How to Know When to Refer to a Specialist: #1 Tip for New Grad NPs
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Show notes:
A major stressor for new nurse practitioners is whether or not they are referring out too much from primary care to specialists. It's a challenging part of the role transition from RN to NP to get a handle on what belongs to primary care and what should be seen in primary care.
As a new nurse practitioner, it's super normal to be asking questions like: When should you refer to a specialist? Are there other tests you could do first? Should you wait it out? At what point can you be sure?
This episode is a must-watch for all new grad nurse practitioners and nurse practitioner students!
When to Refer to a Specialist from Primary Care
In this video is my NUMBER ONE strategy to help you:
Feel more confident with your referrals
Deepen and broaden your knowledge base
Take excellent care of your patients
The step-by-step to do it and pitfalls to avoid (that I made...)
Any guesses?
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WEBVTT
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Hey there. Welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable and take the best care of their patients. If you're looking
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for clinical pearls and practice tips without the fluff, you're in the right place. Make
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sure you subscribe and leave a review so you won't miss an episode. Plus, you'll find
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links to all the episodes with extra goodies over at RealWorldNP.com slash podcast.
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So you're ever unsure about whether or not to refer your patient or you're really
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sure that you need to refer out your patient, but they don't want to go. This video
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is for you. So I'm going to be sharing one resource in particular that's going
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to help you feel really confident about your referrals, deepen and broaden your knowledge
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base and help you take really excellent care of your patients. If you're new here,
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I'm Liz Rohr from Real World NP and you're watching NP Practice Made Simple,
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the weekly videos to help save you time, frustration and help you learn faster so you
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can take the best care of your patients. That's what we all want, right? So before
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I jump in, for example, you have a patient who is 57 who hasn't had healthcare in about
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10 years. And last week you did an established care visit with him. You did some blood tests
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for him and his white blood cell count was 25. You checked it again today,
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about a week later, and it's still at 25. So if you haven't watched the high
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white blood cell count video, definitely go back and watch that. You can kind of go
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through this step by step, but there are certain scenarios which might be a little
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bit unclear. So you've gone through all of your things. You repeated the test,
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you did the differential, you did the peripheral smear. He doesn't take any
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medications. You don't know if he has any medical history because he hasn't been to
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the doctor. This is it. That's kind of like leaves you in a scenario of like,
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should I refer them out or should I keep them in house? Are there other tests that
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they would recommend, et cetera, et cetera? So the one resource that I recommend is
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something I refer to as cold calling. And so what it literally means is you pick up
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the phone and you call a specialist. So before you turn this off, run away screaming,
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maybe not screaming, but run away horrified, stick with me because, you know,
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your first thought might be that there's no way that I'm doing that, which is
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fine. But again, stick with me. But if you feel like, okay, maybe I could do
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that, I'll stick around. Step two, or the thought two might be, how would I
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even go about doing that? What would I say? That's overwhelming. So this is
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what I'm going to, that's what I'm going to talk about in this video. So
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I'm going to break it down step by step, exactly what to do applying it
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to this case, hypothetical case, and literally this, the words that you would
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use and the information that you would get from doing this. So I think most
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people are afraid to do this because they're worried that they're going to
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call and that someone is going to yell at them and make them feel stupid
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and they're going to be really embarrassed. So I'm not going to tell
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you that that's never going to happen. It definitely happened to me like one
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time out of the like, feels like hundreds of calls that I've made. And
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I'll talk about pitfalls and what to avoid to help you avoid that. But I
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mean, worst case scenario, your ego gets a little bit bruised, right? But
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your goal here is to take really good care of your patients and to expand
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your knowledge base. So it's a tiny risk. But again, we'll just follow
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my steps and you can kind of avoid that. So step one, that's the thing
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that most people are afraid of, right? Someone's going to yell at them
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or get upset. Option number two, outcome number two, is that it will be
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a neutral experience because this is not just me that recommends doing
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this. This is the specialists themselves that experienced physicians
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talk with experienced physicians and do the exact same thing. So this is
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not again, this is not rocket science is not something that I've come up
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with on my own. It's just expected and specialists have told me that
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right. So so it's a neutral experience because again, it's expected or a
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possible outcome. A third possible outcome is that it's awesome and
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that the specialist says thank you so much for calling me. I love this
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referral. I love this question. I love to teach. Here is my personal
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email, my personal phone number, cell phone number, right? That
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hasn't happened all the time. But it's definitely happened a number
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of times where I got like an arsenal of specialists that I like held onto
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at my last job. I'm still building them now in my new job. Keeping those
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possible outcomes in mind. What is it? What steps do you do? So
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literally one, two, three. So step one, what you're going to do is
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look and see what specialists your office typically refers to. And
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what I mean by that is that my clinic in particular is community
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health. And I have some restrictions about insurances and
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different places that patients can go based on transportation and
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again, mostly insurance. And so looking at those possible options. So
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example, in this case is not a real doctor, a real case, but Dr.
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Weinstein is at the practice that we typically refer to in
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hematology. So identifying their office, getting a sense of that.
