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.

Magical

And it's March. Halfway through, actually. It's still mostly cold which is just frankly weird for Austin.  I'm starting to get the hang of things at work, mostly learning my way around the electronic charting system and all the little special stuff. Things like, I finally had a patient that needed labs drawn and I didn't know where the forms were. I wanted to refer another for a sleep study and didn't know who was preferred for that. One of the quirks of this practice (which is actually smart) is that the initial meeting is always a consultation and we haven't entered into a treatment relationship yet. This gives us the option to decide that we don't accept a client. That finally happened to me. Basically, I was out of my league completely - no specifics, but quite severe and chronic illness, many attempts to get help, many medications tried, all to no avail. So a new grad can help you? I asked. The client gave me a nasty laugh -- oh, I'm only here because my parents insisted. Well, that kind of clinched it. There's no therapeutic alliance present, and this is simply doomed. Oh, and I almost forgot...the only drug that's ever worked is something highly abused. Right. Let me whip out that Rx pad, just a min. But interestingly, it still bothered me. This person clearly needs help. And I can't provide it.

My daughter is in New York for Spring Break. It's an interesting feeling to have a child so grown up she can can plan and execute a trip alone to the City. I'm really glad that she's kept in touch with her NYU friends. And she's staying with my fantasy son-in-law, a nice Jewish boy whose dad is a producer/screenwriter in Hollywood. He stayed with us for a week last summer for the Austin experience. Alas, she says they're just friends. She rented a little Soho apartment and then cooked dinner for her friends. Look. Yep, that's Turkish/Lebanese food. Our favorite.

I went to a retirement party for a woman I worked at Exxon with for years. She had the office next door to me for about the last 5 years I was there, when she wasn't traveling the globe. I think she was one of only 3 systems architects for the entire Refining division. Very successful, and single, no kids. It was a lovely party, at Damien's in Houston. Great food, I had scallops. I saw people I had not seen since 2005, when I left to become a nurse. And yes, most of them had not aged well. Exxon does not have a culture that encourages self-care - one of the reasons I left - but some people looked remarkably the same and still others seemed really happy (some of those were retired!). I'm not real big on reunions -- but Suzanne was special to me and I wanted to see her.

And speaking of reunions, I had a great meeting with the office of UT's employee assistance program, and I think I'll be able to partner with them to see their patients that need medication. They are looking for a provider who can see people promptly and collaborate with them, and that is something I'd like. We'd have monthly meetings to go over cases and that would be a little something extra that I'm not getting in private practice. Oh, I have been calling the therapists of some of my patients to compare diagnostic impressions, but those little doses of collaboration are brief. This would be more. I remembered something when I was there, meeting with all the therapists - when I was a freshman Business student at UT in 1980, I got a work-study job at the Counseling Center. And here I am, back again, as a provider. I never could've predicted that. Isn't life surprising? Wonderful. Magical. When a patient looks at me alone in my office, with tears in their eyes, and admits to me their deepest wish, or secret they've never shared....I feel that magic.

L'Wren Scott killed herself. I saw it on the twittersphere last night and just could not believe it. Such a young talented person who seemed to have this charmed existence. A celebrated designer, wealthy (apparently), Mick Jagger's girlfriend by god....how does that add up to miserable? Well, it's certainly an example of how mental illness doesn't discriminate. In my opinion, almost every suicide is in a severe depression. There are a few other instances where people choose that route, but in most cases it's the deep, dark pit. It made me intensely sad. I thought of Alexander McQueen, an even larger talent when he decided to end things. Dani got to see his Met exhibition and she had the glossy book of photographs of his creations....such incredible beauty. And often fragile, not of this world. As he was. And L'Wren.

