Interview with an Orthopedic Nurse Practitioner
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Show notes:
It’s super common for new NPs — and experienced ones — to get anxious when encountering orthopedic complaints.
It’s a conundrum — on one hand, it seems like it should be simple. After all, you can feel all the musculoskeletal body structures right there.
But at the same time, there are so many (SO MANY!) nuances to each body part. And there’s a lot of ortho lingo to wrap your head around.
That’s why it’s helpful to understand exactly what an orthopedic nurse practitioner does — and what that means for working in primary care.
Orthopedic Nurse Practitioner Interview
So sit back and enjoy — this week, orthopedic nurse practitioner, Yessica Salazar, has stopped by to talk ortho with us...and left behind so many great clinical pearls that I just know will help you in your daily practice:
How to order knee X-rays the right way
Her approach to medications for orthopedic complaints
Non-invasive treatment options for patients
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WEBVTT
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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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Thank you so much for being here.
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Can you introduce yourself?
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Of course.
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Actually, it's my pleasure to be here.
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I'm a big fan of everything that you've been doing lately for all these nurse practitioners
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that I think are benefiting so much, and I appreciate very much what you've been
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doing.
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But I'm Jessica Stelzar.
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I created NP Insiders, and I basically did that because I see a need for clinicians,
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nurse practitioners, especially to learn a little bit more about orthopedics.
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And we see so many orthopedic patients in primary care, in the urgent care setting, in the
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emergency room.
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And a lot of these patients go to these places looking for nurse practitioners and
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clinicians that can help them relieve their pain.
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And that is mainly like their goal, right?
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Like, I was looking at some of the data from the literature and I found out that
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about 213 billion health care dollars are spent every year on these patients.
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You know, the back pain, the shoulder pain, and the knee pain.
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And then we also have all these patients getting older and older, and we have to
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learn how to properly manage them and how to treat them.
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And not always the answer is a referral.
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There's a lot that we can do in primary care to take care of them.
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Totally. So you are a primary care or an orthopedic NP?
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So I'm an orthopedic nurse practitioner, but I also do board certified in orthopedics
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and I am board certified as a family nurse practitioner.
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I do work also in the walking clinic where the majority of the patients that come
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in have orthopedic conditions.
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So I see a lot of the back pain, the shoulder pain, the knee pain, the
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recently, you know, the elbow pain, which is not so much elbow.
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A lot of it become the lightest.
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And then unfortunately, they, you know, they have been given things that
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perhaps don't really work properly.
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And I've been so glad to be able to help them in those terms.
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How long have you been working in orthopedics for?
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So orthopedic orthopedics kind of landed on my lab.
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I remember graduating from NP school, all my experience from graduating actually
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back when I was a nurse was in ICU.
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And then I did family and then I graduated.
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And then I had three jobs.
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I had a job, I think it was at an urgent care, kind of like walking clinic.
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I had a job at a plastic surgeon office.
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And then there was this job at the orthopedics department at a university.
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And the lowest paid was the one I chose.
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It was the orthopedic job.
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And I think that the reason that I chose it was more of a strategic
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decision rather than then, oh my God, I've always wanted to do this because
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from my interviews, I got the, the, I felt right.
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That I was going to learn so much more from this, from this opportunity.
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And I think that was the right decision.
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I was trained alongside with the residents.
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I was trained by world renowned orthopedic surgeons and, and they,
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they really supported my growth.
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And I mean, the first year was really hard because in NP school, as you know,
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you don't get a lot of orthopedic experience.
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I mean, we're very good and we hammer down the, the hard stuff and the
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lungs and the kidneys and the diabetes, but then most of the
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skeleton is like, yeah, yeah, yeah, they have pain, but you know,
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that's not like that, that that's not life threatening.
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Like these are the things that you need to know.
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And, and so to land a position right at a school in orthopedics was a big
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challenge, but I said to myself, okay, I'm ready.
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And I think that I'm going to be able to learn the
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most out of this opportunity.
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And one of the things that I was thinking earlier today is at least
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for me, I like to be the engineer or the architect of my career.
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And I think that as NP, sometimes we, we marry with a certain specialty
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or, or, or what have you, and we don't see what is it, the trees for the
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forest or the forest for the trees.
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I can't remember the right way to say it, but that is so true.
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And because I opened my, my, my eyes, my mind, and I just took the
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plunge, this has led to so many opportunities.
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I, I even was able to, I've been able to all these years to first assist.
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I love that.
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Unfortunately, recently, like when you work like at a university level or like
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university hospital based, there's a lot of residents, so you don't get to do a
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lot of the handsome things, which I'm trying to do more like on the outside.
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And that's something that I also have on the works, right?
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Like, cause I'm at first assist, but I'm also getting the actual
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certification, I think I mentioned that earlier to you off camera that.
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Unfortunately, from nurses, like we are asked so much to show for like, okay,
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well, if you're an NP, you have to be either family or acute, or you have
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to, you know, to have this specialty and you have to have this
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certification board and you have to have this other certificate.
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And if you don't have it, then you cannot do that.
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And then we'll, we see other healthcare providers that are not like
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asked for as many things as we are and whatever it is, what it is.
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But I continue to grow and, and to invest in my, in my knowledge.
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And I think that as nurse practitioners, we have to do, we have to do this,
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right, to, to, to be able to, to get to where we want to get to.
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It is possible.
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Yeah.
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And I think one of the questions, so we asked some questions, um, what
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questions the audience had for you as an orthopedic NP.
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And, um, one of the questions on that topic was like how you came into it.
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Like, did you, did you find a job apply?
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Did you know a person?
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Did you do a fellowship?
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Did they just happen to train you because that's just the
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culture of orthopedics?
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Like, do you know what I mean?
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Like, was there any sort of formal fellowship or residency
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program that you did?
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So I think, no, no, no.
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Um, I get this a lot, right?
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My, my, my experience was very different.
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I went into, into the interview and I did do a lot of research
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before I went into the interview.
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And I knew a lot of diagnoses when I went to the interview.
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So I was clinically ready to answer diagnoses, like orthopedic
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related diagnosis questions.
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And I think that that in them during that interview, that even
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though I was a family nurse practitioner with relatively zero
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experience in orthopedics, I had that desire.
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And, and I read an entire book.
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It was about a thousand, a hundred pages of my orthopedics.
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I'm very intense when I want to woman up for my own heart.
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I love that.
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And, um, and, and so they saw that initiative and they saw that desire.
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And I think that, that that's what won them over during the interview.
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They also noticed that I had ICU experience and you know,
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the word around the block is that ICU nurses, um, love to learn.
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And, and, and they're very like focused and, and, and, uh, demand
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a lot from themselves and give a lot of themselves.
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So I don't know if that helped them to make the decision and to hire me.
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But I think that I want to, I want to believe it did.
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And then the interview just went really well.
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I had three rounds of interviews.
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I was interviewed by, by a CFO first.
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And then I was interviewed by like the clinical manager.
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And then I was also interviewed by a panel of surgeons.
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And then I was interviewed again by the same surgeons because they
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really wanted to go with me, but they wanted to make sure
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that I was the right fit.
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Yes, for sure.
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And so that was kind of like the final interview, but that's how
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like I landed that position.
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And, um, one, I want to say to nurse practitioners, do not be turned off.
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If you see a job posting that says you need three years of experience
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in this specialty or that specialty, my, my personal life, real experience
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is that that job said that you needed three years of orthopedic
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experience and I had zero.
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Totally.
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So it really, um, it really comes down to, to wanting to do, um, and wanting,
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you know, to be prepared and, and, and, and then just having happened,
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happening to be in the right place at the right time.
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And then the opportunity, um, lands on, on your lap.
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That's awesome.
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That's so awesome.
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Um, and, uh, so some of the other questions I, you and I could
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talk for a very long time.
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So we're going to try to, we're going to try to narrow it in.
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When we have talked for a very long time about this.
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Um, but I think, um, it's so hard to pick all of the questions
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that people had were so good.
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I think it could be like hours, right?
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If we wanted to talk about all of them.
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So we're going to try to focus in.
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I think the main theme of the questions were a couple of things.
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So one of them, I mean, I think the general theme of what I'm trying
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to convey in these, um, interviews is like, what do we wish we knew?
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What do specialists wish we knew in primary care?
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They're like, oh my God, another referral that is for this.
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That shouldn't have come to me.
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Like those kinds of things, like not, and there's no judgment.
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There's no shame about referring people.
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I think that our aim here is to help with the educational piece, right?
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Cause I think a lot of new grads feel uncomfortable with the
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amount that they refer anyway.
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So no judgment on that.
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Um, but yeah, so from that perspective, what, what are some, like, what are
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common pitfalls you see of primary care providers sending to orthopedics
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that shouldn't come to orthopedics, for example?
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And so I'm going to preface my answer by, by it depends.
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Everything is relevant.
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Um, so I, uh, so far I've been in orthopedics almost, I think six
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years is going to be six years soon.
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And I've had two different positions into different hospitals in orthopedics.
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So the first one, um, had a different approach.
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The one that I'm in right now has a more strict approach and they do
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desire for the patients to be worked up, um, before or prior to, to
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referral, um, where I was before it was more a financial, uh, driven, uh,
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specialty, so they didn't mind seeing, you know, whomever.
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However, however, there's a caveat.
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There's a lot of surgeon dissatisfaction when they see 20
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patients in one clinic day, and only one or two were surgical.
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Like they're not really using the, their specialty and their skills
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to, to, to the top of what they could do if that is the
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bulk of what they're doing.
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Right?
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So if you're a surgeon, I'm not a surgeon, but I've, I've
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worked with plenty of amazing surgeons.
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But the mindset, and this is for all MPs to know the mindset of the surgeon
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is that they want to do surgery.
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So it is awesome if you can get into a relationship with surgeons where
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you get the patient, um, to do conservative therapies and, and to
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exhaust conservative measures before you do that referral, and this
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is very common in, in osteoarthritis, unfortunately.
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So you get a lot of like, yes, I have knee pain.
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Okay.
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For how long?
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Well, for three months.
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And it's kind of like mild, they haven't really tried any
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conservative treatment and they're coming to a specialist.
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If I were a patient, I definitely would like for my primary care
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provider to know that I'm going to be spending a lot of money
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going to that specialist and probably not going to get so
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much out of that visit.
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Right.
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And so if I can save that money by doing more of the conservative
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treatments, um, that are out there that, that I can do and that I'm
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interested in doing then by, by all means, you know, if I, if I have
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failed that then by all means that I want to go and see a surgeon.
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And, and so that's kind of like something that, that I do have
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noticed a lot, but then the other side of the coin is that if as a
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primary care or urgent care, or even emergency provider, you're
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seeing these patients coming in, but you're not very familiar with
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what to do, then you have no choice, but to refer.
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So then how do we figure that out?
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And I've been doing a lot of thinking about learning more.
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Yes, for sure.
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For sure.
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And I think that like, I think it's, it's challenging.
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Cause I, when I have students and new grads that I'm mentoring,
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like I talk about like, what is the rationale for referring?
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Cause I think I remember when I was a new grad, especially being
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like, so nervous that I just would do something instead of like,
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okay, take a second.
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What is the rationale for this?
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Don't panic.
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Cause like the main reason to refer is either for diagnostic
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clarity or for treatment.
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And so it's not wrong to refer people to orthopedics for
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diagnostic clarity, but there's so much opportunity for us in primary
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care to like, know more stuff so that we can hold onto that.
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Like sooner.
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And one, and one thing too is to have at least like your differential
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diagnoses, right?
