Transcript: Diabetes Case Study in Mentorship for Nurse Practitioners

Liz Rohr:

Hey, there. Welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational company for nurse practitioners in primary care. I'm on a mission to equip and guide new nurse practitioners so that they can feel confident, capable, and take the best care of their patients. If you're looking for clinical pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and leave a review so you won't miss an episode. Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com/podcast.

 

Liz Rohr:

Hello, and happy new year. Welcome to 2022. This is the first episode of the year for us at Real World NP. I'm actually mixing things up a little bit today with this episode. Typically, I record a video and post to the podcast with the same episode every week. However, because Omicron is surging and childcare is a little bit variable because of coronavirus, I am going to be doing just podcast for maybe just this week or maybe for the next couple of weeks. We'll see. We'll see.

 

Liz Rohr:

But recently, I'm actually in the process of expanding mentorship, and I've been interviewing nurse practitioner candidates to join the Real World NP team. And we were discussing a case study, like an example of what mentees bring to me, so that we can just have a conversation about it. And it occurred to me, that if I was a new grad, it would be really helpful for me to hear this, the types of case studies that mentees are bringing for Real World NP.

 

Liz Rohr:

So, in this episode, I'm going to be talking about a case study, a real-world, real-life case study that nurse practitioners bring to me and a behind the scenes of talking about the conversations and the thought process behind the management. I love me some diagnostic algorithms, so when it comes to diabetes, like what to do first, next, next, next, next, that kind of thing. This is a case study that has a patient who has diabetes, but it's less of a focus on the diagnostic algorithm and more of a focus on just holistic general management in the real world. All of that stuff applies. All of the diagnostic algorithms apply, but I think one of the things that is so unique about these conversations that I have with mentees is that there's so much more to it than just those diagnostic algorithms.

 

Liz Rohr:

Just for context before we jump in, the context here is that if you aren't familiar, through Real World NP, the company, the medical education company that is a Real World NP, I take clients. I take one-on-one nurse practitioner mentees, and they sign up to work with me. And we do one-hour phone calls for about 12 weeks, three to six months, depending on the preference of the person. What we do is discuss cases, pretty much whatever they feel like they need support with. I guess to step back a little bit even further is that when I was a new grad nurse practitioner, the dream solution that I wanted for my problem was that I wanted this safe space with an experienced clinician, nurse practitioner, physician, et cetera, any provider, who gave their full time and attention to discuss cases and issues I was having, and quite honestly, to answer the questions I felt too dumb to ask.

 

Liz Rohr:

And I wanted to talk with somebody who wasn't going to make me feel stupid. Real talk. And this is what I've heard over and over again, the same kind of desire for other nurse practitioners. So, that's what I do. That's what the mentor calls are. They're just an hour of safe space time. They don't have to do anything in this formalized case presentation, buttoned up, perfectly done, and presented way. They can literally just show up to the call with no preparation. They just say the things that they want to say. They can talk about a case. They can just brain dump it out, word vomit it out, and then, we work through it and see what is most supportive for them.

 

Liz Rohr:

And just to, again, a little bit of context is that the three main things that we cover when it comes to these mentoring conversations, the first one is usually, it's a reassurance type of question, where they've taken an action. They're discussing all of these cases after the fact, not in real time. In the clinic, it's just like, this is what I saw this week. They want to know that they did the right thing and to see if they were missing anything because they don't know what they don't know. None of us know what we don't know until we learn. And so, there's so much experiential learning that is you something you can't learn from a textbook. So, that's what they're really looking for.

 

Liz Rohr:

The second thing is that they just need a brain break. And what I mean by that is that they will read about cases. They'll see patients in the clinic. And pretty much with every patient, they have to look something up. I've certainly found this to be true when I was a new grad nurse practitioner that every single patient, when I wasn't seeing patients or managing my inbox, I was glued to the resource, UpToDate. And I'm not affiliated with them in any way. It's just my favorite resource. I just remember, I had a mentor, and her name was [Christina 00:05:42]. And sometimes, I knew the resources to consult, and I knew what I could do on my own, but my brain just physically hurt so much from all of this new things that I was learning and doing that I would just need a brain break sometimes.

