Saturday, March 10, 2012

On Jobs and ultimately, Identity

hello blog readers!

it's been quite awhile but I've finally had a spell of time to catch up on sleep and thinking and so here i am, back in the blogosphere. currently i'm in sunny san diego for a conference for the nla--that would be the national lipid association--and the proceedings of this meeting thus far has prompted me to reflect further on something i've been thinking a lot about for the past 7 months or so and that is: what am i?

by this, i mean not my heritage (although it is a long running joke amongst friends close and not-so-close friends as to whether or not i'm filipino chinese or just straight chinese. i think i've finally found the answer, by the way. to borrow a phrase from my hs bff's husband: "i'll be whatever gets me the most stuff." actually i believe he said money, as in scholarships, but you get the point. while money is nice, i will also accept food, special service and treatment, and hugs). i mean my job.

years ago when i endeavored to take on nursing school in new york, i had not realized exactly how much political, professional, and personal strife being a nurse could produce. and the fact that no one knows really what nurse practitioners are, what they do, etc, that strife just multiplies, about 10-fold. people know what nurses are. in fact, i was well informed prior to entering the field. "you're going into nursing? but don't you have to like, clean up shit? literally?" and indeed, there was a lot of shit cleaned. 6 garden south, the floor that taught me basically everything i know, is notorious for prolific poopers. people in hospitals know what nurses do: we give meds. we clean shit. we "page the doctor" (i'm not sure if i'm the only one who does this but sometimes i don't actually page the doctor. especially if its a question where all parties involved--me, the patient, the doctor--know the answer is no.). according to grey's anatomy, sometimes we service the doctor, in a questionable, grey-area kind of way. and this is a very safe niche in which many nurses thrive (not with that last part). that's what makes them so good at their jobs--they have very well defined roles.

it gets a little hairy when you leave that safe little bubble. when i tell people i'm a nurse practitioner, there is inevitably a slight pause, a puzzled glance, a cock of the head and the dreaded question: "what... exactly IS a nurse practitioner?" it's incredible that these people eagerly devour every bit of news in the Times about how their blood thinner medication might cause "anticholinergic effects" (never mind that they don't actually know how these things might manifest themselves) but despite the positive press that NPs have gotten in the last 10 years or so, i still have people (who are purportedly "used to working with NP's") asking me to pass on messages like a goddamn secretary, not really sure what my role is. nine times out of ten i am referred to as "the nurse" or "the PA" and i have no choice to respond, whatever pride i may have swallowed, anger set aside.

i think part of the problem is that i myself am not really sure what i am. columbia university's school of nursing, being among the first ones in the country like it, was highly politically charged, surging forward with creating degrees like the DNP which didn't do much except cause even MORE confusion, and as such, my young health care provider-naive self was inundated with"NPs are better than MD" statements that sounded dangerously like upsetting propaganda. casual one-liners like "stay out of the hospital in july--that's when the new doctors come in" and over-exaggerated stories of brilliant nurses defying doctors to save the life of the patient catapulting the heroic role of the RN above that of the MD just further confused me about what exactly i should be looking forward to at the end of 2.5 years of nursing school, after which i would join the ranks of (assumed) MD-ball-busting NPs the world over. if i can't answer the question myself, how can i possibly hope to educate the discouragingly witless masses who have no clue about what it is i do apart from refilling their xanax prescriptions?

NPs have been called many things by the media, including "mid-level provider," "physician-extender," and oddly, "media darlings" (not sure where that last one came from, but it's so weird that it actually came from the media. is that like a journalist's version of talking in the first person?). of all of these, while "media darling" sits best with me, i think the one that i'm most apt to agree with is "physician extender." and NPs can bristle at this all they like, i don't give two flying fucks. i would never work in isolation from an MD and i would never presume to think that my pitiful training (or lack thereof--) could even begin to equal theirs, and i think it's crucial to work alongside one. does that make me an extender of a physician? in the words of my super wise, soon-to-be-four nephew: my not know. other[negative] words that come to mind that involve the word "physician", that may or may not involve my job are: lackey. slave. bitch. ass-wiper (figuratively this time). more positively: collaborator, helper, right arm, keystone on which his practice stands without which all of his patients would leave him for his lack of availability. see? there are really no good words.

i think the best way i've heard my job described was by a friend who i went to nursing school with and she remains an RN but currently works in a job that, interestingly enough, was previously occupied by an NP, further blurring all boundaries. she says that she differentiates between RNs and NPs like this: "RNs are nurses that you think of in the hospital, and NPs are nurses that are like doctors." when i protested this description (but what will columbia think!), she shrugged her shoulders and said, "the patients aren't going to know anything beyond that."

and it's true. at the end of the day, the masses aren't going to give two shits about whether or not i can diagnose or prescribe or write soap notes or whatever. what they want to know is:" are you going to give me a fucking zpack to kill this cold before it starts?" (the answer is no, now go fuck off.) or "i am in pain/throwing up/shitting myself literally and i'm scared i'm going to die. can you answer whether or not i am?" and usually the answer is yes.

while i may not have a concrete defined answer as to what exactly an NP is, i sure as hell have a very defined list of what an NP isn't. an NP is not:

1) a fucking secretary. i can't tell you how many times i have been requested to call a patient back only to find that they only called to ask if i wouldn't mind passing on a message to the Doctor? actually i do fucking mind. i have a secretary whose job it is to do that and God help me if someone else asks me to let my boss know that she self adjusted her dose of lisinopril to 5. wait, now 10. wait now 7.5. now back to 5 again. shoot me in the face.

