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Archive for December, 2016
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.

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."

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."

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."

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."

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."

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."

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?"

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."

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."

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."

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."

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
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May God bless your good work sir. saving millions of lives daily. i am very much grateful to you sir. friends for the past 20years I've been a carrier of Genital Warts. i have visited many traditional center and others temples all to get my self a cure. but all my time was worthless. i was checking a blog and i saw a comment on Dr Akuna strong herbal medicine and ho...
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