A REAL doctor!

I had one of those experiences last week that I know is not specific to military medicine. I am sure it happens to our civilian counterparts, to other NPs and PAs. And I know it happens on a near daily basis at military treatment facilities worldwide. As I walked into the exam room and introduced myself as a nurse practitioner, the patient announced she was “forced” to come to our clinic and “wasn't allowed to see a real doctor” downtown. I was slightly taken aback. Here I was, running on time, in a pretty good mood and ready to assess and treat to the best of my abilities, and then WHAM. I took a deep breath and realized she wasn’t slamming NPs; she had a grudge against military providers, regardless of education background.

Some people think we are on active duty because we can’t cut it in the “real world,” that we are somehow subpar when compared to our civilian peers. And, people do sense a lack of control, since they have to enroll with a provider at a military clinic, requirements put in place by TRICARE (basically, our military HMO/PPO/insurance provider, depending on current terminology). In reality, we are all credentialed and/or certified in our specialty and really have two specialties to maintain, our civilian requirements and our military ones. I honestly believe military medicine should be it’s own specialty, since we have to know how various military-specific careers affect disease processes. And don’t even get me started on deployment medicine—who needs malaria prophylaxis, who is more resilient and able to tolerate the stress of deployment, etc. I could go on and on!

So, what did I say to that patient that day? Basically, a toned-down version of the above. That she is actually lucky, that we are a unified practice of providers all credentialed in our fields, who “get” the difficulties of being a military family. Then I asked, “What can I do for you today?” and we progressed on with the visit. I hope it was a positive experience for her and she won’t be so opposed to military providers in the future. Time will tell.

As NPs, that is all we can do; try to show the world—a patient at a time—what we bring to the table and what we have to offer. And, to hope that, over time, the response won’t be, “I wasn’t able to see a real doctor” but that patients become more accepting and some will even prefer to see us for what we have to offer!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Patient Centered Medical Home

If you stick around the military long enough, you will experience change, which may come as a surprise to people, since we are known as one of the biggest bureaucracies in the world! Since I have been on active duty, we have changed the names of our units (remember Strategic Air Command?), added new units (Space Command is a great example) and closed multiple bases. In the medical service, we have tried multiple ways to provide consistent, quality care to our patients (Primary Care Optimization and Primary Care Management, to name two) and now, we are changing again.

A few years ago, we started hearing more about something termed Family Health Initiative (FHI), and most of us feared it was just another attempt at putting a shine on what was quickly becoming a failing mission. We were undermanned, overdeployed and, in many cases, overenrolled. A case in point, before leaving Texas for Afghanistan, I was assigned more than 2,000 patients, well over the suggested cap of 1,500. But, we had a couple unfilled provider positions, and the patients needed a provider, so we muddled through as best we could. And, when I deployed, the sole primary-care physician who remained carried a load two to three times that until replacements arrived.

With that kind of workload, we had very little control over schedules, and a frequent complaint was the feeling of “running on a hamster wheel,” as we tried to meet the rising demands. I don’t think this was an issue specific to our little corner of the world; it was a frustration voiced by providers at many military treatment facilities and likely echoed the struggles of our civilian counterparts, who experience their own provider shortages.

So, we spent a few days last week learning more about FHI (now renamed Patient Centered Medical Home) and making plans for implementing this philosophy over the next few months. This is not a military-specific patient care theory, but a model being executed in the civilian community in an effort to maximize available providers and contain health care costs. For us, it will involve a change in staffing ratios and a decrease in maximum enrollment numbers. We will be shifted into teams of eight, composed of a physician, a mid-level (a term I still don’t love), a nurse and five medical technicians. (That’s the ideal composition. When we continue to deploy and our staffing is already below expectations, we will aim for three technicians per team.) We will be responsible for 2,500 patients (1,250 per provider) and be given more freedom to creatively meet patient demand through improved template management.

I honestly can’t yet say that I am 100 percent on board with the change. Part of me still sees it as a name change with lots of empty promises. One concern: Even though there is a strict cap placed on enrollment, as well as “cross booking” between providers, there are still requirements to see patients who are promised care and, after dividing those between our available providers, we are again back to 1,500 patients each. Also, there is an expectation to meet the needs of our patients on a daily basis. So, if there is a spike in viral illness and a need for more acute or walk-in visits, we are expected to do it. This can wreak havoc when my leaving work on time is necessary to make our usually maxed-out, kid-centered evenings work as planned! Between homework and sports, there is little room for overtime at work!

I would love to become a convert to anything that will provide consistent care to our patients. I know they are tired of seeing a new provider every visit and “starting over” every time. Rumor has it that, after the first few months of working out the kinks, most providers really enjoy the new model. I’ll keep you posted on the transition.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

Some nurses still eating their young

First of all, somehow, in just two months, I’ve managed to precept an adult health NP student for more than 135 hours! It was her first semester, and it reminded me so much of how things were five years ago when I did my first adult health rotation!

I attended graduate school at Uniformed Services University of the Health Sciences (USU). The military’s own graduate-level university, USU has both medical and nursing programs. USU Graduate School of Nursing offers a doctoral program as well as master’s degrees for family nurse practitioner, anesthesia and perioperative clinical nurse specialist.

Within the first few days, six of us gravitated toward each other and we were just as tight when we graduated two years later. We studied together, laughed together—sometimes cried together—and, in our free time, got our families together. We were an incredible support group for each other, and we all stay in contact today. Four of us are still on active duty, one has left the Air Force to start medical school and one, fulfilling a lifelong dream, is is providing health care in India.

I remember those first few days, thinking I knew so much, then walking into clinical, terrified, trying to just remember my own name. Now, five years later, it was a great experience to support another NP through those first scary patient interactions. First, we would talk about the questions to ask and the assessment to do, and then I would turn her loose. She quickly took to the whole process and I watched her confidence grow as she formulated her own style in the exam room. Simply talking through disease processes and looking up current research has done much to reinvigorate my own practice. I look forward to spending more time together over the next year as she works through her program.

Contrast that with another experience I’ve had recently. I conducted a medical legal review for a pending case against another practitioner. I won’t go into details, but it was interesting to read the case files and to read the detailed notes made by the specialist reviewer. She even went so far as to conduct a literature review of the standard of care that was in evidence 10 years ago when the initial incident occurred! My frustration? Another NP reviwer, in seeking to build a case against the person in question, used research that wasn’t even published 10 years ago. It frustrated me that, as nurses, we sometimes still have the “eat our young” mentality.

I wonder if there is any way to remove that from our collective culture. Maybe in precepting a new generation of practitioners, we can take away this outdated belief that we have to step on each other to get ahead. I think there are enough opportunities in this world for all of us to succeed without using our peers as stepping stones!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.