Yesterday I had a suicidal patient so that pretty much ruined my day. Not that I minded - I never mind doing what's needed in such cases - but there's a great deal of extra work involved. On top of a very busy day. So I was at work until 7:45, long after everyone else had left. Then a comedy of errors began. I wouldn't have believed it, but here's what happened. I had left my phone at home, which was weird but oh well. My office has no place to store my purse securely so I lock it up in the front office. I often leave patients alone on my couch as I run down the hall to consult with my doctor, and it's just foolish to leave valuables sitting there. So, yes, when I finished up alone, so late, I discovered everyone had left, locked up the front and I didn't have my purse. Great. I didn't have my phone, didn't have anyone's number to call. Who memorizes numbers any more? Not me. I finally figured out I could call the answering service for our office and the other NP, who is on call this week, would answer me. I'd ask her to come back and help me. And know what? They F'ing suck. I called them, they refused to give me any information like home phone numbers, guess they thought I was a liar or something, said that they would just pass the message on. I called them back 3 times, got a different person every time who knew nothing. Finally I gave up and called my momma (really) -- and I hear the cleaning people next door. They let me in with their master key. It's 8:30 by now but I can leave. JFC. So many procedures that need to be fixed. Guess things ain't perfect after all. And guess what? The other NP finally texts me back at 11:30 last night. What the hell?


There's this guy at the gym, I call him Tattooed Love Boy, like the Pretenders song, he is older, big and muscular and bald and yes, heavily tattooed. Good looking guy. He is not a newbie, he's not there every morning with us regulars, but several times a week. And he does his dumbbell sets right in front of the rack, effectively blocking me from getting the weights I need while he grunts and sweats. He should know better - such a breach of gym etiquette. But I finally figured something out. He does it when I'm there by the rack, doing my sets. He steps back when it's just guys around, but when one of the women are there, he's all up in our grill. He's doing it on purpose. I guess he thinks it's a way to spark conversation. He must be shy or something. But know what? It just annoys me. I think if he worked up the nerve to say something, I would snap at him: "What the hell is wrong with you?" Somehow, I doubt that's what he's hoping for.

And in the end

Valentine's Day weekend 2014 was a way-terrific experience. Ken and I went to Park City to see Duncan Sheik perform live and to try cross-country skiing. And both were top-notch. The skiing was good - it is much easier to get up and going than downhill. Of course, years of downhill experience I'm sure helped. The first day, we took a lesson in the morning and then went back in the afternoon and did our own thing for about 3 hours. It was a nice day, if anything too warm. Ah but the next day-- totally different deal. A storm was blowing in, dumping snow as we started. By the end of our second run, I couldn't even see the tracks and my face hurt from all the needles of snow the wind pushed in my face. But it was so beautiful. Gorgeous. And, yes, it's safer than downhill. It's not an adrenaline rush, it's more your body being one with the outdoors. It's such a steady-state cardio workout, I ended up just hearing my breath and feeling the snow. I like it.

My new job couldn't be better. Here's how great they support me -- every day I'm there, the office manager comes by and asks if I have any questions or need anything. I mentioned off-hand that I could use a clipboard. Oh, she says, I'll get you one tomorrow. What color? What style?  This after I opened my desk drawer on the second day and found it had a nice set of supplies arrayed. They asked if I'd like a painting to go over my couch, and then brought in an assortment for me to choose from. We have Starbucks K-cups, cream and milk, and La Croix water in the break room, all free. It's so first-class.

And then there's the stuff that really matters. My schedule is already as full as I want it. I have 7 appointments for Thursday. Already, folks. In two weeks. It's because I can see insurance patients right away. And get this, one of my contacts is a fellow NP that is closing her practice because she's pregnant with her third child. (She plans to resume but not for at least a year or two.) She has hooked me up with UT's employee assistance program, and now I'll get a bunch of those clients referred to me. I'm meeting with UT next week. The best part: I really like it. It's challenging, it's fascinating -- I mean, I'm the shrink, people tell me things that they have never spoken aloud before, and it's a puzzle and an art. Especially prescribing. Which medication to choose? So much less cut and dried than antibiotic or cholesterol meds. And much more critically, is medication even warranted? My supervising physician is so different on that front -- he's so non-meds oriented -- frankly, it's been a little hard to get used to. When I bring my cases in to review with him, he spends much more time on that question and always, always about the therapy. With my previous doctors, it was all about med selection. We got to that very quickly. It's nice to have the opposite, because I like to always be conservative with medication.

