May FNP Update

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The days are flying by but here’s another update on school, life and baby…

Baby #2: If you follow me on social media, you saw that we announced some super exciting news a few weeks ago…we’re having another baby! And it’s a boy! We’ve kept this news to ourselves for a while now but after I had a healthy report at my 20 week sono and we found out the gender, I figured it was time to share. I’m due September 1st, which is about 3-4 weeks after I finish my master’s degree. Good timing? Bad timing? I guess only time will tell! Either way we’re super excited to welcome this little man into our world. For several reasons I thought we would end up with all girls so this news was probably the best surprise we’ve ever had (along with meeting Evy when she was born!) I’m starting to wrap my mind around the fact that I will be a BOY mom too. The thought of having two sweet babies in the world brings me to tears daily and I absolutely cannot wait to meet him and for Evy to meet her little brother.

Pregnancy: This pregnancy has been vastly different than my first and now that we know we’re having a boy, it makes sense. Thankfully I was on a break from school during my first few weeks because those were ROUGH. Nausea, severe exhaustion, and a general feeling that I might die before I make it to twelve weeks. But that passed and now I’m dealing with a whole host of ailments that never happened to me with my daughter- melasma, leg swelling starting at 12 weeks and erythema nodosum. (GROWING A HUMAN IS HARD WORK) Despite all of these things, baby is doing well and I seem to be doing fine working all these hours. That brings me to the next topic…

School: I FINISH IN LESS THAN 90 DAYS. I am in my LAST semester. Yes, this is true but it does not yet feel real. I’ve been in school for almost three years now and I cannot imagine a day where I’m not pouring through books or scheduling clinical shifts. I will definitely be a life-long learner (you have to be in the world of medicine) but it will be so freeing to get to the end. To see the completion of everything I’ve worked for. To simply work normal hours again. So until August 10th, I need all the prayers you’ve got! My calendar is full literally everyday and if I look at it too long, I start to get short of breath. It’s going to be a tight squeeze to get 360 clinical hours in 13 weeks along with my 24 hours per week at the hospital. Honestly I don’t know how I’m going to do it but the Lord hasn’t let me down yet and I’m trying to let go of my control (or lack thereof) and trust Him.

Work: I’ve been back in the ICU for a while now and it’s been both easier and harder to come back than I had imagined. What about it has been easier? Well I haven’t been nearly as worried about leaving my daughter for those long hours as I was when she was a baby. This makes sense because she’s three and way more independent and she’s usually awake when I get home from work so I can help put her to bed. When I went back to work after she was born it really tore me apart (hence quitting for a while). I was constantly worried about her and it took a toll on me. Now, I don’t have any of those worries and thankfully I still get to see her everyday when I get home.

What’s been harder? Well the patients haven’t changed and although I’ve had to pick up on the few new things that have come into effect over the time I was gone, for the most part being an ICU nurse is the same. People still come in crazy sick and you still work to make them better. The hardest thing has been going from being one of the more experienced nurses to feeling back at the bottom of the totem pole. I spent seven years cultivating skills, relationships and a level of respect that kind of evaporated while I was gone. Now there are a ton of new staff who don’t even know me and it’s humbling to admit everyday that I don’t know all the answers anymore. (Essentially I feel somewhat incompetent at work AND at clinical- ha, fun times).

Nevertheless, I’m glad to be back working with patients. It’s funny how my mindset has shifted now that I’m much closer to being a provider. Instead of just giving the diabetes medications, I wonder why the providers chose that drug or that dosage or why they ordered one lab test over another. I find myself correlating patients that I see in clinic with ones in the hospital because many times it’s simply a continuum of care. My patient in the clinic has super high triglycerides that we’re trying to control and my patient at the hospital was hospitalized for pancreatitis due to high triglycerides. In short, many times I’m seeing the beginning and the end, the first signs of trouble and the extreme manifestations of that trouble. I wish I could take pictures of my ICU patients and use them as motivating factors for all the people in clinic who won’t agree to make changes. (Do you want THIS to happen to YOU??) But that would be both illegal and terrible so I won’t!

Preparing for boards: My birthday was a few days ago and I told my husband the two things I wanted to do were exercise and study because those are activities that I hardly have time for anymore! I did get a pedicure and go out to dinner so don’t think I’m completely lame. Still, I wish I had more time to pour over my review book. THERE ARE SO MANY THINGS I DON’T KNOW YET. Or things that I have forgotten over time. So many lab tests. So many obscure diagnoses that need to be on my differential. So many medication side effects. Sick people are complicated? Yes. So extremely complicated. I’m taking a board review class in July because I think it’s essential regardless of the fact that it’s inconvenient. I’ll be missing two potential clinical days and the class wasn’t cheap. But I believe it’s worth it so I’m making room in my life for it.

The reality is that I’ll probably pass the boards but I will still feel like there is a knowledge gap. I’ve heard this from all new NPs. So all I can do is surrender to that feeling of incompetence and use it to continue to learn and take better care of my patients. I’ve come to accept that much of what I need to be a good NP is exposure- hours logged seeing patients. Expertise comes with time and the more hard days I have with difficult patients, the more I’ll remember everything I need to know. Essentially, it’s important for me to continue to mess up because that’s how all of this will get solidified in my mind. That’s a hard pill to swallow when you’re one of those people who wants to get everything right the first time!

Have you had enough? My husband and three year old have been my biggest fans. My husband is rearranging his schedule for the summer so he can home more with our daughter and my mom and MIL are signing up for days to play with Evy. Evy goes around telling people that she’s a nurse practitioner and I can’t stand it I’m so proud of her. Hopefully she will be proud of me too!

I’ll try to post another update in June. Thanks for reading!

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April FNP Update

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Goodness, it’s been a long time since I’ve blogged. When I decided to resume blogging I had the best of intentions in chronicling my journey towards FNP but something got in the way. A lot of things got in the way. SCHOOL mainly. So instead of crafting an eloquent blog post about some existential nursing concept, I’m going to give you a stream-of-consciousness update and be satisfied with it because I’m already working on borrowed time. There’s an open review book waiting for me, scolding me with all the facts I do not yet know about rheumatoid arthritis. And you DO NOT want to ignore rheumatoid arthritis.

So what has been keeping me so busy for the past few months?

Working! What in the world do you think I’ve been doing?

I’m currently finishing up my second-to-last semester in my FNP program with a tentative graduation date of August this year. (OMG DID I REALLY JUST WRITE THAT?) I’m over a third of the way done with my total hours and the days seem to be flying by. As my cumulative hours sheet grows longer and longer, I grow one hour closer to freedom. One. day. at. a. time.

Clinicals have been an unexpected success- not that I always make the right choice, believe me, I’m made some epic blunders- but I am enjoying it more than I ever thought I would. The patients are wacky as ever, the complaints are unpredictable and varied, and the physical exam findings sometimes make me put on my ICU nurse face so that I don’t show that I’m HORRIFIED BY YOUR FEET RIGHT NOW. Or, I’M HORRIFIED BY YOUR LAB VALUES. Or, I’m HORRIFIED BY YOUR NON-COMPLIANCE. It’s the same face I put on in clinic when a patient asks me to look at something I never thought I’d see in a place I never thought I would have to examine. Primary care is awesome, never boring, always full of characters. It’s definitely where I want to be as a nurse practitioner.