 

Liz Rohr:

And I'd be like, "Christina, I know I can look this up, but can you just tell me what I should do with this?" Because most of the time she'd be like, "Well, what do you think? Look it up." Yeah. That's the other thing is that there's total permission to be like, "You know what? Can you just give me some information here? Because my brain hurts. I know I can look this up, but I'm exhausted." So, that's one. One is reassurance. Two is they need a brain break, and they're just looking for information.

 

Liz Rohr:

Number three is that they come to me with those first two. And then, the third thing is actually the role development process that you learn about as a student, but you can't really see it until you've gotten into it. I'm going to talk about those pieces with this case, but it's almost like the things they want and the things they need might be a little bit different. I'll definitely do the things that they want with the reassurance conversations and information giving. But also, there's further discussions about... You'll see, you'll see. Hang tight. Anyway, so that's the context of this episode is that these are the types of conversations that I'm having with new grads. And just to also give you a real life case that I can walk you through the process of how we talk about them. And then, just as an example of what it's like.

 

Liz Rohr:

And so, hopefully you can apply this methodology, whether or not you are a new grad and you're trying to mentor yourself through it if you don't have a support. And or if you are starting to precept students or mentor new grads yourself and you're listening to this channel, this will hopefully help you too. And actually, before we jump in, I'm super psyched. Currently, I've only ever done one-on-one mentoring like I described. And there's so much demand that I am only one person and I cannot fulfill, which hurts my heart a little bit. So, we're actually working on expanding mentorship. Like I said, I'm interviewing candidates, and I'm just so excited. If you are looking for mentorship, definitely go over to the wait list. That's the first come, first served, best way to learn about opportunities coming up this year. It's at realworldnp.com/mentoring. And that way, you can get on the email list, and you'll be notified first available.

 

Liz Rohr:

Anyway, let's jump into this case. This is a real... The other thing I love about this is that you can't make this stuff up. You could, but yikes. This is real life. This is an example of a question of a case that a mentee brought to me. And she works in a federally-qualified health center, which is my background as well. I love federally-qualified health center settings. I've only ever done that, but I don't think I'm ever going to leave. This is a 38-year-old female, and she has a long history of diabetes, longstanding history of diabetes. Her A1C is 14%. She also has a past medical history of gastroparesis. And if you aren't familiar with gastroparesis, I definitely recommend you read about it.

 

Liz Rohr:

And the very brief overview is that it affects longstanding diabetes can cause damage to many parts of the body, of course, but it can lead to gastroparesis where there is a slowing down of the peristalsis. Gastric emptying can cause abdominal pain, and bloating, and things like that. Lots of other things. Anyway, this person has gastroparesis as a complication of her diabetes. And she came to the visit for a follow-up, but also, with a chief complaint of abdominal pain. And she said that it was basically the same gastroparesis pain she's always had, but it just feels worse. And the other pieces of information that this mentee gave to me were that this is a single mom who has three children, and because of the abdominal pain and the diabetes, she wants to make sure that she doesn't want to become hypoglycemic. But because her stomach hurts, she has a hard time eating.

 

Liz Rohr:

And so, what she's doing is snacking on candy basically all day to keep her blood sugar from dropping. And she's not really able to eat real meals right now. I told this to a colleague, and she was absolutely horrified. As it kind of is. It's a really tragic, horrible situation that is real life. You may or may not see stuff like this in your setting. It really depends on the level of complexity of your average patient. But yeah, this is real life. So, this is the information the mentee gave me. And then, she followed with a question of, where do I even start? And I want to pause here and say that this is a fair case presentation. I've gotten a lot of context, a lot of history, a lot of life context for this patient. I still have more questions.

