The Nurse Practitioner's Place

Talking MSN Interview with Kim From Emergiblog

2012-01-22T00:35:00.000-05:00

I have been lucky enough to have continued to blog even after graduating from my Master's Program 4 years ago. It has been difficult at times due to burn out. Several bloggers have made comments regarding such on their own sites. Sometimes, it's due to not feeling adequately commented upon. We all love comments which is why I almost always try to leave a small one on every blog I visit. Sometimes, it's due to a little frustration about one's writing style. I envy people who's writings seem to flow well and are witty. Kim at Emergiblog is one of my absolute favorites and is such a prolific writer and is hilarious! I honestly don't know how she keeps it all rolling with a full time job, school and maintaining her sites. Kudos to anyone who can do it as well as she can. I was honored to be approached by her to be interviewed for one of the many sites that she writes for. Masters In Nursing is a website that discusses various aspects of Master's Degrees in Nursing and gives advice to others on finding the correct route to go about it. I attended the first online MSN program through Florida State University. It was hard but very worth it. I encourage anyone who is interested in furthering their degree to go for it! We need you out here, especially with the shortage of Family physicians. I welcome any comments and questions about what I do as a Family Nurse Practitioner.

Studies prove effectiveness of nurse practitioners - The News Herald

2011-12-31T14:11:00.000-05:00

Studies prove effectiveness of nurse practitioners - The News Herald

Beth Guy was one of my adjunct professors as Florida State University and is one of my inspirations. I am very happy to repost this here on my blog for others to enjoy. Please go to the article and click on the urls that show the actual data that supports our claims. Nurse practitioners and physician assistants provide comparable care to our patients all over the country. If you agree, please write to your Congress and Senate and let them know how you feel. It helps to have the support when critical legislation is being voted on.

Parkinson's Disease In The Crossfire Refers To NPs and PAs As Extenders

2011-12-23T15:49:00.000-05:00

Thanks to Carla Gibson ARNP for passing along a CME opportunity that refers to NPs and PAs as "physician extenders". I stopped by their website and left them the following response. "I am surprised and disappointed that you are referring to ARNPs as physician extenders in your CME course. We are licensed and many are board certified to provide primary care to our patients. My patients often do not lay eyes on the doctor. If he provides no service to my patients, how can I then be an extension of him? Another term that I find offensive is mid-level provider. In my and my patient's opinions, I give top level care to them and their families. Mid-level implies mediocre care at best. Please consider changing your terminology in your CME course. Thanks." What do you think about these terms?

Get Yourself A Whole New Perspective With A NP Student!

2011-12-13T23:03:00.002-05:00

I was wandering around on some of the Nurse Practitioner message boards and realized just how many students there are that can't seem to find preceptors in their areas. Most of the students that are working on their RN-MSN degrees live in a larger city than I do. I am really surprised to see that there aren't that many NPs willing to take a student under their wing.

I wonder why? The first reason that pops into my head is that we are often so busy with the background work of patient care. Paperwork, Paperwork, Paperwork! Actually, I am supposed to be working on some now but decided to enjoy myself and write a blog post instead. A little break from the dullness is how I see students. Often, they can bring out the best in us. We get so bah-humbug with the standard patient care but to a student, it's a goldmine! Things we see on a regular basis are new and interesting to the new student and sometimes can make us think just a little harder.

Put your name out on the NP boards and websites and find a student who will so very much appreciate your time. The ones who do are usually the ones who are completing their degrees online, like I did, while working full time in a hospital setting. It was hard work but so well worth it! While I was surfing the web, I also found an interesting link about the Anatomy of A Doctor and found it to be very similar to the Anatomy of A NP as well. We both like to figure out problems and to help patients. The timeline is a little shorter for NPs though. I have often wondered if physicians found that the length of time in their college studies was really necessary or was a lot of it busy work? How much of those inorganic and organic chemistry classes gets used in real life patient care really? In the NP program that I went through, I was surprised to find that they were still focused on theory and I wanted more medical content. I never was a big fan of theory but expected that in the higher level of NP education that theory would take a breather!

Via:RN to MSN

Nurse Practitioner Loves Students

2011-12-08T22:31:00.001-05:00

I am currently working with a FNP student and am really enjoying our interactions. I really get a kick when I see the light come on in a student's eyes as something clicks into place. I remember how nervous I was and hoped that the preceptor wouldn't ask me a question that I didn't know the answer to and that it would make me feel really stupid. It's not all that different that regular nursing school! You guys thought it got easier? Nope.

