Transcript: Chronic Care Conversations

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.

This week's episode is all about chronic care conversations. The context of what I want to talk about in this episode is that it's a really common frustration that clinicians have, both new and experienced, where they're feeling like it's just not going anywhere. They have a patient who has like diabetes or hypertension that's outside of the goal ranges and it feels like it's just hitting a wall and nothing is changing.

And so, I want to focus in on the types of conversations and ways of having those conversations that is hopefully will help you be more successful in taking care of those patients.

Before I jump in though, I've been talking a lot about chronic care over the last couple weeks and I'm really thrilled to share that I'm launching a brand new course about care of chronic conditions, diabetes, hypertension, CKD, all the bread and butter of primary care.

If you haven't gotten on the wait list for that, it's actually opening up next week. It's at realworldnp.com/courses. If you're on the wait list, I'll be sending you an email for open enrollment, but full transparency, that's the only way that you can get into the course, is by joining that wait list. Hop over there and join if you haven't already. We're going to be doing it live together in January, and I'm beyond excited. It's going to be so fun.

Anyway, jumping into this topic, so when it comes to... I kind of gave an example already, but the example I kind of want to highlight... I'll be working with a new grad, a newer nurse practitioner.

He or she or they will be working with a patient who has diabetes, for example. Their A1C is 10%, maybe 12%. Last time, it was 11%, and it seems like it's either gotten worse, maybe slightly better, and they've already had a conversation with them.

They're trying to figure out the medications like, "What's not working here? Is it the medication choices? Should I change it? Are they taking their meds? How do I talk to this person?" It just kind of feels like, "Where do I even start?" Using that as an example, the first thing I want to say is that let's just normalize this experience, number one. When I was a new nurse practitioner, it's a skill. It's not just learning the medicine. It's the actual skill. You learn a skill, multiple skills, of how to do this job, how to conduct your patient visits, how to elicit a history, time management, make clinical decisions, trust your clinical judgments, step into this new leadership role that has automatically been given to you because of the new role that you have.

That's a lot of stuff. And when I started as a new grad, I was having the same situations happen I think because I just was so focused on learning the medicine, making sure I wasn't making mistakes, learning all of those other skills, and it just felt like I just didn't have the mental bandwidth to even have these types of conversations I'm going to be talking about in this episode.

So, I just want to normalize that this is a skill. These conversations are an extra skill that we need to learn and practice and develops over time. Cut yourself some slack, especially if you're a new grad, but even if you're not a new grad, it takes time to get comfortable with these types of conversations. And real talk, the conversations are what moves the needle in chronic conditions. It's not the medication algorithm, it's the conversations.

Let's do a couple of practical steps. I love systems. I love doing things the same way every time, having a method to the madness. So, number one, aside from giving yourself some slack and acknowledging this is a skill, the first thing is about empathy. Which might sound like a really silly thing to say because if you are a nurse practitioner or nurse, likely you have to be an empathetic person. I think it would be impossible to do this job without having some sort of baseline level of empathy. But, what I'm talking about more specifically is about the experience of having a chronic condition. I think what happens so often, especially like I said, because we're still learning how to do this job and learn medicine, we get really wrapped up in that. But, I think the other part of it is that we have to keep these healthy, emotional boundaries with patients so that we can do our jobs.
But sometimes, it gets a little bit far away from the humanity of the person in front of us, because we're so focused on the algorithms and the medication choices and the frustration of like, "Why isn't this getting better? I understand the risk, and why don't they understand the risk?" I hear that a lot from people. And we just have to get back into that, like lived experience of the humanness. That our job is to be a clinician and keep track of all this stuff and understand it really well, but not everybody is in that place. And also they have an entirely full human experience life outside of the clinic, in between those three-month visits. I just want to give a couple of examples. If you've had a chronic condition or you have a chronic condition, or even if you have a close family member or friend that does, maybe you know exactly what I'm talking about and it's easier for you to remember this, to remind yourself of this. Actually, I'll just want to give you a couple examples.

