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Thing is, I never dreamed that moving to an uber-progressive state would mean I would still be subject to outdated laws that don’t make any logical sense.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.

Fake it till you make it

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Last weekend, I found myself at my first sample sale.

Apparently, there’s this clothing brand out of the UK called Boden, which, as far as I can tell, makes very nice, very pricey clothes for your most well-dressed aunt. The young, cool aunt – the one with a successful boutique business doing something lucrative enough to afford a fabulous, crave-worthy condo and a closet full of, well, Boden.

I shop the clearance racks at Target and H&M. Maybe Loft, but only if I’m feeling a little spendy. So how did I find myself at the back of a mile-long line waiting to file into a convention center filled with communal dressing rooms, aggressively sharp elbows, and piles of off-season fashion?

I blame obstetrics.

*****

Before I’d even started nursing school, I had the idea bouncing around somewhere in the back of my mind that I might want to teach someday. I like talking, I like people, I like the idea of sharing my deep and vast knowledge about the secrets of nursing with the next generation of nurslings. It’s not like I’d actually acquired this deep and vast knowledge at the time I was telling myself all this, but I was confident it was on its way.

And then before I knew it, there I was, a newly minted health care provider, with a license and prescriptive authority and a raging case of imposter syndrome. I’d put on my white coat and grab my stethoscope and bluster into an exam room with a confident smile, certain that any minute now someone was going to figure out that I didn’t belong.

There was no way in hell I felt ready to teach. I barely felt ready to go to work every day.

Thankfully, spending a few years actually working as an actual nurse practitioner does wonders for treating imposter syndrome, and eventually, I felt legit enough that I agreed to start precepting NP students. Precepting is kind of like dipping your toes in the shallowest wading pool at the water slide park of nursing education. You don’t even really need to be wearing a bathing suit. All you’re really doing is explaining why you’re doing what you’re doing with the patients you’d be seeing whether you had a student with you or not.

Don’t get me wrong, the clinical placement is in many ways the crux of the whole learning experience for the student. It’s super important. Check. But for the preceptor? Your expertise is only expected to encompass the stuff you already do every day. Easy peasy.

So when one of the nursing schools I’ve been working with asked me if I wanted to teach a clinical seminar, I thought, you know what? I’m pretty decent as a preceptor. How much harder could teaching a real, live, in-person class be? Nah, I got this. Let’s go.

But it wasn’t until I started really preparing for this class that I realized one of the problems with for-real teaching: you don’t get to only teach the stuff you know and like the best. My class of women’s health NP students wouldn’t be expecting an entire semester of the kinds of things I see in a college health clinic.

In particular, they’d be expecting to spend at least half their time learning about obstetrics.

I haven’t cracked an OB reference book since grad school. My role in managing my patients’ pregnancies typically begins and ends with a urine hCG, a long talk, and a referral.

The first couple weeks of class we managed to keep things firmly in my wheelhouse: vaginitis, molluscum, herpes, IUDs. HEY LOOK, I KNOW SOME THINGS. A one-off question about first trimester screening was deftly turned back to the students, since those things change constantly and who could possibly be expected to keep them all straight? Please.

But next week, I’ll be forced to lead an in-depth discussion of cervical incompetency and cerclage. And just like that, imposter syndrome comes roaring back.

Solution #1: retail therapy. I can’t wear a white coat to class, but if I start dressing Iike an actual grown-up, maybe my students won’t laugh me down from the front of the classroom, right? Which is how I ended up in line on a Saturday morning with hundreds of other women at this sample sale. Yes, I now have a few nice things that I didn’t have before. And they are quite pretty, even though I’m 100% sure I’ll be trashing these cashmere and silk blends in a hot second with my unsorted, overloaded laundry style.

Yet for some reason, the $125 I spent on blouses (not shirts! BLOUSES) doesn’t seem to make me any more of an authority on cervical cerclage than I already was.

So I suppose I need to deal with my discomfort with not knowing everything about everything the same way I did as a new NP: a confident smile, and a metric ton of reading.

And in the meantime. “Hey, you look like a professor!” was an actual quote from one of my colleagues in the clinic this week. BEHOLD THE POWER OF THE BLOUSE.

Impatience

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I get it. We all have somewhere to be.

But waiting a few extra minutes for a clinical appointment isn’t the same thing as a long line at Sbux.

Our appointments are scheduled in tidy 20 minute chunks of time, as if all the work it takes to listen to a patient’s story, perform an exam, come up with a diagnosis, discuss the plan, write the prescriptions and lab orders and referrals and then maybe, MAYBE, write the note couldn’t possibly take more than this randomly assigned amount of time.

