CNM/PA/NP, Home Health Nurses, and Stupidty

First of, my mail was not hate mail. I love this blog and read it religiously. There have been very few entries where I haven't laughed.

Most CNMs have their MSN or MS. That's not career college, that's graduate level education. Studies prove that patients are more satisfied with a CNM attended birth, and a 1998 study shows that neonates delivered by a CNM have a 33% lower mortality rate. Now, of course, this statstic is slightly skewed since the most complicated births are out of the CNM scope of practice, but it's still clear in studies that CNMs are very safe and an excellent choice for OB/GYN healthcare.

Also, studies show that patients cared for by NPs have the same clinical outcome, but higher patient satisfaction rates, when compared to MD/DOs. Also, a recent study shows that patients who have their HIV/AIDS managed by an NP/PA have the same clinical outcome. Unlike PAs *all* new grad NPs have graduate level education. PAs don't even need a college degree -- there's still certificate programs out there. So, if anything, you should be worried about them.

Just a comment on PAs....you should come here. In this state they can only write for 72 hours or 14 days worth of CIIs and CIIIs (and no refills allowed on CIIIs) depending on what the doctor they work under allows them to. And on the state board of medical examiners website we can check to see what their prescribing rights are. It makes it a little easier to keep them in check. But I totally get the frustration. I don't know how many times I've had to call and tell a PA that the strength of medication they wrote for doesn't exist. If they would just think a little bit before they write the Rx it would save them and me alot of time.

Ya know, its against federal law to fill a script for 10mg Methadone with BID 5mg. Or at least that's what I've been told.

In other news, I enjoy the blog.

Ok, so I am filling a new Rx for a NP that we don't have in our system. I call for DEA of physician that she "works under" since she doesn't have her own. The message I get is just f-ing priceless. "THIS IS SO and SO and I DO NOT WORK UNDER ANYONE. I COLLARBORATE (emphasize this word) WITH DR. SO AND SO. DEA # BLAH BLAH." Someone needs a reality check.

I'm getting tired of covering everyone's ass. We are the last bastion before the patient but not getting paid for it. We cover drs, stupid nurses, stupid parents, insurance company formularies, all insurance company contact with the patient (when they need a pa or can't have their medicine because pbm isn't making enough money), patients asses, etc. Louisiana rph's showed the whole country what we are made of. Someone needs to start listening.

I tried to choose the best "place" to share my personal experience with the local doc in the box.

First let me give a little credit to the doctor. We have jobs because they write prescriptions. Some of them may not have brains but they can write an RX

Second- I would like to thank all the patients out there in our "all about me society" because when you say I hope you get to feeling better what I would like to say, "A couple of days in bed is really what I need but you come first AND there is no one to fill in."

Except for annual physicals, UTI's, and an occasional break down because I have a 15 year old who (like the doctor's office) knows everything. It takes an act of congress to get me to go to the doctor. In three years I have missed one day of work to illness, not that I have not been sick other times, but I needed to stay near the porclein throne.

I leave work early one day this weak to head to the doc in the box because I have had this awful cough and drowning in my own snot sickness for a week now. Getting into the PCP is difficult when one cannot call in sick because there is no one to cover. Funny how that works.

I arrive, sign in, fill out the paper work, and proceed to sound as if I coughed a lung up as other sick people just stare. As if they are not there because of illness. Maybe it is just a social call for them...after all we have nothing better to do.

I finally get called to the back and the lady takes a brief history of the meds I have been taken for a week.

To make the story short. I was prescribed a
Z-Pak because apparantely I was running a temp that even I was not aware of and Sinutuss DM. Now explain this one to me. What is in Sinutuss DM? I do not mean literally...AFter all I work in the pharmacy and am familiar with the drug. The three ingredients in sinutuss are available OTC as 3 single products or in combination. What do you think the odds are I have medicated my self with the three products and other products just to cover the bases? The odds are high that I can multiply and get the same dosing.

I am sure many of us are in the same boat...we need to fill RX's to cover expenses. If you are not familiar with the product than you just got your miracle drug. The RX that will fix you. After all we only go to the doctor for him to write a RX because any RX will make a person feel better. It is almost like a patient who brings in the RX for you to fill. "How fast can you get this ready." Do you every want to say, "You mean any drug will do you just want it fast, right?"

