September 1, 2025 • 35 mins
Kristin takes us deep into the world of pediatric autoimmune disease, where conditions like juvenile idiopathic arthritis, lupus, and dermatomyositis affect multiple body systems and require tremendous coordination across specialties. With striking clarity, she describes the challenges of working with patients who've often spent years searching for answers before receiving life-altering diagnoses.
Our conversation reveals the remarkable complexity behind treating these conditions: from reviewing extensive labs and specialist reports before appointments to crafting treatment plans that families can actually implement at home. Kristin shares the emotional weight of fighting insurance battles for necessary medications and supporting families through the ups and downs of chronic illness management.
Perhaps most fascinating is Kristin's parallel life as a professional cellist and how she sees profound connections between music and medicine. "It's not a race, it's a marathon," she explains, drawing parallels between perfecting a difficult musical piece and the patience required when treating chronic conditions. Both demand focus on long-term goals without immediate gratification, a perspective that serves her patients well.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Ashley (00:00):
Hello and welcome to Shadow Me Next, a podcast where
I take you into and behind thescenes of the medical world to
provide you with a deeperunderstanding of the human side
of medicine.
I'm Ashley, a physicianassistant, medical editor,
clinical preceptor and thecreator of Shadow Me Next.
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(00:22):
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field.
I invite you to join me as wetake a conversational and
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(00:44):
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me next, where we will reviewhighlights from this
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When Kristen Graham firstapplied to work in pediatric
(01:06):
rheumatology and immunology, shedidn't know much about the
specialty, just a few glimpsesfrom her time as a pediatric
nurse, caring for childrenreceiving specialized infusions.
She thought her path was headedtowards primary care, but that
application and a little bit ofcuriosity opened the door to
what has now been a decade-longcareer.
(01:27):
Caring for some of the bodyrequire coordination between
multiple specialties and demandpersistence in the face of
(01:49):
insurance hurdles.
She talks about the emotionallandscape of working with
patients and families who havesearched for years for answers,
the patients required to managechronic illness, and the
importance of staying curiousand asking questions, even when
you are the expert in the roomand there's another side to
Kristen.
(02:09):
She's also a professionalcellist.
The way she describespracticing for months to perfect
a piece mirrors the long gameof medicine focus, discipline
and a deep commitment to thepeople you're showing up for.
Her story is a reminder thatsometimes the most fulfilling
careers begin with the jobs wedidn't plan for and that our
(02:32):
passions outside of medicine cangive us exactly what we need to
keep showing up inside of it.
Please keep in mind that thecontent of this podcast is
intended for informational andentertainment purposes only and
should not be considered asprofessional medical advice.
The views and opinionsexpressed in this podcast are
those of the host and guests anddo not necessarily reflect the
(02:55):
official policy or position ofany other agency, organization,
employer or company.
This is Shadow Me Next withKristen Graham.
Hey Kristen, thank you so muchfor joining us on shadow me next
today.
Kristin Graham (03:07):
I cannot wait to chat with you.
Ashley (03:09):
This will be so fun.
So Kristen and I know eachother personally.
I just adore Kristen and, um,there's actually a really great
question that's come of that.
So thanks for being here.
Thanks for joining us, ofcourse, yes, so Kristen's a
nurse practitioner in pediatricrheumatology and immunology.
Such a fantastic career.
You are just insanely smart inmy eyes, for working in that
(03:32):
field, do you?
Feel smart working in thatfield, I would imagine you do.
Kristin Graham (03:35):
It's been a lot to learn, let me tell you, and I
didn't know, I did not knowanything about rheumatology or
immunology when I started theposition I'm in now, 10 years
ago.
It'll be 10 years next month,which is kind of expected when
you start in our field.
Even residents that comethrough have had limited
(03:56):
education and training inrheumatology, immunology and
medical school, and so when theypass through and they do
rotations, which are electives,they don't even have to rotate
with us.
So a lot of people don't getany exposure whatsoever, even in
residency.
But they come through and youknow we expect them not to know
very much.
And so the same thing goes whenwe hire new nurse practitioners
(04:18):
or PAs.
You know, we know that theyhaven't had a ton of education
or exposure in their graduateschool programs, and so we were
just ready to hit the groundrunning and it's going to be a
huge learning curve for newpeople, just like it was for me,
and I learned a ton, a ton, aton in the first year especially
(04:39):
, and it was a while before Istarted feeling like I kind of
knew what was going on in thelay of the land.
So it's been quite the journey.
Ashley (04:49):
I would imagine it sounds just like this hidden gem
of medicine, and I think thefirst thing that I loved about
you was just you as a person.
And then the second thing wasthat you worked in this field
that I knew so little about and,like you said, we get very
little training on it.
Um, let's just jump into that.
Actually, I was going to go adifferent way, but let's jump
(05:10):
into that.
How, what drew you to it?
I mean, if we don't gettraining to it, a lot of
students will say, well, Ash,you know, why do you?
Why do you?
Why did you know you wereinterested?
Kristin Graham (05:29):
And well, I don't know.
Let's ask Kristen, how did youknow you're interested?
Um, so I so, as I, after Igraduated with my master's
program and I was looking forjobs, um, I was working as an RN
in the inpatient pediatric medsurge unit and IMC unit and we
had had a few rheumatologyimmunology patients come through
for overnight admissions tocomplete, like infusion
therapies and whatnot, like IVIGand biologic meds, and so I'd
(05:50):
had very, very little snippets,little peaks inside that world,
but nothing, not a ton.
And so when I was graduating,my intention was to go into
primary care that's what mydegree is in is pediatric
primary care and I was jobsearching, just, was going
through the interview processand wasn't finding what exactly
(06:12):
I was looking for.
And so I was, you know, broughtin my search more, just kind of
like maybe I need to looksomewhere else.
And so opened up into thespecialty world and there was a
job posting for rheumatology andimmunology and, I kid you not,
I applied, not knowing very muchabout it.
(06:32):
I was just, you know, I neededa job, I wanted to get a job and
I had to do some Googlingbefore I did the interview, just
to kind of refresh my, you know, understanding of what that
field was, and so I could know alittle bit more about what I
was going to be getting myselfinto.
So it was really, I feel, likefate.
(06:53):
There wasn't anythingparticular before that moment
that drew me to it, but Icouldn't be happier that this is
where I ended up here on ShadowMe Next.
Ashley (07:00):
We like to talk about quality questions.
This is a segment on the hereon Shadow Me.
Next, we like to talk aboutquality questions.
This is a segment on the showwhere we discuss an interview
question that you might seewhile you're interviewing for
your health professional school,whether it's medical school, pa
school, nursing school, etcetera.
Now, kristen and I did not geta chance to discuss a quality
question, but what she justmentions brings up a really good
(07:23):
example question, but what shejust mentions brings up a really
good example.
Tell me about a time when youdidn't know much about a patient
population or specialty youwere stepping into.
How did you approach that steeplearning curve?
One of the most importantthings you can do as a future
clinician is admit when youdon't know something and then
take action to learn it.
Kristen shares how she steppedinto pediatric rheumatology
(07:47):
knowing very little about thefield, but she embraced the
challenge by asking questions,researching constantly and being
open to what she didn't know.
For you, this question isn'tabout having the right answer.
It's about showing that you'rewilling to be vulnerable, to
learn quickly and to earn trust.
(08:12):
That's the kind of growthmindset admissions committees
and future patients are lookingfor.
Keep in mind that there's moreinterview prep, such as mock
interviews and personalstatement review over on
shadowmenextcom.
There you'll find amazingresources to help you as you
prepare to answer your ownquality questions.
