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6c40d742c112a378e187813655139587-huge-aaWhen Aakash Shah's patient-mentor told him he wished his diabetes was more like tuberculosis, Aakash was eager to get an explanation. Here's the story of how a patient's childhood TB and adult-onset diabetes illuminated the holes in our healthcare system.

By Aakash Shah

“Mr. Williams” is a storyteller. Each time he catches my gaze fixed on a picture frame, he lets out a knowing sigh and then launches into the memory behind each photo. There was Michael’s graduation, Nathan’s wedding, Lauren’s first child, and the entire family, three generations in all, gathered together around the Christmas tree. Mr. Williams has been blessed with a beautiful family – a wife of 55 years, four sons, three daughters, and nine grandchildren – and he knows it. As it turns out, he knows a bit about what ails our healthcare system, too.

As a first-year medical student, I’m attracted to primary care for its strong physician-patient relationships, but my exposure to it is limited. Growing up, my visits to the pediatrician were few and far between, and I had no interaction with other doctors. That all changed during my first month of medical school, when I met Mr. Williams’ primary care physician through a course designed to allow students to view our healthcare system from a patient’s perspective. We decided that I would follow Mr. Williams over the course of the year to better understand his primary care experience. A few weeks later, I found myself sitting in Mr. B’s living room drinking tea – green is his favorite – and enjoying Mr. B’s life story.
While recounting a memory about a visit to the hospital as a teenager, Mr. Williams joked that he wished diabetes were more like tuberculosis. Glancing at his medical history, I noticed that he had an episode of TB when he was in high school and had been diagnosed with diabetes about four years ago. Feeling as though I had missed the punch line, I asked him to elaborate. He explained how he felt that the healthcare system handles cases of tuberculosis much better than diabetes.
Those words stayed with me as I rode the elevator down from his apartment later that evening. It struck me that Mr. Williams was describing what Sendhil Mullainathan, the MacArthur Award-winning Harvard economist, has dubbed the “last mile problem.” The medical community has invested a tremendous amount of energy, creativity, and resources into finding solutions to diseases like TB and diabetes. The effort has paid dividends. It has taught us how to harness the power of antibiotics, insulin therapy, and a plethora of other life-changing treatments. In the case of TB, the healthcare system follows the patient and sees him through until the disease is gone. However, in the case of diabetes, we’ve yet to go the last mile and perfect the science of chronic disease management.
Though I’m not sure exactly how to go the last mile on diabetes care, I know that the road ahead is through primary care. And like many others who see the potential of primary care to revolutionize healthcare delivery, I’m excited for the journey.
This piece first appeared on Progress Notes in 2011 when Aakash Shah was a first-year student at Harvard Medical School. 

Read other patients' perspectives on the healthcare system:
Posted by Sonya Collins on Apr 27, 2017 2:12 PM EDT
096926b7cb6cc1e7478aefd7f3c820c1-huge-amA medical student and aspiring family physician asks his future colleagues in other specialties not to let all the social justice work fall on the shoulders of primary care providers. 

