HCDM 17 | Family Nurse Practitioner

 

Working as a family nurse practitioner is so much more than just being aides of physicians. Instead, they work as collaborators of medical doctors and spend the most time with patients, assisting them with all of their needs. Alexa Maestrone, FNP-BC sits down with Richard Marn, MD to explain how her profession differs from a registered nurse and physician assistant, how she maintains an effective work-life balance, and why she recommends her work to students who are aspiring to pursue a career in the medical field. Alexa also shares the one thing that makes her profession close to her heart – building deep relationships with patients. She tells her most memorable stories of helping patients, even going beyond what the work requires her to accomplish.

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Pursuing A Career As A Family Nurse Practitioner With Alexa Maestrone, FNP-BC

In this episode, you’re going to learn how a particular advanced degree in nursing can allow this particular nurse to write prescriptions for patients and that particular degree is a nurse practitioner. We’re going to talk to Alexa Maestrone. She is an outpatient family nurse practitioner that works specifically with neurological surgery with NYU Langone Medical Center, both in Manhattan and Brooklyn. You’re going to learn how a nurse practitioner is different from a physician as well as a Physician Assistant or PA.

During this conversation and what you’ll soon learn is that a nurse practitioner does a lot of quarterbacking, a lot of coordination of care for their surgical team. She does work intimately with office managers, the other nurses, surgeons, other physicians and she also works with PAs. PAs I found and talked with Alexa after our recording are very skilled, but they also have a lot more focused on the technical aspects and skills in medicine. A nurse practitioner is a bit more managerial, a little bit more management and it involves talking with patients in a wide breadth of different environments as well. In future episodes, I expect that we will soon get a number of PAs on this show so you can hear their perspective in this light.

A little bit about Alexa. She went to college at Wagner College, where she got her nursing degree. She was also a nurse in the neurosurgical ICU as well as a private practice plastic surgery nurse in the office of Dr. David Hidalgo. She eventually got her nurse practitioner degree at Wagner College, and is currently working, as I mentioned at NYU as a nurse practitioner.

Alexa, how are you doing?

I am well. Thank you for having me.

What do you do as a nurse practitioner?

I think it’s important to define the role of a nurse practitioner. Very plainly put, a nurse practitioner is basically an advanced practice nurse either with a Master’s degree or with a doctorate. They manage the nursing as well as the medical care of an individual within a certain population. That can mean a lot of different things. There are various specialties such as women’s health, family, pediatrics and etc. It’s important to realize that it only takes part within a certain population. Because I’m a family nurse practitioner, it doesn’t necessarily mean I would go and take care of neonates, but perhaps my specialty would be more adults and children with less complicated conditions.

Do you have a subspecialty that you work in as a nurse practitioner?

Yes, I work in neurological surgery, neurosurgery.

As a nurse practitioner, what do you do for these patients on a day-to-day basis? What’s your day like as an NP?

For example, I work outpatient. I think that what I do in terms of inpatient and outpatient work is very different as an APP or Advanced Practice Provider. I work outpatient and what my typical day looks like is I arrive at the office. I review my patients on the schedule for the day. I make sure that I have enough time to be able to address the patient’s needs within that allotted time. I also make sure that I have any consoles and anything else that I may need in order to advise the patient appropriately. In between, what we do is I do a lot of reviewing of new patient requests. I contact those patients as well to make sure that they’re seeing the appropriate specialist. I also return patient calls for medical advice and such during the perioperative period. You do a lot of coordinating of care as a nurse practitioner and that’s also really important to point out that a lot of nurse practitioners do that on a daily basis.

Nurse practitioners sometimes stick their necks out and try to do what they think the patient would want them to do. Click To Tweet

What are the characteristics of an NP stand out from a registered nurse, the basic nursing degree?

A nurse practitioner, in order to be a registered nurse, you can have an associate’s degree or you can have a Bachelor’s degree. Whereas to be a nurse practitioner, you either need to have a Master’s degree or you need a doctorate and that’s considering education. With regard to what I can do is I’m allowed to do everything that a registered nurse does, but I’m also permitted to diagnose and prescribe.

How does a nurse practitioner differ from a PA or an MD?

In New York State, nurse practitioners are allowed to function after 3,600 hours without a collaborative agreement with a physician. For instance, I could open up my own practice if I wanted to after 3,600 hours of practice under a collaborative agreement with a physician. That’s the cut and dry sort of way of putting that. Nurse practitioners and PAs fundamentally are different in a lot of things and I think that in terms of collaboration, we have a lot to bring to the table, which is why APP, stands for Advanced Practice Provider, it’s all encompassing of physician assistant as well as nurse practitioners.