In reality, things don’t work that way. Patient care takes the time it takes, and exactly how much time that might be is impossible to predict with 100% accuracy.

Sometimes, a visit is straightforward, and this 20-minute guess isn’t too far off: your colds, your strep throats, your uncomplicated UTIs.

But what about the patient with a constellation of nonspecific and/or seemingly unrelated symptoms over several months? Something that requires a little detective work?

What about the patient with a list of 4-5 separate problems, all of which need to be evaluated here and now, and fine, why not, since by the time you’ve asked enough questions to determine whether some of these list items are non-urgent enough to be rescheduled for another visit you’ve already done most of the work anyhow?

What about the patient presenting for the first time with an eating disorder? Or suicidal ideation? Or a sexual assault? Do you really think it’s appropriate for their clinician to enter that visit with a clock ticking in his or her head, rushing the history and exam, and then at some predetermined time chirping “Welp, time’s up! Good luck with all that!”

This is not an academic question. This stuff happens to clinicians all day, very day. It happens to me all day, every day. It’s the nature of the job. And so when one of these particularly challenging situations presented itself in my office earlier this week, did I rush the patient through her impossibly difficult story? Did I even look at the clock once? OF COURSE NOT.

But did that mean I was crazy behind for the rest of my patients that afternoon? Uh, DUH. Obviously. I can’t make extra time materialize out of thin air. I can’t be in two, or even three, rooms at once. Believe me, I wish I could. Because that would be spectacular. For so many reasons.

I suppose I’m writing this because I’m tired of being asked to do the impossible. I’m tired of being measured by all the wrong benchmarks. I’m tired of getting heaps of attitude when I’m running late because you know what, I was providing care for another human being in need of care, dammit, and spending that time with them was the right thing to do. Sorry, but one person’s suffering means more to me than another’s inconvenience.

Wait, no. Not sorry.

Shouldn’t the quality of the care I provide mean more than how long someone waits to see me? Isn’t the part of the visit that really matters the part that happens AFTER the visit begins, rather than before?

Can’t everyone just be a little more patient?

In defense of the EHR

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I know they’re just about as popular to defend as taxes, but I have to say that I absolutely love that I live in the age of electronic health records.

The typical line you get from providers when it comes to EHRs is about how they’re just about THE WORST THING EVER when it comes to patient care. Sure, maybe The Man needs us to use EHRs for billing and coding and a bunch of stuff we really don’t want to bother thinking about, but it’s SO not worth it when it means all we do every day is click click click tiny boxes instead of looking our patients in the eye. Please for the love of God give me back my paper chart!!!!!!!!!!

I respectfully disagree.

Here are some things I ❤ about EHRs:

– I love that I can look up my patient’s records from the ED last night, or last week, or last year, giving me a heads up on what really did or didn’t happen (hey, stories change) and reducing unnecessary duplication of care.

– I love that there’s no paper chart to go missing. No matter what room I’m in, if there’s a computer in there (and there always is) I can get in that chart and do what I need to do. (Unless the printer’s out of paper. And the printer is usually out of paper. This is not the fault of the EHR.)

– I love that I don’t have to struggle to interpret Dr. ShakyHandwriting’s chicken scratch ever again.

– I love that I don’t get loads of grief from my colleagues for my own terrible, shameful, no-good handwriting. Ha.

– I love that I can type out my notes instead of write them by hand. In addition to the aforementioned legibility problem, I type a million times faster than I write with a pen and paper. Not an exaggeration; I’ve clocked it.

– I love that there’s a record of the exact prescription written for each patient, along with a digital trail showing when and where it was sent. No shady business.

– I love that I can send notes and labs and prescriptions and whatever else I want without getting up and fiddling with the stupid, stupid fax machine. In the time that passes as I wait for the fax machine to dial the number, and make that terrible AOL-era dial-up connection sound, and finally FINALLY start transmitting the fax, I can actually feel death approaching. The passage of time becomes just that palpable. And since I dislike reminders of my own mortality, anything that reduces my use of the fax machine is a good thing.

– I love that if I’m taking off-hours call, we have this fancy little iPhone app that creates a magical time-space portal to our ENTIRE EHR, which means I can look up that patient’s chart from bed, at dinner, at the movies, in the potty, WHEREVER. (Yes, I call it a potty. And don’t judge. Big thanks to parenthood for giving me the opportunity to study the tile pattern of restroom walls all over town in painstaking detail while waiting for my offspring to finish her business.)