By Amulya Iyer

Mr. FM is a charming, gregarious, middle-aged Dominican man who lives with his wife and children in upper Manhattan. He is generally happy and healthy. Though he has an enlarged prostate, this shouldn’t prevent him from living a full life. In an ideal world, I would never have met him as an inpatient, but unfortunately, he came to the emergency room with dangerously high potassium, after a month of vomiting and a week without urinating. His untreated prostate had led to urinary obstruction. Mr. FM was hospitalized and dialyzed, but never regained complete kidney function. When he was discharged with nephrostomy tubes on both sides - catheters inserted in the kidneys through the skin that drain urine into a bag outside the body - he was at risk of being on dialysis for the rest of his life.
During his hospitalization, I spent a lot of time with Mr. FM, partly because medical students have time to spend with patients, but also because I liked him. He is an affable, intelligent man, with a supportive family. His wife and brother-in-law were always at his bedside bringing him snacks and coffee that he would lovingly force upon me. When I asked him why he hadn’t gone to the doctor sooner, he responded that he did not like doctors and never had a good experience with them. In fact, the only reason he came to the emergency room at all was because his wife dragged him there.
Looking back in his chart, however, I saw several visits to primary care doctors over the last year that repeatedly noted his enlarged prostate and his medication noncompliance. Yet none made any reference to the potential barriers to his compliance. Maybe his noncompliance could be chalked up to the language barrier. Mr. FM speaks Spanish only. Maybe he didn’t understand how or why he had to take the medication. Whatever the case, the doctor’s job isn’t simply to know that you treat an enlarged prostate with an alpha-blocker. Any computer can tell you that. And clearly that knowledge had not been enough to prevent the potentially life-threatening repercussions of the condition. It is the doctor’s job to think of Mr. FM’s illness in the entire context of his life.
Throughout medical school, I saw scenarios like Mr. FM’s repeat themselves again and again. So many advances in science and medicine are inaccessible to patients because the healthcare system isn’t designed to include time to educate and advocate for the most vulnerable. As a primary care doctor, I want to be a patient advocate and combat the systemic inequality patients face.
Since expressing my desire to go into primary care, however, I have received various responses from my classmates, the most puzzling from a student applying to dermatology who said, “Wow, that’s really good of you.”
But it doesn’t feel like a sacrifice, or a “good deed,” to forego the higher-paying fields that make up most of my school’s match list - a school that tried to eliminate the family medicine department just last year. I love people and hearing their stories. I love the challenges of motivational interviewing. And I love grassroots community engagement, which is possible in primary care.
Primary care is often held up as a beacon of morality, a field that “righteous” students pursue, but social justice in medicine should be the purview of every field. All of medicine and healthcare should be altruistic and dedicated to service. The homeless man who sleeps in Central Park and the man who looks over it from his penthouse apartment both need primary care, but they may also both need dermatologists - or urologists in the case of Mr. FM.
Despite following him for nearly two weeks as an inpatient, recommending nephrostomy tubes and outpatient prostate surgery, the urology team would not see Mr. FM for follow-up because they didn’t accept his insurance. So rather than have follow-up with a doctor walking distance from his home who knew his entire case and had access to his records, Mr. FM was forced to see a urologist 45 minutes away. And he only got that appointment because of the relentless phone calls that another medical student on the team made. On the day of Mr. FM’s discharge, with tubes sticking out of his kidneys, I couldn’t help but be disappointed about the additional barriers we were placing in front of him.
I’ve been in touch with Mr. FM for the past few months through phone calls and text messages, ensuring that he understands his medications and attends his appointments with a complex array of specialists. When I met up with him at a recent appointment, he was doing quite well. I know when I become a family doctor and have thousands of patients, it will not be possible to follow each one so closely, to walk them through every step of their care. That’s why we need system-level changes, which won’t happen without advocates throughout medicine - not just primary care.
After all, in medicine - not just primary care - every human being is a potential benefactor of your skills and has a right to the care that you can provide. Of course, I don’t expect all my classmates to enjoy the same things I do and go into primary care like I will. But I would like to make a plea that every medical school graduate be thoughtful about the way they practice medicine, the patients they treat (and the ones they don’t treat), and the imperative they have to use their training and skills to address the irrefutable health care disparities in our country and around the world.

Amulya Iyer is a fourth-year medical student at Columbia University and plans to pursue a residency in family medicine.

Posted by Sonya Collins on Apr 20, 2017 10:59 AM EDT
4665fcefa45d8a892d09808b1059a4ae-huge-peA nursing home resident and outspoken advocate for other residents explains how trauma, which is all too common among her peers, can lead to misdiagnoses and inappropriate care. The solution, she says, is trauma-informed primary care in nursing homes. 

