Transitions

Ah, September. Back to school, and the end of summer – those three months of overheated bliss, where stress tops out at coordinating a weekend BBQ schedule and dealing with beach traffic.

Unless you’re me!* Hi, world. I just moved my entire family 3500 miles across the country.

I won’t bore you with the details – except to say that moving out of a house that you’ve filled with far too many personal belongings, driving across the country with two teensy kids, finding a place to live in one of the toughest real estate markets in the country from afar, and transferring all your various NP-related licenses to the most administratively labyrinthine state in the history of forever had me doubting my sanity in very real and discomfiting ways (/rant over) – but as I get settled in the new digs and come out of the fog, a few reflections:

1. Making a long-distance move? Drive it. And take your time. All that “flyover country” has a lot of awesomeness to offer. One example: It turns out that Sioux Falls totally rocks. Those falls (not just a name) are straight-up gorgeous. And some of the best Mexican food outside SoCal can be found in a tiny taqueria tucked in the shadow of a huge meatpacking plant. Who knew? I mean, besides the South Dakotans?

2. Traffic is bad everywhere; the badness just has different flavors. Boston has volume + poorly marked roads. California has volume + commuter rage. (she says from the comfort of her road-rage-free seat on public transportation)

3. Beaches are awesome. Never turn down the opportunity to live near a beach if it’s remotely possible. The sight of the ocean greeting you as you drive home makes #2 (see above) worth it. (Sort of.)

4. Starting over is hard. All the awesome stuff you did in that last job might have gotten you the new one, but it doesn’t buy you much capital on the clinic floor. You’re still the new guy. Hazing, mostly of the subtle variety, may or may not ensue.

And tomorrow? Actual patients. In my schedule. Because I have a schedule.

I may still find myself getting lost on the way to the bathroom, but I have a schedule.

Wish me luck.

*and, I’m sure, the majority of human beings… but a girl can dream, right?

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Being a grown-up is overrated

You know it’s true.

Like, way overrated.

I mean, I guess there are some upsides. Wine. There’s an upside. Unlimited cake. There’s another.

But right now I’m having trouble remembering all the others.

Today, I had to turn down what sounded like a really cool job. I turned it down because:

1 – it paid peanuts (when really, cash is my preferred currency)

2 – it had a fairly crappy retirement package compared to my current situation (and this proves just how grown-up I am – I seriously didn’t even bother signing up for the retirement plan with my first few nursing jobs because the stack of paperwork was intimidating and besides, I was pretty sure I was never growing old, like never ever), and

3 – it didn’t provide as much schedule flexibility, which suddenly matters when there are these small people living with you that share your DNA who kinda want you to show up for recitals and book fairs and ice cream socials, many of which happen at times and in places that conflict with your typical full-time job + 10 days of paid vacation time per year.

Despite these very material issues, this new job sounded super exciting. I’d have had tons more responsibility (plus/minus?) and a fancy title. Fancy titles feel like the emotional equivalent of a sparkly tiara. I love tiaras. Yes please.

So there I was, considering this peanuts-paying but sparkly-tiara-providing position where I’m being told how awesome all these strangers think I am, and yet at the same time…

being told by my current powers-that-be that – you know what? Maybe you’re not so special after all. I mean, don’t get me wrong, we’d like you to keep doing what you’re doing (and then some, and then some, always more please) but don’t get any ideas about getting a tiara of your own someday.

You know what pre-grown-up LB would do? She’d tell her current tiara-withholding powers-that-be to go screw off, and take the crappy-paying tiara-providing position elsewhere. Just to make a point. Fine, some might call it a tantrum. A tantrum with consequences.

But just to prove what a grown-up I am, I did the thing I knew I had to do. I looked at the numbers, realized I really didn’t have any other choice to make, and I turned down the elsewhere-tiara, trudging back to Land of Mediocrity Celebrated.

I know it was the only choice I could make. But it still sucks.

Because being a grown-up is overrated.

But at least I still have 2:1 matching on my 403B. And that’s certainly something.

