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Anonymity

For one of my MSPC courses, I was asked to create some sort of illness narrative. I wrote a poem based on one of my own experiences as a patient, and I thought I’d share it here. 

Jarred from sleep, confused only pain. Surely, it will pass probably reflux.

After hours of waiting, hoping; the pain remains, wrenching, worsening, unrelenting. I wake him, whispering we must go.

We arrive, beating sunrise, to help. I feel calm, knowing relief is near. Finally, taken back, for treatment.

An hour passes with no aid. I am crying, aching, abandoned. My nurse finally stops by. He sees tasks, not a person. Unmoved by my tears, my pain.

My eyes plead, see me. If not as patient, as colleague. I am suffering, I need you.

Eventually, I find the culprit. My gallbladder is betraying me. I will remove him, this traitor. The pain he caused, only a memory.

But forsaken, by my carer, forgotten, by my own, I cannot forget, the indifference.

photo credit: Tiia Monto, wikicommons

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What Medicaid Means to Me

“I don’t understand your American health care system”

- Doug Altman, Health Statistician, during Q&A at Evidence Live 2017

There are so many things we could discuss regarding the proposed healthcare reforms. For sure, our current system isn’t perfect. That said, I don’t think there exists a system that is perfect. Perfection can only exist in a vacuum. People and the world are dynamic, and even the best system will eventually need adjustment.

I’m not opposed to adjusting our system. I’d be the first to tell you it’s broken, and most front line health care professionals would agree.

However, slashing medicaid is not a step toward fixing the system.

Medicaid covers the most vulnerable in our system. Yes, this includes the poor, and the unemployed, who are no less worthy as human beings than anyone else. But Medicaid provides for more than that. The disabled. Many children, including the premature and severely ill, are insured by Medicaid. Most older patients who live in nursing homes have this paid for by Medicaid, their Medicare does not pay rent for their living facility, which usually runs $3,000-$6,000 a month.

There are abuses in Medicaid. Care could be provided more efficiently. However, I almost cannot contain my rage when this debate moves toward insinuating that Medicaid patients are less valuable or deserving.  By stamping all Medicaid beneficiaries as abusive slackers, a diverse group is oversimplified.

A mom whose husband becomes permanently disabled will lose health coverage for herself and her children.

The young adult born with a congenital heart defect requiring twice yearly specialist follow-ups who is trying to come into their own will lose coverage.

Grandmothers and grandfathers across the nation will be forced out of facilities and will likely suffer when their working families cannot provide the care they need throughout the day.

Children born early will likely die, or will grow up in poverty because their parents can’t afford the bills from the first years of their lives.

Children will miss essential care and vaccinations.

Most of my Medicaid patients are not on Medicaid because they’re lazy or abusive. Most are enrolled in the plan due to circumstance. Certainly, some have made poor life choices. But I have made poor life choices. It is only through luck and circumstance that I am as fortunate as I am today. I haven’t worked harder than many of my Medicaid patients, and I’m not more deserving.

Medicaid patients already have difficulty accessing care. When I provide services to a Medicaid patient, I am reimbursed a fraction of what the service I provide costs. But at least I get something.

I work in a private practice. If suddenly these patients are uninsured, those who can’t pay out of pocket will eventually be discharged. This is true of private practices everywhere, and many will opt to not even take the financial risk, discharging these patients when they become uninsured.

I want to provide care to those patients, but because of the health system we work in, we also have to run a business. We have to keep the doors open.

Decreasing Medicaid benefits will mean fewer get the basic, essential care they need. These vulnerable patients will only be seen in the ED, when they are in crisis, when care is the most expensive. We KNOW that providing preventive care, rather than reactive care, is more affordable. We have lots of good data that show this.

Forcing Medicaid patients into crisis and treatment in the most expensive setting will not save our system money. It WILL harm people. It WILL bankrupt hospitals when these patients incur $50,000 bills they can’t pay back.

