Mara Saunders is a fantastic acro-yoga athlete as you can see above, but also a compassionate and talented adult nurse practitioner with years of experience working in a variety of settings. She and I used to work together at La Clinica, and I was always impressed with the depth of her knowledge in all things primary care, and how great she was with patients. Now she’s mainly working in a virtual team providing telemedicine care for the hip primary care clinics of One Medical, and has offered to tell us more about this innovative role for nurse practitioners and how she got here.
Tell me about yourself and where you currently work. What is your role at your workplace?
I’m 34, have been an RN since 2006, and an NP since 2011. I have an undergrad degree in public health, and came to nursing via the MEPN program at UCSF.
Currently, I work at One Medical Group, which is a San Francisco-based medical startup. I’ve been here just over a year, and am primarily part of the virtual medical team, which offers 24/7 phone, email and mobile access for our patients, and also supports our primary care and office-based providers by managing almost all episodic care requests, emails, medication refills and interim correspondence between visits.
I also provide on-site urgent care one day a week at our various downtown SF clinics, and help to run a monthly on-site clinic at Levi Strauss headquarters, which is one of our Enterprise business partners.
What’s does your typical work day look like?
Ha! Typically I roll out of bed, make coffee, log on and start working! That’s actually the truth 😉
I start my day by logging onto our EHR, which is the portal from which we take most of our tasks. We have queues of medication refills, emails, mobile cases (e.g. digital dermatology cases or Treat Me Now cases that patients have submitted), and triage encounters that have been noted and queued up by our administrative team. We are also live in a variety of chat rooms throughout the day- some with our district and regional provider colleagues, which helps us to communicate with one another about logistics and clinical cases, and some that link us with administrative staff and our RN team, which works alongside us.
The work part typically involves a combination of what we call synchronous and asynchronous tasks- a synchronous task would be responding to a patient triage call- either urgently transferred from our admin team via a chat room (we take turns being the point person for these urgent calls), or taken from our triage queue within an agreed-upon time frame (typically within 2 hours of the original call), or our newest platform- video visits! Asynchronous tasks are things like medication refills and answering emails. We also have weekly meetings with our district virtual team, and the opportunity to sit in on weekly clinical rounds via a virtual video platform.
Can you describe your career path and how you got to where you are now?
One word to describe my career path: Circuitous!
The longer version:
I started in public and international health, did some travel and work in 3rd world countries, and got to thinking, “I need more hand-on, practical skills to offer in places like these.” I took a few grant-funded jobs in public health, and decided that an MPH wasn’t for me, but my work led me to UCSF’s MEPN program, and that seemed like a good fit. I started out that program in a Clinical Nurse Specialist track, focusing on community and international health, but I was also working on an acute care transplant floor at UCSF from the time I got my RN license, and took a year off to work full-time in the hospital before I went back to start my masters.
By the time I got back, I had a better sense of what the different degrees (CNS vs. NP) meant, and decided I wanted more advanced clinical training than the CNS would offer (and also a more marketable degree), but didn’t want to lose the breadth of the CNS training, so I lobbied my department to let me do both. It took an extra year, but I came out prepared for 2 licenses, and even though I haven’t technically used the CNS much in my professional career, I’ve appreciated having the broader perspective of that background, not to mention the additional training in research and program management that it offered.
After school, I continued to work in the hospital as a Med-Surg clinical instructor for a couple years because I enjoyed the work and the flexibility it offered. Then I went to India for a month on a medical expedition. Then I took a grant-funded job at UCSF that seemed like my dream job (and was basically handed to me) and it turned out not to be at all what I thought, so I left that after only a few months.
Then I took some time to figure things out, went to South America and did some volunteer work and some soul-searching, came back and taught some more, and took a job in Physical Medicine and Rehab. This also turned out to be a really bad fit- mostly because of the setting I was working in (first NP working in a solo practice that was trying to establish a new EHR and practice style without really having the primary MD on board)- so I left that after 6 months, and had 2 months of terrifying unemployment before taking a job as a primary care provider and Senior Care Manager at a federally-subsidized community clinic. I stayed there for 2 years, working really hard, learning a ton, loving my patients, but hating a lot about the clinic and how it was run.
After a year and a half I went down to part-time and took my current job at One Medical as a part-time gig, thinking it would make the primary care more sustainable, but ultimately it was too hard to maintain a complex primary care panel on a part-time schedule, and I was ready for a personal break, so I left and increased my hours at One Medical.
What is the most difficult thing about working in a non-traditional primary care role? What is the most liberating thing?
Well, working in a startup means you have to be open to change because new things are constantly coming down the pike. It’s fast-paced, and we don’t always get things right the first time (or the second) but if you can roll with it, there is usually movement toward improvement eventually.
The most liberating thing- you mean besides working in my pajamas? Well, I guess the same thing: change. So many of the healthcare institutions that I’ve worked in feel very stagnant and resistant to change, even when what we’re doing makes no sense and doesn’t serve anyone. I like being in a setting where people are smart and energetic and motivated to do things better!
What is the biggest difference you noticed in your NP practice when you transitioned from working in a federally qualified health center to a private, membership-based primary clinic?
The patients. Big change. It’s a much younger, healthier, more affluent (in terms of both finances and personal resources) population we serve.
What do you feel are the most significant challenges for outpatient primary care NP’s today? How do you overcome these challenges?
Probably the specter of burnout. I think a lot of us end up, at least initially, in settings where we are isolated, don’t have proper mentorship, and are maybe overworked but under-utilized as far as our potential. How to overcome this I don’t entirely know, but I definitely think working in a place where you are among fellow NPs, especially as a new NP, is critical. This is NOT the time to be a pioneer! Believe me- I tried it. Twice.
What do you know now that you wish you’d known when you first started practicing as a nurse practitioner?
Probably what I said above- it’s okay not to hold out for the IDEAL, UNIQUE, WORLD-SAVING job cause it’s probably not going to pan out the way you think. Go for something solid, where NPs have gone before and paved the way for you to have support and success while you’re learning, because there is SO much learning that happens in your first years after school. Also, it’s okay to leave a job in less than a year if it’s really not serving you, and you’re really unhappy. Don’t risk early burnout because someone told you that you have to stay a year to make it look good on your resume.