Transcript: How To Know When To Refer to a Specialist: #1 Tip for New Grad NPs

​Liz Rohr:
So if you're ever unsure about whether or not to refer your patient or you're really sure that you need to refer out your patient but they don't want to go, this video is for you. So I'm going to be sharing one resource in particular that's going to help you feel really confident about your referrals, deepen and broaden your knowledge base and help you take really excellent care of your patients. If you're new here, I'm Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. That's what we all want, right?

So before I jump in, for example, here's a scenario that we can kind of apply to walk through this. For example, you have a patient who's 57 who hasn't had healthcare in about 10 years. And last week you did an established care visit with him. You did some blood test for him, and his white blood cell count was 25. You checked it again today, about a week later, and it's still at 25. So if you haven't watched the High White Blood Cell Count video, definitely go back and watch that. You can kind of go through the step-by-step. But there's certain scenarios that which might be a little bit unclear. So you've gone through all of your things, you've repeated the test, you did the differential, you did the peripheral smear, he doesn't take any medications, you don't know if he has any medical history because he hasn't been to the doctor and this is it, that's kind of leaves you in a scenario of like, "Should I refer them out or should I keep them in house? Are there other tests that they would recommend?", et cetera, et cetera.

So the one resource that I recommend is something I refer to as cold calling. And so what it literally means is you pick up the phone and you call a specialist. So before you turn this off, runaway screaming, or maybe not screaming but runaway horrified, stick with me because your first thought might be that, "There's no way that I'm doing that," which is fine, but again, stick with me. But if you feel like, "Okay, maybe I could do that. I'll stick around," step two, or the thought two might be, "How would I even go about doing that? What would I say?That's overwhelming." So that's what I'm going to talk about in this video. So I'm going to break it down step by step exactly what to do, applying it to this case, hypothetical case, and literally the words that you would use and the information that you would get from doing this.

So I think most people are afraid to do this because they're worried that they're going to call and that someone is going to yell at them and make them feel stupid and they're going to be really embarrassed. So I'm not going to tell you that that's never going to happen. It definitely happened to me one time out of, feels like hundreds of calls that I've made. I'll talk about pitfalls and what to avoid to help you avoid that, but I mean, worst case scenario, your ego gets a little bit bruised, right? But the goal here is to take really good care of your patients and to expand your knowledge base. So it's a tiny risk, but again, just follow my steps and you can kind of avoid that. So step one, that's the thing that most people are afraid of, right? Someone's going to yell at them or get upset.

Option number two, outcome number two is that it will be a neutral experience because this is not just me that recommends doing this. This is the specialists themselves that experienced physicians talk with experienced physicians and do the exact same thing. So again, this is not, rocket science. It's not something that I've come up with on my own. It's just expected and the specialists have told me that, right? So it's a neutral experience because again, it's expected. Or a possible outcome, a third possible outcome is that it's awesome and that the specialist says, "Thank you so much for calling me. I love this referral. I love this question. I love to teach. Here is my personal email, my personal phone number, cell phone number," right? That hasn't happened all the time, but it's definitely happened a number enough times where I got an arsenal of specialists that I held onto at my last job. I'm still building them now at my new job.

Keeping those possible outcomes in mind, what steps do you do? So literally 1, 2, 3. So step one, what you're going to do is look and see what specialists your office typically refers to. And what I mean by that is that my clinic in particular is Community Health. I have some restriction restrictions about insurances and different places that patients can go based on transportation, and again, mostly insurance. And so looking at those possible options.

So for example, in this case, this is not a real doctor, a real case, but Dr. Weinstein is at the practice that we typically refer to in hematology. So identifying their office, getting a sense of that. Step number two is getting your ducts in a row. And what I mean by that is two different things. Number one, you always want to get all of the data together, right? You want to think about your case presentation. If you haven't watched the How to Ask Questions the Right Way video, definitely go back and watch that as well because that really helps you set up... It talks about the mistakes that I made as a new nurse practitioner and then I still see a lot of new nurse practitioners make in terms of communication with specialists and with other colleagues and things like that, and how to ask questions in the right way to help answer the questions that you're looking for, right? So definitely go back and watch that.

