PART I – Final Stretch
With one week left in my Vermont stint, I find myself getting excited about going home, where I know I belong. At the same time, I feel emotionally fragile and weepy when I think about leaving this pleasant little enclave that Edie and I have called the “Nothome” for the past several months.
When I look back on my 49 years and particularly on the 17 years since I became a nurse practitioner, I realize that I have been very resilient in my life and especially in my career. At the same time, I am terrible with transitions and goodbyes, and I think that I have a tendency to grieve losses a little too deeply.
Career-wise, I am the kind of person who can be in a job in which I am ridiculously overworked, repeatedly stripped of my professional dignity, and figuratively beaten over the head with a sledge hammer, and I will still spend months regretting leaving, even when Edie and the close friends who have endured my suffering with me can barely contain themselves in their happy dance. Not that this has ever happened or anything…
It’s definitely time to be home. I need my human and furry family, and they need me, at least I hope they still do. Come to think of it, Aggie and Hedwig haven’t called lately, and there have been a few nights when Edie has allegedly fallen asleep before our Skype dates. I have heard rumors though, that the 7-year-old has wistfully said “I miss Grammie Cindy” a couple of times at the dinner table. That alone is reason enough for me to go home.
I came to Vermont last October with the intention of working a twelve-week contract in a good-paying, relatively low-stress, no-commitment position. By phone and on paper, the expectations and hours sounded reasonable, and the people seemed friendly.
Of course, The Voice used her sales pitch from wherever the hell she’s located in the world (allegedly Fort Lauderdale, but I still have my suspicions). I don’t think Chris had placed a provider at this particular location before, so she had no idea what it would actually be like. The game is for her to promote me to the client sight unseen, and promote the location and clinic to me, also sight unseen. Then, after a brief phone interview between me and the Chief Medical Officer of the clinics, we basically hope for the best.
We all know that unless I screw up in a big way (like kill someone…oops), three months will go by quickly. When they hire someone they’ve never actually met in person, I’m sure the agency and the clients think “Thank God for malpractice insurance.” On my end, it’s more like, “Well, I can put up with just about anything for 12 weeks if they pay me enough.” They hope it doesn’t turn into a new Investigation Discovery Network series called “Who the Bleep Did We Hire?” and I hope it’s not “Cold Case: What Happened to the Nurse Practitioner from Maine?”
I’ve always loved Vermont, having spent time here on skiing, cycling and camping vacations over the years, not to mention countless road trips passing through from Boston to Montreal and Maine to Montreal. Vermont was actually my first choice for relocation when I was looking for jobs out of graduate school.
Apparently, whatever higher power or Karma or big fluffy orange cat who orchestrates things in the universe had other plans for me, and sent me to Maine to find Edie. Now that I’ve had a taste of working in another state, I’m even more certain that Edie is the reason that I ended up in Maine. I thought I went to Maine for my career, but I think Vermont would have been a much better fit.
I have liked aspects of every NP job I’ve had in Maine, and by most accounts, I’ve done well at all of them clinically and in terms of making strong connections with co-workers and patients. It’s mostly been the other stuff that has been difficult: The politics; the hours; a loss of focus on patients; hypocrisy; a leaning toward “sweat-shop” medicine; and the overall disintegration of how primary care is run in many places. Usually, this has been driven by disastrous economics and by administrators, and state and federal politicians who are more concerned with butting heads than with promoting vision and insight and taking a hint from a few states and countries that have more progressive health care policies.
Although I’ve had some fantastic career highlights, by last summer, after nearly 16 years of being an NP, I was ready to quit being a nurse practitioner. When I had work, I almost always had an underlying sense of chaos and panic. When I was out of work, I almost always had an underlying sense of chaos and panic. Physically and financially set back by Worker’s Comp and other injuries and surgeries, I was chronically overwhelmed and depleted; feeling and probably looking like an emotional crash test dummy. I decided that being an NP was bad for my health. It only took a couple of sledge hammers to my knees, shoulders and psyche to figure that one out.
Then I was lured to Vermont by the previously-mentioned persuasive and persistent Voice, not to mention an ailing bank account, and maybe an intuitive need to flee from a toxic career environment for a while.
My first sign that Vermont was going to work out well was on Halloween, just two weeks into the gig. The clinic staff was invited to dress up if we wanted to and also bring goodies to give out when the hospital employees’ kids would come by in the afternoon to trick or treat.
