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cf1f54850f53b2c0be6a23fcb65d2ae7-huge-0fAs we enter the season of giving, today on the blog, we'll look back at one of many blog posts about the students that give to their communities through many hours of volunteer service in student-run free clinics. 

By Katie Gesbeck

One evening during my first year of medical school, I was waiting by the entrance to The Salvation Army to let another student back into the free clinic.  The weekly clinic was organized by MEDiC, an organization of student-run free clinics in the Madison area.  A family with four small children was returning to spend the night at the shelter, and one of the kids saw the stethoscope around my neck.

“What’s that?” A boy who was about five years old asked.

“It’s so I can listen to hearts,” I explained. 

Then they all wanted to know if I would listen to their hearts and if they could listen to mine.  Spending that time with them, showing them how to listen to my heart, and making sure they all had a turn was the highlight of my day. I knew that I wanted to have interactions like that every day. 

That wasn’t the first time I had considered pediatrics as a career. Even as a college undergraduate I knew I was interested in pediatrics. I worked as a research assistant at the University of Wisconsin Hospital in Madison within the department of pediatrics, observing and coding data from over 400 pediatric acute care visits.  Even though most of the visits were children with upper respiratory infections, every child was different and presented a unique puzzle.  Also a puzzle was how the doctors found the right way to communicate with each family.  These challenges spurred my already-discovered interest in pediatrics that dates back to assisting in the infirmary at a summer camp when I was a teenager. 

My experiences so far as a medical student have continued to reinforce my desire to become a pediatrician.  They have also shown me definitively that I want to care for the whole child and build the long-term relationships that are possible in primary care.

While on rotations, such as neurology, psychiatry, and surgery, I found myself frustrated at focusing on only a particular organ system or problem and not on the child as a whole.  I enjoyed my time with these children so much, however, that I found it hard to say goodbye.  I still wonder how each of the patients is doing; it was hard leaving and not knowing what eventually happened with each child.  Primary care will allow me to follow children over time and watch them grow and develop.

Throughout all of my rotations, and even after each rotation ends, I try to follow the children as much as I can.  I especially enjoyed following a baby boy whom I met on my PICU rotation.  He and his family were a delight to work with. His parents even instituted a policy that everyone who entered the room had to say something positive to their son before leaving.  Two weeks after my PICU rotation ended, I stopped by to visit him.  I was thrilled to see the progress he was making.  His parents proudly showed me that he was no longer intubated, he no longer had IVs, and the only “wire” was his pulse oximeter – the finger clip that monitors the heart rate. 

I also loved following the progress of a six-year-old girl with Guillain-Barre Syndrome – a disorder in which the immune system attacks the nervous system.  It was inspiring to watch her begin breathing on her own and regaining her strength as she completed physical and occupational therapy.  Even more fulfilling was how much I could tell she was improving over the week while we painted and played games together.  A couple weeks after that rotation ended, I asked the physician who was taking care of her how she was doing, and he told me that she was ready to be discharged, so I stopped by to visit her.  She excitedly showed off her increased strength and how she could propel a manual wheelchair.  Before I returned to my clinical duties, we spent some time roaming the halls and reading one of her favorite books in the schoolroom. 

I have learned so much from all of these children and their families.  As a primary care physician, I look forward to really knowing my patients and coordinating their care with other providers or specialists when necessary.  Each patient will have unique needs, and even for patients with the same medical problem, the care and management will not be the same.  Following families over time and developing relationships with them will allow me to provide the best care and to help them improve and maintain their health. 

Katie Gesbeck wrote this piece in 2012 as a fourth-year medical student at the University of Wisconsin School of Medicine and Public Health.  

There's more on the blog about student-run free clinics.
Posted by Sonya Collins on Dec 1, 2016 12:18 PM EST
a0cdb07dd9d27a6c33b4a0053b82f910-huge-awNovember is National Diabetes Awarenss Month. Primary care providers take care of many patients with diabetes during their careers, but how often does one of those patients tell providers exactly what he wants and how he'd like to be treated? Here, in a piece from our archives, read 17-year-old Trevor Torres' refreshing perspective.

By Trevor Torres

My name is Trevor Torres, though I’m also known as the Diabetes Evangelist. At 17 years old, I’ve launched a speaking career through which I share my unique perspective with the health care community -- that of an empowered teenage patient. Before I began public speaking, I recorded a video for the Institute for Healthcare Improvement (IHI) Open School. It exploded in popularity and led to the start of my speaking career. In that video – as someone who has spent a lot of time with doctors – I talk about what I expect from health care providers. I thought the health care professionals and trainees who read this blog might like to hear my perspective, especially because they will undoubtedly take care of lots of diabetics and teenagers during their career in primary care.

There's two main things I expect from my heath care providers. One: Don't condescend. When I was first diagnosed with diabetes, the doctors said, "You can give yourself insulin in one of two ways: You can do it based on your blood sugar, so if you have higher blood sugar, give yourself more insulin. Or you can do it based on what you're going to eat, so if you're going to eat x amount, give yourself x amount of insulin." Now maybe I’m one of the smarter patients, but I was like, "Why don't I just come up with an algorithm that incorporates both variables?" That's probably a little atypical, but the bottom line is if your patient already has something like that figured out, you don't need to simplify the explanation down to what you perceive your patient's level of understanding to be. You can explain something, and then if your patient doesn't understand it, they can ask for clarification. That may be just me, but I really hate it when I feel like I'm being talked down to. And that also might be my age: I know we kids are a little uptight about that!
 