You know, there's two points tothat that I really want to
remark on, and the first is thateven a small exposure while
(08:34):
you're working as an RN, on thefloor with the kids getting IVIG
and these really specializedtreatments that you didn't
always see, even just a smallsnippet of that, was enough to
open the door for you to say,hey, I remember that you know,
when you start, when you, afteryou've graduated, um, it's just
amazing to me how such a smallwindow of what we've seen can
really can really looking to thefuture, can really expand and
(08:58):
show us things.
It's just very cool.
And then the second one is thefact that you researched before
you had to go on your interview.
It's just amazing and it's sogood.
I love getting to hear a medicalprofessional say that they
still do that.
I would still do that.
So if you have an interviewcoming up, get in there.
Research, learn about what thejob entails Maybe the people
(09:19):
that are interviewing you, ifyou can.
Those sorts of things.
Thank you for commenting onthat.
We don't talk about that enough.
Kristin Graham (09:24):
Yeah, no, I think it's great to you know, be
vulnerable and like, admit thatyou don't.
You don't know a whole lotabout something and I'm going to
research it and I'm going tolook it up.
And you know, I'm not going tobe ashamed that I don't know
everything, because nobody canbe expected to know everything
you know.
And even if my patients ask mea question I don't know the
answer to, I'm not afraid to say, oh, you know, I don't.
(09:46):
I don't know the answer to thatright now, but I will
definitely look it up and I'llget back to you and I'll let you
know.
So I think it's great to askquestions.
I think it's concerning when weencounter medical professionals
that are afraid of askingquestions.
I think that is a little bit ofa red flag.
(10:06):
So I really appreciate thevulnerability that comes with
asking questions, which is soimportant for the learning
process.
Ashley (10:13):
I'm sure when you first started, lord knows, you had
enough questions.
Um, when you, when you firststarted on this incredible job
in rheumatology and immunologyyou've been there for gosh you
said 10 years now.
Yeah, 10 years, yeah,unbelievable.
What.
What does a typical day looklike for you?
I think a lot of peopleprobably have many, many
(10:34):
questions as well about thiscareer.
Kristin Graham (10:37):
Sure.
So when I first get into theoffice on a workday, the first
thing I do is review myin-basket and get results
reviewed.
Our specialty is very lab heavy, so we order a ton of labs, we
order a lot of imaging.
So reviewing everything that'scome in from patients you saw
the day before or a couple ofdays prior, addressing anything
(10:59):
that needs to be addressed.
We also have an infusion roomthat's connected to our clinics
for patients that are prescribedIV infusions for their
treatment, so like IVIG orintravenous immune globulin for
people who have immunedeficiencies, and then biologic
therapies which areimmunosuppressants or
(11:22):
immunomodulatory medicationsused to treat their autoimmune
disease.
And so we do have a largeportion of our patients that get
IV infusions connected to ourclinic.
So we have to ensure that theyhave all the orders they need
and that their medications arecorrect and everything's lined
up so they can get theirinfusion smoothly.
(11:42):
So we kind of review that andthen we get our day started with
seeing return patients.
So as a nurse practitioner, wesee all the follow-up return
patients, whereas the attendingswill see brand new patients
that have been referred to us.
So we see return patients whoare coming in for follow-up or
for checkups and it depends.
(12:02):
The frequency varies dependingon what process or what point
they're at they are in in theirum journey, in their diagnosis,
and if they're a new diagnosisthey come more frequently versus
if they're well controlled inremission they come less often.
But, um, the bread and butter ofwhat we see in rheumatology
would be JIA, which is juvenileidiopathic arthritis, um, and
(12:26):
there's multiple different typesof JIA.
There's about six differenttypes, seven if you're getting
fancy.
But it all depends on kind ofthe character of their arthritis
how many joints are involved ifthere's fewer.
If there's four fewer jointsversus more than four joints
involved.
If they have small jointinvolvement versus like axial or
spine involvement, hip kneeinvolvement.
(12:49):
Also, if they have otherfeatures associated with it,
like if they have psoriasis,they would fall into like the
psoriatic arthritis category.
If they have systemic JIA, whichis the most serious and severe
form of JIA, just like it sounds, it involves multiple body
systems.
You can develop interstitiallung disease with that
(13:12):
pericarditis.
You can have skin rash, flare,fever and then the most serious
complication being likemacrophage active activation
syndrome, which is essentiallylike a cytokine storm where your
body is in this acutehyperinflammatory state and can
be life-threatening, so thatwould be the most serious form.
(13:32):
So we see lots, lots and lotsof JIA and people can have JIA
in itself or they can havearthritis in association with
other autoimmune diseases likelupus, like sarcoidosis.
So we see arthritis kind ofwithin a lot of our different
(13:54):
disease processes and not alwaysby itself.
I would say lupus is probablythe next big thing that we see
Systemic lupus, also discoidlupus, just affecting the skin
and scleroderma.
So having skin fibrosis um isanother big one juvenile
dermatomyositis, so inflammationof the muscles and the skin
(14:17):
which can cause severe musclepain and weakness, where we see
kids come in who were previouslywalking, running and cannot get
out of bed because they havesuch severe muscle weakness they
can't sit up in bed, they can'tget up out of bed, they can't
walk, they can't swallow.
So some of these diseases haveextremely severe repercussions.
(14:39):
So you get a whole wide arrayof things that we see and you
never know what you're going towalk into.
It's always a mystery what yourday is going to, how it's going
to unfold.
You just have to be on yourtoes and ready for whatever
comes in.
Ashley (14:57):
It's incredible, kristen, thank you.
Thank you so much.
I really enjoyed listening tothat.
Some of those disease processesthey do coincide with
dermatology, which is what I dolike dermatomyositis, for
example.
So I would imagine inrheumatology and immunology it's
a really cool field because youare focusing on these very
(15:17):
specific diseases, but they'reaffecting full body systems.
And so you really you have alittle bit of all areas of
medicine, I would imagine.
So again, I've told you guysshe's a genius, the smartest of
the smart, to do rheumatology,immunology.
You have to be so.
It's cool when you mentionedlabs and imaging.
That's very digital, it's verytechnological and there's a lot
(15:41):
of numbers there and a lot ofdecision-making there, but you
also get the human real human.
Kristin Graham (15:48):
So many physical exam findings.
Yes, you get everything whichis so cool.
So, like for lupus for instance, you can have so many different
body systems involved, like theskin.
You can have the arthritis, youcan have the lung disease,
pericarditis.
You can have neurologicaleffects, you can have cerebritis
affecting the brain that cancause seizures or cognition
(16:11):
issues.
You can have hallucinations,psychosis, suicidal ideation.
So there's just a ton to cover.
Renal disease is a big one.
We see a lot of lupus withkidney disease which if it goes
untreated it can result inkidney failure and dialysis for
these patients.
So when we see like a bad lupuspatient for follow-up, it takes
(16:36):
a lot of time to go throughtheir chart because it may have
been three or four months fromthe last time you saw them, but
they may in that time periodhave seen multiple other
specialists like dermatology,pulmonology, cardiology,
neurology.
You know the list goes on andin order to get a good grasp of
(16:56):
how they're doing you have to gothrough all of those notes.
Hopefully you have them all.
Go through all those notes andsee.
You know what's the status oftheir lung disease.
What's the status?
What was their most recent echoand EKG?
What was their most recent PFTand you know, is their skin rash
controlled?
So it takes a lot of reviewbefore you even go into the room
(17:20):
.
You're looking at all this, allthese documents and labs and
imaging results that might beavailable to you before you even
step into the room.
