Tips for Presenting at Conferences

Posted on March 2, 2012 by

I am preparing a discussion on health information technology for a presentation that I am giving later this year. In my preparation, it struck me that it might be a good idea to give some brief tips here on this blog for preparing a presentation. There are many specialty clinical conferences taking place around the country and they are a great way to present something that you are working on or to share your subject matter expertise.

Most NP/DNP programs today require some sort of capstone or evidence based research project. There is often valuable clinical knowledge identified from these projects and therefore should be shared with the health care community. Some of the work may be identified by other clinicians and researchers for ongoing analysis.

Without further ado, here are some of the helpful tips for preparing and presenting at a conference:

  • Choose a topic that you are passionate about and have expertise on.
  • Identify the correct conference venue to present at. For example, if your topic is focused on pediatrics, it probably isn’t a good idea to want to present it at a geriatric-focused conference!
  • Obtain the conference’s guidelines for presenting. The conference host will usually have very extensive guidelines to assist you.
  • Pay attention to their schedule. The conference requires submission of materials by certain deadlines.
  • Make an outline. It sounds so elementary but an outline will enable you to set your course and stick with it. The guideline should clearly state the objectives of your talk. What will the audience be learning about and what new knowledge will they have after your lecture.
  • Perform your research and put it all together in a clear concise presentation (using Microsoft’s Powerpoint or Apple’s Keynote). Remember to not make the slides so busy so that its not hard to read from the audiences perspective. Also determine if you will use any other presentation materials such as an erasable whiteboard, etc.
  • Prepare any handouts that you want to include in your presentation.
  • Practice, practice, practice. Some people have a natural talent of public speaking, but many do not. You will need to practice slide transitions and try to avoid any transitions that will be too distracting from the material. Be sure to practice giving your presentation alone and then practice with an audience of family/friends.
  • Be sure to find out what equipment the venue will provide. Most offer the projector, microphone, and whiteboard. Some will offer a computer as well (if you are making the presentation on Keynote or bringing your own Apple laptop, you will have to either bring the appropriate VGA adapter or ask if the conference will provide the adapter – for usually $20, I would make sure that I had my own adapter).
  • Arrive at your designated timeslot and room assignment in plenty of time prior to the presentation. There will usually be a presentation in session before you so you may not be able to set up too far in advance.
  • Someone from the venue will be there to help with set-up and any technical difficulties.
  • Give your great presentation!

You will eventually receive some type of feedback report from the conference host after well after completion of the conference . Be sure to read all the comments and try not to take any negative comments too personal. You will decide if you want to add or change something the next time you present based on the feedback.

If you still aren’t ready to present in front of an audience, consider a poster presentation. Many conferences will have designated areas for poster presentations where attendees will walk through. The “presentation” is to smaller groups of attendees or individuals as they walk by.

There is no reason not to share any work that you are passionate about or spent significant time studying. This type of work is considered gray literature and contributes to the body of knowledge. Good luck!

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5 Tips for Nurse Practitioner Students to Maintain Balance

Posted on March 1, 2012 by

While this post can be about the physiology of the inner ear in maintaining balance (with a differential diagnosis list including vertigo and Meniere’s disease), the balance I’m specifically referring to is the school/work/life balance. Let’s face it, being enrolled in a nurse practitioner program is intense. There are many stressors for students including meeting assignment deadlines, tasking tests, learning and being productive in clinicals, preparing for the certification exam, and paying for school. Add on a job, family commitments, and other aspects that are part of life and it is enough to take its toll on the student. Having been a NP student some years ago and recently completing the DNP last year, I’d like to offer 5 tips for nurse practitioner students to avoid a meltdown.

1. Plan and Schedule: It is so essential to schedule a regular time to perform school work and study. Since most NP students are adult learners, there is no luxury of merely attending classes full-time. Having and maintaining a schedule is especially important for students enrolled in on-line asynchronous NP programs.

2. Partake in Regular Physical Activity: It is not necessary to join a gym and try and find time to go and workout. A brisk 20 minute walk two to three times a week in your neighborhood or on a treadmill will do wonders to help clear the mind and reduce some stress. One can also partake in some simple stretching exercises or Yoga. It may sound silly, but scheduling the time for this activity in your calendar can help you to stick to it.

