What Do Patients Need When The Cancer Prognosis Changes? | Michele Neskey, PA-C

You can study medicine for years and still feel unprepared for the moment you deliver news that changes someone’s life, then immediately have to walk into the next room and do it all again. That emotional handoff is one of the most invisible skills in healthcare, and it’s exactly what we unpack with Michelle Nesky, The Posh PA, who has spent more than 20 years as a physician assistant in oncology.

We get practical about what oncology care really looks like: the difference between medical oncology, surgical oncology, and radiation oncology, and why treatment goals can range from cure to recurrence prevention to long-term control of metastatic disease. Michelle shares how she “resets” between patient encounters, why you have to process hard moments instead of stuffing them down, and how relationship-heavy cancer care changes the way you communicate. We also talk about the game-changing shift toward immunotherapy, biomarker testing, and personalized cancer treatment, plus a reality check on chemotherapy side effects and how far supportive care has come.

Then we pivot to the other side of her work: helping future PAs get accepted. Applying to PA school through CASPA can be uniquely stressful because prerequisites and requirements vary across programs, and a small mistake can cost you an interview. Michelle breaks down what strong applicants do differently with essays, strategy, and interview prep, including the kind of “emotional reset” question that separates good candidates from unforgettable ones.

If this helped you, subscribe, share it with a friend who needs it, and leave a review so more pre-PA students and healthcare learners can find Shadow Me Next.

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Transcript

21 Years As A PA

Ashley Love 0:00

Take it from Michelle Nesky, the posh PA and someone who has spent 20 years in oncology. Getting into PA school is hard, even harder than getting into medical school. But there are some days where getting in is the easiest part of becoming a great clinician. Because one day you'll walk out of a room where your bad news has changed everything for a patient and step right into the next like nothing happened. It's the same voice, the same presence. Today I'm talking to Michelle, and she sees this gap all the time. So, what are the students who actually thrive in this environment doing differently? Welcome to Shadow Me Next, a podcast where I take you into and behind the scenes of the medical world to provide you with a deeper understanding of the human side of medicine. I'm Ashley, a physician assistant, medical editor, clinical preceptor, and the creator of Shadow Me Next. I invite you to join me as we take a conversational and personal look into the lives and minds of leaders in medicine. This is Shadow Me Next with Michelle Nesky, the Posh PA. Michelle, thank you so much for joining us today on Shadow Me Next. You have dedicated your life to being a PA and now to helping multiple of the next generations of PAs at this point. Thank you for what you do and thank you for sharing it with us today. Thank you so much for inviting me. I'm excited. It will be so fun. So you have um worked as a PA for a few years now. Can you tell us about how long?

Michele Neskey 1:31

Yeah. Um, this is my 21st year as a PA. I graduated PA school in 2005. So my God, I can't even believe I'm saying that. It's so crazy. Yeah.

Ashley Love 1:41

Absolutely incredible. And you really have, you really have flexed all the muscles of being a PA over those 21 years. Describe a couple of those roles that I think, you know, as pre-health students, we always talk about we love the lateral mobility. We love the fact that we can participate in and politics and policy formation, all of that. Have you done all of those things?

Michele Neskey 1:59

Yes, in some way or another. Um, I think, you know, what's what I think is funny is we do talk a lot about the versatility and flexibility of moving through specialties. I personally have been in the same specialty for 17 years, but I did start off as a hospitalist medicine PA, which was like an inpatient job right out of college. So um, and it was great because you know what? I didn't really know what I wanted to do. I wasn't, I had a lot of friends in PA school who were like, I want to do this. I I've had day one of PA school, I'm gonna be an orthopedic PA. And I'm like, I have no idea, you know, like I have no idea what I want to do. And so it was a nice way to learn from other PAs because it was a very heavy PA run service and be able to kind of see some of the other specialties and what I wanted to do. So then when we I moved to Miami with my now husband's uh residency for his residency, that's where I got my first oncology job. So I was in, you know, internal medicine first.

Ashley Love 3:01

So I think it's a really important thing to not specialize initially. And if it's not everybody's story, right? But I I was in GYN, which is generally it's a pretty, a pretty general specialty. Um, and you just you're able to hone in a lot of those skills that you learned in PA school. Yes. Um, and of course, oncology, really, you're you're dealing with all body systems and oncology. So you know, dermatology is a little bit different.