 

*****

 

(Besides, that tiara was probably made out of twisted aluminum foil and stick-on plastic gems anyhow. Right? Right?)

 

*****

 

(Btw – I promise to get back to writing about actual health care stuff here soon. The last 6 weeks of my life have been dominated by professional uncertainty. Now that a few of those question marks have been taken care of, I’m getting back in the saddle.) (So to speak.*)

 

 

*no actual saddles will be harmed in the writing of this blog

The beginning of the end/the end of the beginning

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The same thing happens to me every year.

I’m heading to work in the same sleepy way I start pretty much every day. (I wish I could say I WAKE UP EVERY DAY READY TO TAKE ON THE WORLD! but that would be a dirty lie. Plus, annoying.)

So there I am, riding the train with all the other groggy commuters as we all zone out, staring at the free paper the guy pushes in our hands on our way in, or at our various depersonalizing digital devices, or at nothing at all, eyes unfocused until the conductor calls out our stop.

Eventually, my stop is called. I get up, moving forward slowly with the zombie-walking masses onto the platform and up the escalator.

As I emerge on to the main level of the station – which just so happens to double as a footpath through campus – I remember that it’s not a routine, mundane day at all.

It’s graduation day.

And every year, the sight of those no-longer college students, those-not-so-young-anymore young adults, dressed in their grown-up best with black polyester gown flapping open in the late spring breeze, gets me.

Now sure, I may also have been known to tear up at a really well constructed Coca-Cola commercial, BUT STILL. It’s a pretty amazing sight.

I mean, think about everything this moment – wearing the respectable yet still-uncomfortable heels Mom insisted you’d need for job interviews and carrying the mortarboard hat you stayed up until 2am decorating with scrapbook material from Target – represents.

It doesn’t only represent the end of your childhood. It represents the beginning of the rest of your life – the part where you start down the path you’ve chosen over the past 4-6 years, and continue down that path until…maybe…forever? AND EVER? Let’s hope you made the right choice (nervous laughter). BUT NO PRESSURE. Enjoy your day!

Oh right. That’s where that glint of terror in their eyes comes from. It’s hiding behind the breathless anticipation of all the pomp and circumstance, sure, but it’s there.

There’s an exuberant finality to this Hallmark-approved milestone that makes graduation both really, really exciting and really, really scary, all at once.

When I was a kid, I always thought of adulthood as this time where you’d become A Thing – a doctor, a lawyer, the president, a rock star – and then you did that Thing for the rest of your life.

But speaking as a Certified Grown-Up (GU-C) myself, I think we need to rethink our thinking on this. Mentally committing yourself to one profession for the rest of your life at the age of 22 feels a little like preparing for years to climb Mt. Everest, finally making it to the top, and then pitching a tent (presumably a very small one) and staying there FOREVER.

Yes, graduation day is exciting. But it’s really just the beginning of the rest of your life – just like every day is the beginning of the rest of your life. (Except this one comes with a really good party and thirty years of loan repayment.)

I guess what I’m saying is that if you’re not sure you’ve found your Thing by the time you’re standing there with that heavily decorated cardboard square on your head, don’t let it get you down. Even those of us who thought we’d found our Thing by the time we graduated from college, or grad school, or insert-milestone-here, later realized that the person we’d become wanted to do another Thing altogether.

Because that’s life. Life is evolution. The person we are at 22 might not be the person we are at 30, or 40, or 55. Each of those people has learned some new stuff about themselves and the world, and the super fun thing about all of this is that each of those people gets to decide to change course and start doing a completely different Thing if they feel like it. It might not be easy, or cheap, but it’s your choice to make.

So with that, here’s to all my soon-to-be-former patients: enjoy the party, tell Sallie Mae I said hello when she comes calling, don’t forget to get that repeat Pap in 6 months – and in the meantime, just do the Thing you think you’re meant to be doing, right now. The rest will sort itself out in the end.

Resilience

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I have this baby at home. He’s super cute, as babies tend to be. Fairly uncoordinated, as babies tend to be.

