Why NP?

I previously shared my journey, to becoming a Family Nurse Practitioner in the blog, The Road to Becoming a Family Nurse Practitioner, however I did not discuss at length why I chose this particular path. I recently had a question from a reader trying to make a decision on her career path, and wondering if becoming a nurse practitioner is the road for her. As I wrote about in the previous blog post, I started college straight out of high school without much direction. When I became interested in the sciences, many of my classmates were either pre-med or pre-pharm. These fields both seemed to be the most lucrative and stable of the other options available, so I began to research these. The school I attended Southern Oregon University, also had a BSN (Bachelor of Science in Nursing) program, which I considered. Having zero experience in healthcare, or having known anyone in these fields made my decision a bit tricky. I ruled out the nursing option because in order to start this program you had to be accepted in the second year of school and once starting this track it would be difficult to change paths to another field, such as pre-med or pre-pharmacy. Furthermore, I was in a program Western Undergraduate Exchange, which gave me reduced tuition, and this program was specific certain majors, oddly enough not including nursing. I decided against pharmacy because I felt that the work would be too isolating for me, and I wanted to have patient interaction. The thought of medical school, although appealing, seemed absolutely daunting. Not only the rigorous training, but the length of time and amount of debt required terrified me. I knew that making a commitment to this would mean I was absolutely sure this was what I wanted to do. I started by getting some experience shadowing a family practice physician and volunteering in the ER. The physician I shadowed was great, and really developed my interest in family practice. As a volunteer I was able to understand the varying roles and functions within the ER. I seemed to moving in the direction of medicine, but still had doubts. When I discovered the careers of physician assistant and nurse practitioner, I also began to consider these fields. Less time in school seemed more appealing. I put off any major decision after I graduated with the goal of getting some practical real-life work experience in healthcare. I moved to Portland,Oregon, however the entry-level job prospects in healthcare were almost non-existent. Even minimum wage jobs in some hospitals or clinics required certifications. I had no money to continue more certifications. In the midst of looking for work I continued shadowing physicians, volunteering at a free clinic, and studying for the medical entrance exam, the MCAT. After taking the MCAT and getting a decent score,  I interviewed for a front-desk position with a female spinal surgeon. When she reviewed my resume, she asked if I was planning on going to medical school. I told her my story and reservations about medical school and balancing a life outside work. She expressed her difficulties balancing her life with kids and family, and in a nutshell said she would have taken a different career path if she did it over again. This really resonated with me, as I did want a family and kids. I put off applying to medical school and started researching PA and NP programs. These two roles are often used interchangeably, however the training and scope of practice is different, as I would learn. The physician assistant programs are usually 2-3 years and often requires 2 years of paid direct patient contact hours, although some programs do not require these hours. Many entering the PA programs are EMTs, many of my coworkers working in the ER were working towards admission to a PA program. I cannot 100% speak for the education in these programs, but from my understanding one major difference in the curriculum of PA vs. NP is the PA program follows the medical education model, rather than the nursing model.  PAs also always practice under a physician's license, and therefore cannot open a practice or bill independently. Historically the PA role came from the need for jobs for army corpsmen returning from Vietnam War, and thus PAs tend to be very strong in the areas of orthopedics, urgent and emergent care. When I worked in ER the PAs definitely outnumbered NPs. The PA programs also are not specialized, and thus require a post-graduate residency or on the job training for specialized fields. The advance practice nurse programs, in contrast all requires a RN license, and hence the skills of a nurse. The programs are usually specialized, and thus clinical hours are usually completed in an area of specialty, rather than a round robin of different acute and outpatient settings. I was drawn to the Family Nurse Practitioner program because I wanted to practice in primary care, and I also found it advantageous to have the experience of a RN as well as the potential to practice independently. What I have found to be most valuable in my education and unique to APRN programs, is the experience as a RN. Nurses spend more time with patients than any other position in healthcare. They are at the bedside when the patient is vomiting, having diarrhea, having a psychotic episode, or comforting a family member while the patient is coding. When you are so close to patients during their time of illness, you have no choice to develop a deeper understanding and empathy for your patients. I'm not saying other healthcare professionals aren't able to develop this level of empathy or understanding, I just feel that this level of contact creates a special understanding. I also feel that nurses have extremely strong assessment skills, and often develop an intuition of when a patient will crash before anyone else. I am absolutely happy with my career, and feel I am doing what I always wanted to do. Do I have any regrets or wish I had gone down a different career path? Sure, but ultimately I feel this was the right choice for me. I sometimes wish I had the higher income and prestige of a medical doctor (MD), but that is not why I wanted to get into the field of healthcare. I sometimes wish I would have just gone straight into nursing and saved myself the additional time of doing the entry-level program, however I just didn't have the insight into APRN degrees at that point in my education. My advice to anyone debating between nursing or another medical degree is to pursue the BSN degree first. This way you are able to later pursue an advance degree in any other field, but also have the valuable experience of being a nurse. Doing the entry-level program was especially challenging, for the fact that while transitioning into the role of the RN, I was also taking the graduate MSN courses. While I was in the MSN program, I sometimes felt that I should have just gone to medical school, as I had spent so many years and energy towards the advance practice degree. The average time after receiving a Bachelor's degree to becoming a doctor is 4 years plus a three year required residency, and often times longer for specializations. In total I spent almost five years to receive both the BSN and MSN degrees. I in no way feel that the nurse practitioner program was a "cop out", as these programs were extremely challenging and the clinical  hours required grueling. I do regret however, that I was discouraged from applying to medical school by one female physician's opinion. When I look back I realized I never sought out any female mentors to give me an insight into balancing a career and family in medicine. All the doctors I shadowed were male, and all my classmates I studied for the MCAT with were male.  I now see on social media so many female physicians mentoring each other, and several doing really challenging careers with several children. I think it's so important to have a mentor, but especially one that you can ask questions about work-life balance and perhaps comes from a similar background or situation as yourself.  I also find that nurse practitioner and physician's assistant programs, because of the brevity in comparison to medical school, lack in some areas. I felt that my particular program lacked education on diagnostic imaging. There are now many residency programs available to NPs and PAs, which I did not elect to do, however I feel would be a benefit especially for a specialization. As a nurse practitioner, there are some areas that require additional continuing education or self-study to fully grasp. My parting words for this post is that there are pros and cons to any graduate healthcare program. In the end, whatever path you take will lead you to a rewarding, lucrative and in-demand job, so you can't go wrong.