Michele Neskey 3:23

We're very, very internal medicine heavy, like very internal medicine heavy. Here's what I knew I didn't want to do. And so I like for me, I was like, I am not for surgery. Okay, it's not for me. And I am not for unfortunately like OBGYN. I passed out twice in the OR during OBGYN. I'm like, this is not for me. So there were things like I knew I didn't want to do. And I think that that's always good too. You don't really think about that. It's like, here's what I know I don't want to do, and then you know, kind of move on.

Ashley Love 3:57

And you know, it's so funny you mentioned surgery because you also mentioned your husband's residency in Miami. Yes, he is a surgeon. Correct. Absolutely not, not for me at all.

Michele Neskey 4:06

Yes, he is a head and neck cancer surgeon. Um, long surgeries, very detailed, you know, very he's very tactile. I have, you know, he always says my I have floppy baby hands, you know, we're very different in that kind of way. Um, but yes, it was a very interesting journey for us. Um, I met him before I went to PA school and before he went to med school. And so he got into med school first. Um, I got into PA school a year later um in different states. So my gosh. Yes. So we did a long distance relationship for four years, essentially. Like through PA school, through med school, and then got married and moved to Miami for a residency. And we're both from the Northeast, you know. So um, so it was definitely a big change and there's definitely challenges in that. But you know, I think ultimately that's what makes us like our marriage kind of stronger today, because there isn't anything either one of us won't say to each other at this point. Um, very open communication, um, very honest, you know, about where we were with things, and you know, um, it's definitely an evolution for sure, but it can be done. So absolutely.

Ashley Love 5:20

So very similar. I mean, similar. I'm sure in in head and neck ENT he gets a lot of cancers as well. And you you do a lot of oncology. Do you guys talk shop at home or does work really does work stay at work? Um sometimes.

Medical Vs Surgical Oncology

Michele Neskey 5:32

Uh we've shared patients. So we really, yeah. So we used to work at so when he did his residency, we were not at the same hospital. But when he did his fellowship, and then when we moved to South Carolina where we are, we worked in the same hospital and he's basically surgical oncology and I'm medical. Right. So we would share patients in that way. And so that was kind of fun. We don't work directly together, right? But like we're sharing, we share that patient. So I'm like, oh, you saw a day, you know. So that's kind of a fun thing. Um, we don't work at the same now, but we still kind of share some patients um ancillarily. Uh, we don't talk a lot of shock at home. Um, especially he doesn't want to, yeah, you know. Um, however, when we have a bad day or when we like there's been a really hard patience or whatever it is, it sort of is like you don't have to talk to me today. Like I get it. You know what I mean? So, like that's kind of a nice understanding that we can support each other through that. And sometimes that just looks like, let's just talk about anything else, you know. So we don't talk a lot of shop at home, so which is good.

Ashley Love 6:42

No, it does. And you know, it's it's such an interesting distinction because as I tell people, you know, we pick, we pick being a PA for the lifestyle. And a part of the lifestyle is who you're going to spend your life with, right? And my husband works in finance, and I come home and I start talking to him about the holes that I have made in people's faces, and he says, Ash, I love you. I do not love the words that are coming out of your mouth right now. Please be quiet, you know? And I said, okay, like let's change the subject, but just you know, that's why I'm a little snippy, you know. I had a I had a silver dollar size hole in somebody's nose today, and it just didn't look like I wanted it to look at the end, you know. So um, so it's very interesting, you know, when when looking at these careers, um, it's sometimes it's a group decision and you know, sometimes it's it's focusing on what your life is going to look like 10, 15, 21 years from now. You mentioned something that I want to touch on quickly, and that is medical oncology and surgical oncology. Could you give us a little definition and maybe explain the differences of those?

