Tag: advanced practice

Harness the Power of Neuroscience to Make Learning (or Teaching) Medicine More Efficient

Advanced practitioners are continually learning, from completing annual CME to hands-on education through daily practice, but medical education does not have to be so hard.

By Jordan G Roberts, PA-C

Perhaps you’ve heard the saying that getting a medical education is akin to sipping water from a fire hose on full blast. There is so much information to learn and so little time in which to learn it all. This affects each of us at all levels of training, from the student to clinician to academician.

If you’re a student, you may relate to the feeling of just trying to keep your head above water. It’s all too easy to drown in information or fall behind if you miss an important lecture or even a single day of studying. It’s even harder at this level because every concept, disease, medication name is completely new and foreign to you.

As practicing clinicians, we need to ensure we are obtaining a certain amount of ongoing, accredited continuing medical education every year. It’s all too easy to fall into the trap of doing things they’ve always been done when you don’t keep up as much as you’d like.

And of course, as an educator, it’s almost inevitable that some of the time you’ll struggle to find ways to help certain students academically. How does one teach another to efficiently retain and understand the important concepts crucial to patient care itself?

There is good news. Medical education does not have to be so hard. Researchers and everyday people have been developing and refining a technique that can take anyone’s memory to almost superhuman levels.

And it’s not hype. Peer-reviewed studies have shown this technique to be incredibly successful as well as easy to learn and implement. One trial showed that medical students retained more information in a shorter time period and improved their test scores by a significant margin.

It’s so successful in fact, that there are entire groups of ‘memory athletes’ who compete across the globe to determine who has the strongest hippocampus in the world.

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Jordan G Roberts, PA-C helps medical education companies create and distribute the best medical education around. He helps students and clinicians improve their clinical game by using his background in neuroscience to teach simple ways to learn complex medical topics. He is a published researcher, national speaker, and medical writer. He can be found at Modern MedEd where he promotes clinical updates, medical writing, and medical education.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Advanced Practitioners Bolster Practice Revenue, Productivity

Primary care practices with a non-physician provider to physician ratio of 0.41 or greater reported earnings of $100K+ more in healthcare revenue per physician.

A recent report from the Medical Group Management Association, which compiled data from 2,900 organizations, shows that primary care practices that employ a higher number of non-physician providers, such as physician assistants and nurse practitioners, generate greater healthcare revenue, as well as increase productivity. The 2018 MGMA DataDive Cost and Revenue report showed that physician-owned primary care practices earned $100,749 more in healthcare revenue per physician, and hospital-owned primary care practices earned $131,770 more in revenue per physician, by employing more non-physician providers, specifically a non-physician provider to physician ratio of 0.41 or greater. The data revealed that primary care practice operating expenses are increasing, as well, and have grown 13% since 2013, from $391,798 per physician to $441,559 per physician, which makes the added revenue from employing advanced practitioners essential. The data shows that leveraging physician assistants, nurse practitioners, and other non-physician providers could help medical practices overcome the growing burden of higher operating expenses, while also improving access to care and patient satisfaction.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

More Nurse Practitioners Now Pursue Residency Programs To Hone Skills

There is a growing cadre of nurse practitioners who tack on up to a year of clinical and other training, often in primary care.

Michelle Andrews

The patient at the clinic was in his 40s and had lost both his legs to Type 1 diabetes. He had mental health and substance abuse problems and was taking large amounts of opioids to manage pain. He was assigned to Nichole Mitchell, who in 2014 was a newly minted nurse practitioner in her first week of a one-year postgraduate residency program at the Community Health Center clinic in Middletown, Conn.

In a regular clinical appointment, “I would have been given 20 minutes with him, and would have been without the support or knowledge of how to treat pain or Type 1 diabetes,” she said.

But her residency program gives the nurse practitioners extra time to assess patients, allowing her to come up with a plan for the man’s care, she said, with a doctor at her side to whom she could put all her questions.

A few years later, Mitchell is still at that clinic and now mentors nurse practitioner residents. She has developed a specialty in caring for patients with HIV and hepatitis C, as well as transgender health care.

The residency program “gives you the space to explore things you’re interested in in family practice,” Mitchell said. “There’s no way I could have gotten that training without the residency.”

Mitchell is part of a growing cadre of nurse practitioners — typically, registered nurses who have completed a master’s degree in nursing — who tack on up to a year of clinical and other training, often in primary care.

Residencies may be at federally qualified health centers, Veterans Affairs medical centers or private practices and hospital systems. Patients run the gamut, but many are low-income and have complicated needs.