But I’m not blind. I’m not an ostrich with my head in the sand. I’m not wearing rose colored glasses. I’m really not engaging in any one of the many possible metaphors one could use for ignoring glaring problem areas. Such as:

– Templates. Whoever invented templates, I hereby declare you the enemy of sanity. I can feel my hand cramping into a permanent claw as I strain to center my clicker inside one. tiny. box. after. another. All told I’m guessing at least several hundred (thousand) tiny boxes will be clicked by the time I’ve finished writing one template-based note.

Happily, my hands still look like hands rather than velociraptor appendages because I’m allowed to use words and sentences like a normal literate human being within my clinic’s EHR. But opting out of using templates myself only solves half the problem, because I’m still forced to read other people’s terrible template-based notes, and then guess as to whether the story created from all those little checked boxes is really the story they meant for their note to tell.

– Vulnerable to technology fails. Today, in fact, was a happy little reminder of this particular weakness. Our EHR was down all morning. Semi-organized chaos ensued as we tried to figure out who was here to see which provider without accidentally seeing patients out of order and thereby inciting mutiny among the impatient crowd. I was told this conversation actually happened at the front desk:

“There will be a bit of a wait to be seen, since our computer system is down.”
“Can I schedule an appointment for this afternoon?”
“Well, no, because our system is down.”
“…Um, so, can I schedule an appointment for tomorrow then?”

But this unscheduled journey into the past just reminded me how fantastic having an EHR the rest of the time truly is. My concerns are not deal-breakers, they’re areas for improvement. I mean seriously, in the age of Google, and Siri, and marketing software that somehow places the exact product I was looking at on potterybarn.com last week into a Facebook ad today, you can’t tell me that the tech geniuses driving up rents in Silicon Valley aren’t capable of designing an EHR that allows us to create coherent, accurate notes in a provider-friendly format.

Make it happen, techies.

#AbxScore

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I stumbled across an article circulating around the twitterverse today – the comfortingly titled “Antibiotic Resistance Will Mean the End of Just About Everything As We Know It” – and I was left with a gnawing unease about my antibiotic prescribing habits.

Until now, I think I’ve tended to cut myself too much slack. I’m already SO much more conservative with prescribing than other providers I work with – so the story I tell myself goes – and most definitely moreso than these patients’ providers back at home who prescribe successive Z-packs over the phone from 3 states away, right? And don’t get me started on antibiotics being available over-the-counter everywhere else in the world. So really, if a particularly insistent patient comes to see me and presents some halfway decent story about their miserable and worsening nasal congestion, am I the absolute worst person in the world if I cave from time to time?

The danger of this line of thinking is the same pattern that led me to gain back half my baby weight in the 2 years after kid #1 was born, one delicious pastry at a time. If one ice cream sandwich is good, two is better, right? And it’d be a serious tragedy if the remnants of that fettucine alfredo was just thrown away LIKE TRASH simply because no one was courageous enough to finish it off.

But after a particularly contentious meeting with a clinic scale, I decided to make a change. I downloaded one of those calorie-counting apps, where it calculates your daily caloric limit, and then you enter every bite of nutrition that passes your lips. Super fun time! But seriously, IT WORKED. It kept me honest. Before grabbing justonemorecookie, I’d think about how I’d have to enter it into this dumb little app, and see the number of cookies consumed staring me in the face. Blergh. Somehow the cookie didn’t look so irresistible anymore.

So I’m just kicking this idea around here, but what if we all (we all = MDs/DOs/NPs/PAs working in primary care, urgent care, retail clinics, etc) started doing the same thing with our antibiotic prescribing?

It could be like a game. I hear these hashtag things are popular, right? So what if we started posting our daily #AntibioticScore? And by score I mean numeric value, as well as SCORE! Yeah, brah!

Actually, #AntibioticScore is kind of long. And my fingers trip up over all the i’s and the t’s and whatnot. So let’s abbreviate, shall we?

#AbxScore = # of questionable antibiotic prescriptions NOT given due to spectacular patient-centered education and counseling / total # of questionable antibiotic prescriptions possible.

Today, I saw 3 patients with vague-ish URI symptoms who were here for – let’s face it – antibiotics. At the end of each visit, they all left agreeing with me that they really didn’t need antibiotics after all. So today’s score would be 3/3, or 100%! GO ME. (It is likely not a coincidence that today is the day I decided to start tracking myself. It’s like deciding you’re going to commit to wearing that FitBit the day that you happen to go hiking and kickboxing and cycling, all in one exhausting 24-hour period.)

Now, your daily #AbxScore doesn’t include legitimate antibiotic prescriptions. I also saw two cases of strep throat, and one patient with a UTI, but these don’t get included in my #AbxScore because, um, they clearly needed antibiotics. I get that there are plenty of real, valid indications for antibiotics. I’m not insane, people.