It actually gets a little harder in my opinion. You have to come up with so many differentials in the office setting and it comes from collecting a body of knowledge as a nurse and then building on it over time. That's why I wondered how effective a NP can be if they haven't spent a lot of time on the hospital floor honing those skills of subtle nuance changes in patient's conditions.

You will also become somewhat of an expert in certain types of skills in the office setting. My seemingly particular skill is gallbladder disease. I tend to attract bad gallbladders for some reason. They also come in waves.

Unfortunately, waves of other types also come into my setting. Cancer is one that I am getting tired of swimming through, especially this time of year. I hate when bad things happen around the holidays. You never enjoy them them same when a loved one is diagnosed or dies during the Christmas season. Right now, I have approximately 5-6 people who are either recently diagnosed with cancer or I suspect will be soon. Most of them are lung cancer from past smokers.

PLEASE encourage your patients to stop smoking or dipping tobacco. I hate telling people that they don't have long to live because of something preventable. For the next few weeks, I will be ordering more chest xrays for some of my past and current smokers. I hope I don't find any more problems for a long while.

Reasons for NPs to Blog | Nurse Practitioner Blog

2011-11-19T23:46:00.000-05:00

Hope everyone had a wonderful Nurse Practitioner Week! I came across Stephen's entry about NP blogging and had to agree wholeheartedly! I also didn't see that many NP blogs so I started one myself. It has been an interesting journey from a student to a Novice and onto a more experienced NP. I won't say expert though as I am sure that I have room for improvement. Click on the link and see what he says about his start in the blogging world.
Reasons for NPs to Blog | Nurse Practitioner Blog

A Great Nurse Practitioner Interview

2011-11-14T21:19:00.001-05:00

When someone thinks of getting medical care, the first person who comes to mind is a doctor. The last person they think of is a nurse or the many other healthcare professionals that could possibly treat them on a day to day basis in those offices. In the small town of Branford there are a few doctors’ offices. All of which that carry a physician, nurses, and a nurse practitioner. One office however, is where the only general practice female nurse practitioner in town is. When you call for an appointment in that office it runs on a day by day basis, but you have to call early because their nurse practitioner is quite popular. Jennifer Scott, ARNP, came into this small town with the practice that branched out not knowing what was going to be in store for her. Since then the abundance of patients has been an overwhelming surprise. It only takes one visit in that office to see that you do not have to carry an MD behind your name to be a great medical professional, because most of the patients here come to see Jennifer.

After speaking with Jennifer in a personal interview it was revealed that she had two very good reasons for not pursuing an MD as opposed to her ARNP license. Jennifer Scott, ARNP said, “The first reason was my age. I was already 30 years old before I started the prerequisites. I didn't want to take 12-15 years to become a medical doctor because it would take me too close to retirement age before I could even get started. The length of time also meant more expenses. It cost me $83,000 to get my degree and you can just about double that or more for a doctor's degree. The second reason was because I knew that I was going to have a difficult time managing a family with four children and didn't want to have to complete a full time residency which would interfere”, (personal communication, October 16, 2011).

The credentials between an ARNP and that of an MD are very different. Not only are the years between nurses and nurse practitioners different, but if they do not meet the criteria that is required of them, they will have to sit for the boards once again. According to Jennifer, “Nurse practitioner credentialing requires Board certification every five years. RN’s have to renew their licenses every two years while doing their continuing medical credit classes (CME’s) which I also have to do on top of my NP CME’s. One must practice a certain number of hours yearly to maintain their credentialing or they must sit for the board exam again,” (personal communication”, October 16, 2011).

The American Nurses Credentialing Center of the American Nurses Association and other professional organizations certify registered nurses with master's degrees based on predetermined standards, including passing a written examination and practice time in a specified area. This national certification provides tangible recognition of professional achievement in a defined functional or clinical area of nursing. It also did not used to be mandatory to be certified but is now a requirement of all new ARNP’s. The fees for the certifications are, “$315 for Certification, for a Retake or Recertification is $195, an Endorsement is $195, for a Verification Request it is $30, for a Replacement Card and Certificate it is $20”, (Anonymous, 2011).

In order for Jennifer Scott ARNP, to renew her license she needs “100 total credit hours of CME in a two-year license cycle (cycles ending in December 31^st of each year), a minimum of 20 total credit hours in category 1, and 12 credit hours in the areas of patient safety or risk management either in category 1 or 2”, (personal communication, October 16, 2011). According to Jennifer she can do most of the things a regular physician does. She can write prescriptions and send referrals for patients. Jennifer stated that, “The only practice limitations in the State of Florida that I have are the inability to write controlled substances, sign home health and nursing home orders, and I cannot declare death. I can do everything else a doctor can do based on my individual training and experience”, (personal communication, October 16, 2011). One of the last things I inquired about was whether or not she participated in forums for patients or other health professionals. Although she does not participate in an online forum she does however take the time to write a blog for other ARNP’s and try to answer questions or help them with discovering things in their paths to medicine. “I don't belong to any forums as a nurse practitioner but I do blog about nurse practitioner issues as a way to help influence practice. I also write to my congress and senate to inform them of my opinions and how I think that they should vote on key issues,” (personal communication, October 16, 2011).