By Penny Shaw, PhD

Making the transition to life in a nursing home can be highly stressful. It’s a dramatic life change that new nursing-home residents are not prepared for. Deterioration in health, feeling abandoned by family, wanting to remain at home in a familiar environment, loss of privacy when sharing a small space with a stranger, a shattered sense of security and role in the community – these are all part of the transition into a nursing home. The loss of choice and control to choose previous routines and preferences, as well the numerous institutional rules, policies and practices to follow can lead to adverse emotional reactions. Primary care physicians using a trauma-informed approach to care successfully address feelings of being overwhelmed which, in long-term care facilities, are referred to as relocation stress or transfer trauma.
Transfer trauma has a wide range of physiological, cognitive, mood, behavioral and social manifestations: fatigue, appetite and digestion problems, headaches, sleep disturbances, confusion, difficulty concentrating, shock, anxiety, depression, and poor hygiene.
I personally suffered from transfer trauma when, after a year in a respiratory hospital where I knew the staff well, I was transferred to a nursing home. I remember the fear I had the night before leaving, when I talked to my night nurse about not knowing where I would be going. My stress was such that upon arrival at the nursing home, I’m told that I was confused and waving my arms. I had no idea where I was. I didn't talk and the staff gave me a communication board. They thought I was unable to speak because of a tracheotomy I had. But actually, I was traumatized. My functioning declined. I had been active in the respiratory hospital – had gotten up to do watercolors, talked to staff and patients, but now I was bedbound. As I later learned from reading my medical record, I had been misdiagnosed with psychosis and given an antipsychotic I didn’t need.
Other residents in the facility where I live are often traumatized. An older woman unable to walk after a fall wanted to go home and was sad, thinking this was the end of her life. Another woman was distraught saying she'd lost her home, now lived in a cubicle and was alone, as her daughter wasn't visiting her enough. A woman asked me her first day with us "Is this a prison? Can I leave if I want to?" I reassured her she could. A man puzzled over how he had survived a major head injury, only to end up in a place where people told him what to do. Another man, tragically, who could not accept that his wife had placed him in a facility, deteriorated and died.
Primary care physicians familiar with trauma recognize the varied symptoms and use a trauma-informed approach for diagnosis and treatment. During assessments, they look for signs of trauma. They ask questions of residents. In clinical decision-making, they identify symptoms indicative of trauma and diagnose correctly. They realize that mood disturbances might not be a sign of mental illness like bipolar disorder, but instead are normal given the circumstances. In this approach, physicians use the appropriate standard of care – non-pharmacological first, avoiding unnecessary drugs with a potential for adverse side effects, thus preventing additional health problems. Trauma-informed care plans connect physical, cognitive, mental and behavioral health to promote healing, eliminating or delaying progressive disability.
Trauma-savvy physicians also provide clinical leadership, guidance and support to staff in training on trauma and trauma-specific interventions. Education changes staff perspective. They become more sensitive, caring and tolerant of symptomatic behaviors, no longer seeing residents as behavioral problems, complainers or troublemakers. Physicians also help staff develop competencies in trauma-specific treatment techniques to develop coping strategies including emotional support, by talking to residents so they can express and have their feelings validated as normal. Other techniques include orienting, supporting and reassuring residents that they understand what happened to them. These interventions start the process of re-establishing a sense of physical and psychological safety and developing coping strategies. Giving residents a voice and some control reduces the power differences between staff and residents. Empowering residents can counter feelings of powerlessness and decreases learned helplessness and unnecessary dependency.
As I have seen in my facility, residents can learn a new outlook and become more optimistic and hopeful about recovery. They become more motivated, build a new lifestyle as close as possible to what they lived before, and usually accept their situation. The journey of recovery is incremental, and if distressing symptoms persist, professional psychotherapy is arranged.
Trauma-informed primary care physicians also realize that a nursing home is a resident's home, and that environment affects mental health and well-being. Design features of the built environment – both architectural and interior – have clinical utility. Windows with exterior views reassure residents they're still part of the larger world. Natural light, pleasant resident rooms with soothing paint colors of blues and greens, and homelike furniture are comforting and uplifting. Access to the outside and gardens provide a welcoming, restorative encounter with nature. Giving residents a choice in wall art and room furnishings and providing operable windows for fresh air give residents a sense of personal control over their environment. Physicians should encourage facilities to allow for patient choice in the surrounding environment as much as possible.
The significant effects of trauma-informed care, policies and environment are numerous: improved physical and cognitive functioning, psychological and emotional stability, fewer maladaptive behaviors, improved social interactions, staff and resident satisfaction and lower mortality rates.
I encourage primary care physicians, especially those who care for patients in nursing homes, to seek more information about trauma-informed primary care. Too often health care providers jump to the conclusion that people in this population simply have mental illness or cognitive decline when it is trauma causing these symptoms and it can be treated.
More information on trauma-informed care is available at the Substance Abuse and Mental Health Services Administration's National Center for Trauma-Informed Care and the National Council for Behavioral Health's Trauma-Informed Primary Care initiative.
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, Shaw is a board member of the Massachusetts Advocates for Nursing Home Reform and of the Disability Policy Consortium of Massachusetts. She was named a “Trailblazer in Elder Care” by the U.S. Department of Health and Human Services’ Administration on Aging’s Administration for Community Living. She is a 2016 recipient of a National Consumer Voice for Quality Long Term Care Leadership Award.

Posted by Sonya Collins on Apr 13, 2017 11:56 AM EDT
67f985037329d0cf56e11dad0cd8eb8e-huge-reFriday, April 7, is World Health Day. This year's theme is depression, the leading cause of illness and disability worldwide. In observance of World Health Day, WHO is encouraging people to speak openly about depression and suicide through their #LetsTalk hashtag. In that spirit, today on the blog, a medical student speaks openly about her ongoing battle with depression and suicidal thoughts. She encourages others to speak out as well.

By Rebecca Powell

There are two versions of me.

On the wards, I am the student who shows up early, the enthusiastic learner, the integrated helpful teammate, and a friend to patients. I am known for my big smile, even among strangers who do not know my name.

At home, I am a dark cloud, crying in bed with the covers over my head so that my roommate will not overhear. I sleep too much, eat too little, and struggle to find interest in any non-medical activities. I know the criteria for major depressive disorder. Since starting medical school, I have full-blown, rip-roaring, unrelenting clinical depression.

This little dark cloud has called the suicide crisis line three times in the past school year. Twice while working the long hours that are the norm during a third-year surgery clerkship and once, ironically enough, while working on the inpatient psychiatry unit with suicidal teenagers. I have a positive family history for major depressive disorder, and had several episodes of depression during stressful times in high school and college. During college, I thought I had found the depths of my depression, but I was wrong. It was medical school that pushed me beyond the point of passive suicidal ideation to active suicidal planning, which is a huge, dangerous leap that, as I interviewed psychiatric inpatients, made me feel I should be sitting in their seat.