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When, when I, unfortunately, and you see this a lot, like I am
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referring because of a symptom.
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Well, let's try to at least get to a diagnosis.
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Like, what is this?
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What are we talking about?
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Like, let me bring up the knee because knee pain is so common,
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right in primary care.
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So knee pain is a symptom.
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It is not a diagnosis.
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So what is this?
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Right?
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Like is the patient an older patient?
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Are you thinking more of a degenerative finding?
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Is this osteoarthritis?
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Is this a meniscal tear?
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Are we talking about a patient in their twenties and their thirties?
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I do see a lot of clinicians going for the MRI before they
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even order the X-ray, right?
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Like the plain X-ray.
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And then especially like on our older patients, like in our
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fifties or sixties, they come in with MRI and yet they don't have
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plain films.
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Well, we should start with the plain films first and then
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talking about the plain films, I, you know, you mentioned some of
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the questions earlier, but there's a way, there's a right
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way of ordering the plain films and we can talk about that.
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I was going to say, maybe let's segue into imaging because I
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think that's like such a big question.
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And I know for me, like my orthopedic knowledge is fair.
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But I am not an orthopedic NP.
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I'm primary care.
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I try to be jack of all trades, but it's not as robust as I
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would like.
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So I think for me, I'll just speak from my own personal
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experience.
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So like, for example, if I have a knee pain, I've done a
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couple of interviews talking about physical therapy and I
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please don't take offense to this.
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I think I might've already told you this, but I think like
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the general pathway of orthopedics is NSAIDs, physical
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therapy, injections and surgery.
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Like that tends to be the general arc.
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I don't know if that's real, but that's like what I've
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seen in primary care at least.
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And so I tend to refer patients to physical therapy, but
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when it gets to that place, if they have fully, fully
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engaged in the recommended physical therapy for that
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full course, no improvement.
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Then I'll refer them to orthopedics.
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And I personally don't love ordering imaging first
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because it feels like there's a different request based
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on the office.
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And maybe that's not real.
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So why don't you tell us, I think that I think I'm
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sharing that as an anecdote because I think that's a
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very common experience for people where they're trying to
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write by the patient still are not clear with diagnostic
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clarity.
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And then aren't quite sure where to go from there because
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it seems like sometimes orthopedics will order
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different imaging or reorder imaging, things like that.
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And so orthopedics does that because they're not
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because the patient is basically coming with the
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wrong images.
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Okay.
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And so I think that we can say, I mean, not good,
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obviously, but I think we can save the patient time
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and money if we get this cleared up.
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So I don't know how it works at your clinic or different
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hospitals work differently, but kind of like the main
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type of films out there for knee pain or for knee x-rays
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is kind of like a three view or plain three view AP
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lateral.
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Unfortunately, that is not the right one that typically
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is done mainly in the emergency room when the
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providers are trying to rule out a fracture and you
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don't want to get an x-ray on a weight bearing status,
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right?
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You don't want to get weight bearing x-rays.
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You want the patient to be to be non weight bearing
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so that in case they have a fracture, you're
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basically ruling, you're not damaging or giving
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more harm to the patient.
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But the right films to order, and I'll give that
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to you, are four is actually four of them.
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The first one is the AP and the AP has to be weight
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bearing and when you order that, you have to stay
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there and I have to do it all the time even in
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specialty practice.
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Standing AP or weight bearing AP and that is
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actually the only way that you can visualize the
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joint space and the practicality of having a
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00:19:04.180 --> 00:19:08.010
weight bearing AP is so that you can see if there's
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narrowing of the medial joint line or lateral
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joint line, if the patient no longer has any
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cartilage and the knee is bone on bone, or if
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there is enough cartilage and this is kind of
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like a benign x-ray.
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And so when you have enough cartilage, then
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you basically, the cartilage doesn't show on
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the x-ray.
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You just see kind of like a gap.
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And fortunately, and I know like in primary
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care, a lot of the providers are mainly
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reading the reports rather than actually
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visualizing the x-rays.
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But if you do have some time and you do have
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the chance, look at the x-rays because you're
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going to learn so much from them.
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So that's one of the views, right?
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Then you also want to get a weight bearing
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flex knee or like a PA view and that's
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basically from the back of the knee and that
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way you don't miss like osteoarthritis but
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like in the back, in the posterior aspect.
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00:20:03.890 --> 00:20:06.350
And then you can also get a merchant view,
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00:20:06.430 --> 00:20:08.550
it's also called the sunrise view, and
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00:20:08.550 --> 00:20:10.030
that's basically looking at the knee from
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the top and looking at the patellofemoral
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joint and then you can right away like
368
00:20:15.790 --> 00:20:17.550
diagnose, well not right away, but it
369
00:20:17.550 --> 00:20:19.390
can kind of like guide you into your
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potential diagnosis.
371
00:20:20.330 --> 00:20:23.190
If there's narrowing, how much narrowing
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there is, then if you have narrowing in
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that merchant or sunrise view, then maybe
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the patient has some sort of patellofemoral
375
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syndrome of some sort, especially if the
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patient says I'm having pain walking
377
00:20:34.790 --> 00:20:36.870
down the stairs and then you see a
378
00:20:36.870 --> 00:20:38.390
merchant or sunrise view that is
379
00:20:38.390 --> 00:20:40.570
narrowing, then that kind of like clicks
380
00:20:40.570 --> 00:20:42.970
and then they could also have
381
00:20:42.970 --> 00:20:45.910
osteoarthritis of the medial joint
382
00:20:45.910 --> 00:20:47.550
line and the lateral joint line but
383
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then you're also depending on the
384
00:20:49.010 --> 00:20:50.650
symptoms and the history that you get
385
00:20:50.650 --> 00:20:52.590
could be leaning more towards the
386
00:20:52.590 --> 00:20:54.090
one that is causing most of the
387
00:20:54.090 --> 00:20:55.050
symptoms, right?
388
00:20:55.150 --> 00:20:56.570
And then the last view is kind of
389
00:20:56.570 --> 00:20:58.030
like the lateral view but that one
390
00:20:58.030 --> 00:20:59.510
doesn't give a lot of information so
391
00:20:59.510 --> 00:21:01.790
if you don't have to get that
392
00:21:01.790 --> 00:21:02.830
one, you don't get that one but
393
00:21:02.830 --> 00:21:06.910
definitely the way-bearing AP, that's
394
00:21:06.910 --> 00:21:08.630
essential, like that one is
395
00:21:08.630 --> 00:21:11.390
essential. The merchant view, I
396
00:21:11.390 --> 00:21:13.330
definitely do recommend it and the
397
00:21:13.330 --> 00:21:15.070
way-bearing flex knee, the posterior
398
00:21:15.070 --> 00:21:17.930
anterior view. Those, that one is
399
00:21:17.930 --> 00:21:19.770
also called the Rosenberg view
400
00:21:19.770 --> 00:21:22.170
but those are kind of like the
401
00:21:22.170 --> 00:21:23.010
main ones.
402
00:21:23.750 --> 00:21:26.830
Otherwise, then you do miss the
403
00:21:26.830 --> 00:21:28.890
correct diagnosis, right?
404
00:21:29.590 --> 00:21:32.390
Totally. Do you ever get x-rays
405
00:21:32.390 --> 00:21:34.230
and then you can skip the MRI
406
00:21:34.230 --> 00:21:35.490
because you've gotten all of those
407
00:21:35.490 --> 00:21:36.930
images or is it? Absolutely.
408
00:21:37.270 --> 00:21:39.110
Cool. That's good to know because I
409
00:21:39.110 --> 00:21:41.490
feel like sometimes like
410
00:21:41.490 --> 00:21:43.510
I just first and maybe this is just
411
00:21:43.510 --> 00:21:44.970
the healthcare system but I feel like
412
00:21:44.970 --> 00:21:46.570
sometimes I see that where it's like
413
00:21:46.570 --> 00:21:48.250
it's almost like you need an x-ray
414
00:21:48.250 --> 00:21:50.550
to buy you an MRI, right? Because
415
00:21:50.550 --> 00:21:51.630
the MRI doesn't get approved unless
416
00:21:51.630 --> 00:21:52.810
you have something first
417
00:21:52.810 --> 00:21:54.310
and so sometimes it feels like
418
00:21:54.310 --> 00:21:55.930
there's going to be an MRI
419
00:21:55.930 --> 00:21:57.170
done anyway so I'm going to like
420
00:21:57.170 --> 00:21:58.590
let them do the right one
421
00:21:58.590 --> 00:22:00.570
but that's really helpful, that's
422
00:22:00.570 --> 00:22:03.350
really great. That's really...
423
00:22:03.350 --> 00:22:05.630
And when it comes to like
424
00:22:05.630 --> 00:22:07.330
imaging, a lot of the times
425
00:22:07.330 --> 00:22:09.890
you don't even need that MRI and I
426
00:22:09.890 --> 00:22:11.270
think that's why too like
427
00:22:11.270 --> 00:22:12.730
they have implemented and put all
428
00:22:12.730 --> 00:22:13.990
these things into place
429
00:22:13.990 --> 00:22:17.410
because unless you're completely
430
00:22:17.410 --> 00:22:19.750
incapable or unable to diagnose based
431
00:22:19.750 --> 00:22:21.130
on clinical symptoms, physical
432
00:22:21.130 --> 00:22:23.390
exam, and a plain x-ray,
433
00:22:24.110 --> 00:22:25.810
then really like there's no merit
434
00:22:25.810 --> 00:22:28.550
for that MRI. The MRI mainly looks
435
00:22:28.550 --> 00:22:29.470
at the soft tissue
436
00:22:29.470 --> 00:22:33.430
so if you're trying to rule out like
437
00:22:33.430 --> 00:22:35.410
osteoarthritis or even a fracture,
438
00:22:36.110 --> 00:22:37.890
x-rays are the things to get
439
00:22:37.890 --> 00:22:40.910
and MRI is more if...
440
00:22:41.590 --> 00:22:43.070
So the clinical picture that I'm
441
00:22:43.070 --> 00:22:44.710
thinking when I want an MRI
442
00:22:44.710 --> 00:22:49.130
is 20 plus, 30 plus year old
443
00:22:49.130 --> 00:22:53.330
who just engaged into trauma
444
00:22:54.190 --> 00:22:55.790
or had some sort of injury
445
00:22:55.790 --> 00:22:57.390
rather like exercise-related
446
00:22:57.390 --> 00:22:59.690
spore and then he's complaining
447
00:22:59.690 --> 00:23:01.270
of instability of his knee
448
00:23:01.270 --> 00:23:03.450
and then he has a big swelling knee
449
00:23:03.450 --> 00:23:06.250
and I can't even do the
450
00:23:07.170 --> 00:23:08.670
instability testing rather
451
00:23:08.670 --> 00:23:10.840
maneuvers like the test for the AC,
452
00:23:12.490 --> 00:23:14.550
ACL or MCL because
453
00:23:14.550 --> 00:23:17.030
they're just so in so much pain
454
00:23:17.030 --> 00:23:18.430
then I do definitely want to get
455
00:23:18.430 --> 00:23:20.150
an MRI so the MRI can look
456
00:23:20.150 --> 00:23:21.170
at the soft tissue and the
457
00:23:21.170 --> 00:23:23.630
ligaments and then I can rule out
458
00:23:23.630 --> 00:23:26.490
or rule in an ACL tear
459
00:23:26.490 --> 00:23:28.390
or even the medial, lateral,
460
00:23:28.470 --> 00:23:30.350
collateral ligament tears.