First thing, I personally have had some chronic conditions. I've had to make lifestyle modifications because of an illness. I've had to take daily medications because of an illness. And I hate it. I really, really resist it. And I know very deeply that this is what needs to happen. I know it. I've learned this as my profession. I'm hopefully approaching expertise in my field. And I still don't want to do it. I just don't. And if you can just imagine thinking about taking a medication every day for the rest of your life, and think about checking your blood sugar for the rest of your life, and thinking about having to go to appointments, having to modify your life because of your chronic condition... You can't just up and go to a restaurant with your friends to celebrate an engagement. Things like that. What does that look like?

And so, just thinking about, imagining yourself in that if you don't have that experience and just trying to remind yourself that this is the context of this visit. That this person is coming to you with all these things in their life and probably resistance because most people just want to live in our normal life. Like for me, I just want to live a normal life. I don't want to have pain, but I just want to live a normal life and I hate making modifications that other people, it feels like other people don't have to do. Anyway, maybe that's TMI. That's number one, with empathy, specific empathy, reminding yourself of that. Number two, I just want to give one more example about empathy and then we'll get into some more practical stuff.

I want to give you an example of going to the vet with my dog. I love my dog. I'm obsessed with my dog. She has this enormous, queenly dog bed. She has two dog beds actually, one enormous and one on top. She's that cushy. I love my dog. When I go to the vet, I cannot, for the life of me, remember when her appointments are due, what the vaccine schedule is, what the vaccines are, what medications she's supposed to take, what their names are, the brand, the generic. I literally know none of those things. They send me a letter in the mail or send me a text or send me an email. I go to her appointments. I'm a really good dog mom. I do really great stuff for her. I love her. I want to have fun with her. I want her to have a full, happy, healthy, long life.

And also, for some reason, I want zero to do with veterinary medicine. I don't care. I don't know why because I love medicine for humans, but for some reason, I have absolutely zero motivation to learn about any of those things. I basically just do what they tell me to do. Which is a perfect example and helps me be so much more empathetic to our patients because I'm like, "Oh, right. I don't care." I mean, I care about my dog and I'm good at giving her the medicine. They prevented, I think it's for heartworm and, I don't know, some sort of tick prevention, flee prevention. I think that's what it's for. It's two different meds. It's changed a million times. I just buy a year's worth and we just keep doing our thing and come back when I'm supposed to. That's all I do. And that's all that matters to me. And I don't need to know more. And that's what it's like for a lot of our patients.

Anyway, hopefully those two examples are just helpful reminders for us when we get, especially when we work so hard and we're moving so fast and there's so much to learn. And it's easy to look at facts and information, data, rather like A1Cs, or lab results, or monofilament test results even. It's easy for us to look at data and say, "Okay, this data is not matching up. Here's the action that needs to happen. Do this." And it's like, "Okay, let's remember that we're all humans," and nobody is a hundred percent ever, ever. I overly applaud patients that tell me they take their medicines every day, because it's hard. Even me as a clinician with a deep knowledge of medicine is not taking my medication every day. I'm like 80%, 90%. I try. That's all we can do as patients. That's the first thing.

Let's recap. The first thing is about giving yourself some slack, acknowledging this is a skill.

Number two is reminders of empathy, of the experience, like the lived life human experience of having a chronic condition that it never stops. It's every day.

And then, the third kind of general topic I want to talk about or theme is talking about like, "Let's just break this down. Why is this so hard, and what can we do about it?" The things I want to highlight about chronic care of chronic conditions is that when I'm just meeting a person, this is a brand new patient to me, transferred from another provider or I just started the clinic, something like that, this person, it's like...

For example, just take diabetes by itself. Think about all the data that I need to know, that you need to know. How long have they had this for? What medications do they take? What complications do they have? What symptoms do they have? That's just baseline information. Next level, what do they understand? Do they understand their medicines? Do they understand the risks and why we care about the blood sugar number? Why do we care? What are the side effects of that? Do they know what dialysis means, if you're talking about dialysis? Because it's a side effect, like renal dysfunction is a side effect of diabetes, do they know what that means? No idea. This is just one visit looking at a brand new person. These are all the questions in my mind.

And then, what kind of skills do they have, especially with diabetes? Have they used a glucometer before? Do they understand how to use it? Do they know how to interpret the results? Do they know what symptoms to watch out for? That's a huge, just think about that. That alone, those are all, when I am seeing a patient with chronic care, I endeavor to build a relationship over time, and we're going to talk about all that stuff. And I actually just want to pause because I'm getting all worked up, but also I want to acknowledge that chronic conditions are never, okay, I never say never, but anything is possible. Chronic conditions are not solved in one day, in one visit. And I know that's really scary, at least it was for me as a new grad where it was like, "But, they need their eye exam, their monofilament, and their urine microalbumin. What if they're in renal failure right now?"

