Diabetes Case Study in Mentorship for Nurse Practitioners
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Show notes:
So many new grads are most worried about building their clinical knowledge base-- for good reason!
But it’s one thing to prepare for clinical topics-- researching algorithms, choosing the best practice based on the evidence-- but an entirely different experience trying to apply them to the “real world.”
Through Real World NP, I have the awesome privilege to work with new grad nurse practitioners on-on-one in mentorship calls.
Some of mentorship is reassuring new grad NPs about their clinical judgment decisions, and it also involves discussing the most up to date guidelines.
But there’s another level to mentorship and “real world” practice that you just can’t get in school.
This week, I want to share with you some of the “behind the scenes” of what our mentoring conversations are like.
I’m covering an example patient case with complex diabetes and medical conditions that I reviewed with a real-life new grad nurse practitioner during a mentoring conversation.
Full disclosure: I hope to someday record a call with a new grad NP (with consent and voice-masking, of course), but for now, it’s just me talking, reviewing what we talked about and the variety of ways we approached the situation.
Hopefully this helps you apply these lines of thinking to your own patient cases!
(Heads up: it’s audio-only this week -- covid times are cray cray and require pivots, but my video equipment is ready for next week!)
Managing Diabetes, Hypertension & CKD Review Course
If you'd like support learning about how to manage these three chronic conditions, including medication management, most recent guidelines, when to refer and examples of real-life patient cases, join us for the Managing Diabetes, Hypertension & CKD Review Course. Join the course here.
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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Hello and happy new year.
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Welcome to 2022.
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This is the first episode of the year for us at Real World NP.
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So I'm actually mixing things up a little bit today with this episode.
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Typically I record a video and post to the podcast with the same episode every week.
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However, because Omicron is surging and childcare is a little bit variable because
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of coronavirus, I am going to be doing just podcast for just maybe just this
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week or maybe for the next couple of weeks, we'll see, we'll see.
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But recently, so I'm actually in the process of expanding mentorship and I've
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been interviewing a nurse practitioner candidates to join the Real World NP
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team, and we were discussing a case study, like an example of what mentees
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bring to me so that we can just have a conversation about it.
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And it occurred to me that it would be really helpful if I was a new grad,
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it would be really helpful for me to kind of hear this, the types of case
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studies that mentees are bringing for Real World NP.
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So in this episode, I'm going to be talking about a case study, a real
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world, real life case study that, um, nurse practitioners bring to me and
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kind of a behind the scenes of talking about the conversations and the
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thought process behind the management.
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So I love me some diagnostic algorithms, right?
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So when it comes to diabetes, like what to do first, next, next,
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next, next, that kind of thing.
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This is, this is a case study that has a patient who has diabetes, but it's
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less of a focus on the diagnostic algorithm and more of a focus on just
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like holistic general management in the real world, all of that stuff
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applies, right, all of the diagnostic algorithms apply.
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But I think one of the things, uh, that is so unique about these
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conversations that I have with mentees is that there's so much more
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to it than just those diagnostic algorithms.
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So just for context before we jump in.
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So the context here is that if you aren't familiar, so with through
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Real World NP, the company, the medical education company that is
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a real world NP, I take clients.
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I take one-on-one nurse practitioner mentees and they sign up to
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work with me and we do one hour phone calls for about 12 weeks,
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three to six months, depending on the preference of the person.
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And what we do is discuss cases pretty much whatever they feel
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like they need support with.
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And I guess the, the step back a little bit even further is that
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when I was a new grad nurse practitioner, the dream solution
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that I wanted for my problem was that I wanted this safe space with an
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experienced clinician, nurse practitioner, physician, et cetera,
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any provider who gave their full time and attention to discuss cases
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and issues I was having.
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And quite honestly, the answer to the questions I felt too dumb to ask.
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And I wanted to talk with somebody who wasn't going
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to make me feel stupid, right?
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Real talk.
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And this is what I've heard over and over again, the same kind of
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desire for other nurse practitioners.
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So that's what I do.
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So that's what the mentor calls are.
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They're just an hour of safe space time.
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They don't have to do anything in this formalized case
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presentation buttoned up perfectly done and presented way.
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They can literally just show up to the call with no preparation.
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They just say the things that they want to say.
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They can talk about a case.
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They can just brain dump it out, word vomit it out.
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And then we work through it and see what is most supportive for them.
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And just to, again, a little bit of context is that the three
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kind of main things that we cover when it comes to these mentoring
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conversations, the first one is usually it's a reassurance type
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of question where they've taken an action.
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They're discussing all of these cases after the fact, not in real time
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in the clinic.
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It's just like, this is what I saw this week.
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They want to know that they did the right thing and to see if they
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were missing anything, because they don't know what they don't know.
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Right.
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None of us know what we don't know until we learn.
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Right.
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And so there's so much experiential learning that is something you
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can't learn from a textbook.
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So that's what they're really looking for.
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The second thing is that they kind of just need a brain break.
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And what I mean by that is that they will read about cases.
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They'll see patients in the clinic and pretty much with every patient,
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they have to look something up.
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I certainly found this to be true when I was a nurse, new grad
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nurse practitioner, that every single patient, when I wasn't seeing
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patients or like managing my inbox, I was glued to the resource up to date.
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And I'm not affiliated with them in any way.
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It's just my, my favorite resource.
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So I just remember I had a mentor and her name was Christina.
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And sometimes like I knew what the resources to consult and I knew what
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I could do on my own, but my brain just physically hurt so much from all of
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this new things that I was learning and doing that I would just need a
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brain break sometimes and to be like, Christina, I know I can look this
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up, but can you just tell me what I should do with this?
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Cause most of the time she'd be like, well, what do you think?
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Look it up.