Plus, sometimes I do make the right choice. I pend an order and then my physician says the exact same thing I just put in the computer. But I did it before he said anything! I proved to myself that I actually know something! I CAN take care of patients by myself! This victory over putting in the correct dose of valsartan (big time stuff, people) lasts for a brief period until I completely forget to address his preventative care needs or forget to ask him what his home blood sugars are or try to order two serotinergic drugs at the same time (gasp!). Then I come back down to reality and remember that I still have plenty of hours to go but that those small wins are not insignificant. I am learning and I am going to be the best NP I can be (insert girl scout wink).

Other than clinical, I’m working two shifts a week at the hospital in the ICU seeing the end result of all these complications that I’m trying so desperately to control in primary care. I’m also studying for board exams, going through my review book slowly, trying to jam all the details into my brain about lab testing for Hepatitis B and the difference between gout and pseudo gout (who gave them those names? Can I punch that person in the face?)

Oh and I have a husband and a daughter who like to see me once in a while when I’m not off saving lives acutely or saving lives preventatively (see self-inflamed pride above). In all seriousness, my family has been amazing throughout this entire process. My husband adjusts his schedule, cooks, does laundry, picks up my daughter and even scheduled me a nail appointment the other day after I thought I was going to lose my freaking mind. Even my daughter has been flexible in her own three year old way, telling me that she’s going to work at the children’s hospital while I go to work at the big hospital. She sends me a toy everyday in my bag so that I “have something to play with while I’m at work.” A big part of me is doing this for them and I couldn’t do it without them.

A few quick resources I’ve found helpful along the way:

The Curbsiders Podcast– If you’re going to be in primary care, you need to listen to this STAT, every episode. Seriously, you should’ve started yesterday. I have (more than once) pulled out an expert answer based on something I recently learned in one of the podcasts and impressed my physician with my vast knowledge of obscure details (yes, my preceptor DEFINITELY thinks I’m smarter than I am). The podcasts are funny, entertaining, and chock full of useful information. Plus, no one from your school is holding a letter grade gun to your head to do it, so the freedom to listen willingly is a plus.

This review book– There are several good review books out there but this is the one I got attached to so I’m talking about it. If you’re just starting FNP school you might want to get through the first few classes before you break it open but this is what I use to study and I wish I would’ve started reviewing it before I started clinicals. Most of the sections are short enough to where you can do it when you have a small sliver of time.

AAFP articles– After I read about a section in my review book I usually look up a AAFP article on the topic to give me more information and solidify what I’ve learned. The articles are simple enough to read and can usually be scanned quickly for the highlights. Top notch, in my opinion (my opinion that literally means nothing to anything).

That’s enough for tonight. I’ll try and share more consistently, even if it is short and sweet. There’s a part of me that comes alive when I’m writing and it’s especially important that I don’t let that flame die out under the oppression of my schedule and upcoming board exam. It doesn’t help anyone if I graduate in August as a talking shell of a FNP who can’t remember how to type her own name.

Thanks for reading!

 

 

 

The Plague

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I believe there is a plague that exists within healthcare, something that I would say is worse than burnout, more devastating than compassion fatigue, and more debilitating than job dissatisfaction. This plague is insidious, internal, individual and communal, and often goes unaddressed for far too long. It has affected me personally, changing the way that I view not only my job but also my own life, seeping into every arena of my mind, contaminating my ability to deal with suffering. I often hear people discussing a host of other issues as they try to determine the problems that our healthcare system faces but I don’t hear many people talking about the plague that I deal with on a daily basis. Maybe someone out there has a solution or a way to deal with it but in my nine years in nursing I have barely heard a whisper about it.

I’m writing today in hopes that I’m not the only one who has been infected.

I heard a speaker the other day talking about trauma. I was expecting the lecture to be about patient trauma, aka the trials that they encounter in life before coming to the hospital. At my facility most of the patients are disadvantaged, economically strained and have had to face dramatic challenges in life. The speaker did briefly address this topic but then she took the conversation in a direction that surprised me. She expanded the definition of “vicarious trauma” to apply to those of us who witness horrific things everyday at the bedside and then have to figure out how to structure our lives around it. Basically she asked the question that I’ve struggled with for years- how do we come back to work day after day, shift after shift, after seeing such potent suffering and death?

To put it lightly, her words struck a nerve with me. I’ve fought to put words to this concept for years now- the idea that I am forever changed because of what I’ve experienced as an ICU nurse. And I’m justified in wanting answers to these questions, of wanting to deal with this plague, because the horrors I’ve gone through are not insignificant.

I’ve watched fathers bleed to death in front of their children. I’ve seen young men become quadraplegic after hanging Christmas lights on their own suburban houses. I’ve watched young mothers hemorrhage to death after a catastrophic childbirth. I’ve held the hands of parents as they let their adult children go after they attempted to blow their heads off with firearms. I’ve seen more attempted suicides than I ever even thought possible. I’ve watched helplessly as we’ve adhered to family wishes and coded little old ladies, cracking their ribs as they flailed like ragdolls on the bed, knowing we would never get them back. And this is not specific to the intensive care unit. No matter what area of healthcare you work in everyone has a story that they would classify as “the worst thing I’ve ever heard.” I’ve seen things that I can never forget and gone through emotions that I wish did not exist.

And yet we go on because that’s what we do in healthcare. But then we’re left to figure out how to categorize and deal with these traumatic experiences on our own. We’re left to figure out our own answer to “how do I come back to work tomorrow?”

I’m not saying that facilities and organizations are not trying to help healthcare providers work through these issues. I know there are support groups and free counseling and a host of other options. But, speaking as a nurse, I also know that nurses are probably not going to be too apt to take advantage of these resources because we pride ourselves on being able to do the job with a straight face and come back the next day as if nothing had happened. We develop callouses of the heart, probably to keep up from getting infected in the first place. I know this because that is how I’ve operated for years.

So why did I start to face this plague in the first place? Because I hit a wall. The experiences I had gone through had shaped me, whether I realized it or not, and I could no longer ignore the behemoth in front of me. I had seen so many horrible things that I started to assume that everything was worst-case scenario. In my mind, nothing could ever be a minor accident, only an accident that led to death, dismemberment or paralysis. I had no middle ground anymore, no rationality, and a very-present fear of something terrible happening to me or my family. I realized I needed to deal with my issues. I also realized that I needed to find the root cause if I had any chance of coming up with a solution to my vast and overwhelming problem.

You might be thinking that I’m just one of those people who is prone to feel anxious, prone to worry. And you would be right. But you can’t attribute this entire plague to personal tendencies. I know men, women, new nurses, veteran nurses, physicians, respiratory therapists….and the list could go on. And they all have felt this way at some point. At some point everyone wonders why in the world we keep coming back to work.

So we’ve narrowed down the major question but finding an answer is a much more difficult task. How do we process these experiences in a helpful way? Do I just live in fear of something horrible happening? Do I try to rationalize my emotions and keep telling myself that I’m overreacting? Do I quit healthcare altogether?

I don’t have the answer, even after years of searching, but I can tell you what I’ve learned along the way:

The first thing I had to do was realize that the world is full of suffering and there’s no way around that. Ironically, I learned this lesson as an adult through both my own experiences and the experiences of others. Unfortunately many people learn that the world is a bad place at a very young age and they grow up with an understanding of this truth. Mine was acquired and left me feeling like I had been lied to all of my comfortable life.

