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Archive for May, 2017
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
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