Unexpected Mentorship Questions from New NPs - Interview with Kara Pesola, NP
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Show notes:
As the Director of Clinical Training at a Federally Qualified Health Center primary care practice, my dear friend Kara Pesola has a front-row seat to see the types of mentorship questions new nurse practitioners have.
I had the absolute pleasure of working with her in her first few years of practice and it’s so special to see her in this leadership role helping new grads during the tough transition to real-world practice.
In this week’s podcast episode, we talked about how the transition to practice can be a shock, and even though we learn so much and study so hard in school and for boards, there’s so much on-the-job learning.
We focused on sharing our perspectives on how we answer the most common mentorship questions that new NPs are bringing up in clinic— am I normal? Am I doing this right? Do you agree with this treatment plan?
But also discussed two common challenging scenarios that new grads face and how we support them through it (these scenarios snuck up on me as a new grad, too!):
Inheriting a panel of patients and the care plans from another provider (especially those with controlled substances— should I continue their meds?)
What to do when patients don’t want to treat their medical conditions (i.e. Diabetes with a persistent A1C of 12%— what do I do?).
This episode is such a gem! I adore sharing the behind-the-scenes of real-world clinical practice, and this is especially relevant if you don’t have a mentor yourself.
Resources mentioned in this episode:
MCSTAP: Massachusetts Consultation Service for Treatment of Addiction and Pain
Sylvie Ratelle STI/HIV Prevention Training Center (training and treatment resources)
UCSF National Clinician Consultation Center (hotline for HIV, Hep C, PEP & PrEP consults, national)
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Liz Rohr (they/she) (00:00)
I'm so excited you're here again. This is so fun being with you. So can you introduce yourself again for the people? They've probably heard you on a podcast, maybe or two before, but can you introduce yourself?
Kara Pesola (she/her) (00:14)
Thank you for having me back. And I am Kara. I am a nurse practitioner that I've been for about eight years now. And for this past year, I have entered our role of a director of clinical training, which for our organization is a new role. And what especially speaks, I think for you, to you, Liz, too, and for me to talk about, right, is like this new role for us is really developing our newest staff at the organization.
that I get to help support the onboarding mainly of like new grad and peace. So I'm excited to be here and talk about that.
Liz Rohr (they/she) (00:50)
That's awesome. Yeah, I love that. I love that you have that position and it's such a good role for you. So one of the things we talked about was I love sharing the behind the scenes of what it's really like to be a nurse practitioner and what are the things that people aren't talking about. I know that I did this when I was a new grad where I was in school, in school, in school, and I was so scared to graduate.
But I was like, no, I'm good. I got this. I got this. And then as soon as I graduated and I started, I was like, I don't have this. I don't have this. I wish that I had listened to people about getting support and all that stuff. And I see that. I've seen that a bunch in person where I've worked with NP students. And I'm like, hey, so I have this website and podcast that might help me. They're like, OK, that sounds nice. Thanks. And then they get into the middle of it. It's like a couple of weeks in, and they're like, I had no idea. I wish I listened to you about how hard it was going to be. Right? So I think that there is like if.
Kara Pesola (she/her) (01:23)
You
Hmm.
Mm -hmm, mm -hmm.
Liz Rohr (they/she) (01:47)
There are people who are needing this and wanting this, and there are people who are like, I'm not ready to hear this, but know that it will come back if you're not in this place, if you're a student. But yeah, I think I'd just love to talk about the kind of intangibles of what are some of the things that people are, what are the most common things that you're seeing, especially in this role? And yeah, just maybe just chat about that a little bit.
Kara Pesola (she/her) (02:08)
Mm -hmm.
Absolutely.
Liz Rohr (they/she) (02:14)
And so you were just kind of sharing before we started recording about how you just facilitated a group mentorship session. And how was that? I don't know, just maybe sharing some stuff of the scope of who was there and what y 'all kind of talked about.
Kara Pesola (she/her) (02:21)
Mm -hmm.
Yes, yes. So as an organization, we just recently onboarded four new grad MPs. And for me, like,
I'm about eight years into being an NP and I still very much so viscerally remember my first year experience, right? I know, right? But to be able to see it again in a different light with our new people that are with us now has been really lovely and also really like eye -opening to the things that are really hard that we don't necessarily talk about in school.
Liz Rohr (they/she) (02:45)
my god, I don't know if that is ever gonna leave us.
Yeah.
Kara Pesola (she/her) (03:06)
or get to practice in our clinical. So with our group of four people who are new for our organization, we've been doing individual like sessions for support and we've just started a group session. So for our first group session, just taking time to be together, like similar with you and your podcast and your listeners, right? To create a small group of support for each other. And what I hear you talk about a lot with your podcast too is just the sensation of
imposter syndrome, this like feeling of what am I doing? Am I like supposed to know what I'm doing? I don't know what I'm doing. Do you know what you're doing? Am I asking too many questions? Because we have folks that have like been here for like about a month and this is our first month of practice and we have folks that are in like their first six months and somebody who's like reaching my fear marker and I can relate to everything that they feel.
Liz Rohr (they/she) (03:48)
Yeah.
Kara Pesola (she/her) (04:05)
to say out loud for people that that is all completely normal. Because I think there is still this idea that especially when you go into healthcare, that you are going to know everything or that you can handle everything or you're supposed to be able to fix everything. And that is not a realistic expectation. That is not fun. Nor is that reasonable or what anybody has to offer, right? So I think that was.
Liz Rohr (they/she) (04:29)
Yeah.