Another thing that I hate is the word "poke," as in, "I'm going to poke you." No, you're not going to poke me, you're going to stab me, okay? A poke is when you prod someone with your finger. A stab is when you insert a sharp metal object with the intent either to inject a foreign substance into the body or to draw blood by breaking the skin! In health care, you stab; you don’t poke.
 
Another thing that's important is to understand how your patient learns. I don't have all the answers about learning, but I know that I personally like to know why something's being done. If doctors say, "You need to eat this way," "You need to do this," "You need this treatment," they better tell me why I have to do it. That way I know I actually should do it. Because people tell you to do things all the time, especially if you’re a kid, and if I did all those things…well, ain't nobody got time for that! But if my doctor says, "You need to take this medication because this is what it's going to do in your body and this is what's going to happen if you don't do it," then I know exactly why I should, and I'll be much more likely to do it! If you’re complaining that your patient didn't do x, y, and z, and you didn't tell them why they should have done those things, then of course they didn’t do it.
 
People like me – teenage diabetics – have a lot of experience going to doctors and other health care providers. So we understand a lot more than we often get credit for. So just say what you mean. I don’t need my health care providers to oversimplify. I’ll understand if you tell me how my medicine works or what changes certain foods will cause in my body. And I certainly don’t appreciate a condescending tone, so just say stab, not poke!
 
Trevor Torres wrote this piece as a 17-year-old freshman at University of Michigan. Diagnosed with type 1 diabetes at age 14, he calls himself a “Diabetes Evangelist” and has started a public speaking career through which he brings his unique perspective to the health care world. For more on this topic, check out his recent keynote speech, “The 21st Century Patient's Perspective - What Millennials Expect From Healthcare” at TrevorTorres.net.


 
Posted by Sonya Collins on Nov 22, 2016 1:52 PM EST
4665fcefa45d8a892d09808b1059a4ae-huge-peA nursing home resident and consumer advocate for others like her, Penny Shaw makes the case for community-based primary care for nursing home residents. 

By Penny Shaw, Ph.D.

I’ve lived in a nursing home for 14 years, and I’m developing a community-based model of primary care because I know it will be better than what is available to me in my facility. I’m 73 years old, and I had an acute non-resolving episode of Guillain-Barre syndrome in 2001. Initially on life support, I was intubated for 5 years.

During the early years in my facility, I received primary and subacute care with 24-hour nursing. Functionally, I have had quadriparesis (muscle weakness in all four limbs) since the acute episode and am a total-care patient, except for being able to use my hands to brush my teeth, eat, read, write and use a computer. I am a lift transfer. My facility did an excellent job of keeping me alive and then removing the tracheostomy tube when I no longer needed it in 2006, but it still took several years for me to truly become my former self again. In 2010, I read my medical chart for the first time, and found I was being given six medications that I didn’t need in applesauce, as well as two medications as needed for sleep. I had all 8 discontinued. Unnecessary drugging is a well-known phenomenon in nursing homes. In 2010, I also requested and received a power chair.

By 2011, I had become a nursing home and disability advocate. I assessed whether I could live in the community. At age 68, with long waiting lists for affordable accessible housing and MassHealth personal care attendant policies which would not have met my needs, I chose to stay in my facility. I did decide to try to live as similarly as possible to my disability colleagues living in the larger world. I started by seeing outpatient specialists that I could have seen in my facility.

Over the years I outgrew the nursing home model of primary care. I didn't like the lack of dignity of talking to my physician while in bed. I didn't like being interrupted unexpectedly by him while doing creative work on the Internet. I was shocked to be asked a question in the reception area about my advance directives, which I intentionally didn't answer. Not only was it a HIPAA violation, but also a social worker came over and asked to be part of the conversation!

I didn't like having a physician, a generalist, disagreeing regularly with the treatments of the specialists I saw. I didn't like my physician not accepting my legal right to refuse his recommendation for change of orders for insulin. These are two examples of the paternalism, rather than person-centered care, nursing home residents face regularly. My physician is basically a good well-intentioned person, so it took some pondering for me to figure out what was actually happening. What I concluded is that in nursing facilities, it is more difficult to maintain professional boundaries as everyone - residents and staff - live and work in close quarters. Physicians are accustomed to making treatment decisions without informed consent, unlike in their private practices. In a published piece, a nationally-known geriatrician and medical director of three nursing facilities wrote that he does employee physicals and probably oversteps some boundaries by giving a few employees medical advice. His statement confirmed my thought that professional boundaries are porous in nursing homes.

Federal nursing home regulations permit residents to choose their own physician, and I would have chosen the other one in my facility, but there was a policy against this. Choosing one's own primary care practitioner, rather than having one assigned, is essential to developing a good relationship, good communication and trust. So I was left with no other option but community-based primary care. I knew it would be best for me. But the decision presented challenges.

The regulations regarding physician's services require not only that each resident have a physician, and another physician when the regular physician is not available, but that the physician sign all orders for care provided in the facility, as well as write, sign and date progress notes. My facility doesn’t yet allow physicians to sign electronically, so this is a barrier for a primary care physician to be willing to take a nursing home resident into their practice. Coming in person to sign takes time and isn’t reimbursed adequately.

