EP 14: Collaborating with Physicians/APPs — Agreements & Escalation

This episode explores physician–nurse practitioner collaboration, scope of practice, and the evolving landscape of full practice authority across states and healthcare systems. The hosts share real-world experiences from hospital systems, the VA, and private practice to highlight how regulations, employer policies, and credentialing requirements impact new nurse practitioners. Listeners will learn how to protect their license, navigate collaborative agreements, understand credentialing, and confidently practice to the top of their scope. 

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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.

Vanessa Pomarico 0:35

Hi everyone, and welcome back to NP Launchpad. My name is Dr. Vanessa Pomarico, and we are here today for episode 14 to talk about the physician and nurse practitioner collaboration and scope. And I'm joined by my friends and colleagues, Dr. Jason Gleason and the soon-to-be Dr. Christopher Gleason. Hi guys. Hello, how's it going? Good. So excited about this.

Jason Gleason 0:58

So excited about this topic. My gosh, did we just think alike? We did, didn't we? Yeah. Yeah. This is a heavy topic for so many listeners out there, I think, don't you?

Vanessa Pomarico 1:06

I I do agree. And it's going to be such a rich discussion because we come from such different uh practice backgrounds. So we'll be able to talk a little bit about what you guys see in the in the VA and then what I see out in the uh, you know, the hospital systems. True. So just a reminder to our listeners, uh, any questions, please send them to nplaunchpad at fhea.com. That's nplaunchpad at fhea.com. And we might just answer one of your questions on air. And remember, just as a quick disclaimer, that our podcaster for education only, we are really here as your friends and colleagues, but we're not here to offer any legal or clinical advice. All right, so let's jump into the scope of practice 101. Where are we gonna where do we begin? So, you know, in Connecticut, we got full practice authority in 2014, which I was very excited about. I was one of a team of nurse practitioners here in Connecticut to get full practice authority. So this is something that's really near and dear to my heart. I'm one of those people that uh look at the uh the AMP map like it's my job to see who's gonna be the next state that's gonna turn green. Uh do you guys have full practice authority in Montana?

Jason Gleason 2:18

We do. This is the Wild West, so we have no other option in in many of our uh smaller towns. So yeah, yeah, we have FBA. Yep. Yeah, we've had it for years, over a decade.

Vanessa Pomarico 2:28

So the nice thing is that the two of you work for the um the VA. And I know that there was a big movement a few years back where everybody in the VA got full practice authority, and we thought, oh, this is gonna be great. If the VA is gonna do it, then the rest of the country has to follow suit. So uh is that is that true? Can you talk to uh the audience a little bit about what it's like to have full practice authority within the VA?

Jason Gleason 2:54

We absolutely would love to talk about this topic. It's so important, and we've had so many nurse practitioners out there work so hard to bring FBA to the VA. And it was a long process led by Penny Jensen out there. Penny, if you're listening, we give you a big shout out and a big, huge thank you for bringing FBA uh to the VA across the country, coast to coast. Every nurse practitioner out there now can practice independently within the VA uh because of the strong work of Penny and so many others. So, yeah, Christopher, what do you think about?

Christopher Gleason 3:20

So when I first started practicing, I practiced in Vermont, which actually does have full practice authority. Okay. So I had I had full practice authority there. In New York, I had to work with uh under the license of a physician and then moving to Montana again and working for the VA have full practice authority again. I really enjoy full practice authority. I think it is something that is key for uh NP's practice, especially in the rural areas, because oftentimes we do not have a physician to collaborate with. And if we don't, then you know, there's a lot of um not just veterans, but there's a lot of patients in general that just won't receive care.

Jason Gleason 3:51

Right, right. You know, you know what's an interesting thing when they implemented FDA across the VA, most NPs out there were very welcoming of it. But we did run into a little bit of resistance in some areas from nurse practitioners that were used to practicing, you know, with a physician close by and having them sign off on on most things that they did. And there was some kind of nervousness about it, like wow, now I'm gonna be able to practice independently. So there there was a little pushback even from our MP community, not much out there, but it was an interesting dynamic to think we fought so hard for this. And then, you know, some some of our colleagues, you know, kind of not drug their feet, but were just nervous about implementing it because they were so used to working so closely with our physician colleagues and now to be independent, that was a big change for them. And and rightly so. I can certainly understand why some of our colleagues out there would be nervous about it. But yeah, we're just so grateful we have FBA coast to coast now and and the VA is rocking it.

Christopher Gleason 4:43

So you'd think the uh physicians at the initial start of the FBA for the for the VA would have been like on board with it because it takes workload off of them, you know, because they're consistently having to sign off orders, sign off notes for for nurse practitioners with a collaborative agreement without without the need for that. That takes a huge workload off of them.

Jason Gleason 5:01

But Vanessa, how was it for you when because you were right there on the front lines when this change happened? How was it in your community? Like how did the physicians respond initially? And then did they get to a point where they thought, I kind of like this. This is nice to have these colleagues that are independent.