My sort-of last day at the old place was Friday. I'm returning on Tuesday to write up a bunch of discharge summaries that I got behind on. It was a typical day there - so busy I barely had time to pee. I had an intern with me all day, and they planned a little cake party for me, but of course, something came up and I had to see a patient and the party turned into a 5 minute deal. So no tears because there was no time. I did an exit interview with some suit up in St. Louis and it was just stupid and pointless. I don't need to bitch and moan to her, and I didn't. But this has been, oh god, such a stressful time. I'm not sleeping well, and my pants are all baggy because I've lost weight. Part of it is just the stimulation of the new job - when I wake up at 3:00 am, I'm running through all the decisions I made about my patients that day - did I pick the right antidepressant? Did I note in the chart that she had seizures as a kid? Did I remember to block my lunchtime meeting next week? Didn't help that my Doc at the old job took a day off this week AND our census popped up. It was a terrible week. And it's over. And I'm going to yoga three times this next week, because I can now. Hoo hah.

So Dani casually mentions to me she's going to the movies. Oh, I say, with who? She says "my boyfriend". My eyes pop out of my head - What boyfriend? Oh yes, she has one of those now. His name is Rakan. Computer Science major at UT. His parents are from Syria. Can't wait to meet him.

Quit

I had a brand-new experience on Friday. I got angry and quit my job. Well, yes, I did give two weeks notice - I mean, I'm trying to do what's responsible for my patients - but after sitting through the ridiculous meeting with the owner where she failed spectacularly to reassure us that the place isn't falling apart,  I said enough. But allow me to back up a few days - so Tuesday, the COO and the Clinical Director quit. The Administrative Head quit the week before. And I quit Friday. Maybe that tells you all you need to know. 

My life has changed considerably. I'll be able to focus much more on my new private practice and I'm full of good feelings about that. I had my first day on Thursday and saw two new patients for evaluations. Of course, both were very complex, what we call "special" populations. The second one I reviewed with my collaborating psychiatrist and agreed that even he didn't have the expertise for the case. But both of them wanted to continue seeing me, and I have two more scheduled for Monday already. This is growing quickly. And I am finding that the staff there are as good as I'd hoped - I am getting the orientation and support that I need. They are smart, capable people. As Ken says, they seem to realize that both process and environment are important. 

Here's a pic of my new office. Every item in it is new - how cool is that? It's so nice after my crummy previous office with the stained carpet, the holes in the walls, the broken handle on the desk, and no window. So obvious they were saving every nickel and dime. I like this so much better. It aligns more with my personality - frugal is not me. Since we only go around once, it better be good. 

Nile took his next step in black belting. This was the most assured that I ever saw him before a test. And he broke his board on the 2nd try. He is assisting with the little kids on Thursdays now, and surprise...he likes that. He's always grumbled about being around them before, but turns out being the teacher is OK. 

I'm looking forward to having a much calmer life. After last week, I was already quite worried about how to fit in both of my jobs. I worked very late on Tuesday, and then they were peppering me with questions from the new job (Did you read that email? Have you turned in this form to Blue Cross? When you check your schedule, you need to look at this.) I could see that it was going to be out of control soon. Now that won't happen. So right now, their expectation is for me to be there two days a week. As soon as I have enough clients, I'll add another day and then another....until I'm at all 5 days. But here's the sweet part: I don't have to work Friday afternoons. I can use that time to catch up on administrative tasks or I can leave. Totally up to me. 

Friday was a really intense day. I walked out of that awful meeting with the owner - and she insulted me personally by the way, implied that I wasn't running my CBT group properly (which I strongly disagree with; and I wasn't the only target of her insults) - went straight to my office and typed out my resignation letter. I think it was 2 sentences, just the facts with no emotions. I'm leaving on this day, thank you for my time here. Then I walked up to the Clinical Director and handed it to her. She read it quickly and said "I totally understand." Then I walked away. And you know what? The owner was there the whole rest of the day and she never said a word to me. Telling. I was in the front office about an hour later, and our PhD Psychologist said to me, "Hey, I just want you to know how completely inappropriately I thought you were treated in that meeting." and this is the only time that day I really allowed things to leak out, I just blurted out "I quit". There were three other people in the office, and their heads snapped around. Late in the day, an announcement went out. It was a difficult day, I had a full slate of patients to see, insurance companies to call. I even had two doc-to-doc calls that I had to do (which is what they call an insurance appeal. I have to talk to the insurance company doctor, instead of just the clerk.) And I lost both of those appeals. I have to say, that's usual. I had a good track record of usually winning. So I'm going to take that as a sign that it's time to move on. 