The only differences between Jennifer Scott ARNP, and a regular doctor is the big MD behind her name. To some of those patients that does not seem to matter. After seeing the impact that this nurse practitioner has had on her patients and community, it is obvious that regardless of the title she is a great asset to the medical community. She quite possibly will do more for medicine than most doctors will simply because she is family oriented, can relate to struggling to get through school, and truly cares about her patients. That is what the healthcare field needs, more ARNP’s.

NP Wonders If PSA Testing Recommendations Are Correct?

2011-10-08T00:15:00.000-04:00

I have been seeing the seemingly new recommendations that we are being too aggressive with the current PSA testing for men over 50. The logic behind the new recommendation is that we are testing too soon and too often in men that are healthy. Most prostate cancers are very slow movers and most doctors say that something else is more likely to kill the patient than the prostate cancer itself.
Most of the time elevated PSA means that there is a benign enlargement or that there is an infection in the prostate giving artificially high numbers. I am of the mind that if a patient is having urinary hesitancy, I will test the PSA level. If it's elevated, the first thing I do is a round of Cipro for 2 weeks and recheck the level. If it moves downward, it's not prostate cancer. If it continues to climb, I make a referral to urology and let them make the final call.

Most of the prior thought process is based on the age expectancy of around 70-75. Well...I have another issue. Men are living until their late 90's now. If I find an elevated PSA at 50 and I ignore it for a long time and it breaks into their bladder or bowel and kills them before their time, I would feel rather neglectful. I certainly don't want to have a painful cancer that could have been prevented. Would you?

I have also seen the reports that the treatments are bad for men's sex life. Sorry to tell you but so is death! I think that being healthy without sex is more important. I understand that most men find their sex drive to be all important but at the age of 70 plus, who really is worried? Certainly not their wives who have already been past menopause and have lost the urge a LONG time ago. I think that they would much rather have their husbands to spend quality time with in other areas.

What say you?

Nurse Practitioner Has A New Student

2011-10-02T21:35:00.000-04:00

I received a call the other day from our HR department asking if I would like to precept a student. I was practically giddy with excitement! Yes, I love students. Too often I hear that there are not enough preceptors out here and wonder why we are so hard to find. I was lucky enough to find three different nurse practitioner preceptors and around five doctors. I would have preferred to have all NPs but I am glad that I saw the differences and similarities by using both.

You don't have to have many years experience for most to use you as a preceptor. Most will accept one year. You also don't have to be in a specialty. I work in a Rural Health office as a Family NP. Help out a local student in your area. It will help you brush up on things and you can give the pointers that you wish that you had as a student.

Do you precept? Why or why not?

EHR is Here!

2011-09-09T21:31:00.000-04:00

I just started our new EHR and thought that it would be a breeze. Well....it's not as easy as it looks. There are too many choices for some things and not enough for others. The patients are not happy about my reduced schedule these last two weeks but I have needed the time to slow down anyway.
I have yet to figure out how to see 25 patients a day and still have time to teach them anything. I know it's all about the overhead but it's all about the tracking data that is expected too. You can't have both and get it all right. I am trying really hard to be everything to everyone but it is getting a little tiresome.

There's a little nag in the back of my head that so wants to have my own office. I think about Barbara Phillips in Washington States with her independent practice and drool. Yet again, there is a big problem in the state of Florida. I cannot sign controls and I cannot sign home health orders. Those are the biggest aggravations I have.

The money that it would take to open my own practice would take me a long time to accrue. I also don't have to pay for my own malpractice. I get paid decently so I can't complain there. I do so hate having a boss. One day, I will be able to do what I want, when I want. It's a goal in life that I look forward to. Unfortunately, I think retirement will come first!

Ummm, Because You're Yellow?

2011-07-30T21:28:00.000-04:00

I had a patient come the other day that I hadn't seen in several months. As soon as I walked into the room, I noticed that their color was just a little bit off. No really, I LOT off. I told the patient that they needed to go to the hospital.

Why? Ummm, Because you're yellow???? No niceties, just the symptom questions popped out like a barrage of gun fire.