Proponents say the programs help prepare new nurse practitioners to deal with the growing number of patients with complex health issues. But detractors say that a standard training program already provides adequate preparation to handle patients with serious health care needs. Nurse practitioners who choose not to do a residency, as the vast majority of the 23,000 who graduate each year do not, are well qualified to provide good patient care, they say.

As many communities, especially rural ones, struggle to attract medical providers, it’s increasingly likely that patients will see a nurse practitioner rather than a medical doctor when they need care. In 2016, nurse practitioners made up a quarter of primary care providers in rural areas and 23 percent in non-rural areas, up from 17.6 and 15.9 percent, respectively, in 2008, according to a study in the June issue of Health Affairs.

[khn_slabs slabs=”790331″ view=”inline”]

Depending on the state, they may practice independently of physicians or with varying degrees of oversight. Research has shown that nurse practitioners generally provide care that’s comparable to that of doctors in terms of quality, safety and effectiveness.

But their training differs. Unlike the three-year residency programs that doctors must generally complete after medical school in order to practice medicine, nurse practitioner residency programs, sometimes called fellowships, are completely voluntary. Like medical school residents, though, the nurse practitioner residents work for a fraction of what they would make at a regular job, typically about half to three-quarters of a normal salary.

Advocates say it’s worth it.

“It’s a very difficult transition to go from excellent nurse practitioner training to full scope-of-practice provider,” said Margaret Flinter, a nurse practitioner who is senior vice president and clinical director of Community Health Center, a network of community health centers in Connecticut.

“My experience was that too often, too many junior NPs found it a difficult transition, and we lost people, maybe forever, based on the intensity and readiness for seeing people” at our centers.

Flinter started the first nurse practitioner residency program in 2007. There are now more than 50 postgraduate primary care residency programs nationwide, she said. Mentored clinical training is a key part of the programs, but they typically also include formal lectures and clinical rotations in other specialties.

Not everyone is as gung-ho about the need for nurse practitioner residency programs, though.

“There’s a lot of debate within the community,” said Joyce Knestrick, president of the American Association of Nurse Practitioners. Knestrick practices in Wheeling, W.Va., a rural area about an hour’s drive from Pittsburgh. She said that there could be a benefit if a nurse practitioner wanted to switch from primary care to work in a cardiology practice, for example. But otherwise she’s not sold on the idea.

A position statement from the Nurse Practitioner Roundtable, a group of professional organizations of which AANP is a member, offered this assessment: “Forty years of patient outcomes and clinical research demonstrates that nurse practitioners consistently provide high quality, competent care. Additional post-graduate preparation is not required or necessary for entry into practice.”

“We already have good outcomes to show that our current educational system has been effective,” Knestrick said. “So I’m not really sure what the benefit is for residencies.”

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Headaches in the Community

An NP with decades of experience discusses diagnosing and treating patients with headaches, based on what she’s learned by specializing in pediatric headache and pain medicine.

by Victoria Karian

Headache is one of the most common problems seen in the primary care office. It is often a chronic complaint, not easily managed, and often an unsatisfying experience for families and providers. You can’t cure headache like an ear infection, it will always come back in some form or another. And while headache is technically a neurological problem, at its heart, headache is a chronic pain problem. It is not as glamorous or interesting as many neurological conditions. Many neurologists are not as interested in headache as they are in other conditions. Patients and families are often challenging and the issues are often multi-factorial, comprehensive and complicated. Chronic pain is a field that takes a certain mindset and approach, not for the faint-hearted. I believe that a multidisciplinary wellness approach to care is best, and our job is to guide the families to adopt that approach. This is time consuming, requiring a lot of counselling and coaching, to achieve good results, and most importantly to prevent disability.

Fortunately, for those of us who work in the headache field, there are many wonderful patients and families, more than happy to work as a team to achieve good results. You can have your chronic migraine patient with several comorbidities including inadequately treated psychiatric issues and significant disability as your first patient of the day. Then you can have a patient with episodic migraine or menstrual migraine, with many family members with migraine, has learned their triggers, has a rescue plan, and is doing well overall. It’s really a mixed bag in the headache world, which makes it a bit different than the usual chronic pain patients, especially in pediatrics. It is also more enjoyable.

I think the most important thing is being able to accurately make the diagnosis, identify appropriate treatment, and obtain buy-in from the patients and families to accept the multidisciplinary approach to care. Since I work in a tertiary care outpatient clinic setting, our patients have already been evaluated, tried some medications or treatments, and have not had success. Patients may have had inadequate medication trials, been given incorrect diagnoses and treatments, and establishing trust is difficult. In these days, instant gratification is desired, and this is just NOT a hallmark of headache care. Daily medications can take a month to see effectiveness (or not). Lifestyle changes take time. Learning cognitive behavioral skills take a while to become effective. Establishing a healthy headache lifestyle along with adequate treatment options is a marathon, not a sprint. There’s a lot of trial and error. Without the families’ trust, this journey is made even more difficult.

