Looping

I am learning so much. I'm finding that much of the work of a new practitioner is hidden, however. When you're not full of experience, research is needed as you encounter new patients and new problems. It's also important to stay abreast of current developments. For example, over the weekend a new study was released that shows an increased risk of pre-term birth when pregnant women are on antidepressants. And not a small risk, I might add, something in the nature of 20-30%. I have two patients in that exact category now, and I will certainly be having a discussion with them. Also, there's this hidden correspondence with other providers. When a new patient comes to see me, they usually have a history with another provider and/or they have medical issues being managed separately. They may be seeing a therapist for just talk therapy. I obtain releases and contact all of them, review records and sometimes call them too. When you're prescribing medication, you need to know exactly what's going on with a person. Beyond just providing better care, it's a safety issue. Many drugs interact. So when does all that work take place? Whenever I'm not seeing patients. And since I'm new, time's pretty short. I'm finding that I need the full time to see a patient, which leaves charting to the end of the day for everyone. That takes several hours usually, for a day's worth of patients. Eventually I'll get faster at this. It's sucking up all my evening yoga right now.

Yesterday was a trying time. I had a suicidal patient that I was very concerned about with means to end things at home. I had to ask him to take steps to ensure that those means were disposed of and then prove that to me. My doctor helped me make all that happen, but I got terribly behind and my afternoon was a wreck. And the patient is furious with me and may never return. That's OK, I did what I needed to do in my small way. Did that fix things? No, but I (may have) prevented a terrible outcome on my watch, and that's all I can control. I couldn't sleep last night after all that -- endlessly charting in my mind. Oh, did I chart that I called the therapist? Did I specify that I requested next visit in 3 days? Did I outline verbatim what the patient said about intent? You see how it goes...I get stuck on a jag while I lie in bed. Which is so close to what my depressed, suicidal patients tell me their experience is like. Is that not ironic? Their minds are often in a loop of rumination over events and choices -- the abusive ex-husband, the shy boy that they used to be and now constrains them so much socially, the perceived shortcomings they possess. We all have these from time to time. Did I really screw up my charting? No, I'm actually coming along with that pretty well. But I couldn't stop obsessing over it. It's like if I get an unusual stimulus big enough that day, it really screws up sleep. It takes a while to come down. And I think patients experience the same thing. (by the way, details changed/obscured to protect confidentiality above)

So I tweeted something today: Good news! Texas gives Nurse Practitioners full practice authority, and joins16 other progressives states. #hell #AprilFool
And of course, the followup: Reality is that Texas is among the 13 most-restrictive states where we are squarely under a doctor's thumb. #changeiscoming
We will see how long that takes, of course. I wrote a big check to CNAP (Coalition for Nurses in Advanced Practice) this year to help move it forward. It's interesting, I am already starting to have some ... constraints ... with my supervising physician. Who in general is one of the good guys, helpful, respectful, smart and not in my face at all. However, he lacks experience and knowledge in eating disorders, which is exactly my area of specialty and that I obviously expected to bring with me to this practice. I have about 3 ED clients right now, and recently he asked me to limit it to just that. I about fell out of my chair. Apparently, he believes that they pose an extra risk (I don't agree) and he lacks experience with them. We talked and agreed on a plan to get him informed but he expects that to take a couple of months. And I'm not happy about that. I wish now that I'd thought to bring it up before we signed our contract -- I didn't. But all of a sudden, I see the allure of those 16 states. Beyond the financial boost (yes, the physician takes a cut of what we earn), there's a freedom to use your skills and experience as a professional. Here's a map of those states if you're interested. Map for NP Restrictions

Nile and I are back at the Animal Shelter. We go every other Sunday evening for 3 hours. It's good for both of us, and it's really fun to be so surrounded by the cats. Bonus: it's not kitten season yet! Because of the prolonged "winter" here, the feral cats bred less. And maybe all that spaying and neutering is paying off. Fix your pets!

I gave a lecture to my old psych NP class at UT, along with the former COO from my previous job. We talked about eating disorders, of course, for about an hour. It was nice to be back, but strangely didn't even felt like I left. I guess it's been a little less than a year. I am amazed at how much I have learned in this short time. The human brain is such a great thing. And it was fun to dress up like a professional - I used to wear my yoga clothes to class as I was always trying to squeeze in a class either before or after being at school. Here's a pic of the retail therapy that provided the cute new dress that I got to wear from Anthro - a definite perk to not being a student any more - making a little (very little right now) money. And hey - I got the word yesterday that one of the insurance plans accepted me! This is the one that initially said they won't accept anyone - even physicians - without 3 years experience. Our savvy office manager then sent in a letter outlining what they should make an exception for me, and they DID. Way cool.