NP Week 2016: How this Pediatric NP Found her Niche Abroad

Kicking off National NP Week with a special "How I Work" - all the way from Malawi

Nov 14, 2016 - Guest Author


Ashley Ramirez is a Pediatric Nurse Practitioner (PNP) with a background as a Neonatal & Pediatric Intensive Care Nurse for the past decade. Recently, she worked as a Fetal Medicine PNP at UCSF Benioff Children’s Hospital in Oakland, California. As of July 2016, Ashley joined the Peace Corps as a Pediatric Nurse Educator and is currently working and living in Malawi, Africa. You can find Ashley on Twitter @AshJRamirez, or on her blog, Life As a Pediatric Nurse.


Choose one word that best describes your work style:

Focused. Working in the Intensive Care and Critical Care setting my whole career, my pace is usually one speed: Ready. Set. Go! Over the years I have noticed there is always work to be done. Sometimes it can overwhelm you as the projects tend to pile on. It ends up being extremely daunting. However, I noticed I work best when I can identify tangible goals and projects, breaking them into little chunks to focus on. I prioritize them and slowly execute them in small doses. Creating little internal deadlines for each project. There are always endless projects to be done, but having a good sense of prioritization is key. You can then focus on setting goals and timelines to help make it possible.

As I am learning the Malawi language (Chichewa), we say “Pang’ono a Pang’ono,” meaning bit by bit.

What is your device of choice?

In clinical and travel: iPhone, but my MacBook Air is a close second

Favorite apps & software?

iPhone:

UpToDate
Doximity
Medscape
WHO e-Pocketbook
NPR news
BBC news
Camera +

Macbook air:
Microsoft and Google drive: sharing docs and storing files for education, powerpoints, lectures and modules

How does Doximity help you in your work as a clinician?

Healthcare and technology is at an interesting time. Although technology is making a positive impact, unfortunately there’s a lot of barriers in the system, which in turn impedes optimal delivery of care to high risk patients. Communication within mixed healthcare systems is a blaring obstacle. In turn, we continue to work in silo, duplicating a lot of the workload. Because of this, it translates to marginal gaps in care that is provided. Doximity was a great portal to really connect with providers in the community and optimize the coordination of care. More specifically to this high risk population accessing different healthcare systems.

When I was in the states, I used it daily. In California, I was a coordinator for a Fetal Medicine Program as a Nurse Practitioner. Most of my work involved coordinating care with nearly a dozen pediatric specialists and their respected colleagues to develop individualized plan of care for high risk pregnancies. Doximity was instrumental in connecting with the specialist to coordinate and optimize care in an urgent fashion.

What’s your secret to staying productive?

Taking time to unplug. I have that motto of “Work Hard, Play Hard." I feel like there is a time for everything. As stated above, I am very goal oriented and work great with deadlines. But once achieving those little deadlines I also think it’s healthy to unplug and treat yourself. I truly believe on the weekends people need to turn off your phones and be unplugged with life. Hiking and running is my key to being disconnected and staying balanced. I love getting lost in the wilderness or near water. Lake Malawi has been a new replacement for my Tahoe or Marin headlands fix.

What do you wish you knew when you were a student?

Knowing you are your greatest critic. To have more confidence and be more gentle on myself -- we are truly our worst critics. I’m always so hypercritical, often inflicting fear that initially limited myself in taking risks. Once you realize you don’t have to be a genius to achieve big things, life truly is an adventure of taking risks. The goal is to aim for progress, not perfection. Once you are able to change your perspective, it slowly falls into place. As long as you have a great work ethic and solid plan, you can achieve anything you put your mind to.

Who is your mentor?

I have several mentors. The ones most pivotal in my life include a select group of my Advanced Life Support (ALS) colleagues at Alta Bates Medical Center and my Nurse Manager, Joan Werner. Joan was the initial game changer in my career projection. She pushed me to achieve more and taught me about planning and goal setting. She was the most supportive, nurturing mentors I could’ve asked for. She embodies everything a Nurse should be.

