A Nurse Practitioner's View

Happy NP Week

2009-11-10T21:14:00.002-05:00

Happy NP Week to all of my NP colleagues out there!

If you are a patient of an NP or work with one, be sure to recognize the fine work they do every day.

Here is the press release from the American Academy of Nurse Practitioners and the theme this year is 125,000 Solutions to the Primary Care Shortage.

(I'm a bit late, but also Happy PA Week to all of my physician assistant colleagues).

AHRQ Ad Campaign: Questions are the Answer

2009-11-07T09:09:00.004-05:00

I came across this well thought out commercial that has appeared on TV from the U.S. Department of Human Health & Services' Agency for Healthcare Research & Quality (AHRQ). Their website has a few other public service announcement-type of ads. With their, "Questions are the Answer" campaign, they are encouraging patients to ask questions about their care and to take an active role in the provision of their care. Hopefully, patients and providers alike will embrace this idea so that there are more answers than questions.

Any questions?

H1N What?

2009-10-13T19:15:00.004-04:00

With all the talk about H1N1 influenza, I think it;s important for folks to understand where the H1 and N1 come from.

The "H" comes from the substance hemagglutinin and the "N" comes from neuraminidase. There have been identified influenza strains of the H and N types and this is how some influenza viruses are classified. The particular "swine" flu that has garnered so much attention is of the H1N1 type. A few years ago, the fear was of the avian type, H5N1.

This past Spring, the Wall Street Journal Health Blog did a good job explaining some of the background regarding the naming of this particular strain of influenza.

This may help us all understand the nomenclature and rationale behind what has become household names.

Provider Ratings

2009-09-28T10:38:00.003-04:00

I recently decided to obtain auto insurance quotes from most of the major insurance companies websites. The quote process is generally very simple: enter your information and you get an instant on-line quote. As I feel it necessary to perform some due diligence and not just go with the least expensive quote, I Googled "auto insurance ratings." Well, what a frustrating experience. I wouldn't say that I am now more confused - only that it wasn't at all helpful. The Web is filled with a smattering of reviews and many of the negative ones seem that there is more to the story than what is written. In addition, we mostly know that an unsatisfied customer is much more likely to take their story to the Internet and post it as opposed to a satisfied customer with no issues.

What's my point to this post? I have come across various articles and websites that give patients the opportunity to rate their health care provider. In fact, here is an example of such a site. One can even go to Yelp to get provider-specific ratings from their patients. I have some concerns over what impact these ratings may have on providers and patients. Clearly, objective data cannot be disputed such as the education, training and the certification of providers. However, how much emphasis can we place on subjective data? Does this truly help us when choosing a provider? The patient who claims to be "mis-diagnosed" is much more likely to post this experience than someone who is truly satisfied and happy with their care.

I would much rather see some sort of qualitative data (i.e. percentage of patients with diabetic complications, number of hospitalizations, etc) when choosing a provider. Unfortunately, much of that data is nearly impossible to aggregate with the archaic paper and pen records system of most practices. So, we are largely left with subjective data to guide our decision when choosing a provider (this also assumes that we actually have a choice when it comes to choosing providers - I'm not sure most of the un or underinsured are taking to the Internet to research this kind of data).

What do you think? Are these rating sites helpful? After all, nearly every other industry uses customer ratings on their websites (think eBay and Amazon). Should health care also follow suit? Could this create a new independent agency whose purpose is to perform these ratings (such as a J.D. Power & Associates)?

Now I must go back to making that auto insurance decision!

Mandatory Flu Shots

2009-09-26T10:12:00.003-04:00

The New York State Department of Health recently passed emergency regulations requiring all healthcare personnel working in hospital and nursing homes to receive mandatory influenza vaccinations or face termination of employment.

I am a vaccine advocate and believe that vaccinations have decreased and in some cases eradicated some infectious illnesses. I do, however, worry about the mandate aspect of this law and how it will be truly be enforced.

What do you think? Good idea? Cutting-edge? Violation of privacy? I'd love to hear your thoughts.

You Can Count On Us

2009-08-31T23:28:00.005-04:00

Pennsylvania Governor Ed Rendell, a longtime champion of NP practice writes a column in today's USA Today, "Health reform can count on nurses." I am encouraged by this support and recognition for the thousands upon thousands of NPs, Nurse Midwives, Nurse Anesthetists, and Physician Assistants practicing and caring for patients in community, hospital and out-patient settings every day. We are not a new concept nor fad. Our practice is centered on our patients.

