood of $5000. Tummy tucks? $7000? Who the fuck knows? And a face lift? What, another $5000?

So if you are dishing out upwards of fifteen grand to spruce up the bod, it seems egregious to then seek out the services of a free clinic and use public funds for your physical. At the very least, it seems as though a generous donation is in order.

NewFNP didn't say anything, though. She just did her first implant breast exam and then sent out the referral for the mammography.

Breaking the law

It was yet another busy Monday in newFNP's clinic and, with newFNP still fighting her URI, she was fighting to stay afloat. She has eight charts at home to finish and some unfinished business to attend to tomorrow.

As such, newFNP was certainly not counting on a knock on her exam room door at 4:15 as she was conducting two well-child checks on siblings. She never expected her colleague FNP to say, "You have got to see this. Someone forged a prescription on a patient you saw last week."

But this is, in fact, exactly what happened.

Apparently, the two-year old patient's mom felt that the Ibuprofen prescribed by newFNP just wasn't enough. She thought that she should just add on "amoxicillina 250mg." Just like that. Just a Spanish language medication and dosage written in chicken scratch above newFNP's graceful and fluid script.

Thankfully, the pharmacy faxed over the prescription in order to verify it. They, however, asked newFNP to verify the sig, not to verify that it was a big fat forgery. What the fuck? Doesn't the pharmacist say something to the patient? Something such as, "Ahem, do you know that it is fucking illegal to forge prescriptions, you cow!?! You know, illegal as in jail."

The patient's mom had the audacity to call the clinic today, demanding that her child be given Amox and threatening to take him to the hospital, change clinics and make a scene if we didn't give it to her. She insisted that newFNP wrote her the prescription. NewFNP refused to talk to her. She let her clinic manager know what the situation was and went about her business.

Why do patients like this always think that threatening to change clinics is something newFNP will respond to? Please, newFNP will pay this patient five bucks to change clinics so she never has to deal with her fraudulent-prescription-writing ass again.

So long sucker!

Ahhh... cable TV

NewFNP likes to fancy herself as healthy, but here she is - sick again. NewFNP attributes her illness to being exposed to all manners of rhinoviruses day in and day out and believes wholeheartedly that it is only the most virulent of said viruses that tend to knock newFNP on her ass. Which is where she has been all weekend. On the couch, flat on her ass, in and out of consciousness, thanking God that her boyfriend had the good sense to buy a huge flatscreen TV so that she may be entertained by the likes of Dirty Dancing, CSI and Caddyshack.

Nobody puts Baby in a corner.

NewFNP did take some time during her convalescence to think about her current employment situation. She reviewed some physical assessment texts and thought about where she might be taking her career. As we all know, her attitude is in the toilet. However, newFNP would like to change that and certainly does not want her career to follow that path.

But here is why newFNP's attitude sucks.

Sometimes people just break newFNP's heart. When newFNP hears about food insecurity from a featherweight 22-year old man, it just makes her emotional. Imagine leaving one's country to come to the US, in hopes of a better existence, and not being able to find adequate food. Of knowing that you have latent TB, but not being able to afford the $10 medicine to avoid active TB infection. Of finally securing a job, but working six days per week and not being allowed to leave early to get to the clinic. There was something more about this patient, though. His modesty, his sincerity... he really touched newFNP.

Then there are the people who make newFNP want to scream. This week, a patient told newFNP that no matter how much he weighs, he never changes in size. In fact, he claimed, one time he lost one hundred pounds, but still wore the same sized jeans. "One hundred pounds?", newFNP verified. Confirmed. One hundred pounds and still a size 42 waist. Diagnosis: delusional liar? Reality challenged? How is newFNP supposed to help someone who has clearly lost touch with all that is real? NewFNP notices that her trousers are roomier of she loses 1/100th of a pound.

And finally there is that old chestnut about support staff not providing support. NewFNP does not want to micromanage, nor does she have the time to do so. But when newFNP's reputation is on the line, you bet that she will be all over the staff's asses in order to get things done. You betcha that newFNP can find 30 seconds in between patients to ask if phone calls have been made and abnormal pap logs have been updated.