Another thing I had to accept is that the world isn’t fair. I wanted life to operate in some predictable manner. For example, I adhere to the rules, I play nice, I strive for honesty and integrity and things will work out. Seems plausible, right? Only to someone who hasn’t lived in the real world. The nicest people get fatal cancer and the most horrid people in society recover without a scratch. That’s just the way it is sometimes.

So the world is full of pain and suffering and it is by no means equitable. I accept that life is fragile and I have only a miniscule amount of control over it. Well now I’m just depressed and left with a nihilistic viewpoint that robs me of any motivation.

That might be true except here’s another thing about nurses- it’s hard to keep them down. When they hear something impossible, they want to do whatever it takes to turn the situation upside down. They don’t give up. They don’t back down. Nurses are the definition of making lemonade out of lemons. Healthcare providers sacrifice their own time, their own lunchbreaks, and even their own health sometimes to make sure that others are taken care of.

If there is a plague, then there are people fighting against it. When there is trial, individuals always rise to the task. And so I decided I had to do the same. I had to find a way to fight back against the sorrow, the heartbreak, the unfairness of it all.  I came to terms with these realities and then decided that my only method of fighting back was to do my job to the best of my ability and to push back the darkness one kind word or one hug or one smart clinical decision after another. I decided to face my fears, knowing that I would still be impacted by the trauma of others but that I was actually trying to turn the equation in a positive direction. What else can I do? I can’t change what has already happened to people but I can change how it goes from here.

This is my working thesis and it is still very much in progress. I don’t have the answers and I still have days when I feel an overwhelming amount of pain for the people I’ve taken care of that day. But I know I’m not the only one who has had to make a real, all-encompassing effort to deal with the things they’ve seen. We all have and we need to see the good we’re doing in the midst of all the sadness.

For every tragic story, there is a family member who leaned on you to get through it and they will never forget your kindness. For every unfair circumstance, you have made a good call that benefited your patient. For every time you’ve wanted to cry at work in the supply room, well, you’re justified in letting out that emotion. Your job is not in vain, although it seems like it sometimes. And there is a reason to come back tomorrow. The darkness is real and weighty and potent but it does not have to win.

We won’t let it.

 

 

The Weight I Cannot Carry

Carefree woman arms outstretched on the mountainIt drives me crazy sometimes that I really don’t have control over anything.

I see this everyday as a nurse and it often makes me feel powerless. I can hang all the antibiotics in the world but I cannot cure someone of ARDS. I can hope that this patient doesn’t have to go back for more surgeries but nobody, not even the surgeon, can say 100% that it won’t happen. One inch to the right and the bullet would’ve killed him. One inch to the left and he would’ve lived. I can do everything in my power to help save someone and they can still not make it. I can tell a patient a million times over to limit alcohol consumption but they can refuse. And then they could die in a week or live to be ninety, who knows? For all the miraculous interventions that we’ve come up with in medicine, many, many aspects are still out of our control. And while we all intuitively know this, we ignore it most of the time. We want to be the masters of our own fates, and our patient’s fates as well.

The randomness can be terrifying, the fact that we have no control over the majority of things that happen. This man was just walking down the street and someone shot him. This lady was minding her own business and someone stabbed her. This child was living a healthy life and now has cancer. This can breed fear like wildfire in your life if you let it, if you don’t find some way to combat these thoughts. You have to find a balance, the line between defiance and acceptance. Resignation and initiative.

I’ve recently gotten a taste of this lack of control in my own life. A week before Christmas my NP preceptor for January informed me that she was leaving her practice and basically wished me luck in finding a new one. Being only a few weeks before the start of my semester, you can imagine how I felt about this news. I threw a big fit (not to her), if I’m being honest. So now I’m going to have to defer the start of my semester and I’m scrambling to find a new preceptor on such short notice. It’s frustrating and discouraging and I hate that there’s a big hole in my perfect plan now.

I have absolutely no control over the fact that my preceptor decided to leave me with no options. I can’t fix the fact that I have to wait six more weeks to start my clinical semester. I can blame everybody and everything in the world but that won’t change the outcome. It’s out of my hands. But as maddening as that is, I’m starting to accept that this is how life works. Plans don’t work out. People get unexpectedly sick or laid off. Storms hit and car wrecks happen and pregnancies don’t make it. This is the reason why hospitals exist! I can fight against this and I often do, but it’s futile. I exert very little control over anything in life and yet I still try very hard.

To be fair, sometimes the uncontrollable turns out to be good news. A positive pregnancy test or an unexpected promotion or an accident that turned out to be a fender-bender when it should’ve been worse. Just as many bad things are out of our control, many good things are too. And there’s hope in that. Without that juxtaposition, I think we’d all give up and live meaningless lives. This is the reason why we hope for remissions and good lab results and why people work in labor and delivery. Sometimes life unexpectedly throws you something joyful.

There are a million insidious questions that I believe every healthcare provider has to face at some point. Questions like: Why do bad things happen? Why did this person die and not this one? Why is everything so out of our hands? How much impact can we really make as healthcare professionals? How much should I push and how much should I leave it be?

Obviously we believe that our words and actions carry some weight otherwise we wouldn’t show up for work in the morning. I can’t make someone get a screening colonoscopy or a mammogram but I can inform them of the benefits and risks, try to convince them that it would be good for their health. I can rejoice when someone decides to quit smoking at my advice. But sometimes I will also have to lament when someone refuses to take their insulin and ends up with an amputation, despite my admonitions. I will never give up advocating for wise choices because it’s not all up to genes or luck. We are still responsible, while not being in full control. We have to become comfortable with this oxymoron, as frustrating as it is.

Control will often fail us for another reason. People are allowed to make their own choices, even bad ones. They’re allowed to sign out AMA and ignore medical advice. They’re entitled to refuse that surgery or to keep doing IV drugs. They don’t have to listen to and follow your advice. People are not black and white and neither are their motives, choices and responses. You can’t control the heart and as healthcare providers, that should never be our aim, even when you see the train coming full speed down the tracks for someone.

For me, it comes down to humility. I have to accept that many things are out of my control. I don’t control the universe. I don’t control my patients. I can’t control many aspects in my own life! I can kick and scream about all of it or I can resign myself to do the best that I can- promoting smoking cessation and praying for that sick ICU patient and hoping for a good outcome. But then I have to leave it. I can’t live my life in paralyzing fear of the unknown but I also can’t think that I can control every outcome.

The only thing I can do is decide not to carry that weight on my shoulders.

I don’t know the answers to the questions. I don’t know why this person was allowed to live and this person’s life was cut short. I will never know why this person smoked for forty years and never got cancer while this child died of leukemia at two years-old. I don’t know the answers, but I think it’s still worth struggling with the questions. Even if we don’t find answers, we find out something about ourselves. We discover why we get out of bed at the crack of dawn and go to work day after day. We remember why we spend hours in surgery. We realize why we always, without fail, mention smoking cessation at every visit. We don’t limit our tears when someone close passes away. We learn to embrace everything that comes, in full measure, the whole spectrum.

We learn to live in an unpredictable world- to rejoice over the good and mourn over the bad and appreciate what is in front of us. We learn to embrace both joy and pain, exaltation along with sorrow. We learn what it means to live openly and humbly. We learn not to fear tomorrow no matter what it holds. We learn how to truly love, even with no guarantees.

We learn what it means to be human, the full messy whole of it.

And that is the best thing we can do for our patients, and ourselves.

 

The People Fade, but the Stories Do Not.