In addition to her inspiration and autonomy she allowed our ALS group to have, I was able to grow into a mold from my stellar colleagues. Some of the accomplishments my colleagues have accomplished has raised the bar within our practice in resuscitation and stabilization in the Delivery Room. It was inspiring to live and breathe how small, simple changes can make a huge impact. Work became a constant PDSA cycle: Plan, Do, Study and Act, which has now been ingrained on my work ethic.

As an NP who is currently working abroad, what advice do you have for other clinicians interested in working in another country?

There are plenty of opportunities, especially in Pediatrics, and it’s not all about helping patients directly. Think about global health on a more sustainable level. It’s wise to invest your time in a strategic initiative that is long term with goals. The book “Dead Aid” is a must read to gain a new perspective.

Think of global health as a continuum; working collaboratively with in-country support on the higher level. Helping solve issues together rather than put a band aid on identifiable problems. We as health care professionals always have good intentions “to do good,” but sometimes we lack a feasible plan with tangible outcomes.
My work in Global Health has definitely changed my outlook on medicine and it just changes you, in general, on a different level. I think working in global health has drastically expanded my skill set and importance of the systematic approach in the delivery of healthcare. It has helped me step back and see the big picture -- not to jump into projects to be a savior and for personal gain, but actually evaluate what the greater good is. I am still learning this.

Working in Global Health is a constant reminder of why I do what I do. There are barriers and obstacles in all of our line of work, no matter where we are in the world. Struggles will always be there. At the end of the day, being able to shape a new generation and help improve care through education and training has been a big shift for me. To possibly have an impact on improving care that is provided to little humans who are faced with lack of access and lack of resources. It’s about problem solving and learning together to help improve care, no matter where they are born in this world. It’s all just a humbling experience. I may not see the change, but I hope somewhere down the line I can help motivate a Malawian to help save lives one breath at a time, one baby at a time and thus a trickle effect. It definitely is not easy but I think it’s worth it.

What’s the first thing you do when you wake up?

Usually blast my playlist of choice via Spotify. Music is my mood lifter. Also, if I can squeeze in three-four morning runs or yoga session then it’s a great week -- or perhaps stressful. Nonetheless, that’s how I filter through it all.

What’s the last thing you do before you go to sleep?

I know it’s horrible, but check my messages and emails. However, during periods when work and life are pretty crazy, I listen to a guided mediation playlist.

How do you decompress?

Exercise! Hiking. Trips to the lake. Running. Basically anything that gets your body moving, distracts the mind, being grounded by the outdoors and feeling unplugged from work.

I can’t live without...

iPhone. I’m constantly listening to music, taking pictures or using google maps.

What are you currently reading?

"Shantaram" by Gregory David Roberts, and always have “When Breath Becomes Air” by Paul Kalanithi on hand.

Do you have a favorite song?

Eek. I can’t just say one. Currently, the albums Rihanna - Anti, Beyonce - Lemonade, Petit Biscuit - Petit Biscuit and other random songs by Major Lazer, Mura Masa and Kygo are always playing on loop.

What’s the best advice you’ve ever received?

Such good questions.. Perseverance. Passion and Patience. Honestly, I can’t say there is one magic advice that was that powerful in one single moment. Rather, I think facing challenging moments sprinkled with small, kind words of encouragements; focusing on the three P’s listed above are essential. Over time, finding a positive, consistent way of coping with tough times eventually leads to a silver lining. Life isn’t about one single moment, one single piece of advice nor one single path. Life is a string of failures that eventually lead to success. Just remember to have a little fun during the process.


NP Week 2016: How this Tech-Savvy NP is Breaking the Mold

Continuing our NP Week series, we profile FNP Helen Lu, who's reinventing what it means to be an NP in our digital world

Nov 14, 2016 - Guest Author


Helen Lu is a Family Nurse Practitioner primarily working in Clinical Informatics. She has a background in family practice and is an Epic-certified Physician Builder and a clinical EMR trainer. Her day primarily consists of training providers, building clinical content on Epic, identifying and troubleshooting workflow issues, and providing support to her clinics, while her clinical duties are in in-home assessments. She is currently based out of Sacramento, CA.