When did you start turning this color yellow? When did you start noticing your sclera turning yellow? How long have you been so tired that you could barely get around? Any itching? Any muscle aches? Any abdominal pain? Trouble with bowel or bladder? Didn't the people in your family notice this or think that is was a bit unusual that you look nine months pregnant?

When they started to say that it wasn't a big deal, that's when I pulled out the BIG C word. You know it.. Cancer... The other big words such as liver failure, and of course the ultimate big word DEATH. They sat up a little higher and started to pay attention.

Or I thought, until they said that they couldn't take the time to go to the hospital because they had other pressing appointments to attend to. I reminded the patient that death waits for no man as they say. They asked if I was serious? Of course! I told them the patient needed an urgent evaluation for several possible scenarios. Gallbladder obstruction or cancer, pancreatic cancer, liver cirrhosis or cancer, and Hepatitis B or C to name a few.

Ohhh.. well I guess I will go in after my spouse's non-emergent appointment in two days..
Argh!!!!! At least go for a stat CT scan so I can at least know what might be going on! Okay. Now we are getting somewhere.

CT scan completed shows cirrhosis of the liver with ascites along with a gallbladder full of stones. Next on the list is to get the person admitted to the biggest hospital so they can be evaluated by a Hepatologist. Call goes out to the ER so they have a head's up about why they will be coming. A fax of the most current labs and the CT scan report sent.

Here comes the call from the patient... They want to ask you some questions (relayed through the nurse from the doctor who couldn't walk over to the phone himself).

Why is this patient here? (Did you even LOOK at the test results and the labs, let alone the patient???)

Has he seen a Hepatologist? (Ummm, No.. If you had read my enclosed note, you would have seen this is new to me and the patient!)

Why did you send him to us? (Well, the patient refused to be admitted two days ago locally and he requested to go to your illustrious hospital because he likes you.)

Oh, okay says the nurse. I guess we'll see what we can do.

Yes, I thought. Please do that.

How Can Your Nurse Practitioner Help You Today?

2011-06-21T22:54:00.000-04:00

That's the question of the day most of the time. I see many types of patients in the rural health office that I work in. For the most part, my patients actually have problems that I can do something about. Some are not so lucky.

I cannot help the patient who comes from another office with no records and has been receiving narcotics and Xanax indiscriminately. I understand that you are in pain and it seems to be the most important thing about you. I am sorry that the doctor wrote you meds that you became addicted to. I can't do that. Not even if I could, would I do that. I am thinking of your future and your families future. No, I doubt any pain management clinic will take Medicaid because they don't pay well. In fact, forget about seeing any kind of specialty for the problem that is causing your pain because as much as you would like them to fix the problem and get back to work, it's NOT going to happen. This contributes to the whole problem in general. The cycle goes on.

Don't get me wrong. I am not some person who doesn't understand your pain. I have lived with pain for the last 25 years of various kinds. Some fibromyalgia and some from different surgeries. Car accidents are no fun and neither are knee injuries on the job nursing for years at the hospital. I also have allergies to codeine and morphine and Tramadol makes me feel like I am dying. I know that when other nurses and Docs take my med history they look at me like I look at you, usually disbelieving that I will not be asking for the heavy meds. I take Ibuprofen and suffer. Maybe one day, I will need something stronger. I hope to God not. I have to work to diagnose and treat patients. I cannot be impaired in any way.

I also cannot fix the cancers that other providers has missed. Unfortunately, most of them are cancers that you contributed to by smoking two packs of cigarettes daily for the last 20 years. I'm sorry that they never got an X-ray or asked how long you have been losing weight. I'm really sorry that you had a bad Pap smear but you never went back for a follow up according to your records. Sometimes, providers miss things but mostly cancers are found in early stages if you do the basic check ups.

The excuses are usually related to not having insurance or any money. Find where your local Federally Qualified Rural Health office is located and get seen on their sliding fee system. Most have x-ray available at least.

I hope that you come to see me and ask me to help you today. I really do. Just make sure that you aren't seeking drugs because if you do, you can keep on walking.

NP Wonders If It's In The Preservatives?

2011-05-29T21:32:00.000-04:00

I have been asked many times at the office what I thought of the Autism link to vaccines. I am still not convinced that there is a link between the two. In my humble opinion, it's in the preservatives in our foods.

Look at the numbers of us "oldies" who all got our shots back in the days when who knows what levels of contaminants were in them and we all made it out just fine. Then came the days of fast food, MSG, and preservatives,microwaves and then boom! Attention Deficit Disorder was all the rage. Now it's Autism.

