Hello and welcome. I am here today with Felicia. She is a assistant professor and health coach coordinator at Bucks County College, Bucks County Community College, teaching nutrition and health coaching. Outside of teaching at the college, Felicia is also the owner and registered dietitian behind Perosa, is that how I pronounce it?
Peraza. Peraza Nutrition LLC. She's a registered dietitian SM certified personal trainer and national board certified health and wellness coach with a master's degree in dietetics administration. Within her private practice, pros and nutrition LLC, she works one on one with clients to create realistic wellness solutions that will build a foundation of healthy eating and exercise habits.
Felicia started my dietitian journey back in 2013 to share her experience with others in hopes of demystifying the field of dietetics. Felicia is currently a mentor for fellow dietitians, starting their private practice and dietetic internship preceptor for RDs2B. Welcome to today's episode. Thanks for having me, Libby.
Yeah, super excited to have you. And Felicia was recently a guest inside of our membership, which is really fun. So we talked inside of the membership about being a better clinician and skills that you can focus on to improve how you can not only get better patient outcomes, but really. Feel confident about applying your skills as a dietitian.
So today I was hoping we could go over the three scenarios and kind of talk out what tips you have to help the listeners improve their clinical skills. Anything you want to add to that before we get started? No, I think that that's a great start. Alright, cool. So thank you so much for your time and for being here.
So can you bring up the topic of the first case study and we'll, we'll kind of give a recap of that. So, if you're working with a patient who is maybe unmotivated or maybe not making as much progress as you would hope that they are. So the, how often would you say in your private practice or with working with dieticians, does that happen?
I'd say probably it's it's at least on a daily basis that one of my patients is either like getting really stuck in terms of their progress, so they've been kind of doing things for a while, but they're just kind of hitting a plateau, or they feel like things aren't moving along quick enough as well or I've got patients to where they.
Each appointment they come in and they're like, you know, I'm, I'm, I'm off track again. And so it's kind of this constant, like on track off track on track off track. And then really, we don't see much in terms of progress because they're kind of starting and stopping back and forth between our appointments.
And so, with that, do you think that's an insurance thing, or is that true across the board? Is that also true for cash pay? I see with both. One thing I did notice I'm primarily insurance based. When I first started, I was more cash paid and I did find that people were more cash pay if they were getting like unmotivated or not making progress, they were more likely to cancel than with the insurance because it's like, you know, my insurance is, is covering it.
But with the limitations on like with some of the insurance plans as to what they do cover, I do find that sometimes people are, are still very, Okay. You know, cautious about those appointments and how they spend them because they, you know, want to save that time and if they feel like they're not making progress or the appointment might not be worthwhile for them, they might, you know, cancel or keep pushing back their appointment because they're like, I'm not ready or I'm not, you know, making the progress I should, I should, you know, hold off on scheduling until I'm ready.
Yeah, and so the problem with that, well, do you want to share the problem with that? I'll hear your perspective first. Yeah, well, I mean, feeling ready. I think that that's a lot of people will never actually feel ready. And so it's, it's a matter of, there's never a perfect time to put nutrition first and to put yourself first.
It's a matter of helping identify helping you as, as practitioners, our role is to help them identify. Some of their limiting beliefs around nutrition, and they have to take the action. Like, they're responsible for taking the action on us. So I think a lot of dietitians and a lot of our clients put that responsibility on themselves and say, oh, my client's not going to result.
It's my fault. And I want to take that stigma out and say that, you know, let's be really clear about our role and their role. Because there's only so much we can do and that's why I love the model of stages of change behavior change. So if we're clear with where they're at on the stage of change model, and we're using our toolbox of motivational interviewing tactics, that's the best that we can do.
Right? We can standardize our care and look at being consistent with processes and writing notes, whether it's cash pay or not. But there's only so much control we have over so many things, but people will make excuses to not start or do, do a lot of things nutrition or not. So I think there's never a best time, but there's always great to put our, to put nutrition 1st.
So there's just a lot of angst and anxiety that I see a lot of our clients have around air quote results with our clients. Anything you want to add to that or anything I was missing. No, I think that was great. It's funny because I. I used to be very scared of when a patient would tell me like, I'm not feeling very motivated or I'm not making enough progress.