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Yeah.
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So that's the other thing is that if there's total permission to be
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like, you know, can you just give me some information here?
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Cause my brain hurts.
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I know I can look this up, but I'm exhausted, right?
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So that's one.
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One is reassurance too, is they need a brain break and they're
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just looking for information.
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Number three is that they come to me with those first two.
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And then the third thing is actually like the role development process
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that you kind of learn about as a student, but you can't really see
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it until you've gotten into it.
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Right.
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I'm going to talk about those pieces with this case, but it's
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almost like the things they want and the things they need might
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be a little bit different.
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Like I'll definitely do the things that they want, right.
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With the reassurance conversations and information giving, but also
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there's like further discussions about you'll see, you'll see hang tight.
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So anyway, so that's the context of this episode is that these
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are the types of conversations that I'm having with new grads.
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And just to also give you a real life case that I can sort of walk
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you through the process of how we talk about them and then just
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like, as an example of what it's like.
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And so hopefully you can like, apply this like methodology, whether
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or not you are a new grad and you're trying to like mentor yourself
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through it, if you don't have the support and, or if you are
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starting to precept students or mentor new crowds yourself and
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you're listening to this channel, this will hopefully help you too.
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Um, and actually before we jump in, um, I'm super psyched.
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So I have currently, I've only ever done one-on-one mentoring
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like I described, and there's so much demand that I am only one
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person and I cannot fulfill, um, which hurts my heart, um, a little bit.
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So we're actually working on expanding mentorship.
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Like I said, I'm interviewing candidates and I'm just so excited.
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So if you are looking for mentorship, definitely go over to the wait list.
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That's like the first come first served best way to learn about
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opportunities coming up this year.
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It's at realworldmp.com slash mentoring.
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And that way you can get on the email list and you'll
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be notified first available.
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So anyway, let's jump into this case, right?
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So this is a real, the other thing I love about this is
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that you can't make this stuff up.
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I mean, you could, but yikes.
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I mean, this is real life.
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This is a, this is an example of a question of a case that a
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mentor mentee brought to me and she works in a federally qualified
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health center, which is my background as well.
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I love federally qualified health center settings.
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I've only ever done that, but I don't think I'm ever going to leave.
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So this is a 38 year old female and she has a long history of
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diabetes, long standing history of diabetes.
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Her a one C is 14%.
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She also has a past medical history of gastroparesis.
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And if you aren't familiar with gastroparesis, I definitely
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recommend you read about it.
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And the very brief overview is that it affects a longstanding
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diabetes can cause damage to many parts of the body, of course,
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but it can lead to gastroparesis where there is a slowing down of
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the peristalsis, gastric emptying can cause abdominal pain and bloating
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and things like that, lots of other things.
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So anyway, this person has gastroparesis as a complication of her
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diabetes, and she came to the visit with kind of like for a follow
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up, but also with a chief complaint of abdominal pain.
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And she said that it was basically the same gastroparesis pain
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she's always had, but it just feels worse.
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And the other pieces of information that this mentee gave to me
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were that this is a single mom who has three children and because of the
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abdominal pain and the diabetes, she wants to make sure that she doesn't
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want to become hypoglycemic, but because her stomach hurts, she,
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it has a hard time eating.
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And so what she's doing is snacking on candy, basically all day to
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keep her blood sugar from dropping.
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And she's not really able to eat real meals right now.
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So I told this to a colleague and she was like, absolutely horrified
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as it kind of is.
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It's, it's a really tragic, horrible situation that is real life.
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Like you, you may or may not see stuff like this in your setting.
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It really depends on how, on the level of complexity of your average
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patient, but yeah, this is real life, right?
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So this is the information the mentee gave me.
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And then she let, she followed with a question of like, where do I even
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start and I want to pause here and say that like, so this is, this
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is a, this is a fair case presentation, right?
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I've gotten a lot of context, a lot of history, a lot of
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life context for this patient.
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I still have more questions, right?
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But again, the context of mentoring is that it's fine.
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All of it is welcome, right?
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And I'm here to help support them and lower the anxiety and walk through a
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case and help them if they don't know what the questions are, the further
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information to provide is we're going to talk through the case and I will
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ask questions so that they will know next time to ask those questions
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themselves, or give that to me as a presentation, or if they forget,
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that's totally fine.
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Maybe they knew it all along and they're like, Oh, I forgot.
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I'm just like, my brain is not working well right now because
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I'm so anxious, right?
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So here's how this typically goes in these conversations.
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Again, remembering that most people are coming for number one reassurance
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of did I do it right?
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Did I miss anything?
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Am I going to hurt them, this patient, or they're looking for
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information because their brain hurts so bad that they just
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don't even know what to do.
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They don't even have the capacity to consult their resources, right?
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Or maybe they don't know what their resources are, right?
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So the first thing I do in a case like this is validate a number of things.
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Number one is the feelings.
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That's a huge part of what I do with real world NP of all the content that
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I make and the services that I provide is that it's not just about the
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medicine, it's about the role transition, both personally and the
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other kind of like holistic components of becoming a nurse practitioner,
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which we'll talk about in a sec.
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But first is like the validation of the feelings part, right?
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Because this is an overwhelming case.
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It's overwhelming to be a new NP.
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They're likely very anxious.
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I mean, I can just tell from the way the person's talking that
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they're incredibly anxious, right?
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And I just want to validate like, wow, this is a really tough case.
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You did a great job with your case presentation because they did.
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That's really great amount of information that you've got.
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Not only did you give me a lot of information about the medical
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condition, but also about the person's life context, right?
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They're doing a good job.
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And the other thing to validate is the underlying question that most
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new grads have is like, what's normal for primary care?
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Is this normal?