A friend of newFNP's recently noted that he felt that newFNP sometimes feels anger toward her patients. NewFNP disagrees, but she certainly does feel frustration toward many patients. Quite simply, how could one not feel frustrated given the challenges one faces in community health and probably in all healthcare settings?

Working through these frustrations is one of the challenges that newFNP faces. Sometimes she is great at it, sometimes not so much.

Unqualified

NewFNP works in the poorest service area within her county. Almost every single health outcome indicator (overall mortality, teen births, infant mortality, obesity, cardiovascular mortality, insurance coverage - you get the picture) is the worst in her entire huge county. Her patients are exclusively covered by public health insurance, if at all.

So when newFNP has a patient who has some wealth accumulated, she finds it, frankly, a little surprising.

For instance, when newFNP asks her patient if she has health insurance and her patient responds that, no, she doesn't qualify for health insurance because she owns her home, newFNP is surprised. NewFNP's patient's net worth is greater than that of newFNP, yet newFNP is working, paying off five years of grad school loans and going home to her rented apartment, albeit a sweet-ass apartment with hardwood, washer & dryer and arched doorways located in a chic and safe area of her city. Perhaps newFNP will one day achieve the dream of home ownership herself, but she is currently unwilling to sacrifice her HMO and 401(k).

NewFNP's landed gentry patient must think that state-funded insurance is the creme de la creme, because she asked newFNP if newFNP "qualified" to receive it. Almost! If the state took newFNP's loans into account, she just might qualify for public insurance and section 8 housing!

At any rate, newFNP believes that this speaks to the need for universal health insurance. Should newFNP's patient have to sell her house in order to qualify for public health coverage? Does being a homeowner make newFNP's patient a woman of means? Might newFNP's patient end up costing the public health system more money if she can't get the care she requires? No, no, yes.

NewFNP does not like to think about how much longer we have until the next presidential election, but is she ever hopeful that the pendulum will be swinging left!

A community health fairy tale

NewFNP works for an organization that has four clinics. She is generally at one site, but floats from other sites time to time. Some might say that we are all sister clinics. Others might call one clinic or another an evil step-sister.

As newFNP's readers know, newFNP's clinic is down one full-time provider. The other NP works three days per week. That leaves newFNP alone two days per week. So fine, newFNP has to go it on her own. NewFNP has to fill out the paperwork for all of the kids needing school physical documentation, organize the type 2 diabetes group, help the HR director re-apply for the HPSA score and write letters for patients applying for disability. By the way, is having dyslipidemia a disability? Hmmm, newFNP thinks not. Denied!

Did newFNP mention that she has zero hours of administrative time during her work day?

All this to say that, frankly, newFNP doesn't need anything extra. NewFNP most definitively does not need another clinic, her organization's biggest clinic, sending her a walk-in s/p abscess I&D wound care patient. And furthermore, newFNP does not need that patient to walk-in without a either a courtesy phone call from the dickhead at the front desk of the other clinic or a copy of the patient's registration info and progress note faxed from the clinic.

Why can't other people understand that taking five minutes to extend professional courtesy makes a difference? This is what continually floors newFNP about working in community health. Some of her colleagues just don't have common sense, nor do they think to extend courtesy to each other. Certainly a phone call is a chance to express thanks for the extra work, to give a heads up that you might be keeping your staff over an hour late due to the complexity of the walk-in patient and that you will likely be missing a date with your boyfriend.

But no. In walked newFNP's patient with a 2-inch gaping wound in her buttocks, covered with approximately 800 bandages and 35 rolls of tape. It took 15 minutes just to get the bad dressing off this poor lady's irritated skin. After diluting the wound with one liter of diluted hydrogen peroxide, newFNP packed her patient's lovely lady lump with three feet of iodoform. Three feet. During this process, newFNP's patient told her that the other clinic sent her because newFNP's clinic was bigger, that the evil step-sister clinic was closing early and that they didn't have the supplies to do the dressing change.

Interesting phenomenon indeed. The clinic had the supplies to slice open this woman's butt, pack the wound and cover it, but not to check on her healing and change her bandage.

It's one thing to have patients dumped from other clinics, but to get screwed by one's own colleagues! That just leaves a bitter taste in newFNP's already tart mouth.