There are some forms of Autism that are very obvious and the children are very behind in their skills and have some types of bizarre behaviors. What about the now milder forms such as Asperger's where children have no social skills? Hmmm? The computer and video games age has nothing to do with this? Too many children, including my youngest, have been glued to the computer screens and haven't been forced to go outside and play with other kids in the sandbox and learn how to get along these days.

What is your opinion?

Frustrations Of A Nurse Practitioner Student

2011-05-15T13:13:00.000-04:00

I received an email from a frustrated NP student and thought it would make a good post.
"I am ending my first year of NP school. I'm tired and frustrated. The faculty at my school is so focused on preventing cheating, they make it difficult for those of us who do not without reward. And, the cheaters are of course getting better grades. We have to have a B in all classes, I have had a 4.0 until I started the NP program but knew I would probably not keep it.
Is this a common problem. I'm so frustrated right now, I am considering giving up my dream. The research class this semester was all podcast with no contact and I'm riding the line between the B and C. In my clinical and didactic I have an A. I simply have had enough of the "I'm the research professor and I have a PhD " attitude.
Does this get better? Is this normal?

Hi there! It doesn't seem to get better while you are in the middle of the process, but it does. As long as you make the grade to continue through the program, that's all that counts. I remember beating myself up in nursing school about not getting a higher grade, but then realized that I wasn't in competition with others. I was in competition with myself. I had to give myself room to not do as well in some areas because I did really well in others. It happens in real life practice as well. I understand my areas of weakness and I know my strengths. That's the art of medicine and nursing and one needs to understand their problem areas and when to ask for a second opinion. That goes for doctors as well. There are many times that my collaborating MD will ask my opinion about a patient or disease process.

Regarding the cheating factor? Yes it happens in every area. All it does is make that person a weaker provider. The temptation is great when one is under heavy stressors of family, friends and work while attempting to achieve your dreams. Professors often have the "Everyone will try to cheat" just like we all have the "Everyone is a seeker until proven otherwise". It's not good but it's true. Once you have been burned over and over, you tend to judge. It's human nature.

Podcast classes and online classes are difficult if you are a visual learner. I am a mixed learner. I have to have hands on training to make things stick. It didn't change when I moved up from RN to MSN. I HATED statistics and struggled really hard with it and if I don't start soon on my DNP, I will have to repeat that class. Math has always been my mind block. Disease process has always been my strength. Struggle through and get to the good stuff.

It will all be over soon!

Test post from my new iPhone

2011-04-22T00:07:00.001-04:00

This is a test of my new blogwriter lite app on my new phone! Things are going well in the new office and I am eagerly awaiting the electronic charting system coming in June.
What types of systems are you using in your offices? Anything you would change? Chime in!

MRSA Protocols- Are They Being Used In Practice?

2011-04-01T22:36:00.000-04:00

In Advance For NPs and PAs, a March 9, 2011 article was featured on the following study of protocols used by health care providers to treat MRSA infections. I was surprised to see that some providers were still using Keflex to treat these infections. Some providers still were not sending cultures on these infections. How can we adequately treat an infection without knowing what will actually kill the bacteria? My impression of the following information is that the protocol that I do is somehow a new treatment regimen. I have been doing incision and drainage with appropriate culturing with first line Septra for the last 3 plus years. I also use mupricion ointment to nares twice daily and Hibaclens during the regimen if they have had more than one outbreak within a 6 month period.

Taking Aim at MRSA
Protocol use by an NP-PA team
Anita D. Barnes is a family nurse practitioner who is an assistant professor of nursing at Stephen F. Austin State University in Nacogdoches, Texas.
A 2009 study reported a variety of approaches used by ED physicians to treat CA-MRSA SSTIs.6 The study surveyed 225 ED physicians nationwide: 56% reported always sending cultures for testing and 19% said they never did so. The physicians prescribed trimethoprim-sulfamethoxazole (TMP-SMX) 60% of the time, either alone or in combination with another antibiotic. Nineteen percent treated patients with cephalexin alone, and 13% prescribed cephalexin in combination with another antibiotic. Cephalexin is not recommended in the CDC protocol.

What are you doing as providers to treat MRSA infections? Do you find the information alarming that some providers are still not culturing infections?

Mingling With The Lt. Gov. Jennifer Carroll and State Representative Elizabeth Porter

2011-03-11T22:38:00.000-05:00

I was happy to be a part of the Republican Lincoln/Reagan fundraising dinner this evening. I made sure to take advantage of my husband's connections as the exclusive photographer to say hello to her and other political representatives of the State. One person that I made a real effort to speak to was State Representative Elizabeth Porter.
I spoke with her in detail regarding Nurse Practitioner concerns regarding the current problems with prescription authority and that Florida really needed to join the ranks on the other states that already give us the authority to fully treat our patients with the appropriate medications. I really hope that the politicians are listening to our concerns. Their voters depend on our medical care.