Choose one word that best describes your work style:

Comprehensive. I strive to be efficient, helpful, pleasant, and empathetic on a daily basis.

What is your device of choice?

Microsoft Surface Pro.

Favorite apps & software?

For work: WebEx, Epocrates, HCC helper, UpToDate, ASCCP Mobile, Figure 1
For Social Media: Facebook, Instagram, LinkedIn, Pinterest, Doximity, for articles and connecting with colleagues from work

How does Doximity help you in your work as a clinician?

New clinical guidelines, interesting articles to read on the go, social networking with specialists and classmates.

What’s your secret to staying productive?

Spotify and headphones! I try to focus on one task at a time with my undivided attention (although very difficult), this helps me complete tasks the correct way the first time.

Describe your journey to medicine.

When I was 2 years old, my mother was diagnosed with Lupus, an unpredictable chronic autoimmune disease that attacks the body. The disease, coupled with the extensive medications taken, caused her to have complications such as osteoporosis, muscle pain, and kidney problems. She woke up in the morning not having the choice to say “I’m going to do this, this, and this today,” rather, “What will my body allow me to do today?” She was frequently tired, nauseous, irritable, and prone to infections. I was always sure to be circumspect around my mother when I was ill, mostly in fear of giving her a cold she might not be able to fight off. This was one way my mother’s illness taught me to be independent; I had to take on the responsibility of taking care of myself, as well as the rest of my family. Although witnessing my mother’s illness was always a stressful matter, it sparked my interest in medicine and blessed me with the opportunity to grow. It taught me the importance of being compassionate, with the ability to understand that not everyone is capable of taking care of themselves.

What do you wish you knew when you were a student?

I wish I would've known at a younger age that an open heart and an open mind will allow you to go anywhere. Status will get you nowhere.

Who is your mentor?

I am lucky to have had mentors at different stages of my life. My Mom, who led me to believe in myself. My brother, who told me "The World is Yours, take it" at a very young age. My family, who has always been the catalyst I needed. My preceptors, professors, and colleagues who always knew the correct answers and always provided the right guidance. My patients, who teach me something every single day.

As an NP who is very tech-savvy, what is your advice for others looking to become more involved in digital health/technology?

Networking, continuing to learn, and a keen interest in digital health/technology.

Do you have a favorite song?

Rachel Platten - Fight Song

What are you currently reading?

"Think Like a Freak" by Steven Levitt and Stephen Dubner

What’s the best advice you’ve ever received?

I try to live by this every day.
“You cannot give to anybody in this world what you do not have. And therefore you must concentrate on getting. You must become the most beautiful, sensitive, wondrous, magical, unique, fantastic person in the world to be able to say that I have all of these things so that I can give them away and share them with you. If I don’t have wisdom I can only teach you my ignorance, If I don’t have joy I can only teach you despair, If I don’t have freedom I can only put you in cages. But everything that I have, I can give them away. And so, I dedicate myself to becoming the best ‘me’ the world has ever known.”
-Leo Buscaglia

What would your colleagues be most surprised to learn about you?

I love to karaoke! Though I'm not very good at it.

How this Johns Hopkins Orthopaedist & Military Colonel Battles Burnout

In celebration of Veteran's Day, we wanted to highlight 30-year military veteran, Colonel James Ficke, MD

Nov 11, 2016 - Guest Author


Colonel James Ficke, M.D., is Robert O. Robinson Professor of Orthopaedic Surgery at the Johns Hopkins School of Medicine and director of the Department of Orthopaedic Surgery. He is also orthopaedist-in-chief of The Johns Hopkins Hospital. During his deployment as deputy commander of clinical services at the 228th Combat Support Hospital in Mosul, Iraq, from 2004 to 2005, he was the senior orthopedic surgeon, treating more than 600 U.S. soldiers and Iraqi patients for war injuries. He is nationally renowned as an expert on the treatment of complex foot and ankle patients, lower extremity trauma patients and amputees. This is how he works.