Yes, let’s fix health care. I’m open to lots of different ideas. Certainly, I have some preferences and ideas of my own, but I’m not closed to anything that improves the quality of care while decreasing the cost. But the ACHA is not that. Decreasing Medicaid coverage will do the opposite of that.

Health policy crafted without significant input from clinicians will never be effective. We work in this system. We see the human costs. We have a microsystems and macrosystems perspective. You can’t just cut line items without understanding the repercussions.

So, please, consider calling your representatives. As a patient, I’ll still be okay if this bill goes through. But as a clinician, so many of my patients, the ones who often have suffered the most, will suffer even more.

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Advocate

If you have an important point to make, don’t try to be subtle or clever. Use a pile driver. Hit the point once. Then come back and hit it again. Then hit it a third time - a tremendous whack.  - Winston Churchill

Imagine yourself in a role you're proud of. You're dedicated to a profession that makes you feel a part of something, that gives your life meaning. You have an undergraduate degree in your profession, ten years of experience, and five years of graduate school. You're damn proud to be doing what you do. But, almost every day, based on your title, someone judges you as less capable and less competent than you are.

This is what it feels like to work as a Nurse Practitioner (NP).

Don't get me wrong, I'm no expert. I'm an early career professional, so I think it's reasonable I don't always know as much as or operate as smoothly as my more experienced colleagues. But I am well trained, committed to continued learning, and passionate about high quality care. Also, there's a lot of data to support that NPs provide good health care, if science is your thing.

A major aspect of my day to day professional role is advocacy, not just for my patients, but for nursing. I probably would have also done this if I got a Master's. However, as one among the growing ranks of Doctors of Nursing Practice (DNPs), I feel responsibility to my profession to be an advocate. NPs have existed for just over 50 years. DNPs have only existed slightly more than a decade, and only recently has the degree taken off.

Being on the edge of something new, we get to help define what it means. It is important we take that privilege seriously. Nurses have long been hesitatnt to talk about our profession, having avoided educating about our role and advocating for it. Our aversion to doing so has contributed to the fact that people, patients and clinicians alike, think I'm less capable than I am.

Here are some examples of the things that come up in my practice:

I tell every patient "I'm Courtney, I'm a Family Nurse Practitioner, do you have any questions about what that means?" At least once a day, rather than asking questions, a patient tells me what it means, and they're often dead wrong. Sometimes they're downright insulting.

Earlier this winter, I was taking care of a fairly sick patient. Like, without active, daily management, the patient would have been in the hospital. They needed a test from a local specialist. I did the new patient visit with this patient, as well as all of her initial follow-ups. No one else at the practice had seen her. When I called to speak with the specialist, I was told that he doesn't talk "midlevels," as somewhat derogatory term for NPs and Physician's Assistants. Never mind that the patient needed his services and as it went, I was the expert in the patient's condition at the moment.

Twice last week, I had somewhat abrasive patients tell me why I was particularly objectionable as a nurse practitioner, despite the fact that I had the ability to help them, and I was the person with time to see them in my schedule.

Pretty much every day, I have a conversation with someone, somewhere about what I do, how educated I am, and what my role is. Again, I believe this is an important part of my role, and that the honor of being DNP compels me to have these conversations.

But it is freaking exhausting. Every day I think, "I should quit this." Having these conversations demoralizes me. To welcome conversations I have to open myself up to, and listen attentively to, the worst opinions of my career. Furthermore, this advocacy brings the potential of conflict, which I really disdain.

I keep having the conversations though. I keep educating about my role. I keep advocating for my profession. I have compassion, knowledge, and provision quality care to offer. The more people understand my role, the better positioned I will be to care for them. And, maybe, 20 years from now, some new DNP will get the pleasure of doing their job without having to be as concerned with these issues.

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Becoming

I've been trying to write this blog for a while. I've been working as a nurse practitioner for just over seven months. I feel like I should write a reflection about these seven months, about becoming a nurse practitioner. On the other hand, I feel like I should write about primary care, the value of it and the experience of providing it. I guess I'll just write and see what happens.