Florida Medical Directors Association's Recent Position Statement Regarding Nurse Practitioner Prescriptive Rights

2011-02-14T20:19:00.000-05:00

Finally, we are getting the support we need in order to take complete care of our patients. I'm still not sure I am in total agreement with the wording of some of the below, but I will take what I can get! Read the below article that I found on the Florida Nurse Practitioner Network website and let me know what you think!

"FMDA Position Statement
Prescriptive Authority for Advanced Registered Nurse Practitioners (ARNPs) and Physician Assistants (PAs) in the State of Florida
The Florida Medical Directors Association (FMDA), in the interest of the highest quality of care for residents in the long-term care continuum (LTCC), is presenting this position statement regarding the prescription of controlled substances by advanced registered nurse practitioners (ARNPs) and physician assistants (PAs) in the state of Florida. FMDA recommends that, with the written permission of his or her collaborating/supervising physician(s) and successful completion of mandatory continuing education that ARNPs and PAs be granted the legal authority to prescribe controlled substances in long-term care settings, including skilled nursing facilities, home care, assisted living, residential care, and hospice programs. These settings are very well-regulated and controlled by current federal and state governance, as well as other credentialing organizations.
Florida and Alabama are currently the only two states where ARNPs and PAs do not have prescribing authority for controlled substances. The other 48 states have given prescribing authority in varying degrees to both of these health care providers, and the evidence shows that their prescribing practice habits have been found to mirror those of their physician colleagues.
FMDA understands that ARNPs and PAs are often the “front line” health-care providers for patients in the LTCC, where pain medications are often indicated. The inability of these health-care providers to prescribe controlled substances can affect the timely administration of medications for the relief of pain and other medical conditions. This has the potential to impact the quality of life for this vulnerable group of patients.
FMDA’s position is that ARNPs and PAs in long-term care settings would be able to prescribe controlled substances only if this was specifically written into their protocol or practice agreement by their collaborating/supervising physician(s). Hence, this would be an option, not a mandate. Individual physicians would ultimately decide which, if any, of the controlled substances could be prescribed by which, if any, ARNPs and PAs in their practice. Furthermore, individual ARNPs/PAs would not be mandated to pursue DEA licensure.
FMDA further proposes that, to further improve quality of care by enhancing the safe and effective prescribing practice of these providers, ARNPs and PAs applying for initial DEA provider numbers in the state of Florida must complete an initial 8-hour controlled substance CME/CEU course. This is a requirement for all prescribers in some states. In addition, all ARNP/PA prescribers would be required to have a 2-hour biennial CME/CEU course on the prescription of controlled substances. This is consistent with current license renewal requirements for Florida physicians (MDs/DOs).
In summary, the Florida Medical Directors Association recommends that the Florida legislature grant prescribing authority of controlled substances to ARNPs and PAs in the LTCC pursuant to fulfilling the CME/CEU requirements and obtaining the specific written permission of their collaborating/supervising physician(s). We believe that this measure would provide for significantly improved access and quality of care for patients in long-term care settings.
Started in 1990, the Florida Medical Directors Association is the official state chapter of the American Medical Directors Association and is a Specialty Society of the Florida Medical Association. It is based in West Palm Beach, Fla.
FMDA represents nearly 250 medical directors, attending physicians, physician assistants, and advanced registered nurse practitioners in Florida’s post acute-care continuum, including sub-acute care, hospice, skilled nursing, and assisted living facilities, as well as in continuing-care retirement communities.
The mission of FMDA is to promote the highest-quality care in the post-acute continuum by providing leadership, professional education, and advocacy."

It’s time to collaborate—not compete—with NPs — The Journal of Family Practice

2011-01-31T21:48:00.000-05:00

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Finally, a physician with some common sense! My patients still ask me every day why I can't write their meds and I tell them about the battles between the insurance companies and our congress/senate and the docs. They are all trying to restrict our practice here in the state of Florida and in Alabama. People need to understand that every state that has passed the ruling for prescriptive authority has NEVER been rescinded.

"According to Dr. Jeff Susman, "It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy? First, because it’s the reality.

In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice."

Enjoy the article and be sure to chime back in here!

It’s time to collaborate—not compete—with NPs — The Journal of Family Practice

How Do You Make Them See The Light?