3. Eat a Balanced Diet: For some people, when the levels of stress increase in one’s life, the more food that is consumed (food that is usually not the healthiest or nutritious). Try to eat regular meals balanced meals that are lower in fat. Of course, the occasional burger or package of gummy bears can also be included – just don’t make it a regular part of your diet. Also watch the caffeine and alcohol intake as these can negatively affect sleeping and eating habits as well.

4. Perform Some Self-Care: Schedule one day a month for a massage. Studies have consistently shown that massages reduce stress (and some types of pain) levels. Or perhaps schedule a short weekend trip free of school and work. Whatever it is you that you find enjoyable, try not to abandon it while you are in school.

5. Consider Working With a Wellness/Life Coach: Wellness coaches are wonderful resources that can help you plan and prioritize things in your life to reduce stress. There are some wellness coaches who specialize in working with nurses and nurse practitioner students since it is well documented that there is increased chaos for these individuals due to long hours and caregiver fatigue. One such wellness coach is a friend and colleague of mine, Dr. Eileen O’Grady, NP. Her unique coaching model takes place remotely and she has helped many individuals looking to prioritize aspects in their lives and get back on the right path.

Remember that if we cannot take care of ourselves, it will be nearly impossible to take care of those around us and our patients. Try to find and maintain that balance so that we can enjoy success and productiveness in what we do.

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5 Must Read Nurse Practitioner Authored Books

Posted on February 24, 2012 by

Nurse practitioners are multi-taskers. NPs are adept to managing complex clinical cases and communicating with patients to partner with them and make shared health decisions.  This ability to connect with patients and other health care professionals makes authorship of literary works an obvious next step. NPs have authored many book titles ranging from a target audience of non-clinicians to health professionals. Today, I highlight 5 must-read books authored by nurse practitioners.

  1. A Nurse Practitioner’s Guide To Smart Health Choices – Award winning author Carla Mills, NP, presents diet and lifestyle tips for patients looking for a healthier outlook. She presents an easy and adaptable format that patients can use to take concrete positive steps. If there ever was a book to prescribe to your patients, this would be the one.
  2. Nurse Practitioner’s Business Practice and Legal Guide, Fourth Edition – Carolyn Buppert is a renowned attorney, nurse practitioner, and author. She is the guru of all legal aspects of nurse practitioner practice and is frequently consulted for practice issues across the country. This book will help those looking to start their own practice and among other things, offers views on malpractice, negligence, risk management and much more geared specifically to the nurse practitioner. A must read.
  3. Confronting America’s Health Care Crisis: Establishing a Clinic for the Medical Uninsured – NP author Anne Parrish describes her experience in setting up her clinic and offers tips and a business plan for those also wanting to set up a similar type of practice.
  4. Nurse Practitioner Certification Examination and Practice Preparation, 3rd Edition – NP author Margaret Fitzgerald’s practice review courses and books are the gold standard for NP examination certification – whether it is the American Academy of Nurse Practitioners Exam or the American Nurse Credentialing Center’s Exam. I had the opportunity of taking her review course in person and it helped immensely in my preparation for the certification exam.
  5. The Doctor of Nursing Practice: A Guidebook for Role Development and Professional Issues – NP author Lisa Astalos Chism takes a look at the genesis of the DNP degree and offers some roles that would be congruent for NPs with their DNP. If you are considering returning to school for the DNP, this book should be on your list.

Of course there are many more nurse practitioner authored books out there. This top 5 list presents some of the great literary work out there!

 

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Let’s Talk Nurse Practitioner Salaries

Posted on February 22, 2012 by

Many nurse practitioner students and nurses contemplating becoming a nurse practitioner often wonder what a realistic salary would look like once they become a full-fledged nurse practitioner. After all, it’s reasonable to want to know what their return on their educational investment will be. Many factors will have an impact on salary. Factors include geographic location, specialty, years experience and private practice versus hospital-based.

A few good resources to check out are Advance for NPs & PAs Salary Survey, the AANP National NP Compensation Survey and salary.com. After checking out these resources, you may find some pretty wide ranges of compensation. This can be attributed in part to the number of respondents and methodology of gathering the data. One option is to average the salary data that is specific to your region and practice to try to get a good idea or at least a range.