So that's.
It's very time intensive.
And then once you get into theroom, you know you're asking
them about their symptoms andwhat they're feeling and what
issues they're having with theirmedications and all that and
then physical exam findings.
(17:41):
You can see all sorts of thingsoral sores, rash, you can hear,
abnormal breath, sounds,arthritis, obviously.
But all of that goes intotailoring their treatment plan
and coming up with the bestmodifications that'll help them.
So it takes a lot to you know.
(18:03):
I think some people don't quiteunderstand how much time goes
into seeing these patients, butit is very time intensive.
Ashley (18:12):
Absolutely, and there's again.
There's a bunch of differentways.
I want to go off with this, butI think I think the biggest
thing that you mentioned is thefact that, because there are so
many organ systems involved insome of these diseases, they
have already been referred tomany specialists from their
primary doctor.
And my question for you isthese are pediatric patients.
(18:34):
They've been bounced around.
They probably feel like they'renot being heard, but the
conversation here is this is abigger picture problem.
How are they frustrated whenthey get to you?
Are parents angry when they getto?
Kristin Graham (18:47):
you Tell us about that and how?
Ashley (18:49):
you manage that.
Kristin Graham (18:50):
That's a great point we do.
We see patients who have hadsymptoms or complaints for years
, sometimes before they're everdiagnosed, and so they've been
passed around from doctor todoctor and they, you know, don't
have any clear answers.
You know they have a lot ofdifferent symptoms affecting
different areas and you knowthere's not one thing that is
(19:13):
being, you know, identified thatcan explain them all.
So they come to us, andoftentimes it has been a while,
and unfortunately that sometimesresults in having patients who
have chronic damage frominflammation that's been going
on unchecked for a long time, um, like joint deformities if they
have arthritis, um, andscarring skin rash, um, and
(19:37):
failure to thrive, you know, notgrowing and developing, gaining
weight like they should.
So it's, you know, I think theydo come in pretty frustrated
sometimes, but the relief offinally having an answer, you
know, is so it's exciting to beable to give them an answer,
although you know it's notexciting to get a diagnosis of
(19:58):
lupus, for instance, orarthritis.
I mean, it's a chronic diseasethat's going to follow you
forever.
There's no cure.
We have great medications totreat these things now and we
continue to.
There's still new biologicscoming out all the time with new
FDA indications.
So it's really such a growingfield.
(20:22):
But our a lot of our diseasesare perplexing and they're very
much a puzzle and it's verymysterious.
So, you know, for people wholove mystery and puzzles and you
know, figuring these things out, you know rheumatology is a
great feel for you.
Ashley (20:41):
So if that's you, then come on in and you are an actual
genius because the things youguys know and figure out, it's
just incredible.
I honestly forget Dr House.
They need rheumatology andimmunology.
They need a show about you guysand of the.
Kristin Graham (20:57):
From what I've heard.
I've never watched house, butfrom what I hear a lot of our
stuff is on.
It's featured in those episodes.
Ashley (21:04):
It's all such a mystery and it literally involves
everything, so they can turn itinto a whole.
Kristin Graham (21:08):
TV show because they have to do all the tests?
Ashley (21:10):
Um, yeah, let's let's talk about the chronicity of
some of these diseases.
You, you, um, you were inpediatrics and we've talked
about that.
Are your patients?
Are they all babies?
Are they mainly like?
Does JIA affect all pediatricpatients, from start to 18?
Kristin Graham (21:28):
So, yeah, so if they're diagnosed um under 18,
or if they've had symptoms youknow from before because, again,
sometimes they have symptomsfor years before they ever get
into CS If they have symptomsthat have been going on since
before because, again, sometimesthey have symptoms for years
before they ever get into CS Ifthey have symptoms that have
been going on since before theywere 18, they would fall under
juvenile arthritis.
But depending on the type ofarthritis, we do see a more
(21:48):
predominant age group, with someof them like an oligoarticular,
which is involving four orfewer joints.
Sometimes we'll see a lot oftoddlers fall into that category
.
So we'll see kids come in withbig swollen knees that are
limping or they were previouslywalking and then regressed and
(22:10):
didn't want to walk anymore,were crawling or just didn't
want to bear weight on theirlegs at all.
So we see a lot of toddlers inthat category.
I'd say psoriasis is probablymore school-aged kids and
adolescents, and then same withankylosing or juvenile
ankylosing spondylitis, which ismore of an anthocytis-related
(22:32):
arthritis picture.
They would fall more intoadolescence typically.
But yeah, we do see a lot ofyoung kids and some systemic
GIAs that are very young too,which is scary.
Um cause they sometimes come inwith.
They've had fever, abundantorigin for you know, ongoing,
ongoing, recurrent um for a longtime and um by the time they
(22:57):
come to us, sometimes they havevery severe disease.
But, yeah, so it can affectvery young kids.
Ashley (23:04):
Yeah, and and and.
Like you said, these arechronic diseases.
This is something that you know.
Perhaps one day they might hearthe news that they're um in
remission currently from this,but it's something that you, you
walk through with them for awhile, especially when,
something that you, you walkthrough with them for a while,
especially when they're seeing,you know they might see the
attending first, but now they'regoing to be seeing the nurse
practitioners for follow-up whatto describe what the
(23:26):
relationship maybe with these,these patients, but also their
families, is like, cause, I'msure you get to know their
families quite well too.
Kristin Graham (23:34):
Oh, yes, very well.
Yes, yes, quite well too.
Oh, yes, very well, yes, yes,um, yeah, they, you know, we see
them for so long, um, and theirdisease there's ups and downs
and they may even evolve overtime, like they may have started
out as one type of arthritisand they kind of evolve and
change, especially when you gothrough, like puberty hormonal
(23:56):
changes oftentimes can cause um,can kind of shake the boat, um,
but yes, we do.
We do get to know the familiesvery well, um, and just life in
general.
You know you have to roll withthe punches.
There's always going to bechanges in these, in our
patients, families, lives, um,they're going to have, they're
(24:18):
going to move, they're going tolose a job, they're going to
lose insurance, and so you kindof have to navigate all of those
hurdles and barriers with them.
We see a lot of families thathave low income or limited
resources, and so we have towork with them, with social work
, to try to figure out what thebest care plan is for them that
(24:41):
they're going to be successfulwith, you know, treatments that
they can afford, that they cando at home if transportation is
an issue, versus if they need tocome in trying to find
transportation for them, and sothere's constantly barriers,
there's constantly kind ofthings changing.
It's almost like a movingtarget.
You have to be ready to make achange to their treatment plan,
(25:04):
because just because theyrespond well to one thing when
they're first diagnosed doesn'tmean that's always going to be
the treatment for them either.
So a lot of times we do seethat they kind of become immune
to certain treatments and whatwas working for them really well
(25:26):
is no longer working for them.
So we have to switch classes ofbiologics or try something
that's longer acting or add inanother medication, and that all
you have to take so much intoconsideration when you're making
a treatment plan, take so muchinto consideration when you're
making a treatment plan and thisis probably one of the most
challenging things is justcoming up with a treatment plan
that the patient will adhere to,that the parent will adhere to
(25:47):
and that they will be successfulwith and won't they'll be able
to afford and all of those otherthings, and so that can be very
challenging.
It's just picking somethingthat they'll be able to do,
cause a lot of our treatmentstoo are unfortunately
injectables, are subcutaneousinjection shots that they have
to administer at home and whowants to give their child a shot
(26:10):
every week or every two weeks,every four weeks?
I can't imagine.
Um.
So that is incredibly heavy,especially when you're
introducing that option for thefirst time.