But if you’re even thinking about using the diagnosis code for an undifferentiated “upper respiratory infection (URI)” at the end of your note – even if you’re more likely to enter the more specific-sounding “sinusitis” or “bronchitis” to feel justified about giving that Augmentin rx – that visit gets entered into the #AbxScore. Which you then post on Facebook or Twitter or your bulletin board at home or whatever, allowing your peers (or children, or pet ferret, or you looking back at yourself in the mirror) to congratulate you on your spectacular antibiotic stewardship.

Now, this is honor system only, obvs. Especially because there’s, um, no actual prize. Except of course SAVING THE WORLD FROM A POST-ANTIBIOTIC FUTURE. (One self-resolving cold at a time.)

Who’s with me?

NP Week, party time, excellent

Happy NP Week!!!

WOOOOOOOT! CUE THE CONFETTI! AND THE FIREWORKS! AND THE T-SHIRT CANNON! AND…and… (ahem).

I know, I know.  There’s a “week” for everything. But since I’ve been a good sport all year long, as essentially every other possible profession in the world gets their celebratory day and/or week, AND since I love having a reason to celebrate anything and everyone, I’m not planning on letting this week pass quietly by.

I’m pretty sure NP Week really just exists as an excuse for a bunch of NP-awareness marketing and outreach. And for the record, I have absolutely no problem with this. Even if it almost seems as though it should be unnecessary in this day and age, since as the AANP rightly points out, there are 171,000 of us in practice, and we’re increasingly stepping in to provide a lot of the care that needs to be provided out there in the big wide scary world that is the U.S. health care system. But despite our numbers and seeming ubiquitousness, the fact is that a lot of confusion remains about who we are and what we do. Oh right, and then there’s this. Also a problem.

And that’s why the AANP created this handy NP Week “Resource Guide”. If you want to learn more about how fantastic and fabulous the NP profession is in general (answer: pretty fantastic, quite fabulous), check them out. Or go here. Or here. Or here.

But since I’m just me, and not part of some larger organization with some larger goal with respect to NPs’ collective position in the universe, I thought I’d celebrate NP Week in my own way: by reminiscing about how exactly I ended up where I am today. And by eating free breakfast pastries, of course. You can never have too many free breakfast pastries.

When I was growing up, I had this idea that I wanted to be a doctor. And since I was one of those kids that did well in school and aced standardized tests, everyone around me assumed I’d become a doctor too. Now, I didn’t want to become a surgeon, or a radiologist, or a cardiologist. I just wanted to become the type of person I saw when I was a kid: the one you’d go see in a tidy little office for sick visits, and well visits, and ask for advice about both the little things and the big things. Who knew to ask about how your grandma was doing, and whether you’d had the chance to go skiing yet this season, and how the college application process was going.

But a funny thing happened after I shipped myself off to college and joined the bleary-eyed ranks of the pre-meds. I started volunteering at my college’s student health center, and realized all the people who were doing the things I’d pictured myself doing (see above) were actually NPs. And then, since I chose “go-getting feminist” as my undergrad activist identity of choice , I started volunteering at the local Planned Parenthood clinic. The providers there? More NPs. I started to realize that all of the people in my life who were actually DOING the things I’d wanted to do all this time weren’t physicians at all, but NPs.

So I changed course. I figured out how one actually becomes an NP, and then proceeded to do each of the things one needs to do, in the order one does them. (I won’t bore you with the details, but suffice to say that the intervening years involved many bed baths, a significant quantity of sputum, blood and poop, and a lot of humility.) But fast forward a few years, and there I was: a brand-spanking-new NP.

And you know what? I was right. I DO get to do all the things I’d envisioned myself doing as a kid. As an NP.

Obviously, the world still needs physicians. And for a whole lot of people, medical school is absolutely the right path for them.

But for me, I know that I’m exactly where I belong, doing exactly what I’m meant to be doing. And so this week, I plan on eating those complimentary pastries – I’m thinking maybe a scone, followed by a danish, but WHO KNOWS – with pride. And then I’ll slip on my white coat, the one with my name and the words “Nurse Practitioner” stitched next to the left lapel, and walk into my tidy little exam room to see my next patient.

The trouble with “supervision”

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I’m a nurse practitioner, or NP. You may have heard of my kind.

We come up a lot in the media these days. Maybe it’s because NPs are going to save health care by filling the looming provider gap. Or because we’re going to ruin health care by filling that provider gap with undertrained, incompetent clinicians. MAYBE BOTH.