Just ridiculous. I mean, it's not, it's not ridiculous, but for the context of a patient that I'm thinking about, it's like, "No, they didn't. They just had their creatinine done. They're fine." There's so many things, information to gather, so much teaching to teach or assess, and skills to assess and then teach and guide and reinforce and remind. And then, remember, again, going back to the fact that they are full human and they have maybe children to take care of, multiple jobs that they're working, they're not sleeping well, they have a sick family member. They want to just go to a restaurant and celebrate someone's engagement, and they don't want to think about all these other things. They just want to be free.

Anyway, I just want to set the stage for that, of just keeping all of these things in mind to set yourself up for success.

This is not a one-time conversation of like, "Hey, your A1C is 10%. We're going to change this med for you. Bye." And of course, you're not doing that. That's an exaggeration. And unfortunately, our medical system is not set up for longer visit times. My point here is that those are the types of things we need to know to help people succeed with their chronic condition management. And we're not going to do it in one day. We get to do it over time. The way that I do it with patients is that, and I talked about this last week, if you didn't catch last week's episode, about the systematic approach to chronic care. Definitely go back and listen to that or watch that on YouTube if you want. It's about what are the bare minimum safety things. That's the first meeting.

And then, from there, I kind of tease it down of understanding of the side effects, because that's harm reduction. Number one, make sure that they're safe. "Do they know how to use a glucometer?" Perfect. "Do they have their medications?" Great. And then, we can go into, "Do you understand the risks, the long term risks of this? How can we explain it in a way that you understand?" The two last things I want to bring up in terms of these ongoing conversations, this is not a one time thing. This is a developing rapport. They're on your panel. You talk to them over months. You can bring them in monthly. Probably you don't have space in your calendar, in your schedule to do weekly or biweekly, but hopefully they can meet with a diabetes educator. They can meet with you. They can meet with one of the nurses and do these regular check-ins so that you feel like you are giving safe care and you know that they feel safe too.

And as long as you've established safety to start, then you can start on those next levels of like, "How are we going to get to these shared goals?" Which brings me again to my last two points, this is a little bit of a wordy episode but my last two things that are really core with having conversations with patients who have chronic care is understanding what their life is like. And I remember when I was a new grad, because I was so overwhelmed, I would meet with a mentor and she'd be like, "Oh, so who do they live with? What kind of work did they do? Do they have any kids?" I'm like, "I don't know. I didn't ask them that." It would make me crazy because I just wanted to talk about diabetes medication algorithms. And now I know, I know like I'm glad, I mean I still tried. I still was like, "Okay, I don't have time for that. That's too overwhelming. How could I possibly have that conversation?" And it also felt a little scary. I don't know, I just very invasive.
It ties into that leadership role type of thing, where you kind of just have to be direct and bold in your communication sometimes.
But anyway, I understand that now. Those are the keys. So, I always ask patients just like, again, routine muscle memory of "Oh, so who do you live with? Are you working right now? Are you in school? Oh, what kind of work do you do? What are your hours like? Do you work regular shift, night shift, weekend, stuff like that? How many days a week?" Most people will volunteer that if they're working seven days a week or overnight. And then, "Who you live with? Who's in your family?" It doesn't have to take super long, but it's really informative.

And that brings us to the last piece. This has been the hardest one for me. I actually did this as my capstone project when I was in grad school, talking about interventions for African American patients with hypertension and what were the interventions that were the most successful, I believe. I'm pretty sure that was the topic.