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In 1957 my grandmother received her nursing pin as a graduate of a diploma nursing program, in the era before the emergence of formal nursing education. Nine years ago my grandfather gave me that pin when I graduated with my BSN and now the pin sits in a pretty box in my room like a treasure, something full of lost memories. It’s grown tarnished over the past sixty years, fading to a dusky golden color that has lost it’s original sparkle, but every time I look at it, it grows in value. That pin has become a symbol to me of many truths- that my actions are bigger than me, that legacies really are something to strive for, even in our culture that seems to think that nothing lasts, and that this profession will never die. The pin has meaning to me now because I ended up with the same job title and because I know how hard she had to work for it. How much she had to sacrifice to be a nurse. How I benefitted from her perseverance.

Although I don’t know a whole lot about my grandmother’s story, I know that she worked on the weekends while my grandfather watched my mother and her sister. I know she wore white shoes and a white hat to accompany her white uniform. I know that she worked at a psychiatric facility, probably straight out of One Flew Over the Cuckoo’s Nest. I know that she was a kind, caring person who loved her family and I can only assume loved her patients in the same way. She passed away when I was in middle school and I wish so badly that I could hear her stories, that we could go out to dinner and that she could tell me the honest truth about what it was like back then. The good, the bad and the ugly. I think I’ve been in the trenches in the trauma ICU but I’m sure she could beat me by a long shot. Working in a psych facility in the 50’s automatically trumps any crazy stories I could tell.

What’s the point of this? Yes, my grandmother was an amazing woman and she should be honored as the first nurse in my family and a contributor to my own career path. But I’m getting at something else. We all have nurses who stand out in our mind, those who have worked extremely hard to love people day in and day out, those people who have impacted you in a significant way. Some of those people are memorable because they’re valiant soldiers who braved bedside dangers and trials, maybe even on your behalf. Others remain lodged in our memory because they were crooks and narcissistic thieves, people who spread shame like a contagious disease across the great name of nursing. Most of us have interactions with a plethora of people but there will always be those who left a mark. Here are a few of the memorable nurses in my life, for both good and bad reasons, and I’d love to hear your thoughts on the nurses who have impacted you.

  1. My very first preceptor as a new graduate in the ICU– I spent the better part of the five months wondering whether she actually hated me or not. She was a fireball, always looking over my shoulder to correct me, always pushing me farther than I thought I could go. I had more than one day where I disappeared into the supply room to cry. She made me take patients that I thought were out of my league, assigned us to double isolation to learn clustering my care, and gave out smiles like rare jewels, reserved only for special occasions. I couldn’t wait to graduate and be free from her. It wasn’t until I started precepting new nurses myself that I realized how great of a preceptor she had been, for stretching me while I was still young and under her care, for actually caring how I turned out as a nurse.
  2. Night shift nurse who scared the crap out of me as a new grad– On one of my first nights on my own after graduating from my ICU nurse residency program, I was assigned to a patient. My patient happened to be positioned next to the patient of a scary-looking night shift RN. She was unknown to me, with bags underneath her eyes and ratty, nasty hair. Her eye liner drooped haphazardly down her face. She told me weird stories about her daughter as I tried to escape her and do my work. And then she told me that nobody actually gives the insulin prescribed on the sliding scale protocol. What good does 2 units actually do anyone? she argued. I politely disagreed and spent the rest of the night avoiding her, terrified of what else was going to come out of her mouth. She got arrested and fired for being high at work only a few weeks later.
  3. My mother’s friend who let me shadow her in high school– As a junior in high school I was fairly certain that I wanted to work in the ED or ICU as a nurse so one of my mother’s friends let me shadow her for a night in the ED at a major hospital. I borrowed a pair of scrubs and fastened all the bravery I could muster as I walked in to the hospital with her that night, having no real idea what I was walking into. I pretty much failed at being helpful, even at taking a temperature, and I almost passed out when we received a trauma patient who had been thrown from a horse. But I walked out after that experience feeling like I had found my true calling, a job that was hard-core and exciting and would push the limits of what I thought I was capable of at that time. I followed that dream and have always been thankful that this nurse took the time to show a high school student what nursing could look like.
  4. The nurse that made me almost have a heart attack– one night when I was a new grad, another nurse told me that I was getting a level one trauma hit in my empty bed. I had never taken a level one on my own and I was literally speechless. He told me to get the rapid infuser and a few other pieces of equipment and I spent the next ten minutes racing around the unit, trying to keep from peeing in my pants. After those ten minutes he couldn’t stand it any longer; he told me it was a joke. I didn’t understand and at first I thought he hated me for playing such a cruel trick. But then I realized that it actually meant that people liked me on the unit, otherwise they wouldn’t have teased me like that.
  5. My many friends on the unit– Seeing death every day bonds people together, and I think this is seen acutely with nurses. I cannot tell you how many of my friends, three specifically, treated me more like a sister than a coworker. We helped each other when one of us was getting overwhelmed. We cried when we lost a patient.  We took snack breaks together. We vented about whoever was on our nerves that day. We switched shifts when someone needed it. We sacrificed ourselves for each other, not out of duty, but out of love. And those memories never disappear.

This is nothing to say of the many physicians, chaplains, managers, patient care assistants, and others who will live on forever in my mind. A few physicians that I would like to never see again (and a few that I loved!), a chaplain who I still miss seeing her shining face, a manager who truly always had my back. I remember the stories because of the people in them. I wonder if I am burned into anyone’s memory, if I live on in their story.

I have no idea whether anyone in my family after me will go into the medical profession. My two year old daughter has a Doc McStuffins bag and carries it around giving “check ups” so I’m hopeful for her. But regardless of whether I hand her my nursing pin one day or not, I hope that she will know that her mother loved her and loved other people and was brave and kind and smart and often made mistakes but always asked for forgiveness. I hope my coworkers remember me in the same ways but in the vein of honesty, maybe I’m even tattooed in someone’s brain for something negative, although I hope not. Nobody is perfect. Legacy is inherently built inside of a family, including a hospital one, and I believe there is value in pursuing a memory that leaves a mark.

A woman wearing white shoes passing out pills to psych patients probably never though she would end up being the subject of a blog post one day. I would venture to say the same thing about us. We simply cannot understand the ramifications of our actions and how they may alter the future. Life is ironic like that. We remember faces long after we forget the names.

We remember the stories, long after the people have faded.

 

 

The What, Why, and How of RN to FNP

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When I talk to people outside the medical profession, I often get asked, “so why are you becoming a nurse practitioner? Isn’t that a lot of school to essentially do the same thing you’re doing now?” I smile. I explain. I do my best to educate. But I still wince at that question because many, many people do not understand the difference between a nurse and a nurse practitioner. The tide is slowly moving in the right direction as nurse practitioners become more prevalent but there is still a huge knowledge gap in the public.

With my friends within the healthcare world, the questions are quite different. “Why did you decide to do FNP?” or “How much time do you really need to commit to school?” or “How in the world are you doing that school along with everything else in your life?” All valid questions based on real concerns. Deciding to become a nurse practitioner is a big career move requiring time, support, money and a huge portion of your sanity. This is part of my story along that journey.

Ever since I graduated from nursing school in 2009 I knew that I wanted to eventually get my master’s and become a nurse practitioner, even before I really knew what that entailed.  To be honest, I didn’t have a whole lot of backing behind that desire other than I had always been a “school person” and wanted to say I had a master’s degree. At that time I was nearly as ignorant as most people on the street about the qualifications, the education, the job description. I think I even revealed my professional plans in my “welcome to the unit” profile at my first job (so naive, not the smartest move). I just though it sounded cool and made me look like I had ambitions.