Kara Pesola (she/her) (04:32)
That's the main thing from the very beginning for me is to like reminder for all of us. And I think at various times in life, it's helpful to say that out loud, right, that no one's meant to have these answers. And that's not really what healthcare is, that we have the guidelines there for a reason, the research is there, we have up to date, all the things that we can check. But it's about having connection with each other, like support to go to and talk to somebody else, right. But I think that was
That's our main theme in the beginning, right? And that this is like hard work and we're all in primary care. Every, anything is hard, right? And I really only know primary care, but just the complexities of having to feel like you need to know everything from like what that rash is that somebody comes in with, right? To how to help with treating heart failure and like uncontrolled type two diabetes, right? That you're gonna maybe do all three of those in the same visit, right? So.
Liz Rohr (they/she) (05:06)
Yeah. Yeah.
Yeah.
Yeah.
Kara Pesola (she/her) (05:29)
That's a lot to say. Like I see you, I feel you. Like, it's the deep breath. Ooh. yeah, right?
Liz Rohr (they/she) (05:32)
I was like, deep breath. We got it. Okay. One step at a time. All those things. That's okay. Totally. I just, I actually, I went away this weekend and I encountered a PA. Hopefully she's going to come on the podcast. She's lovely, but we were talking about that transition to practice and she just remembers having this mentorship experience where she was ready, coming out of school and being like, well, what's the dose of blah, blah, blah, blah for that?
Kara Pesola (she/her) (05:49)
Hmm.
Mm.
Liz Rohr (they/she) (06:01)
And she was like, I don't know. And then the mentor was like, good, I don't know either. Let's go look it up. And just like really not. And she's like, is that OK? And I think the other thing that came up for me when you were sharing about that is I think that there is not only the self -imposed expectations that we need to know everything, but I think there is a cultural expectation from people who are working with you in the clinic, whether it's like, and it's not necessarily like an overt, like you need to know this, but it's like when you have a patient and.
Kara Pesola (she/her) (06:06)
Do it!
Mm -hmm.
Liz Rohr (they/she) (06:28)
your administrative staff or your lab tech or your nurse comes to you for an answer and you're just like, I don't know the answer. But it's like that's their job is to come to you and like you put that on yourself to like have to know that. And like ultimately you have to tell them but like you don't need to know it off the top of your head. And I think that there is an expectation for people who are not in healthcare like patients for example can be surprised if you don't like, like I remember when I graduated from school people would be like, like family members and friends would ask me all these medical questions and I was like.
Kara Pesola (she/her) (06:40)
Yeah.
Liz Rohr (they/she) (06:56)
It's just reinforcing my imposter syndrome because I have no answers for you and you just think I'm an idiot and like you know, it's a big piece of humble pie, but Yeah delicious pie, but it's just it's I'm so glad that you have that mixed experience of people who are like a month in and then a year in and then like you can kind of see How there's different stages of it all but it's a very relatable experience and it's really like that's what I've noticed
Kara Pesola (she/her) (07:04)
Delicious. That's always delicious.
Mm -hmm.
I'm sorry.
Liz Rohr (they/she) (07:22)
over the years is that it's such a repeatable experience over and over and over again across the country. And even internationally, like I don't have, most people are based in the US, but yeah.
Kara Pesola (she/her) (07:26)
yeah, yes.
And hearing you say that kind of makes me remember that like this experience of being new really at anything, but I can relate to the NP experience. It reminds me of like the bleeding pattern expected with the marina, right? Like you might expect like all this like irregularity and discomfort perhaps like this is acute, right? And maybe over the course of the, I get really very similar over the course of three months, there's like a little bit of a drop off, right? And that totally is what I'm hearing people share.
Liz Rohr (they/she) (07:50)
Yes. Yes. Yep.
Yep.
Totally.
Absolutely. No, I love that example. I can see the graph in my mind when I was like in up to date and I tell face. Yeah, I love that.
Kara Pesola (she/her) (08:02)
Right after those first three months. I know. It just reminded me.
But then after a year, things are starting to like stabilize, right? And you know if this is like a thing you like or maybe don't like, right? And you can decide to remove it or continue, which I think is pretty cool. Mm -hmm.
Liz Rohr (they/she) (08:16)
Yeah.
I love that. I love that. I love that so much. So I would love to talk about, yeah, so like what are some of the, I think that there's some really common, like there's some really common questions that people have, and then there's kind of like some more complicated, very common, but also a little bit more complicated questions that people are bringing to you. What are the types of things, I guess maybe just normalize the experience, because people come and seek you out.
Kara Pesola (she/her) (08:42)
Hmm.
Mm -hmm.
Yeah.
Liz Rohr (they/she) (08:52)
in individual sessions or like in clinic time as the mentor, like what kinds of things are they asking of you? What are like the kind of common things that you're just hearing over and over again with these new grads?
Kara Pesola (she/her) (09:01)
Yeah. I, so the number one, right, is this okay? Am I normal? Right? And the answer is always yes. and number two, I feel like is like navigating, like,
Liz Rohr (they/she) (09:07)
Yeah.
Kara Pesola (she/her) (09:16)
kind of like the challenging conversations that come up. And I think that really comes up with the complexities around treating, let's say, I think most commonly for primary care is diabetes, right? When somebody has type 2 diabetes, and let's say they're A1C, they come in and your A1C is 12, right? And how to have that conversation with somebody, right? And what's the urgency level and what to do when somebody maybe doesn't want to treat something.
Liz Rohr (they/she) (09:19)
Yeah.
Yeah.
Yeah.
Yeah.
Kara Pesola (she/her) (09:45)
thing, right, which is also completely appropriate. I think that's like the next level of questions that come up. And I really, I think, going on like off of that, I feel like after that, I speak to like all of our like family nurse practitioners out there. Pediatrics is not one that I do, because I'm adult general and women's health. But pediatrics is huge. And it made me really like, see the people of knowing that like when
Liz Rohr (they/she) (09:46)
Yeah.