For the community provider, having some good baseline knowledge of headache, is a great starting point. In the next posts, I will review the primary headache in pediatrics. Learning to recognize the specific headaches and common treatments, both preventive and rescue, is the bread and butter of headache medicine.

Victoria Karian has been a nurse for 38 years and a PNP for 21 years, most recently working in pediatric headache and pain medicine. Her blog, headfirstpnp.com, was started to share information and common sense insights into acute and chronic headache management with other pediatric providers.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Kim’s Blog: One of the Worst-Ever Days of My Career… and Advocating for Patients

by Kimberly Spering, MSN, FNP-BC

Think about the worst-ever day of your career. Do you have one? Can you recount, in excruciating detail, the episode that you ranked as your “worst-ever?” I’ve had a few… but this experience rates in the top-3 of all time.

My day started as any other routine day…but I paused when I reviewed the chart of a younger male, Spanish-only speaking dementia patient.

He had seen his PCP earlier this week, where his wife recounted that he had increased agitation, hitting her in the head so hard, that she had chronic headaches (and likely a concussion).

His wife had recounted to me that he refused to wash, refused to clean up after using the bathroom, and the only way she could make him change his clothes was to cut them off.

She shared a long history of their decades of married life. His dementia worsened several years ago, but significantly so in the past six months.

At my last visit, he became significantly agitated when I took his blood pressure. He paced non-stop; I assessed his heart rate and lung sounds while he walked. He hit me when I tried to check his temperature, pulse, and oximetry. As a result, I gave up on his assessment.

Today, I came to his home to find him asleep – for about 5 minutes.

His wife admitted that he started to hit her, even when she didn’t try to provide skin care or clean him up. This was a change from his baseline, where he would only become agitated with his wife trying to do personal care.

His risperidone had run out several weeks prior to my visit. His wife felt it caused lower extremity edema, so she did not restart it — and the edema improved. His PCP started him on low-dose Seroquel for his agitation about one week before my visit.

His wife flatly said, “he’s much worse now.”

I recognized signs of violence today. He was pacing, staring and swearing at me in Spanish. I asked his wife what he was saying, via an iPad Spanish interpreter. She wouldn’t tell me. I chose to focus on his wife and not engage him, as it made him worse. I found out later that he was threatening me in Spanish.

His wife admitted to being very afraid of him. After all, he hit her before, and he could not be reasoned with.

Desperately, I contacted our office social worker. She recommended that we call Protective Services.

Well…that person told me to call 911 and the police.

So, after doing so, stressing that the patient was acting erratically, threatening us, and that I was concerned about our safety…the first officer arrived 20 minutes later. Meanwhile, all of the preventative measures that our safety officers had discussed about our safety in the home was foremost in my mind.

And the officer? Well, he he was oh-so-angry at this call he was forced to take.

I explained the scenario. Oh, and remember, the patient/family was ONLY Spanish-speaking, which I mentioned to the dispatcher.

He rolled his eyes and scowled at me. “You should have called Crisis Intervention.”

I explained, through my gritted teeth, that I had done so, and only called 911 at their request. It didn’t matter. With a furrowed brow and muttered words under his breath, he radioed into his precinct, looking for an officer that spoke Spanish. He then informed me that, “no one working today speaks Spanish.”

Um, OK. I use an iPad for my Spanish-speaking patients. It’s required in health care. He refused to use my medical interpreter, who was still online from our earlier encounter. Finally, he reached one of the police department secretaries who spoke Spanish, who was instructed to talk to the patient. I reiterated that he had dementia and no ability to communicate. It didn’t matter; he told her to talk to him.

After many failed attempts, along with my pleading to have his person speak to the patient’s wife, he finally told the office person to speak to her. She clarified the issues, and agreed to complete his involuntary commitment admission paperwork. The patient’s daughter arrived, speaking some English, and the officer requested that she convey he needed to go to the hospital. She did. The patient balked. The officers walked him outside, then determined that he needed handcuffs to take him to the hospital… “for his safety.”

And let’s not overlook the nosy neighbors, congregating in their yard, noticing his predicament.

So let’s look at the global picture here.

