EP 5: Practice Setting Considerations—Making Informed Decisions & Securing Employment

How do I find the right practice setting for me as an NP? In this episode, our hosts dive into the best strategies for picking your “niche” in the medical field—touting the benefits of shadowing in diverse clinical environments. We compare and contrast the most popular positions that NPs occupy, and consider stress levels, work-life balance, compensation, inter-clinic support networks, and more. 

Be sure to like, subscribe and share this episode, and leave us a review on your preferred streaming platform!  

Have questions, an inspiring story, or clinical pearls that you’d like to be heard on air? Email nplaunchpad@fhea.com.

--

YouTube: https://youtu.be/dDbIQ99CH3I?si=trdJMYf8C3UBNA0X

Visit fhea.com to learn more!

Transcript

Voiceover 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico-Denino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Christopher Gleason 0:28

Hey there, Christopher here, kicking this episode off on picking your practice setting, which can have huge short and long-term implications for you. Joining me are my friends and colleagues, Vanessa and Jason. How are my friends doing this week? Vanessa, how are you?

Vanessa Pomarico 0:43

Good. Doing well, thanks.

Jason Gleason 0:44

Doing great. Where does the week go by? Yeah, time flies.

Christopher Gleason 0:48

No kidding. So, Vanessa and Jason, our topic this week is picking a great practice setting. Any thoughts on this, challenges and successes you may have had? Vanessa?

Vanessa Pomarico 0:58

So, you know, picking a practice setting is always tough because if you're interviewing for a particular practice, everybody's going to be on their best behavior while you're in there for an interview. My suggestion is that you always spend a shadow day, whether it's four hours or eight hours. You don't expect to get paid for it, but it certainly will give you a really good idea of how the practice runs, how patients are processed from the time they check in into the, you know, get into the exam room. You'll hear how people talk to patients on the phone and that kind of thing. But it'll also give you a really good idea about the prescribing habits for the other people that you may potentially be working with. And I always say that this is an investment in your future and to spend the time shadowing in a particular practice so you can really figure out whether that's the right site for you.

Christopher Gleason 1:50

Absolutely. That's some great advice, Vanessa. What do you think, Jason?

Jason Gleason 1:53

I I agree a thousand percent. You know, I I think you're gonna before you buy a car, you're gonna take it for a test drive, right? I mean, that's what it's all about. And and so I'd recommend exactly what Vanessa said. You're not gonna be paid for it, but spend some time shadow, right? And I think if you're still in school out there, because we have some NP students in their last six to 12 months of their program tuning in, you know, if if you're still in school out there and if you know a place where you want to work for sure, like that's your dream job, go to them and say, hey, can I shadow here for for a few days? Or better yet, get a preceptor there for your clinical hours. It's almost like your audition for employee future employment, right? So what a great opportunity to learn about them. They can learn about you. And who knows how that'll go out. But if you don't do these things, if you don't do these things and test it out for a drive before you you buy the car, you can get into a place where you've taken a job, you're into it, and you hate it. And you don't want that. You don't want that for them, for the patients you're serving, or for you. So be sure you take the car for a test drive around the block and uh hit the accelerator.

Christopher Gleason 2:53

All right. So let's look at some different practice settings and do a little bit of a compare and contrast. So first up, let's look at primary care versus urgent care, what changes day-to-day. So primary care, there's continuity, there's uh you're looking at chronic disease, prevention relationship building, and long-term outcomes. In the urgent care setting, you're looking at high volume, rapid decision, um, a lot of procedures, uh injuries, and a lot of ruled out thinking. Now, when we're looking inpatient, what are we looking at? We're looking at rounds, admissions, discharges, consults, team coordination, and systems navigation, which can be really, really challenging at times. Um then when you're looking at practice settings, one of the things you want to ask is ask about pace. You know, scheduled visits versus walk-in versus sentence driven days. There's as they all of them have very different stress profiles. One of the things to look at too is if your clinic um pays you based on RVUs, because that in and of itself can be can be very stressful uh stress inducing. And for those that don't know what RVUs are, basically you're paid per visit. And and uh when you're doing the interview, ask about support. You know, do you have imaging and labs on site? Is there specialist access? And who's who's there to back you up for uh tough cases? Jason, what are your thoughts on the pros and cons of telehealth?

