“The physician will ...”

People who know me well will not be surprised that I was recently pretty fired up by some otherwise benign statements. I tend to be a little sensitive when it comes to physician-centric verbiage. I have a healthy respect for my MD counterparts, and it frustrates me to be sidelined or to feel our role as NPs is not being supported. (I also tend to shudder at the terms “mid-level” or “physician extender.”)

So what set off my tirade a few days ago? I read the Accreditation Association for Ambulatory Health Care (AAAHC) standards for Patient Center Medical Home (PMCH). Have you read them? If you work in a PMCH or Family Health Initiative (FHI) clinic, you should. You might be surprised at what we NPs no longer need to do as, apparently, “the physician will” do everything!

A little background is needed, I suppose. All U.S. Air Force (USAF) facilities, as well as most other armed-services facilities, are in the process of changing their clinical operating model from one where the goal is to see your Primary Care Manager (PCM) to one where you are able to see only your PCM or his or her team partner (a team typically made up of an MD and a “mid-level” NP or PA). Under the new system, providers were rumored to have more control over their schedules, creative templating was encouraged and we were no longer restricted to the traditional, clinic-wide template of 20 or 30-minute appointments. A minimum number of per-week appointments was established, and we were given the flexibility needed to ensure that each of our populations was taken care of. We were allowed to do this as uniquely as we chose.

All USAF facilities are inspected by the AAAHC, and careers can be made or ended by inspection results. As an additional duty—yes, as in “in addition to doing all the patient-related care”—I review the inspection criteria and, through a series of self-inspections, make recommendations to the senior management team regarding our adherence to the standards on which we will be inspected.

So, on a rare day when no patients were scheduled—we were waiting for a planned base “incident” to happen, so we could prove our ability to care for a mass influx of “patients”—I took the opportunity to review the new PCMH standards from AAAHC. I was shocked to see how prejudiced the verbiage was and how it completely sidelined the role that NPs (and PAs, for that matter) play in today’s health care arena. The standards were completely based in physician-centric terms and gave the impression that physicians are the only deliverers of health care.

Get with the times, AAAHC! In some states, we can practice independently, hanging out a shingle and seeing patients without the oversight of a physician. If we seek accreditation in that instance, will we fail because there is no physician guiding the patient-care decisions?

It frustrates me that this national organization, one from which facilities seek accreditation, can be so close-minded about what is needed for health care to survive. Do we as NPs recognize the training and schooling that our MD counterparts must endure to practice? Yes! And we know our role in health care. and that most of us do not need a physician to direct that role. We are counterparts, members of a team, who work together to provide the services our patients need most. Does a team need a leader? Yes, sometimes it does, but in health care, that leader is often the most experienced member, not just the one with the MD behind his or her name.

I don’t know that this physician-centric rhetoric will ever change. A friend of mine (gasp–an MD even!) thinks that, as the “silverbacks” who currently head up these types of organizations move on and a generation that has trained alongside NPs comes to “power,” things will be different. I hope so. Only time will tell.

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

Checking out the "real" NP world

I have to admit, as a military FNP, I am a little sheltered from the “real world” of NPs. In our community, FNPs usually work in primary care and, occasionally, pediatrics. We don’t typically specialize in areas such as surgery or dermatology. There are programs in the military for our PA counterparts to branch into specialty practice—most common is surgery or orthopedics—but they are not available to us. Why this is, I cannot answer. I would think it has much to do with the current shortage of primary care providers, but if that is the case, why do PAs occasionally specialize?

Over the last few months, I have met more and more civilian FNPs and am frequently surprised by their ability to specialize. One works in general surgery at the Veterans Administration (VA) facility in town, and prefers to specialize in breast surgery. I was thrilled to hear this because, historically, the VA has been a “man’s world” where there were few services tailored to the female veteran. Another friend works in oncology, both inpatient and outpatient. She talks about how removed she feels from “regular” medicine, and my head spins thinking of all the complicated medication regimens she prescribes.

