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Archive for February, 2017
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
Andrew Morris-SingerWith so much in flux in healthcare, many of us are scratching our heads about how to make meaningful change in the midst of the uncertainty. After nearly 20 years in community advocacy and primary care, PCP Founder Andrew Morris-Singer shares his thoughts. Whether working in policy reform, systems transformation, or grassroots activism, he invites you to consider adding the following strategies to your playbook.
1. This isn’t our first rodeo.

For too long, our nation’s spending priorities on healthcare have been misplaced. With 18% of GDP going to healthcare, a meager 5% of that is invested in primary care - this, despite the proven value of primary care in promoting health and reducing costs. The American model relies on late, invasive, “sick care,” instead of preventive, comprehensive, primary care. For those of us in the primary care community, it’s been a prolonged, uphill battle to advocate for our field and our patients - but we’re making progress. So although this particular moment in time seems fraught with its own myriad challenges, our efforts will continue unabated.

2. Think glob5 Ways to Make a Difference in Healthcareal and act local.

It’s hard to know what’s going to happen with federal healthcare policy right now. Our new administration and Congress has been opaque about details of what to expect in the coming months and years pertaining to concrete policies. So while Washington continues to play politics, we have tremendous opportunity to effect change at the state and local levels. Elected officials and decision makers are facing budget shortfalls, excessive healthcare spending, and complex populations whose health and social needs defy traditional approaches. If you have creative solutions, now’s the time to speak up. Take action locally - that’s where you have the most power and agency right now - and it’ll feel really good to rack up a win.

3. Double-down on your values.

Just because many of our values seem under assault, now is not the time to compromise on them. What it means to be American is defined as much by what we believe as it is by what we do. And it is those beliefs that are the foundation of all of our institutions, especially those in healthcare and health promotion. So defend them boldly, unapologetically, publicly, and continually. If that means turning up the volume as we debate, cajole, and engage with others, so  be it. If our nation is willing to sacrifice life and limb in far-away lands defending these values, surely we can show up and speak out at town halls and other public spaces. But in this war of ideas, remember that we are NOT at war with our fellow Americans who hold different ideas and ideals. We must stop maligning the character of those with whom we disagree, and start aligning with the values and principles that move our country forward.  

4. Build your team.

Contrary to tales of the lone champion, the fact is that most of us mere mortals will be unable to achieve our goals without working as a team. If your goal is to make a difference, start building that team now - a core group of people as passionate about the issue as you - a community who will shoulder the weight of the effort with you. They’ll add insights and ideas, access to different networks, skills you don’t possess, and support when you hit obstacles (which you most surely will). Remember, humans evolved a powerful innate drive to form tight-knit communities and teams for a reason: It’s helped keep us safe and able to navigate challenging, uncertain times - times like these.

5. Leverage the head and the heart.

Managing change is tough work - whether in our clinics, classrooms, or communities. Our systems are complex and the stakes are high. But we must resist the tendency to focus solely on the technical aspects of reform - the data, the policies, the processes. To be sure, they’re necessary, and we need to get them right. But they’re not sufficient to create and maintain the changes we seek. We need to also engage the heart - explore the motivations and emotions that ultimately drive behavior. Humans are hardwired to be emotional - it’s the fire that drives what we do. So wanna bring that community health activist onto your team or penetrate the white noise of data, requirements, and prompts that now suffocate your average health professional? Tell your story. Get personal. That’ll help fire them up and engage them far more than any table or workflow. Only then - once they’re on their feet - can you start marching together toward change.
Posted by Nate Leskovic on Feb 28, 2017 12:21 PM EST
d8bbb0b7b006674a9ebd67690cdb3ac3-huge-13Today, in a post from our archives, then-first-year medical student Eric Lu illustrates the crucial need for primary care through a brief encounter on the street.

By Eric Lu, MD

I didn’t expect to bump into "Max" on the streets.

“I was kicked out of the house by my wife,” he sighed. Max shifted around on his feet, eyes puffy and cheeks pink.

“Did you start using again?” I asked.

Max looked down and didn’t say anything. In the three years I had known Max, an alcoholic and former drug user, he had been clean. But recently he had started struggling. He lost his job, began drinking again, experienced episodes of depression, couldn’t afford medication for his diabetes, and became overweight. Now it appeared that he was using heroin and was homeless. 

In my work with drug users in Boston through the Prevention and Access to Care and Treatment (PACT) program, I encountered many individuals like Max. I remember thinking to myself, how could I even begin to help them? When I entered medical school and thought about which field could address the spectrum of problems that people faced, I turned to primary care.