And it's like, Oh gosh, what am I doing wrong? And over the years, I've, I actually am more excited about those individuals because I love being able to kind of really dig deep with them and you know, what's working, what's not working. Let's look at motivators. Let's kind of take a step back from goal setting and.
You know, take a look at values and using different tools, like something called decisional balance, which is great when someone's in that like contemplation stage of the pros and cons being really equal. And that's, I love that space because it's a lot of like really digging deep with an individual and you get those moments where they're like.
You know, that makes sense, or this all of a sudden is the thing that, you know, gets them over the hump. Or sometimes it's just that much closer in the pre contemplation to getting to preparation and not that all of these big elaborate goals are happening. But I really love that space and being able to kind of like.
Just workshop with someone and it used to scare me when I first started, let's, let's take a moment. And for this case scenario, before I move on to the next 2, which are also really, really great comments scenarios, let's, let's hold some space for a moment about your journey of when you felt scared to them.
Now, where you feel empowered to help this difficult. Like scenario with, with patients, what got you from feeling like, oh my gosh, this again to now feeling like you like that type of population, like what helps make that change and what tips do you have for the clinician? Who's not feeling like they like this type of client?
Yeah, I think there was a combination of practice and just kind of like, really getting through those, like, scared moments. And also expanding my knowledge in like. The stage of change I learned about when I was in my undergrad, but I went through a coaching program and I learned a lot more and I got to like really dive deep into motivational interviewing again after I had already been practicing and working as a dietician.
And so I was able to kind of see it a little bit differently than when I was in my undergrad, kind of learning that information. So it was a combination of like. Really revisiting motivational interviewing and really looking at the stages of change looking at like resources about how to help individuals when they're in a different chain, a stage of change, because that was something that I didn't really recognize before was like, you identify someone's in a stage, but then like, what?
Do you do in those instances? So it became more exciting to kind of like practice those newer skills. But also the, the actual practice itself and seeing individuals one on one that helps build my confidence too, because just the more you could practice those skills, the better you're just going to get at it too.
So, so that's, thank you for sharing that. And what I'm hearing is education and application. And what I, what I see is a gap from a lot of our listeners is the, is the lack of application. And so a lot of our clients will come to us and say dietitians and clients say, so they'll say, well you know, I'm frustrated because of X, Y, and Z.
But the reality is they're not actually getting clients under their belt to work with. So my theory is you get 20 to 50 sessions at least, and start working with this population. It's not just this population. There's always going to be people who are not motivated. That's just how it is counseling, whether it's cash pay or not.
If you're getting working with people and you're understanding their motivations and you're using your toolbox and getting experience and reflecting on that, that's the best way that you can improve. Yeah, absolutely. It feels scary, right? It is very scary because it's the unknown and especially if you're working for yourself or you have, you know, your own practice and it's, it can feel like a lot of pressure to say, like, if I'm losing someone, I'm also losing income.
So you want to, like, hold on to them as tightly as possible. And so sometimes it feels like, well, if I'm practicing these skills, I'm not. Being a good dietitian, that's what I used to say to myself if I'm practicing, but it's like, no, I am bettering myself in this process. They're getting a great experience still too, and I'm fine tuning what I need to, to become an even better clinician.
So. And what, what helped you with that mindset? Because I know we talked before about it's easy to say those things. It's not easy to do it. What helped you overcome your fears? Was it an affirmation practice? Like, what helped you actually say? Like, I'm just going to get these sessions under my belt, which is.
Sounds so simple, but it's not. Yeah, it was, it was definitely a combination of like positive self talk. I, I keep a business journal and I kept it when I first started and just kind of one being able to like put my thoughts on paper. Like for me, I'm, I am someone who when I journal, I'm able to kind of like, Take a step back from it versus like the constant stream of thoughts in the head so that it was actually really helpful And being able to talk to not just another dietician about it who was going through it that could provide support But then also like my partner my husband and who is someone who can provide that like external like hey Take a step back first and kind of like check there so I think having both that like personal support, having the kind of professional support from like the dietetics community, and also being able to like really work through my own thoughts as well and have that like positive affirmations, which I used to be like, what positive affirmations?
