#8 What do you do?: An interview with my wife

        I am frequently asked by friends, "So, what does your wife do?" after sharing with them that she works in New York City. First of all, I tell them that she is a nurse, but this time an advanced practice nurse who is more empowered and independent than those with an associate or bachelor's degree. Next, I inform them that she is a family nurse practitioner, which often times I receive the follow-up question, "What is that?"

        The U.S. Bureau of Labor Statistics projected nurse practitioners (NP) as the fourth leading percentage change of employment between 2020-2030. Their job has become a crucial solution to addressing the primary care crisis in the U.S. What does a primary care NP do? My wife is a private-type person, but I was able to convince her to share her experiences. Update: In January 2022, the U.S. News and World Report listed NP as the 2nd best job for 2022. 

        I condensed our interview to fit in this blog. Some terminologies were simplified to allow laypersons, such as me, to understand what my wife meant.

Grand: Can you tell us what a family nurse practitioner (FNP) does?

Aileen: I assess patients' health complaints. I assess when they verbalize acute symptoms, such as shortness of breath or chest pain. I diagnose and manage many of their diseases and conditions in the primary care setting. If a referral to a specialist is needed, I order it for further testing and evaluation of their conditions. I follow-up patients and determine whether or not my management is effective. I prescribe medications and make adjustments if needed. If the treatment is not effective, the patient and I problem-solve to make it work. I do preventive care at different levels: primary prevention such as annual physical like ordering screening tests (e.g., colonoscopy), secondary prevention to avoid complications of existing conditions, and tertiary prevention to avert additional and further complications. An example of secondary prevention is referring a diabetic patient to a podiatrist when he or she complains tingling sensation of the legs. It could be neuropathy, so a specialist must further evaluate the patient. In short, under New York state laws and policies, I evaluate patients, diagnose, order, and interpret diagnostic tests, and initiate and manage treatments, including prescribing medications.

G: How did you become an FNP?

A: First of all, I earned my Bachelor of Science in Nursing (BSN) degree, then I studied further to earn my FNP specialty. I studied for three full-time years for my doctorate, including making more than 1,000 clinical hours in different settings such as in different primary care clinics and urgent care. My program of study was BSN to Doctor of Nursing Practice (DNP) because the university where I earned my degree does not offer a master's program for NPs anymore. I passed the FNP exam from the American Academy of Nurse Practitioners and complied with the New York Board of Nursing requirements to get certified as an FNP.

G: So, how do you introduce yourself?

A: To my new patients, I say, "Hello, I'm Dr. Pacheco, family nurse practitioner." My established patients call me "doctora." However, a patient's reception of me as a healthcare provider is not always positive. I remember during my onboarding, a patient who came for an urgent appointment told me, "I want to see a real doctor." I informed my physician-mentor, then she told the patient, "Hey, look. There is no other available doctor.  Either Dr. Pacheco will treat you now, or you make another appointment and tell the scheduler that you want to see a physician." The patient eventually agreed. That was my first, and hopefully the last, negative encounter with a patient. I think 99.9% of my patients care more about the quality of care I provide rather than my credentials.

G: Who are your patients?

A: Mostly are Latinos, but I also have patients from African-American, South Asian, and West African communities. So far, I have seen patients from 6-month to 82 years old. I see patients of all ages and gender regardless of their ability to pay. The most common conditions I manage include asthma, high blood pressure, high cholesterol, type 2 diabetes, and obesity. I also treat different conditions of the eye, ear, nose, and throat (e.g., otitis media, strep pharyngitis), gastrointestinal (e.g., acid reflux), heart (e.g., hypertension), respiratory (e.g., asthma), skin (e.g., eczema, urticaria), seasonal allergies, sexually transmitted infections, swelling, osteoarthritis, and many more.

G: What is your typical day look like?

A: Busy. My official time is 9 AM - 5 PM, but I usually go to my clinic one hour ahead to review labs and finalize after-visit notes and telephone encounters from patients and other providers. By 9 AM, I start seeing patients. Depending on the purpose of the visit, I am scheduled to see patients in 15-30 minute intervals. I eat my lunch between 1-2 PM, but sometimes I have only 30 minutes. I rush to the subway between 5 to 5:30 PM to catch my train, prepare and eat my dinner in my apartment around 6:30 PM, watch Netflix, call you, Gabe or Graecia to have our virtual family prayer, then I sleep around 8:30 PM.