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Is this like a regular case?
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Do you see cases like this?
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Would you manage this?
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Would you send this person to a specialist?
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Would you send this person to see the physician, your
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collaborating physician instead of you seeing them?
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What should I know?
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What should I know already, right?
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What don't I know?
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And then there's all the feelings that come in with that, right?
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The inadequacy feelings that a lot of new grads have.
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So that's usually where I start.
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I'm like, you know what, this is a really tough case.
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And depending on, and this is, I don't want, I don't want this to be too
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sprawling of an episode, but there's one of the things that I'm realizing as I
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continue on in my practice is there's like a philosophy of practice.
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There's like a, your personal comfort level and desire for what type of
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nurse practitioner you want to be.
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So for me, I love complex cases, love them, right?
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That's my jam.
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So like, I'm comfortable with this.
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I'm comfortable with maxing out my, my scope of practice.
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And also there are people who are not comfortable with that.
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And regardless of the number of years of experience, we'll never want to
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deal with complex cases like that.
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They really like the bread and butter of primary care and
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like the regular stuff, right?
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So that's another thing that's part of that validating
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conversation of like, you know what?
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Yeah, I totally see patients like this all, not all the time, but
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enough, especially with diabetes at the age of 14, I see this all the time.
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This is a complex case though.
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Life is complex.
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The medical conditions are complex.
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And this is up to your comfort level, which may evolve over time,
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especially as you're brand new.
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And as you get more experience, you might decide, Hey, I love cases like this.
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I just need more experience.
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And maybe for now I'm going to get some help versus later on, I'm going
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to keep them as long as I can, because I love that, right?
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So anyway, so validation is number one.
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And then the next piece is more questions.
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There's always more questions, right?
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And I think because people are, they're learning or they're anxious or
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whatever, or it's just a brain dumping safe space, whatever, right?
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Let's ask some more questions, right?
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So for this case, I have some more questions and this helps not only
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if mentees might just not remember in the moment that they already have
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that piece of information and they just didn't share it with me, but it
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also helps them like kind of learn as they go, what questions they need
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to ask for each chief complaint going forward, right?
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And so if they presented a chunk of information to me next time, they'll
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probably learn like, Oh, okay.
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She's going to ask me this question every single time.
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I bring up a patient with diabetes, right?
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And then the other thing I want to say about more questions is that another
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kind of theme of new grads is that again, all of this is based on like
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my experience too, as a new grad myself as a very stubborn, overwhelmed,
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anxious nurse practitioner, new grad.
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And there's a tendency to hyper-focus on like the fix.
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So that's what I was kind of alluding to is that there's this next level
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aside from information and reassurance that there's this like, it's not
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just about fixing problems.
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It's not just about what medication do I use for that A1C of 14, it's
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about this holistic level to your practice, which evolves over time.
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Anyway, so I have, you typically have more questions for them for this
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case, before I get into the nitty gritty of it, the two other places
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that I go after I asked those questions of more details, I usually
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ask them what they think, right?
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In this case, so this person didn't necessarily share with me from
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the outset, what they did as an example, right?
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And in real life, they did, but in this example, it was a word
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vomit of what should I do?
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Where do I even start?
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But then I asked them, what do you think?
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And most people, myself, I'll just speak for myself.
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When I was a new grad, I hated that.
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I just wanted them to tell me what to do.
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I wanted them to tell me one right way.
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What was the right way?
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Tell me how to do it.
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And they were like, no, like Liz, what do you think?
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You know more than you, than you give yourself credit for.
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What do you think?
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And then when I asked mentees that it helps explain their thought process.
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It helps me understand what their thought process is because they walk
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me through what they did and then I can clarify, of course, what they
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were thinking when they did that and why, and where the gaps are, right?
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If they didn't know why they're like, I don't know.
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I just, someone told me to do it.
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Right.
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And then we can get into that.
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If that's the focus of the call, right?
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It also helps build their confidence, right?
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Because again, most new grads know more than they think, but it's
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really, you just want validation, right?
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You want to know you did it the right way.
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And then I usually also ask like, what are they worried about?
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What questions do they have for me?
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And like, what are their main concerns here?
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Just to get really more specific, right?
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Because if they're just looking for reassurance versus do they have
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gaps in their knowledge, they want me to help them with their brain
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break of just like telling them stuff.
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I'm very happy to go into telling stuff, but I have to be like
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what the people want, right?
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So let's get back to this case.
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Let's get back to this case.
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So this 38 year old female, A1CO14, chief complaint of
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abdominal pain, as well as gastroparesis, as well as some
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significant psych, uh, you know, social things that are going on.
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So similar to other videos that I've made when it comes to the very
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specific, like chief complaint with diagnostic algorithm episodes, same
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thing, and maybe I sound like a broken record if you've been here for a while,
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but it's always a triage based safety first approach, right?
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And so I usually, again, depending on the answers to all of those
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questions of where we've gone in this mentoring conversation, these are
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the types of things that we'll focus on, right?
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So the questions I have in that triage based approach of safety
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first, like what are the absolute worst case scenarios here?
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What are the red flags?
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How would you know?
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I break it down by problem, right?
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So diabetes specific, let's start with those red flags.
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Again, if they have volunteered this awesome, if they haven't, then I will
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walk them through my process if they don't have their own process, right?
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As an example that they can use, they don't have to use my process.
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So let's talk about diabetes.
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So usually I'll say, you know what diabetes first, right?
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Let's just break it down by problem.
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What are the safety things for diabetes assessment?
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What medications does this person take?
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Did they have a point of care, um, blood sugar level at the visit, right?
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That's usually one of the things in terms of a triage, right?
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00:18:03.570 --> 00:18:07.490
Because we want to know what their labs were and what symptoms they have.
