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bf84ab9b24e1ee5737779dc8ee2123f6-huge-deMedical students across the country are calling for their institutions to provide leadership training. But once that training became a reality at Brown, these two med students learned that community leadership isn't as straightforward as it may seem. 

By Denise Marte and Matthew Perry

Our first week of classes at Brown Medical School was a whirlwind introduction to the social determinants of health. Before diving into the basic science curriculum, we gave our attention to systemic healthcare problems such as insurance gaps, spiraling costs, and health inequality. One lecture ended with a particularly memorable line, “Our healthcare system is a mess, but you all are going to fix it.” No pressure though.
Medical education doesn’t typically include leadership training sufficient to take on this mandate. But as the system has become more complex, medical schools have begun to implement important and necessary new strategies to equip students to tackle structural problems in the field. Here at Brown, the Primary Care-Population Medicine MD-ScM program and its Leadership in Healthcare course are two examples. We value these courses and the opportunity they provide to build an important skillset, but translating these skills into community work is complicated. As our faculty create these programs and students begin to complete the courses, we must stop and challenge the assumptions of what it means to learn leadership as students in a new place.
Our medical school employs an active learning model. That means that much of our learning is hands-on and takes place in a community setting. But are we mindful of the possible consequences of learning and practicing a lead-first mentality in those environments? Doctors have a specialized set of skills and knowledge which can be a powerful resource in any setting. But when we step out of the hospital, those skills may be more useful when they are guided by the expertise of those who live in the communities in which we are learning, working, and presumably leading. For that to be possible, we need to reconsider our default position as leaders. More generally, our leadership training should involve fostering accountable relationships in which we see ourselves as partners first.
If medical schools are to teach leadership, we must consider the context of that education. At Brown, as must be the case at many universities, many students are new to the area and unfamiliar with the values, needs, and challenges of the people living there. Yet healthcare leadership training encourages students to take the lead at the local level. While we are learning to study structural problems and propose interventions, are we sure that we’re identifying the issues our communities consider most important?
Leadership training in medical school teaches students to bridge medicine and social services with an eye toward preventive care. As such, the subjects and environments of student activities are broadening. For students at Brown, research themes range from food security and addiction intervention to healthcare in prisons. These themes often play out in work with vulnerable communities. But the power dynamics involved in such interactions are complicated. While in school, through academic guidance and mentoring, we are learning methods and best practices as we go. But this new work takes many of us outside of traditional healthcare settings, where we are often unsupervised. To uphold our ethical principles, we must ask ourselves if increased community involvement within the framework of leadership training requires new mechanisms of accountability.
For example, as we work on these projects, it is not always feasible for community members to give us feedback. As a result, measures to ensure we are doing no harm are limited. What happens if our projects are having unintended consequences in a community with no routes of access to our administration? Conversely, if student projects are having a positive impact, how do we lend them continuity after we graduate?
What we are learning through our coursework is that teaching leadership in med school is still uncharted territory. It’s a work-in-progress and, fortunately at Brown, a collaborative process with our faculty.
In partnership with student-led efforts, our administration is taking steps to create structures of accountability and continuity. As our Office of Diversity and Multicultural Affairs expands, community oversight is becoming part of its mandate. An upcoming community advisory board aims to bring together different voices from Rhode Island with various non-medical backgrounds. Our administration is considering how existing student projects, whether they involve leadership, community service, or both, can be incorporated into the curriculum for credit, lending those projects continuity and oversight.
One novel idea is the creation of ‘interest clusters,’ whereby before initiating our own projects, students join pre-existing groups that align them with relevant community organizations and services. Within these clusters, students can engage in clinical work, service-learning, or activism. This structure would ultimately help them understand the self-defined values, needs, and challenges of their population of interest before designing their research. They can lend their energy to continuing and improving existing efforts, with oversight from students who are further along in their training and from non-medical organizations. Still, it remains a challenge to foster these structures without burdening our community partners – a longstanding challenge of service-learning models.
Still, continuing to work toward creating best practices is important. If medical students forge into unknown communities with a lead-first mentality before we learn about the people we claim to lead, we will lose the trust of our patients before we even become doctors. It is vital for medical students and healthcare professionals to handle leadership with care. We must be intentional about when and how we see ourselves as leaders and be humble enough to take a backseat when appropriate.
Denise Marte is a third-year medical student at the Warren Alpert Medical School of Brown University. She is interested in primary care and emergency medicine. Born and raised in the Bronx, NY, she plans to return one day and join the leaders transforming New York City’s healthcare system.
Matthew Perry is a third-year medical student in the Primary Care-Population Medicine program at the Warren Alpert Medical School of Brown University. He hopes to practice in primary mental healthcare and to join in the work of dismantling structural barriers to health and well-being.