Michele Neskey 7:41

Yeah, absolutely. So medical oncology, so there's three branches of oncology: medical oncology, radiation oncology, surgical oncology. Medical oncology is we give all the treatments that are IV, oral, um, any type of infusional therapies. So chemotherapy, immunotherapies, um, you see a lot of them on TV, right? Like a lot of the um things on television that you see for any type of cancer. Um, we also do hematology. So it really just depends on what practice you're in. But medical oncology, you can either be hematology oncology or just med on. So hematology oncology means that you do both benign blood disorders and cancer. Medical oncology means you're straight up cancer, no hematology problems or anything like that. But really, we are the ones administering um any kind of medication, you know, to a patient for cancer. Um, surgical oncology, clearly, they are the surgeons, so they're doing the removal of any cancer either curatively or just to take it out for pain purposes or whatever it might be, more palliative. Um, so they take care of the whole surgical aspect and then radiation oncology is obviously giving external beam radiation or proton radiation therapy to specific areas of cancer. Um, so the biggest difference between medical oncology and both surgical and radiation oncology, those types of therapy are really for localized cancers, right? Like you have a spot here, let's radiate it. You have a tumor here, let's take it out. Our treatments are systemic. So they're going throughout your whole body. So while we do give treatments to people who've had surgery to prevent recurrence, we also give treatments to patients who have metastatic, somewhat incurable disease. Um, and so that's really what the differences are.

Ashley Love 9:45

Incredible. And then in medical oncology, which is where you practice the end goals are a little bit different for each patient. Um, right. So, so you know, we all like to think if we have cancer, specifically metastatic cancer, we're gonna go in, they're gonna give me chemo, my hair's gonna fall out, I'm gonna feel like crap, and then I'm gonna get better. And we have seen recent studies that have come out that have shown that yes, we are making major advances in cancer survival rates, but the end goals for patients aren't always um the same. Can you tell us a little bit about that? A hundred percent.

Michele Neskey 10:15

So, you know, sometimes we are treating patients for cure. We're giving them chemotherapy or immunotherapy to cure them, you know. So meaning after surgery, or maybe they they have a type of cancer that doesn't require surgery, like lymphoma, for example, where you can cure with chemotherapy, right? And biologic therapy. Um, and so some patients, we are going for it, like we're going for the cure, you know. Um, other people have had their tumors removed and we're giving chemo as an insurance policy to prevent, help reduce the risk of cancer recurring, right? You we can't say that this treatment will 100% do that, but we have studies that say giving you this treatment after your surgery reduces your risk of recurrence by this much. So most people will go ahead and do that, then they go off treatment, and then they go on surveillance. And then we do have other people who are being treated um for, you know, metastatic cancers or incurable cancers, technically. Um, and sometimes their outcome is to just improve their quality of life, uh, quantity of time here with their friends and family, keep the cancer under control and have them living as normally as possible for as long as possible. Um, whereas other times we can really transition people with metastatic disease into a maintenance mode depending on what type of cancer they have. And they may not need to be on therapy their whole life, but what we're seeing now with some of the immunotherapies is that after two years, you know, if you've had a response, we can stop, you know, and even talking about metastatic disease and two years of no cancer is crazy. Yeah. Like I just think back to when I started this and it was like that was unheard of, like specifically for lung cancer and like things like that, right? Melanoma, yes, yes, melanoma, like all these. So we've come a very long way. So it really depends on the patient, the type of cancer, and you know, what the goals of care are.

Ashley Love 12:18

So and you know, we that was the science, and and as TAs, we love the science, but of course, we love the humanity and medicine too. And I would imagine that the conversations that you're having with all of those different types of patients are very different conversations. How do you how do you navigate that? How do you wear one hat and then take it off? And then the next room you wear another hat, and then you know what does that look like?

Quality Question

Michele Neskey 12:38

Um, you have to sort of treat every encounter as its own, if that makes sense, right? So you you can't bring what you just said in another room into the next patient's room. And if you have to take a second, you have to take a second and it's fine. And most people will understand that, most patients will understand that, you know. Um, and so you just but you have to also, it's okay to do that when you're in the middle of a busy clinic and things like that. But at the end of the day, you do have to process those things because if you don't, you know, they do build up over time and cause a lot of emotional stress and burnout. So I think what's important about that is every patient is its own encounter. And I am there to help them get through whatever situation it is. It is not about me. Like it is about them, right? So if it was a hard conversation, it was triple as hard for them to hear than for me to deliver. And so I always remind myself that that was harder for them than it was for me, even though it was hard for me. And I have to go help the next patient and meet them where they are. And that's I think the most important thing.

Immunotherapy And Better Chemo Support

Ashley Love 13:55

This is the perfect time to break for quality questions. This is a segment on the show where we talk about an interview question you might hear on your own pre-PA or pre-med interview. The quality question here is this Tell me about a time you had to reset emotionally in a high-stakes environment before showing up for someone else. What did that moment teach you about how you handle pressure and responsibility? This is the kind of question that separates strong applicants from unforgettable ones. It's not what you know, it's how you respond under pressure and how you regulate your emotions in those moments. Because medicine is not practiced in isolation, it is practiced moment to moment, patient to patient. So the question is, can you reset or do you carry it with you? And it doesn't just stop at quality questions. There are more resources for you as a pre-health student on shadowmext.com to include our newly released application readiness course. So head on over to courses.shadowmext.com and check it out.