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Like, where are we going with these lines of questioning, right?
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I'm looking at the worst case scenario.
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That's information that leads me to that worst case scenario, hyperosmolar
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hyperglycemic syndrome, HHS, or DKA, diabetic ketoacidosis, which
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leads you again to that question of, do they have type one or type two?
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Do you know?
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How would you know, right?
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It's a, it's a whole can of worms.
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That's why this is, these are like hour long conversation.
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So anyway, first things first, safety first, what meds is this person taking?
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When were their last labs?
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What symptoms do they have?
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What is their risk for the worst case scenario here for needing
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hospitalization because of the hyperglycemia.
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And then the next level again, and that safety first is like, that's
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problem specific, meaning the diabetes.
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And then like the holistic life specific, they're kind of
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related in this section of questions.
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Does the patient have a glucometer and do they know the
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symptoms of hyper and hypoglycemia?
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Let's start with those.
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And then when it comes to diabetes on the next level of triage, we
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00:19:00.510 --> 00:19:06.190
could get into history of the diabetes, regular maintenance questions.
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Like when were, what was the date of their diagnosis?
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Cause again, that influences the medication problem fix, right?
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00:19:12.310 --> 00:19:13.590
Um, have they seen a specialist?
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When did they last see them?
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What about their maintenance stuff?
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Microalbumin, eye exam, et cetera.
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And I'm just going to let you know, in my personal
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practice, especially as a new grad, this is like already, this is like,
399
00:19:25.570 --> 00:19:27.530
wow, that's a lot of information to gather, right?
400
00:19:27.530 --> 00:19:28.790
And a lot of things to talk about.
401
00:19:29.390 --> 00:19:32.210
The more things I address with a patient, the more overwhelmed they
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get and the more they forget.
403
00:19:34.250 --> 00:19:36.670
That's just like anecdotal real world experience.
404
00:19:37.030 --> 00:19:40.630
So I'm likely for this person, if I'm a new grad and I'm just meeting them,
405
00:19:40.690 --> 00:19:42.330
I'm not going to ask those questions, right?
406
00:19:42.630 --> 00:19:46.350
Maybe as I'm charting, I can look at that, but the way I'm going to
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00:19:46.350 --> 00:19:48.770
manage it, because this is a, as you can see, this is already becoming
408
00:19:48.770 --> 00:19:50.570
an enormously complex visit.
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00:19:50.730 --> 00:19:53.430
I'm going to focus on safety and triage and bring her back sooner.
410
00:19:53.810 --> 00:19:54.130
Right?
411
00:19:54.170 --> 00:19:57.370
That's, that's how I manage patients like this, especially if I'm just
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00:19:57.370 --> 00:19:58.310
meeting them, right?
413
00:19:58.490 --> 00:20:02.530
So let's, let's delve into the abdominal vein, abdominal pain specific, right?
414
00:20:03.050 --> 00:20:04.410
Again, triage based approach.
415
00:20:05.050 --> 00:20:07.590
What is the worst case scenario for this person's abdominal pain?
416
00:20:07.870 --> 00:20:11.710
Um, some sort of obstruction, some sort of acute abdomen situation.
417
00:20:11.850 --> 00:20:15.030
Is there some sort of perforation because they have a blockage and
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00:20:15.030 --> 00:20:17.370
there was a bowel per who knows, right?
419
00:20:17.610 --> 00:20:19.130
Cause of the gastroparesis, right?
420
00:20:19.310 --> 00:20:22.170
Is it could be something that's not gastroparesis, right?
421
00:20:22.350 --> 00:20:26.450
Because that's another pitfall that I had as a new grad is that people
422
00:20:26.450 --> 00:20:28.470
would say, Oh, I have this thing and it's from this.
423
00:20:28.490 --> 00:20:29.590
And I'd be like, Oh, okay, sure.
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But our job is to be skeptical, right.
425
00:20:31.670 --> 00:20:33.870
And to assume the worst, that's literally our job.
426
00:20:33.910 --> 00:20:36.630
And it's not that we're not believing them, but it's like, it's on us.
427
00:20:36.750 --> 00:20:36.930
Right?
428
00:20:36.950 --> 00:20:38.330
So you're going to take it with a grain of salt.
429
00:20:38.450 --> 00:20:40.690
Oh, that sounds like it's like the chronic pain that you've always had,
430
00:20:40.690 --> 00:20:43.950
but I do have other questions to make sure we're not missing anything.
431
00:20:43.950 --> 00:20:45.510
That's how I kind of phrase it to patients.
432
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Right?
433
00:20:46.090 --> 00:20:47.550
So we'll go through it with the mentee, right?
434
00:20:47.570 --> 00:20:50.690
And again, this isn't a question basis, but since this is a one-sided
435
00:20:50.690 --> 00:20:53.690
conversation where I'm just sharing, these are the types of things
436
00:20:53.690 --> 00:20:54.550
that we would talk about.
437
00:20:54.550 --> 00:20:58.710
I'm actually hoping maybe someday that a mentee will let me record our call
438
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and then I can share it with you, but I don't know, most people are really
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00:21:01.370 --> 00:21:02.770
private, so we'll see, we'll see.
440
00:21:02.930 --> 00:21:05.630
But anyway, so when it comes to abdominal pain, again, triage
441
00:21:05.630 --> 00:21:09.730
based approach, what are their symptoms following that old cart methodology
442
00:21:09.730 --> 00:21:13.910
onset location, duration, characteristics, what are those red flags for
443
00:21:13.910 --> 00:21:17.810
abdominal pain, doing that full ROS specific to abdominal pain chief
444
00:21:17.810 --> 00:21:22.910
complaints, right, GI, GU, cardiac, respiratory, et cetera.