L'aissez les bons temps roulez

Two big things to talk about. First, I have a new job. I'll be working in private practice with a local psychiatrist. He has one NP and now he's adding me. It's a truly innovative office, they emphasize therapy as much as medication, and his primary technique is psychodynamic. That's right up my alley, with my love of Jung and appreciation for his philosophy. The psychiatrist's wife is also a key player in the office, and she has an ivy league MBA, and they are very focused on data and best practices. But the most remarkable aspect is basically there is no churn. Unlike most other practices, it's not how many billable hours can you cram in a day, it's more how can we do good and feel good about our work. Education and collaboration is a planned, scheduled weekly thing. And he really means all this -- here's proof: he expects 30 billable hours a week, which is lower than most other practices, and I can do 4-6 therapy-only clients a week. That's really different, and it happens to be what I want. I am so lucky. Maybe it will help me heal from the storm that ran through my life when things I loved so much left me. The signs are good. I start Thursday. There will be an overlap period with my other job, but only as long as I want that (per contract, up to a year). Ken is actually urging me to just quit, but a part of me isn't ready. (I have a great husband, just FYI.) It's going to be emotionally very difficult to leave, to admit that I can't fix this. But more proof seems to happen every day; just this week I found out that they've started a new, expensive initiative that basically is just moving deck chairs around. Can I tell you how angry I am that they have money for this ridiculousness, yet my position was cut in half? It's going to be quite a chore to hold my tongue in the two stupid special management meetings I've been asked to attend, never mind the fact that I'm not management anymore. I mean, hell, I'm PRN, how can that be management? I have to drum up some patient emergency that will require my attention.

The other thing to talk about is Carnaval. Www.sambaparty.com. We went last night and it was one of the most fun events I've been to in ages. It was like an indoor Mardi Gras parade, with the creme de la creme of dancers. I was blown away by the quality of the hour-long drum and dance show by Austin Samba School. (and you better believe I'm going to Zumba tomorrow night, ha) The costumes that the attendees wore were incredible -- I was so both over and under dressed. Dani did my makeup and said "Mom, you look like a hooker." False eyelashes are way fun. Well, that really wasn't enough, I had a mini skirt, fishnets and boots with a Lulu top, but man, I needed to show waaaaay more skin. I lost count of the topless women, the ass-less chaps, the thongs (male and female), the innovative body paint....what a feast for the eyes. I'll definitely be spending more time on my costume next year. It's not a time to be classy, let's just say.

One of the things I really liked about the experience, and you'll see this from my pics, was that people of all shapes and sizes were included among the performers (attendees, too -- all 5,000 of us). There were so many women who weren't rail-thin, just full of happiness and great dancing ability, and did they ever strut their stuff. It was impossible not to smile and feel amazing watching it. Made me wish I could have a field trip with my anxious little anorexic patients, so convinced that the scale determines their worth. Oh baby, it does not. All bodies are beautiful! Just watch and learn.

Up

Things are looking up. I don't have a lot of news, but I mostly just want to get that rant off my homepage. Ha. Felt good to do it, but now I am uncomfortable with it being the first thing seen. I had an interview, and it went really well (in my opinion). It's an innovative practice with a psychiatrist that really emphasizes therapy. Already has one NP and seeks another, so I won't have to break any new ground. Lots of experience to learn from. Excellently run, with an office manager that's been there 7 years. The office is simply gorgeous - in a lovely park-like setting, the building is quiet. Obviously been professionally decorated with no expense spared. I would have an office with a window. The only downside is the commute, but it's bearable. And he was amenable to working flexible hours. They asked the magic question near the end: How soon can you start? Anyway, I'm providing them with all my license numbers, diplomas, etc. It's definitely going on to the next step. We haven't talked money yet, but I've already heard that he's reasonable. I must confess, the idea of seeing a wider range of patients with a variety of issues does interest me. This practice only sees adults now, but perhaps I could broaden that - I'm so comfortable with adolescents at this point, as they've been the majority of my patients.