 

Liz Rohr:

But again, the context of mentoring is that it's fine. All of it is welcome. And I'm here to help support them, and lower the anxiety, and walk through a case, and help them. If they don't know what the questions are, the further information to provide is, we're going to talk through the case, and I will ask questions so that they will know next time to ask those questions themselves or give that to me as a presentation. Or if they forget, that's totally fine. And maybe, they knew it all along. They're like, "Oh, I forgot." I'm just like, "My brain is not working well right now because I'm so anxious."

 

Liz Rohr:

So, here's how this typically goes in these conversations. Again, remembering that most people are coming for number one, reassurance, of did I do it right? Did I miss anything? Am I going to hurt them, this patient? Or they're looking for information because their brain hurts so bad that they just don't even know what to do. They don't even have the capacity to consult their resources. Or maybe they don't know what their resources are. So, the first thing I do in a case like this is validate a number of things. Number one is the feelings. That's a huge part of what I do with Real World NP, of all the content that I make and the services that I provide, is that it's not just about the medicine. It's about the role transition, both personally and the other holistic components of becoming a nurse practitioner, which I'll talk about in a sec.

 

Liz Rohr:

But first is the validation of the feelings part because this is an overwhelming case. It's overwhelming to be a new NP. They're likely very anxious. I can just tell from the way the person's talking that they're incredibly anxious. And I just want to validate, wow, this is a really tough case. You did a great job with your case presentation because they did. That's really great amount of information that you got. Not only did you give me a lot of information about the medical condition, but also, about the person's life context. They're doing a good job. And the other thing to validate is the underlying question that most new grads have is what's normal for primary care? Is this normal? Is this like a regular case? Do you see cases like this? Would you manage this? Would you send this person to a specialist? Would you send this person to see the physician, your collaborating physician instead of you seeing them? What should I know? What should I know already What don't I know?

 

Liz Rohr:

And then, there's all the feelings that come in with that, the inadequacy feelings that a lot of new grads have. That's usually where I start. I'm like, "You know what? This is a really tough case." And depending on, and this is, I don't want this to be too sprawling of an episode, but there's one of the things that I'm realizing, as I continue on in my practice, is there's a philosophy of practice. There's your personal comfort level and desire for what type of nurse practitioner you want to be. For me, I love complex cases, love them. That's my jam. So, I'm comfortable with this. I'm comfortable with maxing out my scope of practice. And also, there are people who are not comfortable with that. And regardless of the number of years of experience, will never want to deal with complex cases like that. They really like the bread and butter of primary care and like the regular stuff.

 

Liz Rohr:

So, that's another thing. That's part of that validating conversation of, you know what? Yeah, I totally see patients like this, not all the time, but enough, especially with diabetes at an A1C of 14, I see this all the time. This is a complex case though. Life is complex. The medical conditions are complex. And this is up to your comfort level, which may evolve over time, especially as you're brand new. And as you get more experience, you might decide, hey, I love cases like this. I just need more experience. And maybe for now, I'm going to get some help. Versus later on, I'm going to keep them as long as I can because I love that. Anyway, so validation is number one.

 

Liz Rohr:

And then, the next piece is more questions. There's always more questions. And I think because people, they're learning, or they're anxious, or whatever, or it's just a brain dumping safe space, whatever. Let's ask some more questions. For this case, I have some more questions. And this helps not only if mentees might just not remember in the moment that they already have that piece of information and they just didn't share it with me, but it also helps them learn as they go, what questions they need to ask for each chief complaint going forward. And so, if they presented a chunk of information to me, next time, they'll probably learn, oh, okay, she's going to ask me this question every single time I bring up a patient with diabetes.

 

Liz Rohr:

And then, the other thing I want to say about more questions is that another theme of new grads is that, again, all of this is based on my experience too, as a new grad myself, as a very stubborn, overwhelmed, anxious nurse practitioner, new grad, and there's a tendency to hyper focus on the fix. So, that's what I was alluding to, is that there's this next level, aside from information and reassurance, that there's this, it's not just about fixing problems. It's not just about what medication do I use for that A1C of 14? It's about this holistic level to your practice, which evolves over time.