How are those going to be helpful? But they really are like, what you tell yourself is what you end up believing. So being able to say to myself, like, I got this, you know, and I'm a work in progress and just I have like little sticky notes here on my desk of like reminders to myself and all that stuff stuff for me really definitely helped.
Well, thank you for sharing that because I think that those moments of us overcoming when it felt scary to when it feels like you can embrace. Something uncomfortable is always important to take a moment and reflect on that story. And I love your examples. It wasn't just one thing. It sounds as a recap, like it was a few things, like your support system is your partner, your husband and the dietetics community, which is support system, but that's more peer related.
Right. And then also your introspective practice, which happened to be positive affirmations for your particular example. So as a recap, that's what helps you overcome and get from, Oh, this is scary. Am I good enough? Am I, you know, not being good enough clinician to now saying, approaching your day and your schedule and saying, Oh, I embrace these challenges.
I embrace this application. You know, knowing that you're making an impact. So thank you for sharing that. Let's talk about the second case scenario. Cause I think that non compliance is. Probably the number one issue, one of the top issues outside of cancellations that I know our clients get frustrated about.
So I'm glad we were able to talk about that. What's another issue or something that you see recently that is a sticking point if we were to talk about a theoretical case study? Yeah. I'd say that probably actually a lot of my population right now, it's, it's pretty uncommon to not see this someone coming in with a co occurring mental health condition.
So whether that is anxiety, depression. Bipolar disorder, PTSD. But that is definitely something I'm seeing a lot more of my, in my practice. And this like post COVID, I think definitely kind of ramped that up. But just those individuals and kind of how you're working with someone while also knowing that they're managing a mental health condition and what that can look like.
And so with that, and I, I have a feeling, I know we've talked about this before when you were a guest in our membership, like, but that's been the case for a while. We're just not noticing it. Right. If we talk about undiagnosed conditions and situations or diseases, however, you define it in that context.
So then how do you solve for this? Like, what, how do you go about this? How do you demystify how scary it feels? To be a practitioner was such a heavy load, right? So much responsibility from navigating a difficult client to now coexisting conditions that might not even be diagnosed. Yeah, and that that's I think even the scarier part two is like the diagnosis sometimes like being able to check in with patient, especially if they're working with a therapist, it kind of feels like it takes the load off of me because I know that they have that other, you know, healthcare professional in the space with them.
What I find sometimes can be the more concerning is when someone has a mental health diagnosis, but then they're coming to me and they. Aren't working with a therapist or they're not seeing like a psychiatrist or a regular doctor consistently and then it's almost like I'm, I'm worried that they're going to fall through the cracks, especially if they're not managing it well on their own.
It's not to say that, you know, I don't have patients who have co occurring conditions that are actively managing them, but that sometimes is not the case. And it could be because of. Lack of support from a health care professional not knowing what resources are available or just the stigma that's attached to mental health diagnoses and that, you know, an individual might feel like they might be judged or, you know, taken less seriously if there's a health care provider that knows that they have a mental health diagnosis to.
Yeah, absolutely. So, with that is there any other action steps that you want to share? Or it's just a matter of I think what I'm hearing is working with the interdisciplinary team, because if you're working with other providers, and, you know, that your patient has care. in other aspects that are out of your scope, then that, you know, helps you know that you're providing a well rounded that you are providing well rounded care.
So that's kind of my main takeaway from what you're saying. Yeah. And I would say too, you know, if you're working with individuals who have mental health condition, I think kind of the first step is really getting to know what those conditions might look like, because I know for some people, they might have a very, Deep familiarity with mental health diagnosis, maybe for themselves or their family.
But if not, kind of just like learning about what depression is, learning what anxiety is, how that can impact somebody on a day to day. It's not to come from any place of like diagnosis, but to just really better understand the individual. And it's not going to present the same way for everybody. So that's where, you know, listening and really getting to know your, your patient, your client is going to be important.
But then after, you know, kind of having some Some knowledge yourself when you're working with an individual, whether it's your intake paperwork, kind of having a section where they can include that in their, you know, medical diagnoses or that can be a part of the conversation, but also knowing like to follow up, you know, check to see if they're working with therapists.