As a first-year medical student, I have not had any clinical experience, but I have observed that primary care physicians (PCPs) are able to see patients beyond their individual medical problems. Because PCPs develop a strong understanding of their patients over time, they are able to take a holistic approach to illness and manage the intersection of various disease and problems. In Max’s case, a PCP could connect his story together – that he lost his job which caused him to become depressed and take up drugs again – and find ways to tackle not just his problems with substance abuse and diabetes but also his socioeconomic problems of unemployment and homelessness.

Perhaps PCPs are no longer the all-knowing healers that they were a generation ago because today, there is simply too much to know. However, a new model of multidisciplinary team-based care is evolving to accommodate the important role of PCPs and allow them to tackle issues that fit within their interest and expertise.

Ultimately, what attracts me to primary care is the chance to work on the frontlines of medicine and to develop a solid relationship with the local community, allowing me not only to better understand my patients but also to connect them with vital resources. Although fewer medical students are pursuing primary care, doctors I’ve talked to predict a revival of the field. I am encouraged by the efforts of medical schools, such as Harvard and the University of California, San Francisco, to devote resources, energy, and time to primary care innovation and research, and by the World Health Organization’s 2008 report calling for more PCPs around the world to address issues in health care delivery. I see the current problems in primary care not as a disincentive but rather as an opportunity to go into this field, improve our health care system, and provide better care for the people we serve.

Unfortunately, I haven’t seen Max since that chance encounter on the streets, but I know that a strong primary care system would provide the resources and services that he and all of my future patients need.

Eric Lu wrote this piece as first-year medical student at Harvard Medical School in 2011. 

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"My first patient" by Diana Wohler


Posted by Sonya Collins on Feb 23, 2017 9:19 AM EST
611ee5eb26ae440a24441a177ecefb82-huge-06Today on the blog, a family physician who had grown all too accustomed to practicing in a cramped clinic, finds renewed enthusiasm for her work when her practice moves into a new space.

By Anne C. Jones, DO, MPH
The first time I walked into our clinic building, it was a foundation. No walls, only steel rods and markings for where offices and rooms would be. I gathered with my colleagues for the beam-signing ceremony, a ritual in the construction and architecture world that signifies the completion of the foundation and the transition in focus to the interior. Together, my colleagues and I ascended the stairs and walked into what would soon become our clinical care units. The smell of wood, dust and machinery was striking and created a buzz of excitement. There was a feeling of hope and positivity. The anticipation of a new space heightened once we were able to walk through and physically imagine what could be.
Six months later, we arrived for work in our new integrated medical and mental health units. There were cheers, wows, and selfies. The building smelled of fresh paint, packing tape, cardboard boxes, and shrink-wrap from recently unpacked furniture and medical supplies. That new smell continued to fuel our excitement. It reinvigorated us for our work.
And then, the first patient arrived.
We looked at each other all with the same question on our faces: How are we going to see patients here today?  In the old building, we knew what to do. We walked briskly down the halls to keep up the pace, knowing that each room (even broom closets!) was being used for something. We pivoted to the right when crossing paths, without looking up from our screens, knowing that two people could not fit side-by-side in the halls. We placed our laptops on any clean surface, ready at a moment’s notice to pick them up if someone else needed the space. We spoke in whispers behind closed doors to ensure that nothing private seeped through the walls. We worked to see every patient, even though we knew our space could not accommodate the demand of one exam room per clinician. However impractical, we did these things with ease. It was our routine.
How did we manage to see our patients those first few weeks in the new building? I’m not sure if they noticed that we were still searching through boxes to get them what they needed. Our boxes were tightly packed with otoscopes and microscopes, posters and educational materials. The first patients helped us see what we needed to unpack first. They must have sensed our excitement, many hearing that they made history as the first patients seen in the new space.
But we had brought with us so much more than boxes full of supplies. We’d brought the values that formed our foundation as an organization: a health-care system founded upon a strong primary care workforce, with care for the whole person at its core, and a partnership between clinical care and public health that enhances care for the individual and in turn, the community. This is reflected in the new space that allows for collaboration of primary care and mental health care systems to meet the integrated needs of our patients and clients.
A new building has a distinct smell. That smell of newness comes with a sense of hope, possibility and ideals. Over time, the hope turns to gratitude from patients and staff alike for the space that finally matches the quality we strive towards in our service to patients and the community.
But that new smell wears off. Staff and patients get used to new spaces. The experience, however, reminded me what it’s like to feel that newness about my work. It rejuvenated my hope for our health-care system: that it is possible to find ways to keep the excitement and newness - of space, of teams, of technology - in our daily work, and keep our daily work continually open to the new.
In primary care, it is important to create systems that are of high quality for staff and patients. It is equally important to create systems that are resilient and responsive to the needs of an ever-changing population, where the reasons that cause individuals to seek health care are different for everyone and always a bit unexpected. We must be prepared to care for the needs of everyone, but we cannot be too rigid in our thinking. By working together and staying open to the needs of the patient and community, whether on the first or last day of our practice in a particular space, we create systems that are stable in their very ability to transform.
In this time of health-care transformation, the new seems to be ever upon us. What keeps practice feeling new for you? What forms the strength of your foundation? Let us allow these questions to guide us toward the power that exists when we begin to answer them, together.
Anne C. Jones, DO, MPH, is Interim Director of Medical Services at Cornell University’s health service. She practices osteopathic family medicine and public health, serving the integrated needs of patients and the community. She is a graduate of Rowan School of Osteopathic Medicine, Maine Dartmouth Family Medicine Residency, and The Dartmouth Institute for Health Policy and Clinical Practice.