I started by calling Fenway Health in Boston as this practice has a history of advocacy on behalf of individuals suffering from health care disparities. With openings only for a couple of recently-board-certified physicians, and given my complex medical needs, I hesitated. Through a colleague, I was directed to Rushika Fernandopulle, who graciously gave me a consultation, and helped me focus on MassGeneral Hospital where I receive my acute and specialty care. I called the physician referral service and now have a primary care practitioner at MGH. My former physician, in his role as the medical director of my facility, has agreed to sign the orders my community primary care practitioner wants. This eliminates the need for her to travel to my facility to sign. My medical director's willingness to accommodate me like this indicates his decency as a person.

The health care delivery system I now have – a community physician, scheduled appointments, private office space, confidentiality and professional boundaries has had a positive psychological impact on me. I have been given back my personhood, my dignity, empowerment in my health care. I am more normalized and happy. Without doubt, a community-based model of primary care is best for me.

Having met and talked to residents and family members in other facilities, and on a toll-free nursing home helpline I answer, I know care delivery problems in nursing facilities are systemic. They are not due to lack of professionalism on the part of any individual physician. The delivery of primary care in nursing homes is thus in serious need of reform. As I work out the details of redesign for myself, I am hopeful I can develop a model of community-based primary care that can be useful to other residents.

Penelope Ann Shaw, PhD, is a former teacher of English as a second language and a doctor of French language and literature. Now a nursing home resident, she is a board member of the Massachusetts Advocates for Nursing Home Reform and of the Disability Policy Consortium of Massachusetts, as well as a policy advisor to the Nursing Home Division of Center for Medicare and Medicaid Services’ Survey and Certification Group. She is a 2016 recipient of a Consumer Voice Leadership Award from the National Long-Term Care Ombudsman Resource Center.

Related reading
The most vulnerable patients can face greatest barriers to care by James Chin

 
 
Posted by Sonya Collins on Nov 17, 2016 1:28 PM EST
ad0f9a0d52ab71ed11d24d2ccc60a4ee-huge--aIt's National Nurse Practitioner Week. Today on the blog, in a post from our archives, Jane Tuttle, Ph.D., family nurse practitioner, gives us a glimpse into the work of nurse practitioners and shows us how they expand access to care for our population's most vulnerable patients.

By Jane Tuttle, Ph.D., FNP-BC, FAANP

I was fortunate to have become a nurse practitioner (N.P.) in 1976, just a few years after Loretta C. Ford, Ed.D., public health nurse, developed the N.P. role with Henry Silver, M.D., a pediatrician. These visionary leaders recognized that registered nurses, with additional education and training, were in an ideal position to provide primary care to children in the face of the pediatrician shortage happening at the time, and indeed many children from that decade and beyond grew up knowing an N.P. as their primary care provider. 

Since then, N.P.s have proven themselves to be highly effective as primary care providers, and from state to state, they have varying scopes of practice. The N.P. role has successfully expanded to acute care, behavioral health, and other areas. I have been teaching others to be family nurse practitioners since 1985 and continue to practice in a primary care clinic serving adolescent mothers and their children. 

On a typically busy recent clinic afternoon, Jenna, the 18-year-old mother of a two-year-old girl I was seeing for a well child visit, told me that she had had unprotected intercourse with her child’s father two days earlier. She did not wish to become pregnant, so I was able to provide her with emergency contraception. We also discussed all of her options for family planning and contraception and made a plan for her to start a more reliable form of contraception.

Like Jenna, an increasing number of people consider an N.P. their primary care provider. Patients often describe us as more approachable than physicians. I can’t say how Jenna might have handled an office visit with a doctor, but her candor with me regarding unprotected sex helped prevent her from becoming a teen mom for a second time. Many teen moms, and others who struggle to access health care, might not have a primary care provider at all if it weren’t for N.P.s. We increase access to care, spend more time with the most vulnerable patients, and all for about 15 percent less than the cost of physician-delivered primary care.

As health care reform takes hold across the U.S., we expect to uncover increasing numbers of people who have previously unmet health care needs. Access and cost are going to be increasingly important issues in the years ahead. Nurses are poised to make a significant contribution in these areas, and we count on the support of patients and other providers.

The Institute of Medicine’s 2010 report, The Future of Nursing: Leading Change, Advancing Health, made the following recommendations which should inform our ever-evolving roles in 2014 and beyond:
 
  • Nurses should practice to the full extent of their education and training.
  • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
  • Effective workforce planning and policy making require better data collection and information infrastructure.
Nurse practitioners are a vital part of the health care team. We provide primary care in rural and urban areas, community- and school-based health centers, nursing homes, and many other settings. When I see a patient, my nursing background promotes a focus on the larger context of that patient’s life including their family. I highly value my collaboration with other team members from social work, medicine, and other disciplines, and I know that patients and families benefit from access to the comprehensive services nurse practitioners provide. As health care reform unfolds, we all need to promote and support the participation of nurse practitioners in the best interests of our patients and their health.   

