Wednesday, 18 Oct 2017

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My Nurse Practitioner

Is better than yours.

Is better than many rheumatologists I know.

Is not only a great nurse, counselor, rheumatologist, complex disease manager, joint injector, diabetes expert, clinic leader, mother, wife, and friend – she’s the go to person if you’re a patient, coworker, colleague, cousin or neighbor.

She is one of few great partnerships in my entire career. To go to battle with an NP at my side gives me a tremendous daily advantage.

Leilani Law, ANP is “my NP”. For the record, I don’t own her; I just have the privilege of working with her daily. If you work with an NP or physician assistant (PA), you probably understand outright what I declare.

If you don’t work with an NP or PA, what are you waiting for?  For those of us who do work with NPs/PAs, he/she can be the perfect complement to you, the flip side of your coin, the person who completes you (at work). The benefits are innumerable- scheduling, depth of expertise, consistency, dependability, patient satisfaction, and the intangibles to name a few.

Schedule. I generally do about 7 half-day clinics a week, less during ACR and EULAR and I add a few clinics if I get behind. My clinic is in flux for numerous professional reasons. On the other hand, my NP does 9 half-day clinics, Monday thru Friday. She’s dependable like a Swiss watch. The staff knows it; the patients expect it and her partner rheumatologists are blessed by it. I may be traveling to an advisory board, or my partner could be on vacation, but my NP is there to manage the gout attack, the foggy mental clinic breakdowns and does the blinded assessor joint exams as required by research.

Consistency. I have worked for my NP for the last 20 years! We have an anniversary coming up next month. Can you imagine working with me for 20 years? She deserves a purple heart, a bronze statue in the lobby and eternal thanks for being my better half in rheumatology for so many years. What can I attribute such longevity and success to? I can only suggest it’s the same reason we rheumatologists love rheumatology – it’s the people, the quality of patient relationships and the problem solving inherent in rheumatologic care. Maybe she stays for the challenges and the work environment I’ve assembled.

When I was interviewing for an NP in September 1996, my NP’s name came up the same day from 3 different sources. Hence her hire was inevitable. Within a few weeks, it was clear she was a godsend, a keeper and ultimately the best hire ever. My unplanned plan to retain my NP evolved.

First was my deliberate plan to protect her from the mundane, ridiculous and tedious that may dishearten or dissuade. Instead I would challenge her with patients who she could learn from. If there was an OA knee patient in room 2 and a Wegener’s patient in room 3, she was going into room 3 and I took good care of the pedestrian OA knee case. Second, was respect as a coworker; this fostered better learning and better care between us. Lastly, reciprocation was pivotal in establishing a lasting working relationship. I asked for her help and expected her to ask for mine. Tasks, responsibilities, schedules were the same between us.

Patients. In the beginning, some of my patients were somewhat resistant to seeing Dr. Cush’s “nurse”. They wanted the boss man, big shot, even if he does run behind schedule. However, with my education, encouragement, and explanation that to see the NP would result in a doubling of the number of people directly responsible for the care and welfare of that patient.

Most caught on and when they did, it was interesting to watch my popularity wane as hers soared amongst patients. For every 100 patients that I’ve referred and co-managed with my NP, I’d say there are about 10 who still only want to see me, about 40 who we split care on, and nearly 50 who mainly want to see “Leilani, the nurse practitioner”. They prefer to see her for many, many skills – listening, completeness, phone call follow-ups, a kinder touch and others that I continue to marvel over. They know their rheumatologist is informed and in the mix when it comes to making important decisions. Thus, they prefer the time or temperament of the NP while also having access to their rheumatologist.

My NP is a hard standard for me to live up to. She’s always on time, always pleasant and happy and always right in her assessments and diagnoses. I’ve long given up the hope that comes with hearing one of her presentations and believing we would go into the room and I could show her something new or make a diagnosis; only to find she’d already documented the likely diagnosis of Behcet’s or psoriatic arthritis sine psoriasis. Quite wonderful and humbling. How lucky am I?

