A Nurse Practitioner's View

I'm aware that many people roll their eyes at another "year in review" blog post but it's been some time since my last post here and I think it is a good way to end the year. 2011 was an important year for me professionally as I completed my DNP back in May. It was a grueling 3 years (that I mostly chronicled here on this blog) and in my mind was the right choice for me at this point in my life. I approach clinical problems and scenarios through an alternative perspective and I have really embraced this philosophy. I hope to apply some of this new wisdom to the health care system and patients alike. Because I'm a glutton for punishment, following the completion of the DNP, in the Fall, I enrolled full-time in one of the University Based Training programs that was part of the American Recovery and Reinvestment Act's HITECH Act. Technology has always been my passion and I am so interested in the integration of information technology and health - it is real...

I am posting this for a colleague who plans on writing a book about nurse practitioners.   Seeking nurse practitioners of all specialties to submit stories about the experience of being a nurse practitioner. The NP may live in any geographic area. This may include stories about the role of NPs, patients, circumstances or the health care system. Selected NPs will be confidentially interviewed and audiotaped if agree to be part of the project. Please contact mga11@caa.columbia.edu

The latest nurse practitioner study conducted at Loyola found that "...the nurse practitioner reduced ED visits by improving the continuity of care and troubleshooting problems for patients." These are the type of studies that need to be done. I am sick of the studies pitting nurse practitioners against physicians. The "us" versus "them" mentality is old, tired, and doesn't even belong in today's argument. The time has come to move past this and figure out a way to make the most out of available resources while ensuring that each profession practices to the extent of their education, training, and scope. Do we really need another study to show that NP practice is just as good or better than physicians or do NPs make more referrals or would NPs order more tests to arrive at a diagnosis? Please, this rhetoric is insulting to the entire US health care system. In my opinion, nurse practitioners are not interchangeable with physician practice. We a...

Eat your fish, it’s good for your brain.” This is what every mother said to get the kids to finish their meal. As we age, there are many physiologic mechanisms that occur making memory a thing of the past. While remembering something your wife said thirty years ago is still there, what the heck did you do with your car keys? Here are five tasty ways to encourage memory after age 65, or before.  1. Vitamin B12 Cyanocobalamin (B12) is an essential coenzyme required in many bodily activities. It is necessary to make the heme part of hemoglobin and it is also an integral part of nerve repair. A deficiency leads to pernicious anemia. Subclinical vitamin B12 deficiency can cause pain, electric shock feelings, sleep disturbance, depression, fatigue and memory loss.  Your body needs a chemical called intrinsic factor to absorb B12 in the gut. Production of B12 declines with age, so foods containing B12 are essential to provide optimal absorption. B12 is found in meat, fish and...

I have certainly been keeping myself busy these days! First, I have been immensely busy at my clinical site. Hundreds of flu shots have been given in the last few weeks and I have been inundated with the change of season upper respiratory infections and allergies in what seems like everyone has (really, the care is largely supportive and conservative. I am a big fan of saline nasal irrigation!)  Second, school work continues in the Office of the National Coordinator for Health Information Technology post graduate certificate program as Clinician Leader that I am enrolled in. I am considered full-time and plan on finishing up in May 2012. The amount of work has been intense (an intensity that I thought I was done with following completion of the DNP this past May!) The course work isn't as demanding as the DNP, but there is just so much of it that is condensed into a relatively short time frame.  Third, I am running for Chair-Elect in the Nurse Practitioner Associa...

I recently blogged about the prospect of patients getting access to their laboratory results before the ordering clinician signs off on it. This certainly is a patient-centric approach but is it a wise one? I am mostly in favor of this however, many details still need to be worked out. In our forthcoming electronic health records world, this may be the tip of the iceberg related to patient-centricity and access to their record. I'd love to hear your thoughts and concerns.

Hello, I just wanted to provide a brief update as to what I've been up to for the last few weeks. After completing my DNP this past May , I was actually feeling a bit melancholy thinking that my days of a "student" were officially over. Well, not so much! Since my passion is technology, I happened to be researching Health Information Technology (HIT) and found these University-based training programs set-up by the Office of the National Coordinator (ONC) under the HITECH Act . These programs train either health professionals on the IT side or IT professionals on the health side. Even better, there is grant that helps to pay for the majority of tuition fees! I've always had a passion for technology yet, have been all self-taught with no formal training. The program that I applied to and was accepted offers a clinician leader track. It's been about 3 weeks and the hybrid program is intense! (I thought I was done writing papers, etc!) Thus far, it really is a wo...

