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Archive for October, 2016
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
a5582733b7d0ab1bc38a21f1d4039e2c-huge-imIt's National Primary Care Week! The theme is improving health care access for all. One way we believe that the health care system can do that is through interprofessional team-based care. Many health care providers love the concept, but what to do patients think? That's what we wanted to find out.

By Sonya Collins

Ridie Ghezzi was dealing with depression. Her doctor tried her on one medication, then another, then changed her dose, but it just wasn’t working for her. So she called Amanda Rice, the behavioral health specialist at Dartmouth Health Connect in Hanover, NH, where Ghezzi is a patient.
 
Rice immediately contacted Ghezzi’s primary care doctor – also at Dartmouth Health Connect – who called Ghezzi that day. The phone conversation was long and unhurried. During the call, the doctor decided to change Ghezzi’s prescription, and she made an appointment to meet with Ghezzi, her health coach, and the behavioral health specialist as a team the next month.

“I felt like the wagons had surrounded me in protection,” Ghezzi recalled.a2e8f0f6d32aa0b1c45cbf1a47c77f6a-huge-24

A same-day call back from a doctor? A long phone conversation? An appointment with three health professionals in the room at the same time? If this doesn’t sound like a typical interaction with the health care system, it’s because Dartmouth Health Connect is not a typical clinic. Its team-based model of care strikes a stark contrast to the solo doctor-does-all, seven-minute-visit model that most patients know (and few love).
 
By design, team-based practices, also called patient-centered medical homes, have the potential to redistribute provider workload, change the way health care providers get paid, and – in the best cases – put patients at the center of it all. Providers have many reasons to love the model of care, but what do patients think?
 
Research shows that patients want four things in a medical practice: whole-person care; coordination and communication among providers and between providers and patients; patient support and empowerment; and ready access.
 
If a health care model by any name delivers those benefits, patients are likely to take to it. “Patients love the concept, but if it’s not operationalized, if the practice isn’t visibly operating as a team, they won’t embrace it,” said Christine Bechtel, co-chair of the Center for Patients, Families and Consumers at the Patient-Centered Primary Care Collaborative. Bechtel co-authored the aforementioned research published in 2010 in Health Affairs.
 
What is team-based care?
 
The idea behind team-based care is that doctors cannot – and should not – do it all. They can’t see all the patients, solve all the problems, and complete all the associated administrative tasks in a day’s work. Even if they could do it all, they’re not always the best one for the job. Doctors diagnose, but pharmacists unravel complex medication regimens to discover which one is causing the unpleasant side effects. Dietitians help patients come up with a meal plan to achieve a healthy weight or manage their diabetes. Behavioral health specialists address the mental and emotional issues that may prevent us from achieving optimum health. Sure, doctors can refer patients to these and other specialists, but patients don’t always follow through. And when they do, the referring doctor may never know what happened during the visit.
 
Team-based care can bring multiple health care providers together under one roof, or it can include a care coordinator who quarterbacks care that happens in multiple settings. Team members can free up their teammates to do what they do best, whether it’s diagnose, manage medications, or optimize a diet.
 
“It’s not about a doctor just writing a prescription and telling you what to do,” said Amy Gibson, RN, who is chief operating officer of the Patient Centered Primary Care Collaborative. “It’s about bringing [providers] together as partners who can provide expertise. At any given point in time, it may be the behavioral health specialist or some other team member besides the physician who needs to be leading that team.”
 
Placing patients with the most appropriate health care provider, rather than the doctor every time, can also increase access to all providers for all patients. That’s why some team-based models may offer same-day appointments, email and telephone access to providers, and longer appointments. Team-based models may also allow for innovative payment structures. For example, payers might reimburse practices a flat monthly fee per patient rather than a fee for each service provided.