Read more about medical school leadership training. 
Posted by Sonya Collins on Jun 15, 2017 11:57 AM EDT
a489388c101eec3190f11689d135a820-huge-08At PCP, we are firm believers that students have a lot to offer when it comes to innovating and improving primary care delivery and training.  Our co-founding president speaks about this frequently, often citing the example of a student who used Google Docs to streamline patient flow at a clinic. When pre-med Avanthi Jayaweera heard this story, she couldn't wait to try out Google docs at the clinic where she was a volunteer. Here's what she wrote about the experience in this post from our archives.

By Avanthi Jayaweera

During my sophomore year of college as a pre-med, I volunteered at the front desk of a free clinic, where it was typical to see patients waiting sometimes for more than two hours. At first I figured it was just because some patients took longer to examine than others. It wasn’t until I got certified as a nurse’s aid and started working in the medical department at the same clinic that I found out what was really going on.

It wasn’t that the doctors were taking longer to examine some patients; it was that the  medical staff didn’t always know that they had a patient waiting in the first place.

Our clinic has a pharmacy, dental, mental health and medical department, three of which are managed by the front desk staff. When a medical patient signs in, the receptionist puts the patient’s chart in a bin to let the medical staff know that a patient has arrived. There is no bell, no blinking light, so a nurse would only know when a patient  checks in by peeking down the hall every so often to see if a chart is in the bin. The bin was often blocked by hall traffic, closet doors and even carts filled with prescriptions, so the staff wouldn’t see the chart until long after the patient had arrived. And when the front desk couldn’t find the patient’s chart to begin with, the medical staff again wouldn’t know till much later – if at all – that a patient was in the waiting room.

So it was possible that our department wouldn’t realize  that someone was patiently waiting to be seen until we cleaned up at the end of the day, after all the doctors had left, and happened to find the lone patient still waiting in the lobby. I felt terrible whenever this happened. They had been waiting for hours, and all we could do was offer to reschedule their appointment.

Ideally, medical staff would peek down the hall at regular intervals, see the chart in the bin, room the patient and put a colored clip on the door of the room. Each doctor had a color, so he or she would know if the room held a patient that was waiting for them. But even after the patient was roomed, it was still possible for doctors to miss their patients.

Once, a physician asked me and another staff member if she had any other patients to see. Since the volunteer nurse who triaged her patients wasn’t present at the moment, we told her that if she didn’t see any rooms marked with a red clip, she was done for the day. However, there was a cabinet next to one of the examination rooms that made it impossible to see the clip from where we were standing. Naturally, we found another patient waiting in that examination room at the end of the day. Again, all the physicians had already left. These kinds of situations  occurred so often that I frequently found myself brainstorming ways to check in, room and see our patients more efficiently. I actively monitored the bin to make sure patients were triaged as soon as they came in. I even organized and labeled documents in separate folders to make it easier for the volunteers to triage patients, but this still didn’t fix the core problem.

Finally a light bulb went off at the annual AMSA convention when I heard Dr. Andrew Morris-Singer mention using Google Docs to manage patients more efficiently. This system would be perfect to use at our clinic, I thought. At my next shift, I spoke to a director at the clinic to discuss how we could use a Google Doc to track patients and facilitate easier communication between the front desk and the medical department. The front desk staff would note in the doc that they had checked a patient in, and then the medical staff would see the update to the doc on their own computers at their station. No longer would it be necessary to crane their necks down the hall and squint to see a chart in the bin.