Bathtub safety

NewFNP has a hunch that it is going to be a grand day at work when, driving to work at 8AM, she sees no less than five commercial sex workers standing on consecutive corners, white patent faux leather thigh-high boots, Daisy Dukes and Huggy Bear caps-a-plenty. Is there no vice squad in newFNP's major metropolitan area? Can the lady walking down the street in a tee-shirt and no pants or underwear find it within herself to cover her huge ass? What the fuck?

Seriously people. Can't we all agree that there are certain things that newFNP, as well as the majority of the rest of the world, do not need to see except at the movie theater or on C*O*P*S? There is only so much vice that newFNP can tolerate so early in the morning. This morning exceeded newFNP's quota.

So, hours passed with no obvious prostitution, leading newFNP to think that her day was normailzing, when newFNP was saw the chief complaint of "hurt her vagina." Now, newFNP is no stranger to curiously worded CC's, such as "little ball on the peanuts, " "soap in the right eye x 9 days" and "cough and flames x 2 days." What does newFNP have, a dragon for a patient? So, clearly, "hurt her vagina" isn't the oddest CC, but it's no "med refill" either.

Apparently, newFNP's 200-pound patient had slipped while exiting the tub. Her fall was broken by the tub wall, with her labia bearing the brunt of the force. Her left labia majora to be exact.

NewFNP uttered the words "oh shit" upon seeing her patient's horribly swollen purple labia. It was the size of newFNP's fist. It looked like a seashell. NewFNP imagines that she felt what all men feel when they see another man take a hit to the testes. Youch! Again, newFNP did screen for abuse - none. All of the pelvic bony structures were intact and the patient had full ROM at the hip, thus no x-ray for this uninsured patient.

Ice. Ice. Ice. Ice. Ice. Frozen peas baby. Mold 'em to your downstairs. Motrin 800mg TID with food. NewFNP thinks that pelvic rest is an obvious plan, but said it nonetheless. A little prayer that this will resolve quickly for the patient.

Man, oh man. What a day.

NewFNP's patients need the ERA!

Gender equality has yet to make it to newFNP's patients. Sure, in our practice, the medical and dental directors are both women, as are the CFO and COO. The majority of the providers are female. NewFNP can't imagine that any of them go home to loser husbands who sit on the couch, drink beer and watch TV.

Yet newFNP has patient after patient tell me that they can't find a moment for themselves, that they care for children and homes all day long, only to care for children, homes and partners once the men come home from work. And these women have complaints of fatigue, dizziness, "low blood pressure," and sadness.

And they have no friends. NewFNP asks about friends/support systems, but these women don't have them. NewFNP screens every patient for IPV, but the majority of these women deny abuse. They are just socially isolated. If newFNP didn't have her girlfriends, oh man, that would be a grim existence indeed.

Now don't everyone go and write newFNP, telling her that she is naive and all of these women are abused and denying IPV. Please. NewFNP doesn't screen just once and she gets that it takes more than once to gain confidence. Some of these women will disclose abuse; others are just married to beer-stained couch cushions.

NewFNP knows that we are supposed to be culturally sensitive, but newFNP finds it pretty fucking difficult to be sensitive to husbands/fathers who are as lazy as tree sloths. Yeah, yeah, these guys work all day, but so do their wives. Caring for children all day long is exhausting. How much pretend play can one engage in? NewFNP isn't talking about in the bedroom now, but speaking of... Is it any surprise that these women have no sexual desire? NewFNP thinks not. In fact, newFNP is hard pressed to think of a woman who is going to want some sweet lovin' if all she does is work around the house and see her husband watch WWF while sipping on a cool Pabst Blue Ribbon.

NewFNP had an awesome 28-year old patient today who is a mother of four. She does aerobics most days making her a clear outlier in newFNP's practice. Her husband would like another baby, mostly, she believes, to keep her around the house more. She told him that is would be a cold day in hell before that happened. NewFNP felt so proud of her!

Now newFNP is all riled up and needs to see if her boyfriend did the dishes or made the bed or did something today!

A personal tale

It should be no news to newFNP readers that newFNP's schedule is busy, overbooked, conducted in Spanish and often overwhelming. Given that, little personal difficulties may cause newFNP to experience her work stress on a continuum ranging from extra-stressful to unbearable.