Jason Gleason 4:10

Boy, Christopher, so many good points that you brought up. You know, I I just think it really hammers home to you have to be comfortable with your site, right? And and all the things that you you you put forward here about knowing what do you do with those tough cases? What do you do when you're in the middle of nowhere? And I'll tell you what, you you don't think NPs are gonna be put in that situation. They are. In our state of Montana, as I mentioned a number of times, geographically we're the fourth largest. We're really spread out, but we only have a million people. So you might be the only NP, the only healthcare provider at all. Some patients have in the middle of nowhere within 100 miles or so. So it's so important you know who your resources are. And and here's something to consider if you're a new NP out there and you're applying for jobs, often what we do as human beings is we jump to the first job offer, right? Yep, oh, I've got a job offer, good, I'm gonna be making all this money, it's gonna be great. But make sure you match up your experience, your interests, your your past experience as an RN and certainly your training as an NP. Because if you get into a situation, let's say you're an NP with not a lot of experience, and you take a job in the middle of nowhere, okay, that's fine on most days where you're doing, you know, day-to-day stuff, routine visits, those kind of things. But you're also covering the emergency department. Think about this. What are you gonna do when an MVA happens near you and somebody comes in with a brain injury? What are you gonna do with somebody with a sucking chest wound? Because that's the reality in the middle of nowhere. So if you think, oi, I'm I I would not do good in that setting, don't take that job. Because in some communities, I think there is such desperation because they're so understaffed and there's such a need that they're not gonna just take anybody, but they'll be happy to take somebody that's qualified on paper. Make sure it's beyond the paper, though, for you. Make sure it fits with you for safety. For patient safety, it's paramount, but also for you for you from a liability standpoint. So that's what I'd recommend. Regarding telehealth, I think telehealth is amazing, especially for our rural underserved areas. What a great, fantastic tool it is. An example in Montana here, it can take a lot of time for a neurologist to respond to a stroke code. Telehealth, the patient's in the ED, they go to CT, it confirms that it's been confirmed that they don't have a hemorrhagic stroke, they're a candidate for TPA. They get telehealth on board within five minutes. The neurologist, who might be thousands of miles away, is evaluating the patient, talking to the team, looking at imagings that have been uploaded to the system. And within minutes, they can make life-saving decisions uh in those cases. So telehealth is remarkable when the resources are available uh for the institution and for the providers to utilize.

Christopher Gleason 6:41

Vanessa, what are your thoughts?

Vanessa Pomarico 6:43

So I think in terms of a practice setting, a lot has to do with your personality and where your interests lie. So, yeah, let's face it, primary care is not for the faint of heart. Um, I'm one of those people that I happen to like having relationships with entire families. I had one of my most brilliant students who had been an ED nurse and didn't want to do primary care. She did it for a little while, didn't like it. She very much liked that quick turnover, you know, the rapid decision making, being able to do very procedure-driven practice. And so she subsequently ended up in the ED and in urgent care. And I think, again, depending on where your interests are and the type of personality you have, you have to really choose wisely about where you want to go. If you're kind of an introvert and you're not good with high volume, working in an ED or urgent care is probably not going to be the best thing for you. And you're going to be unhappy with it. That's not to say it may change your mind, but I think fundamentally you really need to look at your wish list like you would anything else, whether you buy a car, a house, you're dating, you're pretty much dating your profession to kind of see where do I want to land. In terms of talent.

Jason Gleason 8:00

Oh, go ahead. I'm sorry.

Vanessa Pomarico 8:02

Go ahead.

Jason Gleason 8:03

Oh, with that, I was just going to add the point. You know, when you talk about volume, right, in our walk-in clinics in ED, here's a reality check for you. We're talking 40, 60, 80 patients a day, a shift.

Vanessa Pomarico 8:13

Right.

Jason Gleason 8:13

I remember working a 12-hour shift in a walk-in, 80 patients. It was insane. And if you're not used to that volume, Vanessa, right, you're going to get buried. You're going to get buried. And I would add to that, if your personality, if you're, if you have a personality where you're more like relationship building and connection, long-term commitments, if that's more your personality, then primary care would be great for you because that's what you're going to do with those patients, build that relationship over time, right? But if you're of the personality where you're very impatient at times and maybe you don't really have a lot of your compassion meter tends to deplete quite quite quickly, right? Where patients drive you absolutely bonkers and you wish never to see them again on the face of the planet Earth, right? You never ever want to care for them again, then the ED or the walk-in is probably a good place because you're not likely to see them on a regular basis. But if you love relationship building and that long-term commitment uh to care with people you really get to know well, primary care would be a perfect place for you to set up shop.

Christopher Gleason 9:09

And Vanessa, you were going to touch on telehealth?

