A house call during his first year of residency has helped this doctor remember that every patient is a human being with a story not just a disease.
 
By Aftab Iqbal, M.D.
 
During my ambulatory care rotation, I got the opportunity to tag along with my attending on a house call to a geriatric couple. The husband, “Joe,” had recently been in the hospital for severe respiratory illness. His wife, “Sally,” had recently fallen and broken her hip and was recovering from a hip replacement.
 
While my attending checked on Sally, he advised me to talk to Joe. We chatted a while about the Red Sox and the Patriots. His main concern about his health was when he could get off oxygen. He hated being tied to the oxygen cylinder all day. I looked through his file, and it seemed he had very severe lung disease. His pulmonary function tests looked horrible. He went on to tell me how frustrated he felt because he didn’t know the time frame and prognosis of his disease. He was fairly active before he was in the hospital. He drove, spent most of his time outdoors and was an active member of his community. He still got out and drove to get groceries sometimes, but the visiting nurse constantly reprimanded him for this because he could get light-headed. I looked into the eyes of an independent 80-plus-year-old who was feeling claustrophobic and helpless. I skimmed through his chart again, and it looked like his lungs were irreversibly damaged. I told him that I would examine him first, review his chart carefully and then we could have a discussion about the prognosis in front of the attending, who knew Joe’s background better than I did. 

more...

When this medical student traveled to Brazil on a Fulbright Fellowship to work in a community health center, she found that everyone could access comprehensive, community-based, team-based primary care for free. She shares here some lessons for our own health care system.

By Michelle Jose-Kampfner, M.D.

Rio de Janeiro: Beautiful beaches, majestic mountains, sequined-clad samba dancers, and innovative primary care delivery. You probably didn’t expect that last one. Neither did I! But it was indeed what I found. 

In 1988, the Brazilian constitution declared that health care is a human right, to be provided by the government, and to that end it created a single-payer health system. In practice, however, many middle and upper class Brazilians choose to purchase private health insurance or receive it from their employer, so the government provides health care largely to those in Brazil’s lower socioeconomic strata. In the 1990s, recognizing the increasing burden of chronic disease, the government created a national primary care policy, the Estratégia Saúde da Família, or Family Health Strategy (FHS). During a gap year from medical school, I went to Rio de Janeiro on a Fulbright Fellowship to study this policy, both the macro aspects and the day-to-day experience of providing patient care under the policy. To that end, I worked as an intern at the Ministry of Health in Rio de Janeiro, and as part of a health care team at one of the FHS Clinics. 

more...

We close our National Nurses Week series with an impassioned call to action that ran yesterday on HealthCetera, the Hunter College Center for Health, Media and Policy's blog. This nurse sends us off with an important question, "If nurses and their stories are so amazing, why does my newspaper arrive every morning without a single nurse story in it?" and the inspiration to render the question unnecessary.

By Amanda Anderson, R.N., B.S.N., C.C.R.N.

Each morning, I wake up running. A million thoughts, a million tasks; I usually get distracted in the middle of making a pot of coffee. Instagram, Facebook, NYTimes, Twitter. The last thing I can do is sit with my laptop to write. The voice of my story is buried – deep within a long list of thoughts, assignments and e-mails.

But some mornings, if I push past it all and glue myself down, my story is there, singing its way into existence. Pieces of it, lines of it, waves of text and feeling and thought. Past the distraction of the newspaper landing on my doorstep, the plants asking me for water, last night’s dishes crowding the sink.

This morning, I’m following the fleeting voice of my story like Alice, running through Wonderland in search of that crazy cat. I’ve managed to get the coffee brewing, I’ve warded off my Internet addiction for a moment, and here I am.
 

more...

A nurse in an HIV clinic wanted to train her nurse and physician colleagues to be dietitians until she learned that the most effective approach for patients and the most efficient use of patients' and providers' time was to bring dietitians on board with her team. Read about the program she designed to assess nutrition in adolescents with HIV.

By Patrice Wade, D.N.P.

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

more...

Shocked by a tense interaction she witnessed between a nurse and a resident, this nursing student saw the urgent need for nursing and medical students to learn to work together and communicate with each other.

By Karrah Hurd

After six weeks in the accelerated bachelor of science in nursing program at the University of Rochester, I was already on clinical rotations in the hospital. I was learning clinical functions that my second-year medical school friends had no idea how to perform: catheterizations, wound dressing changes, how to calculate and administer medications.  There’s just not enough time in the first two years.