Once I got the okay, I began creating a table that would provide enough information to sign patients in and give the medical staff the entire responsibility of  managing the medical charts at all times. After using the Google Doc for just a couple of days, the entire clinic was so impressed. The front desk had no more charts to deal with and the nurses were able to track and manage each patient from the time they walked in to the time they left.  The physicians and other staff members also started using the Google Doc as a reference to determine where each patient was instead of searching for colored clips on doors.

After just one week, staff members were telling me how much the new system had improved patient management. And for the first time, patients were telling me "Wow, that was fast!" as I took them to their rooms. I’m relieved that I don’t have to apologize for long waits anymore. And I still can’t believe that as a volunteer, and an undergrad at that, I actually implemented a system that radically changed how our clinic runs, streamlined clinician work flow and improved patient experience.  Even though I may not be a physician yet, I can still take part in making a direct improvement in our healthcare system.  

Avanthi Jayaweera wrote this piece in 2013 as undergrad at Virginia Tech before she graduated with a dual degree in Biological Sciences and Spanish. 
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Posted by Sonya Collins on Jun 8, 2017 2:04 PM EDT
da474602de887d6e3a7251ba89d443d6-huge-chThis medical student was skeptical -- and a little embarrassed -- about learning mindfulness-based stress reduction (read: meditation), so he was surprised to realize that he had gained a valuable tool that he hopes other primary care providers will embrace. 

By Charles Ebersbacher

During the year that I took off from medical school to complete my MBA, I enrolled in a stress-reduction study. I’d become interested in preventive medicine but found the diet and exercise aspects of it easier to grasp than stress reduction. By participating in a study, I thought I might learn some stress-reducing techniques that could help some of my patients. I only had to commit to six hours of questionnaires and saliva testing to earn $70. And, if randomized to the mindfulness-based stress reduction arm, I might get to spend two hours a week for six weeks learning mindfulness-based stress reduction (MBSR). Fortunately, I did.
My first exposure to the concept of mindfulness was during medical school orientation. I’ve practiced sporadically since then – usually by lying on an osteopathic manipulative therapy table and listening to a guided mindfulness video on YouTube as a break from studying. Though to the untrained eye, it might have looked as if I was procrastinating or taking a nap.
I had heard of studies that showed a reduction in physician errors and improved pain management among those that practice MBSR. But even after my exposure to mindfulness, I still felt a little embarrassed about practicing it. Some students and physicians see mindfulness as alternative medicine and not “sexy” enough to study, so I didn’t want to be associated with it. I didn’t like to be seen at the weekly training provided as part of the study, and I don’t like using the phrase “meditation.” The only person whom I told that I was in the study was my girlfriend. I made sure not to be seen by anyone else as I headed there with my yoga mat. In order to avoid small talk and the chance of running into anyone, I showed up as close to the start time as possible – not very mindful.
But I got so much more from the study than a touchy-feely, new age way to manage stress. Although mindfulness may seem like a personal activity, I found the group setting instrumental for understanding some of its complexities. The class made me accountable for meditation, making me do it every day and discuss it every week with the group. Others shared the same difficulties I experienced, such as an active mind or the urge to move after lying still for 45 minutes, like we did in the first exercise of the course. I wanted to crawl out of my skin after lying still for so long. Fortunately, others shared this same experience giving me peace of mind and allowing me to further relax on future exercises.
Looking back, it’s interesting that I thought I could grasp the diet and exercise parts of preventive care but not the stress reduction. Mindfulness is like healthy diet and exercise in many ways. You don’t always want to eat right or exercise, but when you do it – just like when you practice mindfulness – you feel better. And just as you can’t expect results from one workout or one healthy meal, you cannot expect stress to disappear after one mindfulness meditation session. All three require practice and dedication to yield results. Also like diet and exercise, mindfulness practice is best enjoyed when practiced in a variety of ways. No one wants to do the same workout or eat the same healthy meal every day. Likewise, I don’t do the same meditation exercise every day. I didn’t realize this until deeper study, but there are numerous techniques. Those who embark on this journey, I think, will be pleasantly surprised by the results just as those who train for a 5k, half-marathon, or greater, and prove to themselves they can do it. 

