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In our last Progress Notes installment of the year, med student Devorah Donnell asks us all to resolve to be part of the change we want to see in primary care. Read her story, then take the pledge to be part of the change. Help make everyone's New Year happy and healthy!

By Devorah Donnell

I met my patient who sat with her eyes fixed on the floor, looking skeptical and tough but on the verge of tears. In her presence, the room felt sad and dark despite the sun streaming in through the blinds. Ester was a 50-year-old female who had gone to the emergency department because her co-workers thought she was having a heart attack, but when it was deemed non-cardiac chest pain that was most likely associated with anxiety, she was sent to the psychiatry office where I was rotating. As we discussed her severe depression and suicidal thoughts, multiple health concerns, and family history of death at a young age, she shared with me the most important factor: She had never been to a doctor. At 50 years old, she had seen a doctor for the first time that she could remember the day before in the emergency department.  She had never seen a primary care doctor.

One year earlier, while signing up patients at UConn’s free mobile medical clinic for migrant farm workers, I greeted a family that timidly approached the big, empty metal warehouse where we were set up on a farm. Guillermo stood next to his wife who held their 6-month old infant fussing in her arms.  After I asked who would like to see a doctor, Guillermo and his wife signed up, explaining that their infant did not need to be seen because “she was not sick.”

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Posted by Sonya Collins on Dec 19, 2013 3:08 PM EST
A project associate at Colorado Coalition for the Medically Underserved, Denali Johnson explains why integrated, team-based care makes sense. We think it makes sense, too, and we hope institutions of health professionals training will start to offer more opportunities for health professionals trainees of various disciplines to learn together as integrated teams. If you agree, take the pledge!

By Denali Johnson

Life without a car is challenging. Sure, during the summer my legs are nice and toned from my bike and during the winter I have plenty of entertaining bus stories. There is no denying that I have reduced my carbon footprint. However, it can get frustrating trying to do simple things, like running errands. Say what you will about chain stores, but being able to bike to Walgreens and pick up prescriptions, photos, and nail polish in the same spot makes my life a lot easier.

The idea behind integrated care is similar. Why have your primary care provider, physical therapist, and behavioral health coach spread across the city? Why wouldn’t you want all the moving parts of your wellness under one roof? The concept behind integrated care is simple—it is a model of health care delivery that attempts to care for the whole patient. In this setting, both physical and behavioral health providers work together to coordinate treatment and follow-up care.

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Posted by Sonya Collins on Dec 17, 2013 11:48 AM EST
Convinced that there was no viable way to practice family medicine in the current model -- the discipline he was most passionate about -- this medical student was elated to learn about an innovative model of care that could make it all possible.

By Brian Gans

When I first entered medical school, I was very attracted to family medicine as a discipline, but I wasn’t attracted to practicing in a model that limited me to less than 15 minutes of face time per patient but required 45 minutes of paperwork to get reimbursed and left no room or time for innovation.  It was disappointing that I couldn’t go into the field that was most attractive to me, but I just wasn’t willing to enter that environment.  A year later, only in my second year of medical school, I can’t imagine doing anything else.

We all know that our health care system is broken; that it’s a hamster wheel where doctors and patients are rushed through appointments while the cost of health care skyrockets out of control. I didn’t think there was a viable way for doctors to practice primary care in this system until I learned about direct primary care (DPC). DPC is an emerging model for practicing primary care medicine that has made me incredibly excited to pursue a career in family medicine.

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Posted by Sonya Collins on Dec 12, 2013 9:19 AM EST
She'd conducted research and made tables and lists to help her decide what specialty she wanted to practice, but this resident discovered she wanted to practice primary care when she was least expecting it.

By Ambereen K. Mehta, M.D.

I spent all of medical school trying to figure out which specialty to practice. It was a big decision. It would define my medical career. I wouldn’t just be a doctor; I’d be a neurologist, a dermatologist, an orthopedic surgeon. So I approached the decision from all angles. I made tables of all the pros and cons of each of the specialties I was considering, including ophthalmology, my father’s field. 

My father loves being an ophthalmologist and his passion is contagious. For a long time, I considered it. My mother had already planned out a father-daughter private practice for us. I even spent a summer doing research at the Wilmer Eye Center. Ophthalmology had many pros including caring for the elderly and a public health component, but I still hadn’t found whatever I was looking for. I was looking in the wrong places. I found it, actually, in a Starbucks in Washington, D.C.
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Posted by Sonya Collins on Dec 9, 2013 10:30 PM EST
Making the transition to a clinic setting after working as a home-visiting nurse, this nurse practitioner is reminded of the importance of defining the patient's goals of care.

By Michelle Nall, MPH, ANP-BC

I moved to Florida three months ago to take a job as a primary care nurse practitioner in a clinic for the underserved and uninsured. This position followed four years spent as a home-visiting nurse practitioner working with high acuity, chronically ill patients in the Boston area.  I didn’t realize it would be such a transition to go back to taking care of patients in the clinic setting after spending several years caring for them in their homes, on their turf, and on their terms. Just as I was starting to feel I had a handle on this new job in this new setting, a patient threw me a curve ball.
 
Mrs. Jones, an 80-year-old woman with mild dementia, very poorly controlled hypertension, and diastolic heart failure, came into the clinic with her son, a middle-aged man who, when he wasn’t working local day labor jobs, was his mother’s primary caretaker. The reason for her visit was listed as “needing lab work” and she had not come to our clinic in over a year.