 

Liz Rohr:

Anyway, so you typically have more questions for them for this case. Before I get into the nitty gritty of it, the two other places that I go after I ask those questions of more details, I usually ask them what they think. In this case, so this person didn't necessarily share with me from the outset what they did as an example. In real life, they did. But in this example, it was a word vomit of what should I do? Where do I even start? But then, I asked them, what do you think? And most people... Myself, I'll just speak for myself. When I was a new grad, I hated that. I just wanted them to tell me what to do. I wanted them to tell me one right way. What was the right way? Tell me how to do it. And they were like, "No, Liz, you, what do you think? You know more than you give yourself credit for. What do you think?"

 

Liz Rohr:

And then, when I ask mentees that, it helps explain their thought process. It helps me understand what their thought process is because they walk me through what they did. And then, I can clarify, of course, what they were thinking when they did that, and why, and where the gaps are. If they didn't know why. They're like, "I don't know. Someone told me to do it." And then, we can get into that if that's the focus of the call. It also helps build their confidence. Because again, most new grads know more than they think, but it's really, you just want validation. You want to know you did it the right way.

 

Liz Rohr:

And then, I usually also ask, what are they worried about? What questions do they have for me? And what are their main concerns here? Just to get really more specific. Because if they're just looking for reassurance versus do they have gaps in their knowledge, they want me to help them with their brain break of just telling them stuff, I'm very happy to go into telling stuff, but I have to be mindful of what the people want. Let's get back to this case. Let's get back to this case.

 

Liz Rohr:

This 38-year-old female, A1C of 14, chief complaint of abdominal pain, as well as gastroparesis, as well as some significant social things that are going on. Similar to other videos that I've made, when it comes to the very specific chief complaint with diagnostic algorithm episodes, same thing. And maybe I sound like a broken record if you've been here for a while, but it's always a triage-based safety-first approach. And so, I usually, again, depending on the answers to all of those questions of where we've gone in this mentoring conversation, these are the types of things that we'll focus on. So, the questions I have in that triage-based approach of safety first, what are the absolute worst case scenarios here? What are the red flags? How would you know? I break it down by a problem.

 

Liz Rohr:

So, diabetes specific, let's start with those red flags. Again, if they have volunteered this, awesome. If they haven't, then I will walk them through my process if they don't have their own process as an example that they can use. They don't have to use my process. Let's talk about diabetes. Usually, I'll say, "You know what? Diabetes first. Let's just break it down by problem." What are the safety things for diabetes assessment? What medications did this person take? Did they have a point of care, blood sugar level at the visit? That's usually one of the things in terms of a triage.

 

Liz Rohr:

Because we want to know what their labs were and what symptoms they have, like where are we going with these lines of questioning? I'm looking at the worst case scenario. That's information that leads me to that worst case scenario. Hyperosmolar, hyperglycemic syndrome, HHS or DKA, diabetic ketoacidosis, which leads you, again, to that question of, do they have type one or type two? Do you know? How would you know? It's a whole can worms. That's why these are hour-long conversations.

 

Liz Rohr:

Anyway, first things first, safety first. What meds is this person taking? When were their last labs? What symptoms do they have? What is their risk for the worst case scenario here for hos needing hospitalization because of the hyperglycemia? And then, the next level, again, on that safety first is that's problem specific, meaning the diabetes. And then, the holistic life specific, they're related in this section of questions. Does the patient have a glucometer? And do they know the symptoms of hyper and hypoglycemia? Let's start with those.

 

Liz Rohr:

And then, when it comes to diabetes on the next level of triage, we could get into history of the diabetes, regular maintenance questions, like what was the date of their diagnosis? Because again, that influences the medication problem fix. Have they seen a specialist? When did they last see them? What about their maintenance stuff? Microalbumin, eye exam, et cetera. And I'm just going to let you know, in my personal practice, especially as a new grad, already, this is like, wow, that's a lot of information together and a lot of things to talk about.