Yeah.
Yeah.
Yeah.
Kara Pesola (she/her) (10:13)
our NP schools when somebody's in clinicals, the amount of people that they actually have to see to like move forward, right? It's not that high, right? I saw somebody was like, I think it was four babies. They only had to see four babies in order to like graduate and to move forward, right? So like, it makes a whole lot of sense that like, to feel this discomfort with like pediatrics, right? With newborns, with like young kids, right? Like we don't get enough of that, like in our practice.
Liz Rohr (they/she) (10:21)
Yeah.
Yeah.
Yeah.
yeah.
Absolutely. Yeah. So I feel like it feels like there's a couple of different categories where it's like people are coming with like a direct clinical question of like, did I manage this correctly? Or like, what would you do in this situation? Or, you know, something like that. And then there's like this, you know, just like fund of knowledge. I love that expression. I don't know why, but like fund of knowledge, like gap where you're helping them with that. And then there's this like, am I normal? Am I asking too many questions?
Kara Pesola (she/her) (10:52)
Mm -hmm.
Yeah.
Mm -hmm. Yeah.
Liz Rohr (they/she) (11:06)
have to look everything up, is that okay? And like, I just, I feel, I don't know if this is how they say it to you, but it's like, I feel like I have to leave the room every time I come up with a plan. Like, are they concerned about that when they bring that to you kind of thing? Like, is that normal?
Kara Pesola (she/her) (11:16)
Mm -hmm. yeah.
Yes, and I reference you for maybe folks who maybe don't know, right? Like, so Liz and I, I got to work with Liz when I first became a nurse practitioner, and I am forever grateful for that. And I remember one of the first things that you had said to me was like, like, do that, right? Just that's just what you do, right? Like after you write, right? That you like say, great, okay, and you kind of sum up what we did for you. So we talked about like your blood pressure and your back pain, you know, I'm just gonna go look up like
Liz Rohr (they/she) (11:30)
Yeah.
Every patient. Yeah.
Kara Pesola (she/her) (11:48)
what medications we're going to do, and I'll come back and we're going to review it, right? That that's the expectation that I leave and then I come back, right? And I also like adding for people, I had a preceptor that always told me that when she's listening to people's lungs, that's when she also takes a deep breath, right? And then she remembers like, these are the things that we are going to do if I need a moment for myself. But I share that with everybody, right? That that is the normal to leave the room and to come back.
Liz Rohr (they/she) (11:53)
Yes. Yeah.
Yeah.
I love that.
Yeah, those two norms of I'm going to leave the room and come back, and I discuss it openly with the patient, comfortably, confidently. I mean, I've had maybe one person question me in a million years of practice. People don't care. They're like, OK, that's fine. They'd rather you know and feel confident and take care of them and be attentive than to brush them off. And then I love, I'm sorry.
Kara Pesola (she/her) (12:17)
Right.
Mm -hmm.
Mm -hmm. Yeah. Yeah. No. Yes.
Yeah. I bring up up to date algorithms in front of people, right? Just to say it like I bring up like the up to date algorithm, like in front of somebody, right? And that's like, so I think people also really like that, right? That it's like normal. And I think myself as a patient likes that too, right? That like we're talking this out together. I'm like, we're, we're letting them know we're keeping like they're, they're a part of like the discussion and you're showing them that this is what I, this is what I see, right? This is where you are. And this is what we're thinking, right? That's like really helpful for people.
Liz Rohr (they/she) (12:43)
Yes. Yeah.
Yeah.
Yeah.
Yeah, yeah, totally. Such partnership, yeah, I love that. And then just like adding in, I wish I had done that so many years ago, like when I started, when I, like me taking the deep breath with the, like that's so brilliant.
Kara Pesola (she/her) (13:06)
Yeah.
Liz Rohr (they/she) (13:16)
Because that really, it's one of the quickest ways we can calm our bodies down is to take those deep breaths and those diaphragmatic breaths. And it might not always be accessible, right? It might be that kind of shallow chest, upper chest breathing because you're so stressed. But even if you're not coming up with a plan, even if you're like, I need to go look on up to date, I can breathe in this moment. And it's going to take me how many extra seconds to do that? Excuse me. I love that.
Kara Pesola (she/her) (13:28)
You
Mm -hmm.
Liz Rohr (they/she) (13:42)
So yeah, so like, you know, just kind of coming back to that, the normalization of like, it's so normal to ask a million clinical questions and to doubt yourself because you're so used to, new grads are so used to having a preceptor approve everything. And that takes a while to trust your own judgment and your own decisions. And then you also have the like, you know, those kind of common things of like looking everything up and having all those questions and all of that is normal. And then I think that the third thing that we had kind of talked about before was getting into those more complicated questions.
Kara Pesola (she/her) (13:54)
Yeah.
Mm -hmm.
Liz Rohr (they/she) (14:12)
that snuck up on, I think snuck up on me and I think that you probably still see that and then I think you had that experience too. So I think the kind of the three, I think maybe three, I'm looking at my notes here, but I think the main three things we talked about is like, what if somebody has a condition that they don't wanna treat? How do we manage, like,
Kara Pesola (she/her) (14:20)
Mm -hmm.
Yeah.
Mm -hmm.
Liz Rohr (they/she) (14:38)
I think that the overarching, excuse me, the overarching theme is like stepping in as a new provider when some provider has left. Not everybody has that. Sometimes people get hired and then they build a brand new panel, but a lot of times people are stepping into someone's old panel and it's like whether it's controlled substances or a certain way of managing their chronic condition. I'm only thinking of two, but I think those are the two main kind of overarching things that kind of sneak up on people that you have a little bit longer discussion that's not just like, like, you know, listen to April 20th.