I love Halloween and jump at any opportunity to dress up. This likely dates back to my love of the 1967 Canadian children’s TV program called Mr. Dressup, in which a Mr. Rogers-like actor named Ernie Coombs and his puppet sidekicks entertained me with stories, songs, crafts and skits that they conjured up from the costumes that resided in their magic trunk. I think I was in my 20s when it occurred to me that “Dressup” wasn’t an actual last name.
I usually include Moxie on Halloween. In recent years we’ve worn matching costumes. As long as I don’t put anything on Moxie’s head, she doesn’t seem to mind the costumes at all, and she clearly loves the attention from me and from everyone who admires her. I was a little sad this year because I had our costumes all picked out for 2012 long before I got this job away from home. I’ll be saving the newest duo costume for 2013, but decided to use my half of last year’s costume in Vermont.
I dressed as a giant banana and the clinic staff and patients seemed to appreciate how ridiculous I looked, even without my banana-dog sidekick. There’s just nothing like going to work in a banana costume with a stethoscope around your peel. I had a good time, and it set a good overall mood for the next three months in a new place.
I brought along several bunches of mini bananas to give out, along with snack size candy bars. When the kids came in the afternoon, I held out the bag with bananas and chocolate and told them that they could take one of each if they wanted to.
What surprised me was that more than half of the children just took a banana. What the hell was wrong with these children? I know Vermont is ranked the healthiest state in the country, but this was very strange to me. I’d say “Really, you can take some chocolate too” but at least half of them politely refused, some of them laughing and others looking quizzically at the funny-looking giant banana and backing away.
Then more bizarre things kept happening. Patients would call in with upper respiratory infections and I would expect to have the “viral vs bacterial” educational discussion with them, because waking up with a scratchy throat, or two days with a stuffy nose does not merit a trip to the clinic to ask for antibiotics.
Instead, many of these patients had truly been sick for more than two weeks, had already tried over-the-counter meds, nasal rinses, herbal treatments, homeopathy, or standing on their heads holding hands and chanting with the local alpaca goddesses before finally breaking down and scheduling an appointment at the clinic.
They would tell me they “didn’t feel great” but had been going to work and were finally pushed to come in by a friend, significant other or coworker but they really didn’t want antibiotics and was there anything else they could try? Then I’d listen to their lungs between their hacking coughs and would hear an orchestra of wheezing or pneumonia. I’d spend the rest of the visit trying to convince them to take an antibiotic and to take a few days off work to rest. Some of these patients had no work benefits and were understandably reluctant to miss work, but others had more than enough sick time. It just wasn’t in their work ethic to ever consider using it. This has happened more often than not, and sometimes I feel like an antibiotic-pushing goof-off-enabler.
Pain management has been another interesting difference in Vermont. There are substance abuse and addiction problems here, like everywhere in the country, but for reasons I can’t figure out, they don’t overwhelm our clinic. In Maine, I rarely got through a day without seeing patients who were either blatantly or subtly trying to get me to prescribe narcotics for them for reasons that were suspicious for “You’ve got to be kidding me.” Like many providers, I have experienced unpleasant occasions in which people have been unhappy, rude, or outright belligerent if they did not get their pain meds of choice.
I don’t like not being able to trust my patients. My whole philosophy of caregiving is premised on “listen to the patients” because they know innately what’s best for them. My job is to give them information, options, and guidance and help them figure out what they need, not to just tell them what to do. I do trust most of my patients, but sadly, the pervasive drug problem has changed my perspective over the years. Getting burned a few times (that I know of) by people who misused or diverted medications that I prescribed to them in good faith has soured my warm fuzzy feelings about erring on the side of treating someone’s ambiguous pain.
As providers, we’ve heard every possible excuse. It’s amazing how often narcotics get “lost” or “fall down the sink.” That never happens to blood pressure or thyroid meds. Oddly enough, it doesn’t seem to happen very often in this little piece of Vermont. In eight months, I think I’ve been played for narcotics a total of five times, and none of the encounters became at all contentious.
In the Sneezeville region of Vermont, it goes something like this: A laborer or farmer comes in two days after falling off the back of his truck (he’s been working since then) with pain in his side. He is clearly in pain, having trouble moving around, and splinting and guarding with his arms. I ask if he’s taken anything for the pain. “Nope. Don’t like that stuff.” I examine him, order an x-ray and discover a couple of broken ribs. Then I spend the next 15 minutes convincing him that he really needs to take some time off work, that some ibuprofen would probably make him more comfortable, and it might also be a good idea to have something stronger on hand for the pain so he can get some rest. There I am, pushing drugs again, amused that I find it refreshing.