461
00:23:30.970 --> 00:23:33.530
So then that's why
462
00:23:34.330 --> 00:23:35.810
that's like one of the reasons
463
00:23:35.810 --> 00:23:38.450
why I would go for that MRI
464
00:23:38.450 --> 00:23:42.290
before even thinking of the x-ray
465
00:23:42.290 --> 00:23:45.050
but definitely if you don't learn
466
00:23:45.050 --> 00:23:48.550
if no one takes anything else
467
00:23:48.550 --> 00:23:50.590
except the imaging,
468
00:23:51.070 --> 00:23:52.550
go for the x-ray first.
469
00:23:53.510 --> 00:23:54.890
And the right imaging.
470
00:23:54.890 --> 00:23:57.730
So I have a question based on that.
471
00:23:58.130 --> 00:24:01.530
So like my experience of ortho so far
472
00:24:01.530 --> 00:24:04.990
is like in school I think
473
00:24:04.990 --> 00:24:06.830
every school does their best effort
474
00:24:06.830 --> 00:24:08.030
to do as much as they can
475
00:24:08.730 --> 00:24:09.790
with the amount that we need
476
00:24:09.790 --> 00:24:10.650
to learn that time.
477
00:24:11.030 --> 00:24:12.570
I feel like the way that I
478
00:24:12.570 --> 00:24:13.790
at least the takeaways
479
00:24:13.790 --> 00:24:15.210
that I've gotten from ortho is like,
480
00:24:15.210 --> 00:24:16.290
oh it's just the structures
481
00:24:16.290 --> 00:24:17.350
that are in front of you.
482
00:24:17.510 --> 00:24:18.570
This is easy.
483
00:24:18.630 --> 00:24:19.910
Just do these special tests
484
00:24:19.910 --> 00:24:21.050
and you'll have your answer.
485
00:24:21.310 --> 00:24:22.290
Is that real?
486
00:24:22.290 --> 00:24:23.350
Because I feel like that's
487
00:24:25.150 --> 00:24:26.150
I'm being like very candid
488
00:24:26.150 --> 00:24:26.910
on this interview.
489
00:24:27.410 --> 00:24:28.970
I just feel like is that
490
00:24:28.970 --> 00:24:29.930
I don't know.
491
00:24:30.050 --> 00:24:30.910
Do you feel like you feel
492
00:24:30.910 --> 00:24:31.930
comfortable with the special test?
493
00:24:32.090 --> 00:24:32.510
Because I guess,
494
00:24:32.550 --> 00:24:33.870
so I guess the context is that
495
00:24:33.870 --> 00:24:35.530
I work with a lot of new grads
496
00:24:35.530 --> 00:24:37.070
and I think there's this expectation
497
00:24:37.070 --> 00:24:39.090
similar to ordering a lab test
498
00:24:39.090 --> 00:24:40.470
being like, okay here's this lab.
499
00:24:40.750 --> 00:24:41.910
Here's your answer.
500
00:24:42.790 --> 00:24:43.710
For me it feels like
501
00:24:43.710 --> 00:24:44.870
those special tests
502
00:24:44.870 --> 00:24:46.870
are difficult to learn,
503
00:24:47.090 --> 00:24:48.730
difficult to like
504
00:24:48.730 --> 00:24:50.290
feel the true differences
505
00:24:50.290 --> 00:24:51.470
and like may or may not
506
00:24:51.470 --> 00:24:53.130
related to the actual underlying.
507
00:24:53.690 --> 00:24:54.670
Like I feel like your knowledge
508
00:24:54.670 --> 00:24:55.750
as a specialist NP
509
00:24:55.750 --> 00:24:56.870
is like so sophisticated
510
00:24:56.870 --> 00:24:57.990
that you can see
511
00:24:58.450 --> 00:24:59.610
the whole picture
512
00:24:59.610 --> 00:25:01.130
and it's not a plug and play thing.
513
00:25:01.170 --> 00:25:01.750
Do you know what I mean?
514
00:25:01.850 --> 00:25:02.590
Like does that make sense?
515
00:25:02.590 --> 00:25:03.470
Yeah, no, no, no.
516
00:25:03.470 --> 00:25:04.190
A hundred percent.
517
00:25:05.330 --> 00:25:06.690
But so here's the thing.
518
00:25:06.750 --> 00:25:08.450
I think the difference between
519
00:25:08.450 --> 00:25:09.850
like let's say orthopedics
520
00:25:09.850 --> 00:25:11.090
and other specialties
521
00:25:11.090 --> 00:25:12.130
or even you know
522
00:25:12.130 --> 00:25:13.050
as a family nurse practitioner,
523
00:25:14.010 --> 00:25:14.930
as a family nurse practitioner
524
00:25:14.930 --> 00:25:16.870
I also practice a little bit
525
00:25:16.870 --> 00:25:19.130
and I also do work also
526
00:25:19.130 --> 00:25:19.990
in the urgent clinic
527
00:25:19.990 --> 00:25:21.090
like I was telling you earlier.
528
00:25:22.390 --> 00:25:24.190
But here's the thing.
529
00:25:24.310 --> 00:25:25.930
Orthopedics is very hands-on.
530
00:25:26.590 --> 00:25:28.250
So it's not we don't depend
531
00:25:28.250 --> 00:25:29.930
so much so on labs
532
00:25:29.930 --> 00:25:32.510
rather than on our touching
533
00:25:32.510 --> 00:25:34.350
and feeling and watching and seeing.
534
00:25:35.250 --> 00:25:36.750
And it's very you need
535
00:25:36.750 --> 00:25:39.170
to develop this tactile sense
536
00:25:39.170 --> 00:25:42.770
and also you depend a lot on the imaging.
537
00:25:43.030 --> 00:25:44.850
So you're not reading reports.
538
00:25:45.070 --> 00:25:45.750
As a matter of fact
539
00:25:45.750 --> 00:25:47.490
when patients come in
540
00:25:47.490 --> 00:25:49.970
and they just have the little piece of paper
541
00:25:49.970 --> 00:25:51.070
that's another pet peeve.
542
00:25:51.470 --> 00:25:53.650
Tell your patients to take the CD
543
00:25:53.650 --> 00:25:56.470
with the images when they go
544
00:25:56.470 --> 00:25:57.370
to the specialist.
545
00:25:57.630 --> 00:25:59.190
Yeah, that's a big takeaway.
546
00:25:59.850 --> 00:26:01.110
Like if you go to
547
00:26:01.110 --> 00:26:02.070
like an orthopedic surgeon
548
00:26:02.070 --> 00:26:03.310
and you take your little report
549
00:26:03.310 --> 00:26:05.410
from the radiology department
550
00:26:05.410 --> 00:26:07.070
that says that you have an impression
551
00:26:07.070 --> 00:26:09.070
and you have a list of a million things.
552
00:26:09.530 --> 00:26:11.150
That's not high yield.
553
00:26:11.710 --> 00:26:14.550
Like the orthopedic surgeon wants to see
554
00:26:15.210 --> 00:26:16.830
what the knee looks like.
555
00:26:16.850 --> 00:26:17.790
Like the intricacies
556
00:26:17.790 --> 00:26:19.690
like what does it look like on imaging?
557
00:26:19.890 --> 00:26:21.290
Because many times
558
00:26:22.090 --> 00:26:23.410
I'm not going to say they get missed
559
00:26:23.410 --> 00:26:26.310
but like there's many things
560
00:26:26.310 --> 00:26:28.490
that you can think of
561
00:26:28.490 --> 00:26:30.170
when you correlate that clinically.
562
00:26:30.930 --> 00:26:33.170
And so in school
563
00:26:33.170 --> 00:26:36.410
I just think that they threw at us so much
564
00:26:36.410 --> 00:26:38.610
and it was like oh so comprehensive
565
00:26:38.610 --> 00:26:40.110
I cannot do this.
566
00:26:40.330 --> 00:26:42.350
But there's a lot of high yield
567
00:26:43.210 --> 00:26:45.070
physical exams that you can do
568
00:26:45.070 --> 00:26:46.730
that are so easy.
569
00:26:48.330 --> 00:26:49.630
And I don't know if I say this
570
00:26:49.630 --> 00:26:51.490
because I have done this so much
571
00:26:54.470 --> 00:26:56.550
but I really think that
572
00:26:56.550 --> 00:26:58.910
nurse practitioners have the capacity
573
00:26:58.910 --> 00:27:00.070
I promise you.
574
00:27:00.490 --> 00:27:02.470
You and everyone as a nurse practitioner
575
00:27:02.470 --> 00:27:04.970
has the capacity of doing the essentials
576
00:27:05.530 --> 00:27:07.710
and the essentials can be as easy
577
00:27:07.710 --> 00:27:09.090
and let me just walk you through
578
00:27:09.090 --> 00:27:10.630
like a physical exam for the knee
579
00:27:10.630 --> 00:27:11.910
now that we're talking about the knee, right?
580
00:27:11.970 --> 00:27:12.770
Let's talk about knees, do it.
581
00:27:13.990 --> 00:27:15.790
So watch the patient walk.
582
00:27:16.730 --> 00:27:18.310
Like do they have a limp?
583
00:27:18.310 --> 00:27:21.170
You know that will tell you a lot, right?
584
00:27:21.170 --> 00:27:22.570
And you don't have to have them
585
00:27:23.150 --> 00:27:25.330
run the catwalk or walk the catwalk.
586
00:27:25.370 --> 00:27:27.650
No, it has to be just five feet, right?
587
00:27:27.650 --> 00:27:29.250
Like and you can notice that
588
00:27:29.250 --> 00:27:31.550
like is there their gait ontology?
589
00:27:31.650 --> 00:27:33.930
Do they have a trendling gait?
590
00:27:34.230 --> 00:27:35.910
So that's something that you can pick up
591
00:27:35.910 --> 00:27:37.890
in less than two seconds, right?
592
00:27:37.950 --> 00:27:39.150
You don't want to miss that.
593
00:27:39.370 --> 00:27:41.910
Visualize the knee, visualize the skin.
594
00:27:42.270 --> 00:27:43.570
That's another key thing
595
00:27:43.570 --> 00:27:46.630
and I've had many patients come in
596
00:27:46.630 --> 00:27:48.590
with very tight clothing
597
00:27:49.130 --> 00:27:52.830
that they cannot lift their jeans or pants
598
00:27:52.830 --> 00:27:54.150
and I'm like, no,
599
00:27:54.190 --> 00:27:55.770
I'm gonna have to step out of the room
600
00:27:55.770 --> 00:27:57.150
and you're gonna have to get on a gown.
601
00:27:57.350 --> 00:27:58.270
You have to do that.
602
00:27:58.290 --> 00:27:59.570
Like if you're dealing with
603
00:27:59.570 --> 00:28:00.690
multiple skeletal things,
604
00:28:00.690 --> 00:28:02.250
you have to visualize the skin
605
00:28:02.250 --> 00:28:04.270
because the last thing that you want to miss
606
00:28:05.870 --> 00:28:09.530
is redness or warmth or big swelling
607
00:28:09.530 --> 00:28:11.730
or a draining wound and pus.
608
00:28:11.910 --> 00:28:12.790
Like you don't want to miss that
609
00:28:12.790 --> 00:28:14.910
because you didn't look under the hood, right?