I invite everyone to read the blogs on my NP Blogroll. You will find examples of the extreme care and commitment we give to our patients. It certainly seems as if Governor Rendell is reading. Its exciting to ponder who else may be reading as well.......

Forms, Forms and more Forms

2009-08-27T09:38:00.004-04:00

It's back to school time and that means droves of physical forms flowing into offices as a requirement for school. Each form is different in its length, complexity and readability. Some practices have refused to complete forms and will attach a copy of their own. Some practices charge an additional fee to have the forms completed.

Why can't we ascribe to a standardized school form that everyone can use? I have seen some forms ask only for height, weight blood pressure and immunization history while others require a complete review of systems, physical exam, diagnosis, and dietary restrictions.

What do you think? Should we have a standardized physical form? Do you charge extra for completing patient's forms? If you are a parent or a patient, what do you think of this superfluous and redundant paperwork?

I'd love to hear your thoughts.

Evidence-Based Prevention

2009-08-11T12:54:00.003-04:00

Here is an article from the U.S. Preventative Services Task Force and is a resource for NPs to implement evidenced-based preventative practice.

When the buzz today is about health care reform, here is a good place for us all to start - talking about a preventative proactive evidenced-base approach rather than the opposite of that (which is what we largely have now!)

For the Record

2009-08-02T20:21:00.006-04:00

Here is a very informative interview about current NP practice and health reform from nurse practitioner, Dr. Thad Wilson, president of the American College of Nurse Practitioners (ACNP). Dr. Wilson eloquently provides clarification of the NP role and how our health system will be a better place when full inclusion and barrier-free practice is consistent along state lines.

Thanks, Dr. Wilson.

There is a post on the same site from a third year medical student about health reform and refers to chatter about nurse practitioners supplanting primary care physicians on a particular board. The posts on that board are certainly entertaining and show how turf wars are alive and kicking.

I hope that folks will read Dr. Wilson's interview to get an alternative perspective and realize that we need to work together to ensure that our families and our communities will be taken care of in the health care system of tomorrow.

Flaming

2009-07-27T19:04:00.003-04:00

Here is a rather short and short-sided article written by CNN Money about an "endangered breed" of "family doctors."

Interestingly, it ends with asking the question:

Should specialists, nurse practitioners and physician assistants be encouraged to fill in the gap left by shortage of primary care doctors? We want to hear about your experiences.

Now, the article mentions nothing about NPs or PAs yet asks for reader experiences. Fair enough. However, the barrage of degrading and insulting comments from self-identified physicians and others in healthcare are downright angry. I wonder what impact this has on their patient care.

Get it Right

2009-07-24T11:37:00.004-04:00

The media has picked up a story of a tragic alcohol-related death of a 16 year old male. His autopsy reportedly revealed a relatively low blood alcohol level but high levels of papaverine, a drug sometimes used to treat erectile dysfunction in men. What do the headlines read?

Erectile drug mystery in teen's death at party

Traces of erectile drug found in dead teen

The problem here is that papaverine needs to be INJECTED into the penis to work for erectile dysfunction. Oral forms of papavarine are not routinely used and will do nothing for erectile issues. The headlines can cause people to panic because the complete medical information is not presented in the articles. This boy suffocated on his own vomit when he was unconscious due to a combination of alcohol and this medication found in his bloodstream. Questions surround why this medication was found in his bloodstream and perhaps these articles were crafted to bring increased attention to the case as his family were growing frustrated with the investigation (Orinda mother calls death investigation 'shockingly passive').

Nonetheless, a tragedy such as this should highlight the need for teen education when we are talking about toxic drinking. A new program has begun at Stonybrook University in Long Island, New York called the Red Watch Band that specifically covers this topic. This project was started after a Stonybrook faculty member lost her own son, a college freshman while away at another college, to an alcohol overdose.

When used properly with consultation from your health care provider, there is little need to worry about the FDA oral prescription medication (Viagra, Cialis and Levitra) or injectable medications (Edex, papavarine) used to treat erectile dysfunction although reading only these headlines may cause you to think otherwise.

WOW - Obama on Nurses

2009-07-15T23:33:00.003-04:00

Here is some validation for the work that we do as recognized by our Commander in Chief. Thank you, Mr. President. Now its time to "Buck up!"

Succinct

2009-07-15T23:12:00.004-04:00

Here is a great initiative that the Institute of Medicine and the Robert Wood Johnson Foundation has launched on the Future of Nursing in America.