A lot of parents have a hardtime imagining like how am I
ever going to give my child ashot, an injection?
So it's a big.
It's a big task to kind ofovercome and to determine what's
(26:37):
going to be best for thatpatient's circumstances and that
family.
And then you just add inanother layer with insurance and
you can come up with the mostperfect plan for them.
And then you have to get aprior authorization, because 80
to 90% of our medications thatwe prescribe needs a prior
authorization.
And then insurance says no, wedon't want to do that, that's
(26:58):
not preferred.
So that adds in a whole notherlayer of challenge.
But we're very much used to it.
It's a big part of our job todo appeal letters and
peer-to-peers with physicianreviewers.
That's a huge bulk of our job.
We do those every day.
So we're ready for the fight.
Ashley (27:22):
Ready for the fight, that's exactly what I was just
about to say.
There's been a lot of infoabout peer-to-peers popping
around on social media, right,now and ensuring them.
I know you've seen them andwell, I know it's frustrating,
but is your experience shine alittle bit of light on it for us
and your experience?
Are these always so dramaticand terrible I know they it
(27:44):
feels that way when they don'tapprove something you've worked
so hard to develop, or is it?
Is it more symbiotic sometimes?
Kristin Graham (27:52):
Yeah, I tell you it's really luck of the draw.
It just depends who you get onthe other line and like what.
If you know, sometimes it'sreally luck of the draw.
It just depends who you get onthe other line and like what.
If you know, sometimes it'sit's fine and it goes so
smoothly, and sometimes they'rethey're just like tell me about
this patient and tell me what Ineed to know so I can help you
get this approved.
I mean, that's not, that's notthe norm by any means.
(28:12):
That is a more of a rarity.
But I really appreciate it whenyou get that um, so yeah,
they're just looking forinformation.
They want to, almost like theyneed some more education to be
able to determine, you know, ifthis is justified or not,
whereas other people it's likeit doesn't matter what you say
it and they don't evenspecialize in your field and it
(28:35):
doesn't matter what you say orwhat articles you throw within,
what evidence is behind yourdecision-making.
It's like they just have ato-do list and they're just
checking a box, that they did apeer-to-peer and they're going
to deny it, so you never knowwhat you're going to get.
Honestly, we do use a lot ofbiologics and therapies that are
(28:59):
off label, so we run into it alot.
But it is a challenge and we dohave, you know, usually we have
a lot of support, eitherpersonal experience or, you know
, clinical trials or casestudies to support our
decision-making, but sometimesit just feels like it doesn't.
(29:22):
It just doesn't matter.
Ashley (29:24):
Thank you for sharing that.
It's such a mystery, I think,to so many people in medicine,
but also at home.
They think that this approvalprocess is maybe something
different, and this is whereyour clinician is going to bat
hard for you.
Um, you know cause?
we're invested in our patients,but we're also invested in this
(29:46):
plan that we have developed andfor you after these appointments
and all the lab work, all ofthe data you've collected,
talking to the patient aboutwhat they're going to be able to
afford, what they're going tobe able to actually dispense to
their child, and then somebodysay, no, it's you know it is, it
is a fight, yeah Cause.
Kristin Graham (30:05):
Then you're back to the drawing board and you
have to contact the patient andsay, well, this didn't pan out.
We have to kind of go back andtalk about our options.
So, but it just comes with thejob better options.
Ashley (30:20):
So, but it just comes with the job.
Kristen, you I found out soI've known you for a while and I
found out when I was doingresearch for this interview that
you are a cellist, aprofessional cellist.
You have, um, you're not just Isaw you side eye my piano when
you walked by it when you cameto my house.
You're not just a musician, youare extremely, extremely
accomplished and, first of all,bravo.
I think playing the cello isincredible, but do you see, do
(30:48):
you see any overlap in music andmedicine?
I know there's been plenty ofdiscussions about this, but I'd
be interested to hear, to hear,your thoughts on the subject.
Kristin Graham (30:52):
Yeah, I think so .
I mean, I've been playing cellosince I was in elementary
school, since I was nine.
I started on violin first andthen switched to cello.
But I, you know, over thatperiod of time you're in lessons
, private lessons, you dodifferent courses and
(31:15):
performances, rehearsals, you'reconstantly working on new
pieces and kind of perfectingthem.
It can take months and monthsand months just to perfect one
piece, and let alone you knowone line.
That's giving you challenges.
You can go practice one lineover and over and over again,
(31:36):
and so it's a very slow processsometimes.
To prepare for performance, andI find that you have to be
focused on the end goal andthere's not immediate
gratification.
So you have to be patient, youhave to be determined to reach
(31:56):
the same goal and have that slowprogress over time to be
performance ready for something.
And I find in medicine,especially with kids with
chronic illnesses, it is a longhaul.
It is not a race, it's amarathon.
You're constantly you mightcome into bumps in the road.
(32:18):
You have to be patient.
When you start a medication,sometimes it takes weeks or
months to become effective, soyou're not going to see results
right away.
So you have to be in it.
You have to be patient, youhave to be just determined to,
you know, meet the end goal.
And that's kind of, I think,one thing that overlaps a lot
(32:41):
with music and medicine thatI've, I feel like I've
experienced.
Ashley (32:48):
That's beautifully said , and I'm so glad that you
described it that way, because Ithink for a lot of us, you know
that medicine is a long haul,but when you put it that way and
you think about how somebodypractices to perform, suddenly
it becomes a lot more tangible,you know.
So I love that.
And, of course, god, justhearing you speak, there's so
(33:10):
many connections.
It doesn't surprise me that youended up in rheumatology and
immunology, because there's somany connections.
You know you play.
You play with a symphonyorchestra sometimes as well, is
that correct?
Yeah, so you are one piece, onebeautiful, perfect, sometimes
soloist piece in this giantorchestra of moving parts.
It's just like what immunologyis.
You know, you guys are like theshining star of medicine, in my
(33:32):
opinion.
So, um, there's so manydifferent ways to pull from that
, but, um, you've got to, you'vegot to bust your instrument out
at some point.
I would love to hear it, Iwould love to see you in action.
And I do want to say just onemore thing, and that's I'm so
grateful for my friends inmedicine, especially for you,
and I think that even as amedical person, having friends
(33:52):
in medicine too, it's just sucha gift, and I'm so grateful for
you, and just knowing thatyou're out there taking care of
our kids and our teens it'scomforting.
So thank you so much.
Kristin Graham (34:03):
Oh, thank you, Thank you.
Thank you for that.
Yeah, I love medicine.
I'm so glad I ended up here.
You know there was a pointwhere I was considering pursuing
music but I decided I didn'twant to be a starving artist and
I wanted to have a little bitof a normal schedule.
A nine to five sounded a lotbetter.
So I initially started collegeas a dual major and then decided
(34:27):
that was a little insane.
If you've ever done a dualmajor with music, performance
and nursing, you know that it'spretty crazy.
But I'm sure somebody who'sdone it but it it wasn't my cup
of tea.
So I decided to go with themore reliable tract and at the
time it was a very kind ofunemotional decision.
(34:47):
But I'm really glad I ended uphere and I still get to play
music all the time, which is agreat outlet, and it's so
necessary when you're inmedicine because it can be so
stressful.
So you need to have thoseoutlets.
So I think it's been a verynice compliment to my my day job
.
I love that.
Ashley (35:07):
I love that.
Kristen, thank you so much fortaking the time to share your
story with us.
Thank you for joining us onshadow me next.
Of course, thank you for havingme.
Thank you so very much forlistening to this episode of
Shadow Me Next.