Becoming a nurse practitioner has been interesting. It's not dissimilar from other professional transitions I've experienced - becoming a Registered Nurse, becoming an educator. In general, the process is the same: get papers, become thing, feel like impostor, do thing, obsess about it less, slowly actually become the thing.

This transition has felt the same, yet very different. The level of responsibility I have now was a huge adjustment. As with other jobs, I'm not on my own, not even the slightest. My primary physician partners are amazing and they support me every day. On the other hand, I have to decide sometimes. I can't leave a room and ask them for help on every decision. I'd be useless, and that would be boring for us all.

In the beginning, every decision was excruciating. Even the decision to give an antibiotic took my entire brain space. "Over-prescribing leads to resistance. Antibiotics have side-effects that are not insignificant. But, what if this is a bacterial infection and I can help this person get better?" The worst part was that I barely felt competent and comfortable enough to convince myself, let alone my patients, of what I was deciding.

The intensity of these decisions has decreased. They don't take so much heartache and intellectual strain. However, that the decisions are easier is both reassuring and disturbing. I am learning and growing, but there is always the specter of becoming too lax and not paying enough attention. Honestly, that  sums up my experience providing primary care thus far. It is a practice of contradictions.

Everything I do may help or harm. I trade in statistics and likelihoods. It feels like I don't know enough but that I also know too much, all at the same time. Without ever being 100% sure, how could I say I know enough? But then, I know enough to be scared of the risks of each action.

For every test I order, I should be considering multiple things. Will this test change my care? Is the cost and actual patient harm (there is some harm in every test) worth performing the test? Will I make the patient worse or kill them if I don't order it? This same balance exists with other choices - prescriptions, follow-ups, referrals, on and on.

Then there's the juxtaposition of the system vs. the patient, the macro vs. the micro. Systemically, I contribute to bacterial resistance, opioid addiction, and skyrocketing costs (to name a few) when I decide incorrectly. On the other hand, I have to care for the patient in front of me. Is the risk of messing up on the macro level worth what I'm doing on the micro level, or vice versa?

Seven months ago, these thoughts permeated my every decision and made things hard. Now, I still think about them, but I can decide more easily. However, I now worry that I am becoming too comfortable. I'm so familiar with the cognitive biases that I'm at risk for that I can't help but thinking about them. I know I probably make mistakes based on these thought errors every day. Certainly, getting too comfortable, and letting my thought process become overly automatic increases the risk of messing it up royally.

I know this is really the area of "the expert," that the art of truly mastering something is to walk the path between these contradictions as accurately as possible. I look forward to maybe getting there one day. In the meantime, there's a lot of anxiety to be had.

It's not all bad. I do really love my job. I have wonderful patients who give me the privilege of their company and their trust. I've learned a lot about providing care in the last seven months, and I think I am objectively better than I was seven months ago. I've been growing into the other parts of my role as well, including advocating actively for my profession within my organization and with my patients.

When I say, "I'm a nurse practitioner" now, I actually believe it. Thought there's stress, there's also joy in getting to decide. I get to help set the tone and guide the way forward. It's amazing to get to be in that position.

It will be interesting to continue to grow as a nurse practitioner. It amazes me how this growth and these transitions seem to happen both quickly and slowly. I just hope as I become more competent, I can hold onto the things that make me safe to practice, my compassion and my questioning of what I think I know.

I guess this one was about me. Maybe the next one will be about primary care more generally. Or maybe it will be about something else completely.

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Being a patient, part two

Also known as that day I had terrible pain, and was on the receiving end of health care.

Patient centered care

I've not been a patient frequently in my adult life. But each time I do require something beyond my normal primary and preventive care, the experience is, informative. Twice, I've ended up in the emergency department, once when I broke a finger off my hand and today.

When we talk about burnout in healthcare, we're all susceptible. But certainly, emergency departments are places that may foster this more commonly than other areas. I feel like almost once a week, I see a friend who works in the ED post something about how they have to have walls and can't be emotionally vulnerable.