Mindfulness might be particularly useful in primary care practices. While providers routinely discuss stress reduction with patients, now that I’ve experienced it, I’m not sure we understand what we are discussing. For example, stress reduction in a group setting may have a more significant impact than trying it alone, but I’m not sure primary care providers are recommending that. Clinicians who understand the tools for stress management, such as mindfulness, will be better equipped to help their patients.
What’s more, mindfulness can be a powerful tool for clinicians themselves. When I first learned about mindfulness, I saw it only as a potential technique for patients, but I see now that it will be just as beneficial to me personally. Mindfulness is not only about stress reduction but training your mind to focus on the present, the current patient, or even removing yourself from your patients and enjoying life outside of medicine. Through mindfulness, I learned how to accept what was going on in my head, categorize it, and make a mindful choice as to whether I wanted to address the thought now or later. A mindfulness routine could allow primary care providers to more efficiently process all the complaints, medications, and regulations each patient has. Increased efficiency may lead to improved patient interactions and ultimately improved care. As burnout in healthcare reaches epidemic levels, we could all benefit from a little mindfulness.

Charles Ebersbacher is a third-year student at Ohio University Heritage College of Osteopathic Medicine. He is interested in innovative patient care and lifestyle medicine.  

Want to read more about complementary and alternative medicine? 
Posted by Sonya Collins on Jun 1, 2017 1:46 PM EDT
085eed1adc2af27ea2c75c96a14ec751-huge-6dToday on the blog, a family physician dedicated to the elimination of health inequities, explains why we need to shift the focus of the healthcare reform discussion.

By Anthony Fleg, M.D.

Like many Americans, including many of my colleagues in healthcare, I’m concerned about the future of healthcare reform. There’s little question that the proposed American Health Care Act (AHCA) currently under consideration would have a tremendous impact on the most vulnerable Americans - a reality that not only troubles me as a family physician, but should also give pause to individuals from across the country and across the political spectrum.

Let’s take a step back and look at the bigger picture. As the White House works to get a law passed, the conversation, almost entirely, will be about health insurance and the healthcare system, ACA vs. AHCA. But it’s our failure to invest in systems of health, not healthcare, that have us lagging behind other nations of the industrialized world. We need to shift the conversation from improving healthcare to improving health.

Health begins with the foods we eat, the education we receive, the neighborhoods we live in, the jobs available to us, and the health of the natural environment. These social determinants of health far outweigh healthcare and health insurance in their importance to the overall wellbeing of our communities and nation. For the one in three children and two in three adults in New Mexico who are overweight, access to the best healthcare and best health insurance will only serve to treat the downstream consequences of their weight. Investing in better health infrastructure – healthier food systems, more walking- and biking-friendly communities, improved early childhood and public school education – is much more important for improving health than health insurance.

Second, the major health disparities in this country are rooted in much larger unaddressed societal inequities. Some groups of Americans can expect to live into their 80s, while for many marginalized communities, making it to your 60s is beating the odds. Take, for example, a person who lives in poverty, amidst violence, and who has few prospects for employment. Giving that person the best health insurance and access to the best healthcare will do little to change their prospects for health. While hard to quantify, best estimates are that only 5-10% of inequities in health (e.g., those which are unjust, unfair, and preventable) are due to inequities in healthcare. Inequities in health, the reasons that some groups live sicker and die younger, have very little to do with what healthcare or what health insurance people receive. Beyond anything we debate about health insurance, if we are interested in creating a healthier nation, we need to put attention and resources into addressing social determinants of health and societal inequities.

I hope the national dialogue moves far beyond the AHCA and begins to focus on creating a more health-promoting and equitable society. With that as our focus, creating health policy for a healthier America, instead of for political agendas and tax cuts, becomes the mission.  That’s a mission worth pursuing.

Anthony Fleg, M.D., M.P.H., is a family physician in New Mexico dedicated to working for the elimination of health inequities. He helps coordinate a love-funded, people-powered partnership called the Native Health Initiative, which he credits with keeping him grounded through his years of medical training and practice. Email:

Posted by Sonya Collins on May 25, 2017 11:56 AM EDT

May is Mental Health Month. No matter how common mental illness is among their patients, physicians often think they should be impervious to it themselves. Today on the blog, in a post that originally appeared on KevinMD, family physician and regular Progress Notes contributor Kyle Bradford Jones opens up about his nearly lifelong struggle with anxiety and depression. He urges his colleagues not to just push through their symptoms but to seek help.   