Alternate to the white coat

I've been obsessing over white blazers lately. A white blazer is a perfect summer staple that can worn with jeans or a dress and heels for a very chic look. I also think it's a great alternative to a white lab coat that looks stylish and professional. The trend with healthcare professionals seems to be away from the white coat. Some healthcare professionals feels that it creates a divide between the provider and patient and can cause the so-called "White Coat Syndrome". A psychiatrist I follow on social media wrote this article about why she doesn't wear a white coat.When I worked in the ER almost none of the providers wore white coats. When I moved to the clinic I started wearing one since I was new and wanted to convey professionalism to the patients who did not know me. Obviously a white blazer is not a substitute for a white lab coat, but I think it's a great piece to have in your wardrobe nonetheless. Here are a few I've been eyeing that can easily be transitioned from the office, conferences, happy hour, or networking events.


My thoughts on Faith-based Healthcare education

Recently someone ask me a question about how I discuss abortion with patients, and I realized I had really not had any preparation in my education about discussing abortion with patients. I did my graduate education at a private Evangelical Christian university, which may explain why I did not receive training to talk about this subject. Prior to this program I had only attended public secular schools, and thus when I applied to this program I didn't have any idea what to expect in terms of the religious aspect. I grew up going to a Christian church, but my parents were very loose in terms of their religious beliefs. I chose to apply to this institution for the particular entry-level FNP program, not taking into account the fact that it was a religious-based school. Roughly half of the cohort in the program also chose this program without regard to religion. Incorporating prayer and faith into the curriculum and classroom felt foreign to me at first. As I spent more time at this institution, I came to appreciate the prayer and re-connection with a spiritual side I had long neglected. We prayed in most classes daily, and each course required a faith integration assignment. I had two courses required regarding spiritual care, one requiring a lengthy paper dissecting a theme from biblical passages and theologians throughout the centuries. My theme was grief, and the assignment has been very meaningful to my practice in the past and currently. I ended up loving that class, and the class discussions were so engaging, and at times emotional. At the end of the semester each student presented their papers, and one presentation in particular had the whole room in tears and hugging one another. I felt the religious aspect of the program added to the humanity of medicine, which is often neglected in most curriculums.  The flip side of a faith-based  institution was that the topics in medicine that did not align with Evangelical Christian doctrine, such as care of LBGT patients or abortion, were simply not taught. The problem with the omission of such topics were that sites for clinical rotations were not faith-based, and thus students were still required to see LBGT patients and patients who sought abortions. During our mental health rotation my fellow classmates and I did hours at a mental health hospital with a wing dedicated to LBGT patients. This was my favorite unit, and I would always enjoy the group therapy sessions more than anything else during these clinical hours. One student however, refused to sit in during these sessions on the LBGT unit, because she didn't agree with these "lifestyles." During our lecture discussion in class that week, my good friend and classmate who is always outspoken, brought this to the attention of the professor asking "Since this is a Christian University are we going to talk about interacting with gay people in clinical settings?" The professor just left it as an open-ended question, and the discussion did not move any further. This academic program very much emphasized "vulnerable populations" in healthcare, but somehow LBGT community who are an extremely vulnerable population in healthcare, were not at all discussed. The reality is if a patient walks into my clinic who is transgender, I cannot just refuse to talk about this or treat the patient. I also need to understand the medical treatment behind gender- transitioning, which was never taught. In the graduate-level women's health course, abortion was never