When it doesn’t work
 
Simply declaring a practice to be “team-based” is not enough to convince patients. Bechtel selected her current primary care provider because it was a team-based clinic. She has been a patient there for several years now. But every time she goes, she says she feels like a new patient that no one knows. She fills out paperwork for the receptionist, who asks her why she is there. She then sees the medical assistant (MA), who takes her vitals and asks her why she’s there. The MA then leaves her with a doctor, physician assistant (PA) or nurse practitioner, who again asks her why she is there.

6fdda907c4100770eef3b10984c50415-huge-0e“Where is the team part of this? I’ve just been asked why I’m here three times,” Bechtel said. “It’s so obvious to patients when they’re not operating as a team.”
 
For patients, a team-based model like this one just seems to place more barriers between their doctors and themselves.
 
“Oftentimes, what patients observe, unfortunately, is that they can’t get to their doctor because it’s ‘team-based,’” Bechtel said. “They ask, ‘Well, what does that mean?’ And the practice tells you it means that all providers can access the medical record and read each other’s notes. But that’s not a team.” Shared access to an electronic medical record may streamline the workflow for providers, but it’s not necessarily a visible improvement in the patient’s experience.
 
Even the best intentioned team-based clinics may not get full buy-in from patients if patients don’t know what team-based care is. Patients need to be fully oriented as to what the new model offers, what issues it addresses and how patients can make the most of it.
 
“If no one ever explains to patients what a team-based approach is, that you might sometimes see a different person, but that person is always going to know what’s happening with you and has full access to your doctor and your records,” Bechtel said. “If no one ever says that, the patient experience isn’t going to be good.”

When it works
 
Team-based care that works puts the patient at the center and addresses the patient’s needs and concerns ahead of those of the provider or payer. “We haven’t done such a good job of knowing and engaging our customer in health care, and we’re trying to make that happen through the patient-centered medical home,” said Gibson.
 
Whether patients like Ghezzi can cite precisely those four things that research says patients want, the way she describes her experience reflects these values. Her physician teamed up with the behavioral health specialist to address her complaints as a whole person. The providers communicated with each other prior to contacting her and then engaged her in a conversation with them during a group appointment. The quick call-back demonstrated their support for her and her ready access to them.
 
“Everyone is working together, recognizing that none of these things are separate from each other. Emotional and physical are interconnected,” Ghezzi said. “And you feel, by the kind of care they give, that it’s all being worked on as a whole.”
 
Is a rose a rose?
 

Many medical practices can call their model team-based, but that doesn’t predict what the patient’s experience will be. At the same time, whether or not patients even know the name of the model, they will know whether their health care providers are working together as a team with the patient at the center.
 
“If you build it will they come?” Bechtel asks in the title of her 2010 Health Affairs article on team-based care. The answer, she says, is “if you build it with them, they will already be there.”

Sonya Collins is an independent journalist who covers health care and scientific and medical research. She is the editor of Progress Notes. 

Read more about team-based care.
Posted by Sonya Collins on Oct 4, 2016 9:29 AM EDT
c0360b13e6964753f926952a94499b36-huge-snIt'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. Through this program, PCP is helping to develop the next generation of primary care leaders. 

By Stephanie Nothelle, M.D.

For the last three years, the student hotspotting program has allowed teams of health professional trainees from all across the country to take control of the health care system and help the patients left in the shadows. A team of students gave a kidney failure patient – dependent on hemodialysis for her survival – a second chance at survival. After the patient had been kicked out of all the units in her community, the team negotiated readmission to a local unit. This intervention cut her hospital admissions from over 200 a year to just a handful. Another team cut a patient’s emergency department visits for a patient with sickle cell disease in half when they introduced her to a primary care physician whom she can call instead of 911 when she doesn’t feel well. 


