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QandA with Sara D. Back, FNP-C, MPH, AAHIVS, at North Central Bronx Hospital, Department of Medicine (HHC) in New York City, New York | NEWS-Line for Mental Health Professionals

Q&A with Sara D. Back, FNP-C, MPH, AAHIVS, at North Central Bronx Hospital, Department of Medicine (HHC) in New York City, New York

Sara Back is a family nurse practitioner at a public hospital in the Bronx, New York. After years of public health work (program development/research) in the field of HIV/AIDS, Sara decided to pursue nursing in order to more completely provide needed services and care. While being an NP is not without its challenges and obstacles, overall, Sara finds the work rewarding.

Q: Why did you make the transition from political science and public health to nursing?

A: I grew up in a "left of center" home where we were raised on the philosophy of doing good in the world and helping to bring about change for the betterment of others. (The Hebrew phrase is "tikkun olam"—"fixing of the world".) While that philosophy was a bit daunting and overwhelming in childhood, it soon became a part of my world outlook.

In retrospect, it would have made more sense for me to take the science track in college. However, being engaged in the social sciences/political science provided me with the critical sociological/economical/political background and understanding of some of the inequalities faced by many. I knew that I would work in the social sector but was not sure in what capacity. My career has been more of a series of steps/stumbling rather than a planned out path.

During college I worked with two wonderful sociologists who were investigating the quality of life of patients with chronic end stage renal disease. The contacts made on this job led me to secure a job with the NYC Department of Health AIDS Program Services at the start of the epidemic. I was fortunate to be hired to develop/implement and oversee the first HIV serosurveys in NYC funded by the Centers for Disease Control and Prevention. This job, which was challenging, exciting, and frustrating, led me to go back to school and secure my Masters of Public Health. I continued my work in HIV/AIDS and worked in programs mostly located in underserved areas locally, nationally and internationally.

At some point though, while doing this public health work, I was frustrated I "could not do it all"—develop programs and provide clinical services to the persons in our programs. I realized that having both clinical and public health skills would provide me with a powerful combination. I then decided to obtain my clinical nurse practitioner degree. My hope and goal was to mix both of my passions: public health and clinical care. I started the transition to nursing in the mid-1990s. The progression from political science to public health to clinical was a natural progression, and the three degrees are but parts of a whole perspective and outlook.

Q: What motivated you to become a nurse practitioner?

A: The decision to pursue this degree emerged out of many factors and influences:

• Members of my family worked in the medical field;

• In the early years of the HIV/AIDS epidemic, I was so impressed by my colleagues in this field who were nurse practitioners and treating patients with AIDS when many other healthcare providers did not want to interact with them; and

• I gravitated toward this degree, as it seemed to be more holistic approach to medicine and patients.

I'm sure the following statement would not be considered "politically correct" but at times I feel that had I pursued a medical degree my work life would have been a bit easier in terms of baseline knowledge; not feeling like I am "always behind the 8-ball;" and in terms of not having to justify/explain my role as an NP.

Q: Can you describe the facility where you work?

A: North Central Bronx Hospital, a public hospital located in the Bronx, New York, is part of a network of approximately eight city hospitals. I work in the outpatient/ambulatory care department. The overall mission of the hospital is to provide quality care to all regardless of ability to pay. Therefore, many of my patients are uninsured, undocumented and had have little access to healthcare prior to coming to our clinics. We provide the full spectrum of services from primary care to specialty services inclusive of allergy/asthma, OB/GYN, pediatrics, HIV/AIDS, podiatry and ophthalmology. My clinical work is divided among three clinics/services: ambulatory care/primary care, HIV/AIDS and allergy/asthma.

Our ambulatory care medicine clinic is part of a medical residency program. In addition, other providers such as nurse practitioners and social workers often take on mentoring students. We have some research grants and as the healthcare arena changes, our clinic will be participating in NYS Home Health and Federal Medical Home programs.

While the clinics' mission is admirable and critical, since we are primarily funded by city funds and Medicaid/Medicare reimbursement, unfortunately, we are chronically understaffed and overextended.