Vanessa Pomarico 5:15

So, you know, as I said, I I worked with a team of nurse leaders in Connecticut to get full practice authority. And it was when I was the president of our state nurse practitioner association. So it wasn't just one person, it really takes a village. And we had a really dedicated team of nurse practitioners. And one of the first things that we did was we really encouraged a lot of our nurse practitioner colleagues to then apply for for independent practice, which was nothing more than filling out a form online. And that's when we got the pushback from some, like you said, Jace, not a lot of people, but there were a few people that said, I don't want this. And I think I think a lot of people who give us that pushback are the ones that are not terribly confident in their own practice because I think that they were just concerned that that what they perceived as their safety net was going to be moved away. And and one of the things that I always talk about is is the fact that even though you have full practice authority, so in Connecticut, you have to work uh um three years and 2,000 hours. And it can't be, you know, you have to meet both of those. So if you're working part-time and you don't get the 2,000 hours, you have to get three years plus 2,000 hours before you can apply for independent practice.

Jason Gleason 6:29

Oh, wow.

Vanessa Pomarico 6:30

And and so it it depends on each state with their board of nursing and what are your nurse practice act actually spells out because it the scope is really what's defined by law. It's really not what somebody lets you do. So you so for those people who are listening, you really need to be familiar, very familiar with your nurse practice act. And this can be found on any state website and their Department of Public Health website. And this is especially important if you're planning to move to another state. So, for example, you know, we kind of split our time between Connecticut and New Orleans. Well, New Orleans and New Orleans is or Louisiana is not a full practice authority state. So if I ever plan on practicing down there, I would then have to find a collaborator if the institution where I went to go work didn't have one. So, and that can be that can be money, and we'll talk about that in in just a little bit later in the program. But so for for our listeners, they really have to make sure that you know you're familiar with your board of nursing, what the nurse practice act is all about, and and then the prescriptive authority, the prescriptive authority, you know, the schedules can vary um depending on what state you're practicing in. And as we know, you have to have now they've made it uh mandatory that within the next five years, everybody has to do an eight-hour training, which we talked about in one of our previous um episodes. Yeah. But so you need to think about what schedule medications that you're going to be allowed. You need to think about fulfilling the required CEs for prescriptive authority, but you also have to think about the collaborative agreement. So even though we work in a full practice authority state, the hospital systems here still require nurse practitioners to have a collaborative agreement. And when I first went to go work for the company or the organization and they handed me a collaborative agreement, I remember the doc saying to the whatever, whoever the higher up was that was there for me to sign it. And he said, Do you have any idea who she is? Like, not that not that everybody knows me, but he knew I was very involved in it. And so, and I tried to educate them and said, This is not even keeping in line with state statutes, but it was because it was a very old bylaw and a bylaw that wasn't going to be changed because our physician colleagues don't want that. And I don't know, you know, is it that they I've heard a lot. Um, some physicians feel that we don't have the education behind us, and so we shouldn't be allowed full practice authority, that we need to be micromanaged and we need to be um, you know, under a microscope. And then other people, you know, I got the feeling when we were going through our hearings that some of them were just a little bit threatened by what we do. Um, although I wouldn't ever hear that out of anybody's mouth. But then we have the other kind of pace is that we have uh our physician colleagues who would go to the mat for us. And they oh yeah, they came out and they went against their physician colleagues and they said, you know what, we're in favor of this. And so I really think it depends on how deep the pockets are for the AMA in your particular state and whether or not they are going to be able to pay their lobbyists a heck of a lot more than we can pay ours to help fight for it. So you know, you really have to think about that and you have to think about who's gonna sign your collaborative agreement because some places will not pay for that and you have to pay out of pocket. And I've heard up to $30,000 or $40,000 to pay for a collaborator. Um, there was one nurse practitioner that very sadly here in Connecticut, her um, her physician colleague, it was just the two of them in a practice, and they were in a very rural area of Connecticut, and he died very tragically, I think in a motor vehicle accident. And she was trying to find somebody to be her collaborator and couldn't find anybody. And she finally found somebody and they wanted $30,000 and like 10% of her income. And she ended up having to close the practice, right? Isn't that crazy? She ended up having to close the practice because, you know, that kind of money was just going to put her out of uh business. And it's funny because I actually kept a little checklist to see how many times do I actually go to my physician, and we have we have three of them in our practice, but yeah, uh, how many times do I actually go to them with something? And the amount of times that they came to me was equivalent to the amount of times that I went to them. It is.

Jason Gleason 10:55

It's their colleagues, right? Yeah, and we appreciate them. I know I certainly appreciate my physician colleagues and we appreciate each other, you know. You know, in Montana. Oh, go ahead. I'm sorry.