445
00:21:22.910 --> 00:21:26.590
And then, um, again, these are, these are the problem focused versus
446
00:21:26.590 --> 00:21:28.330
the holistic solution type of thing.
447
00:21:28.370 --> 00:21:30.190
Hopefully this is making sense where I'm going with this.
448
00:21:30.490 --> 00:21:33.690
And then the next level you can do in that focused problem-based
449
00:21:33.690 --> 00:21:36.590
solution is like what diagnostic testing have they had?
450
00:21:36.730 --> 00:21:38.330
Uh, what was the date of their diagnosis?
451
00:21:38.390 --> 00:21:41.270
What's been the trajectory since their diagnosis, what things have
452
00:21:41.270 --> 00:21:44.190
happened, what medications have they tried, et cetera, what specialist did
453
00:21:44.190 --> 00:21:46.450
they see and when did they last see them, right?
454
00:21:46.770 --> 00:21:50.970
So that's like safety first focusing on the problems, which leads to the
455
00:21:50.970 --> 00:21:54.530
suggestions of treatment, which is, you know, where most new grads want to go.
456
00:21:54.590 --> 00:21:58.070
Most new grads for this type of case are like, Hey, their diabetes is 14.
457
00:21:58.150 --> 00:21:59.530
What medication should I prescribe?
458
00:21:59.950 --> 00:22:03.410
But clearly as you've listened to this episode, there is a lot more
459
00:22:03.410 --> 00:22:08.030
information we need to know before we even touch the solution, right?
460
00:22:08.350 --> 00:22:11.990
So that's like focusing on the problems, the specific diabetes
461
00:22:11.990 --> 00:22:13.350
and abdominal pain problem.
462
00:22:13.590 --> 00:22:17.470
But I want to tell you about the next thing I want to shift to is like
463
00:22:17.470 --> 00:22:22.110
when I was, when I was interviewing the NP mentors, it was pretty cool because
464
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it was very validating for me, even talking to them and seeing their line
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of thinking and thought process.
466
00:22:28.130 --> 00:22:32.150
When I presented this case to them, because the reality is the first
467
00:22:32.150 --> 00:22:36.350
step of becoming a nurse practitioner and being a new grad is all of those
468
00:22:36.350 --> 00:22:40.130
problems, specific medical management, diagnostic algorithms, this, this,
469
00:22:40.190 --> 00:22:41.010
this, and this, right?
470
00:22:41.130 --> 00:22:44.390
Learning that stuff you learn in school and then you reinforce on the
471
00:22:44.390 --> 00:22:48.450
But the next level is like all this stuff that makes a real change for
472
00:22:48.450 --> 00:22:49.610
patients, right?
473
00:22:50.010 --> 00:22:53.330
Because we can look, we can stop right here and say with this case, no red
474
00:22:53.330 --> 00:22:57.470
flags, I suspect that it's her chronic gastroparesis, but I'm worried
475
00:22:57.470 --> 00:23:00.550
about an obstruction, so I'm going to get a KUB, I'm going to get
476
00:23:00.550 --> 00:23:04.430
an abdominal X-ray to see if there's any fluid levels and stool
477
00:23:04.430 --> 00:23:05.650
impact, stuff like that, right?
478
00:23:05.650 --> 00:23:07.870
You could decide I'm like, okay, I'm going to go from there.
479
00:23:08.050 --> 00:23:12.130
However, as, as you develop in your practice, you can add this next level
480
00:23:12.130 --> 00:23:12.430
on.
481
00:23:12.430 --> 00:23:15.290
So these, these are the things that I did not want to hear as a new grad.
482
00:23:15.490 --> 00:23:18.670
I just wanted to hear about the diagnostic algorithms and I was like,
483
00:23:18.670 --> 00:23:19.570
yeah, yeah, yeah, whatever.
484
00:23:19.770 --> 00:23:22.410
When we were talking about this part, I guess I'm just trying to be
485
00:23:22.410 --> 00:23:26.110
transparent here, but now that I'm an experienced NP, it's like, we
486
00:23:26.110 --> 00:23:29.310
all kind of agree that obviously everyone has different practices, but
487
00:23:29.310 --> 00:23:32.190
for the most part, this is, everyone agrees that this is where the
488
00:23:32.190 --> 00:23:32.990
change cuts, right?
489
00:23:33.170 --> 00:23:35.750
So the next steps are the holistic perspective, right?
490
00:23:36.070 --> 00:23:41.470
Now that I have more of the, or of the diabetes management stuff down
491
00:23:41.470 --> 00:23:44.390
in terms of the diagnostic algorithms, medications, et cetera.
492
00:23:44.530 --> 00:23:49.150
I know that if I give a medication, if I throw a glucometer or medication
493
00:23:49.150 --> 00:23:52.890
at somebody that's that's like asking for it not to be done, right?
494
00:23:52.950 --> 00:23:55.530
Because there's so much more that the patients need, right?
495
00:23:55.690 --> 00:23:59.550
So the next kind of questions I have for patients are about like
496
00:23:59.550 --> 00:24:01.330
what's going on, like what's this bigger picture?
497
00:24:01.390 --> 00:24:04.410
Like if you can practice as a new grad, again, giving yourself grace
498
00:24:04.410 --> 00:24:08.190
because your focus is learning the medicine and this will develop over
499
00:24:08.190 --> 00:24:09.330
years, right?
500
00:24:09.490 --> 00:24:13.030
But like, this is like the magic of mentorship is that we get to talk
501
00:24:13.030 --> 00:24:16.430
about these things and hopefully this will help you think in this way a
502
00:24:16.430 --> 00:24:18.890
little bit more and practice thinking this way, right?