And it turns out of that systematic research review, the most impactful thing, regardless of dietary interventions or group program or community health workers, there were so many different nursing specific interventions that I was researching. Not medications, like medications or medications, but we're talking about nursing specific stuff. And it was motivational interviewing across the board was the only effective thing statistically. And so, I don't know how much you got into that with school, but it doesn't have to be fancy. It doesn't have to be done in this very exact specific way. Really all that it takes is humility, putting your ego aside, having courage, being brave, and asking. Just being honest.
For example, this is how it goes for me. "Mr. Jones, I'm really concerned about your health. I really want to help you achieve your goals and what you want to do in your life and stay healthy. I've noticed that we've worked together for a couple of months and my goal for you is that I want your A1C, your blood sugar test level to be 6.5%, or I want it to be lower than what it is." Just leave it super simple. "I want to understand what your goals are so that I can help you the best way for your life, because what I want doesn't really matter. It's about you have your own life." I'll say stuff like that and I'll just say, "If you're open to it, I'd love to hear from you, what's important to you about your diabetes? What's most important to you in your life? What are you worried about? What are you concerned about?" And it's kind of awkward, at least, maybe it's just me. I'm just awkward, but I'll just fumble my way through it.
And it's like, "You know what? I'm going to hold onto humility and I'm going to hold on to these highest, best intentions that I have, and I'm going to get through it. I'm going to survive, and it's going to be easier next time." I don't know why this is so scary. Maybe this is just me. But if this is you, let me know. These conversations feel hard, especially when you have less time in your visits, but it really goes back to that point I was making earlier about this is not done today in visit one. Visit one is safety, safety assessment.

Again, go back to last week's episode if you want to have a systematic approach to assessing safety and chronic care visits. Safety first and then how do you go in a harm reduction way in your interventions. Do they understand the alarm signs and symptoms? Do they know how to check their blood sugar for diabetes example? Do they take, understand their medications? Those are the main things to start with.
And then, you get into those long term, long term effects. "How do you think this is going?" I love that question. And again, I also love scripts because it's less overwhelming and less, I don't know, scary. I'll just say to them like, "How do you think it's going? What's stressing you out right now? What is most important to you? How can I best help you?" And we just kind of figure it out and see how it goes. Because, the heart of motivational interviewing... If you want to practice that skill and become an expert in it, amazing, I love that. And also, the point of it is that we're getting to their ambivalence, what they're ambivalent about, and what's holding them on either side. The thing that's driving them forward is like, "You know what? I really want to go to my daughter's wedding. I don't want to die before then. I don't want to lose a foot. I don't want to go blind." And so, you work backwards from there and we talk about how we help them achieve those goals and what support structures do they need for them and their life.

Anyway, it's not as neat and tidy as an algorithm diagnostic approach for diagnosing a condition, but honestly it really is so crucial. We have to know the medication patient algorithms. We have to. We have to know how to do medicine, but we also have to do this too. We have to eventually learn how to do this. Again, giving yourself slack, practicing being humble, being courageous, and taking up space as the leader that you now are as a nurse practitioner. Like it or not, you are, and just practicing. It's easier to practice when you're a student.

By the way, if you're a student listening, go ahead and practice this because you don't have the time crunch, and the patients, if they think you're an idiot or give you a face that implies that they think you're an idiot, it doesn't actually matter. Right? Because, you're like, "Hey, I'm a student." It doesn't actually matter when you're a new grad too because them thinking something about you is a them thing and not a you problem. If they don't want to work with you, then they can see somebody else. Anyway, it feels safer when you're a student to practice feeling like an idiot. At least that's how I feel when I'm practicing stuff like this. But yeah, it's been several years now, so I've gotten better and better at it and I've also developed those kind of scripted questions.

Anyway, I hope this was helpful. And definitely, definitely, definitely, if you have any interest at all in joining us to talk about diabetes, hypertension, or CKD, I'm beyond excited. We're going to be doing that live class. It doesn't have a fancy name, I wish it did. It's just diabetes, hypertension, and CKD review, talking about medication algorithms and titration, and clinical decision making, and when to refer to specialists, and nephrotoxic meds, and a whole bunch of stuff about renal because I love renal. Actually, I was just a peer reviewer of a renal chapter in a textbook so I'll be sure to share that when that comes out. Anyway, I love renal stuff and I know it's really tricky. If you want to join us, it's going to be super fun. Again, that's at realworldnp.com/courses is the wait list. And we're only going to open it over email. Get on the wait list and then we'll talk about it, and you can join us. It's going to be great. I hope you have a wonderful, wonderful rest of your week.

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 and 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, patients' stories, and extra bonuses I really just don't share anywhere else. Thank you so much again for listening. Take care and talk soon.