Vanessa Pomarico 11:05

That's okay. I I was just gonna say that that was one of the things that we brought up in when we were doing the public health hearings, you know, is that we are, you know, the c collaboration is inherent in our fields. So we should never think about not collaborating with people. We do interdisciplinary collaboration all the time. Oh, it shouldn't be any different as a nurse practitioner.

Jason Gleason 11:27

Not at all. Not at all. Yeah, I agree completely. You know, in our state, it's so interesting. Over my two decade career, I started out in family practice in one city in Montana. And in that city, NPs were like put under the thumb of physicians everywhere. It was crazy. I mean, even though we're a full practice authority state and we were then, but the practice I worked with, the physicians had to keep an eye on everything we did, right? And control everything. But it it got to the point where it was really affecting patient care because we had a nurse practitioner who was a pioneer, amazing, brilliant nurse practitioner that left the practice, which was a big medical group that I was an employee of, she left that practice and started one on her own. Well, when she went out on her own, even the radiologist in town, and this is a town of about 35,000 people, so not many radiologists in this area. And you know, in in a town, there's a group of radiologists that do all your readings, and if you're not friends with them, and if they don't want to do your readings, then you're kind of sunk as a practice, right? And so when she left this big practice to go out on her own, she got blacklisted and she was brilliant. There was no all of her skill set, her knowledge, everything, her competency was a hundred percent. There was no reason why patients should not go to her. But just the fact that she was an NP going out on her own ticked a lot of people off to the point where they blackballed her to the point where the radiologist in our community of 35,000 refused to read any of her radiology diagnostics. Anything X-rays, CTs, mammograms. So her patients would have to drive 35 miles to the next town to get any kind of diagnostics done. And as you can imagine, sometimes these are serious tests that patients need, you know, life-threatening things that are going on with them. And so it was just a nightmare for her. But she took them to court and she won, you know. So and I share that example because every state is even different within a state. Like you can be in one city where it's very restrictive and they know how to work around the FPA, you know, in many ways, physicians do for whatever reason. And then I moved to a larger town in Montana, 70,000, and they're very friendly to NPs. And we have a lot of independence, right? As we should. So our listeners out there, if you're in a town or city where it seems pretty restrictive, check the cities around you. And some of them can be quite close by and they can be completely night and day different from what you're experiencing where you're at uh currently. So so check out all options.

Christopher Gleason 13:42

I'm kind of questioning why they don't um push for full practice authority for MPs. If we look at primary care as a whole right now, there's a huge need for providers in primary care. Yeah. And a lot of MPs actually fill the role of of uh primary care providers. So you think that they would be pushing for you know nurse practitioners to get full practice authority because a lot of physicians aren't going into primary care, they're going into the specialty market.

Vanessa Pomarico 14:09

Yep. We see the same thing here in Connecticut. And and and again, that I think that's why we were able to get it. We first of all, we showed up with a lot of data, you know, the safety data, you know, how many uh nurse practitioner visits, our patient satisfaction surveys and and that kind of thing. But, you know, again, our our listeners really need to know what goes into having full practice authority. And then as a new provider, you might, even though you move from like like Jason, you moved from a full practice authority, you know, um, job into a different position. People need to know that when you're uh when you're applying for a different position, that you need to know that sometimes the facility policy is not necessarily going to align with the state policy because the some facilities, as as I said, the organization I work for, they override the state law. But then also, too, when you're when you're applying for your privileges, which is different than full practice authority, but when you're applying for privileges at that hospital or within the hospital system, even if you're not admitting patients there, they sometimes want you to do that. It's actually called like a refer and follow um privileges. But you need to make sure that you don't sign up for something you're not trained or competent to perform.

Christopher Gleason 15:23

Right, absolutely, right. Absolutely.

Vanessa Pomarico 15:24

You know, so anything that like certain procedures, let's say putting in or taking out a Foley, you know, taking out IV lines, that kind of thing is not an issue. But sedation, um, certain high-risk medications, certain procedures that you didn't learn in your nurse practitioner program doesn't mean that you see one, do one, teach one makes you an expert. So make sure that you're not signing up for something that you're not trained. And you that, you know, again, in a court of law, if you get called in there, they're gonna say, Well, what made you train to drop an A-line? You know, and in my in my nurse practitioner was uh a program was a family nurse practitioner. We didn't learn things like that again because it was a primary care education. So um that becomes an issue. So, you know, really just again, making sure that you know what your board of nursing scope or practice is and um, you know, what your organization's scope of practice is. So these are just some of the key points. They're actually going to be in your show notes. Um, so I'd I'd like to actually move on to a couple of other things. Um collaboration and supervision rules, things like signatures, charts, and agreements. Do you have any of that at the VA?