2010-12-19T18:41:00.000-05:00

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I see so many patients that are in various stages of mental health difficulties. Most are coping fairly well, but a few are not doing as well as others due to the time of year. I am sure that you all have noticed that October through January is a tough time for patients due to family member losses, changes in their income, insurance status or just the winter time blues.

I screen for anxiety and depression on just about every visit and it's not hard to do. Just ask them, "How are you really doing?" You will amazed at the number of patients who are struggling and just wanted someone to listen. In the rural setting where I work there is almost no access to mental health resources. It would be nice to just sit and talk to patients and counsel them but I only get paid by seeing them for medical reasons. I wish that we were in the old days when your health care provider took care of the entire person. I feel like the trend may be coming back with nurse practitioner led medical homes.

Unfortunately, I also get patients who try to take advantage of my concern for their mental health and ask for inappropriate medications such as xanax or valium without having tried any of the baseline drugs such as Celexa, Prozac, Lexapro, and Wellbutrin etc. I ESPECIALLY hate when patients ask for meds by their street names. Don't they realize that it makes big bells ring in our heads when that happens? Or the usual "I've tried all those and the ONLY thing that works is Xanie bars." I tell them that if that is the only medication that works, then they need to be under the care of a psychiatrist and that it's out of my scope of practice in Florida to write those meds.

As soon as our expansion finishes, I hope to hear that a mental health counselor will be available to help us with the longer consultations that are needed. For you new NPs, brush up on your mental health meds because it's becoming more and more part of Family practice.

Change of Shift Is Up At Emergiblog

2010-12-10T22:57:00.000-05:00

It's that time again! Change of Shift is up over at Emergiblog. My post was chosen as her editor's pick and I am honored. I only wish that I could write as well as Kim. Click here to enjoy!

He's Gotta Ticket To Ride and The NP Says It's Okay

2010-12-06T21:19:00.000-05:00

I had a new patient show up at the office the other day and my office nurse called me into the room quickly. She was concerned when he said that he was a diabetic and that he hadn't been feeling well for the last few days. As my trusty nurse knows to do, she got a glucose reading which said "hi". He also showed her a draining abdominal wound. His color was a a pasty greyish tone and he was slightly diaphoretic.

After obtaining a set of vitals, I told the nurse to prepare to make a call to EMS for transport to the local hospital for this patient. He asks why I think that he needs to be admitted and I proceed to explain the significance of "hi" on a glucose monitor and the likelihood that his sugar was at least 500 and was probably higher and that he needed IV antibiotics, fluids, and monitoring for a few days. With a grateful smile, he said okay. I left my nurse to monitor him and to give report to the EMS for me as I had several other patients that had been waiting.

After I finished with the patient, I asked my office nurse if the information was handed to the EMS and she was rather upset. She said that the female paramedic walked into the room and said "oh, it's you again to the patient." Excuse me? My nurse responded. The paramedic said," We've taken him to the hospital a few times and that the ER just releases him and tells him to find a primary." She asks the patient, "So, what's wrong with you now?" To which he replies, "I'm sorry to bother you again." The paramedic turns to my office nurse who proceeds to give report of a blood sugar of hi and that he has an infection that needs to be checked. The paramedic then proceeds to question whether our machine was right so she goes out to get their machine off the ambulance to recheck our work.

Well.....that just pissed in my office nurse's coffee.. Here's what she said, after of course, their monitor read hi too.

"First off, this man is a new patient to us and he is very ill. We don't care how many times that he's been taken to the hospital before, if my NP says he needs to be seen, then he goes." Second of all, turning to the patient, "you don't EVER have to apologize for being ill. You are here obtaining primary care from my NP and when you get out of the hospital, you come back and we'll see how you are doing and make a plan from there." She hands the EMT his packet of paperwork and tells the patient "here's your ticket to ride and it'll be okay."

Footnote: He was admitted with a blood sugar of 654 and was in for three days. He came back to the office for a follow up and states that he was feeling much better now. He thanked us profusely for my nurse making him feel important enough to take care of.

How sad is that? I was so angry that a patient was made to feel that they were a bother and that they weren't good enough to treat with common respect. Don't get me wrong, I get a little burned out by some of my difficult patients. You can better believe that they leave my office feeling like they are the only patients of mine to take care of because that's my job.
If you don't like your job, find another one. Just find another one that's not in health care.

Change of Shift is Up!

2010-11-11T21:06:00.000-05:00

Click here for the newest edition of Change of Shift. It's a wonderful compilation of nursing stories on the web. I submitted from NP Place.com this round. Enjoy!