One theme that I’ve heard frequently among registered nurses is that they are making (or will make) more money in that role than they would as a nurse practitioner. While this may be true in some instances, it is really hard to compare the two different roles to one another. Most NPs that I have spoken to did not pursue the extra education and training for a large financial payoff. For many, being an NP is about being to diagnose and implement interventions for their patients within a collaborative yet autonomous environment.

One troubling trend that seems to be consistent with nurse practitioners and physicians alike is the lower compensation for jobs in primary care-type settings. This however, hasn’t seemed to keep NPs away from primary care though some purport that the majority of NPs end up in specialty care. This just isn’t true. When you look at the number of NPs practicing women’s health, school-based health, correctional, occupational, and community based health, these make up the majority of jobs that NPs are in. As greater emphasis is being placed on primary care with the Affordable Care Act, we are hopeful that those in primary care will find parity with the specialty counterparts.

So how much will a nurse practitioner make? I’ve seen hourly rates range from $37 – $60/hour. Yearly salaries can be from the mid $70′s to over $100k. Other factors to consider beyond a salary are benefits including paid time off, continuing education money, licensing/malpractice reimbursement, and health insurance coverage. In many cases, these benefits are negotiable and need to be the best fit for your particular situation and circumstance. For instance, you may not need health insurance coverage since your spouse has coverage. This might be a good place to negotiate a higher dollar amount in lieu of the health insurance coverage.

It may seem tempting to go after the job with the highest salary. However, there are many other factors that may ensure a better fit beyond money. Good luck negotiating.

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NP Career Option: Correctional Health

Posted on February 16, 2012 by

I have spent some time behind bars. No, not from incarceration but providing health care to inmates. Correctional health was my first nurse practitioner job and it was a great learning experience. Correctional health is not for everyone and today I wanted to share my experience about this career option for nurse practitioners.

One can expect to see and treat many of the same conditions that would be treated in a primary care practice: episodic care, chronic illnesses, dermatologic conditions, sexually transmitted infections, and trauma for example. According to the CDC, the most infectious diseases encountered in correctional health are:

  • Hepatitis
  • HIV/AIDS
  • MRSA
  • Sexually Transmitted Infections
  • Tuberculosis

The most chronic diseases encountered are: 

  • Arthritis
  • Asthma
  • Cancer
  • Diabetes
  • Heart Disease
  • High Blood Pressure
  • Stroke

Mental health and substance abuse and also areas commonly seen in correctional health. Dental services are usually part of the health services as well.

Typically a inmate has an initial history and physical, bloodwork, and tuberculin skin test (TST) planted upon arrival. The clinician makes their assessment, prescribes any medications as necessary and consults and arranges with the correctional staff as to whether the inmate needs care that is of higher acuity or can be put into general population.  From there, inmates can follow up with the various chronic care clinics or sick call/episodic clinics as necessary.

The working conditions in correctional health are probably among the most challenging. One can expect to walk through multiple metal detectors as safety is always a primary concern and bringing belongings from the outside is not usually allowed. The facilities must be staffed 24/7, 365 days a year so shifts can also vary.

The actual employer of the health care staff varies by institution so benefits and salary depend on the employer. Some of the state correctional facilities hire the clinical staff as state/county employees with the usual benefits that state workers get (i.e. pension, health care benefits, etc). There are also agencies that contract with correctional facilities to provide health care services. The health care staff is employed by the agency. They, too, offer benefits to the health care staff that may be higher salary than the state counterparts but the benefits may not be as good.

As a new nurse practitioner, my correctional health experience was an overall good one. I got to see and treat many people with common health conditions and I learned a lot from my mentor at the facility. Ultimately, I wanted to focus more on health promotion, wellness, and proactive health which was admittedly difficult to do in correctional health.

For more information about correctional health, check out the National Commission on Correctional Health Care (NCCHC) and the CDCs website dedicated to correctional health.

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NP Career Option: Occupational Health

Posted on February 14, 2012 by

Many nurse practitioners find themselves right at home in occupational health (aka employee health). NPs are a good fit for occupational health since much of it involves health education, preventative care, precise record keeping, and documentation. Occupational health settings vary among institutions. Hospitals utilize any mix of registered nurses, nurse practitioners, and/or physicians. I have been working in occupational health as a nurse practitioner for the last 2 1/2 years and have become quite familiar with the setting.