If you liked this episode or ifyou think it could be useful
for a friend, please subscribeand invite them to join us next
Monday, as always.
(35:29):
If you have any questions, letme know on Facebook or Instagram
Access.
You want stories you need.
You're always invited to ShadowMe Next.
Hello and welcome to Shadow Me Next, a podcast where
I take you into and behind thescenes of the medical world to
provide you with a deeperunderstanding of the human side
of medicine.
I'm Ashley, a physicianassistant, medical editor,
clinical preceptor and thecreator of Shadow Me Next.
It is my pleasure to introduceyou to incredible members of the
(00:22):
healthcare field and uncovertheir unique stories, the joys
and challenges they face andwhat drives them in their
careers.
It's access you want andstories you need, whether you're
a pre-health student or simplycurious about the healthcare
field.
I invite you to join me as wetake a conversational and
personal look into the lives andminds of leaders in medicine.
(00:44):
I don't want you to miss asingle one of these
conversations, so make sure thatyou subscribe to this podcast,
which will automatically notifyyou when new episodes are
dropped, and follow us onInstagram and Facebook at shadow
me next, where we will reviewhighlights from this
conversation and where I'll giveyou sneak previews of our
upcoming guests.
When Kristen Graham firstapplied to work in pediatric
(01:06):
rheumatology and immunology, shedidn't know much about the
specialty, just a few glimpsesfrom her time as a pediatric
nurse, caring for childrenreceiving specialized infusions.
She thought her path was headedtowards primary care, but that
application and a little bit ofcuriosity opened the door to
what has now been a decade-longcareer.
(01:27):
Caring for some of the bodyrequire coordination between
multiple specialties and demandpersistence in the face of
(01:49):
insurance hurdles.
She talks about the emotionallandscape of working with
patients and families who havesearched for years for answers,
the patients required to managechronic illness, and the
importance of staying curiousand asking questions, even when
you are the expert in the roomand there's another side to
Kristen.
(02:09):
She's also a professionalcellist.
The way she describespracticing for months to perfect
a piece mirrors the long gameof medicine focus, discipline
and a deep commitment to thepeople you're showing up for.
Her story is a reminder thatsometimes the most fulfilling
careers begin with the jobs wedidn't plan for and that our
(02:32):
passions outside of medicine cangive us exactly what we need to
keep showing up inside of it.
Please keep in mind that thecontent of this podcast is
intended for informational andentertainment purposes only and
should not be considered asprofessional medical advice.
The views and opinionsexpressed in this podcast are
those of the host and guests anddo not necessarily reflect the
(02:55):
official policy or position ofany other agency, organization,
employer or company.
This is Shadow Me Next withKristen Graham.
Hey Kristen, thank you so muchfor joining us on shadow me next
today.
Kristin Graham (03:07):
I cannot wait to chat with you.
Ashley (03:09):
This will be so fun.
So Kristen and I know eachother personally.
I just adore Kristen and, um,there's actually a really great
question that's come of that.
So thanks for being here.
Thanks for joining us, ofcourse, yes, so Kristen's a
nurse practitioner in pediatricrheumatology and immunology.
Such a fantastic career.
You are just insanely smart inmy eyes, for working in that
(03:32):
field, do you?
Feel smart working in thatfield, I would imagine you do.
Kristin Graham (03:35):
It's been a lot to learn, let me tell you, and I
didn't know, I did not knowanything about rheumatology or
immunology when I started theposition I'm in now, 10 years
ago.
It'll be 10 years next month,which is kind of expected when
you start in our field.
Even residents that comethrough have had limited
(03:56):
education and training inrheumatology, immunology and
medical school, and so when theypass through and they do
rotations, which are electives,they don't even have to rotate
with us.
So a lot of people don't getany exposure whatsoever, even in
residency.
But they come through and youknow we expect them not to know
very much.
And so the same thing goes whenwe hire new nurse practitioners
(04:18):
or PAs.
You know, we know that theyhaven't had a ton of education
or exposure in their graduateschool programs, and so we were
just ready to hit the groundrunning and it's going to be a
huge learning curve for newpeople, just like it was for me,
and I learned a ton, a ton, aton in the first year especially
(04:39):
, and it was a while before Istarted feeling like I kind of
knew what was going on in thelay of the land.
So it's been quite the journey.
Ashley (04:49):
I would imagine it sounds just like this hidden gem
of medicine, and I think thefirst thing that I loved about
you was just you as a person.
And then the second thing wasthat you worked in this field
that I knew so little about and,like you said, we get very
little training on it.
Um, let's just jump into that.
Actually, I was going to go adifferent way, but let's jump
(05:10):
into that.
How, what drew you to it?
I mean, if we don't gettraining to it, a lot of
students will say, well, Ash,you know, why do you?
Why do you?
Why did you know you wereinterested?
Kristin Graham (05:29):
And well, I don't know.
Let's ask Kristen, how did youknow you're interested?
Um, so I so, as I, after Igraduated with my master's
program and I was looking forjobs, um, I was working as an RN
in the inpatient pediatric medsurge unit and IMC unit and we
had had a few rheumatologyimmunology patients come through
for overnight admissions tocomplete, like infusion
therapies and whatnot, like IVIGand biologic meds, and so I'd
(05:50):
had very, very little snippets,little peaks inside that world,
but nothing, not a ton.
And so when I was graduating,my intention was to go into
primary care that's what mydegree is in is pediatric
primary care and I was jobsearching, just, was going
through the interview processand wasn't finding what exactly
(06:12):
I was looking for.
And so I was, you know, broughtin my search more, just kind of
like maybe I need to looksomewhere else.
And so opened up into thespecialty world and there was a
job posting for rheumatology andimmunology and, I kid you not,
I applied, not knowing very muchabout it.
(06:32):
I was just, you know, I neededa job, I wanted to get a job and
I had to do some Googlingbefore I did the interview, just
to kind of refresh my, you know, understanding of what that
field was, and so I could know alittle bit more about what I
was going to be getting myselfinto.
So it was really, I feel, likefate.
(06:53):
There wasn't anythingparticular before that moment
that drew me to it, but Icouldn't be happier that this is
where I ended up here on ShadowMe Next.
Ashley (07:00):
We like to talk about quality questions.
This is a segment on the hereon Shadow Me.
Next, we like to talk aboutquality questions.
This is a segment on the showwhere we discuss an interview
question that you might seewhile you're interviewing for
your health professional school,whether it's medical school, pa
school, nursing school, etcetera.
Now, kristen and I did not geta chance to discuss a quality
question, but what she justmentions brings up a really good
(07:23):
example question, but what shejust mentions brings up a really
good example.
Tell me about a time when youdidn't know much about a patient
population or specialty youwere stepping into.
How did you approach that steeplearning curve?
One of the most importantthings you can do as a future
clinician is admit when youdon't know something and then
take action to learn it.
Kristen shares how she steppedinto pediatric rheumatology
(07:47):
knowing very little about thefield, but she embraced the
challenge by asking questions,researching constantly and being
open to what she didn't know.
For you, this question isn'tabout having the right answer.
It's about showing that you'rewilling to be vulnerable, to
learn quickly and to earn trust.
(08:12):
That's the kind of growthmindset admissions committees
and future patients are lookingfor.
Keep in mind that there's moreinterview prep, such as mock
interviews and personalstatement review over on
shadowmenextcom.
There you'll find amazingresources to help you as you
prepare to answer your ownquality questions.