610
00:28:14.910 --> 00:28:17.810
And so that is something that like,
611
00:28:17.850 --> 00:28:19.850
let's say that if you're in primary care,
612
00:28:19.970 --> 00:28:21.670
you can kind of like prepare for the next day
613
00:28:21.670 --> 00:28:23.090
and you see that the main complaint
614
00:28:23.090 --> 00:28:24.670
is kind of like that knee pain
615
00:28:24.670 --> 00:28:26.510
or hip pain or shoulder pain,
616
00:28:26.650 --> 00:28:30.250
then I don't know if you have like clerks
617
00:28:30.730 --> 00:28:32.690
or MAs that can kind of like do the call
618
00:28:32.690 --> 00:28:33.690
and just say, hey, you know,
619
00:28:33.690 --> 00:28:35.390
just make sure you're coming for this
620
00:28:35.390 --> 00:28:36.490
musculoskeletal complaint,
621
00:28:36.850 --> 00:28:38.110
bring comfortable clothing
622
00:28:38.110 --> 00:28:40.670
or clothing that can be removed really quickly
623
00:28:40.670 --> 00:28:42.770
so that the clinician can visualize
624
00:28:42.770 --> 00:28:43.510
and look at the skin
625
00:28:43.510 --> 00:28:44.510
and do a thorough assessment.
626
00:28:44.510 --> 00:28:46.190
So that is another key.
627
00:28:46.350 --> 00:28:47.810
And then you don't really have to do that
628
00:28:47.810 --> 00:28:49.350
when you have the patient in front of you
629
00:28:49.350 --> 00:28:50.610
and you're dealing with diabetes, right?
630
00:28:50.650 --> 00:28:52.110
Or hypertension, right?
631
00:28:52.110 --> 00:28:53.630
But these are like little nuggets of wisdom
632
00:28:53.630 --> 00:28:54.770
that you don't want to think about
633
00:28:54.770 --> 00:28:56.670
when you're dealing with musculoskeletal care.
634
00:28:57.710 --> 00:28:59.070
I can say like every single time
635
00:28:59.070 --> 00:28:59.850
I have a knee pain,
636
00:28:59.890 --> 00:29:01.190
they're always wearing tight jeans,
637
00:29:01.470 --> 00:29:02.730
like every single time.
638
00:29:03.210 --> 00:29:04.150
Like, oh man.
639
00:29:04.170 --> 00:29:05.210
And then you can see it.
640
00:29:05.210 --> 00:29:05.970
And then, you know,
641
00:29:06.070 --> 00:29:07.210
something that I've seen a lot,
642
00:29:08.250 --> 00:29:09.290
like you ask the patient,
643
00:29:09.850 --> 00:29:11.810
okay, so have you had any surgeries in the past?
644
00:29:11.870 --> 00:29:13.490
Oh no, no, no surgeries.
645
00:29:13.490 --> 00:29:15.710
And then I'm looking at the knee and I'm like,
646
00:29:15.730 --> 00:29:16.950
what is this big scar?
647
00:29:17.070 --> 00:29:17.730
Oh, yeah.
648
00:29:19.790 --> 00:29:22.550
I was so young and I'm like, okay.
649
00:29:22.810 --> 00:29:25.070
So then by just visualizing the skin,
650
00:29:25.470 --> 00:29:28.470
you can really get a lot of information.
651
00:29:29.390 --> 00:29:31.230
Then the next thing is super easy
652
00:29:31.230 --> 00:29:32.470
when they're either sitting
653
00:29:32.470 --> 00:29:35.310
on the examination table or laying down.
654
00:29:35.570 --> 00:29:36.710
You can feel for crepit.
655
00:29:36.810 --> 00:29:38.670
So you kind of like put your knee on,
656
00:29:38.670 --> 00:29:40.810
your hand on like the patella
657
00:29:40.810 --> 00:29:42.870
and then have them extend and bend the knee.
658
00:29:42.870 --> 00:29:45.050
And then you feel that grinding.
659
00:29:45.730 --> 00:29:47.510
And then that could be,
660
00:29:47.510 --> 00:29:50.490
that could either be patella femoral
661
00:29:50.490 --> 00:29:52.810
or just arthritis
662
00:29:52.810 --> 00:29:54.830
that is kind of like really advanced.
663
00:29:55.210 --> 00:29:56.610
So that's another key thing
664
00:29:56.610 --> 00:29:57.970
that you can pick up right away.
665
00:29:58.250 --> 00:29:59.470
Then you lay them on their back
666
00:29:59.470 --> 00:30:01.530
and then you want to assess the range of motion.
667
00:30:02.870 --> 00:30:06.990
I will try in my channel to kind of like
668
00:30:06.990 --> 00:30:09.430
give a visualization of how to do this
669
00:30:09.430 --> 00:30:10.630
because I know in words
670
00:30:10.630 --> 00:30:14.970
doesn't always translate properly than when you see it.
671
00:30:15.290 --> 00:30:17.550
But you want to know the limits of range of motion.
672
00:30:18.010 --> 00:30:20.390
Like can the patient make the leg straight?
673
00:30:20.510 --> 00:30:21.470
That's zero degrees.
674
00:30:21.550 --> 00:30:23.690
Can they bend it in how far?
675
00:30:24.670 --> 00:30:27.110
Sometimes you can miss a contracture
676
00:30:27.110 --> 00:30:28.910
like when you don't have them laying flat
677
00:30:28.910 --> 00:30:31.050
because they're like, you know,
678
00:30:31.050 --> 00:30:33.730
they cannot make their leg straight like their knee.
679
00:30:34.630 --> 00:30:36.530
And they basically they're like there's a bend.
680
00:30:36.550 --> 00:30:38.690
They cannot go all the way down to zero.
681
00:30:38.690 --> 00:30:40.830
And then you want to do ligament testing.
682
00:30:40.890 --> 00:30:43.770
You want to test your MCL, your ACL.
683
00:30:44.970 --> 00:30:45.810
There are certain maneuvers
684
00:30:45.810 --> 00:30:48.430
are better than others in clinical practice.
685
00:30:49.250 --> 00:30:53.690
And then that's kind of like a quick knee assessment.
686
00:30:54.870 --> 00:30:56.110
Doesn't take that long
687
00:30:56.110 --> 00:30:57.930
once you know what you're looking for.
688
00:30:57.950 --> 00:30:59.530
If you don't know what you're looking for
689
00:30:59.530 --> 00:31:01.050
and if you don't know how to do it,
690
00:31:01.070 --> 00:31:03.710
then I feel you're going to just be all over the place.
691
00:31:03.730 --> 00:31:05.210
You're not going to be focused, right?
692
00:31:05.230 --> 00:31:07.230
And then that can be a little bit overwhelming
693
00:31:07.230 --> 00:31:08.810
for both the patient and the clinician.
694
00:31:08.990 --> 00:31:10.530
And then you have so much information
695
00:31:10.530 --> 00:31:12.350
that you don't really know where to go.
696
00:31:12.670 --> 00:31:15.710
Yeah. And I think I've kind of noticed that to myself
697
00:31:15.710 --> 00:31:17.750
in terms of like when it comes to orthopedics,
698
00:31:17.850 --> 00:31:20.790
it's almost like a lot of people think about it
699
00:31:20.790 --> 00:31:27.050
from the diagnostic maneuvers first.
700
00:31:27.410 --> 00:31:29.650
And it's almost like you kind of have to go backwards
701
00:31:29.650 --> 00:31:31.390
like where you need the differentials
702
00:31:31.390 --> 00:31:32.910
and the structures.
703
00:31:33.070 --> 00:31:35.730
And then you're verifying it with the maneuvers
704
00:31:35.730 --> 00:31:38.630
versus maneuvers first and diagnostic clarity next.
705
00:31:38.730 --> 00:31:39.710
Does that make sense?
706
00:31:40.170 --> 00:31:40.990
Yeah, no, totally.
707
00:31:41.130 --> 00:31:43.870
But one of the main things is the history.
708
00:31:44.510 --> 00:31:48.150
Like so important because it really can guide you
709
00:31:48.150 --> 00:31:49.050
into what you need to test
710
00:31:49.050 --> 00:31:51.510
and what you should pay attention more than
711
00:31:51.510 --> 00:31:53.190
one thing more than the other.
712
00:31:53.930 --> 00:31:55.570
Like for example, if I have a patient
713
00:31:55.570 --> 00:31:57.570
and the patient is in their 60s
714
00:31:57.570 --> 00:32:00.790
and they're having pain that is chronic
715
00:32:00.790 --> 00:32:02.030
and it's bilateral
716
00:32:03.890 --> 00:32:06.790
and they're having pain going up and down the stairs.
717
00:32:07.050 --> 00:32:09.070
And they have tried everything and nothing works.
718
00:32:09.090 --> 00:32:12.210
So I'm thinking, no, this is arthritis.
719
00:32:12.390 --> 00:32:15.070
Now, if I have a younger guy or younger girl,
720
00:32:15.510 --> 00:32:18.470
a younger patient in general coming in
721
00:32:18.470 --> 00:32:22.230
and they say that they just have been experiencing
722
00:32:22.230 --> 00:32:24.770
a lot of swelling, it's constant on and off.
723
00:32:25.170 --> 00:32:28.230
Then I'm thinking, could this be a meniscal tear?
724
00:32:29.030 --> 00:32:31.910
If I have a patient that comes in and says,
725
00:32:32.310 --> 00:32:36.350
I had this injury and I feel that my knee is giving way,
726
00:32:36.370 --> 00:32:38.990
then I'm thinking, well, could this be an ACL tear,
727
00:32:39.330 --> 00:32:40.970
an ACL related injury?
728
00:32:43.610 --> 00:32:46.710
Like I'm paying attention to what they're telling me
729
00:32:46.710 --> 00:32:49.130
and the complaint that they're saying in the history.
730
00:32:49.610 --> 00:32:52.730
And then that history is really what's going to guide me
731
00:32:52.730 --> 00:32:54.090
into then my physical exam
732
00:32:54.090 --> 00:32:57.950
and then what kind of imaging and treatment
733
00:32:57.950 --> 00:32:58.830
I want to do.
734
00:32:59.590 --> 00:33:01.430
And especially in primary care,
735
00:33:01.550 --> 00:33:03.650
I think we can start treatments
736
00:33:03.650 --> 00:33:05.290
even without getting the imaging,
737
00:33:05.630 --> 00:33:07.090
especially if it's something chronic.
738
00:33:08.430 --> 00:33:10.390
Yeah. And actually I think that's a beautiful segue
739
00:33:10.390 --> 00:33:13.090
because I just want to ask you all the questions
740
00:33:13.090 --> 00:33:15.630
but I'm trying really hard to hold myself back.
741
00:33:16.030 --> 00:33:17.990
You are a wealth of knowledge, my friend.
742
00:33:19.050 --> 00:33:21.750
If we want to segue into talking about some treatments.
743
00:33:22.910 --> 00:33:25.510
So I think the main, if I remember correctly,
744
00:33:26.250 --> 00:33:27.130
with so many questions,
745
00:33:27.130 --> 00:33:30.050
I think the main thing and you actually,
746
00:33:30.070 --> 00:33:31.330
you can also speak to the main things
747
00:33:31.330 --> 00:33:32.510
that you're seeing in orthopedics
748
00:33:32.510 --> 00:33:33.870
and also in urgent care.
749
00:33:33.890 --> 00:33:35.830
But I think arthritis is like a huge question
750
00:33:35.830 --> 00:33:37.490
of like how to help people.
751
00:33:37.730 --> 00:33:40.630
And then people also have questions about opiates,
752
00:33:40.770 --> 00:33:43.230
which you can talk about or not talk about,
753
00:33:43.310 --> 00:33:43.590
it's up to you.