Vanessa Pomarico 9:11

So telehealth, you know, I think telehealth is is really changed the landscape of healthcare, and it's been a huge um boon in terms of patient access. So losing telehealth for me was not a good thing. And I was really advocating that that they kept it. But you know, it's it's not without its own problems. So, like Jason had mentioned, you know, about the ease of being able to, you know, access care and that kind of thing, telehealth is great. But for those patients that don't have a smartphone, don't have a computer, maybe live in a rural area where they still have dial-up internet, uh, it becomes a little bit more challenging in terms of navigating that because you know, you can have 20 people on your schedule for the day and they say, oh, so-and-so can't come in. They want to do a telehealth, and now you're waiting and waiting. And this happened to me just a couple of weeks ago. 25 minutes, the patient could not get on. They couldn't hear me, they couldn't see me, they they didn't have uh the they didn't know how to access, you know, turning on their microphone and that kind of thing. Um, they didn't really understand their smartphone. And so it threw me behind for the whole afternoon. And my it ended up being an hour and 15 minutes later before I got onto the visit. So, you know, it when you're trying to stay on time, which I try very hard to do with my patients and to be respectful of their time, sometimes the telehealth can be a challenge. But I think all in all, telehealth is here to stay as long as our insurance companies uh will continue to pay for it because it really does help with that access to care. And that was proven during the pandemic when um many offices were closed or patients weren't driving to different places. And it was really a lifesaver for those of us in practice.

Jason Gleason 10:56

Well, and Vanessa, when you mentioned uh, you know, patients that are not very tech savvy, at the VA we have video calls with our patients. I remember when they launched this, I was seeing an older couple, I was seeing the gentleman in this older couple, and um, his wife was running the laptop and trying to get the camera angle, you know, to show me a rash. And I saw parts of his body I in the office shouldn't have never seen, right? So so you never know. Tech savvy is it's so critical, right? They have to know how to use the devices so we can really evaluate them well. So great point.

Vanessa Pomarico 11:27

And be appropriate with what they're what we're triaging because it's kind of a very similar situation um with a patient who had he wasn't sure what it was, but it wasn't a hemorrhoid. And his wife was acting as the as the photographer. And before I could say, no, no, no, no, please don't do that. The next thing you know, uh you did mention this in the beginning. So please garbage. Don't be offended by this. But the patient literally bent over, spread his cheeks, and the wife went into a close angle. And I thought, oh, we have taken telehealth to a whole new level. Um so we have to set some boundaries with patients as to what's appropriate and what's not appropriate. You know, and the other thing with telehealth too is the privacy issue. You know, if you have somebody that's not doesn't put their earbuds in and the whole family is listening to the conversation that I'm having with them, it's not necessarily a private visit anymore. Or they have the TV on so loud that you have to say to them, could you please turn off the TV? Or they're not looking, you know, they're looking away. And they're answering, you know, uh uh, uh-huh. But I could tell that they're watching, you know, die hard on the on the on the movie. So we we, you know, it it has its own set of problems, but I think all in all, it really has been a huge bone for um for health care.

Christopher Gleason 12:44

Excellent. Absolutely, absolutely. So speaking of uh telehealth, when you're looking at telehealth for a clinical practice, what are the things you're gonna be looking for? You're gonna be looking to have strong history skills, you want to have clear red flag triage. These patients are in their homes, they're in locations that may not be near um uh medical access. So you're gonna know, you know, when you're doing when you're doing the assessment on them, when you're uh working with them, are they having those red flags that that's gonna make you want to send them to um a more higher level of care? And you know, it's have comfort setting limits, you know, when you need when they need in-person care. And that kind of goes back to being being able to understand that uh red flag triage and being able to send them that higher level of care. So another practice setting is an FQHC or RHC. So RHC is rural health care. FQHC is a federally qualified health center. We touched a little bit on rural health centers earlier um when uh Jason was talking about a little bit about stroke access and things of that nature. As far as FQHCs, it's called the uh Federally Qualified Health Center. I usually used to work when work as in one, excuse me, as a registered nurse. Um they do a lot of care uh care with Medicaid and Medicare. Um they have a high emission impact, definitely uh a lot of complex social determinants. And um and the good thing about them though is they have common loan repayment pathways, and actually I utilized it to uh repay my student loans from from nursing. So that was a really um uh good benefit for me. So the once you're going beyond the FQHC, let's go into a little bit of specialty, let's go into the deeper expertise, the narrower problems, and often a steep um early learning curve, but great mastery later. Touching a little bit on this, I um I used to work in primary uh not primary care, excuse me. I used to work in pain management, and that is very, very specialized. So going from the primary care setting that that family care into the pain management setting, there was a huge learning curve for me. And it took me, you know, I would literally say probably months to get that a good understanding and a good footing under me. So when you're going into the specialties, uh that's something to really, really take into consideration. And actually I would ask uh both you, uh uh Jason and Vanessa, what do you guys think about specialties and and the requirements of going into specialties? Vanessa?