G: What do you love about your patients?

A: Very respectful, they listen to me, they follow my instructions, they are candid ("I don't understand you"). They appreciate the help I extend to them, especially when they feel taken care of and listen to their concerns. They trust and are confident with my decisions regarding their health. I have a patient that because she loves the service, I provide, transferred her children and mother to my care. I am now seeing the whole family.

G: Why did you choose to become an FNP?

A: I want to be empowered in my profession. I want to expand my services on how to help patients with their healthcare needs. Being an NP afforded me the authority to manage their health conditions. I also want professional growth. I am learning tremendously in my current position every day. I love providing health teaching to my patients. Health promotion and disease prevention have been my passion. It's very satisfying to see my patients modify their lifestyles and make healthier decisions because I help them see their benefits. It's also fulfilling to empower patients to take care of their health. When patients feel that they are in control of the trajectory of their health, they become more involved they take care of themselves. I help patients achieve that kind of empowerment.

G: What are the challenges of being an FNP?

A: Language barrier is one. I don't speak Spanish, so my time is doubled up when calling an interpreter to make the interpretation. My time seeing patients are fixed to 15 min for follow-up or same-day appointment. However, it does not always happen that way. For example, a patient came for a refill of medications for his hypertension, diabetes, and cholesterol. However, after checking the patient's blood sugar levels, I ended spending 45 minutes to manage his worsening conditions. I sometimes experience a backlog when seeing patients depending on their health status. However, I am so glad that they are patiently waiting for me because I guess they like how I treat them. 

G: What are the qualities or attributes a family NP must have to become successful?

A: First of all, you must have compassion for your patients. If you have compassion, you value and treat them with respect, and you provide them with high-quality care. Patience is another one. Some elderly patients come with one million complaints. I just listen to them then focus on the most concerning. Having a good relationship with patients is also very important. Patients will adhere to your instructions, especially the medication you prescribe, when you build trusting relationships. Being a good listener and keen observer are also critical. One time a patient came for an annual visit. He indicated no symptoms in the COVID19 screening, but when I started to see him in the treatment room, I noticed his red eyes and looking lethargic. He insisted that he was okay, but he eventually revealed he was diagnosed with COVID19 three days earlier when I persisted. Of course, I canceled the appointment to prevent infection in the clinic. On another occasion, I saw an elderly for an annual physical, but she was having tremors. She said it was normal of her, but I said it was not normal. After history taking and physical exam, I referred her to a neurologist for further evaluation and management.  Finally, an NP must demonstrate critical thinking and good judgment. The NP must be fully aware when a patient shows up and know what to do next if he or she sees something concerning about the patient.

G: Why do you think NPs are important in the country?

A: They are very important because they have become a viable solution to the chronic shortage of primary care providers in the U.S, whether in the rural or urban areas. Primary care is critical because it prevents patients from going to the emergency room for conditions that can be addressed in the clinic. Thus, primary care prevents the overuse of emergency room services and hospitalization. High-quality primary care services also avoid the exorbitant health care costs, especially among those without health insurance and vulnerable populations (lack of formal education, experiencing poverty, etcetera). In addition, primary care NPs work with patients to prevent the onset of chronic diseases and complications.

G: What advice would you give for those who would like to become NPs?

A: Reflect and evaluate yourself if this is the career you are really passionate about. You will get burned out if you choose this career for the money. You must have the proper perspective, and that is you enter this profession because you want to help people, especially those who need your service the most. Choose the population and age you want to work with. Do you want to see patients across the life span, mental health, geriatrics/adult, pediatrics, neonatal, or emergency medicine? Also, pursue it before you get married and have kids because the program is very rigorous and requires a lot of your time and energy. If you're married, make sure your spouse and children are part of the decision-making process because they will be affected whether you like it or not. You will need physical, mental, and emotional support from them as you balance personal, academic, professional, and family responsibilities. It is also costly to earn an NP degree. Look for scholarships from your work, the university, or the federal government.

G: Do you have other thoughts you would like to share?

A: Being an NP is a very fulfilling career, especially when you see most of your patients get better with their health. I don't have regrets because I enjoy what I do, especially when working in an organization with a lot of support and collaboration.

For more information about the NP profession, visit the American Association of Nurse Practitioners website.