IJMSC Insights: Jeffrey Hernandez on Caring for Men With MS

Jeffrey Hernandez, DNP, AGNP, MSCN

Image credit: University of Miami Health System

Jeffrey Hernandez, DNP, AGNP, MSCN, has worked at the University of Miami’s Multiple Sclerosis (MS) Center of Excellence since 2010 when he started as a medical assistant. He earned a Bachelor of Science degree from and became a registered nurse at Miami Dade College and went on to earn a Master of Science in Nursing degree with a focus on adult-gerontology primary care nursing from the University of Miami (UM). In 2020, he earned a Doctor of Nursing Practice degree from UM. Throughout the time spent earning his degrees, he continued to work at the UM MS clinic, moving from medical assistant to registered nurse to MS nurse practitioner and, finally, to supervisor of advanced practice providers.

At the Consortium of Multiple Sclerosis Centers (CMSC) annual meeting in 2023, Dr Hernandez gave a presentation as part of the Fundamentals of MS Care track. His presentation entitled Caring for Men With MS and the question-and-answer session afterward hit upon many topics that are currently being discussed in the MS community, such as the influence of sex, gender, and race on MS diagnosis, disease course, and care. He joined the International Journal of Multiple Sclerosis Care (IJMSC) to talk about his clinical practice and to provide insight into his particular patient population.

IJMSC: Can you tell me what attracted you to MS care and what has kept you in the field for more than a decade?

Jeffrey Hernandez: Actually, I just happened to land in it. In 2010 I was looking for a new opportunity as a medical assistant and, in my search, I thought that being at a university would be a great honor with the resources and the education that they offer. Aside from the opportunity to take care of patients that were living with a chronic disease, I thought, “Why not join an organization that would likely have a huge impact on my career?” And it did, particularly through mentors and supporters like William Sheremata, Silvia Delgado, Kottil Rammohan, Leticia Tornes, and my coworker for 13 years, Reshma Richardson, who have not only continued to support me throughout my career, but [have] encouraged me to continue my education and further my ability to care for people with MS. It’s been a roller coaster, but a positive one. I’m super appreciative of all my mentors and colleagues.

Can you tell me about a typical workday in the clinic?

Now more than ever, it really does vary. I have 4 days of clinics Monday through Thursday, usually, and I have 1 administrative day, which is typically Friday. Two of those clinic days, I spend half a day doing clinical research. Then in the afternoon, I’ll see some patients in the clinic. So it does vary by day and by week, and sometimes administrative tasks are added that [take place] after 5 pm. But you do what you can with what you have, and taking care of the patients comes first. I want to make sure that patients get taken care of and get their questions answered.

One of the reasons I wanted to talk to you is that both of us attended the CMSC’s 2023 Annual Meeting and I found your Foundations of MS Care presentation interesting. It touched upon a lot of hot topics in the MS space, including underserved and under-researched populations, particularly men with MS, which was your specific topic, and caregiving in MS, too. I think it was your first CMSC, so how did you find the meeting?

Yes, it was my first CMSC as a faculty presenter. I had a great time. The presentation came about because of Beverly Layton, who was instrumental in putting everything together for us. I learned a lot from my colleagues and I learned a lot throughout the week.

In your presentation, you mentioned that the population at the clinic where you work was well supported by their family members, but that you saw some changes during the pandemic. Can you tell me what caregiving looked like before, during, and after?

Prepandemic, we were not used to utilizing video or phone calls at all for patient visits. During the pandemic, it was heavily relied upon, and happily, because we needed to give them care but reduce their exposure because we weren’t sure how they would respond to an infection like that. I serve a large Hispanic population and, prior to the pandemic, they would come in with family members, especially [for] the first visit, sometimes [with] 2, 3, 4 [people]. During the pandemic, it became a lot easier to include their family members knowing that they could just pop [in] on a Zoom call or just talk in the background. Post pandemic, in my opinion, we are able to continue to utilize what we learned throughout the pandemic. I’m in Miami, and some people come to visit me from, for example, West Palm Beach, which is about an hour and a half to 2 hours away. And sometimes their spouse is working; [but I can tell them], “Call your wife or FaceTime her.” I’ll just prop them up on the monitor and that way they can listen in. And if we have any questions that maybe the person doesn’t remember, or they want to talk about something more intimate, we can talk about it. Sometimes people don’t necessarily remember all the things that they want to talk about so the family members help [them] remember.