You know, there's two points tothat that I really want to
remark on, and the first is thateven a small exposure while
(08:34):
you're working as an RN, on thefloor with the kids getting IVIG
and these really specializedtreatments that you didn't
always see, even just a smallsnippet of that, was enough to
open the door for you to say,hey, I remember that you know,
when you start, when you, afteryou've graduated, um, it's just
amazing to me how such a smallwindow of what we've seen can
really can really looking to thefuture, can really expand and
(08:58):
show us things.
It's just very cool.
And then the second one is thefact that you researched before
you had to go on your interview.
It's just amazing and it's sogood.
I love getting to hear a medicalprofessional say that they
still do that.
I would still do that.
So if you have an interviewcoming up, get in there.
Research, learn about what thejob entails Maybe the people
(09:19):
that are interviewing you, ifyou can.
Those sorts of things.
Thank you for commenting onthat.
We don't talk about that enough.
Kristin Graham (09:24):
Yeah, no, I think it's great to you know, be
vulnerable and like, admit thatyou don't.
You don't know a whole lotabout something and I'm going to
research it and I'm going tolook it up.
And you know, I'm not going tobe ashamed that I don't know
everything, because nobody canbe expected to know everything
you know.
And even if my patients ask mea question I don't know the
answer to, I'm not afraid to say, oh, you know, I don't.
(09:46):
I don't know the answer to thatright now, but I will
definitely look it up and I'llget back to you and I'll let you
know.
So I think it's great to askquestions.
I think it's concerning when weencounter medical professionals
that are afraid of askingquestions.
I think that is a little bit ofa red flag.
(10:06):
So I really appreciate thevulnerability that comes with
asking questions, which is soimportant for the learning
process.
Ashley (10:13):
I'm sure when you first started, lord knows, you had
enough questions.
Um, when you, when you firststarted on this incredible job
in rheumatology and immunologyyou've been there for gosh you
said 10 years now.
Yeah, 10 years, yeah,unbelievable.
What.
What does a typical day looklike for you?
I think a lot of peopleprobably have many, many
(10:34):
questions as well about thiscareer.
Kristin Graham (10:37):
Sure.
So when I first get into theoffice on a workday, the first
thing I do is review myin-basket and get results
reviewed.
Our specialty is very lab heavy, so we order a ton of labs, we
order a lot of imaging.
So reviewing everything that'scome in from patients you saw
the day before or a couple ofdays prior, addressing anything
(10:59):
that needs to be addressed.
We also have an infusion roomthat's connected to our clinics
for patients that are prescribedIV infusions for their
treatment, so like IVIG orintravenous immune globulin for
people who have immunedeficiencies, and then biologic
therapies which areimmunosuppressants or
(11:22):
immunomodulatory medicationsused to treat their autoimmune
disease.
And so we do have a largeportion of our patients that get
IV infusions connected to ourclinic.
So we have to ensure that theyhave all the orders they need
and that their medications arecorrect and everything's lined
up so they can get theirinfusion smoothly.
(11:42):
So we kind of review that andthen we get our day started with
seeing return patients.
So as a nurse practitioner, wesee all the follow-up return
patients, whereas the attendingswill see brand new patients
that have been referred to us.
So we see return patients whoare coming in for follow-up or
for checkups and it depends.
(12:02):
The frequency varies dependingon what process or what point
they're at they are in in theirum journey, in their diagnosis,
and if they're a new diagnosisthey come more frequently versus
if they're well controlled inremission they come less often.
But, um, the bread and butter ofwhat we see in rheumatology
would be JIA, which is juvenileidiopathic arthritis, um, and
(12:26):
there's multiple different typesof JIA.
There's about six differenttypes, seven if you're getting
fancy.
But it all depends on kind ofthe character of their arthritis
how many joints are involved ifthere's fewer.
If there's four fewer jointsversus more than four joints
involved.
If they have small jointinvolvement versus like axial or
spine involvement, hip kneeinvolvement.
(12:49):
Also, if they have otherfeatures associated with it,
like if they have psoriasis,they would fall into like the
psoriatic arthritis category.
If they have systemic JIA, whichis the most serious and severe
form of JIA, just like it sounds, it involves multiple body
systems.
You can develop interstitiallung disease with that
(13:12):
pericarditis.
You can have skin rash, flare,fever and then the most serious
complication being likemacrophage active activation
syndrome, which is essentiallylike a cytokine storm where your
body is in this acutehyperinflammatory state and can
be life-threatening, so thatwould be the most serious form.
(13:32):
So we see lots, lots and lotsof JIA and people can have JIA
in itself or they can havearthritis in association with
other autoimmune diseases likelupus, like sarcoidosis.
So we see arthritis kind ofwithin a lot of our different
(13:54):
disease processes and not alwaysby itself.
I would say lupus is probablythe next big thing that we see
Systemic lupus, also discoidlupus, just affecting the skin
and scleroderma.
So having skin fibrosis um isanother big one juvenile
dermatomyositis, so inflammationof the muscles and the skin
(14:17):
which can cause severe musclepain and weakness, where we see
kids come in who were previouslywalking, running and cannot get
out of bed because they havesuch severe muscle weakness they
can't sit up in bed, they can'tget up out of bed, they can't
walk, they can't swallow.
So some of these diseases haveextremely severe repercussions.
(14:39):
So you get a whole wide arrayof things that we see and you
never know what you're going towalk into.
It's always a mystery what yourday is going to, how it's going
to unfold.
You just have to be on yourtoes and ready for whatever
comes in.
Ashley (14:57):
It's incredible, kristen, thank you.
Thank you so much.
I really enjoyed listening tothat.
Some of those disease processesthey do coincide with
dermatology, which is what I dolike dermatomyositis, for
example.
So I would imagine inrheumatology and immunology it's
a really cool field because youare focusing on these very
(15:17):
specific diseases, but they'reaffecting full body systems.
And so you really you have alittle bit of all areas of
medicine, I would imagine.
So again, I've told you guysshe's a genius, the smartest of
the smart, to do rheumatology,immunology.
You have to be so.
It's cool when you mentionedlabs and imaging.
That's very digital, it's verytechnological and there's a lot
(15:41):
of numbers there and a lot ofdecision-making there, but you
also get the human real human.
Kristin Graham (15:48):
So many physical exam findings.
Yes, you get everything whichis so cool.
So, like for lupus for instance, you can have so many different
body systems involved, like theskin.
You can have the arthritis, youcan have the lung disease,
pericarditis.
You can have neurologicaleffects, you can have cerebritis
affecting the brain that cancause seizures or cognition
(16:11):
issues.
You can have hallucinations,psychosis, suicidal ideation.
So there's just a ton to cover.
Renal disease is a big one.
We see a lot of lupus withkidney disease which if it goes
untreated it can result inkidney failure and dialysis for
these patients.
So when we see like a bad lupuspatient for follow-up, it takes
(16:36):
a lot of time to go throughtheir chart because it may have
been three or four months fromthe last time you saw them, but
they may in that time periodhave seen multiple other
specialists like dermatology,pulmonology, cardiology,
neurology.
You know the list goes on andin order to get a good grasp of
(16:56):
how they're doing you have to gothrough all of those notes.
Hopefully you have them all.
Go through all those notes andsee.
You know what's the status oftheir lung disease.
What's the status?
What was their most recent echoand EKG?
What was their most recent PFTand you know, is their skin rash
controlled?
So it takes a lot of reviewbefore you even go into the room
(17:20):
.
You're looking at all this, allthese documents and labs and
imaging results that might beavailable to you before you even
step into the room.
So that's.
It's very time intensive.
And then once you get into theroom, you know you're asking
them about their symptoms andwhat they're feeling and what
issues they're having with theirmedications and all that and
then physical exam findings.