What got me here? Why the change for the worse and why, when I was studying the very disease I was suffering from, could I not receive the help I needed?

It wasn’t until after my second call to the crisis line that I recognized I needed to be more proactive about my depression. I was working long hours and under constant stress to perform. I had very little autonomy, and was worried that I had made the wrong career choice. In addition, the transition from the first two years of medical school, which took place in an academic lecture hall where I could be a passive learner, to the third year of medical school, where I was now standing shoulder-to-shoulder with the medical team, was not easy. I made an active effort every day to get up in the morning, shower and look presentable, pay attention on rounds and be alert to any “pimp” questions thrown my way. Like a ritual hazing, “pimping” students is a key component of teaching on the wards. It’s when, as Dr. Druv Khular described in the New York Times, doctors ask students “a rapid series of questions, from thought-provoking and relevant to esoteric and unanswerable[, which continue] until teachers run out of questions or doctors-in-training run out of answers.”

Introverted, shy, and depressed, I did not appreciate the sudden expectation to be an active member of a team and sometimes the center of attention. It took all the mental and emotional energy I had to be present all day with the medical team and our patients. Afterwards, I felt exhausted and defeated. I would go home and go straight to bed. Then I’d get up and do it again. It was a vicious cycle with no place for self-care. When I only had a few days to impress a preceptor, any time away from studying or the patient wards, I feared, would be detrimental to my grade.

So logistically it was difficult to seek help. I did not know my schedule more than a week or two ahead, so scheduling an appointment with a doctor was nearly impossible. Primary care providers and psychiatrists usually work 9 to 5, but I usually worked 6 to 6. I had gone into medical school wanting to help others in their greatest time of need, and now I couldn’t even help myself. And it was literally killing me to keep trying.

I waited to see a physician until I was scheduled to work the night shift several weeks after my second call to the crisis line. Instead of leaving the hospital after my shift ended at 6 am, I stayed on campus until later that morning when the clinic could fit me in. That way I did not have to ask my preceptor, who was grading me, to excuse me early or allow me to come to work late.

Even if missing work to see a doctor wouldn’t hurt my standing, medical training puts a lot of pressure on students not to appear weak. I felt that I was under constant surveillance, both by my classmates and my superiors. A budding physician needs to be impervious to psychological conditions, otherwise she will not be worthy of the profession. I worked hard to appear worthy.

Depression cannot always be seen on the outside, but I know I am not be the only medical student or medical professional who has felt this way. Statistics about health care providers and their mental health are thrown around all the time, including higher suicide rates among physicians. Some of my own classmates are fighting this mental illness. I don’t have the answers. I am still struggling with this myself.  But I am writing so that others won’t feel stigmatized or alone and might have the courage to advocate for themselves. I encourage students and preceptors to build an atmosphere of wellness within their sphere of influence, to be examples of self-advocacy, and to be sympathetic of others who may need support. Admitting you need help and seeking it is not a sign of weakness. It is a sign of strength, and it will serve you and your patients for the better. 

Rebecca Powell is a third-year medical student who will be pursuing triple board specialty programs in the fall. If accepted, she will be working towards becoming board certified in pediatrics, child and adolescent psychiatry, and adult psychiatry. 

Read more about depression on the blog. 

Posted by Sonya Collins on Apr 6, 2017 11:51 AM EDT
fae837c762e7213eaf5a4de1bcea7743-huge-viAt Primary Care Progress, storytelling is at at the heart of what we do. It can bridge divides and highlight shared values between health care professionals and patients, among care team members and between different disciplines. Storytelling inspires action, even in the face of overwhelming challenges, which is what we need to transform primary care. Today on the blog, a co-leader of our Hofstra team explains how she passed storytelling skills on to her teammates. 

By Victoria Fort (pictured left)

It was my first patient of the day, and she greeted me with, “I hate coming here.” 
“Go on,” I coaxed. 
“Every time I come here, I see a different person, I haven’t gotten any of the referrals I’ve asked for, and I feel totally dismissed.”

I told the story of this patient at PCP-Hofstra’s recent storytelling event.

