The Myth of Health Coaching in Primary Care

I recently talked with a new grad nurse practitioner who shared some frustrations with me about her first NP job. As a family nurse practitioner, she envisioned herself talking with patients about their health status, counseling them about diet and exercise, and ultimately making an impact on her patient's overall health. Instead, she finds herself crunched for time, managing long medication lists, and ordering an endless string of labs. 

Once in practice, this nurse practitioner experienced the realities that most of us face as NPs. Our patients our on multiple medications, many times ten or more, prescribed as a remedy for diseases resulting from unhealthy lifestyle choices. Administrators pressure her to reach productivity goals leaving her little time to manage her patient's chronic conditions, much less sit down to discuss lifestyle choices and preventative care. Even as an experienced RN, familiar with the complexities of the healthcare system, this NP found herself frustrated and looking for something new. Many nurse practitioners I talk with share similar frustrations. 

For new grad NPs, the realities of employment often come as a shock. The business and clinical aspects of healthcare collide once we're out of school and on the job, placing additional considerations on our patient interactions. We no longer have the luxury of seeing patients within the preceptorship context or the ability to spend as much time on these visits. Practices must generate enough revenue to support themselves and turn a profit, which means NPs must bill a certain amount. The number of patients a provider sees as well as the types and number of tests and procedures ordered or performed all play into this equation. 

Naturally, we all want to help our patients. But, time and productivity pressures from management don't always allow us to do so in the way we think works best. Insurance companies don't reimburse healthcare providers, or at least not well, to offer guidance on measures like diet and exercise, so doing so means taking time away from higher revenue generating visits and activities. 

This isn't a new observation, it's one that healthcare providers have discussed for a number of years. Misplaced incentives are often stated as a cause of burnout and job dissatisfaction. But, they are a reality that many nurse practitioners don't expect as they begin their careers. Nurse practitioner schools emphasize that NPs are to "treat the whole patient" and place a focus on preventative healthcare and coaching. Too often, however, they neglect to weave the realities of working for an employer into their teaching. In the employment setting, nurse practitioners' metrics are closely monitored such as the number of patients the NP treats and the amount of revenue each provider generates for the practice. 

So, if you're an NP student or a new nurse practitioner, prepare yourself for this challenge. This doesn't mean you won't help your patients and provide value to their lives. It does mean that in most settings, idealistic visions of 30-minute conversations where you develop a healthy eating plan with a patient are unlikely. If you're an experienced nurse practitioner, know you aren't alone in your frustrations and consider a balanced perspective of your role. If you don't carry your own weight financially in a practice, logistically it does not make sense for the facility to employ you. However, there are ways you can implement teaching and coaching into your patient interactions on a schedule-friendly scale. We must do our best to balance the realities of our healthcare system with our efforts to provide instruction for our patients. 

Have you been surprised or frustrated by this balance in your workplace? How have you coped? What solutions have you come up with?

 

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Comments

I became a nurse practitioner as a second career without fully understanding what a typical day as an NP in primary care might be like. After graduating from nursing school, I formally studied coaching because I recognized the transformative power of communication in preventive care (too bad the rest of the healthcare industry doesn't quite get it yet...). While I've been disappointed to learn that it is NOT possible to help patients take full personal responsibility for their lifestyle changes during a single 15-minute-or-less office visit where the main focus is prescribing and refilling multiple medications, I have discovered that there are some very effective ways to integrate laser-coaching techniques while aligning the institution’s quality measures (including patient satisfaction) with a coaching-oriented approach during typical primary care office visits. This pragmatic approach to patient coaching is particularly effective in a family practice setting where a single provider follows the same panel of patients over time.

I realize that if I want to do more for my patients than sneak coaching into an office visit whenever I can, I need to either go into business for myself as a health coach, or advocate for paradigm change in healthcare—or possibly some version of both. Ultimately, as the prevailing paradigm of healthcare delivery shifts from a disease model to a prevention model, coaching/counseling will become more highly valued by institutions. With forward-thinking leadership in our healthcare institutions, the integration of new technologies such as genome analysis, wearable digital devices, and artificial intelligence, can pave the way for an emphasis on preventive care in ways that could make coaching profitable. I’m an idealist at heart, and I still have hope.

Lane Therrell

The comments to this article are mind-opening and real. Thank you to those of you who have posted your honest thoughts. I'm halfway through FNP training, and I've seen some pretty unethical things being done in my 10 years as a bedside RN. It's a shame NPs are treated in this manner and forced to the brink of burnout and beyond. I agree, more of us ought to stand up - for ourselves, for our patients, and for what is RIGHT. Erin, thanks for this great post.

Irene

Nice Post...Treating people in general can lead to burnout. Add to this the expectations you have and the realities of an economic model that doesn't address the underlying problem. The ideal situation stems from not allowing yourself to be forced to generate money by grinding out sick patient after sick patient. We must say enough and take a stand. Unfortunately there are a line of others willing to do the job so it can be challenging. Keep up the blogging and just maybe we can reach a critical number of providers who will standup to big insurance, big pharma and other medical industries.

Docofalltradez

Thank you for bringing into light, that which otherwise might have stayed in the dark. I have been a Nurse Practitioner for 16 yrs. I recently resigned my job of 13 yrs due to feeling so disillusioned by the direction the practice was heading. The person walking through the door was seen as a dollar sign and not much more. Good news is, not all jobs out there will be all about the money. Just need some patience and before you know it something good is bound to pop up.

Frank

Every single thing that you write about is what has made choose to go from being an RN and abandon my dream of becoming an NP. I am now about to start an MBA in healthcare with hopes of being able to make a positive change in our healthcare system. I don't know where or how but I do know that mid-levels at my current employer are just as frustrated and share the same sentiment that you have written about. It's sad but true! If you have any advice on where I can take my MBA I'm all ears.

Paul R

I have been an NP for two years and it is not what I expected.  I do feel burnt out and I identify with everything in your article.  I have been unable to reconcile American medicine is about profit and not about the patient.  I have had 5 jobs an an NP -- in two years.  Previously I have been employed for multiple years with companies (Mayo x 6 years and SHC x 3 years until I finished grad school).  I have either been pressed to see patients beyond my expertise as an FNP (OB patients) or pressed to do things that were unethical such as order unecessary testing.  I have changed jobs in hopes that I will find something closer to what I had imagined healthcare would be -- "treat the whole patient and place a focus on preventative healthcare and coaching."  Most of the NPs I have met have also had multiple jobs and feel very disillusioned.  I often think about going back to being an RN or maybe waitressing.  I love seeing, helping and diagnosiing patients but there just is no time to do what is RIGHT nor the circumstances to order what is ETHICAL -- profit is the main goal.  If anyone has a solution I would love to hear it.  By the way I love your blog and have been reading it since I became and NP.

Tammy Cakmak

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