Michele Neskey 15:04

Also gauging the patients. So, first of all, like you said, oncology is a very relationship-heavy specialty, which is what I love about it. We see patients every three weeks, every two weeks, every six weeks, every whatever. And like you get to know them, you know, you get to know their families, you get to know their history. Some people are super interesting and you've connected with them. So if you have to deliver something that's, you know, um technically bad news or whatever, it's a little easier because you have that relationship and you can kind of say, I really don't want to deliver this, but like here's what we here's what we have to talk about. Whereas if you're trying to do it with somebody brand new, it's it's definitely a different conversation. And you just have to read the room and you have to read your patient and knowing their education level, number one, number two, what what information do they want to know? And how can you know you work together to make that process as smooth as possible? So yeah, yeah.

Ashley Love 15:59

I mean, and you know, I uh we're we're on such a sad topic right now, but yeah, it unfortunately that is this is a case. You know, people do get quote unquote bad outcomes and you do have bad news. But like you mentioned, they're I mean, in the last 20 years, advances in cancer treatment are just they're mind blowing. Tell me about something recently that is um you're just so proud of in the cancer community that that we have and that we have available, maybe maybe in an anecdote if you have one.

Michele Neskey 16:27

Yeah, so you know, I think some of the biggest, the biggest shift in cancer treatment came with the advent of immunotherapy and biologic therapy. So just so you know, immunotherapy is either IV or injectable at this point. And what it does is not to go kind of too geek on this, but we can basically it stimulates your immune system to fight the cancer. So these drugs, as opposed to chemotherapy, where we're just literally killing DNA of cancer cells in any way possible and all your other DNA through. So, you know, I mean, so that's why there's a sometimes a lot of side effects from that. Chemotherapy is still a very strong backbone for a lot of our treatments. And just to sort of, you said this in the beginning, people have a very negative outlook on chemotherapy. We've come a long way with chemo, okay? Because we've come a long way with pre-medications. So not everybody loses their hair, not everybody throws up all the time. Actually, I rarely have a patient vomit. It's amazing. So think about back in the day when people were like, you're gonna lose your hair, you're gonna be sick all the time, you're gonna be all thin and skinny. Like some people do have side effects like that, but I can say, like with authority, that very, very few of our patients vomit. So, I mean, we could have nausea, but not a lot of vomiting, you know, not everybody's losing their hair. Um, so I think that's an important thing to know. Every chemo regimen's a little different. Um, but immunotherapy really kind of changed the game, and it's approved for a lot of different treatments. And I think to me, I I have a soft spot for lung cancer. I did um, you know, I worked in a community oncology practice first, which just means it was a smaller, like outpatient office connected to a hospital that had a few physicians and we did heme and onk, and so we saw all diagnoses and all of that. And the physician that I primarily worked with had a specialty in lung cancer. So I kind of started learning about it there. But then when I shifted, when Dave went to fellowship at MD Anderson, I worked at a very I worked in lung only like lung and head and neck medical oncology only. So talk about the different like things. But I will say this uh we have two patients I could name off the top of my head who had metastatic lung cancer, who got immunotherapy for two years, have been off treatment for at least two years, and our are disease, no disease. It's unreal. None. Like stage four lung cancer, like, and there's a lot of nuances that goes into that. Not every stage one cancer is the same. A lot of markers and predictors, and that's also a huge advancement, you know. All these markers we can test for now in tumors to see if this medication will work for you, right? So just such a shift of a more it's much more of a personalized regimen rather than before where everyone just got this, you know. Now it's like this isn't gonna be a good for you, you're gonna get this. So it's definitely more driven to the patient's, you know, um, specific pathology, genetics, you know, all of that kind of stuff, um, where we're really trying to make it more personalized. And I feel like it really has come that way. But those patients that I see, I'm always just like, wow, like this is crazy, you know.