At Hofstra, we devote curriculum time to reflection. It’s a process that’s literally built into our schedule. The faculty value it, and the students all get something out of the experience. However, we don’t get a lot of structured time to reflect on our initial clinic experiences (ICE). We start these experiences by riding ambulances during our EMT training. Then we have weekly office visits with preceptors in general internal or family medicine, pediatrics, OBGYN, surgery, and psychiatry. For most of us, ICE is our first experience with primary care, and based on the stories I’ve heard around school, these experiences can be very mixed.
Knowing this, my PCP chapter co-leader Pratiksha Yalakkishettar (pictured above right) and I wanted to create a structured, safe space for people to share specific stories from their ICE experiences. Our goal was to help students crystalize a single experience, and in so doing, come to a concrete conclusion about what they learned or felt. We called the event ““Breaking the ICE: Owning your ICE experience through storytelling.”
We used the storytelling method that Pratishka and I learned last summer at PCP’s Gregg Stracks Leadership Summit. The technique compresses a challenge, choice, and outcome into a 3-minute story. At the summit, we were asked to tell a story that conveyed our passion for medicine and what brought us to the summit. The stories we heard and shared surprised us. They were compassionate, personal, and created a tighter bond between teller and listener. That’s why we chose to use the same method at our event.
We started the event by asking why we tell stories. We heard entertain, connect, reflect, give feedback, process, and be human. I told an example story – the one about my patient who hated coming to the clinic – and then we broke up into groups of three. Someone would tell their three-minute story, receive feedback and then workshop a part of that story.
e8013ebd0ee3240de5b42fc949522399-huge-piA student in my group of three asked to go last, and when we came to her, she insisted that she had no story to tell. We coaxed her into talking about something, anything, that had happened at ICE. She ended up telling a story about an experience where she didn’t speak up during a patient encounter, and how his outcome could have been improved if she had. A few months later, she was brave enough to speak up for a different patient, in the hopes of avoiding a similar outcome. As she reflected on this, she realized that she hadn’t connected those two experiences before. The weight of that first decision shaped her and helped her become a more confident student doctor. She expressed her gratitude to us for pushing her to reflect, and for holding an event for storytelling about ICE.
Coming back together as a large group, a student shared her story about losing faith in primary care when she saw how it can turn into a referral hub. Over the course of the story, she came full circle to regain hope through a challenging patient experience with a positive outcome.  At the end of the evening, we went back through the list of reasons to tell stories and found that her story covered all of them: entertain, connect, reflect, give feedback, process, and be human.
Holding this event was a proud moment for me as a student. I encourage other PCP teams to explore the possibility of holding similar events. It allowed me to pass on to my friends and colleagues a tangible skill of empowerment and insight, and I believe we all surprised ourselves with our conclusions.   
Victoria Fort earned her MPH from Emory University. She spent four years working with CDC, WHO and several African Ministries of Health to build integrated disease surveillance capacity in the WHO AFRO Region. She is now a member of Hofstra Northwell School of Medicine Class of 2019. 

Watch Victoria tell her story here...

Posted by Sonya Collins on Mar 30, 2017 12:11 PM EDT
March is Social Work Month. Today on the blog, a social worker explains why her work is so crucial to primary care. 
By Tiffany Brennaman, LCSW

“You’re a social worker? How noble and sweet!” I've been a social worker for nine years now and if I’ve learned anything, it’s that this field is about so much more than being noble, and it sure ain’t sweet. I started out working for a therapeutic foster care agency while completing my graduate degree. My first two years in the field, I wasn't thrown to the wolves; I was chopped up into pieces and placed in their food bowls. I responded to crises at 3 a.m. on multiple occasions. I sat in on session after session as therapists explained to children why they would never be able to return to their parents again. I spent a week at the bedside of a comatose teenage girl who'd attempted suicide. I spent six hours de-escalating a teenager in the woods. The evening of my 29th birthday, I slept on the floor beside a child who was on suicide watch. After those first two years, I was ready to quit. Not just foster care, but social work.
But I didn't quit. I went into homeless services and I am currently a social worker for the homeless services program at the Atlanta Veteran’s Administration.
Social workers are becoming increasingly essential to interprofessional teams. While doctors, nurses, psychiatrists, and other health professionals might not always be able to focus a substantial amount of time on building relationships, social workers can be seen as the relationship experts who can communicate most frequently and effectively with clients and their families. During a crisis, a social worker is often called upon to intervene. Most importantly, social workers serve as tremendous advocates for clients. We believe that everyone deserves fair, just treatment, and that social justice does not discriminate.
Prior to my current position, I spent several years working for an organization called Back on My Feet (BoMF). BoMF uses running (yes, running) to help individuals change the way they see themselves so that they can make real change in their lives. This job gave me the opportunity to seek out the good in people, help them see the good in themselves, and use it to propel their lives in a positive direction that could not only benefit them but others as well. 
What made me so beneficial to BoMF? Social workers are acutely aware of the many circumstances that often surround an individual's life choices. We use a biopsychosocial model to look at the person in their environment and examine all the potential contributing factors that led to their lot in life. Using this model, it is easier to decipher not only root causes but also external circumstances that can lead a person to make destructive decisions habitually.
The reduction of recidivism is oftentimes a social worker's primary goal, especially in the field of homeless services. Recidivism can be associated with criminal offenses, but it can also refer to repeated relapses into substance use, hospitalizations, and episodes of homelessness. Reduction of recidivism is of course tremendously beneficial to the client, but the impact on society and the economy is where the long-term change can be felt. Multiple hospitalizations for repeated relapses cost a lot more than keeping someone housed and providing intensive case management. Social workers are typically working the front lines, implementing all possible resources and interventions to reduce the frequency of self-destructive behaviors in a client.
Often, it is these barriers that must be overcome before individuals can even begin to benefit from good primary care, regardless of how much they may need that care. Falling in and out of homelessness, substance abuse, and crime are certainly barriers to medication adherence, self-care, preventive care, and management of chronic disease.. That’s the benefit of having a social worker on a primary care team.
Social work puts clients first. By clients, I don't always mean those who pay for services. I mean those who need help. Our code of ethics will not allow us to discriminate against anyone. We help our clients learn how to take a different road and avoid falling into the same hole over and over. And by ensuring their continued stability, the rest of the primary care team’s work is that much more effective.