754
00:33:43.610 --> 00:33:45.970
I know it's controversial, but yeah.
755
00:33:45.970 --> 00:33:47.190
Any insights you have to share
756
00:33:47.190 --> 00:33:49.210
or things you wish primary care providers knew
757
00:33:49.210 --> 00:33:51.330
about treating treatment in general,
758
00:33:51.350 --> 00:33:53.810
but specifically arthritis plus or minus opiate.
759
00:33:53.810 --> 00:33:54.690
Absolutely.
760
00:33:56.410 --> 00:33:57.590
We don't like opioids.
761
00:34:01.630 --> 00:34:04.410
So opioids, and this is something that I,
762
00:34:04.530 --> 00:34:06.970
this is kind of like the spiel
763
00:34:07.690 --> 00:34:08.969
that I give to my patients.
764
00:34:10.030 --> 00:34:12.850
Like opioid medication is going to only mask
765
00:34:13.449 --> 00:34:17.489
your symptoms, is not going to target the pathology.
766
00:34:17.889 --> 00:34:22.190
And when I, and I try to say that in much simpler words.
767
00:34:22.190 --> 00:34:23.230
Yeah, for sure.
768
00:34:23.230 --> 00:34:25.030
But you do understand what I'm saying, right?
769
00:34:25.710 --> 00:34:29.210
Like, you know, we give all these medications
770
00:34:29.210 --> 00:34:31.889
and unfortunately we have this epidemic, right?
771
00:34:31.929 --> 00:34:33.909
Of patients becoming addicted to opioids.
772
00:34:34.190 --> 00:34:36.570
And it's because we want a quick fix,
773
00:34:36.929 --> 00:34:38.210
but you know what?
774
00:34:38.210 --> 00:34:41.090
That quick fix can actually do more harm than good.
775
00:34:41.610 --> 00:34:43.969
And so when it comes to medication,
776
00:34:44.210 --> 00:34:48.330
especially for osteoarthritis and musculoskeletal,
777
00:34:48.530 --> 00:34:51.190
you want to decrease the inflammatory process.
778
00:34:51.370 --> 00:34:52.790
You don't do that with opioids.
779
00:34:52.790 --> 00:34:54.090
You don't do that with tramadol.
780
00:34:54.110 --> 00:34:55.250
You don't do that with codeine.
781
00:34:55.270 --> 00:34:56.409
You don't do that with morphine.
782
00:34:56.570 --> 00:34:58.210
Like you don't do that with any of that.
783
00:34:58.490 --> 00:34:59.830
You do that with anti-inflammatory,
784
00:34:59.830 --> 00:35:02.590
non-steroidal anti-inflammatory medications.
785
00:35:03.510 --> 00:35:05.730
And, and so, yeah, there's some,
786
00:35:05.770 --> 00:35:08.490
there's some go-tos that I, that I go to,
787
00:35:09.230 --> 00:35:11.330
especially if the pain is chronic in nature
788
00:35:11.330 --> 00:35:13.910
or if the pain is acute, I do have my go-tos.
789
00:35:13.970 --> 00:35:15.670
And if it's the knee, the shoulder, the back,
790
00:35:16.670 --> 00:35:19.050
but NSAIDs are kind of like my,
791
00:35:19.050 --> 00:35:22.290
my go-tos for musculoskeletal complaints,
792
00:35:22.290 --> 00:35:23.750
especially osteoarthritis.
793
00:35:23.770 --> 00:35:25.670
So when it comes to osteoarthritis,
794
00:35:26.150 --> 00:35:29.890
moderate to mild, moderate and severe osteoarthritis,
795
00:35:31.270 --> 00:35:32.710
NSAIDs really, really do help.
796
00:35:33.050 --> 00:35:36.330
And you need NSAIDs for, well, actually the,
797
00:35:36.470 --> 00:35:37.770
so the treatment guidelines, right,
798
00:35:37.990 --> 00:35:39.470
is high-dose long-term.
799
00:35:39.570 --> 00:35:42.410
Now there's a caveat with that
800
00:35:42.410 --> 00:35:43.550
because then you have,
801
00:35:43.590 --> 00:35:45.250
you can get into trouble with NSAIDs, right?
802
00:35:45.290 --> 00:35:46.850
Like patients with renal disease,
803
00:35:47.030 --> 00:35:48.430
patients with GI complaints,
804
00:35:49.230 --> 00:35:50.970
patients with blood disorders,
805
00:35:50.970 --> 00:35:52.890
like you really want to make sure,
806
00:35:52.970 --> 00:35:55.830
I mean, nothing in healthcare or medicine
807
00:35:55.830 --> 00:35:58.510
is straightforward and everything is tailored
808
00:35:58.510 --> 00:36:00.030
to the patient you have in front of you.
809
00:36:00.030 --> 00:36:01.450
So you need to make sure first
810
00:36:01.450 --> 00:36:03.630
if this is safe for the patient.
811
00:36:04.390 --> 00:36:06.810
So in the setting of osteoarthritis,
812
00:36:07.930 --> 00:36:10.350
always, you can always go to the cortisone shot.
813
00:36:10.370 --> 00:36:11.850
You have the cortisone injection.
814
00:36:12.250 --> 00:36:15.430
So let's say that you have a 65-year-old female
815
00:36:15.910 --> 00:36:18.490
who comes in, she has renal disease,
816
00:36:18.510 --> 00:36:19.850
and you're afraid of giving that in
817
00:36:19.850 --> 00:36:22.630
that is basically what's going to help with their pain.
818
00:36:23.030 --> 00:36:25.130
Well, you can do the cortisone injection, right?
819
00:36:25.130 --> 00:36:27.270
Like the intra-articular cortisone injection.
820
00:36:29.430 --> 00:36:31.870
If the arthritis is moderate to severe,
821
00:36:32.250 --> 00:36:34.390
there's nothing else that you're going to make worse.
822
00:36:34.410 --> 00:36:35.170
It's already bad.
823
00:36:35.290 --> 00:36:37.090
I mean, this pathology is not going to get better.
824
00:36:37.250 --> 00:36:38.710
So you're not going to make it worse
825
00:36:38.710 --> 00:36:40.150
if you give the cortisone injection.
826
00:36:40.390 --> 00:36:42.570
You're not going to give the cortisone injection monthly,
827
00:36:43.290 --> 00:36:46.350
but definitely giving a trial of a cortisone shot
828
00:36:46.350 --> 00:36:47.770
is I use a typical,
829
00:36:47.770 --> 00:36:51.010
I don't know if you want to get into like what I use.
830
00:36:51.330 --> 00:36:52.250
You are, if you want.
831
00:36:53.330 --> 00:36:55.850
Canalog 40 milligrams intra-articularly
832
00:36:56.590 --> 00:36:57.890
with some lidocaine.
833
00:36:58.350 --> 00:37:01.730
Like that definitely does the trick for patients.
834
00:37:02.350 --> 00:37:06.510
And so that helps a lot for these type of patients
835
00:37:06.510 --> 00:37:07.670
that have osteoarthritis,
836
00:37:08.070 --> 00:37:10.670
and that you're afraid of throwing that instead
837
00:37:10.670 --> 00:37:13.710
that can actually worsen other comorbidities.
838
00:37:13.710 --> 00:37:18.750
And so I think that a lot of clinicians don't know that
839
00:37:18.750 --> 00:37:21.850
and they abstain from that or just refer out.
840
00:37:22.590 --> 00:37:23.970
But, and that's something else that I would love to do.
841
00:37:24.050 --> 00:37:25.190
I would love to teach,
842
00:37:25.230 --> 00:37:28.390
because I was reading a paper about this.
843
00:37:28.450 --> 00:37:30.330
I would love to teach like primary care nurse practitioners
844
00:37:30.330 --> 00:37:32.030
and nurse practitioners everywhere
845
00:37:32.030 --> 00:37:33.490
how to do these procedures
846
00:37:33.490 --> 00:37:35.390
because this is a high yield.
847
00:37:35.710 --> 00:37:38.350
And even financially and also for your growth
848
00:37:38.350 --> 00:37:40.050
that you can show to your employee,
849
00:37:40.050 --> 00:37:41.430
or even if you have your own clinic,
850
00:37:41.430 --> 00:37:45.630
hey, I can offer this as a service.
851
00:37:46.070 --> 00:37:48.510
And that is something that I used to do in my other job.
852
00:37:48.830 --> 00:37:52.670
I actually was, they work based off of RVUs.
853
00:37:52.990 --> 00:37:55.470
My RVUs were really high because I actually had,
854
00:37:55.790 --> 00:37:58.030
I implemented a procedure clinic day.
855
00:37:58.750 --> 00:38:01.330
And so I, a lot of the patients I saw like,
856
00:38:01.510 --> 00:38:03.350
I'm like, oh, I think that you will benefit
857
00:38:03.350 --> 00:38:04.110
from this or that.
858
00:38:04.110 --> 00:38:05.870
And then I would do cortisone injections
859
00:38:05.870 --> 00:38:07.210
or hyaluronic acid injections,
860
00:38:07.410 --> 00:38:08.690
depending on who I was dealing with.
861
00:38:08.970 --> 00:38:11.230
And then those procedures really kind of like
862
00:38:11.810 --> 00:38:15.310
showcase nurse practitioners in the field.
863
00:38:15.530 --> 00:38:16.810
And I think these are tricks, right?
864
00:38:17.210 --> 00:38:19.410
That all of our colleagues can learn from
865
00:38:19.410 --> 00:38:22.750
and these procedures definitely will kind of like
866
00:38:22.750 --> 00:38:24.310
put them at another level.
867
00:38:25.010 --> 00:38:26.390
Yeah, no, totally.
868
00:38:26.570 --> 00:38:28.070
And I love procedures.
869
00:38:28.270 --> 00:38:29.190
I think they're so fun.
870
00:38:29.390 --> 00:38:31.070
I think the main hesitation that I've heard
871
00:38:31.070 --> 00:38:33.970
from people with starting them is that
872
00:38:33.970 --> 00:38:35.650
discomfort with the diagnostic clarity.
873
00:38:35.770 --> 00:38:38.210
Like, I think that if it was very clear already,
874
00:38:38.210 --> 00:38:39.430
either from their own diagnosis
875
00:38:39.430 --> 00:38:41.450
or a specialist diagnosis of like,
876
00:38:41.450 --> 00:38:43.190
here's what they have, here's the treatment,
877
00:38:43.230 --> 00:38:44.570
or they've already gotten one injection.
878
00:38:44.690 --> 00:38:45.530
It's like, oh, okay.
879
00:38:45.850 --> 00:38:47.610
I can keep doing injections in primary care,
880
00:38:47.610 --> 00:38:49.670
but like, I don't know if I feel comfortable enough
881
00:38:49.670 --> 00:38:51.230
making that definitive diagnosis
882
00:38:51.230 --> 00:38:53.890
that it's not something of all these other options.
883
00:38:54.770 --> 00:38:56.690
Yeah, and one thing with the injections,
884
00:38:57.010 --> 00:38:57.990
especially with cortisone,
885
00:38:59.750 --> 00:39:01.950
you don't want to do it, like I said, very often,
886
00:39:01.970 --> 00:39:04.310
but you can do it like twice
887
00:39:04.310 --> 00:39:06.450
or even up to three times I've seen
888
00:39:06.450 --> 00:39:08.870
some surgeons being comfortable with a year,
889
00:39:08.870 --> 00:39:13.530
especially if it provides a lot of symptoms relief
890
00:39:14.070 --> 00:39:15.130
for the patient.