What can one expect in occupational health? At the core of occupational health are workplace related injuries and their prevention. For someone working in occupational health in a hospital setting, needle stick type injuries are fairly common. Back, knee, and shoulder injuries are also frequently encountered. These happen as the result of falls, trips, and incorrect patient lifting and moving. Injuries of course, can happen to anyone working in the hospital. However, nurses, transporters, engineers and support service staff encounter the largest amount of injuries. Oftentimes, occupational health acts as a liaison between the employee and workers compensation.

While occupational health nurse practitioners treat the injuries incurred from an accident, they often focus on prevention and avoiding reoccurrence. This may take the form of performing an ergonomic evaluation of the employees workplace to identify correctable variables to prevent further injuries from occurring. Occupational health NPs may also serve on various institutional committees to examine systemic issues and getting the necessary resources to allow employees to perform their job without putting themselves at risk for injury (think recommending lift assistive devices, etc).

Occupational Health NPs also perform an initial history and physical on pre-employees to help ensure a health workforce that is able to perform the job that they are hired for. An immunization history is reviewed and any required immunizations are offered. Once employed, most state and federal regulations require hospital employees to undergo an annual screening which can vary from a full physical exam to performing a tuberculin skin test. These NPs can also find themselves performing Fit For Duty evaluations to determine if employees are under the influence of drugs/alcohol at the workplace.

Another job requirement is handling any outbreak of infectious diseases among the staff. This can happen prior to a patient being diagnosed with any highly infectious communicable disease such as tuberculosis or bacterial meningitis. Any employee exposed to these infections is usually screened and prophylaxed accordingly to prevent spread from patient to employee. Surely, prevention is paramount and emphasis should be placed on educating employees to don the appropriate personal protective equipment (PPE) and wear it correctly. Oftentimes, occupational health staff work very closely with the Infection Control/Prevention Staff.

Finally, some occupational health NPs perform episodic care on employees. They can treat ear infections, sore throats, bronchitis, pneumonia, hypertension and diabetes for example. Depending on the institution, occupational health NPs may even run employee wellness initiatives, programs, and immunization campaigns.

As you can see, occupational health NPs must wear many hats in the course of their day. Speaking from experience, I can say that occupational health is a wonderful opportunity and a fulfilling one. Occupational health staff keep the workforce healthy so that they can care for the patients of the hospital.

For more information, check out The National Health Institute for Occupational Health and Safety (NIOSH) and the American Association of Occupational Health Nurses (AAOHN).

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Why Do I Need an Annual PPD?

Posted on February 10, 2012 by

Every health care provider needs an annual assessment for various federal and state requirements. Part of that assessment includes screening for the bacterial infection tuberculosis (TB). Basically, there are two forms of TB infection: (1) active infection and (2) latent tuberculosis infection (LTBI). With active TB infection, typically the symptoms are obvious: weight loss, coughing up blood, and night sweats. However, someone can have an active TB infection without a cough. LTBI on the other hand rarely shows any symptoms at all. Thus, the need for annual screening. The World Health Organization estimates that 2 billion people worldwide have LTBI. The problem with LTBI is that if untreated, may activate at some point and cause an acute infection.

Screening for TB is done via skin testing by the Tuberculin Skin Test (TST) containing purified protein derivative (PPD) and/or with the newer blood tests called Interferon Gamma Release Assays (IGRAs). It depends upon the institution regarding their policy on TB screening and which method they use as both have advantages and disadvantages.

For the TST, 0.1 cc of PPD is drawn up in a tuberculin syringe and is implanted intradermally into the forearm area. A proper implantation results in a wheal formation at the site. The area is then checked in 48-72 hours to measure any induration in millimeters. Many institutions require an initial two-step test which is essentially 2 TSTs about a week apart to catch any delayed response to the initial PPD.  Healthcare staff are considered positive if the induration measures 10 mm or more.

The main advantage to the TST is it’s low cost. The disadvantages include making the employee return twice for one test (one for the implantation and one for the reading), variability of implantation technique and interpretation (i.e. ensuring the results are read in mm), relative low specificity and sensitivity, and positively reacting to foreign born individuals that were administered BCG vaccine.