Tiffany Brennaman, LCSW, is a social worker for the HUD-VASH program at the Atlanta Veterans Administration. She is also a self-help junkie who enjoys running, hiking, yoga, and trying foods from all over the world.

Posted by Sonya Collins on Mar 23, 2017 3:04 PM EDT
March 20 is World Oral Health Day. Today on the blog, a public health dentist explains why oral health is a crucial part of overall good health. 

0b4b64bdeb43318a432788f1165436ca-huge-tuBy Dwayne Turner, DDS, MBA

Like most dentists, I feel strongly that good preventive care must include good oral health care. As the Dental Health Services manager at the DeKalb County Board of Health in metro Atlanta, I know that preventing oral health problems is critical to overall good health. Without early detection and treatment, oral diseases can worsen other diseases and conditions and, likewise, other diseases and conditions can worsen oral diseases. Oral health can also serve as an early warning system for people suffering from certain conditions such as cardiovascular disease, diabetes, osteoporosis, and obesity. Pregnant women who have gum disease are at a higher risk of having a premature birth or a low birth weight baby than pregnant women without gum disease. Serious dental issues can even result in hospitalization. In fact, from 2008 through 2012, over 250 of our county’s residents were hospitalized due to dental conditions.

Two examples of signs we often see are dry mouth and mouth lesions. Dry mouth can be an indication of diabetes or the side effect of a medication. Lesions can indicate a hormone or nutrient deficiency, a herpes or strep infection, cancer, an allergy to an oral care product, or HIV infection. Also, our dentists have seen patients with dizziness that can indicate high blood pressure, skin rashes that can be caused by bacterial infections, and even chest pains that can indicate heart trouble. So, we look beyond just a patient’s teeth to assess their general oral health and their overall health.

I’m very aware of the impact of oral health issues on our county’s residents, particularly our children. Of the almost 84,000 children our program screened from 2008 through 2012, 3% had pain, infection, or swelling and required urgent care. Another 14% had cavities or gum problems and needed prompt care. Among teenagers, in a 2015 survey, only 68% of our high school students reported that they had seen a dentist in the preceding 12 months. 

Our screening efforts include onsite screenings at elementary schools and, during the summer, at places like recreation centers. The emphasis is on serving low-income students who might not otherwise see a dentist. In addition to screening, we also provide sealants and fluoride varnishes. Dental hygiene students often help at these sessions, giving them a chance to hone their skills. Over the course of a year, we reach 23,000 to 24,000 children in these settings. In our clinics, we have 4,000 to 5,000 patient visits every year, where we offer education, screening and treatment including cleanings, sealants, varnishes, fillings, extractions, and root canals.

Good oral health is crucial part of overall physical wellness. Maintaining an attractive smile can also contribute to one’s emotional wellness and self-confidence. Receiving comprehensive oral health care not only promotes good general health for a child or teen; it starts the young person on the road to a becoming a healthy adult.

Dwayne Turner, DDS, MBA, is the Dental Health Services manager for the DeKalb County Board of Health based in Decatur, Georgia. He received a Bachelor of Arts degree from the University of Rochester, a Doctor of Dental Surgery degree from Howard University, and a Master of Business Administration degree from Brenau University.

Posted by Sonya Collins on Mar 20, 2017 11:00 AM EDT
d27388d938d35301c50f81c8e8d47c7a-huge-maTomorrow is Match Day. That’s when soon-to-be allopathic doctors, and pharmacists, learn which residency program they “matched” into and whether the Match will lead them to a clinic down the street or hospital across the country. Osteopathic med students learned where they matched last month. The Match may determine where you spend the rest of your career, and, if you apply in more than one specialty, it could determine which one you ultimately practice.
This day is the culmination of months spent creating pro-con lists that become rank lists, a season spent completing applications and traveling around the country for interviews. Here on the blog, we’ve collected the experiences of Match applicants for years.
Before some fourth-year medical students can even think about rank lists, they must first choose a specialty. We’ve heard from soon-to-be doctors choosing between paths as divergent as surgery and family medicine. And we’ve heard from others who have no doubt why they’re choosing family medicine over specialties such as dermatology. Still, many struggle to choose from among the slightly more nuanced options of family medicine, internal medicine, and primary care.

