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4c74cc7c511d4d566b4769ab6c452636-huge-14At Primary Care Progress, we believe that at the heart of our power to create change is the connections that we make with one another through our personal stories. Progress Notes is a place to share those stories. Here's some of the heartwarming, thought-provoking stories you shared with us in 2016.


January
A student volunteer in a shelter clinic learned how to earn patient trust.
"Few other fields rely so heavily on the confiding of information so intimately connected to one’s wellbeing and personhood. However, such trust must be earned. Fortunately, patients tell us how to do so. It is up to us to listen."

February
A chief resident opens up about the challenges of intern year.
"My philosophy now is to just show up on time and go with the flow. Instead of trying to swim against the current, just let the river take you where it pleases. You may be surprised at where you end up."

March
A hotspotting team delivers truly patient-centered care. 
"What shocked us was as she began to realize how invested we were in helping her achieve her goal, she started making the changes we had been hoping for all along. She started to keep her appointments, had negative drug screens and her total number of hospitalizations began to decrease."

April
A doctor explains the value and challenges of team-based care. 
"I was trained to do all of this myself. I was not trained to share these responsibilities with nurses and pharmacists, nor was I trained in how to create, contribute to, and maintain systems of care for my patients. It was all on me, and in truth, most of us doctors have liked it that way. But we have to change these habits and most of us know it."

May
A psychology student discovers the value of team-based care.
"Initially, patients like Tina come to me to address their psychological well-being. However, they also want to improve their overall quality of life. I cannot think of a better way to improve an individual’s quality of life than through the advancements of integrated primary care."

June
A newly minted family doc learns why teams are as important for providers as they are for patients.
"Part of the reason I chose primary care, and family medicine in particular, is my desire to be the lamp to those in need. But without a team, my lamp would burn out fast."

July
An innovative care model prevents falls, which can be life-changing for the elderly.
"Patients like Rose inspired me to imagine that there might be something better.  Can we find the Roses at risk for falls and illness exacerbations in our communities before the crisis?  Can we build a team that responds to their needs proactively and prevents them from the dangerous and sometimes deadly trips to the hospital?"

August
An early-career family physician writes a letter to a patient she lost.
"Dear Mr. C., There are a number of things I’ve been wanting to say to you since you died three years ago.  The first is I’m sorry."

September
A soldier in the hospital after two mini-strokes meets a pharmacist who changes his life's course.
"That day, during my conversation with the pharmacist, I discovered my answer to how I could serve others, and a passion was ignited in me to become a pharmacist clinician."

October
A medical student learns how to make a real difference in the life of a very sick patient.
"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."

November
A nursing-home resident and advocate fights for dignified primary care for herself and others like her.
"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."

December
A medical student earns the patient trust that eluded providers.
"My preceptor asked if the patient was interested in getting his influenza vaccine. I didn’t tell my preceptor that he already declined it. However, to my surprise, the patient nonchalantly agreed. He glanced over at me and said, 'He convinced me to get it.'”



 
Posted by Sonya Collins on Dec 22, 2016 12:26 PM EST
c375677ac09ae4d120af6eda7792990e-huge-imHofstra University Northwell School of Medicine launched a primary care track called IMPACcT (Improving Patient Access, Cost and Care through Training) last June. Today on the blog, we learn all about the program through a Q&A with the IMPACcT program’s leadership: (clockwise from top left) Dr. Lauren Block, Dr. Alice Fornari, Dr. Joseph Conigliaro, and Dr. Nancy LaVine.
 
What was the state of primary care training at Northwell Health before?
 
Like many institutions across the country, Northwell Health had few trainees entering primary care careers. Over the past five years, about five to 15 percent of graduates from our residency program have entered primary care, less than the national average of 20 percent reported in JAMA. Much as in programs elsewhere, our trainees reported that lifestyle, salary, and negative residency clinic experiences contributed to their decisions to pursue specialty and hospital medicine careers. 
 
What prompted this curriculum at Hofstra Northwell SOM? Who was involved? What role did students play and what input did they provide?
 
Our new medical school, which opened in 2011, has had strong input from general internists. Our dean, chief medical officer, several associate deans, chair of medicine, and designated institutional officer for graduate medical education are all dedicated general internists. As a result, strong primary care training is a focus of our students’ early clinical experiences. In the first few weeks of medical school, all students become part of the local community through a nine-week Emergency Medical Technician (EMT) training, and upon completion are certified EMTs, skilled in the core skills of history taking and physical exam. This prepares them for their early primary care experiences. These experiences are supported by an integrated curriculum consisting of communication skills, physical diagnosis, clinical reasoning, and professionalism to support core skills in clinical settings. Diverse student-led interest groups focus on primary care careers by introducing role models to the students early in their education. Hofstra Northwell SOM supports a student-run clinic providing hands-on experience and responsibility for the care of a group of underserved patients. Each of these opportunities ensures that role models in primary care will be available to students at a critical point in their education.
 
Bolstered by the support of general internists throughout our institution, the Division of General Internal Medicine was awarded a five-year Health Services Resource Administration (HRSA) Primary Care Enhancement Award to establish an interprofessional clinic experience we call IMPACcT. This new primary care educational and clinical program includes trainees from our internal medicine residency program, medical school, pharmacy school, psychology training program, and PA school. Adding to the momentum generated from this award, we teamed up with colleagues in family medicine and pediatrics to apply for and take part in the national PACER (Professionals Accelerating Clinical and Educational Redesign) program, which is jointly funded by the Josiah Macy Jr. Foundation, the American Board of Family Medicine, the American Board of Internal Medicine, the American Board of Pediatrics and the Accreditation Council for Graduate Medical Education. The PACER program has brought together the primary care specialties throughout our institution to work on collaborative projects and share best practices.
 