 

Liz Rohr:

The more things I address with the patient, the more overwhelmed they get, and the more they forget. It's just anecdotal, real world experience. Unlikely, for this person, if I'm a new grad and I'm just meeting them, I'm not going to ask those questions. Maybe as I'm charting, I can look at that. But the way I'm going to manage it, because as you can see, this is already becoming an enormously complex visit, I'm going to focus on safety and triage and bring her back sooner. That's how I manage patients like this, especially if I'm just meeting them.

 

Liz Rohr:

Let's delve into the abdominal pain specific. Again, triage-based approach. What is the worst case scenario for this person's abdominal pain? Some sort of obstruction, some sort of acute abdomen situation. Is there some sort of perforation because they have a blockage, and there was a bowel per... Who knows? Because of the gastroparesis. Is it could be something that's not gastroparesis? Because that's another pitfall that I had as a new grad is that people would say, "Oh, I have this thing, and it's from this." And I'd be like, "Oh, okay, sure." But our job is to be skeptical and to assume the worst. That's literally our job. And it's not that we're not believing them, but it's like, "It's on us."

 

Liz Rohr:

So, you're going to take it with a grain of salt. "Oh, that sounds like it's like the chronic pain that you've always had, but I do have other questions to make sure we're not missing anything." That's how I phrase it to patients. So, we'll go through it with the mentee. And again, this isn't a question basis, but since this is a one-sided conversation where I'm just sharing, these are the types of things that we would talk about. I'm actually hoping maybe someday, that a mentee will let me record our call, and then, I can share it with you. But I don't know. Most people are really private. We'll see. We'll see.

 

Liz Rohr:

But anyway, so when it comes to abdominal pain, again, triage-based approach, what are their symptoms? Following that old cart methodology, onset, location, duration characteristics. What are those red flags for abdominal pain? Doing that full ROS specific to abdominal pain chief complaints. GI, GU cardiac, respiratory, et cetera. And then, again, these are the problem focused versus the holistic solution type of thing. Hopefully, this is making sense where I'm going with this.

 

Liz Rohr:

And then, the next level you can do in that focused problem-based solution is what diagnostic testing have they had? What was the date of their diagnosis? What's been the trajectory since their diagnosis? What things have happened? What medications have they tried, et cetera? What specialists did they see, and when did they last see them? That's safety first, focusing on the problems, which leads to the suggestions of treatment, which is where most new grads want to go. Most new grads, for this type of case, are like, "Hey, their diabetes is 14. What medication should I prescribe?"

 

Liz Rohr:

But clearly, as you've listened to this episode, there is a lot more information we need to know before we even touch the solution. That's focusing on the problems, the specific diabetes and abdominal pain problem. But I want to tell you about the next thing I want to shift to is when I was interviewing the NP mentors, it was pretty cool because it was very validating for me, even, talking to them and seeing their line of thinking and thought process when I presented this case to them.

 

Liz Rohr:

Because the reality is the first step of becoming a nurse practitioner and being a new grad is all of those problem-specific medical management, diagnostic algorithms, this, this, this, and this. Learning that stuff, you learn in school, and then, you reinforce on the job. But the next level is all the stuff that makes a real change for patients. Because we could stop right here and say with this case, no red flags. I suspect that it's her chronic gastroparesis, but I'm worried about an obstruction, so I'm going to get a KUB, I'm going to get abdominal x-ray to see if there's any fluid levels, and stool impact, stuff like that. You could decide and like, "Okay, I'm going to go from there."

