How to Prepare for the First Few Months of Practice

The first day of seeing patients on my own as a NP was one of the most exciting yet intimidating experiences. Everyone’s experience in their first job will be slightly different depending on what type of clinic you’re at and what patient population you’re serving (private practice vs hospital vs FQHC, etc). The experience will also vary based on the pace of the facility and the amount of support you’re offered as a new grad. I was lucky enough to be offered a six week on-boarding process that paced my patient appointments out a bit — but I was still seeing patients every 15 to 30 minutes by week two, and six weeks in I’m up to 4 patients an hour (with the exception of physicals and well woman visits).

As for my level of support from the higher ups? Well . . . it’s there somewhere but I definitely have to seek it out when needed. I still haven’t even seen my supervising physician since I started and the other practicing physicians around me are so busy with their own patient load that I 100% felt on my own from day one. That being said, it was vital that I started out with some prep work as a safety net to answer some of my own questions throughout the day. This can help you evade some panic moments and the feeling of needing to constantly hunt down the closest MD or NP for help. Cause let’s be real . . . there isn’t always that lifeline at any moment in the day at fast-paced (and underserved) clinics.

However, that being said . . . I want to pause and point out that it’s extremely important to recognize the patient scenarios that could use some consulting. It’s never wrong to slow down and take the time to get the necessary questions answered. Especially if you’re stumped. Because unlike many careers out there, this is not one where you can (or should) ever guess. I remember when I got my first patient with hyperglycemic and T2DM who was in with CC of “stomach ache and nausea”. After getting his A1C (12.5%) and BG in office (423) my head immediately started spinning and the words “ketoacidosis” began echoing in my mind. I had never been in this situation during my preceptorship, let alone on my own . . . so I immediately sought out a MD to ask her opinion on next steps and plan for this patient. I did the same thing when faced with the patient in for “medication refill”, and once stepping into the room realized she was short of breath, had facial swelling, and her blood pressure was 190/125. When in doubt, ASK!!

Knowing your own expertise and scope of practice plays a big role here. So let’s dive into my first tip for prep . . .

Know Your Scope of Practice and Personal Limitations

They teach you this in school and it’s banged into your head during board review . . . but what is your scope of practice for your specialty?? If you work anywhere similar to where I am, you’re going to get patients walking in the door to see you with multiple chronic diseases, multiple failing organ systems, dozens of daily medications, and a handful of chief complaints. Knowing ahead of time what you can and cannot do for each patient is invaluable. So much of primary care is knowing where to draw your line of intervention, utilizing outside resources and referrals, and then helping where you can. If a poorly managed sickle cell patient with severe chronic pain comes to you for ER follow-up and medication refill, safe practice is knowing which medications you can safely refill or manage, and then recognizing that the morphine and dilaudid are probably best left to a pain specialist (unless you have this training). The majority of my patients have complaints and diseases that require care by a specialist and it’s up to me to identify in each visit where I can help and what is out of my scope and needs referral. Identifying these boundaries ahead of time and really getting to know what is within your scope makes each visit more smooth and less stressful.

Take Your Boards Early On and Save Your Study Materials

Not all states require that you take your boards in order to practice (ahem, California) but you should (in my opinion)!! And, you should try to take them early on or before your start date, ideally. Then, after you take and pass your boards, keep your study materials as reference in daily practice. I studied using the Fitzgerald in-person three-day review and was given a 140 page workbook that basically sums the whole NP curriculum into one little resource. I take it to work with me every single day and it’s out on my desk next to me as my safety net in case I need it. I use it to quickly look up migraine treatment options, hypertension guidelines, insulin titration, immunization timelines . . . No shame. That book has all of the evidence-based information I needed to pass my boards and it’s now my go-to when my head is spinning and I need a trustworthy resource. My preceptor who had been practicing for 6 years still had hers at work with her, and I highly recommend to do the same!

Make Cheat Sheets

Also on my desk every day is a folder with all my cheat sheets and a notebook for random notes. My advice — make charts, print out evidence-based guidelines, find medication resources . . . whatever you feel you need a quick cheat sheet for, do it! A good example . . . working at a FQHC with low-income patients means I have to be knowledgeable and strategic about what medications I prescribe. I can’t just throw any brand name, fancy medication at my patients (or even you’re everyday cipro/hydrocortisone otic . . . Ugh). Most of the meds will bounce back to me in a message from the pharmacists saying “not covered under formulary” and I’ll have just added more work to my day and a delay in care for my patients. So the very first pages in my cheat sheet folder are lists of common drugs covered by Medicaid and those covered by HealthPac (for my undocumented patients). This saves me SO much time and allows me to learn what medications are widely available to all patients, no matter their income level.

Here is a list of my cheat sheets, in case you need some ideas:

• A list of drugs covered by Medicaid (you can find this online by state)
• Chart: Labs to monitor (and monitoring intervals — ie 4 wks, 3 mo, etc) for commonly prescribed medications in primary care
• Charts: Medication by class (ABX, HTN, DM, HLD, MSK/Pain). Charts include quick reference to: top adverse reactions, contraindications, pros and cons of each drug, labs to monitor.
• Algorithm: Stepwise approach to prescribing insulin (I got mine from my Fitzgerald online study resources)
• Algorithm: Screening for albuminuria in patients with diabetes
• Chart: CHC and COC eligibility criteria for contraceptive use
• Chart: Recommended immunizations for children birth – 6 years old
• Chart: Recommendations for preventative pediatric health care (From Bright Futures)
• Chart: ACOG Cervical cancer screening guidelines
• A list of “must cover” questions/HPI/screening tests for every adult physical and every pediatric wellness exam (created this on my own)
• Lists of evidence based websites for guideline information (USPSTF, Bright Futures, ACOG, GOLD for COPD, etc)

Know who to consult when necessary

You can never be too prepared with resources and cheat sheets at your fingertips. But if you still cannot seem to figure out what to do — that’s when you hunt down or call the more experienced practitioners around you. Do not be afraid to ask questions and always have a list of trustworthy, experienced providers you can count on to consult. Even if these contacts are colleagues at another practice, ask for help and never, ever guess.

**All patient examples have been altered to protect patient identities.**