In 1979, I was awarded a certificate as an adult and geriatric nurse practitioner. I could not admit patients to facilities and required a collaborative MD agreement. Compare this to the truly autonomous role nurse practitioners now fill in hospitals, skilled nursing facilities, ambulatory primary care positions, and emergency rooms. The profession has evolved to truly serve populations across the health care spectrum.—B. Betts, MS, ARNP; PsyD, LP, Mankato, Minnesota

As a family nurse practitioner in Pennsylvania since 1985, I have lived through and participated in the legislative process to advance the profession. I witnessed Pennsylvania’s nurse practitioners first become regulated solely by the board of nursing, removing dual regulation by medicine and nursing and then receiving prescriptive authority. Hopefully I will still be practicing when full practice authority is enacted.—Jo Ann Nicoteri, PhD, MS, CRNP, FNP-BC, Clark’s Summit, Pennsylvania

I remember carrying brown charts, with color-coded tabs that represented various sections in the chart (eg, lab, clinic notes, etc), to the patients’ rooms. The process of flipping through the chart and trying to find pertinent information would have begun prior to the encounter in the provider’s office. Now, I manage my patients visit by using 3 separate screens to chart my notes, review labs or old records, and complete medical orders. It is a more expedient process that allows for a quicker review.—Michelle Lastraes, PA, Stafford, Texas

My practice has seen a shift away from a Medical Model to more of a Business Model with dispensing. The power of insurance companies to direct healthcare has increased with their approval of procedures.  We now see an increase in research along with more biologic care. There has been less hands-on care accompanied by more computerized charting, along with telemedicine. Increased utilization of medical assistants is replacing roles once held by LPNs and RNs. There are longer hours and increased responsibilities and demands for nurse practitioners, but there is also increased autonomy. However, the ever-expanding crisis of shortage in care givers is worsening; this presents a mixed-bag of blessings and problems.—Jennifer Graves, FNP, ANP-BC, Elkhart, Indiana

Advances in social media and changes in insurance reimbursements have shifted patient care priorities to positive patient experiences and good customer feedback. Here are 5 tips to help create a smoother and more positive patient experience.

1. Establish a positive encounter. A first impression sets the tone for the duration of the encounter, and the most important step in creating that positive first impression is to leave personal and professional drama OUT of the encounter. Showing up to meet your patient while distracted, angry, or otherwise in a negative state is unprofessional and shows the patient you cannot handle difficult situations or juggle multiple tasks. Take time to change your outward appearance so as to hide any negative feelings. 

2. Practice a personal approach. Personalize your patient’s experience by using the patient’s preferred name more than once in the visit; this creates a more intimate connection and sets the foundation for a more inviting personal relationship. Engage in culturally appropriate physical contact, such as a handshake when greeting or a supportive arm to assist with ambulation. At each visit, ask about life events or favorite activities and make a note. On subsequent visits, surprise your patient by bringing up the topic in a friendly way.

3. Give thoughtful and useful feedback. Questions may be left unasked because patients feel they are “stupid” or “embarrassing.” Encourage your patient with supportive language. If your patient feels confident discussing difficult topics or embarrassing questions with you, they are more likely to be open and honest, helping you achieve better patient care.

4. Set realistic goals and offer praise when achieved. Discuss treatment regimens with your patients and come up with small obtainable and measurable goals. If you have a broader or larger goal that seems overwhelming, break it down into smaller more easily attainable “step-by-step” goals. Give praise when goals are achieved.

5. Follow up when you say you will. Keeping a relationship strong means sharing responsibilities. This includes the relationship we have with our patients. Be sure to keep your word when making plans with a patient and communicate when your tasks are completed or results are known. Although EMRs make it easier for patients to look up their own results, always close the communication loop by asking for confirmation that results were received and questions are answered.—Joe E Ciavarro JR, PA-C, New York, NY


These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.