By Kyle Bradford Jones, M.D.

Pamela Wible, M.D., a family physician who is an expert in physician suicide prevention, recently asked other physicians why so many in the profession kill themselves. The answers were plentiful, tragic, and not at all surprising.

One physician confessed to having post-traumatic stress disorder after medical school. Another cited constant sleep deprivation. Yet another mentioned the combination of a crushing workload, a difficult boss, and payers who are more worried about the bottom line than patient outcomes. That’s just a sample.

More than 300 physicians commit suicide every year: That’s a higher rate than the national average. Burnout and mental illness have garnered attention both in the mainstream media and medical journals, and threaten to exacerbate a growing primary care physician shortage. But despite widespread recognition of this very real problem, a stigma remains among physicians. Thus, many physicians remain reluctant to seek needed care because they think they should be impervious to perceived weakness. However, we cannot properly care for our patients if we have problems that impede our ability to do so.

This is my story of mental illness, and I hope it can help others with similar health issues.

I began having problems with anxiety when I was in high school. It mostly involved social interactions, and I would get nauseated and sometimes have diarrhea. It usually only lasted a short time, and I could overcome it well enough to function. I didn’t recognize any depression during this time, but the anxiety - combined with the natural angst of adolescence - may have covered up some signs of illness.

At age 19, I served as part of a two-year, church-based mission to Ukraine. My GI symptoms worsened during this time, but I didn’t recognize it as anxiety or depression. I was convinced I had parasites or another infectious process (neither of which is uncommon among Westerners living or traveling in the former Soviet republics). I struggled through it without much medical intervention until I returned home two years later.

My symptoms persisted, especially as I began my pre-medical studies. I saw an internist about my complaints, and he was convinced that I had giardiasis. I had several negative stool tests, however, and eventually I was told I would just have to learn to live with it.

After getting married and dealing with the increasing financial struggles of a young couple going to school, I ended up having a full-blown panic attack while I was working a night shift at a group home for the mentally ill. This experience, combined with the growing understanding of mental illness I gained while working in that setting, helped me to recognize my problem for what it was: I had generalized anxiety disorder.

I was nervous all the time - about life, about money, about getting into medical school. I couldn’t control it. I lost sleep sometimes and significantly overslept at other times. I didn’t eat much. My GI symptoms persisted, and I began to recognize them as irritable bowel syndrome secondary to my anxiety.

I saw the student wellness physician, who started me on Prozac. The first month was terrible because of the side effects, but I stuck with it, and the medication began to help. I was more productive and felt better than I had in years.

After being accepted into medical school, I thought my anxieties were behind me, so I tapered off the medication. That was a mistake.

My symptoms returned, and I tried to fight through them. Despite the staunch independence that prevails throughout the medical culture, I eventually realized I couldn’t deal with this on my own. Psychiatric services were provided to medical students, so I started seeing a psychiatrist, who put me on Lexapro.

It didn’t work quite as well as Prozac, but the side effects were less significant, so I stuck with it. For a short time, I also was on clonazepam, but I found that depressed me too much. I started seeing a counselor. I had seen one during my undergrad years but had found it dissatisfying because I didn’t think my problems were legitimized by the therapist. I had a slightly better experience this time around, but still found it difficult to connect with the therapist and believe that she really understood what I was going through.

I am still on Lexapro today, and it works fairly well. I go through peaks and valleys with my symptoms, and I have had some depression in the years since I started residency. I have tried another therapist but still find it hard to connect and let that person in fully.

Thankfully, I can talk about my issues with my wife. Physician divorce rates are higher than the national average. And we’re more likely to have unhappy relationships, even if we don’t divorce. This underscores the importance of being able to share our feelings with someone we trust, no matter who it is, and of seeking counseling when needed. Now I am giving therapy another shot to help me better manage my symptoms.

Fortunately, I have never considered suicide, or even leaving the medical profession. Despite my illness, I still find hope and value in working with my patients and focusing on their needs.

Being a physician is hard. We all know the pitfalls and frustrations of the profession. The harsh reality is that physicians commit suicide more often and have more problems with substance abuse than the rest of the population.