This gives a wonderful depiction on how nurses and nurse practitioners will be part of providing the solution to health care reform. As we have sensational portrayals of nurses in such recent series as Nurse Jackie and HawthoRNe, it is refreshing to have a vivid description of the impact nurses have in health care in America. This goes beyond the petty back and forth between other health care providers that is good for TV and some blogs and puts us on the high road - that is, taking better care of our patients, their families and our communities. And quite frankly, that to me is what it's all about.

Experts

2009-07-10T20:11:00.004-04:00

A friend of mine was recently browsing McNeill's Monistat website and noted that their "Ask the Expert" section is authored by a team of Nurse Practitioners. Kudos to McNeill for utilizing NPs as experts in women's health.

Rx for America

2009-06-25T20:27:00.005-04:00

ABC News recently sat down with President Obama for their "Prescription for America" forum. You can read the transcript here. It is a wonderfully transparent and thorough conversation on the major issues of health reform today. They address the primary care and nursing shortages, comparative effectiveness, putting an emphasis on prevention/wellness and even discuss nurse practitioners and physician assistants as being part of the solution.

I truly believe we will see steady, incremental progress regarding health reform because all of the stakeholders are/will be part of the process. This has started with a dialogue where respect for each other is paramount. We all know that it is rare for everyone to agree and that's ok. But if we can respect one another's views and roles we are well on our way to addressing this ailing system.

This is a prescription that must be 'dispensed as written.'

Primary Health Care Defined

2009-06-23T20:30:00.005-04:00

Once again, a debate is reignited about physicians versus nurse practitioners over at A Happy Hospitalist's blog. I'm not getting into a contest of who is smarter than who. I have always acknowledged that a physician's education is longer than that of a nurse practitioner's. My education and training has prepared me for a career in primary health care - a field that I am passionate about, am constantly trying to increase access to and one that I'm good at. Primary care is part of that vision of primary health care. There are many definitions of what "primary health care" is and the one that I use is not made up by me in my fairy tale world - it is the one that the World Health Organization defines as:

reducing exclusion and social disparities in health (universal coverage reforms)
organizing health services around people's needs and expectations (service delivery reforms)
integrating health into all sectors (public policy reforms)
pursuing collaborative models of policy dialogue (leadership reforms); and
increasing stakeholder participation

I believe in treating people equally and fairly. I don't treat them as disease, illness, number or an inconvenience in my day. I provide culturally competent and evidence-based practice. I recognize that an individuals culture may have an impact on a prescribed treatment or intervention.

I don't pass myself off as a physician. New York State says that I have showed competency as a nurse practitioner in Family Health, have thus received certification with prescriptive privileges and ultimately national board certification. I'm not making it up as I go along. I don't know it all and am honest and open about that. But I'd be damned if I send a patient back out there without a plan or without collaborating with other members of the health care team. Maybe the word "independent" is the issue. I say, anyone who thinks they practice anything independently will not get very far. The health care system is just that - a system. A system that relies on one another, of different disciplines in the common interest of patients. No one discipline "owns" health care. Would that word "autonomous" be less threatening? I'd be happy to use that describing my practice if we can ultimately work together and make a damn difference in the work that we do.

My education, that is on-going and what I consider life-long, hasn't prepared me to be a physician. As an NP, my education and practice is blended of both nursing and medicine. If/when I am sick, I seek care from a team of providers that is best prepared to assess and treat me in a partnership at that particular time and place.

Maybe I am still too idealistic after 10 years of NP practice. But you know what, that's the stance that I'd rather take than complaining about patients, the staff that I work with and our payment structure (not that some of those issues aren't worth complaining about).

So for now, I choose to focus my energies on trying to improve this health care system and finding ways to ensure health for all.

Smoke 'em if you got 'em

2009-06-12T21:58:00.004-04:00

Today, legislation has passed Congress and is on its way to President Obama that will allow the F.D.A. for the first time to regulate tobacco products. This truly is a huge step. As a health care provider, I see the harmful effects of cigarette smoke, not only on my patients, but on their families and on unsuspecting members of the community. Just recently I spoke with a patient that at one point in his life was smoking 4 packs a day. He now enjoys regular trips to his pulmonologist and annual arterial blood gas draws from his wrist - not fun nor painless. (If you ever thought having blood drawn from a vein is uncomfortable, as is the case with most labwork, drawing blood from an artery is a completely different ballgame).

Unfortunately in this legislation, nicotine (the highly addictive "feel good" substance found in cigarettes) isn't banned altogether but some chemicals in tobacco products are and there are restrictions put on advertising.

It still amazes me whenever I fly and see the no-smoking light above my seat that at one time smoking was allowed on airplanes. Talk about second hand smoke in a closed vessel! You can make a similar argument when it comes to restaurants and bars where in most places it is now banned.