Jason Gleason 16:35

You know, we we don't have to have a physician sign off on our charts, but we do we have chart reviews. So we do chart reviews on each other. It is well organized. Yeah, it's random, you know, random charts are picked for every provider, and we have to do so many every quarter. And it really is it's a nice system. Yeah. And they pick different quality metrics, so we have to look through the chart. And then if we're seeing a lot of red flags, then it goes to a different level, right? Where that provider might have more intense review or but other than that, we don't have any kind of uh collaboration where physicians have to ch sign all our records or anything like that.

Christopher Gleason 17:08

That's was was my point from earlier. See, so when we had to do that when I had to do that collaborative agreement, um the physician that I was working with, who was an amazing physician and and fully supported NPs, he had to sign, he would have to sign off on my charts. And uh over that, you know, 2,400 hours, he would have to sign off all of my charts. I'd have to, I would do check-ins with him and things like that.

Vanessa Pomarico 17:29

You know, it's so interesting because prior to FPA in Connecticut, same thing, we were under collaborative agreement for a lot of years, and I remember at the end of the day carrying all of my charts over to the dots desk, yeah. There'd be, you know, stacks of charts, and he would just sign them. He never even read them. And I remember thinking to myself, this is ridiculous. Just because your signature's on there, you haven't even read my note. I mean, what was he confident in my skills? Maybe, but you know, I don't maybe you just didn't give it to you.

Jason Gleason 17:58

I mean, I don't know. He was angry that he was assigned to signing notes.

Vanessa Pomarico 18:01

I think he was more excited about the fact that I had a lot of charts to sign and that translated into dollars.

Christopher Gleason 18:07

Oh, yeah.

Vanessa Pomarico 18:08

Um, but but I have to say that, you know, even with the with the if you have a collaborative agreement in your state, you know, then you need to think about how much do you need to pay them. Now, I know the psych psychiatric nurse practitioners in Connecticut really had a lot at stake if we did not get full practice authority, because there were so few psychiatrists in Connecticut who would be, who would serve as a collaborator for any of the many of the psych NPs. And I remember one of my psych NP colleagues was telling me that she had to pay this collaborator. And this collaborator had 19 psychiatric nurse practitioners. They had to check in with them once a month, and they had to pay them $250 an hour. And I remember this nurse practitioner saying to me, they never even looked at my charts. We traded recipes. And I thought, well, for $250 or $500, depending on how long you're there for, you know, are they really doing their job or is it just a way to um collect money? I know that at one time uh physicians were paid, as I said, upwards of $30,000 um to act as a collaborator. And I when I first uh got into being a nurse practitioner, I remember there was a doc that was making $15,000 a year just to have her name on my as my collaborator. And I thought, she works a day and a half a week. Like I don't go to her, but she was getting paid for it. And I think the financial incentive was one of the reasons why the physicians were fighting against us getting full practice authority because, like the psychiatrists, they stood to lose a lot of money.

Jason Gleason 19:43

Yeah.

Vanessa Pomarico 19:43

Yeah.

Jason Gleason 19:44

So interesting.

Vanessa Pomarico 19:45

Uh you know, and one of the things too is I used to volunteer at a um post-Catrina, I volunteered at a clinic in Mississippi for a lot of years. And I had to be very careful when I was going down there because the collaborator, the collaborator, or collaborating physician, he could only have like 12 nurse practitioners, you know, uh, you know, under his collaboration. And I had to wait for one of those nurse practitioners to go on vacation or go out on maternity leave before he could do my week down there, just so that he didn't go over his allotted number of people he could collaborate with. So it's, you know, yeah, isn't that crazy? It is a little crazy. So, you know, thinking about collaboration, you know, when we talked uh a little bit just a few minutes ago about those nurse practitioners who didn't feel comfortable, you know, is collaboration really the same as dependence, you know? Um and so we really shouldn't confuse collaboration with dependence, right? I mean, good collaboration, right? Collaboration is really what helps to build competence. How do you guys feel about that, Chris?

Christopher Gleason 20:48

Every day we collaborate every yeah. Absolutely, definitely. There's there's five providers in our practice, uh, and I have no problems with going to, you know, going to them with the questions, concerns, things like that, and collaborating with them throughout the day. So every single and all of us are great with with it.

Vanessa Pomarico 21:05

So awesome.

Jason Gleason 21:07

So you know, again, if you're the source of dependency, I think though, is fear, right? Like lack of confidence in your own skills. And so you're always trying to justify it by, oh, you know, and get the the nice warm fuzzies, like, yep, you're on the right track kind of stuff where you can't really function independently. Right. That's a that's a big challenge for a lot of folks out there.