I get why it happens. You see some terrible, truly human stuff in the ED. You see where the non-existent mental health safety net fails. You have addicts who try to manipulate you, trying to convince you that you are doing them good when you may actually be causing harm. You see people die, you get assaulted, and are exposed to all manner of badness.

I feel these opposing forces in my day to day work too. I have to be skeptical of new patients showing up requesting medication refills. I have to check databases to be sure I'm not adding to possibly unsafe quantities and combinations of medications.

At the same time, I'm surprised daily. Reassured daily. Reminded daily that people, though flawed, and sometimes broken, want to be cared for. I can sell patients on a lot if they feel like I care for them.

So I have to frequently remind myself and check myself. When I go into that room, until someone has proved to me otherwise, it's time to focus, be present, invest in, and advocate for my patient.

My own bad experiences as a patient have been when someone forgot all of this, when someone had gotten too far away from the reason that many of us went into this career.

A few things, relevant to patient care, stick out to me from today.

Ease suffering - This seems basic. But, we sometimes forget, it's not just medicines that ease suffering. Being seen, being validated, these things help. More on those in the next couple of points. Today, I felt like easing my suffering was not a focus for some on my care team.

After checking in, it took 15 minutes for my nurse to come see me. I was promised pain medication, and then didn't see that nurse again. Twenty to thirty minutes later, a new nurse came in - it was shift change. He had my pain medication. When I mentioned that it had been quite sometime and I was hurting, he got a bit frustrated with me because he was new on shift and trying to figure things out.

On average, I saw my nurse once every 40-60 minutes in the ED. After my ultrasound, my pain shot back up to an excruciating level (I don't use that adjective lightly: I have multiple large tattoos, have experienced a couple of IUD placements, had multiple cervical biopsies, broke my finger off my hand with two surgeries to fix it, and did nine months of occupational therapy). I was told he'd check on pain medicine. I didn't see him for another 40ish minutes.

I realize, I'm in an emergency room. I was not the most acute patient my nurse had. On the other hand, it wasn't inappropriate for me to be there. Uncontrolled pain, that a patient has tried to relieve themselves, and can't function with, is an appropriate reason to go to the ED. Especially when urgent care centers are closed. My physician took my pain seriously. Disappointingly, my nursing staff didn't make me feel as if they did.  

Focus on the patient - This is a no brainer, central, right? But how conscious are we of the everyday things we do that might not communicate to the patient that they're your focus?

Certainly, the wait times for pain medication and the infrequent visits from my nurses didn't make me feel focused upon. There are also other more subtle things that tell patients they're not the focus. For example, when the second nurse came in, he walked in with two nursing students. Fine, I'm an educator. I like students.

He spoke to me only the words he needed to. Name? Birthdate? This is zofran for nausea, this is morphine for pain. Then silence.

Partway through this medication administration, my first nurse stopped by the room. He said nothing to me, but stepped in. No acknowledgement of me, my pain, or my wait. Rather, he, my new nurse, and the two students began a lively conversation. They all new each other, or knew of each other. They discussed their jobs and lives, and the difficulties of their days.

I've had this experience as a patient before, and it feels terrible. I go to the ED because I'm desperate and I need help. The people there are charged with caring for me, but when their actions tell me they don't see me, I feel hopeless.

Patients are vulnerable - Sometimes, we forget the power differential present in healthcare. A patient comes to you, and they need something. They may not even know what it is, but they're afraid they're not going to get it. They're afraid they won't say the right thing, or you won't see the right thing.

Sometimes, I feel like my "insider knowledge" makes me more vulnerable than I would be otherwise. Sure, I know the system, but I also don't want to take advantage. I'm hyper-conscious as a patient about not wanting to interfere. I don't want to tell people how to do their job or what to do.

I'm frightened of being perceived as a drug seeker. I'm frightened of not being taken seriously. I'm worried that an illness could turn me into someone who copes dysfunctionally, or has any number of issues.