The volume’s been turned up lately on this line of dialogue because of the looming full implementation of the Affordable Care Act. Apparently, NPs* will either be the salvation or the undoing of the ACA, with its flood of new patients demanding health care services. As if there were millions of people who didn’t exist previously, and the ACA has willed them into existence. Even though I’m pretty sure it doesn’t extend coverage to zombies. If so, my apologies. The backlash makes a lot more sense now.

It could also be because it’s more likely than ever that you’ve seen one of us as your very own health care provider at some point. After all, there are 171,000 of us in practice here in the U.S. In fact, I’m willing to bet it’s 50/50 whether that inappropriate antibiotic prescription you got last week for your cold – oh, I’m sorry, bronchitis – came from an MD or an NP.

What I’m saying is, we’re everywhere. And once we’re in practice, we’re really not all that different from physicians when it comes to delivering primary care.

THAT’S RIGHT. I SAID IT.

People in the “NPs need constant supervision, like small children – I’ve definitely seen them eating paste and coloring outside the lines and misdiagnosing and over-referring to specialists WITH MY OWN EYES” camp seem unwilling to admit that there are some pretty mediocre-to-lousy physicians out there too. Everyone makes mistakes; some people make them more often than others.

And people on the “NPs are sunshine and light and won’t kick your puppy on their way to a golf game after dismissing your puny concerns about your blood pressure” side are hesitant to admit that there are plenty of cold, rushed, and/or unpleasant NPs out there too.

What I’m saying is, we’re all just people.

Which is why I sort of hate the heated debate over the question of MD supervision of NPs, which is what every legislative battle over NP practice has been about since the profession came into existence. As a recap for those who might be unfamiliar with this concept, according to The Law, NPs can work with varying degrees of independence from physicians, depending entirely on the state where they’re licensed. In most states, NP practice is either completely independent or is expected to exist in “collaboration” with medicine, but in 12 states, your practice needs to be “supervised” by an MD. See how I put “supervised” in quotes there? Not an accident.

Now obviously, the very idea of mandating the supervision of an independently-licensed professional is somewhat condescending, but it’s also misleading. The phrase “MD supervision” suggests a physician peering over my shoulder constantly, wearing a hand-knotted white coat and one of those hats with the light on the front, checking all of my notes and prescriptions and probably reexamining my patients to ensure a certain level of quality of care.

This NEVER HAPPENS. Not even close.

When I’m caring for a patient, it’s just me and that patient in the room. I examine them. I diagnose them. And then: I write the prescriptions, and the note, using my name and my license. The only place my supervising physician’s name comes up on a daily basis is as an automatic attachment to each of my prescriptions – which, if you think about it, is kind of unfair to that MD, who was completely powerless over the decision to write it.

And yet, I can’t imagine practicing medicine (because let’s just be honest for a second, that’s what NPs are doing) in the vacuum of my own mind. I need to be able to walk out of that exam room and run a challenging clinical scenario by a trusted peer, whether that peer is an MD or an NP. I need to be able to collaborate with other providers, because collaboration makes everyone’s practice stronger. Whether I’m trying to decide if I should send a patient with probably-nothing-but-maybe-a-PE chest pain to the ED and want to run it by my MD officemate, or the physician down the hall comes to me for advice on managing abnormal vaginal bleeding in a patient who just started the pill, collaboration goes both ways.

I was reading an article today by a woman who left medicine because she just couldn’t deal with the pressure – the constant worry over “did I make the right call?” or “did I write the right dose?” or, ultimately, “will the patient get better or worse because of my care?” I, and every single clinician I know – regardless of their educational background or the letters at the end of their name – feel exactly the same way, all the time.

So when I hear about some new legislation to restrict or extend MD supervision of NP practice, my first (lazier) thought is to say, Well, this doesn’t really apply to me. I don’t particularly want to “hang my own shingle” anyhow. Thanks, but I’ll just keep reading HuffPo and watching the Real Housewives marathon instead of writing that letter to my state rep about HB29378130sdi293832b.

But writing that letter matters. And it doesn’t matter because I want to take a job away from a deserving physician, or because I plan to open my own practice, or BECAUSE SOCIALISM. I just want The Law that describes what I can and can’t do to reflect reality.

And if your provider is still eating paste, whether they have NP or MD after their name, I think we can all agree that they’re the ones that need a little more supervision.

*I don’t take the time to mention PAs here nearly as much as I should. But I would apply pretty much everything I said here about NPs to PAs as well. And on that note: is Physician Assistant not the most inappropriate name ever for what you do? It is absurd that your name wasn’t changed to Physician Associate years ago. You guys should get on that.