Medical Decision Making and Referral for New Nurse Practitioners
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Show notes:
Are you referring too much as a new nurse practitioner? I have this conversation a lot with the new nurse practitioners that I mentor.
This is really about two questions: how to make medical decisions, and when’s the “right time” to refer.
When to Refer to a Specialist
In this video, I lay out the three main options you have when it comes to making sound medical decisions, and the moral of the story when it comes to deciding when to refer out.
If you liked this post, also check out:
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well hey there it's liz rohr from real
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world np and you're watching mp practice
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made simple the weekly videos to help
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save you time
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frustration and help you learn faster so
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you can take the best care of your
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patients
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so today it's i want to talk to you
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about referrals
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and like decision making medical
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decision making and how it relates to
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referring
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i feel like this comes a lot with comes
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up a lot with new nurse practitioners
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um that i work with that came up for me
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when i was new but also in the mentees
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that i work with and
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the colleagues that i have um in person
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in real life
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um but uh yeah so so the kind of
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scenario that i'm talking about
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is that a newer nurse practitioner who
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has either weeks or months of experience
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like we graduate with the
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with the foundational knowledge and the
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clinical decision making
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uh skills to be able to continue to
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learn and grow
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nobody regardless of what program you
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went to
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or what profession you're in knows
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everything or will ever know everything
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right
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um so there's always going to be
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learning on the job right and as you go
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and as you see new presentations of
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things especially when they're not a
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textbook presentation
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so the situation that i'm talking about
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is a lot of
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newer nurse practitioners uh
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there's kind of like three main
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scenarios um and especially like as it
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relates to referring so
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i actually made a video about like how
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to know when to refer so definitely
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check that out if you haven't already
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um and i also made another video about
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um
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uh uh how to make a plan of care so if
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you haven't watched
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either of those definitely check those
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out after this video but really what i'm
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talking about
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is when the context is that you're in
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clinic
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you have to see a patient you're going
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to see a patient you have
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maybe two or three waiting you have 10
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to see in a day you have charts to
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finish from the day before you have
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tasks sitting in your inbox right now of
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things that are sent to you today either
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by phone calls
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medication refills the front desk needs
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you the pharmacy needs you the lab needs
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you
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right like i'm not trying to stress you
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out but that's like the main situation
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right
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so this is the context so you're seeing
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a patient they have a chief complaint
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possibly over red eye right i mean i had
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a hard time picking one
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i i i just came up with red eye i don't
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have a succinct
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situation to share with you but i'm just
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going to improvise so
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if you have a chief complaint in front
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of you someone has a red eye
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and we've let we've learned the
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foundations about that right but one of
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the things
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just i'm just going to throw some pearls
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in here throughout this whole video um
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one of the things about um whenever you
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see a patient even if you learn the
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foundational knowledge for me
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and i find this with a lot of other
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clinicians as well i'm gonna remember
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like the most
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important stuff right and i'm gonna file
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that away
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but i'm also going to look things up to
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refresh my memory right because i'm not
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a walking textbook
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i know a lot of i know a lot of stuff
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but um that is the case for most people
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right
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especially to make sure that things
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haven't changed right there aren't
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updated guidelines or recommendations
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you know et cetera et cetera so so and
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this
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is especially true for newer nurse
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practitioners because you're still
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building your arsenal of knowledge and
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you're still
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building on the patients that you've
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seen right and the types of
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presentations that have come up and
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still at five years in
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i see things that i've never seen before
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right so anyway so the context is that
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you have somebody in front of you
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with you know you're fairly familiar
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right with you know a red eye
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i'm able to talk about myself i'm pretty
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familiar with a red eye but you know
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what i just want to make sure i've asked
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all the history questions and all the
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physical exams
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that i need to do and like figured out
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what those worst case scenarios right
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so you kind of have like three options
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so one and i talk about this and how to
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make a plan of care i usually excuse
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myself if i have to like
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do some reading and investigation i have
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no affiliation with up to date but that
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is
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what my my main go-to resource and so i
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will you know kind of look on up-to-date
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figure all that information out take
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some time to do a little bit of a deeper
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dive on that particular topic
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you know just to either refresh or even
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if it's a brand new thing that you
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haven't seen before
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right because we all have those right um
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uh doing a deep dive on there versus in
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that
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same context of the chaos of clinic life
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and it's especially a presentation
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that's not even matching up with the
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things that you've kind of
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done the work yourself in terms of
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looking things up and you're not quite
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exactly
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sure what you should do which is the
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safest option like
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where you know what to go next you can
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ask scenario one is like you do
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you do the deep dive you feel confident
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with what you have found
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you're basing it off your clinical
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judgment your foundations of knowledge
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the patient experience you have
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versus you know what i just i really
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want to ask someone just to be sure
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or i need some help because i just i am
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up to my eyeballs
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right now that i just need i need some
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more help i just i need a little bit of
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a shortcut here especially as it relates
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to the non-textbook quote unquote