The hotspotting program, built on the work of the Camden Coalition of Healthcare Providers in collaboration with the Association of American Medical Colleges and Primary Care Progress, launched three years ago. Its mission is to teach students to deliver the interprofessional, team-based care that the sickest patients in the healthcare system need. As an advisor for the hotspotting team at my home institution, Johns Hopkins, I have seen students learn in a matter of weeks what it took me years to learn as a physician: how our health care system works…or doesn’t. Moreover, they learn this with a colleague from another profession who they otherwise would not have met until they entered their first job, at which point it would have been more challenging, and less likely, to learn about respective roles and skills. Every list of health professional competencies includes “systems-based learning” and “interprofessional teamwork,” but for the first time, I actually saw trainees reach this competency in a meaningful way. What’s more, while students might not recognize it at first, hotspotting helps them build crucial leadership skills. Development of this skill set is at the heart of Primary Care Progress’ mission.

The students who advocated for the patient with kidney failure, for example, had to connect with the leadership at the hemodialysis unit and build trust to convince them that this patient was worth another chance. They had to communicate a shared goal, which was to keep patients with kidney failure healthy and safe, and use this as currency to advocate for their patient. Since the hotspotting team had already been trained in building rapport and trust with patients and working together to find a common goal, they applied this to their interaction with leadership of the hemodialysis unit. They mastered the foundation of relational leadership, a model that emphasizes the relationships among and between team members just as much as the goal of the team’s work - it just hadn’t been labeled as such. 

When the students get a taste for leadership through hotspotting, eventually they want to lead. With very little guidance from me, the students in our local group have decided to work in pairs, always with someone from another profession, to care for a patient. Quite frankly, at first this notion made me a bit nervous. Would the traditional medical hierarchy trickle into our project? Would the nursing student-medical student pair essentially be the medical student taking charge and the nursing student “assisting?” Time and again, I have seen that my fears are entirely misguided. The medical students quickly see that nursing students bring essential skills that enhance patient care and from which the medical students themselves can learn. After a few bumps, the students’ work together is fluid. They naturally alternate roles, at times taking the lead and at other times following, depending on one another for success. 

One of these pairs worked with a patient who struggled with drug addiction and had a severe illness. There was a treatment for her illness, but the doctors at the local hospital weren’t sure it was appropriate given her ongoing drug use. The students advocated tirelessly and eventually found a physician who would be willing to give the patient the treatment she needed. But when they went to tell her the news, they learned that it was too late, she had already passed away. My heart broke not only for the patient and her family but also for the students, who I knew worked diligently to get the patient the treatment she deserved. In practice, I have seen situations like this turn people sour. Why, they ask, should I put all this work in just for it to end in heartache? But rather than turn sour, the students were mindful about the event, took the time they needed to process and turned to each other for support before moving forward. 

I think about these particular students and the work of student hotspotters around the country when I feel myself struggling in my everyday work. While I am an advisor in the program, the students teach me so much. Seeing their resilience in the face of a broken system is the boost of inspiration I need to steer clear of burnout. The leadership they show gives me confidence that they will usher the health care system into the next decade – a health care system that will have been made better by them.

Stephanie Nothelle is a Clinical and Research Fellow in Geriatrics at Johns Hopkins School of Medicine and an advisor to the school's hotspotting team. In the future, she plans to take care of older adults in the primary care setting and inspire learners to do the same.

Read more about hotspotting.
 
 
Posted by Sonya Collins on Oct 3, 2016 10:41 AM EDT
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Dear Penny, You give us another wake-up call. Boundaries can get loose and good habits can get worn down in the nursing home. As you say, the way that things get paid for affects the doctor-patient relationship. In my HMO, there are financial incentives to keep our patients at home. And some of our patients who need long-term care but still value the sociali...
It is a great article to know what patients want. Each medical professional must read this to know more about patients and keep them happy.
This looks intresting one and thanks for sharing. Any decision patient only input ant output important.
Thank you for sharing such ideas...
Thanks for the full summary of events and new leadership directions we need to take in primary care. Student and resident leadership is vital to the future of primary care, especially Family Medicine, where many of our senior leaders are shifting into health system, regional, state and federal roles, thus creating large need for new and emerging leader...

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