Kara Pesola (she/her) (14:45)
Mm -hmm.
Liz Rohr (they/she) (15:07)
20 milligrams is great for this patient or whatever. You know what I mean? So yeah, so which one do you want to kind of touch on? I don't know if you have any examples that come to mind, but it might be helpful for people to hear that this is something that will inevitably come up, whether it's day one or however long. Do you want to start with the management choices? go for it. Go for it then. Go for it. Absolutely.
Kara Pesola (she/her) (15:09)
Mm -hmm, mm -hmm, mm -hmm. Yeah.
Yeah.
Yes. I think like we should, I chose the other one actually in my head, the controls, is that okay? Like I feel like controlled substances, right? And like, or like what that's.
Liz Rohr (they/she) (15:35)
Yeah, if you want to start with a context patient too, or just a general, that would be helpful, I think, for people, especially if they're... If somebody comes in and... I guess maybe I'll give an example. So I had somebody who came in for their... I'm trying to remember the context of it, but basically they had multiple times a day a controlled substance, pain medication, had been on it for years, had seen this other provider for three or four years.
Kara Pesola (she/her) (15:45)
now.
Liz Rohr (they/she) (16:04)
and it's just coming in for their monthly, the schedule this provider was on was like a monthly, every month they come in and they do a med check, quote unquote, of they just have the conversation, here's what they usually talk about, and then they refill the meds and then they're good. Or it was a schedule of every three months or whatever. But the context is somebody's coming in a little bit hot, I think we talked about before, coming in with some heat of like, yeah. I mean, they're kind of angry, they're kind of upset because their provider has left.
Kara Pesola (she/her) (16:13)
Mm -hmm.
Hahaha!
Why are we doing this different? Yeah.
Liz Rohr (they/she) (16:32)
they have this controlled substance that people give them a really hard time about, generally speaking, whether it's the pharmacy, whether it's the provider, and they're just like, who are you? Brand new grad. You gonna give me my meds? I'm ready to go, right? Like, I mean, those are just the ones that I was like, what do I do?
Kara Pesola (she/her) (16:41)
Yeah. Yeah. yeah. And I know we've talked, like I remember like my first like week, like a practice walking down the hallway to like start like Suboxone and like, which is probably, that is the easiest controlled substance to do, quite honestly, right? But I just remember that like, I...
Liz Rohr (they/she) (17:01)
Yeah, yeah.
Kara Pesola (she/her) (17:05)
I have not had this conversation before at all. Right? This is like, this is like just in that same context that you're saying they're seeing somebody else, they're already a little upset because like, it makes sense, right? They're so nervous that someone is going to stop something, right? It's like to remind ourselves is like, what is behind that like, that like anger or that like them coming in upset, right? But like, yes, going back to what you said, right? So what do we want people to like hear from that?
Liz Rohr (they/she) (17:17)
Yeah. Yes.
Kara Pesola (she/her) (17:33)
you might have a panel of patients that maybe you inherit, right? And folks are maybe they're on like, opioids for pain, but they've been on for years. And maybe the last person had a different idea of a plan than you do. Right? Or maybe
Liz Rohr (they/she) (17:46)
Yeah. And like you're coming in of like, here are the guidelines. Here's a recommendation. I'm terrified to prescribe this controlled substance, whether it's pain or something else. And like, this is a higher dose than I feel comfortable with that I think they should be on or X, Y, and Z, whatever you're coming in with in terms of you're like, I am so terrified to be doing this. And then here's like what I know from school. And then you have this person who's, you know, before you is just kind of like, this is how they've managed this patient. And you're like, I don't know how I feel about that.
Kara Pesola (she/her) (17:53)
Mm -hmm.
Mm -hmm.
Yes. Yes.
Mm -hmm. Yeah. Yeah.
Liz Rohr (they/she) (18:14)
Like, and that's my license and it's like, I've been here for a week and you want me to prescribe how much, how much, how much oxycodone for you? How much Dilaudid for you? What?
Kara Pesola (she/her) (18:17)
You
Yes, yes, right. And you're colonizepam too, right? So, totally, like, hearing you say that again, like, is really helpful to put it in perspective, that that is a really normal and appropriate response to like feel that way, right? Because that does feel risky, right? And yeah, I get that, right?
Liz Rohr (they/she) (18:39)
It feels so scary for, especially for a new grad. And to see like the combination of an opiate and a benzodiazepine is like.
Kara Pesola (she/her) (18:47)
Yeah, you've already got like the box warnings coming up, right? And like, the DEA when you've gone through the whole process has probably scared you, right? That you're gonna like have your license taken away by whatever, right? So appropriate to have all those feelings. And also appropriate to like continue someone's existing plan, right? That's kind of like what I've come back to with people, right? That like,
Liz Rohr (they/she) (18:49)
You want me to do what? Yeah, yeah, yeah.
Yes. Yeah. Yeah.
Kara Pesola (she/her) (19:14)
The first time you meet somebody is not like when you have to then change something, right? They've been on this for some time, right? What's like appropriate is to continue and have a conversation and to make your plan about what it looks like for you and that person looking forward, right? So I think that was the first question is like, can I continue this? And the answer is yes, right? Unless there's like a red flag, right? That like we're concerned about the person's safety with like using the medication, right?
Liz Rohr (they/she) (19:33)
Yeah. Yeah.
Yeah. Right.