503
00:24:18.990 --> 00:24:20.230
Not perfection, just practice.
504
00:24:20.470 --> 00:24:20.650
Okay.
505
00:24:20.650 --> 00:24:21.410
So what's going on?
506
00:24:21.430 --> 00:24:23.550
So this is what I say to the patients, like, tell me about,
507
00:24:24.190 --> 00:24:25.550
um, that sounds really hard, right?
508
00:24:25.710 --> 00:24:27.630
Validation again, that sounds really hard.
509
00:24:27.730 --> 00:24:29.790
Like tell me about more what's going on.
510
00:24:29.890 --> 00:24:32.510
Like what are the, you know, who do they live with?
511
00:24:32.810 --> 00:24:34.870
What's going on with them eating candy?
512
00:24:35.090 --> 00:24:37.710
Is it, instead of making assumptions, like I'm going to assume it's
513
00:24:37.710 --> 00:24:42.490
because of the stomach pain, but does she have any barriers to accessing?
514
00:24:42.990 --> 00:24:44.610
Um, does she have enough money to feed her kids?
515
00:24:44.870 --> 00:24:47.730
Does she prioritize feeding her kids and that's all she can afford for herself.
516
00:24:48.170 --> 00:24:51.790
Does she feel depressed about her diabetes and feels hopeless?
517
00:24:51.810 --> 00:24:55.870
And so she doesn't feel like she can do any of the things that she's
518
00:24:55.870 --> 00:24:57.650
been asked to do or told to do.
519
00:24:57.850 --> 00:24:58.750
What is her knowledge base?
520
00:24:58.830 --> 00:25:01.950
Like, what does she understand about her diabetes so that to figure
521
00:25:01.950 --> 00:25:03.410
out what's driving her, right?
522
00:25:03.430 --> 00:25:07.070
Because if she feels depressed and hopeless and she's not motivated
523
00:25:07.070 --> 00:25:11.450
or doesn't understand the ramifications of this diabetes, this A1C being
524
00:25:11.450 --> 00:25:15.190
14 persistently, that's going to shape your conversations going further.
525
00:25:15.450 --> 00:25:16.730
Who, what does she do for childcare?
526
00:25:16.810 --> 00:25:17.790
What does she do for work?
527
00:25:18.090 --> 00:25:18.530
Right.
528
00:25:18.670 --> 00:25:21.370
Because if she's up all night because she's working night shift and then
529
00:25:21.370 --> 00:25:23.510
she's always sleeping two hours a day because she cares for her
530
00:25:23.510 --> 00:25:25.150
children during the day, right.
531
00:25:25.170 --> 00:25:26.170
And she's barely eating.
532
00:25:26.330 --> 00:25:28.390
Like that's a very different conversation.
533
00:25:28.570 --> 00:25:31.850
And then that kind of brings in those next levels of like, what are
534
00:25:31.850 --> 00:25:33.510
the resources that you have at your clinic?
535
00:25:33.670 --> 00:25:36.910
So do you have a community health worker that can help connect her
536
00:25:36.910 --> 00:25:41.350
with community resources or do you have therapists if they're, you know,
537
00:25:41.350 --> 00:25:43.970
sounding like they're having a hard time coping or they have
538
00:25:43.970 --> 00:25:45.510
diagnosed depression, right?
539
00:25:45.670 --> 00:25:47.310
Do what are their comorbidities with that?
540
00:25:47.590 --> 00:25:51.310
What are the other diabetes resources that you can do for this person?
541
00:25:51.370 --> 00:25:54.530
Like, do they have some sort of diabetes educator at your
542
00:25:54.530 --> 00:25:58.090
clinic or, you know, do you have nurse, nurse visits specifically
543
00:25:58.090 --> 00:26:00.450
that you can do where you can do diabetes teaching?
544
00:26:00.650 --> 00:26:02.910
Does she need teaching for how to use a glucometer, right?
545
00:26:03.310 --> 00:26:05.970
So I'm feeling like this list is getting a little bit long.
546
00:26:05.970 --> 00:26:09.190
So I just want to share that like, I don't know, this is like, these are
547
00:26:09.190 --> 00:26:11.710
the conversations that we're having, right?
548
00:26:11.810 --> 00:26:14.910
So it's, it's about the case and it's about the life.
549
00:26:15.270 --> 00:26:18.210
And so for this person disclosure, I don't actually have all the detail.
550
00:26:18.290 --> 00:26:20.770
This is a conversation I had a while back and I have some notes on it, but
551
00:26:20.770 --> 00:26:25.070
I don't have all the details, but effectively depending on the
552
00:26:25.070 --> 00:26:29.470
answers to those questions, it really changes your management, right?
553
00:26:29.490 --> 00:26:32.450
So I can tell you that like, let's back up for a second.
554
00:26:32.450 --> 00:26:36.190
So if we are just focusing on the diagnostic algorithms, AACE
555
00:26:36.190 --> 00:26:39.650
guidelines or ADA guidelines, like that's where you go for your
556
00:26:39.650 --> 00:26:40.850
diabetes management, right?
557
00:26:41.050 --> 00:26:44.770
So that's the, that's the problem fix is to go to that place and say,
558
00:26:44.970 --> 00:26:45.750
okay, what do they say?
559
00:26:46.130 --> 00:26:50.230
Well, they say anything above 9% should warrant insulin.
560
00:26:50.550 --> 00:26:52.150
So you're just going to start them on insulin right away.
561
00:26:52.550 --> 00:26:55.770
Send them home with a glucometer, send them home with needles and send
562
00:26:55.770 --> 00:26:56.870
them on their merry way, right?
563
00:26:56.930 --> 00:26:57.950
I mean, we're not going to do that.