 

Liz Rohr:

However, as you develop in your practice, you can add this next level on. These are the things that I did not want to hear as a new grad. I just wanted to hear about the diagnostic algorithms. And I was like, "Yeah, yeah, yeah. Whatever," when we would talk about this part. I guess I'm just trying to be transparent here. But now that I'm an experienced NP, it's like, we all agree that obviously, everyone has different practices. But for the most, everyone agrees that this is where the change comes.

 

Liz Rohr:

So, the next steps are the holistic perspective. Now that I have more of the diabetes management stuff down in terms of the diagnostic algorithms, medications, et cetera, I know that if I give a medication, if I throw a glucometer, a medication at somebody, that's asking for it not to be done. Because there's so much more that the patients need. The next questions I have for patients are about, what's going on? What's this bigger picture? If you can practice as a new grad, again, giving yourself grace because your focus is learning the medicine, and this will develop over years. But this is the magic of mentorship is that we get to talk about these things, and hopefully, this will help you think in this way a little bit more and practice thinking this way. Not perfection, just practice.

 

Liz Rohr:

Okay. So, what's going on? This is what I say to the patients. Tell me about... That sounds really hard. Validation again. That sounds really hard. Like, tell me about more what's going on. Who do they live with? What's going on with them eating candy? Instead of making assumptions, I'm going to assume it's because of the stomach pain, but does she have any barriers to accessing... Does she have enough money to feed her kids? Does she prioritize feeding her kids, and that's all she can afford for herself? Does she feel depressed about her diabetes and feels hopeless, and so, she doesn't feel like she can do any of the things that she's been asked to do or told to do? What is her knowledge base? What does she understand about her diabetes? So that to figure out what's driving her. Because if she feels depressed and hopeless, and she's not motivated or doesn't understand the ramifications of this diabetes, this A1C being 14 persistently, that's going to shape your conversations going further.

 

Liz Rohr:

What does she do for childcare? What does she do for work? Because if she's up all night because she's working night shift, and then, she's only sleeping two hours a day because she cares for her children during the day, and she's barely eating, that's a very different conversation. And then, that brings in those next levels of, what are the resources that you have at your clinic? Do you have a community health worker that can help connect her with community resources? Or do you have therapists if they're sounding like they're having a hard time coping? Or they have diagnosed depression. What are their comorbidities with that? What are the other diabetes resources that you can do for this person? Do they have some sort of diabetes educator at your clinic? Or do you have nurse visits specifically that you can do where you can do diabetes teaching? Does she need teaching for how to use a glucometer?

 

Liz Rohr:

I'm feeling like this list is getting a little bit long, so I just want to share that... I don't know. These are the conversations that we're having. It's about the case, and it's about the life. And so, for this person, disclosure, I don't actually have all the details. This is a conversation I had a while back, and I have some notes on it, but I don't have all the details. But effectively, depending on the answers to those questions, it really changes your management. I can tell you that, let's back up for a second. If we are just focusing on the diagnostic algorithms, AACE guidelines or ADA guidelines. That's where you go for your diabetes management. That's the problem fix is to go to that place and say, "Okay, what do they say?"

 

Liz Rohr:

Well, they say anything above 9% should warrant insulin. So, you're just going to start them on insulin right away, send them home with a glucometer, send them home with needles, and send them on their merry way. We're not going to do that. I'm being ridiculous. But some people do. We try not to do that though. That's very overwhelming. Can you just even imagine what that feels like to be diagnosed newly potential... This person's not a new diagnosis, but just imagine what that feels like. Diagnostic algorithm says that. Diagnostic algorithm says to do long acting insulin once, maybe twice a day. And it's a weight-based dosing.

 

Liz Rohr:

So, we can get into that place. I can get into that conversation with that new grad of, here's what we do. We check morning blood sugars. You want the, and off the top of my head, excuse me, I don't remember. I believe, I can't remember. It's supposed to be around less than 130, I believe. Don't quote me on that. But whatever the guideline says. Fasting morning blood sugars, you want it to be within a certain range. And every single day, you start them at the weight-based dose or you start at 10 units of long acting once a day. And then, you titrate up depending on their morning blood sugars, every three to four days. I can rattle that off.