891
00:39:15.530 --> 00:39:18.790
And it's also saving the nuclear option,
892
00:39:18.990 --> 00:39:20.430
which is a total knee replacement.
893
00:39:22.310 --> 00:39:26.490
So if we can continue to manage our patients that way,
894
00:39:26.830 --> 00:39:29.630
then by all means, another thing that,
895
00:39:29.810 --> 00:39:31.670
well, you mentioned it, like physical therapy.
896
00:39:31.950 --> 00:39:33.890
And I was going to say, I'm like trying to hold back
897
00:39:33.890 --> 00:39:35.930
from talking about physical therapy because I'm obsessed.
898
00:39:36.290 --> 00:39:38.150
I like understand what they do now.
899
00:39:38.150 --> 00:39:41.290
I'm like, how do we not talk about this more?
900
00:39:42.670 --> 00:39:43.310
Oh, here's the thing.
901
00:39:43.470 --> 00:39:46.730
So when I started my practicing like in orthopedics,
902
00:39:46.750 --> 00:39:48.070
I'm like, wow, physical therapy.
903
00:39:48.230 --> 00:39:50.450
I mean, these patients kind of are in a lot of pain
904
00:39:50.450 --> 00:39:51.750
and their knees swollen.
905
00:39:51.830 --> 00:39:53.850
And then even the patients themselves say,
906
00:39:54.390 --> 00:39:57.170
oh, I can't even exercise because it hurts so much.
907
00:39:57.210 --> 00:39:58.550
How am I going to do physical therapy?
908
00:39:58.610 --> 00:40:00.230
Well, you have to understand, right?
909
00:40:00.230 --> 00:40:03.710
Like you said, the meaning behind physical therapy
910
00:40:03.710 --> 00:40:07.610
and the theory is evidence-based.
911
00:40:07.610 --> 00:40:10.270
Is that the motion and the physical activity
912
00:40:10.270 --> 00:40:13.110
actually increases the joint capsule flexibility
913
00:40:13.110 --> 00:40:14.390
and the compliance.
914
00:40:14.550 --> 00:40:18.610
And so it allows the joint inside to kind of like expand
915
00:40:18.610 --> 00:40:21.470
and it decreases the inter-articular pressures
916
00:40:22.090 --> 00:40:24.950
that are happening because there's so much inflammation
917
00:40:24.950 --> 00:40:27.310
and swelling and the knee can only swell so much.
918
00:40:27.910 --> 00:40:30.090
And so physical therapy can help that too.
919
00:40:30.090 --> 00:40:34.430
And it also strengthens the peri-articular structures
920
00:40:34.430 --> 00:40:35.710
around the knee as well.
921
00:40:35.710 --> 00:40:41.030
And that load of the weight from the body
922
00:40:41.030 --> 00:40:42.530
doesn't automatically go to the knee.
923
00:40:42.890 --> 00:40:46.270
It can kind of be redistributed, right?
924
00:40:46.290 --> 00:40:48.290
If like the quadricep is strong.
925
00:40:48.510 --> 00:40:52.270
But one more treatment and we missed this
926
00:40:52.270 --> 00:40:56.410
and I stress this, half the patients lose weight.
927
00:40:56.650 --> 00:40:58.870
And it sounds so simple,
928
00:40:58.870 --> 00:41:02.750
but I think in osteoarthritis and in musculoskeletal
929
00:41:02.750 --> 00:41:05.990
pain and complaints and aches is so valuable.
930
00:41:06.050 --> 00:41:09.710
And I've read so many studies about that like 15 pounds,
931
00:41:10.270 --> 00:41:12.330
which yeah, sure, you know, it's a lot.
932
00:41:13.330 --> 00:41:14.710
But in someone who is a little more
933
00:41:14.710 --> 00:41:16.830
on the overweight side is not so much.
934
00:41:17.130 --> 00:41:21.130
Like if they stop drinking, you know, sugary foods
935
00:41:22.970 --> 00:41:25.210
beverages and decreasing amounts of carbs
936
00:41:25.210 --> 00:41:27.310
then definitely they can get there.
937
00:41:27.530 --> 00:41:30.010
But 10 to 15 pounds of weight loss
938
00:41:30.010 --> 00:41:32.210
can drastically change their symptoms.
939
00:41:32.750 --> 00:41:35.870
I had this one patient, she had end stage OA,
940
00:41:36.270 --> 00:41:38.310
but her BMI was about 40.
941
00:41:39.730 --> 00:41:43.690
And I unfortunately just see and it happens, right?
942
00:41:44.150 --> 00:41:45.890
Like patients are getting joint replacements
943
00:41:45.890 --> 00:41:48.450
with this very high elevated BMI.
944
00:41:49.590 --> 00:41:50.970
But sometimes it's at the service
945
00:41:50.970 --> 00:41:55.890
because when they are obese and their BMI is so high
946
00:41:55.890 --> 00:41:58.990
then you basically are exposing them
947
00:41:58.990 --> 00:42:03.050
at the actual knee joint failing
948
00:42:03.050 --> 00:42:04.610
and because of the weight loss.
949
00:42:04.850 --> 00:42:07.390
So you didn't really target, right?
950
00:42:07.390 --> 00:42:12.690
Like that basic non-invasive treatment
951
00:42:12.690 --> 00:42:14.790
you didn't exhaust that you didn't have them lose weight.
952
00:42:14.950 --> 00:42:17.430
And I think that having our patients lose weight
953
00:42:17.950 --> 00:42:19.170
they will feel it.
954
00:42:19.290 --> 00:42:21.290
I had, going back to what I was going to say
955
00:42:21.290 --> 00:42:24.290
I had this patient that I had a one-on-one
956
00:42:24.290 --> 00:42:26.950
like deep conversation with her
957
00:42:26.950 --> 00:42:30.230
and I convinced her to kind of like lose the weight.
958
00:42:30.250 --> 00:42:35.030
She came back three months later, she had lost 35 pounds.
959
00:42:36.650 --> 00:42:39.730
And despite the fact that her knee still hurt
960
00:42:39.730 --> 00:42:43.870
it wasn't as overwhelming as it was the first time.
961
00:42:43.870 --> 00:42:45.410
And she was so happy and excited.
962
00:42:45.430 --> 00:42:47.990
She even brought everything that she had done to
963
00:42:47.990 --> 00:42:50.690
and then I'm like, I want to use you as a model
964
00:42:50.690 --> 00:42:54.030
to all my patients because the thought is like,
965
00:42:54.030 --> 00:42:56.850
I'm inactive, I cannot do any exercise.
966
00:42:57.570 --> 00:42:59.630
Well, you can stop exercising your mouth.
967
00:43:08.410 --> 00:43:11.470
But definitely like, I know it's really hard
968
00:43:11.470 --> 00:43:12.130
it's really hard.
969
00:43:12.270 --> 00:43:13.130
Yes, losing weight is hard
970
00:43:13.130 --> 00:43:16.570
but 80 to 90% of our weight loss
971
00:43:16.570 --> 00:43:19.070
comes from what we eat or we don't eat.
972
00:43:19.650 --> 00:43:22.770
And I've set a lot of initiatives
973
00:43:22.770 --> 00:43:24.630
at my place of employment
974
00:43:24.630 --> 00:43:27.230
where I utilize a lot of the nutritionists
975
00:43:27.230 --> 00:43:29.090
and they have helped big time.
976
00:43:29.690 --> 00:43:32.630
And then there's so many resources online too
977
00:43:32.630 --> 00:43:34.030
where patients can go to
978
00:43:34.030 --> 00:43:36.550
and that I've definitely recommended books,
979
00:43:37.150 --> 00:43:39.310
online resources that they can utilize
980
00:43:39.310 --> 00:43:41.210
so that they can work on their weight loss.
981
00:43:41.430 --> 00:43:43.650
And then I love to see them back
982
00:43:43.650 --> 00:43:46.070
and they're so happy and they're so trim.
983
00:43:46.590 --> 00:43:48.770
And then they're like, I'm doing so much better
984
00:43:48.770 --> 00:43:50.230
and it's such a satisfying feeling
985
00:43:50.850 --> 00:43:53.490
that without throwing so many things at them
986
00:43:53.490 --> 00:43:54.850
and just one or two things
987
00:43:54.850 --> 00:43:56.610
you have such a big impact
988
00:43:56.610 --> 00:43:58.610
and such a high yield impact on them.
989
00:43:58.950 --> 00:44:01.510
And also their complaints and their pains and aches.
990
00:44:01.830 --> 00:44:02.310
Absolutely.
991
00:44:02.770 --> 00:44:04.210
And actually I have just for reference
992
00:44:04.210 --> 00:44:06.330
if anybody watching hasn't seen it
993
00:44:06.330 --> 00:44:08.390
there's two videos on weight loss counseling
994
00:44:08.390 --> 00:44:09.750
and management for medications
995
00:44:09.750 --> 00:44:12.030
because I think like you were saying sometimes
996
00:44:13.150 --> 00:44:16.210
it's hard, I think that's like another
997
00:44:16.210 --> 00:44:17.890
not to go like off on a tangent
998
00:44:17.890 --> 00:44:19.270
but I feel like in terms of schooling
999
00:44:19.270 --> 00:44:23.090
that's another area that we are sort of briefed about
1000
00:44:23.090 --> 00:44:24.310
but it's an art
1001
00:44:24.310 --> 00:44:27.230
because like you that's lifestyle modification
1002
00:44:27.230 --> 00:44:28.130
and that's habits
1003
00:44:28.570 --> 00:44:30.310
that's there's so much involved in that.
1004
00:44:30.410 --> 00:44:32.310
And so I think like if there's one pearl to take away
1005
00:44:32.310 --> 00:44:33.630
I talking about having those conversations
1006
00:44:33.630 --> 00:44:36.010
about weight loss as it relates to orthopedic issues
1007
00:44:36.010 --> 00:44:38.250
is like treating it like you would treat
1008
00:44:38.250 --> 00:44:40.690
the same seriousness
1009
00:44:40.690 --> 00:44:43.510
and the same attention and care and support
1010
00:44:43.510 --> 00:44:45.590
the way that we do for hypertension or diabetes
1011
00:44:45.590 --> 00:44:47.030
like we can make a care plan.
1012
00:44:47.190 --> 00:44:48.190
We can have them come back.
1013
00:44:48.390 --> 00:44:48.950
You know what I mean?
1014
00:44:49.330 --> 00:44:51.030
Like anyway, but that's-
1015
00:44:51.030 --> 00:44:52.650
And you don't have to throw everything at once, right?
1016
00:44:53.410 --> 00:44:54.830
You can start
1017
00:44:54.830 --> 00:44:56.910
because that's something else that I've seen
1018
00:44:56.910 --> 00:44:58.850
like when you throw all these things at them
1019
00:44:58.850 --> 00:45:00.050
they don't know where to start
1020
00:45:00.050 --> 00:45:01.750
or like what's the best approach
1021
00:45:01.750 --> 00:45:04.810
and the patient understandably so
1022
00:45:04.810 --> 00:45:06.910
is going to get overwhelmed and just give up
1023
00:45:06.910 --> 00:45:09.690
because oh my God, I can do this.
1024
00:45:10.590 --> 00:45:14.270
Something else and I've gotten a very funny answers
1025
00:45:14.270 --> 00:45:16.710
from my patients, assistive devices, right?
1026
00:45:16.710 --> 00:45:18.090
Easy like a cane.
1027
00:45:19.150 --> 00:45:22.570
A lot of my female patients don't like that.
