Graduation and summer

Graduation week, but that does not mean the work is done. In grad school you can still walk, even though they give you a little extra time to finish some requirements. Like a 30 page paper and clinicals until the end of the month. I will miss my primary care clinical site. However, it is starting to feel strange that this school part of my NP journey is over in 3-4 weeks.  

But come mid-July it will be time for me to mentally and physically clean my house and mind after years of school dictating life.  

So many stacks of papers, references, Power-points and lecture materials that I thought I might need one day, will be placed with love in the recycling bin. I will keep the important books and notes, but literally there are stacks of paper feet deep. Yes, I still prefer taking notes on paper and reading books with pages instead of e-books. So much easier to write in the margins and highlight in a book.  

Then I will need to take care of, boxes that are rarely opened and need to be evaluated and items tossed or donated.

Electronics and cell phones not used for years need to be recycled.     

Clothes still with tags that I will never wear. They were gifts from my Mother, and sometimes her taste is good and at other times it is not my style, but I still love her for sending them and so will the Goodwill.       

After a good mind and house cleaning the rest of the summer will be studying for boards and working on a resume. Although, no hurry in looking for work yet before September. 

Pediatrics

Another reason I was never interested in pediatrics.  

The other day a friend’s 8 years old, rationalized and told us that we are old because we were born in the "nineteen hundreds".

Their reality is so different from mine. 

Affordable Care Act

A lot of people don’t know that if you are insured you should not be paying a co-payment, deductible or anything for any of these services. But the doctor’s office or insurance company will not tell you that.

Direct from the website:

"Preventive Services Covered Under the Affordable Care Act

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a co-payment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.

15 Covered Preventive Services for Adults

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
2. Alcohol Misuse screening and counseling
3. Aspirin use for men and women of certain ages
4. Blood Pressure screening for all adults
5. Cholesterol screening for adults of certain ages or at higher risk
6. Colorectal Cancer screening for adults over 50
7. Depression screening for adults
8. Type 2 Diabetes screening for adults with high blood pressure
9. Diet counseling for adults at higher risk for chronic disease
10. HIV screening for all adults at higher risk
11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
• Hepatitis A
• Hepatitis B
• Herpes Zoster
• Human Papillomavirus
• Influenza (Flu Shot)
• Measles, Mumps, Rubella
• Meningococcal
• Pneumococcal
• Tetanus, Diphtheria, Pertussis
• Varicella
  Learn more about immunizations and see the latest vaccine schedules.
12. Obesity screening and counseling for all adults
13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
14. Tobacco Use screening for all adults and cessation interventions for tobacco users
15. Syphilis screening for all adults at higher risk

 22 Covered Preventive Services for Women, Including Pregnant Women

The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.

1. Anemia screening on a routine basis for pregnant women
2. Bacteriuria urinary tract or other infection screening for pregnant women
3. BRCA counseling about genetic testing for women at higher risk
4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40
5. Breast Cancer Chemoprevention counseling for women at higher risk
6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
7. Cervical Cancer screening for sexually active women
8. Chlamydia Infection screening for younger women and other women at higher risk
9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
10. Domestic and interpersonal violence screening and counseling for all women*
11. Folic Acid supplements for women who may become pregnant
12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
13. Gonorrhea screening for all women at higher risk
14. Hepatitis B screening for pregnant women at their first prenatal visit
15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*
17. Osteoporosis screening for women over age 60 depending on risk factors
18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
20. Sexually Transmitted Infections (STI) counseling for sexually active women*
21. Syphilis screening for all pregnant women or other women at increased risk
22. Well-woman visits to obtain recommended preventive services*

Medical Marijuana

First, I live in one of the medical marijuana states. I believe for a few individuals it could be a useful medicine. It helps cancer patients, glaucoma patients and some others. But let’s get real most people who claim they use it for medical purposes are just getting stoned.

I was thinking about this again today because I heard on the radio that San Jose had 70 pot club or medical marijuana dispensaries and only 41 Starbucks. They want to regulate and close many of them. So a quick Google search revealed this is common in many big cities like Denver and LA, where medical marijuana is legal. They also have almost twice as many pot clubs or medical marijuana dispensaries as Starbucks. Funny they use Starbucks as a gauge, because we all know they are everywhere. 