PA Admissions Coaching And Resources

Ashley Love 20:02

You know, once upon a time, we would have called it a miracle, is what we would have called that, right? I have a similar melanoma patient who um had uh melanoma of the skin, which metastasized to melanoma all over, brain mets, multiple. And every time I get a note from his medical oncologist about a clear scan, it just I have to smile first. It really does make you smile. And it just, it really, it just blows my mind. Michelle, you are incredible. The fact that you have worked in oncology for this many years is just mind-boggling. And I'm so grateful for your service there. But that is only half of what you do. I know, which is even crazier. So if you are listening to this and you're thinking, dang, Michelle is so cool. I want to be a PA. Where do I start? Well, we will tell you where to start, and that is Michelle Nesky.com, M-I-C-H-E-L-E-N-E-S-K-E-Y.com. Michelle, tell us about some of the amazing resources that you have on your website.

Michele Neskey 20:59

So um, in you know, I had my daughter in 2014. Um, I went back to work and really enjoyed it. But, you know, I have a surgeon husband who's super busy, and um, you know, we kind of felt like I was like, you know, I'm at the point in my career where maybe I can create some flexibility from home. What can I do? And I it started as a blog. Like it started as a blog, not even to like help previews. Remember blogs? I do. It feels like now, you know, everyone right now is posting about 2016. Yeah, I had a blog. Okay. And it wasn't even a blog about PA school. It was like a blog about me and Dave, like how hard it was to be like married to a resident and like that kind of stuff. And then it kind of I had some students come through and clinical research coordinators that I worked with who wanted to go to PA school. So I just started helping them, you know, I just started helping them kind of navigate through it. And I was like, you know, this this is really fun. Like this there could be something here, and just like word of mouth and Boom, like 2019. I'm, you know, I I I'm now like a pre-PA admissions coach, and um, I've been doing it since 2019. Um, so what I do and what my other PAs who are on my team do is we really navigate the process of PA school applications. And it's very confusing and it's very challenging. And every year it gets more and more competitive, and there's more and more components. Um, and I think the biggest people ask me this a lot is it harder to get into PA school than it is to get into medical school? The answer to that is no. It is harder to apply to PA school because of the variable prerequisites and requirements from program to program. And that's where we really help people navigate through that. But then we also help them with their essays and how to shine in their essays, making sure they're not making mistakes on their application by reviewing them. We mock interview people just to prepare them, you know, if they get the interview, like you have a one in three chance of getting in. So let's let's nail it. So we practice with them, you know, as much as possible. And it's been amazing. It's been so rewarding. Did I ever think I'd have, you know, all these followers on TikTok and Instagram? And, you know, no. And also, like I'm, you know, I remember so vividly going through this process by myself with no medical people in my family at all. And when I did it, oh my god, this is great. It was like like the first year of Caspa. So there was like maybe like 30 schools and the rest were paper. Stop it. So I had like paper stacks and like, and I was like, this is bad now, but at least it's not paper. Like it was it was like, so I've had to I've learned so much, you know, about the admissions process over the years and have friends and colleagues who are former program directors on my team and admissions um directors on my team that have like opened my eyes to some things too. So it's been awesome. So now I work uh clinically two days a week and I do the posh PA for the remainder of the time, and it's fantastic.

Ashley Love 24:09

Absolutely incredible. Yes, and I you've amassed a massive following on TikTok and Instagram and YouTube. And it's because the content is stuff people want to hear and need to know, right? I mean, you've nailed both of it and you do it in such a fun, engaging, and exciting way. And obviously, that all just comes back to the fact that you love being a PA. I love it. I love it. It it is a it's the job. I mean, it is just the job. So if you guys who are listening, it's gonna be Michelle.theposhpa, m-c-h e l e dot theposh pa. That's on Instagram and TikTok. You can find her on YouTube at the posh P A. And check her out on LinkedIn too. She's there at Michelle Next. You are incredible. Thank you so much for spending time with us. Thank you for creating this amazing resource. It's been a blast.

Michele Neskey 24:55

Thank you.

Ashley Love 24:56

Thank you so very much for listening to this episode of Shadow Me Next. If you liked this episode or if you think it could be useful for a friend, please subscribe and invite them to join us next Monday. As always, if you have any questions, let me know on Facebook or Instagram. Access you want, stories you need, you're always invited to Shadow Me Next. Please keep in mind that the content of this podcast is intended for informational and entertainment purposes only and should not be considered as professional medical advice. The views and opinions expressed in this podcast are those of the host and guests, and do not necessarily reflect the official policy or position of any other agency, organization, employer, or company.