1. Spanish-only speaking male with advanced dementia
2. Patient hitting his wife at random, argumentative, and a risk to himself/others
3. Heightened safety issues in the home…and a police force that took 20 minutes to respond to my call for a critical situation
4. A police officer who appeared to refuse to communicate with a Spanish-speaking family, until this NP insisted repeatedly that this happen
5. Need for medication management and placement in a long-term facility – which could only occur in the inpatient setting
6. Significant family trauma, as they witnessed their loved one being hauled off in handcuffs to the hospital

I think, without a doubt, this was one of the hardest issues I’ve felt in 27-plus years of nursing/NP practice. The grandson threw himself down in the yard, wailing. His wife sobbed non-stop, watching her husband being carted away like a criminal. And, let’s remember, he has Alzheimer’s Disease dementia with agitation.

He is not a criminal. He is not a derelict. He is not an “illegal immigrant.” Oh, but he just-so-happens to be Spanish-only speaking in a county that is predominantly Caucasian. And…oh yes, he has a NP who is a fighter and advocates for folks like him.

There HAS to be a better way to manage these situations.

A way without using restraints.

Not handcuffing folks who don’t have the ability to understand what is happening. Handcuffing patients should be an absolute LAST resort – not one that is convenient. And frankly, it will agitate dementia patients more if handcuffed.

Increasing education to our law enforcement about treating folks with dignity. These patients don’t understand, nor control their reactions. That doesn’t mean that they should be treated with harshness or lack of understanding.

Let’s imagine, if you will, having a relative with advanced dementia. One who is acting out more, being argumentative, resisting care. Would YOU like your loved one to be arrested and hauled away? Or would you advocate for those in the first response team to use compassion and try to understand the issues?

I’d bet, you would want the latter option.

It is our responsibility to advocate for these patients. Support their needs in declining cognitive function. Be their support when times get tough. Figure out ways to make life easier for them.

Wouldn’t we all want the same? Think about it.

Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

A Day in the Life of a Rural Nurse Practitioner

While the exact daily responsibilities vary according to the type of clinic or office where an NP works, most rural NPs enjoy a great deal of autonomy while performing a wide range of tasks.

from NP Schools

Currently, only about 20 percent of physicians working in rural areas are under 40 years old, and 30 percent are rapidly approaching (or have already passed) retirement age. Due to an aging population and a lack of experienced and trained professionals, there is increasing demand for healthcare professionals in rural areas, leading to a significant opportunity for nurse practitioners to pick up the slack. Take a look at what a typical day in the life of a rural NP looks like.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

From Physician Assistant to PA

“The word ‘assistant’ simply does not do justice to what PAs do in their practices these days,” says AAPA President Jeffrey Katz, PA-C, DFAAPA.

from AAPA

Discussions about the title of the PA profession are almost as old as the profession itself. In recent times, the issue has been debated at the House of Delegates (HOD) at least three times since 1998, including at the 2012 HOD, when a proposal to create a taskforce to consider the issue was ultimately voted down, and again in 2015. Numerous editorials have laid out arguments on all sides. But one thing that almost all PAs have always been able to agree on is that they are, well, “PAs.” And over the nearly 50-year course of the profession, the term PA has become widely recognized in the healthcare community and by patients.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

PAs and NPs Top List for 10 Best U.S. Middle-Class Jobs for the Next Decade

The future is all about health care and technology, and PAs and NPs are at the forefront.

from Market Watch

Nine of MarketWatch’s top 10 middle-class jobs for the next decade require a college degree, and five of those 10 need postgraduate education, on the master’s degree level and above. That includes the best two middle-class jobs, physician assistant and nurse practitioner, which the BLS projects will add more than a quarter of a million new jobs by 2026.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Physicians Look to Disrupt Longtime Regulatory Tradition for APRNs

APRNs are regulated across the U.S. predominantly by boards of nursing, but physicians are pushing for state medical board and regulatory control.

from Journal of Nursing Regulation

In June 2017, at the American Medical Association’s House of Delegates meeting, an amendment to a resolution impacting regulation of advanced practice registered nurses (APRNs) failed by a margin of 254-204, exposing not only a divide among AMA delegates, but a growing and continuing threat to the autonomy of APRNs. The amendment called for placing “APRNs under state medical board and regulatory control, with AMA developing model state legislation”. The underlying resolution was a measure opposing physician assistants from creating their own regulatory boards.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Physician Assistant–Friendly Legislation Boosts Pay

PAs practicing in states with a practice barrier reported lower salaries than their peers in states without that barrier.

from Health Leaders Media

States with more progressive laws governing the practice of physician assistants (PAs) also offer the Masters-prepared clinicians the highest earning potential, according to the American Academy of PAs (AAPA) 2017 AAPA Salary Report.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.