How has the military shaped your active orthopaedic practice?

To start with, I wouldn’t be an orthopaedic surgeon if it weren’t for the military.

The military created my orthopaedic practice. I joined the Army at West Point and studied engineering then went on to Uniformed Services University for Medical School. Originally, I thought I wanted to do wilderness medicine but was exposed to an Air Force orthopaedic surgeon for a 2 week required rotation, and he was so excited about his practice that I was inspired. His name was “Doug Harryman.” He was a mentor for a short period but had a tremendous impact on me.

Ultimately, I served in the military for 30 years because I came into a position of leadership near the 9/11 events. I was at San Antonio, a level 1 trauma center, where we received many of the casualties from Iraq and Afghanistan and it inspired me to stay on Active Duty. Orthopaedic surgery through the military, research, and service of others has inspired my career in foot and ankle and trauma, which were both areas that were needed in the military.

This is a picture in the olive garden of the Benham Monestary in Nineveh Iraq where we had a Medic Baptized. The caretaker served us olives from the trees behind us.

What is the last book you read for fun?

You’re going to get a kick out of this. I must confess, the last book was A Passion for Leadership, by former Secretary of Defense, Robert Gates. I enjoy reading about other people’s successes. It’s a first hand account of leadership by a highly successful individual and icon for us as leaders in academics and organizations. The book depicts his many trials and tribulations and was a remarkable story about how one person came to a position of leadership - especially with such a humble upbringing.

Where is your favorite place you have visited with the military?

Sigh… that’s a little harder question. I have a hard time with favorites and I’m not avoiding your question. Every day in life there is something incredible.

One of the most exciting places was when I served for 1 year in nothern Iraq. We had a Christian soldier baptized in Benham Monastery built in 400AD – this area had one of the largest libraries outside of Rome at the time.

An Iraqi priest was able to baptize him. This was a man practicing his Catholic faith in 2005 in Iraq in peace. I think the most exciting thing about it was that we were at a place defending the freedom of mostly individuals with Islamic faith but freedom of religion was still permitted.

It was one of the highlights of my life because it signified what we did in the military: Preserve freedom of religion/expression for many of those who may not traditionally have it.

What is the first thing you do when you wake up?

Well, like most people, I guess, I shave – shower – grab a cup of coffee – kiss my wife goodbye and head to work.

After taking care of the ‘mechanics of the morning,’ I arrive ½ hour early at work before anyone is there to plan my day, collect my thoughts, and think about the opportunities in front of me for that day.

What’s your favorite type of exercise?

Running. I try to run 3-4 times per week. It gives me time away from distractions and it’s a known fact that people who incorporate an exercise habit into daily practice are happier. They have better health overall. These days in medicine and specifically for Doximity viewers, the notion of burnout is significant. A recent paper showed that up to 45% of physicians are suffering from burnout. I score very low on the burnout ratings, and I have lots of energy and enthusiasm and attribute much of that to getting outside with my regular exercise. Certainly not everyday, but regularly, and that’s valuable.

How has Doximity influenced your career and practice?

Our Department (Johns Hopkins Orthopaedic Surgery) is partnering with Doximity with the “physician referral network,” which is a pilot right now. I’m not a big social networker, but I know many of my colleagues use that feature to keep up with other professionals. It’s a growing way to have a referral network. And clearly the articles are very valuable.

What’s the most important lesson you learned as an Eagle Scout?

Well, you’ve done some checking. I still have the rank of Eagle Scout on my CV. It’s deeply ingrained in my core values including the Twelve Points of Scout Law: Trustworthy, Loyal, Helpful, Friendly, Courteous, Kind, Obedient, Cheerful, Thrifty, Brave, Clean, and Reverent (And yes, he did name them all).

Who has influenced you the most?

Well… I mentor people and I think it’s a skill you have to practice. Sir Ernest Shackleton was a tremendous leader. He influenced my life in the way he led his endurance expedition and brought all of his people home. He kept the unruly members close and taught them accountability.