Jane Tuttle, Ph.D., FNP-BC, FAANP, is a professor of clinical nursing and pediatrics at the University of Rochester and has practiced in primary care for more than 35 years. She directs the Family Nurse Practitioner Program at the University of Rochester School of Nursing and teaches in the HRSA-funded interprofessional Leadership Education in Neurodevelopmental Disabilities (LEND) Program. She co-chairs an interprofessional family research roundtable with Susan McDaniel, Ph.D.
Posted by Sonya Collins on Nov 15, 2016 1:40 PM EST
39097145815dd9f6c076ede586561362-huge-miFor all the strides we make, mental health and physical health continue to be viewed by many as two separate issues, though the two are inextricably linked. As a result, the quality of mental health care suffers. Today on the blog, clinical psychologist Benjamin Miller urges us to adopt language and actions that reflect the "oneness" of mental and physical health in order to begin to better address them. 

By Benjamin Miller, PsyD

What is health? Depending on who you ask the definition can be quite broad.

Our understanding of health is often tied to our experience in health care despite the two being quite distinct and different. Research is clear that what impacts our health has little to do with health care, which begs the question – what is health?

Health is the foundation for achievement. Without it, we cannot achieve our fullest potential and goals. We need health to make sure that we can be successful in life. While we must never ignore major issues like social determinants on our health, we also need a functional health care system that can adequately address our health needs when we are sick. 

But do we have this system? Do we have language to describe what we want? Language is important in our understanding of culture. And language has divided us in health care. Consider the wonderful breakdown of terms according to Moses et al.:

Current taxonomy is frequently misleading and fails to describe the complexity of the entirety of the US health care system. Health is a misnomer, because most activity involves illness. Health care and medical care are not synonymous. Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases. Provider does not accurately describe the dozens of different professions and organizations required for a patient’s care. Payers are paid not to pay too easily; insurers do only modest amounts of insuring because government and employers accept most risk. Economic concepts of cost and value are ambiguous, as measurement is elusive and because one segment’s cost is another’s value. Market is a misnomer because few prices are transparent and many are controlled. Above all, US health care is not a system, as it is neither coordinated by a central entity nor governed by individuals and institutions that interact in predictable ways.”

Having more precise language to describe health may actually help change health care. Consider the issue of mental health. Yes, we use this term to describe what we think of as a mental condition or need; however, science and evidence simply refute this notion concluding that our mental health is inextricably linked to our physical health. It’s really just about health.  It’s about the whole and not the part.   

Our health care system, taking a page from this limited understanding, created an entirely separate system to manage mental health. In fact, legislation passed under JFK over 50 years ago still haunts us today as Kennedy’s promise to better address mental illness was never fully realized. Then, as now, the health care system isolates mental health from whole-person health. We see a piece when we need to see a whole. Kennedy’s legislation, while undoubtedly filled with good intentions, only widened the divide between mental health and the rest of health care because the science was simply not where it is now to inform the policy decisions. Deinstitutionalizing mental health was the right move, but what happened next was a series of unintended consequences that we are still addressing today. For example, consider that there were really no mental health benefits at the time- these had to be created, and in their creation a division emerged of having two separate benefits (one for mental health and one for medical). These decisions are why the battle over mental health parity has been so critical – so that all benefits are treated as equal.

Concurrent mental health and physical health problems are quite common and often go untreated, leading to high health care utilization. Said differently, when both behavioral and physical health problems are treated in a medical setting simultaneously, improper utilization of the health care system decreases, patient outcomes improve, and money is saved. We know what needs to be done, but we are constantly running up against a culture of fragmentation and a history of fractured delivery that presents a substantial barrier for change.
Language changes culture.

While mental health is undoubtedly a critical piece to our health, it is a piece. If we want to decrease stigma around mental illness, perhaps we need to begin to think about our language. If we want our community to begin to demand and expect something different in health care for their health, maybe it’s time we begin to shift our language to be more inclusive of mental health.

To accomplish this, we need to be less afraid to talk about mental health in all settings. We need to be willing and able to have teams that include mental health clinicians. We need to recognize that every time in health care we refer or say “I don’t do mental health,” we further fragmentation and stigma. It is on us, all of us, to begin to reassess our language in service to a much more whole and complete vision of health.  

To help begin to better address mental health perhaps we should consider, at a minimum, the following:
  1. Be careful of using language that furthers the artificial divide between mind and body (e.g. that’s so mental, he/she is crazy)
  2. Provide educational materials that speak to the whole of health (e.g. brochures in a primary care practice, videos or public education efforts on the role of “mental health” in health)
  3. Advocate for payment models that are inclusive of mental health (e.g. global payments that include the cost of mental health clinicians, bundling mental health services into larger medical services)
Health is health is health, and until our health care system reflects that, we must keep pushing for our broadest understanding of health to include mental health. Together we can begin to change culture to make mental health just another facet of health. This will change practice, policy, payment, and most important people’s minds.  

Benjamin Miller, PsyD, is an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine where he is director of Eugene S. Farley, Jr., Health Policy Center. Under his leadership, the Farley Center has worked on four main areas: behavioral health and primary care integration, payment reform, workforce, and prevention. A clinical psychologist by training, Miller has focused his career on creating innovative solutions to fragmentation in health care.
 
Read more about integrating mental and physical health. 
 
Posted by Sonya Collins on Nov 10, 2016 11:03 AM EST
7106d1a8f67e98678b377a997744d6c2-huge-coA leader of our Harvard chapter reflects on lessons learned at this year's PCP Gregg Stracks Leadership Summit. This post originally appeared on Harvard Center for Primary Care's blog.