564
00:26:57.970 --> 00:26:59.110
I'm being ridiculous, right?
565
00:26:59.150 --> 00:27:00.070
But some people do.
566
00:27:00.390 --> 00:27:01.750
So we try not to do that.
567
00:27:01.750 --> 00:27:03.630
That's like very overwhelming, right?
568
00:27:03.650 --> 00:27:06.690
Can you just even imagine what that feels like to be diagnosed
569
00:27:06.690 --> 00:27:08.210
newly potential with this person?
570
00:27:08.330 --> 00:27:11.090
It's not a new diagnosis, but just, you know, just imagine
571
00:27:11.090 --> 00:27:12.170
what that feels like, right?
572
00:27:12.670 --> 00:27:16.290
So diagnostic algorithm says that diagnostic algorithm says to
573
00:27:16.290 --> 00:27:21.590
do long acting, acting, um, insulin once, maybe twice a day.
574
00:27:21.670 --> 00:27:23.370
And it's a weight-based dosing, right?
575
00:27:23.410 --> 00:27:25.130
So we can get into that place, right?
576
00:27:25.170 --> 00:27:27.870
So I can get into that conversation with that new grad of like,
577
00:27:27.930 --> 00:27:28.690
here's what we do.
578
00:27:28.710 --> 00:27:30.610
We check morning and morning blood sugars.
579
00:27:30.610 --> 00:27:33.110
You want the, and off the top of my head, excuse me.
580
00:27:33.130 --> 00:27:33.610
I don't remember.
581
00:27:33.790 --> 00:27:35.990
I believe, I can't remember.
582
00:27:36.050 --> 00:27:38.310
It's supposed to be around like less than one 30, I believe.
583
00:27:38.650 --> 00:27:40.570
Don't quote me on that, but whatever the, whatever the
584
00:27:40.570 --> 00:27:41.650
guideline says, right?
585
00:27:42.130 --> 00:27:43.290
Fasting morning blood sugars.
586
00:27:43.450 --> 00:27:46.750
You want it to be within a certain range and every single day, you
587
00:27:46.750 --> 00:27:49.290
start them at the weight-based dose, or you start at 10 units of long
588
00:27:49.290 --> 00:27:53.590
acting once a day, and then you titrate up depending on their morning
589
00:27:53.590 --> 00:27:55.730
blood sugars every three to four days, right?
590
00:27:55.810 --> 00:27:57.490
I can rattle that off, right?
591
00:27:57.670 --> 00:27:59.650
But we're talking about this case.
592
00:28:00.570 --> 00:28:03.930
I guarantee you, if you just threw that at that patient and left the room,
593
00:28:04.190 --> 00:28:05.470
that would not happen, right?
594
00:28:05.490 --> 00:28:07.670
I can't guarantee, but you know what I'm saying here?
595
00:28:07.850 --> 00:28:10.170
So, so that's like the quote unquote, what we should do.
596
00:28:10.370 --> 00:28:14.290
And also let's look at all the answers to those questions that we ask this
597
00:28:14.290 --> 00:28:17.430
person to understand their life, their resources, their support systems,
598
00:28:17.530 --> 00:28:20.850
what supports you have in the clinic and what they want and what they
599
00:28:20.850 --> 00:28:23.290
believe in, did we give them a, what do they understand?
600
00:28:23.770 --> 00:28:25.170
What can we educate them on?
601
00:28:25.370 --> 00:28:28.150
And that will all change the trajectory of these conversations.
602
00:28:28.150 --> 00:28:30.910
So I think this case, again, moral of the story, I don't actually
603
00:28:30.910 --> 00:28:32.670
remember what happened with this case.
604
00:28:32.830 --> 00:28:33.350
And I apologize.
605
00:28:33.490 --> 00:28:35.470
Maybe that's what you are listening to this episode for.
606
00:28:35.610 --> 00:28:36.470
It's like, what happened?
607
00:28:36.530 --> 00:28:37.190
What happened?
608
00:28:37.650 --> 00:28:40.970
A lot of new grads get, I think get upset if I have a cliffhanger
609
00:28:40.970 --> 00:28:43.170
case study, you know, I get it.
610
00:28:43.270 --> 00:28:44.170
I totally get it.
611
00:28:44.170 --> 00:28:46.750
Um, but I think that this patient ended up getting some imaging
612
00:28:46.750 --> 00:28:49.590
done for their gastroparesis, their stomach pain, because it
613
00:28:49.590 --> 00:28:51.310
was leaning towards being that.
614
00:28:51.530 --> 00:28:54.650
And then, um, there was a plan for the diabetes to have a long, just
615
00:28:54.650 --> 00:28:57.770
have a close follow-up visit, check some labs and have a longer
616
00:28:57.770 --> 00:29:01.650
conversation after she and I spoke, I believe, like she had another
617
00:29:01.650 --> 00:29:04.190
closer visit where she could ask all of those kinds of like more
618
00:29:04.190 --> 00:29:07.270
holistic questions to guide the practice a little bit more.
619
00:29:07.490 --> 00:29:10.050
And I think she like did some short-term management of the
620
00:29:10.050 --> 00:29:11.110
blood trigger being high.
621
00:29:11.250 --> 00:29:13.890
And she knew the patient knew how to use a glucometer was agreeable
622
00:29:13.890 --> 00:29:18.950
to check, um, wasn't at risk for, um, DKA or HHS, she had type two diabetes.
623
00:29:18.950 --> 00:29:22.170
So it was HHS and knew the signs and symptoms.
624
00:29:22.170 --> 00:29:25.530
And so it just had a short follow-up and further conversation
625
00:29:25.530 --> 00:29:27.410
about the medication or she might've started her own one.
626
00:29:27.410 --> 00:29:28.410
So apologies, apologize.