Vanessa Pomarico 14:57

So, you know, I think it's always important to have a good, solid primary care foundation because many of our specialty problems stem from a primary care problem. Now, does that mean that somebody coming out of school can't go into specialty? No, absolutely. They could probably pick up on it. Now, for myself, um, you know, having worked in gynecology, both um gynecology surgery as well as GYN oncology, for me it was just a natural extension to go into a general gynecology office as my first job as a nurse practitioner. And that was a skill that I took with me when I went into primary care. So it was something, a good skill, like you said, it was a much deeper expertise, um, more focused problems, but I was able to bring that into primary care at a time when many of the GYNs were not taking certain insurances. So it was a it was a win-win for the patient, but also for the practice setting. But I think for some people who find primary care to be too overwhelming, going into a specialty care is a really good place to start because they can focus on, you know, one particular area, they can become experts in that practice, and they can really become, you know, uh, like you said, they master all of those particular specialty expertise or problems fairly quickly because it's really just more of a focused practice. I think the the thinking of, you know, back in the day when you got out of nursing school and they say you need a year of med surge underneath you before you go into anything else, I think that's all kind of gone by the wayside. We don't know, we don't longer think about things like that because you can become a master in a specialty practice without having that primary care behind you. But it certainly makes it a little bit easier if you have some primary care experience. Jason?

Jason Gleason 16:48

You know, I I think these are great points. I I um when when I think about specialty care, the NPs that get right out of school, get a license, certified license, everything's done, and they become a hospitalist. I think you should approach that with great caution, right? Because being a hospitalist, you got to know everything about everything. And a lot of stuff can go wrong very quickly with the patients, and you're expected to know that. And a lawyer, a patient's safety, they're not gonna care if you're new or not. They just want their life saved and treated correctly and and and safely. And so I think that would be an area where if you're gonna become a hospitalist NP right out of school, uh, first job ever, then I would definitely make sure there's a very strong mentoring program. And we're talking not not for a week or two, but we're talking months, if not up to a year, and lots of good support where you're not overwhelmed and given, you know, five ICU patients, you know, your first week, those kind of things, but you have to have such strong support. It's all about that. And Vanessa, you spoke to that and Christopher. Um, the other the other thing to this, let's flip it around a little bit. Let's say you go into specialty care as an NP because you love neurology. You love it. You're an FNP trained, you graduated as with an FNP degree, and but you love neurology. So you go into neurology for like a year or two, or maybe five years. You love it. But then you want to switch over to primary care. What you're gonna recognize is you lose what you don't use, right? And those primary care skills that you learn so intensely during your FNP program, a lot of those are gonna go to the wayside. So, in those cases, because some of you out there listening or watching, some of you are facing that. You want to move from specialty back over to primary care, whatever your degree was in. Don't go into this thinking, well, all those skills are gonna come back to me like riding a bike, because the reason they don't is medicine and nursing changes so often, daily. We're getting new guidelines and treatments and all those kind of things. So, so I'd recommend if that's you out there, you know, we often think of our board review courses at Fitzgerald as, you know, just for NP students preparing for their boards. It's not just for that, though. I can't tell you how many times I'm so blessed and honored to have practicing NPs attend our NP board review courses for FNP and Adult Giro uh um curriculums. And it's just great to have them in class. And what I hear from the most is I'm going back into primary care. I'm going back into adult zero, and I need to bone up on those skills. It is a wonderful reset. So if that's you out there, that might be a resource you really want to consider that may not have been on your radar early on because you think, oh, NP board review course is just for new NPs. Nope. It's for CE. It's for CE. If you're transitioning from specialty back to primary care, go for it. Yeah, and I love to have those folks in class. So just a word of Jason. Vanessa, are you seeing that in the review course?