Not surprisingly, falls are a regular occurrence in this house. Maybe there was an unfair wrinkle in the rug, or an unattended Duplo sitting in just the right spot, or an imagined breeze. But whoever it is that’s to blame, the results are the same: you’re walking along, bothering no one – no one! – and all of a sudden you’re on the ground, and you hurt. Much high-decibel sadness immediately follows.

But do you stop walking?

Well, maybe for a few minutes. Hell, your head still hurts. Like, a lot. And who knows exactly WHY this terrible thing happened? It’s scary putting one foot in front of the other when something that seemed so routine ended in tears just a few moments ago.

But no. After a quick comfort snuggle, you get back up and keep toddling across the floor, with renewed zeal fueling your quest to plunge your hands into that ficus planter soil, maybe even tasting its earthy deliciousness one more time before the tall people catch you.

I think I know how he feels.

A year and 24 hours ago, we were bundling up the kids for a crowded T ride into the city, heading for a friend’s apartment on the marathon route to enjoy some fantastic company and a beautiful spring day, and to cheer on a bunch of runners we’d never met. They’d write their names on their jerseys in Sharpie, so we could call them out by name: “Go Sarah/Bill/Melissa! You’re doing great! Wooooooo!” (Our older kid is particularly good at this last part.)

And then a year and 12 hours ago, everything felt, somehow, fundamentally different. The fear of an unknown future following a major terrifying event can seem immobilizing. Even though we knew, deep down, the marathon would continue next year, and the year after that, and the year after that – because you can’t defeat the world’s oldest annual marathon that easily, PLEASE – would we go? As a random spectator, would it feel easier, safer, just to stay home and enjoy the day off from work?

But a lot can happen in a year.

This weekend, our marathon route friend was over for our baby’s first birthday party. She looks at me. So what are you guys doing for the marathon? I pause to think for a moment. Then, with a smile: Nothing…yet. She, also with a smile: Want to come over to our place? We can grill, the kids can hang out…

That sounds awesome. We’re in.

Human beings are pretty f-ing resilient creatures. It’s fundamental to our success as a species. When we stumble, when we feel pain, or fear, obviously we tend to react, at least immediately, with avoidance. Clear evolutionary advantage here: you don’t want the entire family sauntering back out of the cave when just moments ago Grandpa was eaten by the lion that’s still standing outside.

But once you have some time to take stock, reassess the level of risk, make your process a little safer if need be, we tend to get right back to it – whatever “it” might be – even more focused and determined than we were before. We can be capable of some pretty great things, and it’s our stubborn resilience in the face of adversity makes these great things possible.

I mean. It’s not like that ficus soil is going to eat itself.

Dear too-many colleges: here’s why you’re next in line for a Title IX suit

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Another week, another famous institution of higher learning in the news for mismanaging cases of sexual assault on campus.

This time, it was Harvard. The most common response, from what I can tell, seems to be summarized thusly: “Oh myyyyy – even at Hahvahd?” (eyebrows raised in surprise, mouth forming a delicate “o” of prim concern).

The morning the story broke in the local news, I happened to be having lunch with these two guys who work in administration at a nearby college. Guy #1 says to me, “So, have you heard about Harvard? And the sexual assault case?” Why yes, yes I have. Guy #1 continues, in a voice of genuine concern: “So, what can we do to keep people from drinking so much?”

Guy #2 murmurs in agreement, eyebrows knitted with empathy.

LADIES AND GENTLEMEN. EXHIBIT A. This, right here, is the crux of why colleges keep finding themselves in trouble when it comes to dealing with sexual assault.

I know, I KNOW. It’s not like Guys #1 and #2 are alone in their thinking here. Just read the comments section of any article on the college-sexual-assault topic for a primer on the latest and greatest in victim-blaming. The idea that intoxication negates one’s ability to provide consent seems to be a logical stretch for quite of few of the world’s armchair analysts.