The WHAT: After a few years in the ICU I started to get a handle on where I could go with my career. I could stay in my unit and pursue a management position. I could go to CRNA school and live in the OR. I could stay where I was at as a RN. I could become a nurse practitioner. And a few more options that I never seriously considered.

After ruling out all the other possibilities for one reason or another, I decided on nurse practitioner only to discover that, like nursing, the NP job description varies intensely from position to position and environment to environment. I could become an acute care NP and work nights in the ICU responsible for thirty very sick patients. I could move to a specified clinic like nephrology or neurology and work solely with those patients. I could transition to outpatient and pursue a career in something completely foreign like family practice. And that’s ironically what I chose.

The WHY: Why did I choose family nurse practitioner over the other varieties? The standard reasons are obvious: no holidays, more money, less time on my feet, more responsibility. I wanted a weekday schedule with no weekends and holidays. I have a young family and it’s difficult for me to spend twelve-hour shifts away from my baby plus I’m tired of fearing that I’ll have to work on Christmas. I was also weary working in a job that required so much physical exertion. Turning large male patients, standing on your feet for hours on end, and sometimes not being able to take a lunch break until 3pm are all taxing on your body. I know I just turned thirty, but I could see the future and it was full of back problems and tired feet. I didn’t want all that exertion for the rest of my professional career.

The most professionally motivating reason for my career change was that I wanted more responsibility for patient care. I had finally gotten to the point where I wanted to write the orders instead of take them and felt that I had enough experience to take that step. I had always been afraid of such great responsibility (and rightly so) but I had gained enough self-confidence to know that I could learn and practice and become a proficient, caring provider. And while it’s the least romantic of my motivations, a better salary was definitely on the list. Getting paid more money for less physical labor is always a good thing.

But the question of why I chose FNP over ACNP (acute care nurse practitioner) also puts me in a honest place because I’ll have to give you an honest answer. The most compelling reason, the one that comes from a deep place in my heart, is that I was tired of seeing the worse case scenario day after day. I was heartbroken from seeing family members weep and watching people kiss their loved ones goodbye. As much as I loved the intensity of the ICU setting- the adrenaline of codes and the significance of standing in the gap during those crucial moments- I wanted something different. I wanted to work normal hours and to treat happy kids sometimes and to forget that those terrible, horrible things happen everyday. To those of you who are in that setting as ACNP, I respect you more than you can know. You’re dealing with vast responsibilities and dying patients and desperate families. You’re in a different spot than me and it’s a good thing we’ve both found our individual callings.

The HOW: So I applied for a FNP program at a local university, got accepted, and signed up for my first class. However, it didn’t quite work out like I had planned and I will tell you a slightly embarrassing secret about my journey through NP school. I took one class and quit in 2013. I had thrown myself into my nursing graduate research class for that entire semester only to discover upon completion of the class that I did not have the stamina for the program. There were many reasons behind my decision to not resume school, mostly to do with my tenuous health at the time, but I felt embarrassed. I had touted this new career ambition to almost everyone and then found myself backtracking, having to admit that it was too much for me right now.

When I think about that decision now, I see clearly that it was the right call. I wasn’t ready to take on life as a FNP. Two years later in 2015 I started school again and now here I am only two classes away from graduation. During that interim time period I took a new position in the ICU and gained valuable experience that I wouldn’t have had otherwise. So for those of you who find yourself in the same boat, don’t give in to the voices of guilt or shame or insufficiency. Maybe it’s just not the right time for you and there’s nothing wrong with that. Maybe it’s not the right career move for you at all and that’s ok too.

I’m not going to discuss choosing the right NP program because that is a whole other blog post in and of itself. There are a plethora of programs and they each have varied requirements, advantages, and disadvantages. Since I have a daughter, I chose a program that had all the didactic course work online followed by three intense semesters of clinical. I will say that online school is not for the faint of heart- you have to be disciplined and self-motivating. You have to make time when you don’t want to study. You have to stay up late and get up early and make your school work a priority in the midst of everything else you do in life. It’s grueling but in my case, it was worth it to not have to travel to school and find someone to watch my daughter. Choosing a program is a unique decision and you should be prepared to do some investigation.

Finding clinical preceptors is also an arduous part of this journey. Wait, let me rephrase that, an exhausting part of this journey. For my school, I was left on my own to find preceptors, which meant pleading for friends and family to help me. I emailed NPs and never got a response back. I cold called offices and never heard a thing. I did end up finding three fantastic preceptors in my area but that was only because of nice friends who put me in contact with their provider friends. This is where the word networking comes into play. You can never underestimate the value of establishing good relationships with other people in the medical world. If you’re trustworthy, kind and smart, they’re likely to endorse you to other provider friends but if you bad-mouth other people, seem uncompassionate towards your patients, or don’t care about your job, you may have a harder time finding someone who will spend a chunk of time investing in you. In short, make friends and don’t burn bridges.

Remember, preceptors for a NP program (MDs, NPs, PAs) aren’t getting paid to teach you (unless you’re involved in a paid preceptor program). They are giving of their time and energy willingly with no guarantee of a return. Ideally, I would like to get a job at one of the sites that I worked at during clinical because I already have an understanding of how the clinics work, the types of patients they see, and the responsibilities that I would be asked to take on. In this instance, it pays off for everyone because the clinic doesn’t have to spend as much time training you, but this isn’t the norm.

Making the jump into graduate school isn’t for the faint of heart. You have to have a clear vision for your future and be motivated enough to stick with it. You need the support of your family and friends and your job. You will have to give up some things now for a better return later. And if you stumble along the way? Forgive yourself. Nothing in life ever goes the way that we think it will.

I hope this gives you a glimpse of what it takes to go from a RN to a FNP. I hope you can understand my reasoning and my desires. And I hope, if you’re sitting at home contemplating these same things, that this helps you along your journey.

Go get that MSN.

 

The Bottom of the Ladder

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Nobody likes standing at the bottom of the ladder, gazing up at everyone above and knowing there’s nothing but time, labor and learning that will get you any closer to the top.

It’s a well-established phenomenon that nurses have a hard time transitioning from expert nurse to novice nurse practitioner. This makes sense- you’ve gotten really good at your job, knowing what every medication does, what those labs mean, what the physician is going to order next- and now you’re back at the starting line, feeling more insecure than ever, hating the fact that you don’t have all the answers anymore. If you stayed in your area of nursing experience, I can imagine that this transition is less jarring since you’re already accustomed to your future role but I think regardless of where you came from, the rules are different as a NP. And this can make for some serious anxiety.

If you’re entering into a new clinical environment like me then this transition may leave you feeling breathless, alone and scrambling to catch up. I spent my first six years as a nurse in a surgical ICU learning how to titrate vasopressors and check for compartment syndrome and draw ABGs. I will be thankful every day of my nursing life for the experience of learning to handle such acute patients in a tenuous environment because it gave me an extensive knowledge base about both medicine and people. Over a period of a few years, I rose through the ranks, climbing up the rungs, and finally found myself near the top, confident that I could handle any trauma patient that rolled in the door. But  since I had always wanted to pursue a career as a NP, I felt it was the right time to move on and grow in my capabilities as a nurse.