If they're interested in working with one, or if not, maybe connecting them with other resources. So having those kinds of resources available places you can refer them to, you know, whether it's support groups or if they're in crisis, and I think that that also helps, you know, for me as like a feeling comfortable and confident in the appointment is to be able to have resources that I can refer someone to if they don't have that support system in place already.
Yeah, so what I'm hearing what I think I'm hearing is your workflow. So your assessment in some way has an opportunity to capture to give them a chance to share that with you, which we, I mean, we need to have that as practitioners some way to capture medical history. I mean, of course, we can abbreviate that, but that's part of the process when it comes to at least 1 on 1's right individual care.
So you have that in the assessment workflow where you're asking them these questions, and then you as a practitioner aren't, are not ignoring that if they tick something off, and it's, you know, medical related, diagnosed said they have some diagnosis in the health care, mental health space. You're acknowledging what they had put in the assessment form, and then you're, Maybe ask them if they want to talk about it or just checking with resources and mentioning that so that to see that they have care.
I'm assuming you also chart on that to be comprehensive and to at least acknowledge it. So then that way you're being really comprehensive. So to me, that's doing your due diligence. Of course, the, how you counsel about it and their willingness to talk about it as a different topic, but at least you're covering it in your workflow, you're documenting it, you're providing resources or asking them.
And that's. You know, the best you can do. Yeah, that's, that's exactly, you're kind of covering your bases, but you're also coming from a place of like really getting to not just know your patient, but also making sure that you're taking the best care of them while they're in that space with you. So that's going to come with like that kind of that comprehensive approach.
Yeah, and is there any quick scenarios that you feel really proud of any stories or things that have been challenging and maybe caught you off guard when it comes to this particular scenario with you providing help as a in your private practice? Yeah, I actually, sometimes I get patients who have, quite a lengthy list of like medical conditions and mental health diagnoses as well. And they might see a lot of different practitioners. And sometimes if they're really in the thick of like a depressive episode or something like that, they might miss appointments, you know, with their doctor's offices, or they might come off as like being noncompliant, but it's because they're really struggling to get through the day and sometimes coming from a perspective of not just.
You know, actively listening, but really having empathy for that person and holding space for them. I found that there was a patient that I had recently where they were just feeling really frustrated with all the doctor's offices and all the appointments they were having and then also feeling like they were being swept under the rug.
It's like they're talking it up to a mental health diagnosis when really it's something physical that's going on, and they were kind of feeling like they weren't being heard and in session created space for them. Ask questions. I was empathetic and being able to, to be that person, you know, not to be in the role of a therapist, but just, just actually listening to what they're saying.
And again, being empathetic, that made a difference. And they kept scheduling appointments and they actually, their insurance wasn't even covering at that point, they were scheduling appointments because they felt like I was in it with them to understand what they were going through enough to be able to provide.
Suggestions or strategies that were going to be the most helpful for them to manage their nutrition while also dealing with all this other stuff. And they felt comfortable then to, you know, work with me in that process. And we, you know, our goals were a lot different than some of the other patients I work with.
You know, we were looking at more kind of like really easy packaged items to just kind of get through the day, but coming from that like nonjudgmental space. Holding that space for empathy, actually actively listening, that made a difference and made the relationship better. They trusted me more to then actually have, you know, a really good working relationship.
So. Thank you for sharing that. And I think that that's really powerful in terms earlier, we were talking about business skills when I was on your podcast that transfer over to clinical skills, and we talked about listening being a main one. I had said that listening is main one. And I, it's just interesting to hear you talk about that in practice because.
You being able to have that, hold that space to listen, encouraged retention with that client. And maybe another, I can't say this for sure, but maybe this person felt dismissed in other contexts. So there's, there's a lot to be said when it comes to practicing empathy as a clinician. But then in practice, it's not just asking them.
The question that's really sitting and listening and allowing them to speak. And that, that does take some, there's a skill there, take some practice to be able to do that. So you're doing a great service by role modeling that and diet headaches. And then obviously we have to stay in our scope. So referring out, making sure they have appropriate resources and we can't therapize them.