06342c43439598146a048fb782c38113-huge-68Choosing a specialty only opens the door to more decisions that must be made: Where do you want to train? Applicants have shared with Progress Notes which factors they considered when compiling their rank lists. Of course, specifics of the individual programs are a major consideration. Med students have cited residencies’ commitment to healthcare transformation among their top priorities. Some look for programs that emphasize training leaders. Others lean towards programs where they see potential role models. Still others give high marks to programs where they feel a chemistry with the residents already training there. And yes, pharmacy students do residencies, too.
But the program itself is by far not the only consideration. Medical students are open about the crucial role that their personal lives play in the creation of their rank lists. For many applicants, the rank list reflects both professional and personal goals. Some rank programs based on their proximity to family or a partner. Some couples apply jointly through the Couples Match to ensure that they’re accepted to residency programs in the same metro area.
205a685cb01feda35b3dce2d9585faef-huge-bfWhile many factors figure into rank lists, in the end, applicants often go with their gut.
And while applicants anticipate Match Day with butterflies in their stomachs, they can rest assured that their future program faculty are almost just as anxious to learn who their residents will be.
If you’re applying for the Match next year, many of the young doctors in our community have practical tips and wisdom to offer you.
And if you’re matching this year, we wish you all the best!
-- Progress Notes

For more on this year’s event, visit our Match Day 2017 webpage. And please consider investing in primary care by making a donation in honor of those eagerly awaiting that envelope.

Posted by Sonya Collins on Mar 16, 2017 10:10 AM EDT
ffccbea5e19127a2059e410633f87907-huge-paA nurse in an HIV clinic wanted to train her nurse and physician colleagues to be dietitians until she learned that the most effective approach for patients and the most efficient use of patients' and providers' time was to bring dietitians on board with her team. Today on the blog, read about the program she designed to assess nutrition in adolescents with HIV.

By Patrice Wade, DNP

Since I’ve always had an interest in food and nutrition, as a young nurse and student, I just assumed that all health care providers assessed nutrition. After all, we know how important it is. However, as a staff nurse in the ER and a nurse practitioner doctoral student, I learned that wasn’t true. Many providers in both arenas reported that it didn’t take the same priority that medication and disease management do.
Throughout my doctorate program, I had been researching nutrition guidelines for people with HIV and AIDS. I reviewed 26 charts with a tool I developed based on the Los Angeles Dietitians’ Nutritional Guidelines in AIDS Care. The chart review revealed that physicians, residents, and nurse practitioners caring for those with HIV and AIDS were not assessing nutritional status according to guidelines - which state all persons with HIV and AIDS should see a dietitian at time of diagnosis regardless of nutritional status. This started the journey to my clinical inquiry project. 

Originally, I was going to facilitate nutrition training and provide a nutrition assessment tool for nurse practitioners and physicians caring for those with HIV and AIDS. I would work with dietitians to create an easier process for patient referral and then evaluate the project for success with the tool I had used in my initial chart review.
However, the summer before I was set to implement the project, I shadowed a registered dietitian. During that time, I came to fully appreciate dietitians’ expertise. I realized such expertise was imperative to adequately assessing a patient’s nutritional status. I couldn’t just teach nurses how to do this in one training program.
At that same time, I was completing my nurse practitioner clinicals at a busy adolescent HIV clinic, and I saw firsthand that there simply wasn’t time to adequately assess patient nutrition. My original plan to turn nurses and physicians into “mini-dietitians” and expect them to do another in-depth assessment during an already tight visit no longer seemed feasible. What if we could instead have the dietitian in the clinic seeing patients at the time of the visit? This would eliminate transportation issues with follow-up, save the provider time, and allow for adequate assessment of nutrition. Thus, my project was born.
The dietitian that I had shadowed was able to convince her supervisor to allow her to come to the HIV clinic once per week to see patients. To get even more coverage, I contacted the chair of the Wayne State University Nutrition and Food Science program to see if we could have students in the clinic. The chair then put me in touch with the Dietetic program, and they were overjoyed. The dietitian then agreed to take the students on, so they would spend three days per week seeing patients at her office and one day per week seeing HIV patients at our clinic.
Once the dietitians were in place and the provider nutrition pocket guide tool was developed, we executed the program. During each patient visit, the primary provider would ask the five nutrition assessment questions and if the patient answered “yes” to one or more, he or she was to see the dietitian who was already at the clinic. If a patient wouldn’t see the dietitian, the provider was to assess the patient’s personal beliefs related to nutrition to determine barriers, but this was never necessary.
Every patient seen during the study period who met the criteria saw the dietitian. Patients seen in the clinic reported they enjoyed talking to the dietitian and appreciated learning about the importance of food choices. Because poor nutrition is associated with an increased risk of death in people with HIV and AIDS, patients seen during this study could have a lower risk of morbidity and mortality. This study potentially helped save lives.
It was also an exercise in team-based care. The dietitian enjoyed interacting with both the providers and patients in the clinic. The setting allowed her to discuss patient care plans directly with the providers rather than trying to call or email them. The project also benefited the dietitian students. They gained HIV experience, which their program doesn’t offer, while learning how to work alongside other healthcare providers as part of a team - an experience any trainee needs in primary care.