Kara Pesola (she/her) (19:43)
You want to make sure that like they have all of what your your policies are with your organization. But they've had like their routine like screenings for the urine drug screen. They have their controlled substance contract. All of those things are like in place. But like first visit is you continue said plan. Right. And you have a yeah. Yes. Right. And you like your relationship building, which I think is like that is of course the most important part.
Liz Rohr (they/she) (20:01)
Yeah, it's basically a safety assessment and continue. Like, yeah.
Kara Pesola (she/her) (20:11)
And I find that I also just acknowledge always like the discomfort in the room, right? Because if somebody is coming in, they're meeting you for the first time and there's controlled substances, they're already coming feeling anxious that you might stop them right away, right? Because like you said, they've had that experience everywhere they've gone and they feel like they might feel like really defensive. And I would feel the same way I'm sure in that position, right? Because you're
Liz Rohr (they/she) (20:18)
Yeah.
Yeah. yeah.
Kara Pesola (she/her) (20:37)
been forced to explain yourself in very different ways and you're treated differently because of the medications that you take, right? That someone in our profession prescribed for you in the first place, right? Yeah, right? Tons of bias, right? So like to encouraging people to like, take a moment, right? That this is appropriate to keep doing. And it's appropriate to make sure that we are, like you said, doing the safety assessment for somebody. And then having those like goals of care conversation there.
Liz Rohr (they/she) (20:43)
Yeah, and there's a lot of bias. Yeah, right. Yeah.
Kara Pesola (she/her) (21:05)
Right? Like, what is this medicine like bringing to someone's life? Right? Is it improving someone's quality of life or maintaining a quality of life? And that's what helps kind of guide the conversation after that. But for you and that person, like, yes, you are new. And I always acknowledge that with people like this is our first time meeting, right? This is like, we're not changing things today, right? Unless that's something that we decide that we both need to do. But our plan is to like talk about this together and to make our plan going forward. And
Liz Rohr (they/she) (21:30)
Yeah.
Kara Pesola (she/her) (21:35)
That I think is the biggest piece. And that's hard, right? And I think it's hard for our organization, right? We, especially after COVID, things really changed during COVID. We had a lot of our folks, we went full telehealth for a long time, which is wonderful. And it also brought up some stuff for our folks with controlled substances where we hadn't seen people in person for a long time, right? And then...
Liz Rohr (they/she) (21:37)
Yeah.
Yeah. Yeah. Yeah.
Kara Pesola (she/her) (22:00)
that's also what the standard was. So then people felt really uncomfortable that we were asking them to come in. Right. So as an organization, that was our first like hurdle to kind of pass and to remind people that, now we're going we're going back to like what our standard is. Right. So that the being clear is kind is the message that I hear a lot from our folks here. And they really resonate that especially when it comes to like controlled substances, right, that this is what we're doing today. And this is what our
Liz Rohr (they/she) (22:05)
Yeah.
Yeah.
Yeah.
Yeah.
Kara Pesola (she/her) (22:29)
plan for follow up would be right of knowing that like this is when I'm going to see you again and this is how it will be to like request the prescription again like what is like for you and that person to like talk about that in the room together so I think that's the most unsettling piece that a person calls for a refill and then maybe you feel uncomfortable about it and maybe you want them to come in but you didn't quite maybe say that
Liz Rohr (they/she) (22:31)
Yeah.
Yeah.
Yeah.
Kara Pesola (she/her) (22:52)
last appointment so they weren't sure so then if they didn't know that then they get a little upset because they're like why they haven't become in again right but if you can make that very clear when you meet them that's what's going to happen going forward
Liz Rohr (they/she) (22:54)
Yeah.
Right. Right.
Definitely, yeah, and I think you and I talked a little bit before we started. This is not an episode about controlled substances. There's a lot to say, I think, about the management of those in terms of best practices of safety and collaboration with patients. But just using an example, it's just as a particular example of, I think what it brings up for me is remembering when I was a new grad. And maybe you see this in these people now, but you and I have talked about this, but it's like,
Kara Pesola (she/her) (23:13)
Mm -hmm.
Liz Rohr (they/she) (23:35)
So much of medicine is this long game of patient -centered stuff, which I think really ties into the next piece about the, if I don't want to treat something, because it's like, if you zoom all the way out, as scary as all of those facts are that you have this license and that somebody can die from some controlled substance, right? If you take that off the table for just a second and then you zoom out and you see this person has been taking this regimen for five years, they're stable, all of these other things.
Kara Pesola (she/her) (23:44)
Yeah.
Liz Rohr (they/she) (24:05)
You've done all the safety things. They have Narcan. I don't like using brand names, but basically Narcan at home. What are all the protocols around controlled substance management? If they've been doing all of those things, the long game is that we want to support their well -being. We want them to be functional, have functional ADLs. And that's just the thing, especially with chronic pain, is like.
Kara Pesola (she/her) (24:09)
Yeah. Yes.
Mm -hmm.
Liz Rohr (they/she) (24:31)
you just need to live your life because the chronic pain usually isn't gonna go away, right? So it's just like, how do you manage it? And if this is managing and it's safe, right? Like, yeah, so I think it's just so much of it. When I was such a new grad, I was just looking at that one visit and I remember, you probably remember a burn person that had a lot, very high pain medicine. I don't remember that. I can't, but I think it was like week three and it was like all the pain meds. And I was like, wow. And I just, the thought of this person coming back in three months.
Kara Pesola (she/her) (24:34)
Yeah.
yeah.
Mm -hmm. Mm -hmm.