2) a telephone advice nurse. my sister uses this all the time when her kids look funny and she's not sure if she should take them to the urgicare center. it's a great service, very helpful especially for people who are looking to not burden an already overburdened health care system. do you know who answers the phone when you call the advice nurse? a NURSE. an RN. NOT A NURSE PRACTITIONER. that's because RNs are already awesome at triage and have no problem saying "yes you should go to urgicare" or "no you're overreacting." people dial the office for some spectacularly stupid shit. and they always demand a call back. because no they don't want to come in for a visit. they just want free fucking health care over the phone. while i don't have a problem with free health care [FOR THE UNINSURED] these people have health insurance. get your lazy asses to the office so i can bill you like a proper provider. have a cold? make an appointment. have a uti? make an appointment. think you broke your ankle? making an appointment. think you have pneumonia? feel "really fatigued" and you don't know why but you have a 1 month old in the house? think you have low testosterone-induced fatigue but you actually have food coma every afternoon? want to discuss all 50 supplements you're taking to make yourself the virile 55 yo male you want to be? MAKE A FUCKING APPOINTMENT.

3) your shrink. once a patient (over the phone) wanted me to call in a new script for zoloft because her home-bound self had so much time to think about absolutely nothing that she decided she was depressed and wanted an antidepressant. i told her that she should really be followed by a mental health professional and her response was, "why do i need to talk to someone? i'm talking to you now, aren't i?" i had no words, except that she needed to make an appointment.

4) faceless prescription generator. do you know how many times i've gotten a request for a prescription, filled it, and then got another request for THE SAME PRESCRIPTION? upon inquiry, explanations i've gotten included: "oh its cheaper for me to do it this way," "oh i'm travelling and forgot my pills (but didn't forget your viagra, did you?)," "oh, i hate that pharmacy, this one gives me what i want," and my favorite: "I JUST CHANGED MY INSURANCE AND I'M REALLY POOR [even though i still own a place in manhattan, rocked up to your office in a mink coat, and drive a bmw that i can afford to keep in the city] AND YOU JUST NEED TO DO THIS FOR ME OKAY!!" and don't even get me started on the ambien prescriptions. i wish that a study would come out about how it causes cancer and then everyone would stop taking that shit like candy. and they're very feral about their refills. on the dot every month i will get a request to fill their ambien/xanax/valium prescription and if i don't, i will get 5 calls harassing me. also these patients can request things online and i get requests that no one in their right mind would "refill" like: malarone (an antimalaria pill), cipro (for potential traveller's diarrhea) and new rxs for antipsychotics with no documented history of ever having been prescribed them. EVER.

5) a patient bitchbag*. this is really a followup of #3, but once i got a request for a call back to discuss "patient's health" but in fact what he really wanted to do was keep me on the phone for THIRTY MINUTES so he could complain about how his specialists didn't "exhibit a clinical curiosity to get to the bottom of my issues." never mind that they fixed him and he no longer had said issues, but what do i know, i'm not an MD. want to complain about something? GET A WIFE. listening to your problems is either her problems or a shrinks, not mine.

6) an MD bitchbag*. this is particularly troublesome, since i'm friends with so many of them and my interest in self-preservation is often pitted against in their well-being. i think this is a two-part problem. i am a nurse. nurses are supposed to be compassionate. i think i sometimes buy into this (even to my own disadvantage) but other people 100% buy into it. the other part of it is that i am in a unique position to understand everything the MD goes through but without the ability to one-up their horrific day with something even worse, a potential danger if they were to attempt to bitchbag a fellow MD. i could not, for example, say "suck it up, cupcake" because my day couldn't possibly be as bad as theirs. as an NP caught in a compassionate RN role, i am stuck sympathetically clucking (despite my jaded attitude here, it's almost always genuine. the sympathy, not the clucking.) (well, also the clucking). the reason why i am convinced that my presumed role is as a bitchbag and not, for example, confidant or consoler is that this well-intentioned sympathy somehow manages to breed more bitching. instead of being mollified by words of comfort, the clucking, etc begets MORE bitching. there are a few MDs that are prone to drive-by bitchbag bomb me; while i sit innocently in my office, they burst in, explode and then flee. funnily enough, this relationship is rarely reciprocal. were i to complain about my day i would get silence, a dumb stare, or ignored. it's a little degrading.

so in conclusion, while i may not know exactly how to define my role or my job or even my identity, when i think about the emotional and mental drain of constantly combating these misconceptions, the emotional, needy life-suck that these patients can be, and the lack of nourishment i get professionally and personally as an NP, i can think of at least two words that explains what i am:


*what exactly is a bitchbag, you ask? is it a noun or a verb? here's a little education: it's both!


n. "Dear patient, i am not your bitchbag. Sincerely, your friendly NP."
(note: this is not the same as a douchebag, which means: "to be a bag of douche." instead it means to be a receptacle in which people place their bitching. it's sort of like being a garbage can, but instead of holding trash, you hold bitching.

v. "i can't believe he just drive-by bitchbagged me! now i have to catch up on work AND try to detox my life."

it is not a pleasant thing to either be a bitchbag or to be bitchbagged. both experiences--to be in the constant state of bitchbag, and to active state of being bitchbagged-- are soul-destroying, for the victim (in terms of soul) and perpetrator (in terms of karma, if you believe in that) alike.

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