Nurse Practitioner Getting Ready for Meaningful Use and EHR

2010-11-05T23:58:00.001-04:00

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Hello once again from The Nurse Practitioner's Place! I have been on a long hiatus due to an injury from a car accident last year. Boy has it been a bumpy ride! I have been playing catch up at the office while trying to decipher my own handwriting which has gotten really bad.

Paperwork is slowly torturing me to death and I am anxiously awaiting the EHR (NextGen) that is coming by June of next year. Let the template building begin! I am just now really starting to pay real attention to "meaningful use" and am not really sure why it matters in the first place. I can see if you got the entire system for free from somewhere and had to show how well you used it in order to prove it's worth. I don't know exactly but I am sure that it's all about government tracking of health care and how well we are taking care of our patients.

Don't get me wrong! Taking care of patients is very important but they are now worrying that we will be "taking care of the computer" instead of them. This will slow us down and speed us up at the same time. Entering all of the relevant data will be a nuisance for a while but once it's in... Look out clarity of information! I was on the Super User committee at the hospital when we first transferred to electronic records and the older nurses really had a hard time getting used to it. Charting by exception is a wonderful thing. I had never understood the reason for writing No this or No that on every visit when you can assume that it's negative except for the things that you do write. I also realize that "not documented, not done" but we all know that there is so much more involved in a patient visit that isn't all spelled out in black and white but in the nuances of the health care provider relationship with their patient. The only way to totally get every detail would be to videotape the visit each time. I couldn't stand having that done because we all would worry more about how we looked than how we took take of our patients.

So.. how many of you have used NextGen? Leave me some comments so I know what I am getting into!

Reason For The Nurse Practitioner Place Post Delay

2010-10-03T01:52:00.000-04:00

Hello to my faithful readers! I haven't posted in a long while due to a wrist/hand injury a year ago that has been progressively getting worse. After a couple of MRIs, one of which was an arthrogram, a simple x-ray answered the million dollar question. The thumbs are not sitting in their sockets and my right hand has been killing me with all of the writing. Lo and behold, after the orthopedic surgeon got in there, he discovered that the capsule was torn and the ligament had to tight-wired back together with two permanent metal buttons.
I figured that the surgery would be an easy one. I had already done two natural childbirths, a hysterectomy, and two arthroscopic knees without more than Darvcocet.
Well, when the regional block wore off, all hell broke loose in the old pain receptors! I have NEVER felt that much pain in my entire life. I now know why people sue for pain and suffering. I also figured out all the little things that you can't do left handed very well. I'll let you imagine the details for yourself.
In other news, my younger sister had an atypical heart attack at the ripe old age of 38. She told me that she was having some epigastric fullness/pressure and wasn't feeling well. She took some stomach acid reliever and felt better and went to bed. The next morning I told her to come to my office and see the doc and get an EKG done just to check things out. Well... the EKG was abnormal and off to the hospital she went and when I got there, the doctor was waiting on her labs to come back. She had no IV running and was just sitting there in no particular pain other than some pressure and small twinge that was near the left shoulder. I told her that I would check out the EKG with the ER doc and see what the plan was. Off I went for him to say that the EKG looked slightly abnormal and that he would keep her overnight to monitor. I felt better due to the fact that she had no insurance and I was worried that he would just treat and street her as "another typical female anxiety attack".
I went upstairs to see who was working that night and to say hello to some nurses that I hadn't seen in a long time. I ran into one of the docs and he asked me why I was there and then asked to see my sister's EKG for us to evaluate together. I thought that it was a good idea because the one I had seen didn't seem to impress the other doc and a second opinion wouldn't hurt. He took one look and showed me just how back it was and picked up the phone and told the ER doc to fly her out. Okay.....
Back to the ER where her nurse was now in high alert mode... 325 of aspirin, 600mg of Plavix, and a heparin drip was the new cocktail. The nurse looked like she was ready to spook. I asked her how high the Troponin and CPK were and she said 10.9 (high normal 0.4) and that her CPK was 497. Full blown heart attack was commencing and still no increase in pain and her blood pressure was completely normal at 110/69. Still my sister is sitting there with a silly grin on her face as I explain what the commotion was all about. The smile disappeared when the helicopter flight team showed up to take her to Gainesville.
Cardiac cath showed the RCA 100% blocked, the LAD was 99% and the circuflex was 50%. They were a little surprised but were able to get two stents into the RCA and the plan is to do the bypass on the LAD in a few weeks if her ejection fraction holds. (currently 35%).

Word to the wise, never ever discount a female having just pressure and a little bit of chest pain as "just another anxiety attack". Someone can die.

I have already checked my cholesterol levels and plan to have a stress test done sometime soon so don't worry about the fate of The Nurse Practitioner's Place for now!