Right. So it's important to note that as well. Yeah, that's staying within scope can be really difficult, especially when you, you know, have, like, really emotionally charged conversations. And so being able to recognize, like, you know, at what point are you kind of edging towards the edge of your scope, but also knowing, like, what do I do when I get there?
How do I navigate this conversation and having the confidence to be able to say, like, You know, I really appreciate you sharing with me. This is, this is out of my scope. I want to be able to help you with, you know, kind of the next steps here. So whether it's connecting with a therapist or whether it's, you know, sharing external resources, or maybe just kind of navigating the conversation back to, you know, what is within your scope, but that's being able to recognize, you know, where that could be happening to make sure that you're staying within those ethical bounds.
Yeah, thank you for mentioning that because that's also really important and, you know, we can't police that with you, but ethically, we want to stay within our scope. I think that's also another podcast episode for another day. It is, and especially with, like, you said, you know, COVID and accelerating some of these mental health, whether they were existing and not diagnosed before from the provider or not, it is more of a, you know, I guess more of a common topic now than it had been in the past.
So I think it's important that we talk about these clinical skills and how we can handle them to be better dieticians. I had to improve our confidence, which then can help us retain clients, which then helps us grow our business. So, okay. The last scenario I want to talk about, cause I wanted it to bring up three case studies today.
And we went a lot deeper inside of the membership. So I want to thank you again for being a guest and providing your time and Q and a for our clients is just so fun. The last scenario has to do with cancellations. It's so funny, Felicia, because out of the three scenarios we talked about today as a recap, we talked about non compliance, we talked about mental health and other existing conditions, and now we're going to talk about cancellations.
I get the most questions about cancellations, but really, if we could really dig in and learn how to work with non compliant patients and coexisting conditions and operating within our scope, those are actually the really, really important things, but for some reason, everyone wants to talk about cancellations and policies.
Thank you, guys. I just wanted to put that out there. So if you let me know what your thoughts are and if you could just give a couple give some context to this case scenario to help the listeners get some skills under their belt. Yeah. So with cancellations and this can range from like.
Straight up cancellations or reschedules late reschedules or the person who was consistently rescheduling their appointment at the last minute and kind of like how to navigate that. And I've had, I would say in terms of like cancellations, that tends to be that initial patient who's just being onboarded where there's cancellation and the reschedules tend to come from like the follow up patients.
And sometimes those like late reschedules can be. You know, patients I might be working with and have been working with for a period of time. But the biggest thing is really to first just have a policy in place. You know what you're enforcing. So when I first started my practice, you know, I didn't really have a policy in place.
I had other policies, but it's like, then I needed to figure out that I needed a policy. You know, when was the cancellation? Like timeframe is a 24 hours is a 48 hours. But then also following through with like, what happens if they do like cancel or they charge the entire session or they charged a fee.
And I've actually changed that over the years to like charging a fee versus the cost of the session. And that's just the way that I do things because I'm, I'm really not sitting there for an entire hour where their appointment doesn't happen, but it's really that, that, you know, 15 minutes or 10 minutes of, you know, waiting and.
Breaching out to them and then, you know, that, that extra five minutes. So I think the biggest thing is being able to first recognize like what your policy is going to be and then moving towards like, then how are you going to notify individuals of the policy? So they're aware of it when they first get onboarded and reminding them of it as well.
So like I have automated reminders through my electronic medical record system and. They go through text, they go through email, they're in the policies they sign off on, but they're reminded at that, like, 72 hours, the 24 hours and the 10 minute mark for their appointment with the policy about cancellations too.
And I know we talked about this before, but this is standard for other providers. Doctors do this healthcare practice. Therapists do this for some reason. Dietitians and I can speak from listening to our clients over the years. We've served over a 1000 dietitians. Like, they do not create policies or they don't enforce them.
And I've talked about this before. I've created YouTube videos about it. I've talked about this on podcast episodes. The 1st step is to create a policy and not worry about it being a perfect policy, but just have. Contracts are, you need to have them, right? So that, that's what I mean is a contract that will have your policy in it.