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Elbow to elbow for our patients
by Kirsten Meisinger, MD
Posted by Sonya Collins on Feb 16, 2017 10:47 AM EST
d8a4270628aa3278cf1439f47be858da-huge-jmToday is DO Match Day - the day when soon-to-be doctors of osteopathic medicine learn where they will spend their residency training. What's a DO? There are two types of fully licensed physicians in the U.S.: doctors of allopathic medicine (MD's) and doctors of osteopathic medicine (DO's). Today, in a special DO Match Day edition of Progress Notes, an osteopathic medical student explains. 

By James Raspanti

As soon as I entered the exam room to see Jackie, I could tell she was in pain. Her breathing was short and she favored her right side. I quickly introduced myself.
“Hi Jackie, my name is James. I’m an osteopathic medical student working with Dr. Jones.”
She was a regular patient at the clinic but had never been seen by Dr. Jones.  As I would soon discover, Jackie was also new to osteopathic medicine. I took a couple minutes to explain what that meant.
“There are two kinds of fully licensed physicians in the US: doctors of osteopathic medicine (DOs) and doctors of allopathic medicine (MDs). Just like the MDs you are familiar with, DOs use traditional medical, pharmacological, and surgical methods to help patients. In addition, DOs are trained to look more closely at a person’s bones and muscles. Sometimes these structures become misaligned causing pain or impaired movement. Osteopathic physicians can feel for and treat such problems with their hands.”
She gave an understanding nod and said it sounded like a chiropractor.  I agreed with the comparison and moved on to my history taking.
Three nights earlier, Jackie had woken up coughing violently.  While brief, the coughing fit left her with lingering pain and shortness of breath. To date, she was a healthy middle-aged woman with only a medical history of achalasia, meaning that the valve between her esophagus and stomach did not relax properly, making it difficult to allow food to flow through. This put her at increased risk for pneumonia. Fortunately, nothing about her history or physical exam suggested an infection or other serious problem. I suspected a musculoskeletal cause and decided to examine her back more carefully.
It is a common misconception that DOs only perform musculoskeletal manipulations. In fact, these manipulations, known as osteopathic manipulative medicine (OMM), are just a tool that DOs hone on top of the basic science and clinical courses all medical students take.  Though DOs practice in all specialties, OMM is most often used in primary care.  Osteopathic students are required to spend over 200 in-class hours practicing OMM. In OMM classes, we learn to: 1) diagnose musculoskeletal dysfunction by palpation and 2) treat musculoskeletal dysfunction with hands-on manipulation. Perhaps the most unique aspect of osteopathic training is the dedication to palpation. Learning to feel and differentiate superficial skin, subcutaneous tissue, and muscle requires regular practice.
What does an osteopath feel and assess for? Changes in tissue texture and structural asymmetry are two important exam findings. A third relies on motion testing. Detailed knowledge of anatomy tells us that the skeleton moves in predictable ways.  DOs use this knowledge to find restrictions that might cause pain or decreased range of motion. Tenderness may be present as well. I found all of these in Jackie. For her, the culprit was a rib.
“You have a rib out of place. It’s possible your cough was strong enough to displace it. I think I can fix it.” She agreed to the treatment.
I had her lie face down and began by loosening up the tight muscles along her spine. They started to relax within a few minutes. I explained what was to come next - a short quick thrust into her back. I repositioned her body to help focus the force my hands would deliver. The treatment lasted less than half a second. Afterwards, Jackie sat up so I could reassess her dysfunction. I confirmed that the rib was moving better, but the real test came when I asked her to take a deep breath. It was full and painless.
Osteopathic manipulations like the one I used on Jackie are not intended to replace the tests, medications, or procedures that comprise the typical physician toolkit. OMM will not cure heart disease or slow the complications of diabetes. However, common ailments that do respond particularly well to OMM include headaches, carpal tunnel syndrome, and back pain among others. The benefits of OMM are plentiful and include the ability to offer immediate relief, decreased need for anti-inflammatory and muscle relaxant medications, and reduce the costs associated with chronic musculoskeletal problems. A well-trained osteopathic physician can incorporate OMM alongside the standard physician toolkit in formulating a single treatment strategy.
Before entering medical school, I was intent on practicing in primary care. I chose osteopathic medicine because of its focus on preventive medicine, expanded primary care training, and hands-on approach. The opportunity to practice osteopathic medicine in primary care continues to excite and inspire me in my journey as a future DO.