If you have ever seen or been in a pot club or medical marijuana dispensary then you know 95% of them are a joke pretending to be clinics selling medicine. Remember the Speakeasy’s during prohibition or the 1800’s traveling snake oil salesman, that sold alcohol tinctures to cure everything from your libido to the mother-in-law visiting. Well probably cured both of those at times.

Anyway, most of these medical marijuana clinics and pot clubs are nothing more than bars with pot instead of booze.  They have counters, menus of different way to smoke or eat your marijuana, and tables to hang-out with your friends.  Does this sound like a clinic or an Applebee's. 

Two states have now legalized marijuana and a bunch more pretend that it is only distributed as medicine. In addition more than twenty states will fine you less than $100 for getting caught with less than an ounce or growing a few plants. Not even a slap on the wrist.





Outside of a few cases, people need to stop pretending it is some kind of wonder drug for everything from hangnails to gonorrhea,  and the states need to just legalize and tax the shit out of it, like alcohol.

Nurse Practitioners are not Medical Doctors

There is a national bill in the House of Representative called "Truth in Healthcare Marketing Act of 2013," (HR 1427). This would clarify for patients’ who someone is in healthcare.

Even if they have a doctorate or PhD, a nurse practitioner, chiropractor, physician assistant or psychologists is not a medical doctor. If you are treating someone in my family I want to know your background. I am proud to be a nurse practitioner and we have a lot of power as NPs. We perform physical examinations, diagnose and treat illnesses, order and interpret tests, prescribe medications in most states, and plan and implement therapeutic interventions.

On the other hand, I am not foolish enough to put myself in a class with most medical doctors, and patients should not guess who is wearing the white coat. I have met only one NP who was narcissistic and insisted she be called doctor by staff. Beside setting herself up for a lawsuit, I won’t tell you what the staff called her behind her back.  

This is a relevant topic because to be blunt, many patients are not educated enough, and have no clue to know the difference between the people in white coats. I wear a white coat now, but even in my nursing scrubs with my RN badge on, patients regularly call me doctor, and probably only because I am a male. Talk about confused.

Truthfully, anyone with a PhD or doctorate can call themselves a doctor, but that does not make them a medical doctor. In fact there are a lot of people out there in the world with PhDs and doctorates who like to be called doctor, and that is fine. However, I would never have them touch or get close to a real human being.  Thousands of people have Honorary Doctorate degrees like Stephen Colbert or Bill Cosby and can call themselves doctors. Do you really want them, a psychologist like Dr. Phil or the guy at the gas station with a PhD diagnosing your intracranial bleeding or cardiovascular disease?  

Thank God I know some doctors well enough to ask them medical questions, and I do so often. I am not a fool and will not pretend that I have the same education as a medical doctor.

MD's learn the medical model and as medical students they spend 10-15 years in higher education, medical schools and residency, and if they specialize add more years to that.

A nurse practitioner learns the nursing model and may spend 6-8 years in school.

 However, nurse practitioners are better and more equipped to deal with patients in several ways. We were trained to treat people more holistically and not just in a narrow allopathic or western form of medicine. We communicate better with patients and their families. We see the big picture more often. In most hospitals I have worked and research papers I have read, nurse practitioners consistently have a higher overall patient satisfaction score.  

Most docs love us and as NPs and PAs we are part of the solution to the primary care shortage. But a few bad apples can ruin it for a lot of people when it comes to trust and working together.  

Nurse Practitioner Scope of Practice Grades by State

NP's scope of practice varies widely from state to state. I know where I live and many states have current bills trying to improve NP scope of practice. Primarily because of the new Affordable Care Act, the shortage of primary care doctors and an aging population.

The state ranking below are from the Pearson Report. The most interesting thing I found was that only 24 states restrict Doctorate and PhD NP's from calling themselves Doctors. This is a pet peeve of mine, because as an NP you should never imply to a patient that you are a doctor without clarifying you are a NP. (more on that another time)

Hopefully change happens sooner rather than later in more of these states.