1028
00:45:23.730 --> 00:45:25.530
And my male patients either
1029
00:45:27.010 --> 00:45:30.430
because they don't want to be seen
1030
00:45:31.150 --> 00:45:34.730
that somehow they're not a hundred percent, right?
1031
00:45:34.770 --> 00:45:35.830
Because when you see a cane
1032
00:45:35.830 --> 00:45:38.390
there's also that judgment
1033
00:45:38.390 --> 00:45:40.190
but definitely the cane
1034
00:45:40.190 --> 00:45:42.390
and then also teaching the patient
1035
00:45:42.390 --> 00:45:46.410
how to use the cane is so essential
1036
00:45:46.410 --> 00:45:49.530
because I've seen my patients with a cane
1037
00:45:49.530 --> 00:45:51.310
and they're using it on the side
1038
00:45:51.310 --> 00:45:52.770
that hurts them the most.
1039
00:45:53.810 --> 00:45:56.570
No, if they do that
1040
00:45:56.570 --> 00:45:57.970
if they use the cane on the side
1041
00:45:57.970 --> 00:46:00.650
that is their worst side
1042
00:46:00.650 --> 00:46:03.290
they're actually putting even more pressure on that side.
1043
00:46:03.310 --> 00:46:05.550
So they have to use the cane on the side
1044
00:46:05.550 --> 00:46:07.510
that the contralateral side
1045
00:46:07.510 --> 00:46:10.750
opposed to the one that they're having pain.
1046
00:46:11.030 --> 00:46:12.410
And so that's how it'll work
1047
00:46:12.410 --> 00:46:14.530
because they don't offload the weight, right?
1048
00:46:14.530 --> 00:46:17.070
So that they can ambulate better
1049
00:46:17.070 --> 00:46:18.630
and have less symptoms.
1050
00:46:18.670 --> 00:46:20.790
And that is another trick, another thing
1051
00:46:20.790 --> 00:46:23.450
another tool in the tool kit or the toolbox
1052
00:46:23.450 --> 00:46:27.010
like I call it to utilize when it comes to treatment.
1053
00:46:27.310 --> 00:46:27.770
Totally.
1054
00:46:27.910 --> 00:46:29.010
And I think it's so important
1055
00:46:29.010 --> 00:46:32.050
that we don't underestimate ourselves
1056
00:46:32.910 --> 00:46:35.070
whether we're new or experienced in PUS
1057
00:46:35.070 --> 00:46:37.650
like how many options we have.
1058
00:46:37.710 --> 00:46:39.510
And I think that there's a component of
1059
00:46:40.810 --> 00:46:41.850
I want to say selling
1060
00:46:41.850 --> 00:46:43.230
because that sounds super weird
1061
00:46:43.230 --> 00:46:45.150
but like it's almost like
1062
00:46:45.150 --> 00:46:46.550
I mean, it's just communication.
1063
00:46:46.770 --> 00:46:48.710
It's like I feel like I have to sell people
1064
00:46:48.710 --> 00:46:49.790
on physical therapy
1065
00:46:49.790 --> 00:46:51.390
and I have literally no agenda
1066
00:46:51.390 --> 00:46:52.850
aside from helping them, right?
1067
00:46:52.850 --> 00:46:53.730
I get no financial gain.
1068
00:46:53.870 --> 00:46:54.250
Like, so it's not
1069
00:46:54.250 --> 00:46:55.430
I don't even want to use that word
1070
00:46:55.430 --> 00:46:56.510
but at the same time
1071
00:46:56.510 --> 00:46:58.970
it's almost like you need to talk to patients about like
1072
00:46:58.970 --> 00:47:01.030
hey, this actually can be helpful for you.
1073
00:47:01.230 --> 00:47:02.650
Here's how it works.
1074
00:47:02.890 --> 00:47:04.070
Let's try it, right?
1075
00:47:04.110 --> 00:47:06.350
And because I think that so many like popular conception
1076
00:47:06.350 --> 00:47:08.110
is like, oh, just like I need a med, right?
1077
00:47:08.110 --> 00:47:08.830
I need a medicine.
1078
00:47:09.070 --> 00:47:10.830
I need this medicine in particular.
1079
00:47:11.010 --> 00:47:12.270
And even we think that too
1080
00:47:12.270 --> 00:47:13.330
because I think that there's so many
1081
00:47:13.330 --> 00:47:15.250
algorithmic approaches to medical care
1082
00:47:15.250 --> 00:47:15.930
that it's like, okay
1083
00:47:15.930 --> 00:47:17.010
just choose this med first
1084
00:47:17.010 --> 00:47:18.150
or do this thing next like
1085
00:47:18.150 --> 00:47:20.550
but yeah, I mean, it's
1086
00:47:20.550 --> 00:47:23.590
and if we don't fully embody
1087
00:47:23.590 --> 00:47:24.870
and believe the things that we're telling patients
1088
00:47:24.870 --> 00:47:25.690
like look at the research
1089
00:47:25.690 --> 00:47:26.870
and seeing like, okay
1090
00:47:26.870 --> 00:47:28.750
this intervention actually can be helpful
1091
00:47:28.750 --> 00:47:30.070
because I feel like that comes up a lot
1092
00:47:30.070 --> 00:47:31.490
with pain management in general
1093
00:47:31.490 --> 00:47:32.410
where it's like
1094
00:47:32.410 --> 00:47:34.410
everyone just wants to go straight to opiates
1095
00:47:34.410 --> 00:47:35.390
not everyone
1096
00:47:35.390 --> 00:47:36.410
like nobody wants to
1097
00:47:36.410 --> 00:47:37.970
but everybody wants to
1098
00:47:38.430 --> 00:47:39.390
and it's like, oh
1099
00:47:39.390 --> 00:47:40.990
let's talk about heat packs and cold packs
1100
00:47:40.990 --> 00:47:42.430
and so many people like dismiss that
1101
00:47:42.430 --> 00:47:44.070
and it's like, well, there's evidence
1102
00:47:44.070 --> 00:47:44.790
there's research
1103
00:47:44.790 --> 00:47:46.210
like we have to try things
1104
00:47:46.210 --> 00:47:48.530
so, so I
1105
00:47:49.290 --> 00:47:51.090
that's actually a very good thing
1106
00:47:51.090 --> 00:47:52.330
when it comes to like
1107
00:47:52.330 --> 00:47:54.730
the infamous back pain, right?
1108
00:47:54.950 --> 00:47:56.350
Like you just mentioned that
1109
00:47:56.350 --> 00:47:59.510
like heat packs, heat therapy
1110
00:48:00.030 --> 00:48:01.870
but I think when it comes to back pain
1111
00:48:01.870 --> 00:48:03.850
because I know that a lot of
1112
00:48:03.850 --> 00:48:05.810
the questions were related to back pain
1113
00:48:06.570 --> 00:48:08.230
is patient counseling
1114
00:48:09.130 --> 00:48:10.770
and back pain could be a scary thing
1115
00:48:10.770 --> 00:48:11.670
I've had it
1116
00:48:11.670 --> 00:48:12.510
I've had back pain
1117
00:48:13.110 --> 00:48:14.590
and it's debilitating, right?
1118
00:48:14.590 --> 00:48:15.510
And you think, oh my God
1119
00:48:15.510 --> 00:48:16.470
can I get out of my bed?
1120
00:48:16.610 --> 00:48:17.130
I have to stay here?
1121
00:48:17.150 --> 00:48:18.110
No, absolutely not
1122
00:48:18.110 --> 00:48:18.590
on the country
1123
00:48:18.590 --> 00:48:20.030
you actually want to
1124
00:48:20.030 --> 00:48:21.090
get some exercise on
1125
00:48:21.090 --> 00:48:22.270
but the main thing
1126
00:48:22.270 --> 00:48:23.050
with patient counseling
1127
00:48:23.050 --> 00:48:23.650
with back pain
1128
00:48:23.650 --> 00:48:24.750
and also as a clinician
1129
00:48:24.750 --> 00:48:26.810
the understanding should be that
1130
00:48:26.810 --> 00:48:29.870
90% of that acute back pain
1131
00:48:29.870 --> 00:48:30.630
it's going to get better
1132
00:48:30.630 --> 00:48:31.730
it's going to take time
1133
00:48:31.730 --> 00:48:32.730
probably six weeks
1134
00:48:32.730 --> 00:48:34.370
or a little bit more
1135
00:48:34.370 --> 00:48:35.710
but it's going to get better
1136
00:48:35.710 --> 00:48:38.670
and so having that understanding
1137
00:48:39.310 --> 00:48:41.070
it equips you as a clinician
1138
00:48:41.070 --> 00:48:42.430
and also equips patients
1139
00:48:42.430 --> 00:48:43.530
to be patient
1140
00:48:43.530 --> 00:48:45.890
with the healing process
1141
00:48:46.510 --> 00:48:48.150
and not jump right away
1142
00:48:48.150 --> 00:48:49.130
to the opioid
1143
00:48:49.130 --> 00:48:50.070
or something else
1144
00:48:50.070 --> 00:48:51.250
and there's so many other things
1145
00:48:51.250 --> 00:48:52.110
like you said
1146
00:48:52.110 --> 00:48:52.890
healing pack
1147
00:48:54.570 --> 00:48:55.170
acupuncture
1148
00:48:55.170 --> 00:48:56.210
massage
1149
00:48:56.210 --> 00:48:57.990
you know there's gun massage
1150
00:48:57.990 --> 00:48:58.950
massagers out there
1151
00:48:58.950 --> 00:49:00.270
that you can definitely utilize
1152
00:49:01.510 --> 00:49:03.310
and all of that can be done
1153
00:49:03.310 --> 00:49:04.050
the NSAIDs
1154
00:49:04.050 --> 00:49:05.230
actually one of the
1155
00:49:05.230 --> 00:49:06.770
when it comes to treatment plans
1156
00:49:06.770 --> 00:49:07.690
for back pain
1157
00:49:08.270 --> 00:49:09.350
especially for acute
1158
00:49:09.350 --> 00:49:10.710
I like the clothenac
1159
00:49:10.710 --> 00:49:12.850
because that one actually works faster
1160
00:49:12.850 --> 00:49:15.170
and better for the acute episode
1161
00:49:15.810 --> 00:49:17.650
and that is better than
1162
00:49:17.650 --> 00:49:19.270
throwing the opioid
1163
00:49:19.270 --> 00:49:20.250
or the tramadol
1164
00:49:20.250 --> 00:49:21.510
which I so often see
1165
00:49:22.450 --> 00:49:24.870
it's like a little baby step into opiates
1166
00:49:24.870 --> 00:49:25.890
I think people just like
1167
00:49:25.890 --> 00:49:27.050
oh just a little tramadol
1168
00:49:27.050 --> 00:49:27.570
a little codeine
1169
00:49:29.330 --> 00:49:31.310
like can we not though
1170
00:49:32.790 --> 00:49:35.090
I would love to talk to you forever
1171
00:49:35.090 --> 00:49:37.210
I think we do have to wrap unfortunately
1172
00:49:37.210 --> 00:49:39.350
but I think two places to leave off
1173
00:49:39.350 --> 00:49:41.850
I think one is resources
1174
00:49:41.850 --> 00:49:43.250
people are asking about resources
1175
00:49:43.250 --> 00:49:44.890
whether or not they want to become
1176
00:49:44.890 --> 00:49:47.090
a nurse practitioner in orthopedics
1177
00:49:47.090 --> 00:49:49.010
or if they just want to improve
1178
00:49:49.010 --> 00:49:49.990
their orthopedic care
1179
00:49:49.990 --> 00:49:50.830
and primary care
1180
00:49:50.830 --> 00:49:52.790
what resources would you recommend?