James Raspanti is a fourth-year medical student and PCP chapter member at the Chicago College of Osteopathic Medicine at Midwestern University. He is applying for residency in family medicine and wants to practice as a full scope family physician.


Posted by Sonya Collins on Feb 6, 2017 10:23 AM EST
0ba53a5b164c4409210f44c60623a3a9-huge-0dToday on the blog, in a Q&A with Progress Notes, Shantanu Nundy, MD, a primary care physician who practices in the safety net in Washington, D.C., tells us about The Human Diagnosis Project, a smartphone- and web-based application for doctors to collaborate on cases, and how you can participate.
What is the Human Diagnosis Project?
The Human Diagnosis Project (or Human Dx) is an online system built by the world's doctors to understand the best steps to help any patient. We are a growing community of physicians who believe that the insights we accumulate through clinical practice and training should be available to everyone, be it a fellow doctor struggling to make a difficult diagnosis, a resident trying to master clinical medicine, or a patient trying to understand their health.
95cb2209498407f87acb9e1bd1a008e4-huge-unHow does it work?
Users log on and input a case, such as “25-year-old woman with fever, cough, and altered mental status,” and other users offer differentials to try to solve the case.
As the only physician in my safety net clinic, I use Human Dx to get help on challenging cases and to keep up my clinical reasoning and diagnostic skills. When I’m in clinic, I post cases to Human Dx when I’m struggling to figure out the next steps; for example a case with an unusual rash or EKG, or where multiple specialists have said different things and I’m stuck on what to do. When I’m not in clinic, I log in to practice solving teaching cases from all around the world. As I’m doing so, the system is encoding my thought processes and decisions and building the Human Diagnosis Project.
What impact do you imagine the Project will have in the future?
What’s exciting is that the Project is already impacting medicine today. Through Global Morning Report, which enables any doctor to solve the best teaching cases from around the world as brief case simulations, we are enabling thousands of doctors to improve their own clinical reasoning skills. Through Check, which enables doctors to freely collaborate with peers on clinical cases, we are helping doctors make better clinical decisions for their patients and learn in the process. Over time, as the community of doctors contributing to the Project grows, we will have many more opportunities to help doctors and patients and impact the cost, quality and access of health care globally.
650ae846487ffce4ddf0002770687aeb-huge-unHow can clinicians make the most of the Human Diagnosis Project – both in terms of getting the feedback they seek and making useful contributions to help build the tool?
The greatest impact clinicians can make on the Human Diagnosis Project is to simply log in and post cases they are seeing in clinical practice. Every day in primary care, we see cases that are worth sharing. Medicine is incredibly nuanced and a simple case is often more the exception than the rule. You needn’t only post cases you don’t know what to do with; if you learned from it, my guess is that your peers would, too. And by sharing it, you will learn from your peers, too, while contributing to this worldwide effort.
How does this project reflect the current and future landscape of health care?
First, the Project builds on our increasingly connected communities and networks to enable collaboration. In primary care, most of us are making clinical decisions on our own. We aspire to practice team-based care, but at least when it comes to diagnosis and clinical decision making, the clinician usually has little to no help. We don’t routinely have other clinicians see our patients with us. We don't have colleagues readily available to call and get help from. And we don’t have case conferences where we share our interesting cases and ask each other, ‘What would you have done for this patient if you were in my shoes?’ The opportunity here is to leverage social networks to collaborate on patient care.
Second, the Project builds on the increasingly data-rich environments we’re moving into in health care. Data is seemingly everywhere, but insight is still lacking. Without insight, we are getting overwhelmed by data, rather than being empowered by it. The Project is changing that.
Finally, the Human Diagnosis Project is leveraging incredible advances in computer science and machine learning to ‘augment’ the doctor. Right now, the computer in our exam room doesn’t help us deliver better patient care. It just sits there for us to record what we did for the patient after the fact. Projects like this one can help get us to the point where computers help us be the best doctors we can be, for example, by suggesting diagnostic tests to consider, giving us feedback on our clinical reasoning skills, or simply automating tasks that someone with a medical degree and years of training shouldn’t be doing.
How can members of the PCP community get involved?
I invite every doctor, provider, and trainee to join the Human Diagnosis Project and our mission to empower anyone with the world's collective medical insight. Come tell us about your interesting cases, help colleagues with their challenging cases, and earn free CME for improving your clinical reasoning skills. Most importantly, help us build the future of medicine together!

Posted by Sonya Collins on Feb 2, 2017 11:55 AM EST
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