What’s the proportion of patients that prefer telecare versus in-person visits?

I still feel that it’s pretty high, to be honest with you. I have opened up in-person visits, and they’re probably not as well attended as the video visits. Probably, 1) in part, due to Miami traffic, but 2) because it’s convenient for them. Even if they’re at work, they don’t necessarily have to take time off. I try my best not to [accept] video visits when they might be having a relapse or having new onset symptoms because sometimes that requires an in-person visit to physically do the exam. But I think we’ve all become...better equipped [to handle video] and very comfortable with [it]. I feel like my eyes have become sharper since doing videos because my exam findings are usually on point. There are differences, though. For example, you cannot necessarily examine motor strength to the best degree, but you can also see [the person] in their home environment. Sometimes when they come to the visit, they’re very well rested. At home on the video visit you can see them walking around, possibly with rugs on the floor or maybe some wires that shouldn’t be there that would increase the risk of tripping and falling if they’re using an assistive device. If they’re in a wheelchair, maybe they might benefit from a scooter or a person using a regular walker might benefit from a seated walker. In general, you get to see different aspects of their daily life when they’re at home.

Back to caregiving, you mentioned that people bring their family members in for support, especially to the first visit. Do you see differences between caregiving when the individual with MS is a man versus a woman?

When the patient is a man, maybe not [at] the first visit, but usually they’re very straight [and] to the point. They may not divulge all the little details that you really want to know. If you have their support partner next to them, they say, “No, you need to say this” or “You know, he’s downplaying everything.” The partner has more to add to the conversation. I have male patients [who] don’t want to talk about intimacy at all, and then their female partners bring it up. I learned this from my mentor, Dr Tornes—it’s like you’re having a first date, a second date. When I first meet them, I mention that we have resources, meds, so why don’t we look into that and think about it for the next visit, if they’re uncomfortable. I don’t want to make them feel uncomfortable because then they won’t come back. And I need them to come back because we want to continue providing the best care that we can for them.

Can you talk about cultural caregiving differences you’ve seen in your clinic?

As far as the Hispanic population is concerned, one thing that always comes to mind is the involvement of family and how they intertwine. People have different priorities, different opinions, and the patient’s priority might be one [thing] and the family’s might be another. The family might be more risk-averse [while] the patient just wants to hit it as hard as we can. The shared decision-making process has evolved, particularly over time and over my practice, but having the family there to have that robust discussion and talk about each other’s views and opinions does sometimes help the patient, but other times it can add more stress. I’ve had some people where [I’ve asked] them to include their family because I [felt that] perhaps they’re not understanding the gravity of the situation. So having another opinion sometimes does help.

Where do clinical care and research meet? How do they influence each other?

From a practical standpoint, I’m not doing research every day, but it is daily when it comes to taking care of patients. Most of the time, they want to know what’s new, what’s on the horizon, what they can look forward to in the future, and what it [will] mean for them. Many times I tell them, “I don’t know what this means for you yet. Once we get more data, more research, we can talk about it again.” I try to keep as up to date as I can. There’s new information almost weekly. But when I don’t know, I’ll tell the person “Give me some time to look into it and then I’ll get back to you” and I dive into the literature.

Do you find that many patients in your clinic follow the research as well?