But here’s the thing. I don’t really care if some random dude with a laptop disagrees with whether rape is rape when alcohol is involved. I mean, I don’t like it, but one guy with an opinion just doesn’t matter all that much. The extent of his power ends once his opinion’s been expressed.

However. If you’ve made a career for yourself in college administration or college health, and you continue to think that the epidemic of sexual assault on college campuses is really about excessive drinking and morning-after regret, don’t act shocked when your school is next to hit the news with a Title IX suit and a bunch of unflattering media attention of your own.

Yes, you could be the next Harvard. Or Dartmouth. Or Mizzou. Because sexual assault is happening on college campuses EVERYWHERE. It has, without question, happened on your campus. And if this common-yet-ultimately-wrong-minded perspective frames how you choose to respond to a sexual assault survivor’s case once it’s been brought to your attention, there’s a good chance that survivor will feel justifiably wronged. And, if they’re feeling brave enough, they just might decide to take this dissatisfaction with you and your colleagues public. Very, very public.

Don’t misunderstand me. I’m not denying that there’s a problem with binge drinking on college campuses that we need to address. But it needs to be addressed as an issue that’s separate and distinct from that of sexual assault. After all, just because it might be easier to mug someone who’s walking home late at night after they’ve had few drinks with friends, it’s not like the mugging itself isn’t still a crime.

I mean, someone who’s been attacked and robbed isn’t told by the authorities that their mugger didn’t REALLY commit a crime, because, y’know, you WERE pretty wasted, after all, and maybe sorta kinda asking for it by walking down the street in the middle of the night. I mean, who’s to say you didn’t HAND that aggressive stranger your money when he asked nicely? Who knows? He said, she said. You know what? Let’s just chalk this one up to youthful indiscretion and a lesson learned.

Hell no. Safety bulletins are sent out, city and campus police start patrolling overtime, and no one rests until the assailant’s been caught.

Intoxication may make a predator’s job easier. But it doesn’t make them NOT a predator.

In a perfect world, everyone would GET THIS, and this tortured public debate over what-is-or-isn’t-rape would cease to exist. I’m not naive enough to think that sexual assault wouldn’t still happen – because some people are terrible human beings – but society would deal with it the way it does any other violent crime. Meaning a) those who choose to commit a crime are consistently removed from the community for the safety of others, and b) the threat of criminal charges and incarceration might make some of the would-be assailants of the world think twice before committing assault. Both of which would result in less sexual assault. And I’m pretty sure we can all agree that less sexual assault = GOOD.

Those of us who work on college campuses need to be held to a different standard than Random Laptop Guy. You can’t hold regressive and harmful views on a topic as important – and yes, public – as sexual assault, with those views shaping your institutional response to individual reports of rape, and NOT expect that it might come back to bite you someday.

Unless, of course, you’d been hoping to end up on the front page of the Globe someday. In which case, vaya con Dios, my friends.

The end of (quote-unquote) supervision?

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You may already be familiar with how truly, madly, deeply annoying I find the term “supervision”.

I mean, not in its appropriate context, obviously. My daughter, despite being quite precocious for a kindergartener, still requires supervision while using grown-up scissors. My son, who seems to think he’s capable of essentially any physical feat imaginable, needs pretty much constant supervision, since he’s nearly always wrong. Not at all developmentally inappropriate for a toddler, but still. If we want him to survive childhood, supervision is definitely required.

Clearly, supervision has its place. But some problems arise when we start using the word to describe a mandated relationship between a physician and a nurse practitioner. Not the least of which is the fact that I tend to take issue with the intentional misuse of language. It’s kind of a pet peeve.

I wrote something about why exactly I find the word “supervision” so annoying a few months back. (Go ahead, I won’t judge you for clicking.) Afterwards, an NP from another state read it and said something along the lines of “Huh. Supervision? Is that still a thing in some places?”

Yeesh. Why yes. Yes, it is still a thing. In some places. Apparently.

Thing is, I never dreamed that moving to an uber-progressive state would mean I would still be subject to outdated laws that don’t make any logical sense. Maybe that whole no-buying-alcohol-on-Sunday-mornings thing should have tipped me off?