Sure, I could have called my nurses (though no one gave or showed me the call light, I just happen to know it exists) when I was in pain. But, I don't want to be an overly needy patient. I want to trust my colleagues to do their job when I'm the patient, trust them to give a shit. I want to be respectful of the idea the the nursing staff assigned to me have other responsibilities.

I've always felt one of the greatest privileges in my role as a nurse, among the many things I'm charged with doing for patients, is advocacy. All too often we forget how vulnerable our patients are, and how they might need that. I could have used a clinical advocate today.

I’ve worked in emergency rooms. I have dear friends who still do. Part of the reason I couldn’t tolerate the setting as a career has to do with the walls people put up, and the cynicism and apathy people wrap themselves in for protection. The best ED nurses I’ve ever worked with are those who can navigate the full range of human emotion and connection.

For these nurses, the ability to be compassionate and advocate is always within easy reach. Sure, they can distances themselves. They can avoid taking things personally, and set firm boundaries. But they still make the patients who are receptive to it, who are seeking it, know they care. One of my mentors in my nursing undergrad was this type of ED nurse. She was a badass who could intubate you and run 10 drips, but she’d also gave baths to most of her patients who were seriously ill.

I feel like this is the diversity of skills we need to cultivate in all of our clinicians, across specialties. How do we give people a deep well of compassion to draw from, and the skills to not get pushed around? We have to change our training. We have to change the hidden values in nursing and medicine that tell people being a human is weak. And we have to take care of ourselves, and each other.

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Being a patient, part one

As of last Friday, I've been seeing patients as a nurse practitioner for four months. I've been meaning to get back to the blog, and I've been thinking about what to write. I had a few topics, but I'm the past 24 hours have changed my mind.

Last night, I woke up in the middle of the night with unbearable epigastric pain. I tried treat myself with tums. No luck. I sat up. Nein. Heat to my belly. Nada. Repositioning. Not helpful. Pepto. Gross and no dice. The pain just got worse, proved to be intractable, and I ended up in the Emergency Department.

The whole experience made me really consider two things. Self care, and patient centered care.

Self Care

In general, as Americans, we're not great at fostering a culture that values workers as people rather than as productive units. The pressure to be at work is real and relevant to everyone. It's also particularly relevant in healthcare.

Over the last couple of years, there's been increased attention on burnout in healthcare. Clinicians have appalling rates of suicide, drug abuse, depression, anxiety, and other afflictions. I've read plausible articles and discussions that both our professional cultures and the particular personalities more attracted to different health fields may contribute to some of this.

Since starting four months ago, I've been out 3.5 unexpected days. One was a personal day when our AC went out and someone had to be there for the safety of our five pets, as well as to meet the repairman. For 1.5 of those days, I had various infectious symptoms to an extent that would have interfered with my job. Today, I spent seven hours in the the emergency room because I couldn’t exist without thrashing around in pain. 

None of these absences were unreasonable. Yet, each one was really difficult for me to take. Not difficult in a practical sense. I'm really lucky. I have great colleagues, I work at a stable, wonderful job, and I have supportive staff around me who help me work out the logistics of being gone.

Taking a day is difficult for me because of myself, because of my head, and the things that I've learned subconsciously. If I take a day off, I let people down. When I worked in the hospital as a nurse, missing your shift meant that your workload, your four or five patients were now extra for your colleagues. It often meant leaving them to drown and struggle while you took some time.

Though my role is different now, I still feel like I let people down when I miss work. Today, I had a schedule of patients who had to be rescheduled, each with their own suffering. Maybe some of them are very sick and required my colleagues to pick up slack. 

I've left one of my teammates uncovered on their regular day off. Furthermore, every unexpected day off is a day I'm not earning money for my organization. It's a day I'm costing, rather than contributing to the business my colleagues own.

Finally, I feel weak. I’m a nurse practitioner. I don’t get sick. I should buck up and bear it because my work is important. Though I’m human, I already spend time trying to mitigate that and provide skilled, evidence-based, error free care. I don’t have the time to have pain, fevers, diarrhea, or personal concerns.