Our main difference from a physician is that physicians are not in charge of the nursing care. They are in charge of the medical care. I’m not a physician so I wouldn’t speak to what physicians do on a daily basis. But what I can say through my practice is that I noticed that physicians tend to treat a lot of the disease processes, whereas nurse practitioners tend to look at things in the whole picture. What they can do is and one of the pros of being in my position is that we help to drive down some of the costs of healthcare and we know when our hand ends and we need to make a referral to a specialist such as yourself.

As an NP, you get a lot more independence than an RN or an LPN or any other type of a typical nurse that we often envision. What are some of the problems in your specific specialty as an NP that you are helping patients with in the neurosurgical field?

HCDM 17 | Family Nurse Practitioner

Family Nurse Practitioner: One of the pros of being a nurse practitioner is that they can help drive down health care costs.

 

Neurosurgery encompasses brain surgery patients as well as spine surgery patients. That population, I’m taking care of them during the entire perioperative period. From the time of consultation, to post-op and follow up visits, we take care of them amongst the whole time and we are able to manage them and see which medical doctors then they would need to see for their follow up care. I tend to explain this to patients by saying that with neurosurgery, we are the technicians of the brain and the spine. We perform an intervention. We will manage you for that intervention but it’s always important to establish a good primary care, regardless of who that provider is to you. Also to establish follow up with a very good neurologist as well so they can sort of take charge of the medical issues of what may be happening within the brain and the spine.

Could you walk us through a certain patient that you maybe took care of that stands out and how you helped them?

I had a younger patient. I would say in her late 30s. She’s a single mother of four and she had a first time seizure. She appeared to an outside hospital, not the hospital that I’m affiliated with. She had imaging performed there and they saw a rather large meningioma. That’s a type of brain tumor and it needed to be resected which basically needs to be taken out. She wound up signing herself out of that particular hospital, AMA or Against Medical Advice and she presented to my hospital for evaluation.

There was a lot of coordination of care for her because she did not have a very big support system afterwards and the pathology revealed something that needed to be followed very closely with surveillance imaging. What you do with these particular patients is there’s a lot of emotional care being rendered and it’s important to remember that we as providers sometimes need to really slow down and realize that what we’re treating is not only a disease process, but we’re also treating a human who’s going through this.

You realize some of the psychological, emotional and socio-economic things that will impact what this person is going through and whether or not they have a good support system or not. It makes a big difference in how well they do. I also think that it’s important for us to realize that some of these people do require a little bit more support and to be patient and to offer that. A lot of the times, we’ve become very friendly with our patients and which is a good thing because I really do feel that that is quite rewarding.

Would you say that’s the highlight of your job, making those connections with people? Are there other aspects of your job that stand out that you enjoy?

There are a number of things that I enjoy about what I do but I feel that the relationships that I established with my patients in general is probably the most rewarding thing or when they say, “You don’t know what I was going through at that point but because you said what you said, you made it that much easier for me.” That is important.

You serve a key role in the coordination of care for the patient, walk them through step-by-step and hand-holding them a little bit as they go through that.

I probably have an example that I can use to highlight the coordination of care. For instance, we had a different patient who was an elderly woman. She never was a sick woman. She had no comorbidities. She had an episode of what we referred to as word salad, where she was speaking with one of her sons and all of a sudden gibberish just came out. About three weeks later, the same thing happened to her again so she presented to her primary care physician for evaluation of this. At the time, he had some imaging performed and he actually called my office in consultation to figure out what essentially to do with this now because of what he had found on the MRI of the brain that he had ordered as a primary physician.

I had a conversation with him regarding this. I let him know what this looks like on the imaging and that he should make the referral to my office and that we should have a conversation with this patient about what to do next. We had met the patient in consultation the following week. She had the tumor resected with us the following week. Unfortunately, it revealed a very high grade tumor. It was not one of the “good ones” to have if that makes sense. She needed to go for some adjuvant radiation, chemo and things like that down the line.

The patient after consulting with oncology and finding out what the follow up would need to be after her resection, made an appointment with my office and wanted to have a conversation with myself and the doctor. She said that because we were the team who she initiated care with and we started down the road together, that she wanted to kind of see how we felt about what the suggestions were made or the suggestions that were made to her via oncology.