By Colleen Farrell

I arrived a few minutes late to Primary Care Progress's fifth annual Gregg Stracks Leadership Summit in Cambridge, MA. It was a humid Saturday morning this past August, I expected to sneak in and slide into a seat in the back. 

I stepped through the glass door to the general meeting area and was immediately taken aback by the sound of blaring trombones and the sight of energized dance moves from the Primary Care Progress staff. The conference participants were standing, clapping, and laughing; some were even dancing. It was clear that the Leadership Summit wasn’t a typical conference.

Primary Care Progress (PCP) is a national nonprofit that works to transform primary care through the development of the next generation of primary care leaders. The organization serves as a resource and training center for the more than 50 chapters it has established at health professions schools around the country. At Harvard Medical School, the Center for Primary Care’s Student Leadership Committee (SLC) is a PCP chapter.

During the summit's intensive, two-day training, one concept stood out: relational leadership.

As health care providers, researchers, and policy advocates, the PCP team knows that effective leadership requires well-honed technical skills. But they have also learned from experience in the field that these technical skills must be paired with relational skills. PCP describes relational leadership as “a new approach to change-making that places just as much emphasis on the ‘who’ as the ‘what’ and the ‘how.’” The skill-building sessions at the summit were designed to delve further into what relational leadership means at the level of self, relationships, and teams.

Self-Awareness and Storytelling

Each session at the summit began with a story. Steph Nothelle, a geriatrics fellow at Johns Hopkins, began by telling us about a time during her chief resident year when, distracted and rushed, she responded dismissively to the concerns of an intern. The intern left the conversation without receiving the support she sought.

Steph’s failure to recognize her own emotions led to a breakdown in her leadership. She led a discussion in which we generated questions we can ask ourselves to improve our self-awareness. Steph highlighted that awareness of emotions can help to ensure that impact matches intentions.

This emphasis on storytelling and personal experience is woven throughout PCP’s work. In Andrew Morris-Singer’s personal narrative, he described what he learned about relational leadership from his late mentor Gregg Stracks, after whom the summit is named. Andrew, the founder of PCP, described how as an overworked, tired resident he avoided engaging with the emotions of his teammates, “Get done. Get out. Keep the emotions in. That was my game plan for surviving ward time.” Gregg Stracks changed this.

“Thanks to Gregg, we now see that when we bring people together to fix a difficult problem, we must spend as much time eliciting emotional responses to the issue as we do logical responses. This gives us the best chance of creating and sustaining a new team that can solve the problem. The head steers us, but the heart is the engine.”

Storytelling is important for developing our sense of selves, as well as for forming relationships. Mike Mattiucci, a student at University of Rochester School of Medicine and the Harvard School of Public Health, and Dave Fleischer, a leadership trainer at the Los Angeles LGBT Center, built on what we learned about self-awareness, vulnerability, and storytelling during a session on conducting “one-on-ones.” A one-on-one is a conversation one person initiates with another whom she thinks might be interested in joining her project. One-on-ones are designed to find common ground and shared values and require, at their essence, sharing stories.

Putting it into Practice

Time was dedicated at the conference for us to practice telling our stories and conducting one-on-ones in breakout groups. By telling our stories of personal challenges, we experienced first-hand the power of embracing vulnerability and finding shared values.

In another breakout activity, we each took a turn at leading a segment of a mock meeting. One of the most valuable components of this mock meeting was establishing group norms. Group norms focus on the relational, rather than technical, components of team dynamics. When groups establish and practice norms together, meetings can be safe spaces for members to try out ideas, respectfully disagree with one another, and embrace vulnerability.

Lessons for the Future

I left the Gregg Stracks Leadership Summit grateful, inspired, and feeling that I was part of a movement bigger than myself. I hadn’t just learned about relational leadership—I had experienced it.

Brené Brown writes in Daring Greatly that “vulnerability is the birthplace of love, belonging, joy, courage, empathy, and creativity. It is the source of hope, empathy, accountability, and authenticity. If we want greater clarity in our purpose or deeper and more meaningful spiritual lives, vulnerability is the path.” Few spaces in health care view openness around emotions and values as critical for transformation, but the Gregg Stracks Leadership Summit is one of them.

As members of the Center’s SLC, we strive to be a space where students can be themselves, take risks, strive, fumble, and try again. Our community is one of shared values that sustain us. After the PCP Summit, I’ve returned to the SLC and our work in primary care transformation with renewed energy and a deeper sense of the value of our work. In addition to our numerous committee goals for this year, we have another equally important project: continuing to grow and nourish ourselves and our community. That is where change begins.

Colleen Farrell is a fourth-year student at Harvard Medical School and a PCP chapter leader.

Read more about PCP's Gregg Stracks Leadership Summit.

Posted by Sonya Collins on Nov 3, 2016 12:43 PM EDT
9d0c66ef9744f9af71c679f3de252cd9-huge-imIt's World Occupational Therapy Day! Today on the blog, read about occupational therapy's role in primary care. 

By David Goldstein, Jillian Fader, and Sherry Muir, PhD, OTR/L

It's World Occupational Therapy Day, but what’s occupational therapy?

Many of you probably know that occupational therapy is a health care profession that focuses on rehabilitating individuals who have physical impairments and need to regain the ability to complete daily tasks and manage basic needs. Or perhaps, you also know that occupational therapists help children with disabilities in the school system gain the skills needed to participate in school and play.