Q: Typically, what are your day-to-day responsibilities?

A: My day-to-day responsibilities may vary a bit depending on which clinic I am working in. For instance, in the HIV/AIDS Clinic, I not only provide these patients with specific HIV/AIDS care, I am their primary care provider. Therefore, while ensuring that they are doing well on HIV treatment, I also manage any co-morbidities, be it hypertension, diabetes, and/or Hepatitis C. In the Asthma Clinic, I focus on providing asthma/COPD care as most of the patients have a primary care provider in the clinic. Finally in the allergy clinic, I am responsible for delivering and managing the patients on immunotherapy.

In addition to overseeing and monitoring the patients' health needs, many of my patients present with mental health issues, ranging from mild depression to schizophrenia and post-traumatic stress disorder. While I do not provide therapy/psychiatric care to these patients, I try to ensure they are engaged in care, and much of our visits do include basic talking, problem solving and provision of support.

The connection of mind-body health is very apparent with many of my patients. I truly believe that many of my patients experience chronic generalized pain due to PTSD. Thus, I spend time with my patients just listening to them talk about their lives, especially since many lack basic social supports and have not had a provider who takes an interest in their life. Their gratitude for having a provider who cares and does follow-up is a bit overwhelming.

In summary and more concretely, though my clinical days vary based on the clinic I am working in, overall, I do the following: annual physical assessments; three-month follow up to ensure that the patients' diabetes/hypertension/HIV are controlled; lab review and medication modification; medication renewals; form completion for jobs/immigration/social services/disability; getting prior authorizations for medications and procedures (the bane of my existence and such a waste of a provider's time); following up on patients to ensure that they make their needed appointments; and just listening to patients' concerns and issues. Unfortunately since my clinics are understaffed and poorly structured, I often do many other tasks that could and should be done by non-medical personnel.

Q: Can you share a story about your profession?

A: Several stories come to mind but I will share two. When I first started out as an NP, I was working only with persons infected with HIV/AIDS. Since being in the field, I have had worked at three different facilities. I was moved when a core group of the patients I initially treated at my first institution followed me to all three facilities. Their desire to stay under my care has been very special. In addition, I am forever overwhelmed by the generosity of my patients who have so little. They shower me with gifts and treats. One patient in particular always brings me fresh mangos, papaya and other fruit. I feel like the "barefoot NP"!

My patients are very patient with me, and many of them only speak Spanish. I have a workable knowledge of Spanish, and granted, over the years it has improved, but I am far from fluent. Last year when examining a patient, I asked her in Spanish, "Do you have nose pain?' She stopped—looked at me—and started laughing. I then asked her what was so funny. It seems that for the past 11 years I have been asking patients if their "orange/naranja" was hurting instead of their "nose/nariz." My patients must have really not understood my Spanish, thought I was totally loony, or were being polite.

Q: Are there other areas of interest for you as an NP that you plan to pursue?

A: At this point in my career, I am seeking to create a position that will provide a more balanced division between providing direct clinical care and doing more public health projects. For the last 12 years, I have been providing direct care. While it is has been rewarding, it is also very draining. For me it is important to diversify and get involved in new projects/programs. Stagnation is harmful both to the patients and me.

At various times during the last years, I have been fortunate to be able to engage in consulting projects such as implementing HIV/AIDS programs in Africa. However this work has been on a short-term basis. I am pursuing positions that will provide me the opportunity to do more of the programmatic development tasks along side my clinical work on a regular basis.

In addition, I am considering branching out into education. I have been on the NY/NJ AIDS Education and Training Center Speakers Bureau for years and have provided in-services and lectures to other providers on specific HIV/AIDS related topics. I find teaching and providing in-services very gratifying and challenging.

Q: What are the greatest challenges you face as a nurse practitioner?