Liz Rohr (they/she) (25:01)
like blew my mind, because I was new, you know? And I was just like, is he going to make it? And then, which is a ridiculous thing to say, like he was totally fine. But like in my mind, that's like the logic that was there. So I think it's really hard to appreciate when you're a new grad that this is a real long game. And so much of this is like conversations with people of what they're willing to do and not willing to do, because like we don't really actually have that much control. We only have control over what we do, right, and what we prescribe or not prescribe. But like people are going to do what they're going to do.
Kara Pesola (she/her) (25:04)
Yeah, of course.
Yeah.
Mm hmm. Yeah. Yeah.
Yeah, of course.
Liz Rohr (they/she) (25:29)
So yeah, so how does that conversation happen? I guess maybe I'll just throw out another scenario of somebody who, and just feel free to chime in if there's differences that you're seeing, but I think there's a combination of, I'm trying to think of a specific patient, de -identified of course. I think somebody who would come in and I would see their number. So for example, someone with diabetes and their A1C is 12, and I'm looking at their regimen and I'm like, I think they need their eye exam, they need their monofilament, they need.
Kara Pesola (she/her) (25:37)
Mm -hmm.
Liz Rohr (they/she) (26:00)
they need to see, do foot exam, foot specialist, all this stuff. And they're on this meds and like, I don't like that med regimen. That's not guideline. This is my judgy brand new grad mind, so I'm just letting it rip here. It's like, well, how did they get on those meds? This isn't working. And I would go in and I'd be like, all right, we're gonna make some changes.
Kara Pesola (she/her) (26:04)
Yeah.
Mm -hmm. Who's doing this, right?
Ha ha ha!
Yep, bye!
Liz Rohr (they/she) (26:25)
I'm just gonna laugh at myself. Because I think a lot of people also do that, so I'm just being honest. And then I learned kind of slowly, gradually over time, this person's A1C was still 12, still 12, still 12. And I was like, okay, what's going on here? You're not going to your eye appointment? What about the med changes we talked about? What about your blood sugar monitoring? Yeah, so maybe that's a scenario, and I'm bringing that to you. What is your conversation that you're having with the new grads? Is that apt? I don't know.
Kara Pesola (she/her) (26:30)
Jam.
Mm -hmm.
Yeah, yeah, yes.
definitely. Yes. Right. And I think it's like, it's the initial shock of seeing like a 12th, right? Of being like, no. Right. And like, yeah, of course, exactly. Yes. And I'm happy you just said that too, right? Because I feel like in a, I feel like it is taught to that we have to then tell that person that you could die. Right. And
Liz Rohr (they/she) (26:59)
Yes.
And this is my responsibility. This is on me to manage it. This person could die, right? It's all, it's still coming back to that same reactivity.
Yeah. Hey, I'm a brand new grad we just met. You're gonna die. Just need to let you know, right? Like I was such a nut when I just, I said all the things that I needed to say on paper and it was like, that's not the time.
Kara Pesola (she/her) (27:21)
You could die if you don't treat this, okay? Yeah. No, it's not. No, right? And it makes them not want to come. I know, right? I get that. Yes.
Liz Rohr (they/she) (27:35)
but it's on me, I'm responsible. Yeah, but it's like, it's a yes and, right? Cause it's like you are and this person again, zoomed out. Sorry, I keep interrupting you. Go ahead, go ahead.
Kara Pesola (she/her) (27:44)
No, please, this is a yes, right? And it is so basic, the response, right? Of just like, we just go and we talk to the person, right? Like just how, yes, I didn't, yes. Basic, it's not a, exactly, yes, yes. And I say basic, not meaning that it's an easy, like, yes, yes, right? Yes.
Liz Rohr (they/she) (27:54)
Yeah. Which is a skill to develop. I just want to normalize. Like I feel comfortable now. I did not feel comfortable then. Just talking to people was so scary.
Right, like simple, yeah. Simple, not easy.
Kara Pesola (she/her) (28:09)
And like, I feel like with most anything, right, when you go into the room and then say like, so, hey, like the A1C is 12, right, and then you pause, right, because many people also maybe don't know what that means, first of all, right, so it's pausing to under like to see like, hey, what do you like understand about your A1C or how do you feel with your diabetes, right? People always have something to say, right? That is why they are there, right? So that helps guide
Liz Rohr (they/she) (28:34)
Yeah. Yeah.
Kara Pesola (she/her) (28:38)
The whole rest of it is just seeing where someone is at and then asking, what would you like to do? I say, always, yes, of course, we have our recommendations. But before I say anything, I say, what would you like to do? What could we think about with this today? So just reminding ourselves that, yes, we want to think about insulin when someone's A1C is over 10.
but most people are fairly afraid of insulin, right? And like how to have that conversation is not like a, like we need to use insulin or like you can die, right? Or lose your eyesight or like your kidneys, right? It's like having those conversations like about risk without the fear piece, right? And I...
Liz Rohr (they/she) (29:20)
Yeah.
Yeah.
Kara Pesola (she/her) (29:30)
I think every situation of course is different, right? When you go in and you talk with somebody about whatever the diagnosis is, but just talking to somebody first and seeing what they think, right? And then after they share with you how they feel, right? You say like, okay, so like we have options, right? This is what we're doing now. Like, would you like, because everybody, I think, I think, especially when it comes to diabetes, right? So many conditions are very similar to type two diabetes in that sense, but I feel like I just we see that a lot here, but the fatigue,
Liz Rohr (they/she) (29:39)
Yeah.
so much.
Kara Pesola (she/her) (30:00)
medicine, right? Because like a diagnosis, you're given usually like three medicines from the beginning, right? And what that's like from the very beginning and how to like, have that conversation. And I feel like when people, when you get to have a conversation and tell somebody like the why behind the recommendation of like a statin, right? Like, what is this, right? And just telling people that we have all of these options that can help support your body. And is that something that you want to do?