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Posted by Sonya Collins on Dec 5, 2013 10:31 AM EST
Clinical innovation and team-based care could dramatically change the answer to the most common patient question: When do I need to come back to see you? We not only need means of reimbursement for these models; we need to train the next generation of health care professionals to practice in these models. The Primary Care Project is a campaign to promote just that type of training. Read Dr. Earnest's story, then take the pledge.

By Mark Earnest, M.D., Ph.D.

“When do I need to come back and see you?”  Jane asks.

Her simple question is probably the most common question a doctor has to answer.  It comes up in literally every patient encounter. She asked it as we finished discussing the possible side effect of the new medication she will start to control her blood pressure. Like most doctors, I devoted little thought to her query and answered according to my habit and training, but her question deserves a lot more thought. How doctors like me answer this question may be the key to improving access to care and solving the looming doctor shortage.

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Posted by Sonya Collins on Dec 3, 2013 11:49 AM EST
The Primary Care Project has been underway for three months now. Still in phase one, our chapters have been campaigning to collect signatures on a pledge through which signees declare their belief in the value of primary care.  Since the project’s launch, our University of Nebraska chapter has been leading the pack in signature collection. Here, one of the chapter leaders tell us a little about their campaign. Have you taken the pledge?

By Meredith Stein
 
We’re blessed that the University of Nebraska is very supportive of primary care. Emily Prinz and I, co-leaders of our school’s PCP chapter, both come from small Midwestern towns, where we learn firsthand the value of the primary care clinician. A primary care provider is more than a doctor, nurse, or pharmacist. Primary care providers are leaders, role models, and decision makers in our communities.  They speak at Monday night school board meetings and on the sidelines of the Friday night football game.  They take interest in the ongoing well-being of the community and unceasingly give of themselves to those in need. I have always held primary care physicians in the highest regard.
 
It was only after I entered medical school that I realized that choosing to go into primary care is often met with disapproval and stigma. I didn’t find this attitude in my own medical school, but in the medical student culture that I had joined by entering medical school, through talking to students from other institutions nationwide, reading blogs, and engaging with med students online.

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Posted by Sonya Collins on Nov 26, 2013 10:39 AM EST
In his review of Rishi Manchanda's The Upstream Doctors, Dr. Tom Bodenheimer explains what it means to practice upstream and why primary care providers have to do it.

By Tom Bodenheimer, M.D.

How many of us in primary care have patients with diabetes whose A1c won’t go below 10? We counsel them on healthy eating and physical activity. We use motivational interviewing to help them set realistic goals. We prescribe the right medications at the right dose. But the A1c doesn’t budge. We start to talk to our team members about our non-compliant patients. We have spent hundreds of hours with no results. 

Everyone reading this vignette knows the answer. The patients live in unsafe neighborhoods with little public transportation. They have nowhere to walk. They live in a food desert with one fast food franchise whose salad costs twice as much as the cheeseburger and doesn’t satisfy the hunger. The pharmacy is too far away and the waits are too long, so medication refills don’t get picked up. Could the hundreds of hours we spend on our patients be better spent trying to address the conditions that keep that A1c so high? And will it be many more hundreds of hours before the renal failure, the heart attack, and the stroke inevitably take place? 

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Posted by Sonya Collins on Nov 21, 2013 11:40 AM EST
Nursing school dean and PCP advisory board member is encouraged to see a movement towards interprofessional education for health professionals students. At PCP, we love to see students of all the health care professions learning together, and we want to see it at every training institution. It's that kind of change that The Primary Care Project supports. Read Dr. Tilden's story, then take the pledge!

By Virginia Tilden, Ph.D., R.N.

It’s been a long time since I was a baccalaureate nursing student at Georgetown University in Washington, D.C., but my memory is sharp about this fact: nothing in our curriculum taught us to work as an interprofessional team.  In 1967, the year I graduated, nursing was a rigid, rule-based discipline driven as much by hospital policy and faculty dogma as by scientific evidence. And, just like medicine, it was siloed by its own knowledge, traditions, and truths.  Even back then it struck me as odd that we nursing students and fellow medical students cared for the same patients when barely a word passed between us. Further, our faculty seemed unaware of each other, as though the two professions operated in parallel universes with almost private and separate languages about the very same patients for whom we jointly cared.

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Posted by Sonya Collins on Nov 19, 2013 9:16 AM EST
What's the point of knowing that a patient wouldn't recommend your service to their friends and family if you don't know why? That's what the health care providers at UK-based Spiral Health wanted to know. The rehabilitation center has instituted an innovative survey that takes patient-centeredness and transparency to a new level. What would happen if we did this in primary care?

By Cheryl Swan

The problem with most patient questionnaires is that they ask closed questions, requiring just a yes or no answer. What's the point of knowing that a patient wouldn't recommend your service to their friends and family if you don't know why?

Spiral Health's 40-bed rehabilitation unit in Blackpool has just been nominated for a Nursing Times award for our approach to patient care, the cornerstone of which is our unique approach to gathering patient feedback. We use an innovative system called Working Together for Change which gathers meaningful, qualitative feedback from patients and then allows them to decide their own priorities for change within our unit.
 

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Posted by Sonya Collins on Nov 14, 2013 9:28 AM EST
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