I study biographies. I think any biography you read can really influence your life and how you practice.

One of Dr. Ficke’s former residents whom he mentors, Chad Krueger, and one of his own mentors, Mike Yaszemski

What Physicians Are Reading about the 2016 Election

Nov 11, 2016 - Guest Author


In the days after our national election, citizens, physicians, and patients alike observed election results that may potentially change the direction of healthcare.

On November 10th, 2016, Donald Trump released a new plan for health reform on his transition website. Read it here.

These are the top-trending, post-election articles among Doximity physicians:

  • Day One and Beyond: What Trump’s Election Really Means for the ACA. [Health Affairs Blog]
  • Doctors to Donald Trump: First Do No Harm. [STAT]
  • Affordable Care Act Enrollment Surges Following Election. [Wall Street Journal]
  • Women Rush To Get Long-Acting Birth Control After Election. [NPR]
  • 4 Things Trump Can Do to Improve Mental Health Care for Veterans. [STAT]
  • Hospitals Ponder Financial Impact of ACA Repeal. [Modern Healthcare]
  • Donald Trump and the FDA [Forbes]
  • 10 Twitter Experts to Help You Navigate Trump’s Health and Science Policy [STAT]

How the country voted on state healthcare propositions:

  • San Francisco, Oakland, Albany, and Boulder passed ballot measures to place a one or two cent-per-ounce tax on sodas and other sugar-sweetened beverages. [NPR]
  • Colorado passed a ballot initiative allowing physicians to prescribe lethal drugs to terminally ill adults who want to end their lives. [Kaiser Health News]
  • California, Massachusetts, and Nevada legalized recreational marijuana use. [The New York Times]
  • Tax increases on cigarettes and vaping devices passed in California, but not in Colorado, North Dakota and Missouri. [Reuters]
  • California voted against lowering prescription drug prices. [STAT]
  • Florida voted in favor of releasing millions of Zika-fighting mosquitos. [Wired]
  • Colorado voted against ColoradoCare, a single-payer healthcare system. [The Colorado Independent]

To read about all of the healthcare propositions, click here.

Disclaimer: The views and opinions of authors expressed in this post do not necessarily state or reflect those of Doximity.

How this Doctor-Turned-Podcaster Manages His Time

Continuing our "How I Work" series, join us as we pick the brain of ObGyn, Dr. Patrick Beeman

Nov 08, 2016 - Guest Author


Patrick Beeman is an ObGyn and writer, and founder of the podcast InsideTheBoards. This is how he works.


Choose one word that best describes your work style:

Collaborative.

What is your device of choice?

My iPhone

Favorite apps & software?

For USMLE/COMLEX preparation, I love telling people about some of the "new kids" in the board-review space: Osmosis, OnlineMedEd and Picmonic. I think these companies approach their business first as servants of the students who use their platform(s) and offer innovative, high quality, and disruptive products that are revolutionizing the way people learn medicine.

For podcasting, I use Audacity for recording software and record interviews with guests via Skype. To keep the quality as high as possible, my home studio includes my iMac, Audio Technica ATR-2100 microphone, an Audio Technica headphone amplifier and pair of ATH MSR-7s cans (headphones) I got while I was on temporary duty in Japan, and a Yamaha MG10XU mixing board.

For daily clinical work, my go to app is Wheel SP, an Ob wheel app that calculates estimated due dates, allows input of fetal biometrics, and other essential stuff for an obstetrician. I use Epocrates and UptoDate a lot on my phone as clinical references. My newest discovery is the social media/secure medical multimedia app Figure 1.

How does Doximity help you in your work as a clinician?

Doximity pushes useful articles, tailored to my specialty to my dashboard. I've also used it to find specialists to whom I might refer patients. Plus, it's helped me connect with influencers to be guests on the InsideTheBoards podcast.

What’s your secret to staying productive?