Hi All, Please check out my new blog at  Online Nurse Practitioner Programs ! Also, like this new page on Facebook to automatically get new updates. I am very excited to further expand my blogging and audience in this new forum! Not to worry, I will still continue to regularly update this blog with all things related to nurse practitioner practice. As always, thanks for reading. Stephen

A lot of nurse practitioners are finding my blog through searches regarding opening up a private practice from this January blog post . (I refuse to use the word independent since no clinician practices within a vacuum and requires multidisciplinary support to care for the whole patient). I happen to have a dear friend and colleague,  Dr. Joy Elwell, FNP, DNP , who has her own private practice. I asked her a few questions regarding her experience and she was gracious enough to sit down and answer them for me and my readers.  1. Why did you decide to open your own practice?  Well, first, my experience was a bit unique, since I had my own practice within an institution, i.e. I worked for an institution and was able to see my own patients at that site. I decided to leave and open a free-standing practice in the community because at this point in my career, I believed I could serve the community better by being self-employed. I also believed that I would have...

I receive countless spam e-mail messages to my many e-mail addresses. The screenshot of the one that I received below is definitely one of the most bizarre and struck a nerve. Really, this is not a way to advertise a career in nursing. It's unclear to me how or why doctors specifically, are in need of people like me. Perhaps the inference is that doctors tell nurses what to do and nurses are there to serve at their beck and call. We all know that the profession of nursing has a whole science unto itself and that nurses are front line care givers, influencers and advocates in the world of patient care. Sandy Summers is a nurse who runs the The Truth About Nursing website and she dedicates the whole site to correcting the vast negative portrayals of nurses in the media and in entertainment. I can envision her targeting this type of inaccurate portrayal due to the poor choice of wording. I did not click on any of the links for fear of it taking me to some weird phishing site or t...

I check out many health-related websites on a daily basis. I click on links from Twitter and Linked In and see the entrepreneurial ventures of fellow health care professionals. One of the things that irks me of late is the random stock image of health care "professionals" posted throughout websites (for example see below). This woman has been featured on more websites that I can count. It's not that I doubt her professional credentials - she seems to at least have a legitimate Littman-type stethoscope and upgraded smoke finished clipboard. But is it that hard to post a picture of actual clinicians today? When we talk about patient-centered care, I believe patients deserve to see an actual image of their provider rather than the random clip-board touting, lab-coat wearing stock image that graces so many websites. I hope this woman is at least getting royalties from gracing so many sites!  So please, if you have a website and are a healthcare professional or entity, ple...

Lately, there has been increased emphasis on "preventative" care in the US now that there are some  mandates  under the Affordable Care Act. There is even the U.S. Preventative Services Task Force ( USPSTF ) which is a panel of private sector experts who recommend evidence based preventative screenings for certain conditions based on factors such as age and gender. As a family nurse practitioner, I base a large part of my practice on wellness and prevention in addition to episodic (or "sick") care. I believe in "wholistic" care - that is, care of the whole person including mental and physical states. Though lately, I question whether if "preventative" is really the best moniker for this type of care. Prevention assumes that one can completely avoid health conditions by subscribing to certain recommendations, screenings and/or tests. Is it naive or even obnoxious to think that we can prevent disease and illness? I have seen many patients follow a...

I am a huge baseball fan and my favorite team is the NY Yankees. Star third baseman Alex Rodriguez was recently diagnosed with a slight meniscus tear of his right knee. He has played through some pain over the last few weeks and was given conservative treatment by the Yankee training staff up until the point that it didn't really improve. Check out this timeline of events: Friday 7/8/2011 - MRI reveals meniscal tear. I presume the team physician recommends surgery. Sunday 7/10/2011 - A Rod gets a second opinion on SUNDAY with Dr. Lee Kaplan of Miami. Monday 7/11/2011 - A Rod has successful surgery and is expecting 4 - 6 weeks of rehabilitation. That is what I call access to care! From MRI to second opinion to surgery was a cool 72 hours (I surmise that he also needed a pre-op clearance thrown in there as well). Yes, he is arguably one of the greatest players to ever play the game and is also the highest paid player but it is amazing how anyone can get a second opinion ...