discussed, even though some students in this course were at clinical sites where abortions were performed. The curriculum for the women's health course never discussed counseling a patient requesting abortion, or even when an abortion may be a medical necessity for the patient. We had a guest-speaker who worked as a SART (sexual assault response team) nurse talk about care of patients who were victims of rape and incest, but in this discussion there was no mention about how to counsel patients in these cases on abortion as an option. In California a provider has the right to refuse to perform abortions for moral reasons, however the provider should still be able to counsel the patient and make a referral.
 Although I only have my own personal experience at Christian university to draw from, it seems that the avoidance of education on abortion and LBGT-specific care is not only a problem in religious-based medical training institutions.  I recently heard this segment on NPR about the limited sites offering training on abortions for OB/GYN residents in Texas. Furthermore, I also recently read this article, about how LBGT healthcare is also rarely taught in most medical programs. With this in mind, it seems that this is not simply an issue at religious-based institutions, but in general topics that are still taboo in our society. I also cannot speak for all Christian healthcare education, and I would be interested to hear thoughts from anyone else who attended a religious-based institution, or from those educated at a secular medical program how these issues were addressed. I felt overall a religion was valuable in my education, but I would have appreciated at the least a brief education on the topics of LBGT healthcare and abortion.

Implications of Proposed VHA rule for full practice authority for APRNs

Recently the Department of Veteran's Affairs proposed a change in the current policy to allow for full practice authority to all Advance Practice RNs (APRN).  So what does this actually mean? This allows for any Nurse Practitioner or Certified Nurse Anesthetist and Clinical Nurse Specialist (and Certified Nurse Midwives, although the VA does not currently employ CNMs) to practice to their full extent of their training without physician supervision. Many who are not in the nursing field may be confused by all this. Currently in the U.S. 18 states already allow for full practice authority for nurse practitioners. What this means is if the NP in one of these states has completed a MSN or DNP program, and in most states passed the national board certification, he or she possesses the ability to assess, diagnose and treat a patient without a collaborating or supervising physician. I currently work in California, where nurse practitioners do not have full practice authority. The scope of practice of a APRN in California is contingent upon the employer and the standardized procedure in place. A standardized procedure is an agreement between a collaborating physician which outlines what a APRN can or cannot do independently. For example, while working in the ER a very detailed standardized procedure was in place and I had to be signed off on what procedures I was able to do independently. While working at this institution it was required that all APRNs have their charting and orders signed by a physician. In most cases this was more of a formality, and the relationship between the physicians was more collaborative, however some (one in particular) physicians insisted on entering all the orders and plans on the patients seen by PAs or APRNs. I found this type of supervision very demeaning, and felt in this type of situation I was acting in the role of a RN rather than an APRN. At my current place of practice, a private practice, the scope of practice was written collaboratively by myself and the physician who owns the practice. I am not required to have any of my charts or orders signed. The California law does not require a physician physically present for supervision, but available via phone call for consult. Multiple studies have shown that nurse practitioners and other APRNs provider safe and quality care to patients independently. Veterans have unfortunately had long waits to see providers and delay in care. This increase in practice authority for APRNs working at the VA would minimize wait times and delay in care. The full proposal is available to read here. This increased practice authority may also set a precedent for more states to pass legislation increasing the APRNs practice authority. Please submit your comments to the VA here if you support this change.