Vanessa Pomarico 19:30

I am. And I have to tell you, I felt like you were describing me because I had gone into specialty care as soon as I got out of school. And after three years, I thought I would lose my mind if I saw one more yeast infection. You know, and it was it had gotten to the point where like my schedule was like every 15 minutes, whether it was a new patient, an annual exam, a problem patient, a follow-up, whatever. And I just thought, okay, three years, I've done enough, you know, GYN, you know, to satisfy me. And everybody I knew thought I had lost my mind when I took a job in primary care. And I was so, after three years, like you said, everything had changed. And I remember that's when the JNC guidelines had changed. So my hypertensive management, you know, skills were outdated and that kind of thing. And I did exactly what you said. I took the review course and it was perfect for me. And I kept that book as my Bible on my desk. And I had to then, but fortunately, I worked with a wonderful PA who really took me under his wing. And he was my mentor for a year. And he really helped me kind of get my feet wet because it had been four years since I had done a primary care rotation. So it was like starting all over again. But it is possible. So I will just tell people if you're thinking about going into primary care, remember that you have a skill set that will never leave you if you're in a specialty care. Like, say you're in neurology, you can take migraine management, um, or you'll have the ability to diagnose other brain disorders or movement disorders a lot easier than those of us who have not had that kind of background. So you'll always take that skill with you into primary care, and it will it will help your patients in the long run.

Christopher Gleason 21:15

Excellent. Absolutely. And speaking to that, Vanessa, as I stated earlier, I worked in prime uh pain management and we did a lot of uh interventional pain management. So we did a lot of procedures and injections on the um the doing ESIs or epidural steroid injections. So we did it on the cervical spine, lumbar spine, things of that nature. And now working back in primary care, those assessments that I was doing in pain management, I have I've now brought over to primary care, and it's really kind of helped my practice in that regard. So it's great. So looking at, or speaking of specialty care in general, you really want to clarify the onboarding process. So there it specialty often needs a defined ramp and strong physician and pee mentorship, which is what we've we've touched on kind of throughout our podcasts. You want to clarify documentation. And coding expectations, as these can vary widely by sell by setting. So, Jason and Vanessa, what are your thoughts about call schedule, support staff, and autonomy? Vanessa?

Vanessa Pomarico 22:11

So, call is a little dicey subject. I speak an awful lot about this nationally, and it really depends on the setting. But it call being on call after hours is an expectation of our position as nurse practitioners in a practice. Patients have to be taken care of after hours. And sometimes you get paid for it. The vast majority of the time you do not get paid for call. As I said, it is an expectation. Now I've worked in practices that I took call for a weekend. I got a hundred calls from Friday at five o'clock until Monday at eight o'clock. I could barely take a shower without my phone buzzing and the answering service saying, call us, call us, call us. I'd be on with the answering service and someone else would be calling in with another message for me. So then when I went to my next position, I said, How busy is your call? Because I'm not going to agree to take call, you know, without being compensated if it's that busy. And every one of the providers said, if we get 10 calls in a weekend, that's a lot. And they were true to their word. They really, it really did hold to that that we get very few calls. And a lot of it has to do with how well you train your patients and what is considered an emergency versus what can be wait until the following weekend. So call is a lot. Support staff, I would not take a position if I didn't have a medical assistant working with me because it is inconceivable for a nurse practitioner to have to room their patients, do a med reconciliation, see the do your history and physical on the patient, do all of your orders, get your prior authorizations and everything else that our patient that our medical assistants take care of. So if there's no support stuff that's dedicated to you, then I would say think twice about that position. Additionally, you want to make sure that you don't have a medical assistance that's being split between you and somebody else in the practice, because that means somebody's going to run behind because that medical assistant can't be in two places at one time. So it's really critical that you have your own dedicated support staff person. And honestly, the patients appreciate it because they get to know the patient and they the patients know who they need to call if they need to get a message to me. And in terms of autonomy, again, that's part of the interviewing process and whether or not you're going to be micromanaged by the physicians who own the practice, or whether you will have the autonomy to practice to the fullest extent of your licensure. What do you think, Jason?

Jason Gleason 24:44

Ditto to everything you just said. You know, I would say that at the VA, I absolutely love the VA. I think we do so many good things, and it's really a national leader for models of healthcare. And one of the things I was so blown away by when I went to work for the VA, which has been about nine years ago now, is that when you're a provider at the VA, in general, not always, but in general, in primary care, you go in and you have a team. Every provider primary care provider has a team, whether it's a physician or an NPB in the provider. And the team is composed of you as the provider, you have an RN assigned to you or on your team, uh, and they act as the case manager. So they're they're handling all the behind-the-scenes stuff typically that keeps the key, honestly, keeps the place going. Really, they're just brilliant and they're amazing at what they do. And then you have an LPN that checks in your patients for the day and handles the patient stuff, you know, that comes in through the door and that kind of thing. And then you have an MSA or an administrative person that handles scheduling. And every provider in the ideal VA setting, every provider has that team. And I'll tell you what, it improves productivity, it reduces cost, it improves patient safety, and satisfaction goes through the roof, not only for the patient, but for the provider. Because when you have a team and you're well supported, Vanessa, like you said, that support is so vital, right? But we're spoiled in many ways. It's the ideal setting. But I've also heard colleagues in the civilian world, and I've seen this, they show up, they're the nurse, they're the provider, you know, they do it all. And that's not fair to you. And it's unsafe. It's unsafe. So great points. Great points.