This is all true, but occupational therapy has a much wider scope than most health care professionals realize.

Occupational therapy focuses on enabling people to fully participate in their desired occupations, roles, habits, and routines through a lens focused on strengths rather than impairments. Occupational therapists use a patient-centered approach to improve function and participation by addressing cognition and movement in the context of everyday activities. These roles, habits, and routines impact all health behaviors, and therefore, disease courses. Occupational therapists are broadly trained in human anatomy and physiology, physical dysfunction, development across the lifespan, and mental and behavioral health. They are also well trained in identifying how the patient’s physical, social, and contextual environments contribute both positively and negatively to health and disease processes.
 
How, you may ask, can occupational therapy enhance primary care practice?
 
Occupational therapy brings a unique perspective to primary care that improves the quality and breadth of care for patients. Occupational therapists assess functional cognition, performance, habits, roles, and routines that impact health and well-being. The profession is founded on patient-driven, not just patient-focused care, and the belief that intrinsically motivating activities better promote adherence to self-maintenance routines and overall improvement in health status. Within a primary care model, occupational therapists promote self-management of chronic conditions, prevention of chronic conditions through lifestyle modification, management of musculoskeletal conditions, pain management, and redesign of physical environments. They also help identify delays in infants and young children, refer to community resources, and coordinate family and caregiver support. Occupational therapists can assist with case management, be the primary providers for certain patients, and provide direct interventions for a variety of acute injuries and illnesses.
 
Here’s a story of how occupational therapists work with patients in primary care clinics. Jennifer is a 27-year-old PhD student with post-concussion syndrome and a history of panic attacks, depression, anxiety, and ADD. She was seen in the primary care office at least three times a month over the past seven months with multiple physical complaints, especially increasing transient pain, inability to sleep, and increasing frequency of panic attacks. She had no improvement in her symptoms despite significant increases in all medications and weekly counseling sessions for anxiety management. During the occupational therapy evaluation, the therapist suspected that there was an undiscovered triggering event causing exacerbations of Jennifer’s mental health conditions. The occupational therapist ultimately learned from Jennifer that several members of a friend’s family, including children, were killed in a car accident. She had not discussed this accident or her fears with her physician or any other member of the care team, so the occupational therapist strongly encouraged her to do so.
 
Jennifer and her occupational therapist came up with the following plan to improve Jennifer’s sleep, anxiety, and participation in school:
  • Create a consistent sleep plan, utilize good sleep posture, visualization techniques, and have a notebook beside the bed to write down important things that might be keeping her awake.
  • Have Jennifer identify ten important activities that she wanted to do and rank them according to whether she considered completion of these activities to be within her control or out of her control.
  • Discuss how Jennifer might move just three of those activities back into her control and set a goal to accomplish this in one week.
  • Start a “success journal” in which Jennifer writes down at least three things each day that she is able to achieve or do.
Jennifer now reports less pain than she has had since her initial evaluation with occupational therapy. She is now sleeping seven to eight hours a night and wakes feeling rested. Jennifer continues to work with her counselor to manage everyday stressors and take more control over her life.
 
David Goldstein is an occupational therapy student at Thomas Jefferson University in Philadelphia, PA. David participated in the inaugural year of the Hotspotting Learning Collaborative co-led by PCP. He currently sits on the Hotspotting Collaborative’s national advisory council. 
 
Jillian Fader is an occupational therapy student at Thomas Jefferson University. Jillian participated in the 2015 Hotspotting Learning Collaborative and has presented about her experiences at the university and national level.
 
Sherry Muir, PhD, OTR/L, is an assistant professor at Saint Louis University and sees patients in a variety of primary care settings. An expert on occupational therapy in primary care, she has published, consulted and presented on the topic nationally. 
 
 
 
Posted by Sonya Collins on Oct 27, 2016 1:46 PM EDT
5007ac119026da42397d8344edfa1d8f-huge-ffIt's Medical Assistants Recognition Week. Today on the blog, a former PCP chapter member shares how he learned first-hand the importance of MA's to the primary care team. 

By Adam Nelson

“We’ll each do a few and that way it will go faster for the baby,” said Amanda, the medical assistant (MA) who was teaching me how to vaccinate a two-month old.   “Always save the empty bottles, because you enter the lot numbers into the computer later on.” Then she handed me two syringes.  Entering the room with an assortment of needles in hand, I was a bit uneasy about sticking those needles into this sweet, tiny person. I winced slightly watching Amanda give the baby the first shot in her leg, and then I followed suit. Gently holding her other leg and avoiding the temptation to hesitate, I delivered two injections into the baby’s thigh. This was followed by a bright blue Dora the Explorer band-aid, which probably did more to make me feel better than the baby. Aside from the crying, everything went fine and our patient was now doing her part for herd immunity. 

This was a typical afternoon in my community clinic during the first two years of medical school. My class was the first to be afforded this early introduction to clinical medicine. Starting in our first year, each of us spent two afternoons per month with an assigned faculty preceptor in a primary care clinic. At first, my task was to learn and ultimately play the role of the MAs, the idea being to understand the workflow of the clinic from the ground up. I learned how to room patients, start patient notes and interviews, record vitals, draw blood, and administer shots and rapid strep tests. I was glad to have the time to learn, practice and become proficient at these skills. And in learning to function as an MA, I began to realize just how essential non-physician staff members are to a smoothly running clinic. My lecturers constantly spoke of medicine as a team-oriented enterprise, but I was struck nonetheless to experience this firsthand.
 