The IGRA blood tests are a relatively new way to test individuals for both active TB infection and LTBI. Advantages of IGRAs include: just 1 visit for the blood draw, higher sensitivity and specificity, and the ability to distinguish whether a person is truly positive if they were vaccinated with the BCG vaccine. The disadvantages include higher costs and the shorty window in which the sample must be processed.

A positive TST or IGRA requires additional screening and will include a chest x-ray (or sometimes sputum cultures) to rule out active infection.  Assuming a negative chest x-ray, the recommendation will be made to treat the LTBI with an antibiotic for 9 months to ensure eradication of the bacteria. One important thing to note is that if someone has LTBI, it can not be spread to anyone else. Active TB infection can only be spread via airborne droplets.

So the next time you are required to have a mandatory annual assessment, you know why and how you will be screened for TB!

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Research Papers: Shades of Gray

Posted on February 7, 2012 by

For most students including nurse practitioner students, writing an original research paper is part of scholastic requirements at some point in the program. Hopefully, students will have a concise rubric to follow which will ensure that the content of the paper addresses the requirements.

Armed with the 6th version of the APA Publication Manual in hand, the nurse practitioner student sets out to research a topic of interest. (Since many NP programs require APA format for writing, a wonderful resource for APA tips is the Purdue Online Writing Lab. The actual book is still generally necessary but this website makes finding the correct formatting very simple).

To perform research for a paper, the search methods  must be more in-depth and specialized than using your favorite Web search engine. Google Scholar may help identify some articles but for efficient searching that will return relevant articles, databases such as Medline/PubMed and CINAHL must be used. Otherwise, thousands of results may be returned and it is not efficient use of one’s time reading all of these abstracts to see if the article is relevant. Boolean  search methods must be used to focus the search. While that may sound overwhelming, it is simply using terms such as “and” “or” & “not” in the search. “Or” will broaden the search, “and” will narrow the search and “not” will exclude anything following the term.

Today however, I’d like to focus on the grey literature. Grey literature may include articles that were never formally published in a peer-review journal, articles that are not purely clinical research, articles that are not indexed by the major databases, and articles that are ahead of print or located on institutional websites. Grey literature may also contain valuable background information for the research paper. Below are some grey literature databases to use for locating additional articles:

  • Graynet/OpenSigle – a collection of web-based European gray literature resources
  • Mednar – is a free deep-web medical search engine that will return results in real-time
  • The New York Academy of Medicine – a free grey literature database
  • Scirus – contains over 440 million scientific indexed items

Searching for articles needs to be done well in advance of writing the paper to allow for sufficient time to retrieve an article if it is not available in PDF or full-text downloading. Utilize your institutions librarians as an additional resource. My experience with librarians has always been extremely positive and they are generally most willing to help. These search strategies can later be employed when in clinical practice to find the best data for an identified issue for evidence based practice.  

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It’s Never Only a Sore Throat

Posted on February 2, 2012 by

One of the most common encountered conditions that I see is pharyngitis (sore throat). Pharyngitis accounts for approximately 12 million annual visits to offices per year. Thus, the likelihood is that a primary care provider will see their share of pharyngitis.

The purpose of this post is not to give the typical background, etiology and treatment options for adult pharyngitis but for people to consider some alternative causes and avoid the “it’s ‘only’ a sore throat” mantra.

Sore throats can be caused by infectious agents such as viruses and bacteria and by non-infectious conditions such as reflux of acid from the stomach. If the treatable bacterial forms of pharyngitis are not properly addressed, patients can develop issues with their kidneys, arthritis, tonisllar abscesses and even potentially lethal blood clots.

Many people are familiar with the term, “strep throat.” Indeed, group A streptococcus (GAS) is one of the more common bacterial pathogens responsible for causing a sore throat. There is even a rapid strep test which can be performed and resulted in as little as 5 minutes time. However, there is some debate regarding the accuracy of rapid strep testing. (See this blog post by Dr. Robert Centor. Dr. Centor has studied strep pharyngitis extensively and often posts pearls regarding his experience and findings). The rapid testing can help to curb over-prescribing antibiotics for conditions clearly not warranting them. However, as we know, health care is not always so black and white. By the way, I always have the lab run a traditional throat culture when a rapid strep is negative due to the variability in rapid testing sensitivities. The rapid testing will not pick up the non-GAS bacteria.