The one that surprised me the most? A friend who is a women’s health NP recently interviewed for a job in pain management. My first question was, “Can you really do that? Take care of men, too?” And, apparently, she can!

As my time to leave the military slowly approaches—I have just three years left!—it is a little overwhelming to think I will have to go looking for a “real job” and that there are more options than family medicine. I still don’t know that I would choose something else. I enjoy the variety of what I do. But, you never know what door might open when the time comes!

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

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.

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.

Reconciliation

Have you ever had to reconcile two parts of your life? I am currently working to reconcile the need to become proficient in firing at least two different weapons with my calling as an NP. Not only will I be trained to use these weapons, they will become my constant companions for the next year, and I am expected to use them, if necessary.

I did not grow up in a hunting family, nor does my husband own a firearm. We never felt the need to protect ourselves that way. With our lack of experience with firearms and two inquisitive children in the house, we figured the risk far outweighed the benefits. I am not an anti-gun activist—and I do agree that people kill, not guns. I don't care if you own your own arsenal (although I question the need) but I just do not aspire to gun ownership.

As an NP, my job is to help and heal people, not inflict mortal wounds. We have already had the ethics lecture with the vignette depicting the need for triage between a minimally injured American soldier and a significantly injured insurgent. My answer, based on my responsibility to heal and the triage concept, was met with heated discussion from the commanders (all non-medical) about how they would argue to have their troop cared for first. Now, imagine getting back to base after a skirmish only to be presented with an injured enemy troop and discovering you were the one who had fired the offending bullet.

My analytical mind enjoys the challenge of target shooting and the puzzle of disassembling and reassembling a weapon. My desire to keep my fellow PRT members (and myself) safe from the “bad man” will motivate me to become as proficient as possible on all our weapon systems. But, the healer in me will continue to struggle and pray that I never have to pull the trigger on another human being.

Hey Doc, could you look at this...

As previously discussed, my role here is, first and foremost, senior medical provider. The senior part is just to make it sound important. In reality, I am the ONLY medical provider to members of PRT Parwan. I am lucky to have two very experienced and motivated medical technicians, but the buck stops here—with me.

The military is its own animal when it comes to using “mid-level practitioners” (a term I really dislike but it does clarify where we fit into the medical provider picture). In addition to nurse practitioners (NPs), there are also lots of physician assistants (PAs) to be found. And don't get me started on general medical officers (GMOs), medical school graduates with a single year of internship who, for whatever reason, do not enter a residency. They are sent to various assignments in physician billets but are not really qualified for that level.

We NPs continue to be licensed in our state of choice and we carry the required certification, depending on specialty but, within the walls of our military treatment facility, we practice fairly independently. We have full prescribing authority, are empaneled, have our own patients and conduct our own peer review. Some days, I equate it to hanging out a shingle and starting your own practice. I'm lucky. At home, I work with two great physicians who are ready and willing to answer my questions, or help me find answers when none of us have them.

On deployment, the independent practice concept can be taken a step even further. We NPs and PAs are often deployed forward of a hardened medical facility, where the physicians and surgeons stay, awaiting arrival of the really sick and injured. They are a phone call or Internet connection away, but there are no hallway consults. And, with luggage weight at a premium, our reference materials dwindle to what we can load into a PDA or find on a somewhat unreliable Internet connection. You quickly realize that explaining to every last troop what an NP does and what our unique role is is just more than they want to know. They want to know someone is there to take care of them when they are sick or injured, and “Doc” quickly becomes your accepted call sign.

Here at training, I am already getting the request to “take a look at this.” Thankfully, it is usually a sprained ankle, bug bite or, for many, the cold virus that has quickly spread among units (can't be helped when living in such close proximity). My goal now is to build confidence for when we are downrange and the concerns get different. Stress can reveal itself in many forms, including physical and mental fatigue, illness and even thoughts of suicide. As an NP, my strength for that “gut feeling,” when it comes to my fellow PRT members, will be critical, as mission preparedness can often equate to mission success. So, NPs of the world, never fear. I will continue to laud our strengths even while answering to “Doc” for the next year.