1181
00:49:53.470 --> 00:49:56.130
Yeah so I think I mentioned it to you
1182
00:49:56.130 --> 00:49:57.410
when we were talking earlier
1183
00:49:57.410 --> 00:50:00.970
I actually created an entire resource for free
1184
00:50:00.970 --> 00:50:03.930
it's like an orthopedic nurse practitioner guide
1185
00:50:03.930 --> 00:50:05.690
with my top resources
1186
00:50:05.690 --> 00:50:07.050
and this I developed
1187
00:50:07.050 --> 00:50:08.330
when I was doing my
1188
00:50:08.870 --> 00:50:10.570
my board certification in orthopedics
1189
00:50:10.570 --> 00:50:12.150
there's so much out there
1190
00:50:12.150 --> 00:50:13.790
and some of it is phased
1191
00:50:13.790 --> 00:50:14.790
some of it is not
1192
00:50:14.790 --> 00:50:18.650
but I definitely if they go in
1193
00:50:18.650 --> 00:50:21.430
or if we can link the resource guide
1194
00:50:21.430 --> 00:50:22.850
they can download it
1195
00:50:22.850 --> 00:50:24.530
and I have all the links right there
1196
00:50:24.530 --> 00:50:25.650
that they can utilize
1197
00:50:25.650 --> 00:50:28.330
and get their hands on on that
1198
00:50:28.330 --> 00:50:32.250
cool well we don't really have like
1199
00:50:32.250 --> 00:50:33.270
an up-to-date ortho
1200
00:50:33.970 --> 00:50:35.290
I was going to say like
1201
00:50:35.290 --> 00:50:36.650
is there like an app
1202
00:50:36.650 --> 00:50:39.270
or what that thousand page book was
1203
00:50:41.090 --> 00:50:42.630
I'd love to read another
1204
00:50:42.630 --> 00:50:44.590
that was another thousand page book
1205
00:50:44.590 --> 00:50:45.910
like when I came into
1206
00:50:46.790 --> 00:50:48.950
so funny when I came into the specialty
1207
00:50:49.510 --> 00:50:51.530
of course I mean I did my own research
1208
00:50:51.530 --> 00:50:52.830
and that's the book that I found
1209
00:50:52.830 --> 00:50:54.190
I bought it I read it
1210
00:50:54.190 --> 00:50:56.730
and that book was way too much
1211
00:50:57.210 --> 00:50:58.490
for what I should have gotten
1212
00:50:58.490 --> 00:51:02.010
so the book that I recommend is
1213
00:51:02.010 --> 00:51:03.630
I can't remember exactly the name
1214
00:51:03.630 --> 00:51:04.850
but it's multiple skeletal
1215
00:51:04.850 --> 00:51:06.430
and it's the one that is recommended
1216
00:51:06.430 --> 00:51:08.010
for when you're getting
1217
00:51:08.010 --> 00:51:09.090
your board certification
1218
00:51:09.090 --> 00:51:10.170
is by the AOS
1219
00:51:10.950 --> 00:51:13.210
and definitely a great guide
1220
00:51:13.210 --> 00:51:14.910
and it has you want to learn
1221
00:51:14.910 --> 00:51:15.890
about physical therapy
1222
00:51:15.890 --> 00:51:19.230
it has all the physical therapy
1223
00:51:19.830 --> 00:51:21.650
you can imagine
1224
00:51:21.650 --> 00:51:23.730
and how even how to teach it
1225
00:51:23.730 --> 00:51:24.510
and like pamphlets
1226
00:51:24.510 --> 00:51:25.850
that you can give to your patients
1227
00:51:25.850 --> 00:51:29.530
totally yes I love that
1228
00:51:29.530 --> 00:51:31.150
and I just personally speaking
1229
00:51:31.150 --> 00:51:31.990
in primary care
1230
00:51:31.990 --> 00:51:33.230
I'm obsessed with up-to-date
1231
00:51:33.230 --> 00:51:35.490
and Dynamed is another resource too
1232
00:51:36.090 --> 00:51:37.590
there's nothing that's like
1233
00:51:38.390 --> 00:51:39.210
orthopedic in there
1234
00:51:39.210 --> 00:51:41.610
but I think in terms of that diagnostic approach
1235
00:51:41.610 --> 00:51:43.330
of like knee pain
1236
00:51:43.330 --> 00:51:44.630
what location
1237
00:51:44.630 --> 00:51:45.770
what are those differentials
1238
00:51:45.770 --> 00:51:47.210
what are the next steps for imaging
1239
00:51:47.210 --> 00:51:48.090
and the right imaging
1240
00:51:48.090 --> 00:51:50.110
I've not been as successful with maybe
1241
00:51:50.110 --> 00:51:51.350
but that's the another way
1242
00:51:51.350 --> 00:51:52.030
that I've done it
1243
00:51:52.030 --> 00:51:53.290
is like through looking up
1244
00:51:53.290 --> 00:51:54.150
like knee pain
1245
00:51:54.150 --> 00:51:56.230
specifically differentials that way
1246
00:51:56.230 --> 00:51:57.070
for people
1247
00:51:57.070 --> 00:51:58.750
but I'm very excited for them
1248
00:51:58.750 --> 00:52:00.570
to utilize your resources
1249
00:52:00.570 --> 00:52:01.230
so do you want to
1250
00:52:01.230 --> 00:52:01.910
my last question is
1251
00:52:01.910 --> 00:52:03.550
where can people find you
1252
00:52:03.550 --> 00:52:04.830
and learn more from you
1253
00:52:04.830 --> 00:52:06.310
a lot of things coming
1254
00:52:06.310 --> 00:52:08.150
you can share whatever you're not
1255
00:52:08.150 --> 00:52:10.550
but yeah I want to
1256
00:52:10.550 --> 00:52:12.410
well sure thank you
1257
00:52:12.410 --> 00:52:14.050
so yeah so I have
1258
00:52:14.050 --> 00:52:15.230
I have decided
1259
00:52:15.230 --> 00:52:17.030
that I really want to do this
1260
00:52:17.030 --> 00:52:19.810
and so I created my website
1261
00:52:19.810 --> 00:52:23.050
1262
00:52:23.050 --> 00:52:24.530
and so they can go there
1263
00:52:24.530 --> 00:52:25.470
they can click at the bottom
1264
00:52:25.470 --> 00:52:28.550
that I have the orthopedic simple course
1265
00:52:28.550 --> 00:52:29.570
that I'm generating
1266
00:52:29.570 --> 00:52:30.330
I'm creating
1267
00:52:30.330 --> 00:52:32.110
and that's super exciting
1268
00:52:32.110 --> 00:52:33.030
that's in the works
1269
00:52:33.030 --> 00:52:35.130
and then they can download there
1270
00:52:35.130 --> 00:52:37.550
also my ortho MP guy
1271
00:52:37.550 --> 00:52:40.350
also if you just go to my Instagram
1272
00:52:40.350 --> 00:52:43.030
and it's at npinsiders
1273
00:52:43.030 --> 00:52:44.850
and there you can see
1274
00:52:44.850 --> 00:52:46.330
all the resources as well
1275
00:52:46.330 --> 00:52:47.530
I have all the links
1276
00:52:47.530 --> 00:52:48.510
in the link in bio
1277
00:52:48.510 --> 00:52:50.330
and I am definitely
1278
00:52:50.330 --> 00:52:51.570
planning to get serious
1279
00:52:51.570 --> 00:52:53.070
with this whole like
1280
00:52:53.070 --> 00:52:54.290
teaching my MP colleagues
1281
00:52:54.290 --> 00:52:55.650
on social media
1282
00:52:55.650 --> 00:52:57.890
because I think there's such a need
1283
00:52:57.890 --> 00:53:00.310
and I think this collaboration
1284
00:53:00.310 --> 00:53:01.550
is amazing right
1285
00:53:01.550 --> 00:53:03.770
because there's nothing
1286
00:53:04.330 --> 00:53:05.730
there's no better feeling
1287
00:53:05.730 --> 00:53:07.430
that having all this mass knowledge
1288
00:53:07.430 --> 00:53:09.670
and be able to give it away
1289
00:53:09.670 --> 00:53:11.890
you know and share it
1290
00:53:11.890 --> 00:53:15.430
with all the MPs that I know
1291
00:53:15.430 --> 00:53:16.390
or even that I don't know
1292
00:53:16.390 --> 00:53:18.870
or that just happen to find me
1293
00:53:18.870 --> 00:53:19.950
on social media
1294
00:53:19.950 --> 00:53:22.250
because it makes a big difference
1295
00:53:22.250 --> 00:53:24.390
in their lives as clinicians
1296
00:53:24.390 --> 00:53:25.790
and in their patients lives
1297
00:53:25.790 --> 00:53:29.110
so I think that this will be
1298
00:53:29.110 --> 00:53:30.690
something nice and positive
1299
00:53:30.690 --> 00:53:31.250
for everyone
1300
00:53:31.250 --> 00:53:32.610
yes I can't wait
1301
00:53:32.610 --> 00:53:34.570
thank you so much for being here
1302
00:53:34.570 --> 00:53:35.710
you know so many things
1303
00:53:35.710 --> 00:53:36.790
and I can't wait to learn
1304
00:53:36.790 --> 00:53:37.850
more from you
1305
00:53:38.970 --> 00:53:40.870
but yeah thank you so much
1306
00:53:40.870 --> 00:53:41.990
no you're welcome
1307
00:53:41.990 --> 00:53:42.810
it's been my pleasure
1308
00:53:42.810 --> 00:53:43.630
and thank you so much again
1309
00:53:43.630 --> 00:53:44.630
for everything that you're doing
1310
00:53:44.630 --> 00:53:46.230
and anytime you want to have me back
1311
00:53:46.230 --> 00:53:47.230
I'll come back
1312
00:53:47.230 --> 00:53:47.510
awesome
1313
00:53:53.310 --> 00:53:55.190
that's our episode for today
1314
00:53:55.190 --> 00:53:57.130
thank you so much for listening
1315
00:53:57.130 --> 00:53:58.850
make sure you subscribe
1316
00:53:58.850 --> 00:53:59.830
leave a review
1317
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1318
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so together we can help
1319
00:54:03.170 --> 00:54:05.490
as many nurse practitioners as possible
1320
00:54:05.490 --> 00:54:07.430
give the best care to their patients
1321
00:54:07.430 --> 00:54:09.310
if you haven't gotten your copy
1322
00:54:09.310 --> 00:54:10.790
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1323
00:54:10.790 --> 00:54:11.910
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1324
00:54:11.910 --> 00:54:14.590
head over to realworldnp.com
1325
00:54:14.590 --> 00:54:15.470
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1326
00:54:15.470 --> 00:54:17.190
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1327
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1328
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1329
00:54:19.110 --> 00:54:20.550
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1330
00:54:20.550 --> 00:54:21.370
patient stories
1331
00:54:21.370 --> 00:54:22.550
and extra bonuses
1332
00:54:22.550 --> 00:54:23.990
I really just don't share
1333
00:54:23.990 --> 00:54:24.770
anywhere else
1334
00:54:24.770 --> 00:54:26.110
thank you so much again
1335
00:54:26.110 --> 00:54:26.710
for listening
1336
00:54:26.710 --> 00:54:27.370
take care
1337
00:54:27.370 --> 00:54:28.050
and talk soon
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