627
00:29:28.530 --> 00:29:31.870
I like having details, but she had appropriate management for this patient.
628
00:29:32.250 --> 00:29:32.490
But yeah.
629
00:29:32.490 --> 00:29:36.650
So, so I think all of that, like all of the further interventions really
630
00:29:36.650 --> 00:29:38.970
depend on the answers to those questions.
631
00:29:39.490 --> 00:29:40.230
So hopefully, yeah.
632
00:29:40.350 --> 00:29:43.050
So hopefully moral of the story, hopefully this case
633
00:29:43.050 --> 00:29:46.170
highlights that there are.
634
00:29:46.890 --> 00:29:49.910
I think the first thing is like, wow, this is hard, right?
635
00:29:49.910 --> 00:29:52.850
Like this is really hard, especially if you're a brand new grad.
636
00:29:53.210 --> 00:29:56.510
And I've practiced this for several years.
637
00:29:56.510 --> 00:30:00.370
And so I can think about these things at the time of the visit, but if you
638
00:30:00.370 --> 00:30:06.130
aren't even like aware of that holistic way of approaching the case or the
639
00:30:06.130 --> 00:30:10.090
patient and practiced in it and it's in your head and you can do it quickly.
640
00:30:10.090 --> 00:30:13.330
Like this is, this is a lot, this is a lot of stuff and it's complex
641
00:30:13.330 --> 00:30:14.310
and it's high risk, right?
642
00:30:14.310 --> 00:30:17.790
I didn't really even get into all of the different pieces of gastroparesis
643
00:30:17.790 --> 00:30:19.110
and diabetes, right.
644
00:30:19.250 --> 00:30:25.110
And abdominal pain, but also to, um, hopefully this case and that kind
645
00:30:25.110 --> 00:30:29.070
of like background discussion will help you start thinking about some
646
00:30:29.070 --> 00:30:31.090
of those other pieces to talk about.
647
00:30:31.450 --> 00:30:35.150
And I'm also acknowledging that like, this is a lot, like I covered
648
00:30:35.150 --> 00:30:41.610
a lot in this episode and not every single patient needs all of those
649
00:30:41.610 --> 00:30:45.530
things and a lot of our conversations go a lot faster than this whole
650
00:30:45.530 --> 00:30:48.870
episode, because again, this is a one-way telling of a conversation
651
00:30:48.870 --> 00:30:52.750
versus with the way that we talk through it, but yeah, so hopefully
652
00:30:52.750 --> 00:30:56.870
this is a, is a helpful way to hear what it's like number one, if you're
653
00:30:56.870 --> 00:31:00.330
a student and number one, what it could be like in the real world.
654
00:31:00.830 --> 00:31:04.930
And then number two, if you're a new grad, this can be helpful
655
00:31:04.930 --> 00:31:09.530
for thinking about just the, all of the things that new grads are
656
00:31:09.530 --> 00:31:14.610
stressing about and help you feel not alone because it's all, I mean,
657
00:31:14.610 --> 00:31:18.630
I feel like, I just want to like yell it from the rooftops or across
658
00:31:18.630 --> 00:31:23.090
the internet that so much of this is, is like the same role transition
659
00:31:23.090 --> 00:31:25.870
and other new grads are struggling with the same things.
660
00:31:26.350 --> 00:31:29.670
And then the other piece is just to give yourself a lot of grace
661
00:31:29.670 --> 00:31:33.010
and that this is a practice and these are just pick and choose, right?
662
00:31:33.050 --> 00:31:36.190
Can you pick one thing from this episode that you can add to your
663
00:31:36.190 --> 00:31:38.990
practice to try to practice, right?
664
00:31:39.110 --> 00:31:42.270
Again, acknowledging that I was like, I don't know how I'm going
665
00:31:42.270 --> 00:31:45.450
to have time to do this in a visit when my mentor said this to me.
666
00:31:45.450 --> 00:31:50.590
And it's really just about incorporating little pieces over time and keeping
667
00:31:50.590 --> 00:31:55.910
in mind that it's both the medical algorithms, but also trying your best
668
00:31:55.910 --> 00:31:59.550
to zoom out, which it feels impossible at first, like impossible to think
669
00:31:59.550 --> 00:32:03.050
about somebody coming back in three months or a year from now, but just
670
00:32:03.050 --> 00:32:06.470
trying to zoom out and see what it actually looks like in somebody's real
671
00:32:06.470 --> 00:32:10.290
life so that you can, yeah, just take it, take it from there and start
672
00:32:10.290 --> 00:32:14.070
incorporating those little pieces to make it more functional for each person.
673
00:32:18.130 --> 00:32:20.090
That's our episode for today.
674
00:32:20.210 --> 00:32:21.990
Thank you so much for listening.
675
00:32:22.350 --> 00:32:26.610
Make sure you subscribe, leave a review and tell all your NP friends.
676
00:32:26.990 --> 00:32:30.390
So together we can help as many nurse practitioners as possible,
677
00:32:30.470 --> 00:32:32.330
give the best care to their patients.
678
00:32:32.710 --> 00:32:35.690
If you haven't gotten your copy of the ultimate resource guide
679
00:32:35.690 --> 00:32:40.350
for the new NP, head over to realworldnp.com slash guide.
680
00:32:40.690 --> 00:32:43.990
You'll get these episodes sent straight to your inbox every week
681
00:32:43.990 --> 00:32:47.450
with notes from me, patient stories and extra bonuses.
682
00:32:47.790 --> 00:32:49.610
I really just don't share anywhere else.
683
00:32:49.970 --> 00:32:51.550
Thank you so much again for listening.
684
00:32:51.670 --> 00:32:52.950
Take care and talk soon.
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