Most of the time, they do, but generations change. Even within the culture, there may be a generational difference. If [patients] were born here [the United States], even though they’re of Latin or Hispanic origin, some of that is learned, but they also have their own viewpoint and they’re here [in the US], so they have different resources. They know the language better they might feel more comfortable. For them, knowing is important. Whereas the older generation in Hispanic culture, they might be more inclined to say, “No, you decide. You tell me what you think is best.” They really trust you in that sense. Especially in our center and I’m sure across the board for all clinicians, we try to let them know, “No, this is the part where you are involved. You need to help me make this decision. I’ll give you the pros and cons of [the] treatment and you decide if it’s the best option for you.” Sometimes you have that leeway, [but] there are some cases where there is no other option. I’ve had a few people [reject treatments] because of this [adverse] effect or that [adverse] effect. You have to compromise because in the end, if they don’t choose the treatment with me and stay with me, they’ll go elsewhere and as an MS center, obviously this is our specialty. We have to think about it all, including access to clinical trials, which is really important.

In the Hispanic culture, clinical trials are not seen in a positive way. They see it as being guinea pigs or [it] not being for them because they don’t want to be experimented on, especially when you talk to the older generation. I learned from Dr Delgado, my mentor, that this is an important conversation [so that we can] clearly define what the trial is, the study design, and talk about [the] little details in order for them to understand that this is not necessarily just an experiment and that they will be receiving treatment. Our center doesn't have any placebo-controlled trials, but they are always going to be in the back of their minds when you talk about research: “Am I going to get a medicine that is going to be effective? What does it mean for me?” Ultimately, even if they decide not to proceed with the clinical trial, we still want to take care of them.Because this study largely gathered research from patients’ experiences with MC, we believe it highlights the importance of how clinicians continue to learn from their patients and the value of empathetic listening.

How do you personally stay up to date with everything that’s going on in MS research?

At our center, we meet periodically, and we have discussions. After CMSC, we brought back some new things and we talked about them. We network with each other; we network with others. Thankfully, I have a really positive and successful relationship with other nurse practitioners and other physician assistants and registered nurses. If we see something new, we talk about it. Industry is really important in keeping us up to date because they have new data that they can share with you. I went to ECTRIMS [European Committee for Treatment and Research in Multiple Sclerosis], but I didn’t attend every session because that was just not possible. But [afterward], I was able to meet with some medical science liaisons and some clinical science liaisons, and go over some of the data I missed. I do utilize those relationships in a positive way to keep up to date as much as I can. It’s important that we keep our minds and our ears open to hearing and learning from everyone.

Can you share some of your strategies for maintaining a strong clinician-patient relationship?

I try to be as genuine as possible. I keep an open mind. I think that they see that you’re open when you start asking open-ended questions and [don’t cut] them off. I try to remember as much as I can how I would feel to be in their shoes or [to] be their family member and what I would want to talk about. Sometimes [that means] I may not necessarily get through every single [adverse] effect of every medicine, but if they’re focused on a concern, I really try to dive in as much as I can. I ask them, “Do you have any other questions?” and [then] really listen. I’m not trying to control the conversation or to end it because maybe my agenda was different than their agenda. That’s another aspect of clinical care that we sometimes forget. As a provider I’m thinking about what they look like, as far as a physical exam. How are they feeling? What does the MRI look like? Are they taking their medicines? What other medicines are they taking? Are there any interactions? But maybe for the patient, that’s not what they want to talk about that day. Maybe they want to talk about something that came up at work, [perhaps] if they feel that their MS is affecting their performance. Maybe they want to talk about a trip they took and they noticed motor fatigability and they’re not able to keep up with their family and friends. We [often] think we’re talking about everything that we believe they find important, but there might be other things that they want to talk about.

You let the patient lead.

Yes, I mean, as much as you can and when you can. If there’s something that’s pressing, if there’s a new MRI finding, or there’s a new laboratory finding that’s extremely important, then the visit probably will be more focused. Then possibly on subsequent visits you can have more patient-led conversations or open-ended conversation. I try to meet them in the middle. I tell some [patients] that [a particular] treatment is important, but they may want to get pregnant soon, or they want to do this or that. Either you meet them in the middle, or you don’t, but sometimes if you don’t, they’ll go somewhere else. If it’s a strong medical recommendation, I will say that for reasons XYZ [I think they should take my advice], even though I understand that they have other priorities. [I explain that] I’m trying to keep their MS as well controlled as possible so that they have a safe pregnancy or they meet whatever goals they have.