So after years of hospital life now I’ve entered into the world of clinicals in a family practice outpatient clinic. On the first day I asked, “where’s the crash cart?” and everyone looked at me like I was crazy. Eventually I found the AED and that was it. They didn’t even have an IV start kit! Every bone in my body was rebelling, thinking what in the world would we do if someone codes? Call 9-1-1 and start CPR like everyone else, I suppose. The outpatient setting is vastly different and at first I wondered whether I would enjoy the slower pace or whether I would be sitting at my desk the first day of clinical thinking, oh my gosh, have I just wasted the past two years of my life? But thankfully, I have adjusted more easily than I even thought possible, finding the challenges of a clinic different but not less than, still experiencing the thrill of seeing patients except these patients can actually talk to me.

With two clinical semesters to go, I am still at the bottom of the ladder, dreaming about the breeze of graduation on my face and yearning for the freedom of practicing on my own in the high, clear air. After doing online classes for the past two years, I found that I had in fact learned a few things but I still came home everyday with more questions than answers. I spent my hours at home looking up articles, listening to podcasts, trying to be better. Fortunately, I had a preceptor who allowed me to ask dumb questions and look up answers and Google pictures of skin rashes. He made no ultimatums; he didn’t shame me in my ignorance and for that I will forever be grateful. Plus, I quickly realized that even after years of practice, you never stop learning. You never stop reading articles. You never stop changing your care plan based on the newest evidence. In short, I will be a learner for the rest of my career.

I had so many instances this semester where I felt out of my league. Patients who came in and hadn’t seen a health care provider in forty years. Patients with hemoglobin A1C levels so high the point of care machine couldn’t even calculate it. Patients with feet so disgusting that I literally didn’t know if I should send him to an emergency podiatrist (do they have those?) Patients who told me they had thought of committing suicide. Patients that were medical minefields with a list of diagnoses several pages long and too complicated for me to navigate without some help. Patients who asked me point blank what I should prescribe, in front of my preceptor, and I had to admit that I didn’t know. I was out of my league and that’s just part of adjusting to a new role, of being a student.

Even with my preceptor as a safety net, I still feel the weight of the job like a heaviness in my chest, the responsibility crushing at times. There is a holy reverence when you’re taking care of another human being because they’re putting their trust in you. They look you straight in the eye and believe what you tell them. They listen and consider and take the medication you prescribed. So even though I long for a day when I feel comfortable in my new position as a NP, I can’t too easily wish the anxiety away because it’s going to keep me from getting too comfortable and making a mistake. Hopefully, eventually, anxiety and reverence fuse, leaving me a great nurse practitioner with a holy level of fear.

Am I nervous every day that I show up to clinical? Of course. Will I carry that anxiety with me as I graduate, get a job, and start practicing? I’m sure of it. It’s like when I started in the ICU as a RN and someone told me it would be about a year before I was able to come to work and not be terrified that I was going to kill someone. And they were right; it took me a year to feel comfortable there. It’s like that. From what I’ve heard and read, there are some factors that help lessen this anxiety but nothing replaces years of experience.

So here I am, at the bottom and climbing my way back up. It’s a different ladder of course, one with no weekends and holidays and better pay and different responsibilities. It’s comforting to know that I’m not alone; that every nurse practitioner student in the world probably feels the exact same way- excited, nervous, and a little bit terrified at times. There is hardship in this transition but there is payoff too, mostly in the faces of the people I help or the exultation of knowing I made the right call. There will be falls along the way, missteps. Scraped knees and elbows as I try to hang onto the rungs.

But despite all the challenges, despite those days when I wonder if I can do this, I’m confident I’m headed the right direction. I can see the top from here, and it will be worth it.

 

A Clinical Conundrum

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Have you ever found yourself in a sticky situation with a patient? Of course you have; we all have. I recently found myself locked into an awkward moment with a patient during my FNP clinical rotation, unsure of how to proceed. I had to navigate around the issue of divulging personal information and I was unprepared. Do I share my own story with her? Do I hold back and hope that she can find commiseration someplace else? What do you do when you get shoved into these tenuous situations with patients? I don’t think there’s one right answer. It’s not black or white; it’s not a clear divide drawn in Sharpie, although we all wish it would be that easy. No, it’s simply a blurry, gray pencil line that leaves smudges all over you no matter which direction you go with it.

When I was young, unmarried, and working in the ICU I had my fair share of sticky situations, most of them surrounding requests for my phone number. A grandfather patient asking on behalf of his couch-potato grandson (yeah, that sounds promising) or creepy older guys who think it’s funny to make jokes about nurses giving bed baths (let me go find our two hundred pound male nurse and he’ll help you). People get delirious sometimes; they make statements or assumptions that are inappropriate because they’re on narcotics or recovering from head injuries. So, to some extent, you can easily forgive them their verbal fumbles.

Now that I’m a bit older and in the outpatient environment I don’t encounter those invitations as much anymore (probably thanks to that ring on my finger) but I still have awkward moments with patients, mostly around revealing information about my personal life. It’s a fine line that creeps up from time to time and I found I wasn’t trained for it.  Nobody tells you in school how you should act or react to personal questions, probably because it varies with each patient and situation. Sometimes you develop a relationship with a patient and voluntarily want to share more intimate aspects of your life. Stories about your kids, details of your recent vacation with your husband. In these cases, those topics come up naturally and since you both recognize the inherent formality to the relationship, you feel free to share personal tidbits and look forward to seeing that patient again in three months.

Other times patients press, wanting to feel like they know you, searching to get some need met from your relationship that falls outside the boundaries of professionalism. These needs can be obvious or complex. They want to be best friends or they want to manipulate or they’re desperate for attention. They have good intentions but it comes out wrong. They feel like they can’t talk to anyone else in their life so they completely unload on you. These conversations sometimes leave you feeling unnerved and you know that this patient isn’t capable of putting in appropriate stops in your relationship right now. But not every case is clear cut. It gets sticky. And if you actually talk to your patients when they’re on the exam table, you’ll surely encounter this problem at some point. You have to learn to straddle the amorphous line between being a healthcare provider and a friend, a listening ear and a professional.

To be fair, the inverse can be true. Sometimes healthcare providers are searching to get a need met from a patient- approval, attention, friendship- and it can make the patient uncomfortable. In short, the door can swing both ways.

I’ll share my recent example. One day we had a middle-aged woman with autoimmune complaints come into our clinic, so exhausted she could barely sit up in the chair. I had never met her before so I went into the room prior to my physician and talked with her about her chief complaint, did a focused history and performed a physical assessment. From the instant I saw her, my heart hurt for her. Between bouts of crying, with mascara staining her cheeks, she related the events of the past few months- how she had gotten sick out of nowhere, how she couldn’t get out of bed to go to work, how she felt useless to her family. She described a whole host of physical symptoms- fatigue, joint pain, and an inability to eat- and I knew how she felt. It was all too familiar. It was like listening to myself talk years ago when I went to the doctor’s office, desperate for help.

What this patient didn’t know is that I had been diagnosed with an autoimmune disease eight years prior and had struggled along the roller coaster of a relapsing-remitting condition ever since then. I knew what it felt like to be so tired that you can’t even get up and take a shower. I knew the physical symptoms that come from having an autoimmune disease. I knew how depressing it is to feel worthless, useless, permanently glued to your couch and addicted to prednisone.

She was understandably angry. Life had dealt her a harsh hand and she wasn’t coping with it well. She was bitter and hurt and experiencing all the emotions you would expect to feel if you were confronted with a life-long disease that you didn’t ask for and didn’t expect. As I gently asked more questions, she grew more and more hostile. She was taking out months of frustration on me and I couldn’t blame her for it. The conversation culminated when I said, “I know how you feel,” and she shot back sarcastically, “really? Do you know what it’s like to have an autoimmune disease?”