It's a snow day in Austin. A rare event. My gym opened about 45 minutes late, but I got over there and my wonderful spin instructor did two extra songs for the three of us there. Love her. And no work today! Of course, no pay today either! This part-time thing....not gonna work. I'm really trying to put on my big girl panties and smile and have a positive attitude there. There is only one person at work I've bitched to, and I'm going to keep it at that. But the signs continue to be quite negative. I was told that I need to start meeting in person (instead of calling) with parents of adolescents on admission day - which is great, I think it's a good idea, but I'm not there every day. Nobody thought of that. Another example: I had 4 insurance reviews to do today, which won't get done because of the snow. And I'm not there on Monday. Someone else will have to do them that day, or patients could get denied for coverage and we have to eat the cost. Hope that gets done (said in a bitchy voice). I asked how situations like that would be handled when we were discussing this part-time schedule, was told "we have a lot of things to work out" and that was it. Just like the contract I was supposed to sign on Tuesday. Never saw it.

Um, this is turning into a rant again. Damn.

So what else is going on? Running is going really well. My rule is that I run one song, walk one. I'm up to 40 minutes doing that, wearing a knee brace. No more pain than before I started this, so = success. My gym is strangely deserted for a January, and it's because the new location opened in Westlake. A lot of people are going to that one, it's brand new and has a pool. I'm going swimming today, for sure. And yoga, and oh my...it'll be a fantabulous workout day. It's nice not to have a jammed resolutioners crowd, but I'm also worried that they may cut some of the spin classes for poor attendance. And I must, I mean must, mainline my spin every morning or I go into withdrawal. Nothing else quite does it for me, I think it's the intervals. Working so hard you can't catch your breath, drenched in sweat, cranking it up to the nth degree, screaming inside when will this stop?! And then slow down, breathe, recover, and do it again! For 45 minutes! Yeah baby. This may completely be TMI, but it is a lot like sex. You're in a dark room, building up to the climax, breathing hard, focused, straining.... especially when we reach the top, folks sit down on the bike and everyone sighs and squeals. Sometimes I just have to laugh. Yes, it's a spin orgy.

My ham planet cat has learned how to open doors. We have hook door knobs, and he stands on his hind legs, reaches up and opens it. He really likes to do this to the bathroom and then destroy the toilet paper. His girth facilitates this - ha.

I just finished The Goldfinch by Donna Tartt. It's a novel about love, art theft, tragedy and PTSD, and the losses that all of us face in life; the unfinished nature of how things turn out, the missed connections and the way that love actually doesn't conquer all. But still... there remains beauty and meaning, if we are brave and face things. It takes place in New York, Las Vegas, and Amsterdam. It's hard to put in to words why it's so good. It's well written, it surprises, it is deep. And it's absolutely not trite. I guess that's what I value most in a novel. If you want to read more about it, here's a link. I can't recommend it enough. http://books.google.com/books/about/The_Goldfinch.html?id=T2CA83gbtM8C

OK, yoga in an hour.

I'm not crabby, I'm just really bitchy.

This is going to be a bitchy rant. If that's not your thing, walk on by.

As I've often mentioned, I love my job. I work at a small specialized treatment center that I feel really makes a difference in people's lives, especially those of girls and young women. Most of the clinicians there are so capable and there's this wonderful collaboration. It's a stimulating environment to work in, and when I look back on the 5 months I've been there, it's quite stunning how much I've learned.