Christopher Gleason 26:15

All right. So looking at more um information on specialty, uh, what's your one of the things you want to ask is safety notes. Okay, so what happens when you're stuck? What happens when you're behind or worried about a patient? Who do you call? Who are your what are your resources? Knowing that can be key. Also doing a culture check. Do people help each other or do they drown quietly? Do you work in I've worked in settings where like Jason said, you are the you're all you are the only person there. You know, you're the you have a provider and an MA and an MA or medical assistant, and that's all. And in those settings, it's your support is this non-existence, which can be very not only very frustrating, but it can burn you out quite quickly as well. All right. So, Jason and Vanessa, what final thoughts or tips do you have regarding practice setting and building a decision framework to pick the best location to practice? Vanessa?

Vanessa Pomarico 27:09

So one of the things I did with my students, uh, their very last paper to me was um, and I had a page limit on it. They had to take all of the best aspects of all of their clinical rotations and all of the not so good aspects. And they were to develop their dream job. And this was not busy work because I'm obviously the one that had to read it, but it was really to get their minds thinking about what did they want in their dream job? And, you know, would they be able to achieve it? Was it even something that was reasonable or feasible? So I think that you really have to think about what do you want in a job? And how much are you willing to advocate? How much are you willing to give up? And how uh do you have the strength to say no and walk away from that particular position? Because I always say your first job is not necessarily your last job. With every job that you take, every job that you go through, you take something else, you learn something that you'll bring with you. And that's really the basis of our podcast. We talk about all of the things that when the three of us were talking about what do we want people to know? This is so important for people to know that you know, you when you take a nursing job, many times people stay at that job for their entire careers. There's nurses that are still working on the GYN oncology unit that I worked on, and I've been out for 28 years, and they started after me. So they're still there and that's what they want to do. That's not so the case with nurse practitioners unless you happen to get into a place that truly is a wonderful position. And one of the things I want to just say is don't necessarily go by the salary. So there's a practice in our area that they offer, the starting offer is $150,000 to $200,000 a year for nurse practitioners. That is way above the average salary for this particular area. And I always say to my students, you know, if if it's too good to be true, it probably is. So, and come to find out they don't have a support person, they don't even have an office that they can document in. They have to put their laptop on a shelf that's like right outside the patient bathroom. Wow. So you have to look at all of those things. So I would say write down all the things you liked about your clinical settings, the things that you didn't like, and then see if whatever job interviews you go on and check those boxes for you.

Christopher Gleason 29:36

Jason, what are your thoughts?

Jason Gleason 29:37

You know, I love everything that you just said, Vanessa. Especially, again, the bottom line for me would be know what you want before you go in. Because you're excited, you're a new NP or you're switching specialties over to something different you've never done before, right? So you that enthusiasm, that adrenaline rush of even having an interview and a possible job offer may have you settle for less than what you're worth, right? And it's not all about salary. I completely agree. It's about the benefits, the work-life balance, the quality of the folks you're working with, all of that. Yeah, Christopher, anything that you'd add?

Christopher Gleason 30:07

And I agree with both what you and Vanessa said. Um I think going into any sort of work environment, you really want to pursue a passion. I mean, do something that you're gonna love to do. Are you gonna love to go to work every single day? Absolutely not. But if you pursue a passion, there's gonna be more days that you love what you do than there are that you're gonna that you actually hate what you do. So that would be my, I think, my one key takeaway and one one piece of advice. We want you to write your top five values, then match each job to those values, not just salary. Look at the different values. What what do you hold true to your uh self and what do you want to look for in a job? And then score each offer. Look at mentorship, schedules, scope, support, mission, compensation, and and what's your growth path path? You know, do you have any do you have any path for success or path for elevation in the in the company or also run a worst day scenario? We've talked a little bit about this and and how your your why can kind of pull you through that worst case scenario. But what would a bad day look like to you in this setting and can you tolerate that? Look at um two offers. Do they tie? Choose the one with better mentorship and systems, not the one with a shinier title. And also, again, looking at salary and you know, not not letting that be your only factor in picking a job. And remember, your first job is a runway, not a life sentence. Here are some great resources that we are putting here on the screen for you and in the show notes, so you don't have to write them down. All right, so next up is our favorite game, fact or fiction. This is where we'll ask questions, and Jason and Vanessa will say if it's fact or fiction. Do we get prizes? I never asked. No. We should get prizes.