I had no sooner finished blogging about the announcement regarding the governmental plan to utilize mystery callers to assess access to primary care offices to find out that the survey has been put on an indefinite hold . Being a conceptual proponent of this research, I am disappointed that the administration backed down from the seemingly large physician backlash. Then again, as I stated in my last post, will this really tell us anything that we didn't already know? If you have any doubts, just try calling any office on a Friday afternoon, stating that you are a new patient and would like to come in on the same day for an appointment because you suspect pneumonia - oh, and that you have no insurance. Maybe the proper thing to survey is how long it will take to be hung up on or laughed at.....

One of the recent stories that spurred a lot of discussion was in the NY Times, U.S. Plans Stealth Survey on Access to Doctors . It is an interesting concept that will help to try and quantify how difficult (or easy) it is for one to get into to see a primary care physician. They will also evaluate if the office staff will give preferential priority based on the "patients" stated insurance. I applaud this move and believe it will produce some evidence as to how hard it is for new patient to seek care. Many physicians aren't too pleased with this survey as I would imagine it will tie up their resources. I blogged about this concept a few years ago when the AMA came out against the notion of "mystery shoppers." Health care needs to be patient-centric as the retail industry is consumer-centric. Why should health care be any different conceptually? I hope that this experiment isn't more of an exercise on provider's offices (i.e. poorly trained or rude staff...

A little bit on technology and how it is impacting health and patients. As an admitted techno-geek, I am passionately following mobile technology and where it is popping up in health. A cool app that I recently downloaded is Instant Heart Rate for my iPhone 4. This is a free app and requires no external hardware. According to their website, it works by placing your finger over the iPhone's camera and it "tracks color changes in the light that passes through your finger." I used it and found the readings to be fairly accurate. It is also available for Android as well. The basic app is free and for a $0.99 upgrade it adds features allowing you to document what you were doing at the time of recording, viewing graphed results over time, and auto-posting the results to Twitter. As a clinician, apps such as this can help patients keep accurate data to review with their providers at their visit. It is exciting to watch this technology develop. Today it is heart rate monitorin...

My physician's group utilizes an on-line patient portal to schedule appointments, view lab results, and to communicate with my provider. Fortunately, it is very rare that I need to actually schedule an appointment. I've only been a patient of the practice for just about 2 years and I thought I'd schedule my second annual physical. (In fact, I've been there once, a year ago, for a physical on a Saturday). Now, I do question the real value of the annual physical examination but as we all get a year older, there are certain screenings that are recommended . Nonetheless, I fired up the handy patient portal web address and requested a physical examination for any early Saturday appointment in June or July. Since I do work Monday through Friday with my own patient load and responsibilities, I don't think I should need to take a day off to have a physical. The practice has Saturday hours and I thought this would be ideal for me and my schedule. This is the response that...

The systematic review that my colleagues and I have been working on (for what seems like forever!) was finally published in the Joanna Briggs Library of Systematic Reviews! It is very gratifying to have an official peer-reviewed publication under my belt. The title of our Review is, "The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: A systematic review." The work that we studied on group medical visits (GMV) is truly interesting and can serve as a viable model to aide in type 2 diabetes management. Graduation is just over a week away and we just have one more presentation standing in our way. I will be posting some of my reflections on the program and on the DNP in the weeks to come. For now, I will enjoy this moment!

Here are the poll results from the show New York NOW on the the NP Modernization Act Bill that has been introduced in the New York Legislator. I particularly like the comment from "Stephen" - for obvious reasons ;-)

I was recently contacted by a member of the National Health Services Corps (NHSC) and asked to highlight their program here on my blog. It certainly sounds like a wonderful opportunity for NPs regarding loan repayment. So here it goes: The NHSC is a federal program that offers primary care providers financial support in the form of loan repayment or scholarships so they can practice in underserved areas of the country without the burden of educational debt. The NHSC is currently expanding to help meet the need for primary care professionals. The current application cycle for loan repayment closes on May 26th and applications are now being accepted for the NHSC scholarship program . As the country faces a shortage of primary care providers, the NHSC plays a critical role in bringing primary care medical, dental and mental health professionals to communities in which people would otherwise have to travel miles for health care, or go without help. In return, the NHSC offers hel...