Of course, we still have a long way to go when it comes to incorporating healthier evidenced based practices in our lives. Smoking causes cancer and other chronic respiratory problems. This legislation, once signed by President Obama, will be a major step in the right direction.

A Conversation of One

2009-06-04T19:45:00.004-04:00

I love this. Fellow blogger (and I mean fellow only that he blogs, not that I can ever approach the level of "care" that he provides) just loves to rant about NPs. We aren't smart enough, we don't know what we don't know, provide good "nursing education" to our patients, we believe what we do is "good", are good at kissing boo-boos and holding hands, is at it yet again. (I think when his traffic is down, he decides to post about NPs and how "inadequate" he "thinks" we are to drive his blog traffic up.) It's really interesting - he harps on about how bad NPs are (i.e. we are mindless monkeys that can code a good level 5 visit) - he even has an "anonymous" NP post comments that claims their education didn't prepare her for the real world.

I am so over it. I've left respectful comments on his blog only to get shot down. He continues to denigrate NP practice and gets his fellow "colleagues" to add further belittling comments. It must be nice to hide behind his "happy" exterior without fear of ramification. I guess that's why some choose to blog anonymously - say whatever you want yet show up at work the next day and put on a good face to all of the NPs and nursing staff and they have no idea that you threw them under the bus in one of your many blog posts.

The sad thing to me is that I enjoy most of his humor and posts. I'm sure he is a relatively good guy. Well anyway, that's the difference - some choose to hide behind an exterior and say whatever is on their mind. Some others choose to be a real person with no hidden agenda and not hide behind the anonymity that the Internet affords. I suppose that is the beauty of anonymous blogging. Nonetheless, I hope he continues dialoguing with himself and continues to be 'happy.' At least I have a clear conscience when I post.....

May the Schwartz be with you...

2009-06-01T10:21:00.003-04:00

Representative Allyson Schwartz along with nearly 100 cosponsors recently introduced House of Representatives Bill 2350, Preserving Patient Access to Primary Care Act of 2009. The legislation will improve access to primary care and increase the number of primary care providers in part by allowing the Nation's nurse practitioners to lead the Patient Centered Medical Home.

Here is the full text of the Bill.

This has the potential to be monumental legislation for our nation. In addition, an unprecedented number of physician (American Academy of Physicians & American Academy of Family Physicians) and nurse practitioner organizations (American College of Nurse Practitioners & National Association of Pediatric Nurse Practitioners) are supporting this bill. Though it seems that the AAFP is begrudgingly "putting up" with the inclusion of NPs as evidenced by AAFP Chairperson Jim King, M.D.:

The legislation also would allow nurse-practitioner-managed practices to serve as medical homes, as long as they meet the same standards applied to physician practices. Not surprisingly, this has prompted concern from the AAFP."We have some concerns with the way that the legislation includes nonphysician providers in a role similar to that of physicians, especially in the implementation of the patient-centered medical home," King said. "Without data showing the comparability of nonphysician providers to primary care physicians -- whose training and experience are much more intense and extensive -- it is a risk to allow these providers to deliver these services without the standard level of supervision."

These guys continue to play the turf war and it is getting so very tired. Nurse Practitioners want to partner and collaborate with physicians. When they throw around terms like "supervision" it becomes clear that they are only concerned about being the captain of the ship rather than working with everyone to support the efforts of having enough primary care access in this country. We need to have the right provider caring for the patient at the right time and place.

Nurse Practitioners are ready to step up and offer an out of the box solution to address our shortage of primary care. NPs need no further formalized training or education (yet we all know that you must be dedicated to lifelong learning in this field).

Please encourage your Representatives to support this legislation. We can't afford a ripe opportunity for meaningful health reform to pass us by....

Mow the Lawn

2009-05-29T17:51:00.008-04:00

Here is a post of a lighter nature. The new Schick Bikini razor is new on the market and with it comes "viral" advertising of sorts - Mow the Lawn. The ad is posted below:

Now to make this a health-related post, I will add a few tips about grooming since I've seen patients with significant folliculitis (infected hair follicles "down there" that are red and painful) after their grooming regimen:

Use a new razor with clean, sharp blades.
Consider using a pre-shave to soften the hair and protect the skin
Use plenty of cream/gel (I suggest a good hypoallergenic gel - at least for my face)
Use plenty of clean warm/hot water and rinse razor frequently
Use a good aftershave lotion/balm

If you are into genital grooming/shaving, you probably want to avoid using a traditional men's shaving cream and aftershave lotion. There are many products out there made specifically for this sensitive area. This goes for men too. I've seen plenty of infections after guys have used their face razor in the genital region (hopefully not before or after using it on their face - at least I haven't had anyone admit that to me yet!)