Ha, if she only knew. And I immediately started to feel conflicted. Do I share with her that I have a similar condition? Is it appropriate to commiserate that way? Would it make her feel better or make her feel like I was invalidating her feelings? I had no idea what to say and all the words stuck in my throat as I sat paralyzed in indecision.

Without knowing the right answer I blurted out, “actually I do. I have a similar autoimmune disease and I know how you feel. I’m so sorry you’re going through this.”

And the woman broke. Before I knew what was happening, she was bawling, telling me how hard things have been and expressing relief at being able to talk to someone who understood. I held her hand; she cried some more. We finished talking through the necessary components of the visit and then she actually smiled. I hadn’t done anything profound besides write a prescription for some prednisone (the best and worst drug in the world). Mostly I had helped her feel like she wasn’t completely alone. Someone else knows how you feel. Someone else can relate. It won’t always be this hard.

Was that the right thing to say? Should I have kept my big mouth shut? I don’t know. In this case, she responded well to my confession. I saw her several more times during my clinical semester and she remembered my name, asked if I was going to be there during her appointment. I gained her trust and while I still tried to keep the focus off of me and not reveal many specific details of my condition, we developed an appropriate, professional, beneficial relationship.

Afterwards, my preceptor and I discussed the situation. He laid out the pros and cons for me like I’m trying to explain it to you. Both extremes of the spectrum- sharing too much or not relating to your patients at all- can be detrimental. You’re a human being too and your patients should know that. You have a life, a family, your own issues. But you need to be self-aware enough to know when you’re searching to get a need met from a patient relationship. You need to be able to stay professional. In the end, he thought I had made the right call and I let out a huge sigh of relief.

There were other times during the semester when I had patients with similar complaints and I didn’t share my personal experience. Why not? I have no idea. I guess I just listened to that voice in my gut that whispered yes or no, and I went with it. Call it clinical intuition. Call it timidity. Call it whatever you want- you know what I’m talking about.

This topic of divulging personal information with patients is complicated and I make no claims to have it down. I’m not even suggesting approaching the issue from one side of the spectrum or the other- simply relating my own experience. I know I will have to continue to navigate these blurry lines for the rest of my career because I want my patients to know that I care. But I also want them to know that I’m competent and professional, someone they can trust with their life and sensitive information.

We all find ourselves in sticky situations every now and then because medicine is tricky business. Dealing with people is tricky business. We’ve all regretted saying or not saying something to a patient. And we all will have to find our own way of managing the tightrope of professionalism and friendship. It’s blurry; it’s difficult. We all walk around with smudges on our cheeks. But for the sake of our patients and ourselves, I believe it is a line worth walking.

A Collector of Stories, a Reader of People.

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Everyone who sits in the chair or lies on the bed is there to tell a story.

Some stories start with a misadventure- a careless turn taken on an abandoned road or a flailing, drunken mouth at a local bar or a pop that came out of nowhere, annoyingly enough, and is now here to stay. Some are more memorable than others- breaking a bottle of Tequila on your foot for reasons that no one can quite figure out- and some are less romantic like a contagious illness acquired from a sick kid or a bland case of persistent indigestion. Despite the circumstances, the patient still ends up in the office, led to your chair by an element of surprise. Very few people come to the doctor’s office willingly, on a good day. Usually there are wrinkles in the story. Something has to change the direction of the plot and that is the reason for same-day appointments, plain and simple.

Other stories are more despondent, predictable, birthed from the same relentless situation of getting old. Cartilage does not rejuvenate itself; knees do not grow on trees (as much as the orthopedist might want you to believe otherwise) and people are not getting any younger. No, they are not, they are definitely not. No one can cure inevitable decay, just delay it as long as your insurance will allow, and many stories are repetitions. Slight deviations from the usual, symptom-riddled routine. Tentatively turning the page of a book that may snap shut any moment.

Regardless of the reason for the visit, there is always more to be discovered in the story. Always more details and more complications and other diseases waiting to emerge on a routine set of labs. There’s always more because people are vast and endless, full of the unexpected. People are the most complicated subjects in the world and I get the pleasure of trying to decipher them. To learn to read them.

There is always more to the story.

So what is my job? To find out the particulars of the story. How do I do this? By asking questions. By gaining facts, collecting them in my mind like a child gathering polished stones. At first glance it seems formulaic and in many ways, it is. These formulas are exactly what is taught to all the students who have degrees that enable them to ask such questions. What brings you in today? When did that start? How long has that been going on? Occasionally, you’re allowed to ask a question like How do you feel? but even that is too esoteric for everyday use, a special indulgence reserved for an open afternoon on a boring day. Most of the time it’s a fact-finding mission. Does it hurt a little or a lot? Is it acute or chronic? Can you walk on it? Has this ever happened before? The questions are the title page, the introduction, the scattered highlighted portions that catch your attention as you skim through the chapters. These are the facts.

Some people only tell the bare minimum while others, let’s be honest, tell far too much. Sometimes you’ve already done a full assessment, ordered all the appropriate labs and medications, written the discharge summary and the patient is still telling you unnecessary details, much to your chagrin. That’s where practice comes in- being able to to navigate to the right details, ask the right questions, make people feel like their story has been heard, and still get them out then door feeling satisfied with the plan. You become a narrator, guiding them towards a path you think is the best course of action or leading them away from a more deleterious one, from those singed, cigarette-smelling pages at the end. Sometimes your efforts work and everyone leaves happy and on time. Sometimes you spend the rest of the afternoon frantically trying to catch up. And in almost every circumstance, the extra time is worth it because certain people need a little extra listening, to know that their story is weighty and unique and significant. They need to know that their story matters, even to you.

The real down-in-the-dirt interesting part comes when people won’t tell you some vital detail of the story, something that you know may change the crux of the plot and the direction of your diagnosis. These questions are trickier and consist of types like: How many beers do you drink per night? Would you like to be tested for sexually transmitted infections? Have you ever thought of harming yourself? I try to be an unobtrusive as possible by explaining that I ask everyone these questions and I don’t judge; I just need to know the truth. It’s even more fascinating to watch someone unweave a tale they just told you, realizing that they’ve gotten themselves in too deep. The wiggling in the chair, the lame excuses, the backtracking that has no end. Don’t get me wrong- I’m not trying to catch anyone in a lie- but those things have a way of rising to the surface when the patient is lying naked with a hospital gown on, even without my questioning. A nakedness of the soul, if you want to think of it that way.

Some people think they’re lying successfully but it’s almost always painfully obvious that you drink more than one beer a night or that you haven’t been checking your blood sugars, especially because I’ve become accustomed to patients lying to me from years of being in healthcare. (And even if I miss the deception, labs are always unsympathetically honest). People will try almost anything to get away from shame and sometimes you have to leave the visit in the discomfort that there are pages that the patient simply will not allow you to see and you must do your best despite that reality. It’s unfortunate but I cannot force my way into a story that I’m not invited to read.

It’s even more invigorating to watch someone divulge those details to you willing after you’ve established some trust. They recognize that you have to see all the pages, like an editor who must know every upcoming plot twist, and that they will ultimately suffer if they hide sections from you. They tell you their story; they let you in. They admit things that even their spouse doesn’t know, emotions that they’ve locked away, memories that made them who they are today. It’s a humbling experience, reverent almost, and you don’t forget those visits easily. Those are the lines that you memorize and hold close to your heart, the pages you reread on the days when you wonder if you’ve gotten into the right profession.