But getting your ducks in a row in terms of all of the data, right? So again, case presentation, 57 year old man, no past medical history, no medications. The last time he was here was... "I've seen my doctor was 10 years ago. I have no records. And then here's the data that I had. The white blood cell count of 25. Persistently normal, differential, normal smear. Again, go back and watch that High White Blood Cell Count video. I'm not getting it into all those details here, but you can go back and watch that.

And so those are all your details. And then the other part of getting your ducks in a row is kind of doing your first pass going through of like, "Have I asked all the right questions? Have I done the tests that I think that I can do in primary care?" And then also just running it by your colleagues or your supervisor. It depends on your access and who you can kind of ask, but those are kind of the preparing part, right?

And then the third thing is to call them. But before you freak out, I'll talk about that a little bit further, the step by step for that. When you figure out it's time to call them, most of the time you're going to get the front desk. You're not going to go right to the doctor, right? So it's okay, just take a deep breath. They might want to transfer you right to their desk phone. They might want to transfer you to their voicemail. They might want to page the doctor for you. I typically don't recommend doing that unless it's urgent or unless they specifically have requested that, of anybody who calls because they might be in the hospital setting and is this urgent. You have to decide that for yourself, right?

Most of the time though, what you're going to do is talk to one of their team members. And then the way that the specialist office is set up differently, depending on your state, depending on your area, things like that. But you could either have your specialist physician working with a medical assistant. You could have the specialist who has an NP and PA team that works with them, that kind of alternates seeing patients with them every other time that that patient comes to the visit. That's at least how they do it in Massachusetts for the most part. Or they might have a nurse that works in the office that kind of fields calls, right?

And so you can just ask the front desk. So this is literally what you can say, "Hey, this is Liz Rohr. I'm a nurse practitioner. I'm calling from Boston Community Health Center." It's not where I work, but, "I'm calling from Boston Community Health Center. I have a patient that I'm concerned about and I'm deciding whether or not I should send them for a referral if there are other tests that Dr. Weinstein would recommend before sending them. And so I'd love to speak with her or someone from her team. How do you typically do that when primary care clinicians call in? I'd love to leave a message in their voicemail. It's nothing urgent," et cetera, et cetera. And they can let you know. If they're not expecting it, then that's unusual because this is what happens, right? Or they can give you all of those options to page them, leave a voicemail, talk to the nurse, talk to the assistant, et cetera, et cetera, and then they will kind of review the case and then get back to you.

So I usually recommend leaving some sort of message because it doesn't... I don't know. I don't like putting people on the spot, right? And it gives them time to do it on their own time. And again, you're keeping this in mind that this is actually kind of doing them a favor. It's giving them business, right? It's also making sure that it's an appropriate referral, right? And if it's not, then they'll let you know. So that's basically how it goes. You identify the office, you get your ducks in a row, you present your case, and then they call back with their answer or they call back to discuss with you.

A couple of pitfalls to avoid. I was spoken to not very kindly one time. And really what happened is that if you are on the email list, you probably heard this before, but I did not trust my judgment about a third-trimester pregnant woman's murmur as being physiologically normal, and it was. And the OB-GYN that I had called and left a message. He called me back and was not very happy that I called him in the first place and that I should probably have run it by one of my colleagues first. But anyway, long story there. But it is what it is. It was related to that person's specific style of communication, because I met him in person later. He had no recollection, kind of had the same tone about him. So I think that was just his own thing.

But anyway, to avoid that is kind of, again, getting your ducks all in a row and making sure that you're consulting with your supervisor or your colleagues first. And then another pitfall to avoid is apologizing. Do not apologize, because again, this is just standard primary care, right? "Hi, this is Liz Rohr calling from blah, blah, blah, blah, blah. Here's my question. Oh, I'm so sorry we're bothering you." Don't. No apologizing. You're a nurse practitioner now. This is normal. This is what they expect. This is literally what they expect and they ask. I've asked them before about like, "Oh, well, what about a patient who has this and this? Just trying to, you know, making these videos and advising. You know what? Just call. Just call them. Just call your specialist.

So that's it. So did you like this video? If so, hit like and subscribe and share with your NP friends so together we can reach as many new nurse practitioners as possible to help make their first years a little bit easier. Don't forget to grab your copy of the Ultimate Resource Guide from the New NP over at realworldnp.com. You'll get the resource guide, these videos sent straight to your inbox, patient stories, and really truly bonus content that I just don't share anywhere else. So go over there, hop on. And thank you so much for watching. Hang in there and I'll see you soon.