As the months passed and I entered my second year, my role evolved and I started working more directly with my attending physician. My job was now closer to that of a beginning third-year medical student in a more traditional curriculum. After rooming patients, I gathered their history and performed a focused physical exam. In addition to developing clinical skills, I was now able to observe the role of the MAs from the perspective of the physician. From here, I could more fully appreciate that physicians serve as leaders in the team approach to medicine. It was apparent that effectively directing the efforts of other team members required a good understanding of the scope of their work. And not just the scope of the MAs’ work -- I saw here that physicians are expected to lead all the professionals that contribute to patient care: nurses, pharmacists, social workers, mid-level practitioners and consulting physicians. Although it is daunting to know that patient care today requires orchestration of so many different resources, it is a relief to know that physicians have so much clinical support.
 
Now as a third-year on wards, I am grateful to have had this introduction to clinical medicine. For one, it served as a relatively low-stakes arena where I was able to develop basic skills before launching headlong into clerkships. More importantly, I was able to experience the concept of a medical care team from multiple perspectives. For me, the result was a better understanding of and respect for the team approach to medicine and those who work within it. As a third-year, I have already been able to apply this experience when working with nursing staff and support personnel on the wards. The delivery of health care is rapidly changing in order to accommodate increasingly complex patients as well as more restrictive financial demands. Early introduction to clinical medicine and, specifically, letting students become familiar with the roles of other health care professionals, is one innovative way medical education can adapt to ensure physicians are able to meet these increasing needs. 
 
When this piece was published in 2012, Adam Nelson was a third-year medical student at the University of Utah. His class was the first to participate in a revised curriculum that integrates primary care exposure into the first two years of medical school. 
Posted by Sonya Collins on Oct 20, 2016 12:26 PM EDT
72145da9e1b223c986c45c5b47158be8-huge-ciIt's National Physician Assistant Week. Here in a post from our archives, the Physician Assistant Program director at Case Western Reserve University calls for P.A.s to step up and help create the change we need in primary care.

By Cynthia Booth Lord, M.H.S., P.A.-C

Last month I was in a store and I saw a young child fall to the ground after appearing to have fainted.  I approached the crowd that quickly gathered and introduced myself to the child’s parents and said I was a P.A. and I could help.   Immediately the crowd moved back as I proceeded to evaluate and help the child until EMS arrived.  I gave a report, the parents thanked me profusely, and I wished the little girl and her parents well and went on my way.  As I drove home that day I thought about the fact that no one asked me “What is a P.A.?” or “Are you qualified to help?”   Instead, they said, “A P.A., that’s great, would you mind helping us?” 

As I get ready for the week-long celebration of both P.A. Week and National Primary Care Week, I am reminded of the incident with the little girl because it shows just how far the P.A. profession has come in a very short time.  But the path has not always been easy.  I reflect back on a few years ago when I was serving as president of our national association, the American Academy of Physician Assistants (AAPA).  We were in San Diego at our national conference, and I walked from the convention center to the House of Delegates with Mrs. Estes, the wife of Dr. E. Harvey Estes, one of the founding fathers of the P.A. profession.  In her soft spoken North Carolina accent, Mrs. Estes shared stories that demonstrated just how hard Dr. Estes and Dr. Eugene Stead (Duke) had to work to create our profession.  She said that every night Dr. Estes would get calls at home from his physician colleagues, to argue all the things they thought a P.A. could not and should not do.  She talked about those who would call and say, “Harvey, P.A.s cannot do physicals.  They cannot order tests.  They certainly cannot write prescriptions.” And every night Dr. Estes would calmly say, “Yes they can; P.A.s can do that.” 
 
Forty-eight years ago, the P.A. profession was an experiment.  Four Navy medical corpsmen were accepted into the nation’s first physician assistant program at Duke University.  The belief was that P.A.s would provide cost-effective access to primary care and health care, particularly in areas where there were physician shortages. With over 100,000 certified P.A.s today, the profession is a well-established, critical component of our health care system.  It remains a model that is flexible and adaptable as demonstrated by our ability to step in and fill gaps in our health care system as they arise.
 
Drs. Stead, Estes, Silver, Sadler, Smith had the courage to create a change in our health care system.  Their challenges were real and they each made personal sacrifices to ensure the success of our profession. Dr. Estes’ colleagues believed he had a “brilliant career” ahead of him as a cardiologist and cardiovascular physiologist in electrocardiography. Instead, he saw a different need and chose to help create a new type of medical provider.
 
Like those physicians and P.A.s in the early days of our profession, we must have the courage to create change. We must revitalize primary care training and education in our country and P.A.s need to step up to that challenge.  The generalist education, commitment to team-based practice and the relatively short but intense training period of the P.A. curricular model could help bring the revitalization that primary care needs.   
 
The last time I had the privilege of meeting with Dr. Estes, he shared his thoughts about the P.A. profession in the early days, today and in the future.  He spoke of the balance he believes we have created between primary care practice and specialty practice without compromising the original mission of the P.A. 
 