None of these feelings are from other people. They are not informed by things that have been said to me, or things that I have experienced.

I also know I'm not alone. 

For us to truly have an impact on some of the mental health issues experienced by healthcare clinicians, we need to not just encourage self care. We need to change the hidden curriculum that is a part of each of our professional socializations.

Next week, I’ll post part two, where I explore being a patient.

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Being a woman

Earlier today, I posted a personal story on facebook as part of a commentary on one of our presidential candidates. The responses have been humbling, and they made me think, perhaps, I should share more widely.

This is intended to be my professional blog, but I am a professional woman. I am a professional woman who takes care of women. I am a professional woman who takes care of women and who is passionate about the health and choices of women. As such, women’s issues are relevant. So, below, is my original post on Mr. Trump and his comments on women:

If your feed is anything like mine, it's full of Donald Trump. I know some of the reactions to his most recent news piece are things like "boys will be boys," and "it's just locker room talk."

As a young woman who has made her way in this world for 32 years, I have to tell you, I feel it is not. Throughout my life, I have been on the other side of physical and verbal abuse from men both known to me and men I've never met.

As a teenager, a summer camp boyfriend forced me to give him oral sex. I didn't tell anyone, ashamed, and sure no one would believe I didn't "want" it. He WAS my "boyfriend."

I've had every part of my body that is sexualized by society - breasts, butt, vagina - touched unwillingly by strangers. I've had this happen multiple times. When my vagina was last grabbed against my will, I was on a public street, with my boyfriend at the time. He became annoyed with me when I wanted him to feel upset or outraged at the violation.

I've been on the other end of verbal violence much more frequently. Most adult women have, at least once, if not many times, been catcalled. If we yell back, we're bitches, or we're feisty and want more. If we ignore it, we're bitches. If we're approached for a date or a conversation and say no, we're prudes, bitches, sluts, whatever foul words come first. I have many of these stories.

Most of the women in my life have at least one such story. I'm sure my mother an sister each have one. I know at least 50% of my female friends on here have one. For some of you, I know your stories, or I know some of your story.

If you'd be surprised to find all of this, consider that comments like Mr. Trump's most recent tape, might be the reason we have these stories and you don't know.

When I've spoken explicitly of these moments with others, it's only been with women. Those who know, those who have been there. Even though I did nothing wrong in these situations, they make me feel shameful. If my husband, who loves and cares for me, asked me to sit down and describe these things to him, I'd cry, I'd turn away.

We don't tell these stories because of the shame. We don't tell these stories because they may make those who love us uncomfortable, they may cause them pain. At least by holding them in, we can cordon off the hurt. And, we don't tell these stories, because in messages both subtle and explicit, society tells us this is our cross to bear as women, and that boys will be boys.

Certainly, we've all said things we might be ashamed of. Things that go against our better judgement. But this isn't the first time we've gotten a sense of how Mr. Trump sees women. We've had countless reports, statements, and incidents where he makes it clear - women are objects, with a role and a place. He doesn't feel shame when he says these things, he never has in the past. That is the difference between him and the good men in my life who may have made comments they are ashamed of.

I'm not posting this for your sympathy. You don't need to tell me you're sorry for my experiences. Thirty something Courtney is more assertive and more sure of her value than I have been at any other time in my life.

But, if my story makes you feel something, consider this. My story is that of your mother, your sister, your daughter, your wife, your girlfriend, your best friend. Imagine that person on the other end of these deplorable acts, what feelings does that bring?

I don't encourage people to be a one issue voter. I wasn't cheering Hillary on during the primaries. But I cried when she got the nomination of a major party. I cried, because it showed me, just maybe, women can do anything, despite systemic sexism. And I cried, because, just maybe, I might have a leader of the country who knows these stories aren't the exceptions.