5 things my dad taught me

As I've become an adult and a parent, I am now more aware of what impressions were left on me by my parents. As father's day approaches here are some things my dad taught me.
1. How to drive stick shift
Ever since I was a little kid my dad would have me sit in the front seat and change the gears while he drove. When I was old enough he taught me to drive on the back dirt roads near our house. When I drove into a snow bank by accident he would push the truck back out and never really complained when I did it a couple of times in a row. It took me a long time before I mastered driving stick shift on hills, as anyone who had the pleasure of driving with me in my first manual transmission Dodge Neon can tell you.
2. The formula for density is mass/volume
I was a poor student in high school chemistry, but somehow I passed with my dad helping me through homework sessions where I was so frustrated I wanted to pull out my hair. Before we had even learned the formula for density I impressed my teacher by knowing it because my dad had gone over it early with me. Somehow after scraping by high-school chemistry I ended up majoring in chemistry in college and even tutoring organic chemistry.
3. Cross your sevens
My dad being a scientist is very systematic and has computer-font neat handwriting. He always crossed his sevens, which he explained to me was a habit he had picked up from some other smart scientist to differentiate them from letters. I took the seven crossing as a mark of intelligence and continued to do so from then on.
4. Optimism is overrated
My dad isn't a glass half-empty person,  he's a glass completely empty person. Although I am not a pessimist, I developed enough cynicism growing up with a pessimist to be funny.
5.  Stick up for your siblings
When I was around age seven or eight a friend of mine and I picked on my little brother ambushing him with water balloons. When my dad found out he sat me down and told me a story of when his older sister and friend did a similar prank to him, and how it hurt his feelings. To this day that story has really stuck with me. I may not always agree with my brothers, but I will always have their backs.

Flying Solo

I've been a practicing nurse practitioner for a year now, and am finally feeling more confident in my abilities to practice independently. My first job out of school was working in an emergency room, where I was surrounded by seasoned EM doctors, physician assistants, and nurse practitioners I had to reference when I encountered an unfamiliar situation. Although my time in this practice setting was short-lived, the mentorship I received was invaluable. The mentors I had were overwhelmingly helpful in giving me guidance with procedures, x-ray interpretation, and in general when I was second-guessing my plan or diagnoses. When I decided to leave the acute care setting for urgent care and primary care, one of my fears was that I would not have all the resources available to me as I did working in the emergency room. In the emergency room I would be able to consult with any number of providers, and had the quick turn-around time for labs and other imaging tests to rule out many life-threatening conditions. I feared my assessment skills would not be strong enough without all of these tools at my disposal in an outpatient setting. I was also afraid of being the only provider in a clinic, and being faced with a situation I didn't know how to handle. Of course I am faced with situations every day I haven't encountered. That is what I love about my job is that I am always learning. Medicine is not a static field by any means. Knowing where to find the information is the key, which I have written about here. I don't need to have someone holding my hand anymore; I trust my instincts and assessment skills. This week was a testament to this feeling of self-assurance in my practice. I currently work with a physician in a private practice, and although this physician is available most days in the clinic, I am the sole provider several days a week. This week he went on a long-overdue week-long vacation, leaving myself as the only provider the whole week. Being the go-to person for all the patient calls and follow-ups was overwhelming. There were a few urgent situations I had to refer to ER, simply because I didn't have the resources available to me at the clinic to safely manage these patients. The others I was able to handle and follow up on my own. I'm lucky to work with a physician who treats me as a collaborating colleague, rather than an inferior. He trusts me to make judgement calls and to refer or consult when I am out of my scope of practice or knowledge. I would never make the mistake of thinking "I know it all" or be afraid to ask questions, but I feel I no longer have the feelings of self-doubt holding me back either.