Back to the story. The PA (who is fresh out of school and only has a temporary license) said to me, "I do not want to supress the cough because you need to get it all up." I just look at her and think you cannot be a complete dumb ass are you not familiar with all the products I have been taking this week. I just take the RX and walk away...I know I should have been more forcful but one cannot argue with ignorance. I call the next day and get some idiot who cannot speak english and you know is only working the front desk answering the phone and taking messages. Stupid me, this person graduated from medical school OVERNIGHT. I tell her the story blah, blah, blah. Well, this person tells me you have to give the Sinutuss DM a few days to work. HELLO, what have I been doing for a week. THE MAGIC RX is, after all, nothing I can get OTC. She puts me on hold and does not return. I go back to my busy work day and start fuming. I almost feel like I was being treated like a drug seeker. I call back later and ask to be transferred to the PA voice mail. Apparently the doc in the box does not have voice mail for the PA. I get transferred to the nurses station and explain the situation again, including reminding the "nurse" that the Sinutuss DM ingredients are availble OTC and I had already been taking that for a week. She takes a message and I leave my contact information which is the same as the pharmacy number and I do not hear from them again.

Why did this PA feel the SINUTUSS DM was the magic pill for me? Was it because I was not feeling well and did not look fresh and appealing by the time I got to the office. Was it because had slightly urinated on myself because I was coughing so hard I may have smelled like urine? Or was it that she was too stupid to realize the ingredients in the drug WAS the same thing I had taken all week. What did she get extra from the drug rep for prescribing my magic pill?

My prayer-"Dear god, please do not let the PA insult my intelligience as I call her again and tell her what I really need. Because if she calls in Benzonatate it may send me over the edge."

FYI-some insurance will not cover prescription medications when the ingredients of the medication is available OTC. But, I am sure we have all run across that problem before.

Higher/graduate education for paraprofessional occupations (which didn't need those qualifications until recently) is a time-tested political maneuver. It is really a status boosting tool that doubles as a pretext for scope-expansion in the future. Therefore, even they did give out PhDs for crapper-cleaning, it doesn't make crapper cleaners more productive or anything more than crapper-cleaners, contrary to what board members for those "professions" would vehemently insist. Instead, what will always dictate the status and position of a profession in society lies with the entry standards, demands and quality of the graduates.

The NP is just a politically-savvy class of nurses serving as a cut-rate GP. Many of them, I daresay, would not even be able to compete for a place in Pharmacy School much less, Medical School. Sad but true. If you didn't know that, now you do.

I am a PA student that will be graduating next fall. Although we do not receive the amount of pharmacology that PharmD's receive, we do complete an entire year of didactic pharmacology as well as a year of internship. Most PAs do not start writing Rx completely on their own for some time (usually an additional year). I can say that in my short time in rotations, I have seen medication errors on behalf of Physicians, PA's, nurses, as well as PHARMACISTS. Everyone is capable of making a mistake, so labeling all mid-level providers as being ignorant is just absurd.

Every profession has a small percentage of retards that the rest of us unfortunately have to deal with from time to time. Honestly, if all providers knew as much as you hoped they would... many of you Pharmacists would not have a job. Personally, I extensively look up all medications before presenting to my attending physician my treatment plan. When I graduate and enter into practice, I will continue to ensure that all medications I write for are the proper medication, dose, route, as well as the right choice for the patient. If ever in doubt, I will consult with my colleagues for assistance... or even contact a local pharmacist if I still have a question or concern about a specific medication.

I know that I am limited on every aspect of the medications that I will one day prescribe; therefore I must rely on other professionals to assist me in selecting the correct medication for my patients when I am in doubt. Perhaps there are those in my profession that feel as if they know everything� and make careless mistakes out of arrogance. I do however feel very confident in saying that it is a small number of individuals that are idiots and create a negative stigma that we all sometimes get lumped into. I just want to set the record straight for the remaining 95% of us that use good clinical judgment and know when to ask questions when we are in doubt. For there is always someone smarter than you on a given topic� and there is nothing wrong with seeking their advice when it comes to the treatment of patients.

I'm an intern and had my first experience with this yesterday. NP calls in and leaves a message for dilaudid and flexeril. So I proceed to call her back and let her know we need the hard copy for the dilaudid. She didn't give the patient a hard copy before they left the office and we had to deal with the aftermath. Fortunately, she was able to get a hold of the patient before they showed up at the pharmacy demanding their drugs.