That 100% of patients who met the criteria chose to see the dietitian proved the benefit of having services available at the point of care. An integrated approach to primary care is crucial. It is not feasible for an individual provider to be expert in everything, but rather we must build teams and rely on the expertise of each member.
Patrice Wade, DNP, has a passion for nutrition and fitness, which intertwines with her practice, research, and personal life. She enjoys running and competing in races, biking, weight lifting, cooking, playing soccer, and spending time with her family and friends. 

Read other posts about nutrition
Med students need nutrition education for their patients and themselves
Sharing recipes, sharing health


Posted by Sonya Collins on Mar 9, 2017 11:21 AM EST
4a35c09ef8d7a4883bcf3d39cbe2ac4f-huge-deMonday is National Dentist's Day. We're recognizing dentists today on the blog with a post from a public health dentist who works on the frontlines of preventive health care. 

By Debra Bradfield Smith, DMD

The first time I saw my current OB-GYN, he performed a quick exam of my mouth. My first thought was to burst out laughing. I am a dentist and I take care of my oral health. Why on earth was he looking in my mouth? My second thought was, wow, you understand the relationship between good oral health and overall health. Great job! We all need to follow his example. 

On a typical day at the public health dental clinic where I practice, I get many calls from school personnel about children’s problems that can ultimately be traced back to poor oral health. Recently a school nurse called about a child with a toothache. We told the nurse to send the child to us as soon as possible. When I walked in the treatment room, the child was sobbing in the chair and had a swollen face. She had two abscessed teeth, was in severe pain, and had just completed a state standardized test. The entire scenario was heartbreaking. How could she eat or sleep? How could she concentrate on a test? How could I have prevented this from happening?

A few weeks later, I received a call from a school counselor. Concerned about a child with numerous school absences, the counselor had visited the family and realized the child had dental problems. All four of his permanent molars were broken down below the gum line. His family had no dental insurance and could not afford dental treatment. His face would swell and the family would go to the emergency room. The boy would receive antibiotics and the swelling would go down. After a short time, the swelling would return and the cycle would begin again. Once again, I asked myself, how could this situation have been prevented?

Stories like these are very common. Dental decay is the most common illness of childhood and can lay the groundwork for a lifetime of health problems. The good news is that dental decay is a preventable disease. Our oral cavity is teeming with bacteria. Cavities, oral infections, inflammation, and gum disease are caused by these bacteria. Sugar and carbohydrates feed the oral bacteria and cause it to multiply and release cavity-causing acids. In simple terms, our daily goal is to reduce the number of bacteria in our mouth. Brush the bacteria away, floss it away, rinse it away, and do not feed it with sugar and carbohydrates!

It is also very important to prevent oral bacteria from traveling to other areas of our bodies. Numerous studies have recorded a link between diabetes and gum disease. Diabetics with gum disease have a more difficult time regulating blood sugar levels. Studies have shown a relationship between pregnant moms with oral infections and low-birth-weight, pre-term babies. Cardiovascular disease has been linked in recent studies to oral infection and gum disease. Pneumonia and rheumatoid arthritis have also been linked to oral infections. The list of health conditions related to poor oral health continues to grow with every new study. Fewer bacteria in the mouth mean less chance of bacteria traveling to other areas.

We also must keep the bacteria in our mouths from traveling to other more vulnerable bodies. Dental decay is now considered an infectious disease because cavity-causing bacteria can be transferred to an infant’s mouth from parents and caregivers. Infants themselves are born without cavity-causing bacteria in their mouths. It is critical for parents to work daily to reduce the number of bacteria in their mouths so no bacteria are transferred to babies. The American Academy of Pediatrics recommends the first dental visit by the age of one year, but dental prevention must begin before the baby is born. OB-GYNs should discuss the importance of good oral health with their patients. Parents, caregivers, and grandparents should receive the newest information about infant dental care when they visit the dentist every six months.

It is imperative that good preventive primary health care include prevention of dental disease. One cannot have good health without good oral health. Everything we eat, everything we drink, the tobacco that some of us unfortunately smoke or chew, the air we breathe - it all enters the body through our mouth. The health of our oral cavity is vital to the health of our body. I would encourage all clinicians on the front lines of primary care to discuss this relationship with their patients.

My stories have a happy ending. The two children both received the dental treatment they needed. But one must wonder how different their situations would have been - how many fewer days of school they might have missed, how much better they might have done on their tests - if they had received primary health care that included preventive dental care, dental health education, and nutrition counseling.

Debra Bradfield Smith, DMD, is the district dental health director for the South Central Public Health District in Dublin, Georgia. She is a graduate of Medical College of Georgia School of Dentistry.
Posted by Sonya Collins on Mar 2, 2017 2:16 PM EST
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