Some examples.

A lone pimple: extra-stressful.
Bad hair day: pretty much every day, thus no added stress. Thank goodness for My Little Pony-tails.
Forgotten Nalgene: dehydratingly stressful.
Fight with Punjabi boyfriend: extra-stressful, that gaddha.

So imagine what real personal trauma might do.

NewFNP was raised by her maternal aunt from the age of 14, when her mother died suddenly after suffering a cerebral aneurysm. NewFNP's aunt, like her mom, was a single mom with two children. NewFNP's cousins are like her brothers. They snowboarded with newFNP, they white-water kayaked and rock-climbed together.

Two months before newFNP finished her studies, her older cousin was diagnosed with glioblastoma multiforme. She spent the summer after finishing her MSN with him, driving him to radiation every day, watching The West Wing on DVD and eating take-out Mexican and Baskin-Robbins. Last week, he started hospice care. He's 35. Thirty-fucking-five.

NewFNP spent last weekend holding his hand as he walked down the hall, paralyzed on his left, unable to walk alone. She held the container for him to urinate into. She sat by the hospital bed now in his bedroom while he slept. These intimacies that nurses share... well, newFNP has never shared them with another family member. While his mom does this for him on a daily basis, the last time newFNP spent time with him, he was walking alone. He wasn't asking newFNP about his impending death. He wasn't asking about what would happen when he could no longer walk or swallow.

NewFNP has a sweet patient now who had the tip of his finger traumatically amputated by a soccer cleat last weekend. He comes in for dressing changes and evaluation. It's a quiet appointment: cleaning, wrapping, assessing for re-growth of tissue that resembles a finger.

On Monday, newFNP could see him mourning the loss of his normal finger. Cleaning, thinking, Bacitracin-ing, fighting back tears, wrapping, mourning.

The odd thing is, in the midst of experiencing sadness of such depth that she cannot imagine it's resolution, newFNP has been surprisingly peaceful at work. It's not that she doesn't care. It's just - well - newFNP doesn't really know what it is.

She just can't leave the profound sadness at the door.

The real Dr. McDreamy*

NewFNP's clinic is going through a real change.

As of Monday, newFNP's supervising physician is gone. Over the past 18 months, this woman has been there for newFNP to educate, to support, to encourage and, at times, to commiserate. She is so good with patients that she could be an NP! And she was a huge advocate for the providers.

NewFNP has felt her loss frequently these past three days, perhaps most often when she was seeing Dr. Awesome's patients whose appointments the receptionists had neglected or otherwise failed to cancel. One example of this was when newFNP saw three scheduled 8:30 appointments today - 2 of Dr. Awesome's & 1 of her own. Another example was when she saw a physical scheduled for 3:30PM at 5:10PM. Did newFNP mention that this patient has fibromyalgia? Well, she does. 5:10PM - starting time.

Has newFNP mentioned recently that her clinic closes at 5PM?

Scheduling consequences aside, the most horrible thing about losing Dr. Awesome is that a great ally, a terrific leader, an inspirational provider and a physician who doesn't crawl up her newFNP's ass is gone.

And why is she gone? NewFNP thinks that her chronicle of the past year and one-half suffices for an explanation.

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*newFNP has never seen Grey's Anatomy, nor does she endorse super-skinny girls with big pouts or homophobia.

Thar she blows

NewFNP loves derm. Paring down and freezing off warts - love it. Pityriasis - fascinating. Acne - please let newFNP help. And don't get newFNP started on Retin-A. It is her second favorite medicine after the Pill. In fact, scratch that. As newFNP is in her thirties, Retin-A is usurping the Pill's position as #1 medicine of newFNP's life.

Yes, newFNP loves derm. In fact, prior to getting master's degree #1, newFNP toyed with the idea of going to beauty school to be an aesthetician. What a cushy job. Soft music, aromatherapy candles, Sothys or Peter Thomas Roth product as far as the eye can see, comedone extractions.... ahhhhh. Well, newFNP didn't even have the chance to be a beauty school dropout. No, she pursued a career allowing her to benefit humanity in a different way. Who knows, however, what the future holds with the rise of the medi-spa.