Physicians avoid seeking help for many reasons, not least of which is concern about losing their job or practice. But it’s critically important to recognize problems when they exist and seek help. We are much more likely to cause harm to others and ourselves when we avoid getting help. The stigma is sometimes difficult to overcome, but seeking proper services not only helps us, it helps our families, our friends and our patients. I know I’m repeating myself, but I can’t say it enough: Please don’t hesitate to seek assistance when you need it.

Kyle Bradford Jones, M.D., FAAFP, lives in Salt Lake City with his wife Rebecca, and their four children. He is an Assistant Clinical Professor of Family and Preventive Medicine at the University of Utah School of Medicine. He spends his clinical time at the Neurobehavior HOME Program, a patient-centered medical home for people with developmental disabilities. Follow him on Twitter at @kbjones11

Hear an interview with Kyle and his wife Becki at About Progress.

Posted by Sonya Collins on May 18, 2017 10:23 AM EDT
4a08c0ef2e20217c18b4188239954311-huge-jed1588b5c513d70c1467e059930d566f1-huge-chLast year, Johns Hopkins School of Medicine launched its Primary Care Leadership Track. Progress Notes sat down with student leader Jenny Wen and faculty advisor Colleen Christmas to ask them the purpose of the program and how they got it off the ground.

PN: What exactly is Hopkins’ Primary Care Leadership Track? What is its mission?
CC: The PCLT is an optional track in the curriculum for students at the Johns Hopkins School of Medicine who aspire to become leaders in a primary care field. The goal of the primary care leadership track at Hopkins is to train and empower a group of medical students to be compassionate and clinically skilled primary care physicians, innovators, team leaders, and advocates for their patients and communities.
PN: Why is leadership important in primary care?
CC: I think few in our country would argue that the current primary care models are extremely challenging for both providers and patients, and that there are large gaps of need. With the growing complexity of health needs in our country, we need leaders in primary care who are not only expert in primary care clinical skills, but who have the skills and drive to advocate for patients, communities, and the healthcare system to ensure a higher quality, more efficient and effective, and just delivery of primary care. Leaders are desperately needed, and we feel a commitment to meet that need at Hopkins.
PN: What was the motivation to launch this program?
CC: While many things about the medical school experience at Hopkins are amazing, a focus on primary care has not historically been one of them. Increasingly, however, students, many of whom were bolstered by participation in our Primary Care Progress chapter, have urged the leaders of the medical school to provide better resources to support those interested in pursuing primary care careers. At the same time, leaders within the medical school recognized the central importance of primary care in high-functioning healthcare systems and wanted to make Hopkins a leader in primary care training. This resulted in an ideal synergy of interests from which to create the Primary Care Leadership Track.
PN: What was the role of your PCP chapter in launching this program?
JW: Before PCLT was created, primary care interest lived in a small but strong informal network of students who worked through PCP and other school organizations such as the Primary Care Interest Group. These upperclassmen created a very important nidus for students interested in primary care to gather at the grassroots stage. They put on events, panels, and other information sessions and connected us to various opportunities at Hopkins and beyond. I’m very grateful to them for giving us the exposure we lacked—otherwise I never would have discovered primary care or applied to the PCLT. 
PN: What did it take to get the track going?
CC: As we described, the PCLT was brought about by a collaborative partnership between students invested in primary care careers, supportive faculty both within the academic setting and within community settings, and powerful support from leaders of our curriculum, of the medical school education, and even of the health system. We took a deliberate approach to engaging stakeholders at key times in creation of the PCLT to ensure it would meet the needs of students and fit within the general philosophy of the medical school simultaneously. Our medical students were incredibly effective and industrious in the process, serving as the engine to the PCLT creation with the support and guidance of faculty.
PN: What's your advice for other PCP chapters that would like to launch a program like this? 
JW: Having a supportive faculty leader and champion – not merely an advisor—makes a world of difference! Colleen engages stakeholders and recruits mentors on many levels, and she has the long-term perspective of a faculty member and rich experience of leading and running medical education programs. We are extremely lucky to have her support, activism, and guidance. She and her colleagues recently published an article, "A student and faculty partnership to develop leaders in primary care at a research-oriented institution," containing additional practical advice on launching a leadership development program.  
Colleen Christmas, M.D., a faculty member in the divisions of geriatric medicine and general internal medicine at Johns Hopkins since 1999, has focused her career on medical education. She has been a member of Hopkins’ Primary Care Progress chapter since its inception. She is proud to direct the Primary Care Leadership Track.
Jenny Wen is a rising third-year medical student at Johns Hopkins. Before medical school, through the Thomas J. Watson Fellowship, she undertook a year of independent travel and study of how female survivors of sexual violence navigate resources to find justice and healing. Primary care aligns with well with Jenny’s interests in social justice, community health, holistic well-being, and trauma-informed care.