Liz Rohr (they/she) (30:20)
Yeah. Yeah.
Yeah.
Right.
Kara Pesola (she/her) (30:30)
Right? And then, yeah, I think just like that. Right? But it's hard.
Liz Rohr (they/she) (30:34)
I mean, and I just like, it's so novel in a way because like, maybe schools are different now, but I don't feel like I ever talked about that in school. And I'm still feeling that inner gripping of my new grad self of like, but, but, but, you know, but like the moral of the story, the long game of medicine is they get to decide what to do with their body. And I think it's the same thing as controlled substances where it's like safety first.
Kara Pesola (she/her) (30:42)
No.
Mm.
Yeah.
Liz Rohr (they/she) (31:00)
And I think I actually do that, maybe that's just my system of when I see patients because sometimes like you said with the example earlier with like heart failure and the rash and I can't remember what the other one was, diabetes maybe. It's like, okay, what is the most important thing of safety to make sure that I've discussed with the patient, I can document that, right, monofilament can wait, eye exam can wait, right. Do they understand hyper and hypoglycemia? Great, do they know how to take care of it? Great, right, from there, like.
Kara Pesola (she/her) (31:00)
Mm -hmm.
Mm -hmm.
Mm -hmm.
Liz Rohr (they/she) (31:30)
You know, we can talk about more things, but it's like, okay, if we've covered safety, I'm asking you what you understand and what you think and what you feel about it. Like that's gonna lead, right? Because we literally can't do anything else aside from make our recommendations and if they're willing to hear it or not. And I think the thing that's also coming up to me in this conversation is like, and especially in this situation is my therapist and I were talking about stages of change.
Kara Pesola (she/her) (31:55)
Mm -hmm.
Liz Rohr (they/she) (31:57)
And just to reapprise people, there's pre -contemplation. Like, I'm not ready to think about it. Contemplation, I'm thinking about it. I think the next one is preparation. The next one is action. And then the last one is maintenance. And I feel like I learned that in school and I was like, whatever. But it came up in the context of my real life where it was just like an interpersonal thing. And it's like, contemplation, one thing that like just hit me like a rock, where she was like, contemplation can be forever. There's no...
Kara Pesola (she/her) (32:09)
Mm -hmm.
Mm.
Liz Rohr (they/she) (32:26)
guarantee that somebody goes one, two, three, four, five, you can, like, there's no limitation on contemplation. Somebody could be thinking about it forever. And so, and also sometimes if we ramp things up too fast, at least this is what my therapist was saying, whether it's an emotional change or a communication change or a medication change, but it's like sometimes if we ramp things up and we're in contemplation and we're in the preparation stage, if it's too intense for us, we can slide all the way back to pre -contemplation.
Kara Pesola (she/her) (32:40)
Hehehehe
Yes.
Liz Rohr (they/she) (32:53)
And this is like, and as much as we can bring non -judgment to it, I was like, this is just the process. So like, if we walk in and our brand new patient and we're gonna throw all this stuff at them, we've just probably shocked their nervous system to the point where they're gonna go back to pre -contemplation of, you know, who knows what, maybe they were already on their way to change, maybe they already have been working on dietary stuff, you know, maybe, you know, X, Y, Z. So, yeah, I think it's just so.
Those are so, these two examples in particular I think are real skill sets for people to build and it's a hard perspective to have, but it's, I just love that we can share this with people because these are the kind of intangibles that you need a mentor for, you know? And for people who are in clinics and they don't have that kind of mentorship, it's like, that's like a whole, it's like a whole skill set of just having a conversation, right? Cause you're trying to manage your time and you know, all that stuff, so.
Kara Pesola (she/her) (33:34)
Yeah.
Liz Rohr (they/she) (33:46)
Yeah, I love that. But yeah, I think you and I were talking about that, just so much of medicine at this point, especially primary care, is meeting people where they're at and what they want. And ultimately, I think we have our agendas about making health better and the health care system better and health of people better and preventative care and all that. But it's like, at the end of the day, everyone's an individual.
Kara Pesola (she/her) (34:04)
Yeah.
You saying the word partnership really speaks to me, right? That is our role as a, I don't like the word provider anymore. I'm trying to figure out different words, right? Like clinicians, right? Or like that we're like facilitating health and like some, yeah.
Liz Rohr (they/she) (34:21)
Yeah. Yeah, yeah.
Yeah, yeah. Like we have a knowledge and expertise, but we're ultimately a facilitator because they're participant, active participant. I mean, maybe they're not active, but it's not us controlling them. It's not us doing things to them.
Kara Pesola (she/her) (34:36)
Yeah.
Yeah. Yeah. And hearing you say that reminds me like in the beginning, something I think about is like, I would see folks that would still come every three months, like maybe for their A1C. And maybe, like you said, maybe it always was like 12 each time. And sometimes I'd be like, why are they still coming? Right? Like, I'm so curious about that, right? Or being like, they don't maybe want to like,
Liz Rohr (they/she) (34:55)
Yeah.
Kara Pesola (she/her) (35:01)
They're not ready, right? It's not that they don't want to, right? Like they're coming, right? They're making the appointments and they're being there. But it was interesting for me in the beginning to figure out like, I wonder why like somebody is like still coming if they maybe don't want to like take medicine for it, right? Because I definitely have some folks that I've known for years who don't want to treat something and it's mainly diabetes, but still would like to come to check it up.
Liz Rohr (they/she) (35:02)
Yeah. Yeah.
Yeah.