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Novice Expertise

To be a nurse practitioner is to be misunderstood. I suspected this throughout school, but now that I actually have a license and certification, I feel more secure declaring this as true. As a profession, nurse practitioners (NPs) are in their 51st year. Compared to physicians, this span is just a drop in the bucket of time. However, over this half century, nurse practitioners have grown and evolved.

Today, we have NPs entering the workforce who have been prepared at the doctoral level. In many states, nurse practitioners are fully autonomous. The nursing science that forms the foundation of our profession has advanced. Our graduates are increasingly prepared to advocate for our profession and educate people about our roles. All of this growth and change makes nurse practitioners confusing to those within healthcare, let alone patients and laypeople.

I’m grateful for a time that these can co-exist

I'm passionate about being a nurse, and now a nurse practitioner. I chose this profession not for lack of options or ability, but because of nursing's philosophy and values. Now that I have finished my Doctor of Nursing Practice (DNP), been a nurse for almost a decade, and have actually read the nurse practice act for my state, I'm more of an expert on what it means to be an NP than 95% of people. I take seriously my role as an advocate and educator for and about my profession.

this is not the mark of an un-proud nurse

Now that I've graduated, more than any other time, I frequently get opportunities to do just that. This opportunity used to present itself a few times a week. Recently, it's presented itself at least daily, if I leave the house. On the one hand, each one of these encounters presents me with an opportunity to clear misconceptions and to highlight the profession I'm so passionate about. On the other hand, having to do so with frequency is exhausting.

These encounters are happening in both my professional and personal life. Fascinatingly, it is not uncommon to have people with no graduate training in healthcare tell me about my profession or my role. I believe 100% that none of these encounters have been things intended to frustrate or offend me, but a couple of examples from the last few weeks:

I have been called a mid-level more times than I'd like to count. I'll come back to this term in another post, but suffice it to say, the term was created by the Texas medical community to demean nurse practitioners and prevent expansion of their scope of practice. That alone should be reason enough it's no longer an appropriate professional term

I was told what I can and cannot call the physicians who I work on a team with

I am routinely noted to be an "NP" as either my degree, license, or qualifications. The term nurse practitioner is similar to saying "physician" it doesn't tell you anything about my license, degree, or certification. Instead, those are APN (Advanced Practice Nurse), DNP (Doctor of Nursing Practice), and FNP-BC (Family Nurse Practitioner-Board Certified)

I have received advice on how to display my credentials, even though my profession already has recommendations in place.

As I noted above, these are all great opportunities for education. Sometimes, it is difficult to figure out how to give my short elevator speech, or to educate compassionately. This is especially true during quick encounters, or when I'm meeting someone for the first time. I struggle a lot with when and how to initiate these conversations, with my duty to my profession versus my duty to be a kind, compassionate, and normal human being.

All of this is to set up the real point of this blog post, a major source of current distress for me.

When it comes to nursing, our philosophy and theory, as well as the legal and practice foundations of a nurse practitioner I am an expert. Currently, it's part of my daily experience to assert this expertise.

But I haven't seen one, single patient as a nurse practitioner. I'm a novice as an autonomous clinician. I'm TERRIFIED.

Don't get me wrong, I'm really excited. I'm living my dream. I miraculously finished my DNP. I passed my board exam. I've reached a place I've aimed to get to for 11 years. However, passing boards didn't make me feel more qualified. If anything, I feel less so, as if boards weren't hard enough. I haven't touched a patient for 2.5 months. There is SO MUCH I DON'T know. On the other hand, I have a really great team who is going to surround and support me. I couldn't be starting in a better place.

It's just really difficult to bounce back and forth between these two extremes, expert and novice. In one moment I feel compelled to educate people about what it means to be an NP and how qualified I am, and in the next moment I am out of my depth. Even when I know I'm right about professional issues, I feel like a fraud because of all of the being wrong that lays ahead of me.

If I'm honest, I enjoy getting to advocate for my profession. I just wish that the conversation more frequently started with people asking me, rather than telling me. I also wish that my confidence in professional role conferred confidence in patient care.