Intangibles. My NP brings great stability to a clinic, by her experience (amidst a sea of support personnel), regular schedule (in contrast to my helter skelter schedule/travels), training, authority and acceptance by patients. Outpatient clinics can be successful and productive if they can handle the volume that comes their way and do so in a cost effective manner. Having a leader in the form of a NP or PA is an invaluable resource for the MA’s and clinic staff.

I was lucky to have worked alongside several NPs early in my career at the University of Texas Southwestern Medical School. Since then, I’ve made the hiring of an NP a top line item in every job or business model I’ve been involved with. NPs have stabilized hectic clinical services, worked wonders (if not miracles) in research, became the anchor of a great team, got lots done and added to the tons of fun along the way.

Back then I learned that NPs were nurses first, very well trained in medical care and better trained in specific areas of medicine (e.g., geriatrics, adult care, etc.). Once they’ve chosen their career or job they tend to bloom as providers, teachers (of other NP’s or nurses) or managers in areas they specialize.

The Downside? You may train and create and incredibly valuable NP or PA, only to lose him/her to a better paying competitor or position. Sad for you, but great that you were integral in their success and in doing so, amplified the legion of musculoskeletal providers.

Advice. You need to invest in your NP/PA. First, educate and train and then demand autonomy and responsibility. Some rheumatologists I know tend to waste time looking over their shoulder, only to handicap their own time and care, with little overall gain in services provided. Wouldn’t it be great if you could hang a sign like McDonalds “over 20,000 served”? It will be hard to get there on your own. Hence you can either hire 19 partners (good luck finding and managing them!) or hire a few NP’s and PA’s.

May the sun rise and shine on your day, may those stricken and suffering seek your wisdom and then may you find your own Leilani Law, NP to bless your patients, practice and career!

Disclosures: 
The author has no conflicts of interest to disclose related to this subject
Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He is the Executive Editor of RheumNow.com and Co-Editor of the online textbook RheumaKnowledgy.com. Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Jack, I have three PAs who work with me directly. One is with me for 30 years (she and I were awarded the 2014 AAPA Paragon Physician-Partnership Award), and the others for about 14. They are invaluable and allow my expertise to be delivered to many more patients than I otherwise would be able - even when I'm away. They know as much as some of our colleagues and manage expertly our team of patients. Our entire practice of 14 rheumatologists and 22 advanced practitioners (PAs and NPs) is the model by which we all operate. As my partner Paul Caldron says, a highly competent APC is like having an excellent fellow who never leaves. JT
Jack I already bragged about my 'best NP" Betsy in Rheumatology Practice Models for 2016: How 1 + 1 Can Equal 3 Healio Rheumatology i.e. its published already!!!!!!!
So guys, if NP/PA sare "rheumatologists" and better than many physician trained rheumatologists - aren't we doing a disservice to our young trainees by encouraging them to go into Rheumatology? If folks with less than half the training can do an equal or better job - why should they spend the extra years training to be a rheumatologist? I'm not being argumentative. Many in the government are pushing for non MDs to manage pt with the argument that physicians are not needed so much. Are you generally in agreement with this??
Yvonne; I think many rheums are looking for young new talented trainees - and struggling either find them or keep them. There is already research out there that questions the return on investment in those seeking to do a rheumatology fellowship and specialization. You can make the same money or more by just being an internist. But this blog and this issue isnt about money - I didnt even address the cost advantages of hiring physician extenders. This is about who makes your practice better. I have several partners, I wish I had more nurse practitioners like Leilani Law. This blog was a tribute to her and a wake up call for those who have never considered such a hire. Lastly, I do support efforts to have more NPs and PA's. There will be 60 million arthritis patients out there in 2020!, There are currently 1.3 million RA patients and we "rheums" are taking care of less than half of them. I would argue our time and skills are tied up taking care of many who should be getting their care elsewhere from PCPs, neurologists, etc. I am totally against subjugating the care of OA, FM, gout and tendinitis to NPs and PA's. Their talents should be cultivated to take care of RA & lupus too