Of course there are other options such as laser hair removal and the ever so popular Brazilian wax. Whatever you choose (or choose not to partake in grooming) be sure that take the necessary steps to avoid infection/irritation. Happy mowing.........

A Novel Approach to Health Care Reform

2009-05-06T12:44:00.005-04:00

Here is a link to an article where Health and Human Services Secretary Kathleen Sebelius spoke to a nurses union today and stated, "If health care reform is to be a reality, we need you at the front line."

Since health care is multi-disciplinary entity which no one profession "owns," it is encouraging to see an inclusive approach. I look foreword to health care reform and working with my other health care colleagues in making this a reality.

NPs and Primary Care Shortages

2009-04-28T12:44:00.004-04:00

Here is a news-worthy article and clip about NP practice in New York. The piece is from East Syracuse, New York and highlights how NPs can be part of the solution to primary care shortages.

Also, April is Nurse Practitioner month in New York State. This would be a fine time to recognize NP's contributions to the health care system and patient care.

Swine

2009-04-27T23:37:00.005-04:00

Undoubtedly, most are aware of the swine flu by now and the potential impact it has on pandemic fears. While cause for concern, it isn't cause for panic...yet.

Know the symptoms of the flu. That is, remember that influenza is a respiratory illness. Typically, if one doesn't have a cough (usually non-productive), fever and body aches, then it is unlikely that it is classic influenza. Common sense precautions are in order,

stay home if you are sick with mild symptoms, seek care if they worsen
wash your hands frequently, especially after touching your nose & mouth. (Most people don't wash their hands properly if you can believe it. You should wet your hands with water, use soap and scrub for at least 30 seconds {sing "Happy Birthday" twice to yourself}; be sure to get your wrists and under jewelry.
Phone your health care provider if you have specific questions. Also visit credible sites such as the CDC.
Anti-viral medications exist for pre or post exposure to the flu. Of course, these are not without their potential side effects and issues.
Seasonal flu vaccine probably doesn't protect against this strain of swine flu.

This is a trying time for the whole international community as this has the potential to negatively impact so many. Compound that with an already taxed healthcare system and it highlights the need for enhanced communication among providers and health reform. Now more than ever is the time to work together, collaborate and show how we can take care of one another. I, for one, will be ready.

Your Chart: Do you know what's in there?

2009-04-09T23:00:00.005-04:00

This is a wonderful post over at The New Life of e-Patient Dave's website about electronic health records. I strongly encourage patients and clinicians to read it. While there has been much debate about whether EHRs actually improve patient care and save money (I believe they will do both) the move to electronic records will enable transparency when it comes to viewing and reviewing your own chart.

Have you ever tried to get a copy of your own record? It is not exactly the easiest process. Most providers offices require you to complete a records release form which is filled with legal jargon and makes you seriously question if you really want to get these records in the first place. Some providers charge you per page to photocopy your record and good luck in thinking that this will be processed promptly by the staff. Once you get your hands on a traditional paper chart copy, it is nearly impossible to decipher. Is this acceptable? Maybe accessing your health record should be like getting your credit report. I know that in a matter of seconds I can log on to one of the credit reporting websites, enter some information and have complete access to my full credit report.

So now that you have access to your chart, I am reminded by the Seinfeld episode, "The Package" where Elaine has a rash and sees a few doctors only to be shunned by what is written in her chart:

Should patients have the right to question what's in the chart or make their own comments? Can subjective data be debated? Would clinicians document differently if they knew that patients had unfettered access to what's in there? Is our system of charting archaic and does it truly capture the essence of the visit? Could we be making better use of technology and snap digital photos of certain conditions and attach them electronically to the record? If we are to be patient-centric, how much input should patients have in their records? Would clinicians have to "defend" their charting if questioned? These are many questions that could make for some interesting debate. What do you think?

I think we have a long way to go when it comes to transitioning to electronic records. Yet, the time has come. We need to stop talking about it and thoughtfully start implementing it. It all goes back to communication and understanding about disease processes and steps that can be taken to improve health. After all isn't your health record just as important as your credit score?

One Year Blogging

2009-03-28T09:03:00.003-04:00

Hi All,

It has been a full year since I started this blog. I wanted to thank everyone who stops by and reads it. I hope to continue posting with some semblance of regularity and share my view on topics not only specific to nurse practitioner practice, but to all relevant healthcare topics today.

Thank you!
Stephen