A: The challenges are many and varied, and touch on all realms. I would classify the challenges accordingly:

Patient specific: language/cultural barriers (I have many patients from Bangladesh/Albania); overall patient understanding/education; mental health issues that affect physical health; patients' health belief models; and the overall neediness of the patients. In addition many of my patients have chronic nonspecific generalized pain. Dealing with this condition is a challenge especially when there are so few available and good pain clinics. Another challenge is dealing with some patients who try to "scam" the system be it by getting medication and selling it on the street and/or applying for disability when they are capable of working.

Medical system issues: time constraints; lack of resources; poorly trained and ineffective support staff; lack of clinic structures; insurance policies that really do affect the provision of quality care; and a lack of socialized medicine affording everyone the same access to quality care and treatment;

Profession specific: the overall hierarchy in the world of medicine—i.e.: many people/colleagues still do not understand the role of the nurse practitioner; being undermined by having to get MD signatures on such things as VNS forms; general lack of respect by some MDs/others who again do not understand the NP role and/or are threatened by our practice. I am frustrated by the fact that the role of the NP is limited and specific to the US. It would be wonderful if this role was developed and in place in other countries.

Q: What do you like most about your job? What do you dislike most?

A: I do love the patient contact/care—or at least most of it. Granted I have a few patients who annoy me or push my buttons, but with these patients, I try to understand the dynamics with that patient and modify my behavior. Other satisfying components of my work include knowing that I am making a small change in some patients' lives; being autonomous in my clinic; and working with smart and helpful colleagues who are always available for a consult and second opinion.

Since my clinic has such few resources, many of my dislikes relate to environmental/clinic specific issues. For instance, my clinic does not have a working central clinic phone system, so patients have a hard time getting through to the clinic to make appointments, get medication refills and get referrals. Furthermore, our access is limited due to a lack of providers. Often my next available open clinical slot is two months away. Therefore, if a patient calls and needs to be seen immediately, I have to overbook my clinical session. Finally the time limit placed on each patient visit is stressful and unrealistic. Given the acuity of many of my patients, it is unrealistic that I will be able to address their needs in 10-15 minutes.

Q: What do you feel is of the greatest concern to NPs today?

A: The NP profession has always been in a precarious world/position: we are nurses but not; we are providers but not medical doctors. I think that the profession still struggles with how it defines itself and its role. All too often, I feel that NPs continually feel the need to justify their ability to provide medical care. We need to be very clear about who we are, what we can provide, and what our strengths and weaknesses are. If we are not clear, then those around us will certainly not be clear and will not know how to interact with us.

In addition to self-definition and self-respect, I feel that our education is often lacking. We would benefit from having an additional year prior to graduation that was more akin to the medical school rotations. While I do not wish to adopt the MD residency approach, I know I would have benefitted from more clinical work prior to becoming an NP (and not nursing work); we cannot leave all learning to "on the job."

I also fear that with the creation of the DrNP, the profession will be split and fragmented. I am not a strong supporter of this development.

I strongly believe in the importance of giving back to my field—nursing/public health. It is up to us, the current practitioners, to foster/mentor/support and encourage potential and current students. We cannot "eat our young" and we must do away with that perspective often prevalent in the nursing field.

Q: How would you describe your job as a nurse practitioner?

A: Being an NP is both very rewarding and incredible frustrating. I get many rewards in providing quality care to my patients and their families, but the external and internal barriers in the field create obstacles/difficulties that make the provision of this care a challenge. In addition, I am saddened by the trauma that many of my patients have endured and are still enduring in their life. These inequalities are hard to face on a day-to-day basis and often make me feel powerless that we will be able to change and improve the social and economic structures of our society.

Q: What have you learned over the course of your career?

A: I have learned much over the years and learn more each day. If I had to summarize the key take home messages, I would have to state the following:

Not only is it appropriate, it is critical to know your medical knowledge comfort zone and to seek advice/a second opinion when needed;

It is fine to tell the patient that you "do not know" something but that you will seek out the answer;

Being a healthcare provider is physically and mentally draining so it is critical to figure out ways to take care of oneself;

Giving back to the profession is essential;

It is our responsibility to keep current in the field; thus attending conferences/doing CMEs is essential; and finally

It is important to treat each patient as if that person were a family member or yourself (that of course is assuming that you like your family members!)

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