Brain on Fire Review


I read a review on Love and Skye blog about Brain on Fire: My Month of Madness , and was compelled to read it. I won't give the whole synopsis, as I don't want to ruin the nuances of the story, but I wanted to share my reactions to the story as a health care provider. This book is an account of a young twenty-something successful otherwise healthy New York reporter, Susannah Cahalan who suddenly experiences symptoms of paranoia which progresses to psychosis, seizures, and then catatonia. In my advance health assessment course, we were told "Think horses, not zebras" meaning the symptoms a patient presents with usually points to a common straightforward illness a "horse" and not an exotic disease or a "zebra". In this case the diagnosis was definitely a zebra, and took almost a month and a handful of specialists at NYU hospital to finally pinpoint and treat this mystery diagnosis. This story left an impression on me for several reasons. One, her symptoms were dismissed initially as "stress-related" and even as alcohol withdrawal symptoms. The author was fortunate enough to have a supportive family who demanded answers and follow up from the health professionals. As primary care providers we are trained to look for horses, not zebras, but this is a cautionary tale of when the symptoms and history don't add up, to start looking for zebras. Cahalan was also fortunate enough to have access to a team of the top specialists in neurology, infectious disease, and psychiatry working on her case. Had she been in a position without access to specialists or without family support both emotionally and financially, her outcome may have been very poor. I think of how many patients I have seen who do not have someone advocating for them, and if they were to be in this position what would happen. Sometimes, as primary care providers we are the only advocates for the patient. Cahalan researches the history of the disease, and how so many with this disease, many children, have gone misdiagnosed. She also touches on the future of research in the field of neurology, and the possible links of autoimmune illness to mental illnesses, which is really fascinating groundbreaking research. This memoir also highlighted how terrifying from the patient perspective losing touch with reality and memory can be. In my time as a nurse I have often had a glimpse into the minds of those with psychosis or memory impairment, but rarely would I get insight into the patient's personal perspectives on this experience. This is a fantastic read which I recommend adding to your summer reading list.

June Stitch Fix Review: Cargo and more cargo


As I've mentioned in previous posts, I am a big fan of the online clothing service Stitchfix. I first heard of it through a good friend who hates to go to malls, like myself. I am an impatient person, and going to the mall stresses me out to the point where I will grab the nearest item without trying it on and leave, only to get home and realize it doesn't fit right, but won't return the item because it means I have to go back to the mall. For almost three years I've ordered through from Stitchfix. The great part of the company is there is no monthly fee or required monthly purchase. Whenever you feel like having a "fix" sent, you schedule the fix and a $20.00 fee is charged to you when the items are sent. The "fix" is five items of clothes and accessories picked based upon your completed style profile preferences. You are not required to buy any of the items, however if you keep all 5 your receive a 20% discount and the $20.00 fee is applied toward your purchase. As someone who loves convenience, this works wonderfully for me. I have used stitchfix for work clothes, wedding attire, date nights, and casual clothing. My biggest endorsement of the service is this is my 14th fix. I requested some items in the comments for my stylist, including a cargo jacket, espadrilles, a layered necklace and button down blouse. Stitchfix just started carrying shoes, thus I was even more excited for this particular order.

Items I received this fix:
1. Anda Button Down Blouse- I really liked this blouse, but returned it for the reason that the material was hand-wash only, and I had bought a similar button-down shirt literally last week.
2. Demi Cargo Pencil Skirt- I didn't think I was going to keep this item, but it goes with so much I already have and was very comfortable so I kept it. This skirt matches well with a blouse, as pictured below, or a T-shirt or tank.

3. Chaplin Hooded Anorak Cargo Jacket-I have been wanting a cargo jacket for some time, but haven't found one I liked. This one fit perfectly, and is a great spring through fall transitional piece so I kept it.

4. Ciara D'Orsay Espadrille Flats-I really liked the style and color of these shoes, however I begrudgingly sent them back because the heel of the shoe was detached when I walk popped off. The shoes were the most expensive item in the box, and thus if they weren't going to be functional I had to return them. I will request a pair next time that do not have a detached back.
5. Mave Hammered Double Pendant Necklace- Sadly I had to return this item as well. The necklace layers were tangled upon each other, and I was not able to successfully unravel them.

This fix turned out to be all about cargo, but it's all for the better because I love the cargo trend and I didn't have any of it in my current wardrobe.