Jason Gleason 31:51

What do you think, Vanessa?

Vanessa Pomarico 31:52

I think you're right. I think we should get prizes. Like, I should get one of those little mugs that you have in front of you.

Jason Gleason 31:57

Oh, mugs, yes. Would you like a mug? Yes. Write to us. We may we may send you one. Your gift is my presence. We like swag.

Christopher Gleason 32:05

Your gift is your gift is my presence, Vanessa. I'm sorry. Listen to him.

Jason Gleason 32:09

Listen to this guy. I want the trip to Florida or Hawaii. Come on.

Christopher Gleason 32:14

All right. So fact or fiction. Vanessa, more autonomy always means more support.

Vanessa Pomarico 32:20

Fiction. Absolutely. You need to have that support.

Christopher Gleason 32:26

Oops, sorry, go ahead, Vanessa.

Vanessa Pomarico 32:27

I just said you need you need to have that support. And just because you're autonomous, you still need to have somebody because, again, we don't know everything. And so on those days, as autonomous as you are, you may have a problem that walks in the door. You should be able to have somebody that's going to support you with that.

Christopher Gleason 32:43

Absolutely. Absolutely. So, Jason, the same great job can feel totally different in a different setting. Fact or fiction.

Jason Gleason 32:50

Oh, absolutely. I'd say, yeah, yeah, definitely.

Christopher Gleason 32:53

Okay. And that is true. Vanessa, call schedule is one of the biggest hidden drivers of burnout. Fact or fiction.

Vanessa Pomarico 33:01

I would say fiction because call doesn't necessarily need to be that bad. Um, the hidden drivers of burnout, qual may be a piece of that, but it may be all of the other things like not having a support person and too many people on your schedule and you know, overloading and double booking and running behind. Those are more hidden drivers of burnout, I think.

Jason Gleason 33:22

Absolutely. I agree. I I don't think a call schedule alone would be a deal breaker. Right. Right. But it's part of it. It's part of it though. Yeah.

Christopher Gleason 33:29

So next up, FQHC work is always lower acuity than private practice. I'm actually going to take this one on because I worked in an FPHC, and this is most definitely false because we had some very high acuity patients at times. All right. Next up, we're going to do our um audience QA. This is your time to email us your questions, comments, all of those fun things. Our email address is nplaunchpad@ fhea.com. That is nplaunchpad@ fhea.com. First up, which settings are you choosing between and what's your top non-negotiable? Jason?

Jason Gleason 34:04

You know, I would say pay, and that sounds really greedy of me to say that, but I I again I think that NPs are underpaid. Out of all healthcare professions, NPs and nurses are just underpaid for what we do and what we put up with, honestly. And we sell ourselves short. And it's a hard it's a hard thing to change because we're taking jobs because we need to. We need to make an income and a living, right? So pay it's up there. And don't be afraid to say that. It doesn't mean you're greedy. It means that you need to get what you're worth, right? You need to feed your family and you need to have money saved in the bank for retirement. Often we settle for less. Don't do that. Don't do that. But here's the problem: the more of us that do that settle for less, we're never going to get ahead because they're always going to hire that person that will settle for less. And then the one that wants to get more is going to be out on the street, right? So we have to push for that as a profession, not just as NPs, but as nurses. And then I would say for me personally, it'd be schedule. And I can see where these things would be based on the individual, you know, your values and your family and work-life balance. But pay and schedule probably be the most important to me. Vanessa?

Vanessa Pomarico 35:08

I I could not agree more. Um, you know, I think all of them are equally as important, but you know, you don't want to take a job for $80,000. You know, you could be very happy with it, but it's not going to put a roof over your head. And like Jason said, I think for those people that accept lower salaries, they ruin it for the rest of the profession. Um, and so we have to really make sure that we're getting paid what we're worth. And schedule, that's a deal breaker for me. If I was gonna go in and they said to me, you need to see between 30 and 40 people in an eight-hour day, well, I would say bye-bye. Find someone else. Because my schedule, I have to have control over my schedule. And I know that sound makes me sound like a real control freak, um, but you need to have some modicum of control over your schedule because only you know how much time it's going to take and what your rhythm is. And if somebody is going to keep piling double bookings onto your schedule and you don't have the ability to say, stop, there's too many people. You know, I and you look at the schedule and you've got a 92-year-old coming in who has, you know, five really huge comorbid conditions in a 15-minute slot, it's unreasonable. So we we have to be able to uh to really advocate for ourselves.