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presentations that involve off book
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clinical judgment right
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um option three is
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um choosing when to if they need a
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referral or not so do you make the plan
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of care yourself
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uh or do you decide the treatment
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yourself or do you feel like they need a
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further referral
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so i want to pause here and say that a
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lot of newer nurse practitioners that i
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work with
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have a big concern about this right
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we're all very concerned about utilizing
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medical resources in the best way
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possible um you know not over ordering
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tests not over referring not ordering
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too many medications like things like
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that and so there's a really big concern
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about when should i refer
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which also reminds me i have a video
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about that if you haven't watched that
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already definitely check it out
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my top tip for figuring out if you
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should refer somebody
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however i want to just pause here and do
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do some normalizing i hope this whole
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video is normalizing for your lived
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experience as a nurse practitioner or
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soon to be a nurse practitioner
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experience but like
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i don't me personally i don't have any
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judgments about referrals
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my main like judgment if i have one is
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like are you giving safe care and that's
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like
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kind of the moral of the story of what
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i'm pointing towards here is that
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despite whatever avenue you take the
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best
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thing is the safest thing right and you
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might aspire
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as it comes to referrals like
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there is a style there there are
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guidelines there is like the quote you
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know like
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there are wrong things to do you know
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there's there are harmful things to do
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but also within the guidelines of what's
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recommended
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they're stylistic choices right so like
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and and i think that's one of the other
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things that people adjust to as they're
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newer in practice of like there's one
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right way to do things but spoiler alert
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there isn't necessarily one right way
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you know there's a wrong way
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definitely there's a wrong way but like
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in terms of the right ways there's
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multiple ways to do it so as it relates
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to referrals in particular
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like my personal perspective and
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paradigm of practice and desire
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is that i'm going to maximize my scope
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in primary care especially in the
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context of taking care of patients who
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don't necessarily have the resources
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that maybe some other patients do or
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they don't have insurance or something
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like that right so i'm going to try to
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do the best that i can for them
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to keep them in house with all of that
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before referring but other clinicians
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with as much or more experience than me
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physicians nurse practitioners and
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physician assistants
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have a different perspective where they
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are more likely to refer earlier on
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and i just i just really believe that
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there is there is a spectrum here
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because i think that there's a little
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bit of a conversation about that and
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there's a lot of worry about that of
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like
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am i referring too much right um but
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again moral of the story
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is like what are we working with here
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right and i think one other thing i want
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to mention about that in terms of those
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like avenues of of
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of decision making right if you're doing
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the deep dive route and you feel
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confident
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making that decision that you're doing
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the safest care possible right now
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absolutely amazing
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right um or if you feel like you wanted
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to ask somebody
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or if you did that and ask somebody and
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you refer them like that's fine too like
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all of these are fine
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right but also like for me personally
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when i was a newer grad
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i read constantly i came in early i
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stayed late i was reading on the
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weekends
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on the in the evenings at night i
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constantly worked right my brain
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physically hurt because i couldn't i
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couldn't read anymore because my brain
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physically hurt and i still remember
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that
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feeling in my brain and i get it
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sometimes when i'm reading about medical
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things right
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because i still read all the time
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because that's what our job is but um
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i think i just want to normalize that
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like there's there's an experience that
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a lot of people have where they have
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this list
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of all the things that i should know
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about i should know about already
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and and coming back to patient safety
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like what's most important is knowing
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about what you're dealing with right now
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right and there are foundational aspects
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so like if you if you're like oh i
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should really know about ckd like yeah
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like let's go home and read about ckd
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because that influences your patients
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all of your patients with ckd
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right but like there's some day and then
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there's today
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right of like exactly what you're
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looking at and and working within those
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confines right um
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and and always coming back to what is
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the safest possible care for this
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patient
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keeping in mind like work life balance
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patient safety like all of those things
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right so
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i don't know this maybe just going off
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on this video
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but i feel like this is this this
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situation comes up a lot
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for newer nurse practitioners so again
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if you want further information
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actually three video recommendations one
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is how to make a plan of care
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i'll link to all of these down below two
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is
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how to know when to refer which more
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more clarification on that
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uh and uh my favorite tool and number
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three
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is the um oh gosh how to ask questions
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in the most productive way possible i
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won't give away too much in that
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just check that video out definitely
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because you'll you'll get a sneak sneak
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preview or or
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or view of what i used to uh be like i
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was i was a little bit of a mess when i
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was a new grad so
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anyway hopefully that will be helpful
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but um
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but yeah please let me know what
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questions you have and if you haven't
9:54
grabbed the ultimate resource guide for
9:55
the new np
9:56
head over to realworldnp.com guide um
9:59
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in there and i'll see you soon
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you
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