Kara Pesola (she/her) (35:26)
And that's them treating their diabetes, right? Because they want to come back and see how it is. And it took me a while to feel like, what is this? Right? Like I was so confused, right?
Liz Rohr (they/she) (35:26)
Yeah. Yeah.
Yeah. Yeah. No. Yeah. I appreciate you sharing that example because I think it's like, it's hard for us from the clinician standpoint to like, well, if you want to treat something, it's X, Y, and Z and it's, you know, simple, but it's not right. And it's like, it's almost like, like, we talked about a little bit about harm reduction and it's like, maybe that is a harm reduction because it doesn't look like they're doing much, but maybe they are maintaining, maybe coming to the visits and seeing their A1C is maintaining it at 12, but maybe it's not 16. Maybe it's not.
Kara Pesola (she/her) (35:47)
Mm -hmm. Mm -hmm.
Yeah.
Yeah. Yeah.
Liz Rohr (they/she) (36:04)
maybe they're not being hospitalized, maybe this is what's keeping them out of the hospital, which like isn't the best, you know, our quote unquote best standard of care in terms of the metric of that, you know, disease process, but we're reducing harm. We're helping them live their lives, so.
Kara Pesola (she/her) (36:08)
Yeah.
Yeah.
Yes, exactly. Yes. I know.
Liz Rohr (they/she) (36:22)
Love that. Do you have any, thank you so much for your time. Do you have any kind of like parting words of wisdom or pearls of practice? I always like to just throw that out there if there's anything like hanging over your mind.
Kara Pesola (she/her) (36:35)
Mmm.
Well, I think as we talked around, like the themes of what comes up, right, or the themes that at least that I hear, right, I think one that we didn't talk about is like, mental health conditions as well and diagnosing and treating and that is really like, common to come up also like, as a concern in the beginning of practice to like, how do my like, my diagnosing something correctly when it comes to like, maybe like a complex mental health condition or doing the right treatment plan. I feel like that's the one that I also hear a lot about as well. So just
Liz Rohr (they/she) (36:47)
Mm -hmm.
yeah.
Kara Pesola (she/her) (37:07)
like say that out loud for people, right? That like, it's, you're not alone, right? That other people feel the same. And we have specialties for a reason. I can speak to the primary care world. And I feel like sometimes PCPs feel like sometimes a little lost, right? Because they have like the cycle farm background.
Liz Rohr (they/she) (37:12)
Yeah.
Kara Pesola (she/her) (37:27)
but not all that specialized training that our colleagues do. In PCPs, somebody leaves the hospital and maybe they're started on a medicine and then they're coming to us for the follow -up but they don't have a psychiatrist. It's like, I totally feel you and sometimes that doesn't feel great. She's like, I'm not the right person to see this patient, but to remind yourself that you totally are. and like we help
Liz Rohr (they/she) (37:49)
Mm -hmm.
Kara Pesola (she/her) (37:55)
stabilize someone continue their treatment and get them to somebody else. I feel like that's the other big theme that I hear about that maybe isn't covered as much in school or where you went for like your clinicals.
Liz Rohr (they/she) (38:07)
Yeah, and I love you bringing that up. Because it's almost like another harm reduction thing. I talked about it in one, at least one other episode with Daniel, the pulmonologist, because he was talking about practicing as a pulmonologist in more rural settings. And it's like, it's not on us to take on the dysfunction of the health care system and overextend beyond what we have capacity to do or what is safe.
Kara Pesola (she/her) (38:16)
Hmm.
Hmm.
Liz Rohr (they/she) (38:34)
because of the healthcare system shortcomings and there are harm reduction ways that we can support a person within our scope of practice that is appropriate in primary care and connect with the specialists. And I think that it reminds me of the, MCHPAP is the one that's coming to mind for Massachusetts and that's for kids, but it's like Mass Coalition for Psychiatry and something, pediatrics, I'm not sure. But then I think there was like another one that you brought up about like an addiction medicine or pain medicine.
Kara Pesola (she/her) (38:51)
Yeah.
Yeah, yeah, yeah.
Mick, yeah, MC STAP It's like the same kind of thing MCSTAP, right?
Liz Rohr (they/she) (39:02)
consultant mixed up.
Yeah, so those are resources from Massachusetts, and that's one for kiddos And I think you said that there was maybe one developing for postpartum. I don't know if that was you that was saying that. But yeah, so I think that maybe one potential resource to point to is hopefully your clinic has knowledge of your state -based resources that can be helpful. Like the STD, the Sylvia Rattell hotline, am I saying that one right? That's for STI management. And if you just Google Sylvia Rattell STI,
Kara Pesola (she/her) (39:15)
Yes.
Mm -hmm. Mm -hmm. Yeah, yeah, yeah. Yeah.
Liz Rohr (they/she) (39:37)
hotline, like there are just, and like gender affirming care, there's like a national, there are all these different resources whether they're state based or national that can be a consultant on a case of like, hey, I really need support with like this. So yeah, thanks for that.
Kara Pesola (she/her) (39:44)
Yeah.
And the one for HIV care that I absolutely love is the UCSF one. Like they have an HIV like warm, warm line they call, right? Where you call and you're taught like somebody literally talks to you within a half an hour. How cool is that, right? That someone's calling to like talk through like HIV like guidelines and treatment with you, right? There's a lot of cool resources out there. It doesn't make it easier maybe in the moment, right? But knowing that there's a lot of resources out there. Yeah.
Liz Rohr (they/she) (39:54)
Yes.
I love it.
So good.
Yeah.
Totally. Well, thank you so much. I really appreciate it.
Kara Pesola (she/her) (40:18)
I appreciate you. Yes.
Liz Rohr (they/she) (40:20)
Absolutely.
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