You have to be aware of what you don't know and be okay with saying those things. Click To Tweet

At that point, it was a matter of saying, “I’m here to listen to you and this is the information that was given to you by our respected colleagues. I can only help for to clarify some of this information if you need some help, but the ultimate decision is left to you in terms of what you want to do.” Long story short, she decided to not pursue the chemotherapy and radiation. She was an elderly woman in her mid to late 80s. She is sharp as a tack. You could not pull a fast one by her at all.

She had said, “I lived my full life and I appreciate you taking care of mem, but I would like to just go home and figure out what I need in terms of my support system.” Fortunately enough for her, she has four lovely sons who took care of her and were taking care of her. She was being managed by her primary care physician at home. I would say about six weeks after we had this conversation and she was home and I had not heard from her or her family. I received a call from one of her sons. He had called my cell phone and this was in the thick of the COVID pandemic.

Unfortunately, there were a lot of people in specialties working rather short during that time. He had reached out to me and he said, “You are the one person who my mother trusted the most during this whole thing. She is in a position right now where she is not making any sense. She is at home and I don’t know what to do.” I got a little bit more of the story from him in terms of what she looked like and what was happening. I said, “Give me an hour. I’ll give you a call back.” I spoke to some folks over in hospice. I spoke to social work, and a few other people and said, “What do I need to do to get a patient into hospice at this time?”

It was rather difficult at this particular time because of everything that was happening. I had also never had to do something like that before but sometimes what we do is we stick our necks out and try and do what we think the patient would want us to do. I helped to arrange for her to be admitted to hospice during the COVID pandemic. I received a call from her son a week after. He kept in touch with me and told me how thankful and grateful that he was at that point. That’s not something that I would typically do. That’s not a typical occurrence but I think that having that experience as a bedside nurse and understanding how patients are overall and realizing going from a bedside ICU nurse, to now being an outpatient neurosurgery nurse and realizing that there are care and levels of care that are needed across the lifespan. I felt rewarded in that moment when he said that you helped my family during a difficult time and it’s also an emotional thing for me to even discuss

It’s a very vulnerable period to where people are yearning for a helping hand and help. That’s great that you were able to comfort them during that time and coordinate things. For a lot of people, they just don’t have access to good care. What misconceptions do people have about your career?

One of the biggest misconceptions might be that nurse practitioners do everything that the MD tells them to do or that the physician tells them to do. I think that it’s probably most important to point out that it’s more of a collaborative effort. I would say that the relationship that I have with the two surgeons that I work with now is more about me addressing any issue or issues that may be at hand and formulating a solution to that and running it by them and making sure that that is the appropriate intervention.

How would you describe your work-life balance as a nurse practitioner?

I think that the work-life balance as a nurse practitioner is pretty good and it depends upon what type of person you are. I know some people who as soon as it turns 5:00, they’re able to turn it off. Regardless of whatever position that I’ve held in my life, whether it be RN, nurse practitioner, friend or child, what have you, I’m not able to turn that part of myself off because that’s such a part of my identity. I am definitely one of those people who checks their emails at 1:00 AM to make sure that nobody needs anything at that moment.

For your patients, that’s good news.

For my patients, it’s good news. For my practice, it’s definitely good but that’s a choice that I make. I don’t think that every person needs to do that. I also am in a position where I have a very good support system from my secretary to my office manager to the cranial and the spine surgeons that I work with. My inpatient team who is run by a PA and staffed by PAs. These are all of my collaborators and I have to say that we really have an A-plus team and it makes things pretty seamless. I think that it’s me and myself that feels that I feel that I need to always be aware of what is happening. I could probably turn it off at a certain hour. I choose not to because I would rather be ahead and rather know what my team needs from me before they even think that they or feel that they need something I would rather anticipate it and be ahead of the curve.

Thinking about your profession and its outlook, do you recommend this career to students?

HCDM 17 | Family Nurse Practitioner

Family Nurse Practitioner: Providers sometimes need to slow down and realize that what they’re treating is not only a disease but also a human who’s going through a hard time.

 

I would absolutely recommend this career to students. I think that it’s something that is extremely rewarding and if you strike gold, like I did, I got very lucky in terms of the people you’re working with. Sometimes the healthcare system can be a difficult system to navigate, regardless of the title that you hold, but if you have a good team that you are within a good support system, I can say I have never felt embarrassed or ashamed to say, “I don’t know something.” That that’s probably something that you recognize or within time that you have to be aware of what you don’t know and be okay with saying those things and know where your hand ends and where somebody else’s hand might begin. It’s because we’re all there for one common reason and that’s for the benefit of the patient.

Understanding your limits and knowing when to ask for help. What do you think the future outlook is like for your profession as a nurse practitioner? Is it growing or staying steady?

