Transcript:What Is Your Philosophy Of Practice As A Nurse Practitioner?

Well hey there it's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Hey so in this episode I want to talk about something called Philosophy of Practice. I feel like other people say this, so I don't think I came up with this idea, but it's something that I talk about a lot with my new grads when I'm either mentoring them or just in conversation with them. And I feel like the purpose of this episode as well as that Pillars of N.P. Practice episode, which I can link to down below, my main purpose with both of these is kind of, it's almost like lifting the curtain of the mystery for N.P. students, but also like an orientation piece for new nurse practitioners to kind of like help ground you because if you're a new grad or even if you're changing from one type of specialty to another.

Oh my gosh, it's just, it can feel really, really hard. But this, this episode is a little bit more pertinent to, I guess you would still be figuring it out if you were transitioning from another practice after having some experience, but yeah, I think a lot of new grads talk about the role transition being like they're drowning. I absolutely felt that way as a new grad, but like it's just amazing to see the same language being used by nurse practitioners across the country like it's wild.

So that's like that's like a really like unfortunately normal experience of just feeling like you're drinking from a fire hose or you're drowning like all this stuff.

So yeah, so these episodes are really meant to help ground you and like what is going on here and like what am I trying to navigate here just to help you kind of get your bearings, I guess.

So in this episode, I want to talk about philosophies of practice and I love memes, but I am terrible at making them. Really I'm envious of the people who are really good at making them in our hilarious and I really appreciate that. So shout out to me if you are a meme creator and you know what I'm talking about and you want to work on some memes for this I would I would love you for that that would be amazing.

Let me just paint the picture I guess so I guess when I talk about philosophy of practice I'm talking about how like our style like what feels good for us right because medicine is medicine is medicine right and there's algorithms and there's guidelines and there's all this stuff and there's a lot of great area and a lot of choices that we need to make, right? And I think that's one of the pieces of when you're a new grad that you just have to get used to just making a decision and trusting yourself.

And yeah, so when we talk about philosophy as a practice, it's really like what is your style that you bring to a practicing medicine?

So when I have new grads, so I don't do 1-on-1 mentorship anymore. We do have a mentor named Breana who does 1-on-1 mentorship. But when I had clients before, this would come up over and over and over again. And so I think when we learn medicine in that textbook school exams type of way, it's kind of like easy to present a patient that is like a textbook patient that is has a clear answer, clear pathway forward, etcetera, right? They were a little just not like that as you have probably seen or you will see. And then I think there's just like huge massive discomfort that people have when they leave school feeling like, oh gosh, I wish I knew more. I don't know if I know enough, I don't know. I don't feel prepared to check on this role. Like, I feel like an imposter, like all of this stuff. And then that feeling of drowning. Like, oh, it's good still a lot. And again, I'm like not saying this to scare you. I just really want to, if you're a student, but like, it's I really want to normalize and validate if you're feeling this way yourself. Totally, unfortunately, totally normal. I wish it wasn't that way, but yeah.

So a lot of the clients that I see the newer nurse practitioners. So when they come to me, a lot of them are like, here's this clinical case. I have this patient who has her autism. I feel like I get that example a lot. I just think of a very specific client that I had a couple of years ago. And we talked about this case, her 60s, who had her autism. And she was kind of jumping right into, like, what are the treatment options? So I was looking at the treatment options of this or this, right?

Well, first of all, we did a little pause. We did a step back of like, okay, so we'll, well, what are your differentials? Before you jump into treatment, like, let's just make sure we're not missing anything more serious, or more, you know, a test that need to be done, et cetera, et cetera.

So we had that conversation. And then when we started talking about the management options and the work-up plan, work-up that had been done, what are the treatment options plans, what are the next steps forward? I'm just giving this as one example, but I see this literally all the time. It's like, no, no, no, what's the right answer Like, what? I'm going to tell me, tell me the right one. Here are these two options. You can do a top-of-go-thing or you can do a pill. Which one can I do? Actually, I don't think that patient was in our 60s. But anyway, I don't remember the details of the situation, but basically there were two treatment options, and I was like, well, you get to choose a new graph. It's like, so frustrated.

And I remember being the same way when I was a new grad, and that's what I mean by philosophy of practice, right?

So when somebody, when they come in and they have this problem, you have some choices to make, and then you just get to decide, what is your philosophy about that, right? Are you likely, if you're a new grad, you're probably going to be a little bit more of a stickler about everything, because you're just so nervous. But over time, you can kind of decide, hey, are we going to wait and see if these symptoms get better? And then watch out for the alarm signs, are we going to treat them right away? Are we going to do lab tests right away? When are we going to repeat the lab tests? What are those choices? How kind of like exact or free-flowing are you?

If you've been around for a little while, you've probably noticed that I'm pretty relaxed. I'm very committed to evidence-based medicine, and I also appreciate because I have many years of experience working in a federally qualified health center or multiple FQHCs that the real world is a tricky place sometimes. And we sometimes have to do make choices like harm reduction, for example, versus like, oh, this is the gold standard of treatment, but you know what, at least you're doing this thing, which is reducing your heart, right?