It's standard to have a cancellation policy. So first we need to have one. And then the second thing, and dietitians don't often do that. So the first half one, you will be taken more seriously. If you have a policy, you are a professional provider, you can't run a business without policies. And then secondly, if you don't enforce the policy, why do you have it?
So that's that's the other issue I see is that dietitians won't create a policy, or they just throw it out the window when they feel uncomfortable. They get emotional about the policy, or they don't want to enforce it. Of course, there's always exceptions. Right. I'm not, this is not black and white.
We live in a, in a world where we have to make some decisions sometimes if you want to override the policy. But I'm not talking about those five, 10 percent of emergency situations. I'm talking about the general, like day to day stuff where people just don't give notice. They don't show up all of that. And it needs to be honored really, because it goes back to self talk.
Like how can we respect ourselves if we don't if we allow other people's to disrespect our practice. Yeah. And your time, you know, your time is money. And I, one of the things that definitely helped me was like, just reminding myself, like, I am not the only healthcare provider that has a cancellation policy and my doctor's office, if I know show, they will charge me if I lay cancel, they will charge me.
And it's not because they're trying to be mean or anything like that, but I'm, you know, that's their time that are being wasted, but also not the. Another patient can't come and slot into that spot. So that that was something that helped me a lot was kind of reminding myself like all of these other health care providers, you know, a therapist doctor's offices, they have very clear cancellation policies and a lot of the fees can be elsewhere.
Pretty high. Just saw one recently that was like a hundred dollars if you know, show or like cancel for like a therapy fee. And it's like, it can, they can be really high. So, you know, what I'm charged is, is pretty nominal. But you can also, like you said, you know, have some flexibility, but that be not the norm, the norm to be that you are enforcing it because you are a healthcare provider, you are a practitioner and that is your time.
That's, you know, you're not seeing a patient or somebody else. Absolutely. And I just want to reiterate that before dietitians, we tend to be perfectionists. So before we get caught up and like, how much should we charge and thinking about, like, what will it look like for the no show think what matters is just to create something and it's okay if it's not a high amount but just have something on there and then practice enforcing it.
And you can always optimize it that process later and adjust it. Like you mentioned, Felicia, over the years, you've adjusted yours, Pat. So have I, we all have. I think I used to have a 24, now it's a 48. Hour policy, I'd be happy to do 72 hours. I don't know that that's very fair, but the idea is, I think 48 hours is good.
But, but again, it's just having something. And then like over time. Adjusting it, and then if you adjust it, you have to let everybody know so that you're being fair and your business practices and you're being taken seriously. So I think that's a really important topic. Anything else in context of policies and procedures that you want to share or reflections that would be helpful before we wrap up.
I just think the definitely having a policy, but being willing to. Like adjust as you go, because like I said, you know, same thing I was, I was at a 24 hours and now it's like, I think we should move to 48 hours in terms of the timeframe for cancellation. But that also takes some like, you know, critical look at, you know, what's happening in the business and not just kind of going along blindly, but to be able to kind of take a critical look at what's happening, what are trends that you're seeing.
And I also found with like more reminders that that actually helped with keeping patients either from late canceling or. They would reschedule, you know, within that time frame, or they kept their appointment because they didn't forget about it until the last minute. And so that actually was the most helpful and not having so many cancellations and reschedules was having those reminders for patients.
So any way that you can really help to build that in, I think that that's going to be something that can can really help as well. So, yeah. Yeah. Great tips. And thank you so much for sharing those three scenarios and giving some context for clinical skills and some stories about where you were to where you are in growing your business.
And thank you for all the work that you do. So where can the listeners find you and check you out if they haven't already. So right now I have, I have two businesses, the pros nutrition and my dietitian journey. They're both on Instagram, but the right now everything is housed under pros nutrition.
com. We are working on building a website for my dietitian journey. And then we have the my dietitian journey podcast on YouTube which is where we share, you know, information and tips and resources. So you can check us out there. Awesome. Thank you so much, Felicia. It's been an absolute pleasure to be able to hang out with you tonight.
So thank you for sharing your tips and tricks and all your clinical skills with the listeners. Thanks for having me. I really appreciate it.