(17:41):
You can see all sorts of thingsoral sores, rash, you can hear,
abnormal breath, sounds,arthritis, obviously.
But all of that goes intotailoring their treatment plan
and coming up with the bestmodifications that'll help them.
So it takes a lot to you know.
(18:03):
I think some people don't quiteunderstand how much time goes
into seeing these patients, butit is very time intensive.
Ashley (18:12):
Absolutely, and there's again.
There's a bunch of differentways.
I want to go off with this, butI think I think the biggest
thing that you mentioned is thefact that, because there are so
many organ systems involved insome of these diseases, they
have already been referred tomany specialists from their
primary doctor.
And my question for you isthese are pediatric patients.
(18:34):
They've been bounced around.
They probably feel like they'renot being heard, but the
conversation here is this is abigger picture problem.
How are they frustrated whenthey get to you?
Are parents angry when they getto?
Kristin Graham (18:47):
you Tell us about that and how?
Ashley (18:49):
you manage that.
Kristin Graham (18:50):
That's a great point we do.
We see patients who have hadsymptoms or complaints for years
, sometimes before they're everdiagnosed, and so they've been
passed around from doctor todoctor and they, you know, don't
have any clear answers.
You know they have a lot ofdifferent symptoms affecting
different areas and you knowthere's not one thing that is
(19:13):
being, you know, identified thatcan explain them all.
So they come to us, andoftentimes it has been a while,
and unfortunately that sometimesresults in having patients who
have chronic damage frominflammation that's been going
on unchecked for a long time, um, like joint deformities if they
have arthritis, um, andscarring skin rash, um, and
(19:37):
failure to thrive, you know, notgrowing and developing, gaining
weight like they should.
So it's, you know, I think theydo come in pretty frustrated
sometimes, but the relief offinally having an answer, you
know, is so it's exciting to beable to give them an answer,
although you know it's notexciting to get a diagnosis of
(19:58):
lupus, for instance, orarthritis.
I mean, it's a chronic diseasethat's going to follow you
forever.
There's no cure.
We have great medications totreat these things now and we
continue to.
There's still new biologicscoming out all the time with new
FDA indications.
So it's really such a growingfield.
(20:22):
But our a lot of our diseasesare perplexing and they're very
much a puzzle and it's verymysterious.
So, you know, for people wholove mystery and puzzles and you
know, figuring these things out, you know rheumatology is a
great feel for you.
Ashley (20:41):
So if that's you, then come on in and you are an actual
genius because the things youguys know and figure out, it's
just incredible.
I honestly forget Dr House.
They need rheumatology andimmunology.
They need a show about you guysand of the.
Kristin Graham (20:57):
From what I've heard.
I've never watched house, butfrom what I hear a lot of our
stuff is on.
It's featured in those episodes.
Ashley (21:04):
It's all such a mystery and it literally involves
everything, so they can turn itinto a whole.
Kristin Graham (21:08):
TV show because they have to do all the tests?
Ashley (21:10):
Um, yeah, let's let's talk about the chronicity of
some of these diseases.
You, you, um, you were inpediatrics and we've talked
about that.
Are your patients?
Are they all babies?
Are they mainly like?
Does JIA affect all pediatricpatients, from start to 18?
Kristin Graham (21:28):
So, yeah, so if they're diagnosed um under 18,
or if they've had symptoms youknow from before because, again,
sometimes they have symptomsfor years before they ever get
into CS If they have symptomsthat have been going on since
before because, again, sometimesthey have symptoms for years
before they ever get into CS Ifthey have symptoms that have
been going on since before theywere 18, they would fall under
juvenile arthritis.
But depending on the type ofarthritis, we do see a more
(21:48):
predominant age group, with someof them like an oligoarticular,
which is involving four orfewer joints.
Sometimes we'll see a lot oftoddlers fall into that category
.
So we'll see kids come in withbig swollen knees that are
limping or they were previouslywalking and then regressed and
(22:10):
didn't want to walk anymore,were crawling or just didn't
want to bear weight on theirlegs at all.
So we see a lot of toddlers inthat category.
I'd say psoriasis is probablymore school-aged kids and
adolescents, and then same withankylosing or juvenile
ankylosing spondylitis, which ismore of an anthocytis-related
(22:32):
arthritis picture.
They would fall more intoadolescence typically.
But yeah, we do see a lot ofyoung kids and some systemic
GIAs that are very young too,which is scary.
Um cause they sometimes come inwith.
They've had fever, abundantorigin for you know, ongoing,
ongoing, recurrent um for a longtime and um by the time they
(22:57):
come to us, sometimes they havevery severe disease.
But, yeah, so it can affectvery young kids.
Ashley (23:04):
Yeah, and and and.
Like you said, these arechronic diseases.
This is something that you know.
Perhaps one day they might hearthe news that they're um in
remission currently from this,but it's something that you, you
walk through with them for awhile, especially when,
something that you, you walkthrough with them for a while,
especially when they're seeing,you know they might see the
attending first, but now they'regoing to be seeing the nurse
practitioners for follow-up whatto describe what the
(23:26):
relationship maybe with these,these patients, but also their
families, is like, cause, I'msure you get to know their
families quite well too.
Kristin Graham (23:34):
Oh, yes, very well.
Yes, yes, quite well too.
Oh, yes, very well, yes, yes,um, yeah, they, you know, we see
them for so long, um, and theirdisease there's ups and downs
and they may even evolve overtime, like they may have started
out as one type of arthritisand they kind of evolve and
change, especially when you gothrough, like puberty hormonal
(23:56):
changes oftentimes can cause um,can kind of shake the boat, um,
but yes, we do.
We do get to know the familiesvery well, um, and just life in
general.
You know you have to roll withthe punches.
There's always going to bechanges in these, in our
patients, families, lives, um,they're going to have, they're
(24:18):
going to move, they're going tolose a job, they're going to
lose insurance, and so you kindof have to navigate all of those
hurdles and barriers with them.
We see a lot of families thathave low income or limited
resources, and so we have towork with them, with social work
, to try to figure out what thebest care plan is for them that
(24:41):
they're going to be successfulwith, you know, treatments that
they can afford, that they cando at home if transportation is
an issue, versus if they need tocome in trying to find
transportation for them, and sothere's constantly barriers,
there's constantly kind ofthings changing.
It's almost like a movingtarget.
You have to be ready to make achange to their treatment plan,
(25:04):
because just because theyrespond well to one thing when
they're first diagnosed doesn'tmean that's always going to be
the treatment for them either.
So a lot of times we do seethat they kind of become immune
to certain treatments and whatwas working for them really well
(25:26):
is no longer working for them.
So we have to switch classes ofbiologics or try something
that's longer acting or add inanother medication, and that all
you have to take so much intoconsideration when you're making
a treatment plan, take so muchinto consideration when you're
making a treatment plan and thisis probably one of the most
challenging things is justcoming up with a treatment plan
that the patient will adhere to,that the parent will adhere to
(25:47):
and that they will be successfulwith and won't they'll be able
to afford and all of those otherthings, and so that can be very
challenging.
It's just picking somethingthat they'll be able to do,
cause a lot of our treatmentstoo are unfortunately
injectables, are subcutaneousinjection shots that they have
to administer at home and whowants to give their child a shot
(26:10):
every week or every two weeks,every four weeks?
I can't imagine.
Um.
So that is incredibly heavy,especially when you're
introducing that option for thefirst time.
A lot of parents have a hardtime imagining like how am I
ever going to give my child ashot, an injection?
So it's a big.