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Step number two is getting your ducks in a row. And what I mean
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by that is two different things. Number one, you always want to
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get all of the data together, right? You want to think about
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your case presentation. If you haven't watched the how to ask
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questions the right way video, definitely go back and watch that
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as well, because that really helps you set up. It talks about
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the mistakes that I made as a nurse practitioner. And then I
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still see a lot of new nurse practitioners make in terms of
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communication with specialists and with other colleagues and
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things like that, and how to ask questions in the right way
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to help, you know, answer the questions that you're
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looking for, right? So definitely go back and watch that. But
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getting your ducks in a row in terms of like, all of the
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data, right? So again, case presentation, 57 year old
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man, no past medical history, no medications. The last time
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he was here was to see my doctor was 10 years ago, I
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have no records. And then here, here's the data that I
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have. So I have a blood cell count of 25 persistently normal
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differential and normal smear. Again, go back and watch
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that high blood cell count video. I'm not getting into
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all those details here. But you can go back and watch
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that. And so those are all your details. And then the
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other part of getting your ducks in a row is kind of
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doing your first pass going through of like, have I asked
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all the right questions? Have I done the tests that I
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think that I can do in primary care? And then also
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just running it by your colleagues, right? Or your
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supervisor. It depends on like your access and who you
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can kind of ask. But those are kind of like the
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preparing part. And then the third thing is to call
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them. But before you freak out, I'll talk about that a
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little bit further, the step by step for that when you
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figure out it's time to call them. Most of the time
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you're going to get the front desk, you're not going
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to go right to the doctor, right? So it's okay, just
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take a deep breath. They might want to transfer you
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right to their desk phone, they might want to
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transfer you to their voicemail, they might want
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to page the doctor for you. I typically don't recommend
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doing that unless it's urgent, or unless they
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specifically have requested that of anybody who calls
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because they might be in the hospital setting. And
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is this urgent, you have to decide that for yourself.
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Most of the time, though, what you're going to do
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is talk to one of their team members. And then
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the way that the specialist office is set up
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differently, depending on your state, depending on
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your area, things like that. But you could either
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have your specialist physician working with a
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medical assistant. You could have the specialist
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who has an NP and PA team that works with them
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that kind of alternates seeing patients with them
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every other time that that patient comes to the
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visit. That's at least how they do it in
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Massachusetts for the most part. Or they might have
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a nurse that works in the office that kind of like
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fields calls, right. And so you can just ask the
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front desk. Hey, so this is literally what you can
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say. Hey, this is Liz Brewer. I'm a nurse practitioner.
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I'm calling from Boston Community Health Center.
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It's not where I work, but I'm calling from
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Boston Community Health Center. I have a patient
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that I'm concerned about, and I'm deciding whether
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or not I should send them for a referral if
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there are other tests that Dr. Weinstein would
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recommend before sending them. And so I'd love to
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speak with her or someone from her team. How
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do you typically do that when primary care
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clinicians call in? I'd love to leave a message in
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the voicemail. It's nothing urgent, etc., etc. And
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they can kind of like let you know. And if
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they are not expecting it, then that's unusual
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because this is what happens, right. Or they
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can give you all those options to page them,
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leave a voicemail, talk to the nurse, talk to
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the assistant, etc., etc. And then they will
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kind of like review the case and then get
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back to you. So I usually recommend leaving
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some sort of message because it doesn't, I
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don't know. I don't like putting people on the
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spot, right. And it gives them time to do it
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on their own time. And again, you're keeping this
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in mind that this is actually kind of doing
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them a favor. It's giving them business,
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right. Because and it's also making sure that
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it's an appropriate referral, right. And if
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it's not, then they'll let you know. So
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that's basically how it goes. You identify
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the office, you get your ducks in rail, you
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present your case, and then they call back
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with their answer or they call back to
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discuss with you. A couple of pitfalls to
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avoid. I was spoken to not very kindly
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one time. And really what happened is that
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if you're on the email list, you probably
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heard this before, but I did not trust my
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judgment about a third trimester pregnant
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woman's murmur as being physiologically
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normal. And it was. And the OBG ran that I
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cold called and left a message. He called
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me back and was not very happy that I
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called him in the first place and that I
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should probably should have run it by one
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of my colleagues first. But anyway, long
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story there, but it is what it is. And
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it was related to that person's specific
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style of communication because I met him
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in person later. He had no recollection,
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kind of had the same tone about him. So
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think that was just his own thing. But
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anyway, to avoid that is kind of like,
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again, getting your ducks all in a row
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and making sure that you're consulting
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with your supervisor or your colleagues
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first. Another pitfall to avoid is
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apologizing. Do not apologize because
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again, this is just standard primary
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care, right? Hi, this is Liz Rohr calling
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from blah, blah, blah, blah. Here's my
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question. Oh, I'm so sorry for
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bothering you. Don't. No apologizing.
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You're a nurse practitioner now. This is
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normal. This is what they expect. This
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is literally what they expect and they
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ask. I've asked them before about
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what about a patient who has this and
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this just trying to like, you know,
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making these videos and advising, you
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know, just call, just call them, just
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call your specialist. That's our episode
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for today. Thank you so much for
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listening. Make sure you subscribe,
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leave a review and tell all your NP
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Thank you so much again for listening.
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Take care and talk soon.
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