And then it doesn’t just stay their story- you enter in. You become a character and establish yourself in a scene, as a life-altering influence who informs them of a cancer diagnosis or a reoccurring character who resurfaces every so often to fix a smudge or wipe some tears and then recedes into the background until needed further. My story blends with theirs, just for a twenty minute appointment, and suddenly we have shared memories, communal pages. That is the true magic of medicine, the part that I fell in love with a long time ago. It’s the part that keeps it all so darn interesting and keeps me wanting to go back and read more. I am a collector of stories. I am a reader of people.

People never get tired of telling their stories and I hope I never get tired of hearing them, of turning pages that always end up surprising me. I am in love with the narratives of the people who wander in to see me. I am infatuated with being a part of a bigger story than my own. I am a nurse practitioner (or at least well on my way to being there) and a storyteller at heart.

And, strangely enough, I have figured out that those are really the same thing.

The Thing About Clinical.

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Here’s the thing about clinicals, and it is may be the most important thing, I love it.

After doing two years of online class, squeezing in study sessions whenever I could as I chased around a toddler, I am out of the house and going to clinicals twenty hours a week, working with a family practice physician at a family practice clinic. I will do 180 hours over about 11 weeks this fall and again in the spring before finishing up with 360 hours before graduation sometime towards the end of next year. And while the concept of graduation has always felt like a mirage, a distant and unrealistic possibility, I’m starting to be able to taste it now and feel like maybe it will eventually happen.

I absolutely love being a primary care provider (in training), a notion that I was honestly wary about the closer and closer I got to clinical. But I only have ICU experience! What if I go and hate it and all this school was a waste? What if I think it’s boring compared to the ICU high-stakes? What if I end up completely not caring about someone’s sore throat and wishing that they would code in the office instead? Yes, these are real questions that I have had and I’m trying to be honest about my hesitations, as silly as I see them to be now. I had real and tangible doubts about switching to such a drastically different work environment and those were not insignificant.

So, what do I think now? Would I jump into action if someone coded at our office, letting my ICU adrenaline rush back as I pulled out all those life-saving skills that I have grown so fond of? Yes. Of course. I would love that. But there is something SO NICE about knowing that you can stop and go to the bathroom before seeing your next patient and that you don’t have to go completely nuts if you get behind in your morning. No one is going to die if you don’t get in there and look in their ears RIGHT NOW. No one is going to crumble with a hemoglobin A1C of 8 while they’re sitting on that examination table. No one’s life is hanging upon how quickly you can put in those orders for thyroid labs. It’s freeing and it’s still taking me some time to get used to. And even more importantly, I feel like I’m making a huge impact doing primary care, keeping those people from ending up in the ICU to begin with.

I’ve had to be careful not to live out of my ICU experience, which has been harder than I would’ve thought. It’s frustrating to be so good at your job and then suddenly back at square one, wearing a student badge, not knowing what to do with that growth on my patient’s arm. Is it a mole? Is it cancer? Can I just pretend I didn’t see it? It doesn’t matter anymore that I can put together a ventriculostomy and help a neurosurgeon insert it. It doesn’t matter anymore that I can use a rapid infuser and get several pints of blood into a patient in only a few minutes. It honestly doesn’t really matter that I can code a patient because my physician has never had that happen in his office after twenty-five years of practice.

So are all those skills a waste, all that fine tuning of my nursing expertise? Should I just shut up about all the things I’ve seen and done (and some of them are QUITE ridiculous btw) or can I use all of that prior experience somehow? Well, I think it’s a little bit of both. While I have had to stop telling stories of my glory days as if that makes me more legitimate, I have gleaned something from seven years in the ICU and that brings me to my second point: I’m actually, surprisingly, doing pretty well as a PCP.

My physician came to me last week and told me what a good job I was doing, that he was really surprised that this was my first clinical and that I was a natural at this. You cannot even imagine how much those words meant to me. After two years of getting no feedback other than grades on tests, I finally got some real-life affirmation that I made the right decision in going back to school and that I will end up in a job that I will excel at. He went on to describe the difference between the medical residents (who have had no real patient interaction before) and me in one slightly amorphous but significant variation.

He said I’ve got really good “clinical judgment,” which basically means that I can tell a mountain from a molehill or “see through the BS,” as he also put it. When the woman comes in talking about her ankle pain, giving me details as I ask questions and dig a bit deeper, I can somehow tell that she wants to talk about getting on medication for depression instead of treating her ankle. When the schizophrenic teenager comes into the office complaining of abdominal pain, I can somehow figure out that she just wants to talk and there is absolutely nothing wrong with her belly. When the older lady comes in wanting an MRI for knee pain, I can see that it’s osteoarthritis rather than an injury and a MRI would be a waste of time for her. Some of it is reading people, some of it is physical assessment skills, and some of it is just remembering all the stuff I’ve learned over the past two years.

While this ability to distinguish between what the patient is saying and what they really want seems innate to me, apparently not all providers have this. From what I’ve heard, many physicians have to learn this over a long period of time, while I seemed to have picked up this intuition from years at the bedside. I’m not saying I’m better than any of the residents I work with; we just have different acumen at this point acquired from our different backgrounds. And if you think about it, it makes sense- people are just people and you get good at dissecting them, reading between the lines, getting to their true needs the more time that you spend with them. So it seems that all my ICU experience has not been a waste and although I’m not using the same medications or doing the same procedures, I have become pretty good at reading people and that’s more important than I could’ve realized.

And despite my initial preconceived notions, primary care is anything but dull. We had a man walk in off the street who hadn’t seen a doctor in twenty years with feet that were practically necrotic from years of uncontrolled diabetes. I saw an entire family in the same exam room, each with bipolar, who all wanted Adderall and antipsychotics, and I barely got out of the room in under two hours. I had an older woman tell me very seriously, to my face, that “sugar is the new smoking” as she divulged her health plans to me. I’ve had people ask me about getting their animals registered an emotional support animals, which I had no idea was even a real thing. I had to bite my lip as a young male patient explained the intricacies of martial arts to me, with an in-office demonstration.

I have met so many interesting people, some of them nice, some of them grumpy, some of them fastidious about their health care, some who haven’t ever been to see a health care provider, all in only a few weeks. People are just people! Same as they are in the ICU or at a clinic or walking down the street. And people never fail to provide entertainment.

Finally on a personal level, starting clinical couldn’t have come at a better time for me. After our recent pregnancy loss, I needed to get out of the house, to feel valuable, to feel affirmed, and to feel like I still had a future full of hope. And thankfully, I have felt all of those things. Evy seems to be doing fine with the transition and I enjoy only having to split my week, not devote all of it, to work. Seth and I are working as a team to make sure that groceries get bought and dinners get made, and after all the hard things that have happened for us over the past year, God allowed this one thing to go so very right. And I’m so very thankful.

I’m sure I’ll have more stories to add as the weeks go by but I wanted to give you a glimpse of this wonderful new world that I’ve entered into. Thank you to everyone who has prayed for us over the past weeks or months or years. Life is painstakingly hard sometimes, but it is worth it and we have no option but to move forward. So forward I go, into this new world of prescribing metformin and writing for thyroid labs and learning way too much about SSRIs.

It is going to be worth it. It already is worth it!