Many nurse practitioners are becoming constants in specialty services in the hospital. We spoke to EJ, a great hepatology acute care nurse practitioner who graduated from the University of Illinois at Chicago and is currently working there as well.
Tell us a little about yourself and your experience as a Hepatology Nurse Practitioner.
Actually, my role and title has expanded and evolved in the one year since I was hired for my current position. Initially, I was hired as an inpatient Hepatology nurse practitioner. My role compromised of helping manage the liver service at UIC Hospital. My responsibilities included being the liver consult service for other departments, performing large volume paracentesis (LVPs) , teaching the residents how to perform LVPs, being the liaison between the liver service and the transplant surgery service for patients who received or will receive a liver transplant, and educating interns and nursing staff on liver patients.
Since then, my role has expanded to working in the outpatient service as well. There I help patients manage their liver diseases ranging from Hep C, Hep B, autoimmune hepatitis, alcoholic hepatitis and PBC/PSC. We are currently busy helping patients receive the brand new Hep C cure called Harvoni, which is new in the market and has a 99% cure rate which is quite revolutionary. Moreover, I have a clinic where i perform LVPs on patients with uncontrolled ascites.
What drove you to choose hepatology?
To be honest, I got into Hepatology by accident. My heart is in emergency medicine and trauma, but during the great recession it was difficult finding those jobs as a new NP. I got into UIC through connections and I learned that UIC was building a new Hepatology service and they were building a new team, which would include me. This was my draw to the job because it meant I could help hone and decide what my role would be. Like in the ED or trauma, there can be an intensity in Hepatology wherein we have patients who have hematemesis due to esophageal variceal bleeding, encephalopathy, and emergent liver transplants due to tylenol toxicity.
I have grown to love working in Hepatology because of the complexity of the disease processes, the patient population and how much internal medicine is required to keep these sick patients alive. Also, I liked the fact that I could still do procedures and work inpatient.
What kind of education and experience did you need?
In order to work inpatient, the job required an acute care nurse practitioner degree. It also helped that I have experience in the trauma, ED, surgical ICU and working on the floor as well. I think having a varying degree of experience as a nurse can help mold you into being a better NP because you just know how the hospital functions and you see a spectrum of patients. I think UIC requested a nurse with a diversified education and hospital experience because you need exposure to all sorts of patients to understand how to help liver patients. Liver patients seems to be very diverse: young, old, rich, poor, varying education levels, multiple comorbidities etc.
While working inpatient, I am the sole NP for the service. I work closely with the liver fellows as we back each other up and also help manage the residents. In outpatient, there is one other NP and another PA working. I feel that the outpatient side is much more busy especially due to the surge of Hep C patients trying to get treated for the Harvoni medication. Moreover, the outpatient midlevels work hard in trying to prevent these live patients from being readmitted. Liver patients can get so sick so fast that managing them outside of the hospital can be stressful if not skillfully. The other midlevels in the outpatient setting have all had background in acute care settings such as ICU or ED. Rarely do we see liver midlevels without a hospital background.
What kinds of things do you do beyond what people see? What do you actually spend the majority of your time doing?
The majority of the time, I make sure the in patient liver service is running smoothly with the help of my fellow. The residents change liver rotation every month so it is a constant teaching opportunity for me whenever I am working. Beyond what people see is also exciting. Every Friday, I join in a committee of surgeons, hematologists, administrators and other midlevel providers in helping decide who moves up and down our transplant waiting list. We calculate patient’s MELD score and decide to move them up the list defending on the servility of their current condition. Many factors go into deciding who make the list such as physical capacity, social support, disease process and finances. We also discuss new patients who we consider on joining this pool of potential liver recipients. From the meeting, our entries are sent to UNOS, which is the governing body of organ transplants and we wait to see if our patients get a liver or not.
How do you deal with difficult patients?
For the most part, in patient wise, the patients are not difficult because they so very sick. They can present encephalopathic, intubated, or just weak. The difficult part is dealing with family members. More often than not, the prognoses of those liver patients who are admitted are not good. It can be difficult to tell that to a family member. It is also difficult to tell a member that sometimes the only way to save the patient is a liver transplant but it may not be feasible due to high risk for surgery, complications of the disease process, social support, recent ETOH use and no available donors. We do have many resources to help family members understand. We do have a great social work team, palliative team and hospice team at UIC that help out.
What are your average work hours?
I usually work 8 hours a day M-F, but it is very flexible on when I start each day. I am never on call, no weekends and no overnights. I will admit it’s a pretty great job hours-wise.
What do you do differently from the physicians and other allied healthcare professionals on your team?
I am the constant in the liver service. The interns/residents rotate every month. The fellows and attending rotate every 2 weeks. Though there is constant change of management in our service, I am the constant in the group that helps provide a continuity of care for the patients.
What’s the worst part of the job and how do you deal with it?
There’s little I can complain about in my job. Like I stated earlier, I usually work 8 hour days and sometimes an attending would prefer to round at 7 in the morning. Other attending prefer 10 in the morning. So a morning routine is anything but. Also, I understand that I am only in my first year in as a NP, but I hate not being able to answer certain questions related to hepatology. Hepatology is so complex and riddling, that I constantly have to read and relearn. But slowly reaching expert status is a goal that drives me everyday.
What’s the most enjoyable part of the job?
I think the enjoyable part of the job is working with the interns/residents. They are very eager to learn and are intimidated when they start their liver rotation. I do also enjoy performing procedures. Not only do I do LVPs, but I can perform Fibroscans (a brand new non invasive procedure that may take over liver biopsies). Also seeing the patients breakthrough their illness and lead healthier lives is the best part of the job.
What advice would you give to NP’s aspiring to join a hepatology group?
The biggest advice I would give an NP aspiring to join Hepatology is to diversify your RN experience. Try and get that ICU/ED/surgical position. Dealing with very sick and complex patients will really prepare you for the field. If you are eager to learn and are very flexible, you will be a highly regarded candidate for the position. Hepatology is not easy, but if you enjoy a challenge that is fulfilling both mentally and emotionally then this field is for you!