It's a big task to kind ofovercome and to determine what's
(26:37):
going to be best for thatpatient's circumstances and that
family.
And then you just add inanother layer with insurance and
you can come up with the mostperfect plan for them.
And then you have to get aprior authorization, because 80
to 90% of our medications thatwe prescribe needs a prior
authorization.
And then insurance says no, wedon't want to do that, that's
(26:58):
not preferred.
So that adds in a whole notherlayer of challenge.
But we're very much used to it.
It's a big part of our job todo appeal letters and
peer-to-peers with physicianreviewers.
That's a huge bulk of our job.
We do those every day.
So we're ready for the fight.
Ashley (27:22):
Ready for the fight, that's exactly what I was just
about to say.
There's been a lot of infoabout peer-to-peers popping
around on social media, right,now and ensuring them.
I know you've seen them andwell, I know it's frustrating,
but is your experience shine alittle bit of light on it for us
and your experience?
Are these always so dramaticand terrible I know they it
(27:44):
feels that way when they don'tapprove something you've worked
so hard to develop, or is it?
Is it more symbiotic sometimes?
Kristin Graham (27:52):
Yeah, I tell you it's really luck of the draw.
It just depends who you get onthe other line and like what.
If you know, sometimes it'sreally luck of the draw.
It just depends who you get onthe other line and like what.
If you know, sometimes it'sit's fine and it goes so
smoothly, and sometimes they'rethey're just like tell me about
this patient and tell me what Ineed to know so I can help you
get this approved.
I mean, that's not, that's notthe norm by any means.
(28:12):
That is a more of a rarity.
But I really appreciate it whenyou get that um, so yeah,
they're just looking forinformation.
They want to, almost like theyneed some more education to be
able to determine, you know, ifthis is justified or not,
whereas other people it's likeit doesn't matter what you say
it and they don't evenspecialize in your field and it
(28:35):
doesn't matter what you say orwhat articles you throw within,
what evidence is behind yourdecision-making.
It's like they just have ato-do list and they're just
checking a box, that they did apeer-to-peer and they're going
to deny it, so you never knowwhat you're going to get.
Honestly, we do use a lot ofbiologics and therapies that are
(28:59):
off label, so we run into it alot.
But it is a challenge and we dohave, you know, usually we have
a lot of support, eitherpersonal experience or, you know
, clinical trials or casestudies to support our
decision-making, but sometimesit just feels like it doesn't.
(29:22):
It just doesn't matter.
Ashley (29:24):
Thank you for sharing that.
It's such a mystery, I think,to so many people in medicine,
but also at home.
They think that this approvalprocess is maybe something
different, and this is whereyour clinician is going to bat
hard for you.
Um, you know cause?
we're invested in our patients,but we're also invested in this
(29:46):
plan that we have developed andfor you after these appointments
and all the lab work, all ofthe data you've collected,
talking to the patient aboutwhat they're going to be able to
afford, what they're going tobe able to actually dispense to
their child, and then somebodysay, no, it's you know it is, it
is a fight, yeah Cause.
Kristin Graham (30:05):
Then you're back to the drawing board and you
have to contact the patient andsay, well, this didn't pan out.
We have to kind of go back andtalk about our options.
So, but it just comes with thejob better options.
Ashley (30:20):
So, but it just comes with the job.
Kristen, you I found out soI've known you for a while and I
found out when I was doingresearch for this interview that
you are a cellist, aprofessional cellist.
You have, um, you're not just Isaw you side eye my piano when
you walked by it when you cameto my house.
You're not just a musician, youare extremely, extremely
accomplished and, first of all,bravo.
I think playing the cello isincredible, but do you see, do
(30:48):
you see any overlap in music andmedicine?
I know there's been plenty ofdiscussions about this, but I'd
be interested to hear, to hear,your thoughts on the subject.
Kristin Graham (30:52):
Yeah, I think so .
I mean, I've been playing cellosince I was in elementary
school, since I was nine.
I started on violin first andthen switched to cello.
But I, you know, over thatperiod of time you're in lessons
, private lessons, you dodifferent courses and
(31:15):
performances, rehearsals, you'reconstantly working on new
pieces and kind of perfectingthem.
It can take months and monthsand months just to perfect one
piece, and let alone you knowone line.
That's giving you challenges.
You can go practice one lineover and over and over again,
(31:36):
and so it's a very slow processsometimes.
To prepare for performance, andI find that you have to be
focused on the end goal andthere's not immediate
gratification.
So you have to be patient, youhave to be determined to reach
(31:56):
the same goal and have that slowprogress over time to be
performance ready for something.
And I find in medicine,especially with kids with
chronic illnesses, it is a longhaul.
It is not a race, it's amarathon.
You're constantly you mightcome into bumps in the road.
(32:18):
You have to be patient.
When you start a medication,sometimes it takes weeks or
months to become effective, soyou're not going to see results
right away.
So you have to be in it.
You have to be patient, youhave to be just determined to,
you know, meet the end goal.
And that's kind of, I think,one thing that overlaps a lot
(32:41):
with music and medicine thatI've, I feel like I've
experienced.
Ashley (32:48):
That's beautifully said , and I'm so glad that you
described it that way, because Ithink for a lot of us, you know
that medicine is a long haul,but when you put it that way and
you think about how somebodypractices to perform, suddenly
it becomes a lot more tangible,you know.
So I love that.
And, of course, god, justhearing you speak, there's so
(33:10):
many connections.
It doesn't surprise me that youended up in rheumatology and
immunology, because there's somany connections.
You know you play.
You play with a symphonyorchestra sometimes as well, is
that correct?
Yeah, so you are one piece, onebeautiful, perfect, sometimes
soloist piece in this giantorchestra of moving parts.
It's just like what immunologyis.
You know, you guys are like theshining star of medicine, in my
(33:32):
opinion.
So, um, there's so manydifferent ways to pull from that
, but, um, you've got to, you'vegot to bust your instrument out
at some point.
I would love to hear it, Iwould love to see you in action.
And I do want to say just onemore thing, and that's I'm so
grateful for my friends inmedicine, especially for you,
and I think that even as amedical person, having friends
(33:52):
in medicine too, it's just sucha gift, and I'm so grateful for
you, and just knowing thatyou're out there taking care of
our kids and our teens it'scomforting.
So thank you so much.
Kristin Graham (34:03):
Oh, thank you, Thank you.
Thank you for that.
Yeah, I love medicine.
I'm so glad I ended up here.
You know there was a pointwhere I was considering pursuing
music but I decided I didn'twant to be a starving artist and
I wanted to have a little bitof a normal schedule.
A nine to five sounded a lotbetter.
So I initially started collegeas a dual major and then decided
(34:27):
that was a little insane.
If you've ever done a dualmajor with music, performance
and nursing, you know that it'spretty crazy.
But I'm sure somebody who'sdone it but it it wasn't my cup
of tea.
So I decided to go with themore reliable tract and at the
time it was a very kind ofunemotional decision.
(34:47):
But I'm really glad I ended uphere and I still get to play
music all the time, which is agreat outlet, and it's so
necessary when you're inmedicine because it can be so
stressful.
So you need to have thoseoutlets.
So I think it's been a verynice compliment to my my day job
.
I love that.
Ashley (35:07):
I love that.
Kristen, thank you so much fortaking the time to share your
story with us.
Thank you for joining us onshadow me next.
Of course, thank you for havingme.
Thank you so very much forlistening to this episode of
Shadow Me Next.
If you liked this episode or ifyou think it could be useful
for a friend, please subscribeand invite them to join us next
Monday, as always.
(35:29):
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Access.
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