Vanessa Pomarico 21:26

You know, and and again, our our listeners out there, if supervision exists, you know, just make sure that it's true support and not just somebody who's signing your charts off. I mean, that would be that would be really important to know. So, again, a lot of these key points are all going to be in your show notes as well. Okay. All right. So we're gonna move on to the FPA versus the collaborative practice. What changes in our day to day practice? So, you know, again, we already talked about how full practice authority allows nurse practitioners, we can really, you know, work to the highest. Level of our licensure. We can evaluate, we can diagnose, we can interpret, we can prescribe, all perfectly within our scope of practice. But in those states that are reduced or restricted states, those are the ones that may um require the collaborative agreement or even supervisory. Supervisory, if you look at the AEMP map, the full practice authority map, we like to see green. Green means that's a full practice authority state. We have some yellow and we still have some red states. Red are supervisory states, which I cannot believe that we are in 2026 and we still have supervision for nurse practitioners. But those are the really physician-centric states that are really, really giving the pushback on full practice authority uh in those particular states. So, you know, again, something you need to think about checking out, you know, checking out before you move to those particular states. Do you have anything that you want to add to that?

Jason Gleason 22:55

Or No, I think you I think you kind of touched on everything. Yeah, and if you're in one of those states, consider moving to Montana.

Vanessa Pomarico 23:01

Or Connecticut.

Christopher Gleason 23:03

That's right. That's right. Or if you're in one of those states, consider consider being a champion for FBA, you know. Yeah, consider being a champion to push full practice authority forward.

Jason Gleason 23:12

You know, I I love this hot topic, this third one we're talking about. It's a nice summary of everything else we've talked about. And so for our listeners out there, I think it's really important again to recognize that even though you may be in a full practice authority state, that doesn't give you an open menu to do whatever you want, right? You have to check with your employer, the policies, payer requirements, insurance companies may have some requirements for you to follow. And one important thing that I would recommend out there, because there's a difference between full practice authority and you touched on this earlier, Vanessa, is don't do a skill that you're not trained to do, right? And how do you know you're trained to do that legally? It's credentialed. You're credentialed to do that skill. And so when you get out there, this is for our new NPs out there that are going to their first job, when you interview with an employer, I would ask them, what is your credentialing process for procedures? And if they look at each other and say, Well, we don't have one, that probably isn't a good practice to go to because the best practice is a new employer will give you a form, it'll be a list of common procedures done in primary care, whatever specialty you're going in. And you have to check a box that you're asking for those credentials and privileges to be able to do those for that practice. And it's all well documented. Administration signs off on it. If they have a medical director, they sign off on it. So everybody's on the same page. So if a legal issue happens down the road, you pull this document out. And by the way, keep a copy of this document because they tend to get lost sometimes. But if a legal issue happens, bring out your credential list and say, well, you know what? I didn't ask for this procedure and I didn't do this procedure, or gosh, yep, it's right here. I I've done this procedure, you know, a hundred times and I got fully credentialed for it, and then they can't backtrack and you're covered. So make sure everything is documented well.

Christopher Gleason 24:51

And one thing I would recommend to you is when you're oftentimes when you're doing going through the credentialing process, though it can be a long and tedious process. So when you get to that form where you're checking off the the credentials you're applying for, make sure you don't just blindly go through and check things off. Because you could end up with privileges for something that you don't do.

Jason Gleason 25:09

Right. Yeah.

Vanessa Pomarico 25:10

Right. You don't want to, you'll have to accept the responsibility if you sign off for something like that. And then you don't have the appropriate training or education. So if you're not educated and trained to intubate somebody, don't start now. You know, that that's one of the risks of putting a f an FNP or an ANP in the acute care arena when it's outside of their scope of practice. That's not what our primary care education teaches us. Yeah. So great.

Jason Gleason 25:36

Preferentially is not the time to fake it till you make it. Credentially. Don't do that. Not a good thing for your patients, right? Yeah.

Vanessa Pomarico 25:44

So, so let's move into how do we practice our license while we practice how do we protect our license, I should say, while we practice to the top of our our scope of practice. And again, a lot of our um our key points are gonna be here in the show notes. So, you know, if you're not sure, ask. I mean, I think that's kind of a recurring theme that we've been talking about throughout a lot of our podcast, right? Is asking for help. And that has what uh I think one of you coined it as a license protective move. Um, we worked really hard for our licenses, and we're not gonna do anything that's gonna compromise them.

Speaker 2 26:18

Absolutely.

Vanessa Pomarico 26:18

You know, it's just like when a patient says to me, I need you to order, and they hand me this laundry list of labs that they want me to do. Oh, well, my naturopath wants you to order all these. And I always say, you know what, it's my license that's on the line here. I'm not gonna order these for a number of reasons. Number one, I don't know why they're ordering them. Number two, once I order it, I own it. But number three, I am responsible for this. And if I don't have the appropriate diagnosis code to go along with this, you're gonna pay out of pocket. And it's a liability for me to order tests that don't support what I'm doing in primary care. And, you know, could I have said that easily when I was a first year out? Absolutely not. I probably would have been shaking in my boots. So um, again, if you're not sure, ask because again, asking for help is gonna really what is going to protect that hard-earned license of yours. Um, so what about, you know, when we when we we did a whole uh podcast about documentation um and conciseness. So, you know, when we document, do either one of you, you know, document your differential diagnosis or your reasoning for like your higher risk decisions?