In newFNP's clinic, she does not have a lot of opportunity to practice derm. Sure there are plenty of abscesses, but one cannot deny the olfactory component of the I&D which detracts from newFNP's overall satisfaction with the experience.

Enter the epidermoid cyst.

It's like Christmas and Hanukkah all rolled up into one for newFNP. Gross as it may be, there is something very gratifying about expressing 80,000 pounds (give or take) of sebaceous material from a huge cyst. It helps to have lifted some weights prior to the expression of said contents because one truly does need to apply a good deal of pressure. And newFNP would encourage all epidermoid cyst excisers to get the sac wall out, for the love of all that is holy. Sure it would be fun to go through the process all over again, but the patient may feel some dissatisfaction.

For a great article about protecting oneself and staff from the potential spraying contents and for an overall "how to," check out: http://www.aafp.org/afp/20020401/1409.html. Very helpful.

It doesn't take long

The first few days of work after returning from a two-week vacation, newFNP had a sort of Teflon Don-like armor, protecting her from all of the bull crap that had been bogging her down prior to her departure. NewFNP was so well-rested after her vay-cay, she felt like she had received a bull crap vaccine. She smiled, she enjoyed her patients and her relaxed demeanor was remarked upon by many patients and staff, including the C.O.O. In fact, more than one person asked newFNP if she had lost weight! NewFNP must have looked good!

Then, on her 3rd day back in clinic, newFNP began to notice that labels were missing from charts, that blood pressures weren't being recorded, and that her schedule was overbooked. Her M.A. lied to her face at 5:20 PM. The bull crap vaccine must not confer 100% immunity! GSK and Merck, where are you when newFNP is in need?

NewFNP didn't appreciate that there was a ratio at play here: for every one week of vacation, one may expect one day of immunity from the bologna regularly experienced in community health. After that, the protective effect wanes, and how!

And nothing will make that armor disappear like another provider going on vacation and the front office staff both neglecting to cancel her many appointments and allowing many of her patients to be seen despite newFNP having a full schedule herself. Yes, a 34-patient day pretty much wipes out any glow newFNP may have returned with. During her morning commute, newFNP is again fantasizing about quitting.

She is at the 50% mark of her service commitment.

Fucking hell. Another 18 months to go.

NewFNP felt like a rock star today, returning to the clinic. The floors were waxed, the staff gave newFNP hugs. NewFNP had to wonder if she found her way into the wrong clinic!

Ah, but then newFNP saw that the C.O.O. had scheduled her to work two six-day workweeks and she knew that she was, in fact, in the right clinic after all. That fucker.

And - just like that - newFNP was back at it.

After a year and a half in practice, newFNP finds that she is less and less frequently surprised by her clinical encounters. Today, however, was an exception.

It is no surprise that a woman who has had one lifetime pap twelve years ago would feel apprehensive about assuming the position. It is also no surprise that said woman would adopt that "straight leg, buns firmly planted halfway up the exam table" position when readying herself for the pap. In newFNP's practice, it is a little surprising to see a 32-year old woman with only one child (although actively trying for more since her first birth), but not so surprising as to merit a second thought during the patient's first visit on a busy clinical day.

What is surprising is to get the speculum placed and see an IUD string protruding from the os when the patient is quite clear that her birth control method is "condoms sometimes." When newFNP questioned her patient about the IUD, the patient stated that she had received the IUD after the birth of her 12-year old son, but was told that she had expelled it when she went for her one-month check up after insertion. Surprise! The 12-year old IUD is still contracepting! Well, it was until newFNP yanked that MF-er out.

What is even more surprising about this encounter is that less than 24 hours prior to experiencing it, newFNP received an e-mail from a friend from graduate school stating that she had the exact same experience. WTF! NewFNP knew that clinic encounters came in waves, but she didn't know that these waves cross county lines! What a phenomenon!

Flying high

If newFNP can share only one pearl of wisdom with her readers, let it be this: Coach to India is not the way to fly. NewFNP highly recommends the exit row for those who work in community health and cannot charge business class to their already balance-ridden credit card.

Aside from that, newFNP recommends India wholeheartedly. And acidophillus - take acidophillus while vacationing. And bring TP to all public loos.

Back to the clinic tomorrow morning.