10 Free Online Tools for Nurse Practitioners There are several online sites that offer a wealth of tools and resources for nurse practitioners- -and many of them are free. Here is a list of 10 sites that advanced practice nurses might find useful. NursingCenter.com - Created by nurses for nurses, this site is an excellent place to find professional resources, clinical information, and continuing education activities. Other features include free peer-reviewed journal articles, free eNewsletters, job listings, daily news, and a search engine that searched more 100 nursing-specific websites vetted by other nurses. NP Central - This site is operated by a non-profit organization that supports the development and advancement of nurse practitioners. NP Central offers job listings, education information, a list of nurse practitioner organizations by state, and other helpful resources. eMedicine - A branch of WebMD, eMedicine is a highly respected online medical resource. You can browse many...

It's been a while since I last posted and it's because I've been somewhat bogged down with the last few projects for school. To briefly update: We completed our systematic review and meta-analysis on the effectiveness of group medical visits for patients with type 2 diabetes (specifically the ABCs: Hemoglobin A1c, Blood Pressure and Cholesterol[LDL]). We have received peer-review feedback and have edited and resubmitted and are anxiously awaiting their response. We implemented an actual group medical visit model in our clinical agency site and are gathering data and tweaking accordingly via the PDSA cycle. Plus, I am trying to get motivated to work on the last individual paper which must be submitted for publication to a peer-reviewed journal (rough draft is due this Friday and I don't have much thus far - which completely explains why I am blogging right now!) Finally, we are working on our final presentation for the group medical visit project. Whew! We are also get...

Lately, it seems there is ratcheted up rhetoric on nurse practitioner practice making us prime targets for all things anti-NP. The WSJ reports on a study that examined the prescribing habits of NPs and whether there is Pharma influence on those habits. The study found that of the 263 surveyed NP respondents, 93% reported that free gifts had no effect on their likelihood to prescribe the medication that was being detailed by the representative. The study concludes that since many NPs had regular contacts with these reps in the form of face to face and industry backed lunches/conferences, there could be a degree of subconscious influence on prescribing habits - findings that are similar to prescribing habits of our physician colleagues. As you can see in the comments section that follows the story on the WSJ, some are using this study to once again attack NP practice. The comments are laughable as the insinuation is that NPs aren't really educated on pharmacotherapy and therefo...

Congratulations to NP JoAnne Lutz of the Oregon Medical Group for being named in the Top 5 rankings of providers at DrScore.com. According to this press release , DrScore.com is " ... an interactive online survey site where patients can rate their physicians, as well as find a physician based on their service level preference. " Steve Feldman, MD, founder of DrScore, states, " This year marks the first time a nurse practitioner has been in the top five runners up,” Dr. Feldman said. “This may reflect an important trend for medical practices as health care continues to evolve —everyone on the frontlines is vitally important in improving patient satisfaction. ” Important trend indeed and some additional proof that NPs are highly regarding by their patients. It's also time to expand these rankings to other providers beyond physicians to include nurse practitioners and physician assistants to name a few.

On my snowy commute into work this morning for what seemed like 100th snow-laden car ride of this winter, I chuckled when the radio newscaster urged people to stay home. As a healthcare professional, we rarely see a "snow day." Hospitals and clinics don't close. So to all of my healthcare, EMS, police and fire (and anyone else needing to get to work) colleagues: Please stay safe out there when Mother Nature throws this nasty weather our way. Some people must get to work whatever the circumstances are.

There is an interesting trend that I'm observing and don't necessarily see how this is going to turn out. I'm seeing more and more nurse practitioner's opening their own autonomous practices. Many of these offices set out to offer care that is personalized, covered under insurance, and of course high-quality. I'm also seeing more NP specialty/sub-specialty practices such as house calls, incontinence, and women's health. This is in a time when more physician practices are joining together in these conglomerations that aren't necessarily tied to hospitals. You'd be hard pressed to find a solo primary care physician these days yet nurse practitioner solo practices are popping up. The talk about the formation of accountable care organizations can be attributed to health care reform and the spurring of large multi-physician practices. What to make of this? I honestly don't know. Many people and patients have said to me "you should start your own prac...