Like Dr. Estes, we must choose to create a change.  We must have the courage to stand up and say, “We believe in health care that prevents illness before it begins, treats the whole patient, cares for communities, stewards our resources responsibly and is accessible to all.”  We are P.A.s and we believe in primary care.

Cynthia Booth Lord is the program director of the physician assistant program at Case Western Reserve University. 
 
Posted by Sonya Collins on Oct 11, 2016 2:45 PM EDT
04f5368590761fa224a0fe31ef646392-huge-11It's National Primary Care Week! This year's theme is improving health care access for all. PCP is especially proud of one of its contributions to this mission - the Interprofessional Student Hotspotting Learning Collaborative. As hotspotters, health professional students learn to work together on interprofessional teams. They develop crucial leadership skills while improving health care access for the patients who need it most. Today on the blog, a former member of our hotspotting cohort shares her story.

By Eliza Hutchinson, M.D.

“There was one time when I wasn’t here for seven months in a row,” “Pam” told me.
 
I sat with Pam in her third floor hospital room – the floor on which she always stays when admitted to the inpatient medicine service – as nurses, doctors, and janitors poked their heads in the door to say friendly hellos and “Nice to see you again, Pam!” A dining facility staff member entered with a tray, letting Pam know, “I brought you the usual, Pam. I missed you!” Pam smiled and joked with the parade of staff members as I pondered this oddly happy reunion. 

I told Pam that the hospital seemed like Cheers for her, as it is a place where everybody knows her name as the show’s theme song says. She laughed and agreed. “I can’t go down the hall to the CAT scan machine without someone stopping to say hello. It’s like home here.”
 
Later, looking through Pam’s chart, I found her medical problem list, rivaled in length by her list of medical providers, and topped by her number of recent inpatient admissions. I counted a dozen conditions at first glance. Her providers included primary care, urology, pulmonary, otolaryngology, social work, physical therapy, nutrition, nephrology, dermatology, rheumatology, endocrinology, in-home caregiver, Medicaid case manager. Number of inpatient admissions in four years: 42. I was impressed but disheartened and daunted by the number of providers involved in Pam’s care. How could someone attended by so many brilliant minds with world-class skills remain so sick? What could we, a team of six students, possibly contribute to her life?
 
When I first imagined Hotspotting, I pictured working with stereotypical high-utilizing patients: individuals with complicated socioeconomic and psychosocial circumstances with no continuity of health care. I envisioned that we could help patients establish relationships with primary care providers, obtain bus passes for transportation to appointments, and organize their medications. However Pam didn’t seem to need any of these interventions. She had friends, family, financial resources, biweekly appointments with her primary care provider, and a brilliantly organized system to take her medications at the exact times prescribed. What more could anyone do, especially a group of students with good intentions but few real skills?
 
During the next several weeks after Pam’s discharge from the hospital, members of our team attended outpatient medical appointments with her and visited her when she was admitted to the inpatient medicine service again. We visited Pam at home and talked with her about her goals. We learned that she wished for greater mobility than she had in her electric scooter but struggled to walk more than several steps without sitting down to rest. This led her to avoid leaving the house to socialize in the neighborhood as she once enjoyed. She wanted to eat better and lose weight, but she relied on her in-home caregiver to cook, and the caregiver tended to cook cheap, unhealthy food. We saw that the kitchen was full of packaged foods and suffered a notable shortage of fresh fruits and vegetables. As we sat in Pam’s living room and explored her hopes, we also discovered that she was caring for her dying mother, often at the expense of her own health and well-being.
 
These details of Pam’s life would have been difficult to uncover during a 15-minute primary care appointment in an office far from her home. As students with time as our resource, we had the opportunity to understand the determinants of her health in a patient-centered context. Our multiple hour-long visits to her at home, combined with accompanying her to health care appointments, allowed us to better understand her goals and the challenges to achieving them. Accordingly, we are working with her to obtain a rolling walker with a seat, so she can leave the house with an assistive device that not only helps her walk but also allows her to sit for rest at any moment. We are exploring how to help her obtain healthier food through Meals On Wheels. And we can support her when she transitions through periods of grief related to her mom’s illnesses.
 
While I realize that we will not cure Pam of her chronic illnesses, I like to think that we can make a small impact on the trajectory of her life.  For instance, by helping her obtain a walker, we can encourage exercise and socialization, which may decrease her risk of hospitalization for infections from pressure ulcers. The cost of one hospitalization offsets the cost of a walker many times over. By helping her make healthier food choices, not only can we promote weight loss, but also help her to develop a sense of self-efficacy around her health. This increased confidence may enable her to make other difficult lifestyle changes.
 
Perhaps most importantly, by listening to Pam’s life’s narrative, we can validate the difficult experiences she has survived. We can also show her that her perspective is valuable in teaching us about a patient’s experience in the health care system and how to live a meaningful life in the face of serious illness. In this way, I believe that the power of storytelling cannot be underestimated. As hotspotters, I see our role as bearing witness to our patients’ struggles and supporting them as they work toward achieving their goals.

Eliza Hutchinson, M.D., is a family medicine resident at Swedish Medical Center. She wrote this piece as a fourth-year medical student at the University of Washington, where she was a member of their hotspotting team. 

Read more about hotspotting. 
 
Posted by Sonya Collins on Oct 6, 2016 11:44 AM EDT
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