From this increasingly pro-primary care environment at Northwell Health, our Primary Care Progress chapter has blossomed. Originating from our medical school’s internal medicine interest group, our PCP chapter started in 2014 and sent its first representatives to the PCP Leadership Summit this summer. Students returned to tell the newly initiated IMPACcT clinic program about the conference and share skills and strategies learned from other chapters. PCP’s founder Andrew Morris-Singer presented at our Department of Medicine grand rounds and toured our clinical program in November, which focused attention on our PCP chapter and on the incredible resources available through PCP.
 
Who is enrolled in IMPACcT? What will they learn?
 
IMPACcT accepted ten residents, 31 students, two psychology externs, 12 pharmacy students, and eight PA students for its inaugural year. IMPACcT features a team-based approach to care in a clinic-within-a-clinic model as well as longitudinal mentoring and an interprofessional educational curriculum. Students are encouraged to take a hands-on approach to primary care as key members of the patient-centered medical home team and work alongside trainees from other disciplines. Core principles of our clinical program include a focus on continuous quality improvement, continuity of care and expanded access, all using a team-based approach. Key educational topics include health disparities, quality improvement, behavioral health, medication management, team leadership, and PCMH principles.
 
What do you hope to gain from the new primary care track?
 
Our goal is to deliver the highest quality care to our patients while providing our students with excellent clinical and educational experiences and longitudinal mentoring to encourage primary care careers across several clinical care disciplines.
 
How will IMPACcT affect your PCP chapter? How will chapter members be involved in implementation?
 
Our PCP chapter leaders are key participants in the IMPACcT program, where they find a community of like-minded individuals. We support their work to advocate for primary care nationally as we work with our colleagues to promote primary care at our institution and beyond. By inviting our PCP chapter leaders to speak at IMPACcT events and advertising PCP events to our IMPACcT trainees, we hope to achieve success together. We feel incredibly fortunate to have had Dr. Morris-Singer speak at our institution, generating support for national primary care advocacy while spreading the word on PCP’s mission and events. In the future, we hope to leverage our partnership with PCP to offer workshops in relational leadership to our trainees and faculty.

How do the students and trainees like the program so far?

Here's some of the things they've told us:
 
  • “I would totally want to be an IMPACcT patient because you all do the best comprehensive care.”
     
  • “I appreciate the patience and dedication from everyone in furthering my education and clinical skills. I will leave today as a more confident provider solely because of all your efforts.”
     
  • “Everyone has challenged me and has helped me build so much confidence in myself. I will take everything I have learned onto my next rotations.”
Posted by Sonya Collins on Dec 15, 2016 11:12 AM EST
abf76c7c6869fdd6bccaacfe879adf3e-huge-88It's National Influenza Vaccination Week. Today on the blog, read about a medical student who dispelled a patient's misperceptions about flu shots. 

By Puya Jafari

I recently saw a patient about a chronically stuffy nose and was pleased to hear that my short time with him made a difference. As a second-year student still developing my clinical acumen, I use my time to get to know patients, and it seems most patients welcome the chance to share their stories. In addition to this patient’s chief concern, our conversation touched upon his upcoming wedding and his relationship with his future in-laws. I’m married myself and close to the patient’s age. It was easy to empathize, particularly with the stress leading up to a wedding. 

At some point during the interview, I noticed he had declined the nurse’s offer of a flu shot. I wanted to understand his perspective. When I asked, he replied that he always gets sick at some point during the winter when he receives his flu shot. I acknowledged his reason and explained that the flu vaccine does not give you the flu but occasionally isn’t 100 percent effective. However, when it is effective either by preventing the flu or reducing its severity, it’ll save you a lot of trouble by not having to take sick leave or lose time planning your upcoming wedding. I left it at that and once the interview ended we went to see the physician, who is my preceptor, together.
 
The rest of the visit was routine. My preceptor asked if the patient was interested in getting his influenza vaccine. I didn’t tell my preceptor that he already declined it. However, to my surprise, the patient nonchalantly agreed. He glanced over at me and said, “He convinced me to get it.”
 
That was a proud moment for me. I helped someone understand that the flu shot was safe. My preceptor added some praise, saying that even medical students early in their training can make a difference. The moment felt like a primary care victory. But one question still lingered. I didn’t entirely understand why he had suddenly decided that getting a flu shot was worthwhile.
 
He said I convinced him. How? I didn’t cite any research studies. He knew I was a student. The nurse and the doctor were the real authorities on the subject. If it wasn’t the science behind vaccine safety or the legitimacy of the source of information, what else was it?
 
Then the proverbial light bulb went off. Maybe he changed his mind because he trusted my advice. As I mentioned, I spent time getting to know him and understanding stresses he was experiencing with the wedding planning and his relationship with his future in-laws. I empathized quite a bit during the interview. Our chat mirrored the first step we learned in school for an effective medical interview: build the relationship. My patient became an example of how a healthy, trusting doctor-patient relationship can improve health outcomes. 
 
Moments like these fuel my optimism for a career in primary care. Bonding with patients, forming trusting relationships, getting to know patients beyond their chief concern are privileges that I believe students can experience more often in primary care than other fields of medicine. Some may argue that time constraints prevent primary care physicians from effectively building relationships during an encounter. But what I’ve realized is that “getting to know your patient” isn’t merely about flexing interpersonal skills and making friends. It promotes mutual respect, trust and a good working partnership that ultimately can improve outcomes.          
 
Puya Jafari wrote this piece in 2015 as a second-year medical student at George Washington University School of Medicine and Health Sciences
 
Posted by Sonya Collins on Dec 8, 2016 1:42 PM EST
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
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