So anyway, more concrete example I want to share with you is like, for example, a lot of new grads say they have like a lab result, right? So let's take a high white blood cell, white high white blood cell account, for example. So I actually have an episode on this, so it's an oldie but a goodie on the YouTube channel. I believe it's on the podcast as well, but I give a key study example of elevated white blood cell count. And so if you're in clinic, you're practicing in clinic, And you see this high blood cell count of like 15, you know, the normal range is about 4 to 12. I'm talking about US units, you know, between 4 and 11, 4 and 12 and this one's like 15, maybe 17. And they're just like, oh my gosh, I'm going to do all these labs. I'm going to send them to hematology right away. That might be the person that you asked me, like, Oh, I'm so nervous. Should I do this and then you ask one person, they're like, Oh, absolutely. And you might want to do X Y and Z test too right, you might want to oh my gosh, I'm losing the test on the top of my head. It's not test that I would choose. So I'm not even going to mention it. But there's another test that sometimes people go down the route of high white blood cell count. I'm not getting into details of a patient's situation. So go look at that case that if you want to look at it, I think I mentioned that test in there.

And then you can kind of like walk down the hall as a lot of skeptical new nurse practitioners do and ask me how I know. I mean I went all the way down the one may go down the hall and ask another person and I'm like, oh no, no, that's fine. Just watch it to some come back in three, six months, right? And so those are very, very, very different approaches to medicine.

And so that's kind of what I'm talking about by philosophies of practice. And the reason I've brought up means is that I just seems like no matter what clinic I go to, I find some sort of variation of like, if I vibe with that person's philosophy or not. Like, are they too much of a stickler for me? Are they too relax for me? Are we on the same page about stuff like that kind of thing?

And then the other piece of that when it comes to philosophy of practice, again, I wish I had the pictures of this. These are, I spend a lot of time thinking about this, but when I think about that role transition to practice, When we first start as a new grad, it's kind of like, so if you're watching on YouTube, you can see this, but if you're on the podcasts, the listening on the podcast, you can't.

So I'll try to describe it. But basically, it's a series of concentric circles. So there's a circle in the middle, and that's like the must do, right? When we graduate from school, these are the things that we must know that we must not miss, so we don't harm anybody, and we provide safe care, right Here's the must do's, right?

Somebody is having a federal seizure. That's not a good example. But anyway, if there's some sort of urgent situation in at hand? Okay, we need to recognize and know that they're going to the ER. We're going to send them to the ER. We're going to put them on an ambulance if that's appropriate XYZ, right? And then the next concentric circle is like, you know, as we grow in our practice, right? There's like the kind of like other standards of care, right? And it's sort of things like, you know, like, if you really enjoy doing physicals and talking about health education and kind of like, the bread and butter of primary care, like that, this is like the core stuff that we're talking about like seeing all the time. But it's nothing that has like a quote-unquote fancy diagnosis or fancy labs, which is one of things I refer to as, but I feel like other people say that too.

But it's like, oh, okay, they have like complicated cirrhosis or heart failure with kind of renal syndrome, like, oh, no, thank you. Like, no, no, no, that's not who I'm talking about, right? That's that next concentric circle of like, you know what? I'm going to let somebody else handle that, whether it's somebody in my clinic or I'm going to refer them, you know, whenever that diagnosis comes up, something like that.

And then you have another concentric circle, which is like again, if I take those examples of those really complicated patients, some people really thrive there and they really enjoy those particular patients and they might not enjoy doing the kind of like bread and butter of primary care with health education and doing physicals and doing paps and things like that. And just to clarify that concentric circle, I never recommend new grads jumping into that far this scope of practice.

And this is again, maintaining our scope of practice, but just pushing it to our limits of what is, you know, safe and legal, right, in our states.

But yeah, so those are kind of the things to think about as you're going through practice. Like, there are choices that you're gonna have to make. You're just gonna have to decide of like, you know what? I'm gonna try this one out and we'll see how this goes, right? This is an option and this is an option. I'm gonna go with option A, see how I feel about it. Maybe next time I'm gonna choose B because I didn't like how that went or it doesn't feel great to me, et cetera, et cetera. And then that other pieces like kind of like tightly managed do I want someone to be, like turns out like testing and referrals and seeing them, have soon do I want to refer them versus keeping them in the clinic, and then I'm gonna do the work-up, the primary work-up, you know, specialist would do, and then I'll send them out. How fancy do I wanna get with those labs, right? How confident do I feel about interpreting the results, et cetera?

That's really more like, as you grow in your practice over time, please don't do that as a new grad. I do not recommend that.

But yeah, so basically, this is a bit of a longer episode, but what I'm talking about here is, I just want you to be aware of and grounded by, and I can be really jarring to be like, oh, I have to make this decision. I'm like, me, like, really, I have to, but knowing that something that you are only going to discover through practice over time and through talking with other clinicians. And you're like, yeah, I'm down for that, right?

Like I had this clinician that I this physician that I work with at my last job. And here where I were just, I just felt like he's in a pod, but like he just knew more than I did. And I was like, can I just download your brain? Like I've been in practice for seven years, but I still want to know all things you know, right? But the way that we would nerd out on patient cases, like we just really vibed, right? And I think that's something that will just figure out with time and there are different choices when you're first a new grad and you're like oh there has to be one right answer and the reality is that there are many ways to practice medicine excellently and safely and you're going to figure that out as you go.

Hopefully that's a grounding concept for you to think through to kind of like build your confidence there of like you know as long as we're choosing the safest option at the day, there are many, many choices to be had.