Jason Gleason 27:28

You know, I do, but it kind of limited. I don't I don't drag it on and on and on. It'd be like a 10, 10 uh page document, right? If we if we list everything that went on in our heads, but but certainly at least a differential diagnosis and kind of, well, how did I come up with this, you know? Right. Yeah, a nice summary of that. How about you, Vanessa?

Vanessa Pomarico 27:45

Same thing. You know, I might put in my uh my plan, you know, that I had considered this, this, uh, this, but given the fact that, you know, let's say they had a negative viral swab but they've only had symptoms for a day or two, I don't feel that this is bacterial. So therefore, an antibiotic is not warranted. And why do I write that? Because going back to that whole thing about the transparency with patients, they can read our note. And so again, it's just documented in there in case the patients go home and say, you know, she didn't do anything for me. Well, yeah, I did. I did an awful lot for you. I just didn't give you an antibiotic. Right. Yeah. So I make sure that I document that.

Jason Gleason 28:20

How about you, Chris?

Vanessa Pomarico 28:22

Yeah, Chris.

Christopher Gleason 28:22

For me, I definitely just do the I I will do a differential diagnosis. Like you said, Jason, I don't go into like a diatribe with it or anything like that. But I think it's important to at least point out, you know, that you thought of this, this, and this as a potential before you came to your final diagnosis.

Jason Gleason 28:36

And some of our thoughts should never ever be documented anywhere, right? No, there's not sometimes we're out of a job. Yeah, me too.

Vanessa Pomarico 28:47

So true. And and everybody who's listening out there, you know, there was a time when we could write things and nobody would look at it other than you know, uh, between us as a team, but that is not the case now. So, you know, inside voice, inside thoughts, for sure.

Christopher Gleason 29:02

Yes, yeah, and sometimes inside documentation. That's right.

Vanessa Pomarico 29:06

Right, exactly. You know, say what you what say what you want on the side or on a sticky note and then throw it out, but don't put it in the patient chart. No, yeah, because they can find it.

Jason Gleason 29:16

They will, they will.

Vanessa Pomarico 29:18

And then one of the other things too, I wanted to just bring up is you know, we we all have to get our continuing ed every five years in order to stay current. So it's really important to keep your uh continuing ed aligned with what you do. So those are things like your controlled substances, your chronic disease states, things that are changing. Like, for example, the asthma guidelines changed a few years back. And I'm still amazed at how many providers don't realize that the that the guidelines have changed, and it's because they're not going to the appropriate CEs. They're going to CE class, you know, they go to a conference and they'll go to a a session that's something fun for them. They're like, oh, I know everything there is to know about asthma or diabetes when when really all these new things are out. How do you feel about that?

Jason Gleason 30:02

Or some go to the beach and skip the conference all the gate. You know what I mean? Yeah. We've seen colleagues do this, right? Yes. Yeah, yeah. So you know, I just think it's so important whatever specialty you're in, and primary care is a specialty in itself. We have to start looking at it that way because it truly is, right? And we deserve that respect as a as a specialty. But yeah, I I think it it's such a strong point to get CE in what you're aligned with professionally. You know, here's an example. I went to one conference and I would never do a med spa. I have no intention of opening a med spa, but it sounded really interesting to me. So I went to this like two-hour CE event on how to do Botox and other injections and stuff. And it was interesting. And I and I was starting to think, boy, I could get into this and make a little money on the side, right? This might be a good moneymaker and a good business until they got to the very end when they talked about tissue necrosis of the face and showed all these horrible slides of faces with necrotic tissue. And I thought, no way, no way in hell am I gonna do this. But but that's an example of you know, I should have just stayed in my lane and focused on primary care and you know, used every ounce of my time towards that. Because you're right, if you're not doing that, Vanessa, you're missing out on some really, really good stuff. And the and the guidelines change all the time, all the time.

Christopher Gleason 31:10

Right. And I think I think one of the uh a good resource also for CE is um, and I don't know if you two use this, but I use up to date from from time to time to as a quick ref reference and resource, but they have so much good information. And the thing to remember too is when you're going through that information, or whether it be medications, diagnoses, what have you, you'll actually get CE credit for that as you're reviewing this information. Yeah. So it's not only helpful uh in the CE realm, but it's helpful for knowledge in general.

Jason Gleason 31:36

So by the way, I have to tell our audience this is a big update with the American Academy of Nurse Practitioners, not the association, but the academy, two different, completely different organizations. They will no longer require us to submit the actual certificates for our CE renewal. No, now it's just by attestation. So they're going on the honor system, and the the small print to that is they can audit at any time. So you still have to be honest and really D C E. But what a headache that was sending all those certificates in. Now we no longer have to do that. And that's just a news that came out this month. So yeah, newsflash. Are you happy about that for that?