Don’t get me wrong. It’s not like you’d have any idea there were any restrictions on my practice on a daily basis. I go to work and see my patients, order my labs, write my prescriptions, write my notes. Pretty mundane, actually.

Except for this one annoying thing where all my prescriptions have a second name on them: the name of my “supervising physician”.

And even though my “supervising physician” is pretty great, this bugs her as much as it bugs me. And I totally get it. I’d probably be super annoyed too if there were a bunch of prescriptions out there with my name on them that I had nothing to do with writing. Risk exposure much?

Ah well. I’d just assumed it was something I needed to get used to. Just like I got used to the sight of seeing tarps thrown over the beer section at the supermarket whenever I happen to find myself grocery shopping on a Sunday morning. (Actually… nope, still haven’t gotten used to that either.)

But then I finally opened one of the emails that the Massachusetts Coalition of NPs has been sending me to find out WAIT, WHAT? There’s an actual, real-life bill at the State House RIGHT NOW that could fix this?

True story! It’s called HB2009/SB1079, or “An Act Improving the Quality of Health Care and Reducing Costs”. And it’s pretty great. (Even if it could really use a new name.)

I’ve heard that some of the arguments that legislators are hearing against the unfortunately-named bill sound like this:

  • “NPs and CRNAs are not educated enough.”
  • “Patients will be harmed because they don’t know what they don’t know.”
  • “They need continued oversight in order to be safe for patients.”

Here’s the thing, people-who-either-said-these-things-or-wish-they-did. I hate to break it to you, but that ship has left the dock. The train has left the station. The car has left the carport. NPs are already seeing patients and making diagnostic decisions and prescribing stuff – lots of stuff! – on their own, every single day. Whether you like it or not. It’s already happening! You’re too late!

And that’s why I have such a hard time understanding why physicians would be AGAINST removing the supervision language from the books. If my name is going to be attached to someone’s actions, I want to be sure I had something to do with it. But “supervising” MDs? They get all the risk that comes with clinical decision making and prescribing, with none of the power to actually make those decisions. How does this sound like a good deal?

Well, maybe if your income was affected by how many NPs you “supervise”, it would sound like a great deal. As long as that whole risk-under-your-name thing doesn’t bother you too much.

…But wait a sec. If you’re confident enough in the abilities of the NPs you “supervise” to feel comfortable with this level of risk, one might surmise that maybe you don’t actually, deep down, think NPs are all that unsafe after all… which would suggest that all these protests about “safety” may be just a teensy bit disingenuous, no?

In conclusion: this bill rocks, and its time has come. So if you live in Massachusetts and agree with my pointed use of quotation marks around the word “supervision”, please – figure out who your rep is and call, or email, or carrier-pigeon over your thoughts on the matter.

Thank you. That is all.

Quantifying awesomeness

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So, I’ll admit that I tend to think of myself as being a pretty awesome NP. Kind of a rock star.

But I recognize that I might be slightly biased.

My mom, my husband, my kids are all similarly convinced that I, generally speaking, rock when it comes to being an NP.

And they’re, most definitely, totally and completely biased as well. (And more than a little unqualified to judge.)

Isn’t that human nature, though? To think of ourselves as being pretty damn good at what we do? Probably true for everyone, but maybe even moreso for clinicians?

I mean, this job can be hard. REALLY hard. Crazy schedules, crazy patients, crazy admins, crazy insurance companies. If we don’t think we’re particularly great at it, that we’re bringing something special and unique and AWESOME to the table – and I mean even more than that other guy over there – what’s the point?

But we all know that all clinicians are not equally awesome.

Every clinic everywhere has “good” providers and “bad” providers and “okay” providers. It’s not written down anywhere, but when a friend asks a friend who knows some things about who they should ask to see, certain names come up, over and over again, while others are conspicuously omitted.