2011 Pearson Report
NP scope of practice laws


Alabama:  F                       Alaska:  A                      Arizona:  A                     Arkansas:   D
California:   C                    Colorado:  A-                 Connecticut:  B               Delaware:  C  
Florida:   F                        Georgia: F                       Hawaii:  B                      Idaho:  B
Illinois:   D                         Indiana:  D                       Iowa:  B                        Kansas:  C
Kentucky:  B                     Louisiana:  D                    Maine: A-                     Maryland: A-
Massachusetts: D              Michigan: F                     Minnesota: C                 Mississippi: C
Missouri:  F+                    Montana: A                     Nebraska: D+                 Nevada: C
New Hampshire: A+         New Jersey:  B                New Mexico:  A             New York:  B
North Carolina: F             North Dakota:  A             Ohio:  C                       Oklahoma:  C
Oregon:  A+                     Pennsylvania:  C               Rhode Island:  A          South Carolina:  F
South Dakota:  D              Tennessee:  C                   Texas:  D                         Utah:  B
Vermont:  C                      Virginia:  D                       Washington: A+           West Virginia:  C
Washington DC:   A          Wisconsin:  C                   Wyoming:  A

Recovery

 In early 2009 when the economy tanked and unemployment was over 10% I decided this was a good time to go back to school while things recover. The plan then was to graduate, get experience and settle down. Now the economy is recovering and I will be graduating, but I do not know where I want to settle. I am torn because I like my current location and everything about it. On the other hand my mother is getting older and I do want to be closer to her. 

I'm attracted to the west coast and it feels like I still have unfinished business here. But in the end I guess any job offers will still be the biggest influence of where I end up. Hopefully it does not take as long for me to recover from school as it has the economy. 

Confidentiality

 I’m assuming most NP programs are similar to this one and that we meet weekly with our instructor to discuss patients, clinicals and any concerns. For our primary care we are all located in different large busy clinics throughout the metropolitan area. These clinics are not in any way upscale or suburban; they provide services to the inner-city and underserved populations. But this is also where we get the best experience, because many of these patients are train wrecks with extensive problem lists.
 
Nobody has dropped out, so my cohort remains the same ten people after 18 months. We now know each other all too well. These weekly sessions lead by our instructor is a chance for us to decompress from the stresses of everything going on. Of course our favorite topic is patients and their comorbidities.

Everything we talk about is confidential. But we laugh at our patients, we feel for our patients, we get frustrated with our patients and we really care about them. It helps because we know we are not alone in the decisions and mistakes that we make. They are learning points. Our instructor with her decades of experience has some of the best and funny stories about patients and mistakes from her past.   

I want to blog about some of my patient encounters, but it still feels uncomfortable to post anything outside of the classroom for fear of being recognized. Even without identifying points in a post, all those confidentiality, HIPAA and ADA laws make me overly cautious while still in school.

Take what I can get

Feel so mentally beat up lately that even a card in the mail from Southwest Airlines made me feel better.  I Luv you too Southwest, now take me the #%*+ away.  

Paths of Life



As I continue to walk the bigger path of life, it is hard not to look back at the smaller paths and exit ramps taken along the way. People, places and experiences are what shape your life.
And many times I have wondered how one decision, made years ago, along one of the numerous side paths, would have changed everything.

Would I be walking this current path of life to become a nurse practitioner, probably not. And who knows where I would be if one of a thousand decisions had been made differently. Honestly, life’s little journeys can have positive and negative effects, but they are only part of the aspects that make you who you are.

As easy as it is to look back at paths not taken and decisions that could have been made differently, so it is with looking forward on my current path. Sometimes I think that I should never be here, but yet the path is still beneath my feet.

Even though the end is close and I think I will see it just around the next ridge. There waiting for me is another creek to cross or hill to climb. So I will keep walking. Sometimes on a smooth trail, sometimes on a path that is overgrown and strewed with hazards. Life is just that way, and there will be a day when I will look back and wonder if I should have made different choices I have yet to make.