Vanessa Pomarico 32:12

Uh well, so I'm certified by CCNE.

Jason Gleason 32:14

Oh, you are? Yeah, yeah.

Vanessa Pomarico 32:15

I am because at that at the time when I was going to school, uh, Connecticut only recognized CCNE. They didn't recognize A and P at the time. So we all had to be CCNE. But they actually started that a while back because I think the last two times that I've re-upped, I didn't need to, you know, scan that package. You know, I I keep a I keep a file, you know, in a file cabinet with all my continuing ed. And now everything is very streamlined. So you just but just put, you know, to that end, make sure that you're going for your continuing ed because those five years sneak up on you like that.

Christopher Gleason 32:51

Absolutely, absolutely.

Vanessa Pomarico 32:52

And I get phone calls all the time from people saying, where can I get CEs really quick? Right, and overnight. It's due tomorrow. Right, you know, yeah, it's due tomorrow. Sorry, you're not, you know, unless you're gonna stay up all night, you're not gonna be getting all, you know, 75 hours.

Jason Gleason 33:06

You better start practicing your test questions because you're gonna do any test again, right?

Vanessa Pomarico 33:10

Yeah, right, exactly. All right, so we have some resources to share on air, and again, the audience can find these in the show notes. So we have the National Council of State Boards of Nursing, they have the advanced practice registered nurse compact overview and status. Um, and there's a web address for you. We also have SAMSHA, which we we had uh um referred to them in our past podcast, the Substance Abuse and Mental Health Services Administration, the X waiver elimination, that was mainstreaming addiction treatment act, that's the MAT Act. Uh, the American Association of Nurse Practitioners State Environment Map, take a look at it. And uh, if green is your favorite color, we need to keep uh keep going with green. And then the Centers for Disease Control and Prevention, the Prescription Drug Monitoring Program Overview. And those are all really great resources for this particular topic. All right, so moving into my favorite part is fact or fiction. You guys ready?

Jason Gleason 34:06

Here we go. Let's do this.

Vanessa Pomarico 34:08

All right, Chris, scope of practice rules can vary widely by state, fact or fiction.

Christopher Gleason 34:14

Absolute fact. Yeah, and we touched on that a lot throughout the podcast.

Vanessa Pomarico 34:19

Sure. All right, Jason, full practice authority means no collaboration or relationships are needed, fact or fiction.

Jason Gleason 34:26

Total fiction, yeah. You still want to refer when appropriate and still collaborate with colleagues as needed. And you'll do that every single day, honestly.

Vanessa Pomarico 34:33

Right. Collaboration again is inherent in our profession. It's uh we don't need a piece of paper to tell us that.

Jason Gleason 34:39

No, no.

Vanessa Pomarico 34:40

All right, Chris, some signature requirements are employer policy and not state law, fact or fiction.

Christopher Gleason 34:46

That is fact.

Vanessa Pomarico 34:48

That absolutely is fact. Again, looking at your nurse practice act. All right, and Jason, if you're allowed to do it, you're always trained to do it. Fact or fiction.

Jason Gleason 34:56

Uh, another one that goes with the fiction. You know, scope does not equal competency, and we need to make sure that we are credential, absolutely credentialed on paper and keep a copy of that uh throughout your entire career to do all those procedures out there. And don't ask for credentialing and privileging for something that you've never done. Don't fake it till you make it.

Vanessa Pomarico 35:15

That's right. So important to know that. Absolutely. All right. So we're gonna invite you to email your questions again to nplaunchpad at fhea.com. And we have two questions that were sent in to us. So um the first one is what scope of practice or collaboration issue are you navigating right now in your state or job? I I'm not sure if either one of you can answer that since you both work for the VA. Yeah.

Christopher Gleason 35:42

This one's for UBA system.

Vanessa Pomarico 35:44

Okay, all right, throw it back to me. I'll take it. So um, you know, we really don't have, again, because we have full practice authority in our state, but our biggest issue is that we because it's such a tiny state, we have two major hospital systems and they both require thousands of nurse practitioners to still sign a collaborative agreement. And it's a work in progress. A few years ago, I was working on a committee within our health system uh with other nurse leaders, people who were way more well-versed at this than I am. And we had a really dynamic team of people, and it took us two years just to get on the agenda for the board of directors. Two years. And that was because every month I kept saying, Are we on the agenda next month? Are we on the? I think I just wore them down. Um, and then sadly, you know what? Then they all of a sudden they said, Oh, this is great. And so we had one meeting with them, and it was like all of a sudden everybody was on board. And when my nurse practitioner colleagues and I got together, I said, that just went a little too easily. I think there's some something's going on here. And sure enough, there was a huge catch because within the next month, three of the four women were let go of their jobs. So that's why they were just placating us. Yeah.

Jason Gleason 37:01

Yeah. Yeah.