Summer Book Challenge

Happy Friday and beginning of summer! I have so many books given to me by friends and family (mostly mom) that have been sitting on the shelf over the past couple of years neglected due to work, school,and life in general. This summer will be a little less stressful than last summer, so I hope to knock out this stack of books by Labor Day. My goal is by blogging about these reads I can keep myself accountable for finishing them. I am currently reading Brain on Fire (link to review here), which is a page turner, so I should be done with that soon. If anyone has read these or cares to read any of them along with me comment below!

The patient and provider perspective of Managing a Chronic Disease


With so many advances in modern medicine most diseases in America are now termed "chronic", which in layman terms means it's not going away anytime soon. While working as an emergency room nurse, I did encounter true "acute" conditions, such as appendicitis, stabbings and broken bones, however most visits were for uncontrolled or poorly-controlled chronic conditions. I now work as a nurse practitioner in primary care, where most of my job is managing chronic conditions. Uncontrolled chronic diseases I saw in the ER often manifested as heart attacks, strokes, suicide attempts and limb amputations, and thus I understand the importance of managing a chronic condition carefully. On a personal level I have suffered for the past seven years from a chronic illness known as endometriosis. Where my pain was not debilitating enough to prevent me from working, there were and still are many days I was in complete pain and didn't want to get out of bed. Endometriosis is a diagnosis that often takes many years to determine. There is no blood test to confirm the diagnosis, and most often it is not caught on pelvic ultrasounds or CT scans. Most cases are diagnosed through a laparoscopic surgery, as mine was, showing that I had stage III endometriosis with multiple adhesions and lesions. The surgery did help alleviate some of my pain, but I still have days when I have constant dull aching pains in the abdomen and pelvis. My experiences with endometriosis has shaped my practice as a nurse practitioner. My advice to anyone living with a chronic disease is as follows:

1. Find a provider you trust

I know from personal experience this is easier said than done, however continuity of care with a medical provider will improve your health outcomes long-term. In many areas of the U.S. there is still very limited access to primary care providers, let alone specialists. Until the age of 12 I lived in a rural town with a population of 1,000 with only one primary care practice. I also lived in Alaska where there are many remote villages that have only have access to a visiting medical provider once a month. That being said, if you are lucky enough to live in an area where you have options in choosing your provider, take the time to select a healthcare provider you trust. It's especially important to select someone who takes the time to listen to your needs and is able to communicate to you about your medical care, which will improve your health outcomes.

2. Take care of your mental health

When your mental health is not taken care of your physical health will also decline. Often this is a snowball effect, and as the illness progresses so does the decline of mental health. Having a diagnosis of a chronic illness will in many aspects affect your mental health. Facing the frequent pain and infertility associated endometriosis often lead me to feel anxious and sad. It's okay to feel overwhelmed by a chronic disease, but know when to ask for help. Seek out professional help when you need it, ask for support from friends, or find a support group for people going through your situation.

3. Keep records

It's always okay to ask for copies of radiologist reports, labs, and progress notes . The more information you have on your illness to take to appointments, the more it will help your providers and you. Before I entered the medical field I didn't know how important it was to have copies of medical records and never asked for anything. Now when patients bring me charts with lists of medications and dosages, copies of their hospital records, and imaging studies, I am so happy because it makes everything so much easier in knowing the next step to take.

4. Be your own advocate

Unfortunately many medical providers are overworked, and don't have adequate time to give to their patients. This is not an excuse, but it's the reality of the current situation. During the process of getting to the diagnosis of endometriosis, I was brushed off at appointments when nothing came up on ultrasound. Once at an appointment when I asked a question regarding my ultrasound, I was told to "google it".  Your provider may not have the time to explain all the pathophysiology of your disease to you, but should be able to point you in the right direction (not google) of where to find it. Always ask questions about your care and treatment, and if you aren't happy with your treatment make it known to your provider. The more involved you become in managing and understanding your illness, the better outcomes you will have.

5. Give yourself a break

As with any chronic illness there will be good days and bad days. There are going to be days when life just is miserable. Give yourself time to rest and take a break. For me it was hard because I lived a busy life and I didn't want to accept that some days the pain would be too much. Emotional stress only will further exacerbate symptoms of most chronic illnesses, so the best advice I can give is give yourself time to rest and don't beat yourself up about not being able to do it all.