I have seen some ill-appearing patients with a negative rapid strep throat ultimately have non-group A strep grow on a culture. I typically treated these patients with antibiotics upon examination and have seen them improve and have no sequella as a result. One of my most memorable cases of pharyngitis was a young ill-appearing adult ultimately diagnosed with Lemierre’s syndrome (with a negative rapid strep test). Lemierre’s syndrome is usually caused by the anaerobic bacterium Fusobacterium necrophorum, lead to a clot formation in the jugular vein, possibly leading to thrombosis and sepsis. This patient was ultimately hospitalized and recovered well but was required to be on blood thinners for a certain amount of time to avoid further clot formation.

Of course this was the exception to routine pharyngitis. However, if a patient is looking toxic or continues to complain of an increasing sore throat, don’t just write it off as viral. It warrants further and complete investigation to rule out the more serious causes.

Here is a differential diagnosis list for pharyngitis (partially from UpToDate):

  • Group A Streptococcus
  • Non-group A Streptococcus
  • Fusobacterium necrophorum
  • Infectious mononucleosis
  • Primary HIV
  • Neisseria gonorrohoeae
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Corynebacterium diptheriae
  • Arcanobacterium haemolyticum
  • Rhinovirus (post nasal drip)
  • Gastroesophageal reflux
  • Tumors

There are many potential causes for pharyngitis and as clinicians it is always important to take a complete history, perform an examination, and order the correct diagnostic tests. While I was told to “not look for zebras,” if the clinical presentation does not make sense, then its time to delve deeper into the investigation and consider other causes.

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Provider Ratings: How Many Stars?

Posted on January 31, 2012 by

When you are a licensed and practicing provider, the chances are that some web site will give patients the opportunity to rate you. Provider ratings are a very sore subject for many providers since many of the categories are subjective. It is very difficult for a provider to refute a negative rating without violating HIPAA in some way. For example, some sites may ask patients to rate the ease of scheduling an appointment, the bedside manner of the provider, level of trust, and office environment. Today, patients can go on sites such as Healthgrades, ZocDoc, or even Yelp to rate their provider and experience.

While subjective ratings hold some value, objective data would be just as important for someone wanting to find information in order to make an informed decision for selecting a provider or continuing to see that provider. For example, it would be extremely valuable to know the average hemoglobin A1c of a particular providers patient panel or to know the amount of preventable diabetic complications. Some other types of objective information could be the provider’s institution attended and training though I’m not sure how useful that is as a reflection of that provider. Perhaps patients would want to know what conferences or research the provider has been involved with to ensure that thy are up to date on the latest evidence.

Of course, the problem is that the objective data may not be a direct reflection of that provider’s ability. Since I define care as a partnership, the patient, their lifestyle, adherence, and socioeconomic background should be factors into the equation as well. Therefore, you see, there are challenges when it comes to simply rating a provider. Unfortunately, this is not as easy as rating a product on a website such as Amazon or rating a seller on eBay.

This takes us back to square one. That is, provider ratings are difficult to quantify and will remain a sore topic. Electronic health records should allow us to collect de-identified objective outcomes. However, it remains to be seen how this will fit into an overall rating algorithm.

Whether you buy into ratings or not, it is important for all providers to register on the sites and to regularly view their ratings since patients are using these sites. Here are some tips for what providers can do today on these ratings sites:

 

  • Have a set time to view ratings on a weekly basis.
  • Be open and upfront with your patients. Encourage patients to share any concerns about their care and experience.
  • Inform patients about the site and encourage them to leave a rating.
  • Create your own practice website listing your credentials, continuing education, etc.
  • Consider having your own anonymous patient survey on sites such as Zoomerang or Surveymonkey to get feedback from patients to look for suggestions to improve their experience. Anonymous feedback may help to change something perceived as negative that the provider may be unaware of.
  • Set up a Google Alert with your name to have an e-mail sent whenever anything is published about you on the searchable Web.
  • Consider subscribing to a site like reputation.com that will help you to find reviews

Until provider ratings are perfected with incorporating more meaningful and useful data, patients will surely rely on some combination of them, word of mouth, and perhaps an in-network provider based on their insurance carrier recommendation. The bottom line is it is important for providers to be aware of these rating sites.

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