I think that most providers these days encourage patients to try alternative and adjunctive treatments for pain and other health problems, even when they do need medication, so they can at least minimize their doses. In my Maine practices, it was often a tough sell to get patients on board with physical therapy, psychotherapy, nutrition counseling and other non-pharmacological treatment modalities. My patients here come in asking for these referrals.
I know that access to these services and what appears to be a better state health care system is a big part of the differences I’ve observed. I still find it interesting that what feels like a Twilight Zone difference in health care attitudes between Maine and Vermont cuts across age, class, educational, gender, and other demographic lines. The people aren’t that different. And the people are so very different.
PART III – Final Stretch
There’s a different professional atmosphere here also. Every workplace, especially in health care, has some grumbling and office politics, and a degree of drama and chaos. That’s just human nature combined with a high-stress profession. The people here may not realize it, but I don’t think I’ve worked in a health care setting with this level of respect for its employees and patients.
One thing that stood out to me immediately was that almost all of the staff members, as well as many of the patients, are on a first-name basis with the physicians in the clinics. That is not the norm in most health care settings that I’ve worked in.
I have also not heard the kinds of remarks from my co-workers—providers or other staff members— about certain “types” of patients that I heard too often in Maine. Over the course of my career, I’ve heard way too many comments about “those drug seekers” or “those people on Medicaid” or racist, homophobic, or anti-Semitic slurs or just ignorant faux pas. I expect more from my colleagues. Unfortunately, I’ve worked in a few settings in which these comments have been tolerated.
Since I’ve been in Vermont, I don’t think I’ve heard even one disparaging comment from a co-worker that would fit in any of the above categories. There’s an easy-going acceptance and welcoming openness to everyone at face value. People may have bigoted thoughts, but at least they have the good sense and respect not to spew them at work.
There is a sense of family, loyalty and dedication here. Some of the maintenance, dietary, lab, clerical, nursing, provider, and other staff have been with the organization for 20 or more years. This is a gem in its little region of the state: A small friendly rural hospital with all the usual hospital features, on-site primary care and specialty clinics, a satellite clinic in a nearby town, an in-patient rehab facility, and sadly, a highly-rated nursing home that will be closing due to financial problems. I hope for their sake that despite the changes and the economy, they can hold on to the uniqueness and integrity that so many other health care organizations have had to relinquish.
I could go on with other highlights of my time here, but it’s way past my bedtime so I’ll hold off on more details. Since I somewhat obsessively cling to routines as long as possible, I will still be waking to my alarm at 4:30 AM for another several days to get on my exercise bike for exactly 75 minutes before work. I love routines.
Ok. One more story. I sutured a guy’s tongue last week. That was fun. It was a potato chip injury. We laughed a bit during the visit.
He was bleeding profusely and had saturated a towel when I walked into the exam room. I stuffed a wad of gauze in his mouth while I was deciding what to do with him. While we were talking (with his garbled mouthful), he caught me by surprise when he said “I’ll probably wind up in your blog.” I said, “How do you know I have a blog? And, with your permission, you probably will end up in it.” He laughed and said “Sure, it’s okay with me…you just seemed like you’d have a blog.”
I then told him that I hadn’t done much suturing in years, but I had recently taken a refresher workshop and had also dug a metal shard out of a guy’s leg a couple of weeks ago and sutured him up.
I’d take a shot at sewing up his tongue if he wanted me to. “Go for it,” he said, blood squirting through the gauze. The room looked like a Bates Motel shower stall afterwards, but it worked.
I didn’t want to get attached. Vermont grabbed me though, and really doesn’t want to give me back to my adopted state of Maine. The past 17 years of my career may have played out very differently here, in the land of easy-going warmth, cheese, wine-tasting, alpacas, quirky artists, food co-ops, and the well-earned title of the healthiest state in the country.
Being away from Maine has given me some new perspective about my career. I won’t quit being an NP just yet. Being in Vermont has given me a break that I needed, even though I’ve worked more hours than I have in a few years and my body hurts more.
Most importantly, I’ve learned that work and career are not as important as the other parts of my life, and if I have to choose, I choose the other things as priorities. I have a job lined up at home, and hopefully I’ll like it and there won’t be sledge hammers involved. I’ll probably get attached.
Obviously, I’m leaving with sadness and some grief over a difficult, but right decision.
Now I move forward, back to career trepidation, but also to the more important home and personal life, where there’s a 7-year-old who needs her Grammie, a dog and 2 cats who will rest easier with the pack and pride intact again, and a community of women that has been keeping a seat warm at the table. Oh, and there is one extra special woman who is waiting to walk down the aisle with me and stay at my side wherever that aisle takes us.