Posted by Sonya Collins on May 11, 2017 10:24 AM EDT
848fea314baa84640a170d6a421d0782-huge-alIt’s National Nurses Week. Today on the blog, a family nurse practitioner student expresses his hope that the relationships that drew him to nursing in the first place will be possible in a healthcare system that often values speed above anything else.

By Alex Weiner
I first met John at his home in the summer of 2015. John is a 58-year-old man who lives on his own in Cambridge, MA. He had been to the ED nine times in the last month for his COPD. I paused halfway up the four flights of stairs to his apartment, thinking, “How does this guy ever leave his apartment?” We were meeting to discuss his health goals. What were his priorities and what was his journey through the health system in Cambridge like?
I listened carefully as he explained his thought process in the moments before he decided to call 911. “I don’t like going to the hospital but I have no choice,” he said in his thick Azorean Portuguese accent. James, the nurse practitioner (NP) on the team, probed further. “What if we could provide you with the meds that they give you in the hospital right here in your home? Would you still call the ambulance?” “Of course not.” We called the pharmacy and coordinated with them to get John the meds he needed.
But the meds weren’t John’s primary concern, he just wanted to be able to see. He had developed cataracts in both of his eyes from being on steroids for his COPD, and he hadn’t been able to see well for months. His priorities were clear: help me see, then we can work on everything else. If we could help him regain his vision, we might be able to help him quit smoking. After a few visits and some phone calls with a surgeon, we scheduled John for eye surgery.
Working as a Health Outreach Worker with Commonwealth Care Alliance (CCA) in Boston allowed me to connect with so many complex patients like John. Based on a nursing model, CCA works with people on both Medicare and Medicaid to improve their health and coordinate their medical and social concerns. I often found myself in patients’ homes, asking, “What does health mean to you?” Public health taught me that people are truly their own experts. Who was I to tell them what they wanted or needed?  
I just wanted to help people live as independently as possible on their terms. I realize now that though I was working as a health coach, I was already thinking like a nurse.
The only problem with the work was its short term and the way that limited my ability to develop long-term relationships with patients. I connected people to the resources they needed, such as housing, food or mental healthcare over two to three visits, and then I’d get in my car and drive to help the next person. Though the work was incredibly challenging and rewarding, I felt something was missing. I wanted to build the long-term relationships with patients that NPs like James got to build. If I became a primary care provider, I could work with people like John to keep them healthy across their lifespan, rather than just in the short term. That’s why I started the Family Nurse Practitioner (FNP) track at Yale School of Nursing earlier this year.
I’m learning fundamental nursing skills and educating patients on their illnesses, but since I’ve been on rotations in the hospital, I have started to wonder if those longitudinal relationships that I long for in primary care are even possible. I see the swiftness of the healthcare system, the quick in and out of the providers that leaves patients’ heads spinning. I’m afraid that I’ll be stuck on that fee-for-service hamster wheel as an FNP in a low-resourced health center where I talk to my patients for seven minutes a year about their unmanaged diabetes. Why would anyone choose primary care under those conditions? How do we expect our patients to trust us, listen to us, and take our advice with them back into their worlds where their health is determined mostly by where they live and the food they eat? How is that good medicine?
Fortunately, I’ve learned that organizations that value relationship-based medicine do exist. Some have been around for a while and more are cropping up, acting as much-needed disruptors to a fundamentally broken system. Iora Health or Southcentral Foundation, for example, are truly customer-centric organizations in the business of delivering health. In these models, providers and patients can build trusting relationships while the highest quality of care is delivered at a lower cost.
These innovative models of care give me hope and a vision that when I’m out of school and working as an FNP, I’ll be part of a team that includes health coaches and others who believe in relationship-based care. That team will nurture relationships with patients like John to keep them healthy across their lifespan. And this business of relationship-based, patient-centered care will be the standard, not the innovation.
Alex Weiner is a family nurse practitioner student at Yale School of Nursing. Prior to enrolling at Yale, he worked at Commonwealth Care Alliance in Boston and received his MPH in health management and policy from Drexel University’s Dornsife School of Public Health. You can follow him on Twitter @aweiner87.
Posted by Sonya Collins on May 9, 2017 11:37 AM EDT
e493a197e8538afc5e4a6e7f4da7ff8f-huge-meAt Univiersity of Hawaii's John A. Burns School of Medicine, the PCP chapter pairs students interested in primary care with mentors in their chosen specialty. Second-year med student Megan Sumida tells us all about it. 