I’ve been thinking about this topic recently because of a conversation I had with a certain administrative type from a certain clinic this week. While we were chatting about unexciting clinic business, he let slip that roughly half of the patient complaints the clinic receives are consistently about one particular clinician. He then brushed them aside because he thinks of this clinician as being stingy with prescribing antibiotics, so therefore the fact that 50% of the clinic’s complaints are about 1/10 of the clinical staff may not the best measure of the quality of this guy’s work. Besides, he sees A LOT of patients. Very, very quickly. No drama. Admins love a high volume:drama ratio.

Hmm.

Zoom out.

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There’s currently this great experiment underway to figure out how to measure which clinicians are particularly good at what they do, and to reward those who are the MOST AWESOME in an effort to inspire everyone to be even MORE AWESOME than they may already be.

On one level, this makes perfect sense. Why NOT pay more money for better care? Why not reward high quality? Isn’t that how the rest of the world works?

But measuring quality in health care isn’t the same as counting how many widgets an assembly worker makes, or how many five-star Yelp reviews you get.

Briefly, a probably-incomplete rundown of what seem to be most common approaches to quality measurement in healthcare:

a) Volume. How many patient visits can you squeeze into X minutes? Easy to measure – the greater the number, the greater the reward. In a fee-for-service environment, the reason for this relationship is obvious: more visits = more cash. But even outside the FFS world, this idea – that part of what makes one clinician better than another is how on-time they run, or how soon a patient can get an appointment – is a pervasive one. And who knows, maybe it should be. Access matters, right?

b) Patient satisfaction. How happy was your patient with the perceived quality of the care provided? If health care was just like any other consumer-oriented business, this would make 100% perfect sense.

BUT. Studies show that patients may not always be the best judges of the actual quality of the care they just received. Scores go up when providers hand out more antibiotics and more narcotics. Scores go up when providers order more expensive tests and procedures. Satisfaction matters, but so does averting a post-functioning-antibiotic future, avoiding the unintentional promotion of opioid addiction, and keeping medical costs from bankrupting the nation.

c) Adherence to clinical guidelines. How many patients got a flu shot this year? How about a Pap smear, or a mammogram? Hard to see what could be wrong here. Lots of people who know lots of things spent lots of time creating those guidelines. Flu shots are good. Early detection and treatment of cancer is good.

But what about shared decision making? Does judging clinicians based on their adherence to guidelines, above all else, result in strong-arming patients into taking medications, or having tests performed, or whatever it might be that they don’t want, or can’t afford, or may not even be considered appropriate care in 5 years? (cough mammograms cough)

Having a conversation with the patient and discussing guidelines, and the evidence behind the guidelines, in a shared and mutually understandable language is always a good thing. But is it possible that overreliance on adherence to guidelines as a marker of quality misses something?

d) Measuring outcomes. How many of your patients’ LDLs, blood pressures, and A1Cs are within normal limits? This, also, seems reasonable. Considering that part of our job (most of our job?) is to try to make these things better, it makes sense that we be judged on how well we do.

But we also all know that controlling chronic illness is harder in some populations than others. Access to care matters. Wealth matters. Community norms and expectations matter. Does rewarding clinicians who can show better outcomes unwittingly drive them away from caring for more at-risk populations?

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Back to this unpopular-with-the-patients clinician. Sure, he’s decent at avoiding prescribing antibiotics for colds. But I also happen to know he’s not great with the interpersonal skills. He also doesn’t bother to spend much time explaining what he’s thinking and why – to anyone, really, about anything, let alone his diagnostic and care plans with his patients. So you can consider me completely unsurprised to learn that he receives a far-greater-than-average number of “He did nothing!” complaints than the average clinician.

Not for nothing, but I’m also known for being stingy about prescribing antibiotics. And yet I consider it a point of pride that even my most pre-visit-antibiotic-committed patients leave their visit agreeing with me that their nasal congestion is viral.

I don’t actually have any answers here. I feel like each of these quality measurements dances around an aspect of care that matters, but also somehow misses the bigger point. It feels like there’s got to be a way to measure and reward the intangibles.

Any ideas?