Setting goals for the day before going to sleep and using the very early morning hours when I'm "fresh" for tasks that require the most creative energy (like working on content for InsideTheBoards or writing an article on bioethics) while saving more time-consuming, but mundane tasks for the evenings when I'm tired (like catching up on email, editing articles or podcast shows).

What do you wish you knew when you were a student?

I wish I had known the "mind hacks" that make undergraduate medical education more efficient, especially studying for board exams. Someone should have told me on day one of first year to do USMLE-style questions. I wrote about the difference that multiple choice questions make in your medical education here. Osmosis, the medical education platform I mentioned above, is doing its best to integrate the best principles of learning discovered in neuroscience into its platform. Things like spaced repetition, memory anchoring, and just doing a bunch of self-assessment questions can drastically increase your retention, efficiency, and long-term memory.

Who is your mentor?

The late Edmund Pellegrino, who has been called the father of bioethics, was my inspiration for becoming a physician. He became my mentor and I've always wanted to model my career after his. One of the best academic experiences I ever had was being his fellow at the Georgetown Center for Clinical Bioethics when I was a medical student.

As an MD-turned-podcaster, do you have advice for other doctors who are interested in alternative ways of using their clinical knowledge?

Many doctors sell themselves short. But a medical education and practice imparts more than just clinical knowledge. There are a bunch of skills a person acquires on the way to becoming a doctor. Besides learning your specialty, you have to be somewhat of a teacher, researcher, communicator, executive, manager, mediator, counselor, scientist, humanist, and writer (although interminable clinical note-writing can have a detrimental effect on one's writing skills) to become a physician. In the first two years of medical school, I was always writing and submitting popular and academic articles on bioethics topics while in class. I wrote boards-style questions during third and fourth year and eventually became the director of content for one of the major Osteopathic question banks. As a resident, I became a MedSchoolCoach.com advisor and have helped premeds perfect their applications to medical school, practice their interviewing skills, etc. I still do a little bit of this work because working with med school hopefuls helps maintain the original idealism that inspired me to pursue medicine as a career.

My dad was in radio broadcasting growing up; I always admired what he did and wanted to emulate it. I was a philosophy and theology major in college and always fancied myself a writer. The result? After becoming a doctor (and during the process, too) I found ways to apply my clinical expertise to writing and media. Clinicians should ask themselves what they think about at work, what they do when they leave the clinic or wards, or what they wish they had more time to do. And then consider ways in which their role as a doctor could be applied to these.

What’s the first thing you do when you wake up?

I try to get in some quiet time/religious devotion and/or exercise.

What’s the last thing you do before you go to sleep?

It's a bad habit, but I'm usually checking my social media feeds for news (and opportunities to troll my friends' by antagonizing—I mean commenting on—their profiles).

How do you decompress?

Working out or writing.

I can’t live without...

My family. I'm in the military and stationed nine hours from three of my kids, who live in Cleveland with their mom, and five hours from my wife (who is a psychiatry resident) and newborn, who live in Cincinnati.

What are you currently reading?

Faulkner's The Sound and the Fury.

Do you have a favorite song?

So glad you asked this. I love music. It's a little-known secret that part of the reason I'm doing the InsideTheBoards podcast is to connect with some of my favorite artists and share some of the songs I love with a wider audience. My favorite song is by a little-known artist, Rich Mullins, "We Are Not As Strong As We Think We Are" which, I think, captures the agony of loss better than anything I've ever heard: "I tremble like a hill on a fault line just at the thought of how I lost you."

What’s the best advice you’ve ever received?

From my mom and dad: stop living so far in the future.


Patrick Beeman is an Ob/Gyn and writer. He worked on the Case Files series and has written practice questions for four question banks including USMLE-Rx. Most recently he was the director of content for a leading board-preparation question bank until founding InsideTheBoards to teach students the principles board exam question writers use to construct test items in order to help them reduce stress, improve efficiency in studying, and to help them achieve the scores they deserve. Listen to the InsideTheBoards Podcast for the USMLE, COMLEX, and Medical School tips.