Can you hear the "yes, but..." coming? Our break-even census number is 11 patients, and since about late summer, we have not consistently been at that number. I've still had plenty of work, at first it was because I was learning so much, but I've taken on other tasks. I am the liaison to all the insurance companies, so I have to interface with them for each patient about every 4 days and get authorizations for continued stay. It takes time to collect the data from everyone on our team and build the story of what that patient needs. I also do three therapy groups each week and work with two different interns on separate days. I revised all of our medication management policies, which basically was non-existent. I was busy in spite of the low census, and I definitely worked more than 40 hours a week. I went in every Sunday afternoon, and frequently I had to meet with patients who were struggling over the weekend since none of the therapists were there. Sometimes I left early because of that, but not lately. In spite of all that, I knew that the organization was worried about the low census. In the past month, they laid off our HR person and our PR person. And guess who was next? Well, I'm their third-highest dollar employee, right behind the COO and the clinical director. But here's the deal, they really can't lay me off. Nobody else can do what I do - they aren't licensed to diagnose, treat, and prescribe. Only the doctor can, and he works only 8 hours a week, and half of those are meetings. I was thinking that they might consider dropping me to work only 4 days a week, or expanding my role to take on more of the therapist tasks. But they had something else in mind. And it didn't go down well.

So the delightful day before my birthday, the director tells me that they are dropping me from a salaried employee to only 25 hours a week, and keeping all my duties intact. I would work 3 days a week, and they propose that I see patients in a private practice using my office on the other days, and use a 60/40 split for the money I make on those days. The only problem with this is they were "too busy" to get me credentialed with the insurance panels all this time, so I've been billing under the doctor's name. I can't take any insurance patients on my own. And that's a ridiculous split - I would never agree to it. The going split around town is between 20 and 30, and that's with providing billing and insurance processing. They want 40% of my money just for me to use an office that's empty anyway? They also asked me to propose an hourly rate. So  I went away and started thinking about this.

The next morning, I see the COO in the coffee room and say, oh by the way, I forgot to ask when you guys want to implement this. He says, next week. My mouth falls open. I can't stop myself. I say "you are kidding". He says, oh I'm under a lot of pressure from Dr. M (our "headquarters" organization is a treatment center in another city; the doctor there owns both facilities). That's just peachy. You expect 2 weeks notice from me, yet you give me 5 days. That's just great. Later, in the weekly leadership meeting (and that they nicely inform me, I'll no longer be attending) our administrative head tells us that she worked all weekend on a proposal to fix financial problems that have recently been uncovered at HQ. Seems that their census has been low for months too, and they had been very sloppy about billing and record keeping when times were flush. Now they're not, and discovering that they have huge problems. Hmmmm. Could there be a connection to their sudden decision to cut my job to the bone?

Anyway, I calculate a rate that basically turns my salary into an hourly rate, I don't add on anything for the lost benefits. I am generous. I tell them the next day what I want, and that I want a 70/30 split and want to be credentialed. I offer to help with that process, filling out forms, making calls, whatever. Reasonable, no? I do this without being pissy, either, in spite of how I feel. And then I wait. And wait. So it's Friday, and all of this is supposed to start on Monday and fucking finally, he meets with me and counters my hourly rate with one dollar below that and they won't compromise on the 60/40 split. I say nicely through clenched teeth, I decline your offer. I can stay for the 3 part-time days but at my original rate and I'll find something else to do on those 2 days off. And incredibly, he says Well I have to run that by the owner. Great. Let me know by the end of the day. I'm not showing up to work without us coming to terms.

And at 2:00, they come back and agree to that.

I'm incredibly sad about all this. I really was doing work that fed my soul. But I can't stay at a place that feels they need to humiliate me. One dollar less? What is wrong with you people? I've had uncomfortable, strong signals for a while that our COO isn't very competent, and this just confirms it. Throughout all this, he kept saying this was not his choice, it was all coming from HQ, it was out of his hands. You fucking ballless wonder. So what exactly do you do here then? And the serious financial mismanagement is not trivial. I don't believe these people are good businessmen and women. I see reaction, I don't see strategic thinking.

I have a job interview Thursday, at an office with a psychiatrist that I've heard wonderful things about. The only downside is the drive. He's up 360 on Spicewood Springs, but that's reverse traffic so I don't think it will be bad. And it avoids Mopac, which is about to become a disaster area for years when they start building the toll road. My plan is to start working there on the 2 days I'm off, he can start getting me credentialed, and then I'll quit and go over there once my practice on those 2 days fills up. Actually, a pretty good deal because many times the first 6 months of a private practice are pretty lean as you build your clientele.

And I'm closing with a picture from the hot sauce fest this past summer. It allows me to do what I wanted to do all week. I look pretty happy.