Vanessa Pomarico 37:02

So, and it's kind of dead in the water now. I keep, I keep reaching out to our APP director and saying, where are we? What are we doing? But uh, they just they haven't really made any movements. So that's the biggest issue we're navigating right now. All right, then the other question we have is how do you set clear escalation expectations with an MD collaborator without friction? Either one of you want to take that?

Christopher Gleason 37:26

I think the key to this is just transparency with whoever you're working with as a collaborator. I mean, most physicians are going to want you to have, you know, an escalation procedure in place. So if you come across something that you need that collaboration with, then they're gonna want to be there for it. And I just think, you know, transparency through that whole process is key.

Jason Gleason 37:42

You know, I think we've all had the challenges in the past where we have a mentor or a collaborator where we just don't gel well with them, right? That might be that we we perceive them as being kind of the honry one in the practice and we're kind of not afraid to go to them, but it's just such a pain in the butt to go to them each time. If that's your case out there when you get out to a new job as a new NP, make sure you find somebody that you gel well with. And the other person isn't a bad person, right? Don't frame it in that sense, but just go to the medical director and say, Hey, can I get a different collaborator? Because I need someone I can feel really comfortable and connected with. And then utilize that, right? And we collaborate, like Christopher said, in our in our pod, we have five providers and we collaborate daily and we're not assigned to each other. We just kind of approach whoever's available or or we each have our niche, you know, and specialty within primary care. And and we just kind of utilize our our strengths and resources appropriately. So yeah, gel well with your collaborators out there. And if you don't have one, make sure you you put a lot of effort into finding.

Vanessa Pomarico 38:38

Right. And that's again part of your uh when you're interviewing, yeah, right from the get-go, make sure that you ask that question. Who will be my mentor? Who will be my collaborator? And it might be one and the same person, but again, you need to make sure that you gel well with them. You know, it's an interesting point that you bring up there, Jason. You know, I worked at a practice and one of the docs was a little bit nicer than the other doc. The other doc was just always grumpy and grouchy. And I don't think that he disliked nurse practitioners, but he certainly I hated having to go to him. I hated it when the other doc was off because I'd go to him and he would, it was almost like I was just such a nuisance. And and I wasn't, it was legitimate things. Or I was seeing one of his patients and and it made it really uncomfortable. So, like you said, Jason, frame it in a way that, you know, they're not a bad person. We don't know what's going on in their personal life. But also, too, it may be that they don't want the responsibility of having to be a collaborator. So, you know, if you can't sit down and and make a good effort at at gelling with that collaborator, then like you said, Jason, it's a great suggestion to go in and see if you can find somebody else that will collaborate with you. All right. So, what are our take-home tips for tonight? We're gonna talk about uh your take-home tip is to define your escalation triggers with your physicians. And then, you know, we talked about huddles in a lot of our previous podcasts. So, really those monthly huddles with those tricky cases, everybody learns from them. Uh, and as a matter of fact, when we do it, we actually set it aside and go, oh, this is gonna be a great one for the huddle next week.

Jason Gleason 40:12

Yeah.

Vanessa Pomarico 40:12

Um, we happen to do them weekly, but some people do them monthly. But those tricky case huddles where people can really uh learn from them and everybody will learn. And if it's a case that you have, put it aside. It doesn't matter how seasoned the physician or the other nurse practitioner are, they're they're gonna appreciate a tricky case. Yeah. And then again, knowing your state's scope of practice, you need to know your full practice authority and keep a link to the Board's Practice Act or your state's practice act, nurse practice act. Keep it handy uh so you can very easily get it at the touch of a button. So your homework today is to bookmark your state practice act and any of your board of nursing rules. And there are some states out there that the board of medicine oversees nurse practitioners, or it's a combination of the Board of Nursing and the Board of Medicine. So make sure that you know that it's not just one. If you have to, if you live in a state where both the Board of Nursing and the Board of Medicine uh work collaboratively over nurse practitioners and the nurse practice app, then you need to know if you have to go to them, you have to approach both. So make sure that you know who is who what those rules are in your particular state. And then making sure that you review your supervision or your collaborative agreement, uh, depending on what you have in your particular state. So that's your homework for this week, everybody. All right. So before we wrap up for tonight, I'm gonna ask you if you could please drop us five stars if you think we deserve it. Uh, make sure you hit follow, then tap subscribe. And more importantly, make sure that you share this with another nurse practitioner colleague, uh, your friends, your family, even another nurse practitioner student. And make sure you stay in touch with us at npaunchpad @fhea.com. And one more thing, because we appreciate you so much, we want to share some special savings for you. So if you go to the fhea.com website and you use the code launchpad20 for 20% off of our continuing ed library. And we have a ton of continuing ed there for you and memberships. It's our way of thanking you for supporting our show. So great topic again tonight, guys. Thanks so much, everybody, and we'll see you next time on the next episode of NP Launchpad.

Voiceover 42:26

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