By Megan Sumida
During the 2014-2015 school year, the University of Hawaii’s Primary Care Progress chapter launched a primary care mentorship program through which first-year medical students interested in primary care were matched with primary care physicians in the community. Mentors and mentees participated in up to six half-day shadowing experiences and communicated with their mentors outside of the shadowing experience to discuss the pros and cons of working in primary care.
The newly launched primary care mentorship program was nothing short of a success. Our chapter leader, Nash Witten, sent the application email to our MS1 class and received 15 responses from us the very same day. The process for pairing us with mentors took into consideration students’ post-graduate training; the specialty areas they were considering, such as pediatrics, family medicine, and internal medicine; where they lived; their preferred practice setting, such as private practice or community health center; and personal passions.
As a first-year student in my first unit of medical school, I was excited for the opportunity to begin working with primary care physicians in the community. I was paired with Dr. Brit Reis at Reis Pediatrics. I first met her in September 2015, and in the following eight months learned invaluable lessons about how to interact with young patients and earn their trust. While the program technically ended in December, we continued meeting through the rest of the school year. It was a challenge to balance those meetings with the academic and extracurricular demands of medical school, but it was worth it. I cannot overstate my gratitude for the time Dr. Reis took to teach me.
While I learned a lot from Dr. Reis about medicine, such as clinical exam techniques and treatments, the way she interacts with her patients is something I found especially admirable. Dr. Reis creates a space in which even very young pediatric patients can share their opinions on their healthcare.
The importance of effective patient-physician relationships first became clear to me when I was serving with City Year Los Angeles prior to medical school. At City Year, near-peer mentors work in underserved communities with students who are at high risk for dropping out of their public-school system. These students encounter external challenges that affect their ability to achieve their highest academic potential. I learned how common it is for adolescents to feel they are unable to share trauma and other challenges with parents, physicians, or other adults who could help them. As a peer mentor, I often felt helpless to address the problems my students faced. As a physician, I want to be better able to address those issues that affect students outside the classroom.
That’s one of the reasons I admire Dr. Reis. She builds trusting relationships with teens and adolescents who are often difficult to connect with. I’m continually impressed with how open they are with a physician they don’t see very often. Because of the rapport she establishes with her young patients, Dr. Reis is able to address sensitive health issues that other physicians might miss. There is so much to learn from the way she engages with them—from tone, to body language, to the way she words questions—because open connection is integral to successful care. Her patients are empowered to think about their health as something they are participating in, rather than something adults control.
I was proud to recently present on our PCP chapter’s mentorship program at the 2016 Hawaii Health Workforce Summit. But the program wouldn’t be possible without all the students and mentors who participated. I would like to thank those who participated in our inaugural year and subsequent cohorts. I am excited to see where this program takes us in future years and to continue promoting interdisciplinary collaboration, mentorship, and community outreach in primary care throughout the Hawaiian Islands.

For more information about the University of Hawaii Primary Care Progress Chapter, visit our website.
Megan Sumida is a second-year medical student at the University of Hawaii John A. Burns School of Medicine in Honolulu. She is interested in pursuing pediatrics and practicing in Hawaii.

Continue reading about innovative mentorships.

Posted by Sonya Collins on May 4, 2017 1:27 PM EDT
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
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