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!

 

 

 

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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!