Christopher Gleason 36:20

Absolutely, absolutely. And I agree with you both. I think you know, looking at your salary and um and your schedule are key in finding that right job. So, what's one interview question you wish you asked before taking a job?

Vanessa Pomarico 36:33

Vanessa Well, there's a lot of questions I would ask, but one of my biggest peeves is to make sure that we are good antibiotic stewards. And so I'm gonna just tell a quick story. Um, I know somebody that had come to me, um, was taking this job. I strongly encouraged them to do a shadow day. They didn't do the shadow day, they took the job, and within one day of being there, realized it was a pill mill. And the doc was writing out a ton of narcotics. And it was a, you know, 10-minute visits over and over and over again. And um, she ended up having to leave the job, obviously. And and the practice ended up being closed by the Department of Public Health. So I would I would ask that about uh how many, you know, what kind of conditions do you have in the practice? Are there a lot of narcotics that are written? And then making sure that they're good antibiotic stewards. Because if the one thing I don't like hearing is when the patient says, Oh, Dr. So-and-so just gives me two ZPACs because the first one never works.

Christopher Gleason 37:34

Yep.

Vanessa Pomarico 37:35

Run. Jason, what do you think? Yeah, right.

Jason Gleason 37:39

You know, we could have a whole episode on antibiotic stewardship in itself, right? It's such an important topic, and I'm thrilled that you brought it up. You know, um, I I don't know about you guys, but tell me, you know, I can, I think it's a good estimate that the last time I wrote a script for a sinus infection was about 12 months ago, right? Because we're bombarded all the time with the request. But here's a reality check for those new NPs out there. It's very, very seldom and rare that you're writing scripts for antibiotics. It should be that practice, right? With that stewardship in play. And again, it comes down to, you know, like what was it, 98% of all sinus infections are viral or environmental, only 2% are bacterial. So that's such a great, and I would not have thought of that during an interview to ask that about antibiotic stewardship. What is one way, because like at the VA, Vanessa, we have reports that come from our pharmacy. They track antibiotic prescribing. Does your clinic do that for you? Like give you a report, like when was the last time you prescribed antibiotics or how often?

Vanessa Pomarico 38:33

No, because we're an outpatient clinic. We're the primary care affiliate for our large hospital system. So unless they're running like a metrics program, they really don't, they don't do that because it's an out, it's not a huge system like the VA system is. However, um there are um audits, chart audits that the insurance companies do. And they will send you like a monthly or a quarterly summary of what you've prescribed. Um, and so that's where you would find, you know, am I am I ordering too many of these or not enough? And like you said, I have to tell you, last week, or this week actually, was probably the first time that I actually wrote out a prescription for a patient for a bona fide sinus infection because she had gotten sick a few weeks ago, she cleared up, and then she got better, you know, that double sickening.

Jason Gleason 39:24

Yeah.

Vanessa Pomarico 39:24

Um, and then I thought, okay, this is like classic sinus infection. But every time a patient says, Oh, it's green when it comes out, okay, well, that that that color doesn't make a difference to me.

Christopher Gleason 39:37

No, all those are great, great points. So, next, let's um let's start off with our three tips and tricks that you guys can take home for the week. So we talked about shadowing and interviewing someone in two settings before committing. This is so, so important because you do not want to end up in a setting that you're not gonna be happy in. And like Vanessa's friend ended up leaving in shortly after starting. Ask support questions. What's the MA rate ratio? What's RN coverage? Do they have triage? Does do they have call or on and what's their onboarding process? You know, write a one-page ideal day and compare it to each setting's reality. What's their hours, acuity, and call? And your MP practice project or homework for the week is list your top three non-negotiables, schedule, salary, autonomy, and rank them. Thanks so much for your time. It's been an honor for all three of us to connect with you during during this episode. Can you please do us a favor? These simple actions will help us grow this podcast, broaden its reach so all of us can help and support more of our NP colleagues and friends across the country and around the world. It's easy. Please drop a five-star rating, hit follow, tap subscribe, and most importantly, share this podcast with your colleagues, family, and friends so we can continue to build a community of friends looking out for, supporting, and strengthening each other. As we sign off, stay tuned for our next episode. Clinic Workflow and Templates. Have a great day.

Voiceover 41:06

You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.