The nurse practitioner role in general is definitely expanding. There are plenty of more nurse practitioners every year. Nurse practitioners in general, I firmly feel that it is a great career. It definitely looks at the patient as a whole. You’re not treating any one thing in general. We’re definitely helping to expand accessibility to good care, as well as driving down a lot of healthcare costs. I think that with a lot of good prevention and preventative care and efforts, that’s probably where we’re going to benefit patients. It will definitely be more appealing in the long-term and more people will be looking into this career once they are able to find out what we do.

You can also go to a lot of different other sub specialties, not just neurosurgery. You can do family practice, pediatrics, cardiac and oncology. There are different ways you can go and utilize your NP degree.

For instance, my, one of my best friends who I went to nursing school with. I did my Bachelor’s degree with her. We also did our Master’s degree together. She is not only the cardiology nurse practitioner at NYU, she is a preventative cardiology nurse practitioner at NYU. She makes a lot of assessments and helps to recognize various risk factors for her patient populations.

I want to talk a little bit about how you got to where you’re at. When you were in high school, where you already thinking about being an NP or nurse?

I will be totally honest with you, I was not. I knew that I wanted to help people. I did not know in what capacity I wanted to do that. I was definitely not one of those 15 year olds who said, “This is what I want to do for the rest of my life.” I know that there are some people, they wake up and they say, “I want to be a fireman. I want to be a doctor.” I didn’t know. My grandfather, for instance, was a Doctor of Veterinary Medicine and he was senior microbiologist for a very well-known pharmaceutical agency. I knew that I was interested in the sciences because of him. I just didn’t know in which capacity and I knew that I wanted to help people.

When I applied to college, I started considering becoming a physician. I started volunteering in the hospital system when I was eighteen years old and I got to observe what the different disciplines did and exactly the roles that they played in the life of the patient. I got to see that the nurses were there mostly with the patients and how valued these nurses were by other members of the staff such as the advanced practice providers and the physicians around. I can even say through my hours when I was in nurse practitioner school, I relied so heavily on those nurses to be able to tell me what was happening with my patient at that point in time. I could have been covering twenty patients on any particular day.

Those nurses had four patients and they were with them for 12.5 hours. I relied so heavily on them and their assessment skills at that point in time. When I was volunteering and I realized the relationships and the bonds that were formed, I said, “I’m going to switch from chemistry to nursing.” I switched to nursing and I that required me taking classes one summer, so this way I could graduate on time. Because although I had my chemistry, I didn’t have nutrition and anatomy and physiology.

Those other prerequisites, do you mean.

It is for the nursing program. Whereas a lot of those things, physicians do them in med school a lot of the time. It’s not all the same prerequisites even though there are two health science degrees.

Know where your hand ends and where somebody else's hand might begin. Click To Tweet

Reflecting back, would you have done anything differently?

I think that the only thing that I would have done differently is I would have taken more time to look into scholarships that are available for people looking into the Health Sciences. As we both know, it’s a number of years and school is very expensive. As my eighteen-year-old self, I probably should have looked into the different money that’s available because there’s a lot of it out there. Nobody’s going to hand it to you, but if you look for it, you can get it.

Before we end, I have what we call rapid-fire questions. Usually, they are yes or no questions or maybe a short answer. What’s the fastest speed you’ve ever driven in a car?

120.

Is it in the United States?

On a track in a Ferrari.

One to ten, how hot Do you like your shower water?

A twelve. Steaming.

What’s something you could eat for a week straight?

Grilled salmon.

HCDM 17 | Family Nurse Practitioner

Family Nurse Practitioner: Nurse practitioners don’t necessarily do everything that doctors tell them. It’s more of a collaborative effort.

 

High School, awesome or terrible?

The best years of my life.

Beaches or snow?

Beach.

If you could ask God one question, what would it be?

Why me?

If you were stranded on a tropical island, what two things would you want with you?

My cell phone and a hatchet.

Where can our readers go to reach you and learn more about you?

The best way to do that would be through you, Richard. I am always willing to speak with anyone who might consider a career as a nurse practitioner. I think that it’s a great move and I would be happy.

I appreciate you coming on board and sharing your experiences as a nurse practitioner.

You’re welcome. Thank you so much for having me, Richard.

To learn more about our guest, visit HealthCareersWithDrMarn.com or HCWithDrMarn.com. If you like what you learned on the show, please subscribe, rate and review the show on your favorite podcast app. Thank you so much for reading. I appreciate your support. I will catch you next time.

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About Alexa Maestrone

Continuing my nursing education, and acquiring new knowledge through evidence-based practice.