 

Liz Rohr:

But we're talking about this case. I guarantee you, if you just threw that at that patient and left the room, that would not happen. I can't guarantee, but you know what I'm saying here? So, that's the "What we should do." And also, let's look at all the answers to those questions that we asked this person to understand their life, their resources, their support systems, what supports you have in the clinic, and what they want, and what they believe? And did we give them a... What do they understand? What can we educate them on? And that will all change the trajectory of these conversations.

 

Liz Rohr:

I think this case, again, moral of the story, I don't actually remember what happened with this case. And I apologize. Maybe that's what you are listening to the episode for is what happened? What happened? All of new grads, I think, get upset if I have a cliffhanger case study. I get it. I totally get it. But I think that this patient ended up getting some imaging done for their gastroparesis, their stomach pain, because it was leaning towards being that. And then, there was a plan for the diabetes to just have a close follow-up visit, check some labs, and have a longer conversation.

 

Liz Rohr:

After she and I spoke, I believe she had another closer visit where she could ask all of those more holistic questions to guide the practice a little bit more. And I think she did some short-term management of the blood sugar being high. And the patient knew how to use a glucometer, was agreeable to check, wasn't at-risk for DKA or HHS. She had type two diabetes. So, it was HHS. And knew the signs and symptoms. And so, just had a short follow-up and further conversation about the medication. Or she might have started her on one. So, I apologize. I apologize. I like having details, but she had appropriate management for this patient. But yeah.

 

Liz Rohr:

So, I think all of that, all of the further interventions really depend on the answers to those questions. Hopefully, moral of the story, hopefully, this case highlights that there are... I think the first thing is, wow, this is hard. This is really hard, especially if you're a brand new grad. And I've practiced this for several years. And so, I can think about these things at the time of the visit. But if you aren't even aware of that holistic way of approaching the case or the patient, and practiced in it, and it's in your head, and you can do it quickly, this is a lot. This is a lot of stuff. And it's complex, and it's high risk. I didn't really even get into all of the different pieces of gastroparesis, and diabetes, and abdominal pain.

 

Liz Rohr:

But also too, hopefully, this case and that background discussion will help you start thinking about some of those other pieces to talk about. And I'm only acknowledging that this is a lot. I covered a lot in this episode. And not every single patient needs all of those things. And a lot of our conversations go a lot faster than this whole episode. Because again, this is a one-way telling of a conversation versus the way that we talk through it. But yeah, so hopefully, this is a helpful way to hear what it's like, number one, if you're a student and number one, what it could be like in the real world. And then, number two, if you're a new grad, this can be helpful for thinking about just all of the things that new grads are stressing about and help you feel not alone. Because I feel like I just want to yell it from the rooftops or across the internet that so much of this is the same role transition, and other new grads are struggling with the same things.

 

Liz Rohr:

And then, the other piece is just to give yourself a lot of grace, and that this is a practice, and these are just pick and choose. Can you pick one thing from this episode that you can add to your practice to try to practice? Again, acknowledging that I was like, I don't know how I'm going to have time to do this in a visit when my mentor said this to me. And it's really just about incorporating little pieces over time and keeping in mind that it's both the medical algorithms, but also, trying your best to zoom out, which it feels impossible at first, impossible to think about somebody coming back in three months or a year from now. But just try to zoom him out and see what it actually looks like in somebody's real life so that you can yeah, just take it from there and start incorporating those little pieces to make it more functional for each person.

 

Liz Rohr:

That's our episode for today. Thank you so much for listening. Make sure you subscribe, leave a review, and tell all your NP friends, so together, we can help as many nurse practitioners as possible give the best care to their patients. If you haven't gotten your copy of The Ultimate Resource Guide for the New NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to your inbox every week with notes from me, patient stories, and extra bonuses I really just don't share anywhere else. Thank you so much, again, for listening. Take care, and talk soon.