On the other hand, in the nursing program, our heavy clinical schedule doesn’t provide us much time to perfect writing SOAP notes (or subjective/objective assessment and plan), for example, which medical students practice every day.  It was clear that we were each acquiring distinct knowledge and skills that we could share with each other -- if given the chance. 

more...

The IOM's 2010 report The Future of Nursing: Leading Change, Advancing Health called for "nurses [to] be full partners, with physicians and other health care professionals, in redesigning health care in the United States."  We need a culture of collaboration and interprofessionalism in education and practice. Here, an R.N. makes the case for interprofessionalism in family medicine in this post that originally ran in 2012 on STFM's blog.

By Courtney Kasun, R.N., M.N.Sc.

One year ago, I began teaching in an interprofessional student clinic.  The student clinic itself had been around for decades, staffed by students in our family medicine clerkship.  However, after a recent campus-wide push for more interprofessional education across health care disciplines, we began adding nursing and pharmacy students to our clinic and having all the students see patients as an interprofessional team.

more...

For National Nurses Week 2013, Jane Tuttle, Ph.D., family nurse practitioner, gives us a glimpse into the work of nurse practitioners and shows us how they expand access to care for our population's most vulnerable patients.

By Jane Tuttle, Ph.D., FNP-BC, FAANP

I was fortunate to have become a nurse practitioner (N.P.) in 1976, just a few years after Loretta C. Ford, Ed.D., public health nurse, developed the N.P. role with Henry Silver, M.D., a pediatrician. These visionary leaders recognized that registered nurses, with additional education and training, were in an ideal position to provide primary care to children in the face of the pediatrician shortage happening at the time, and indeed many children from that decade and beyond grew up knowing an N.P. as their primary care provider. 

Since then, N.P.s have proven themselves to be highly effective as primary care providers, and from state to state, they have varying scopes of practice. The N.P. role has successfully expanded to acute care, behavioral health, and other areas. I have been teaching others to be family nurse practitioners since 1985 and continue to practice in a primary care clinic serving adolescent mothers and their children. 
more...

Working alone, a primary care physician would need 18 hours per day to provide all the necessary preventive and chronic care to a panel of 2,500 patients.  Ann Lindsay, M.D., co-director of Stanford Coordinated Care, shares her clinic's solution.

By Ann Lindsay, M.D.

In a 2003 paper in the American Journal of Public Health, Yarnall et al. found that a primary care physician with a panel of 2,500 average patients would need to spend 7.4 hours per day on preventive care in order to meet the recommendations of the U.S. Preventive Services Task Force. That’s on top of the 10.6 hours per day needed to manage the top ten chronic diseases in a patient panel of that size, according to Østbye et al. in a 2005 paper in the Annals of Family Medicine.  That’s an 18-hour day to provide standard care, and that doesn’t even include time for many of the other responsibilities that typically fall to physicians, including deciding intervals for patients with diabetes or depression; selecting vaccines to be given; ordering diabetes retinal screenings, mammograms, and diabetes foot testing.
 
In the best-case scenario, the doctor feels overburdened. In the worst case, his or her performance rates are low.
 
So what is a doctor to do?   Work in a team, that’s what. 

more...

Andrew Morris-Singer, M.D., president and principal founder of PCP, asks why internal medicine residents spend the majority of their time learning to deliver care that the majority of patients will never need.

By Andrew Morris-Singer, M.D.

“That makes no sense!” a friend recently blurted out after I explained how the majority of internal medicine residents are trained in this country. Her incredulousness was less about how they were trained and more about where.

No doubt. When you consider that the overwhelming majority of practitioners will ultimately be practicing almost exclusively in the outpatient environment and that cost-conscious health care reform efforts are specifically aimed at replacing hospital-based, predominantly late, “sick care” with proactive and preventive ambulatory care, it’s remarkable that future physicians spend so much of their time training on the wards of academic hospitals. The research supports what so many of us avidly question.

more...

In March at the Association of Health Care Journalists annual meeting, PCP's president and co-founder, Andrew Morris-Singer joined a panel of experts to discuss the future of primary care.  Here, Carolyn Crist  summarizes the panel in this post that originally ran on HealthCetera, the Center for Health Media & Policy's blog.

By Carolyn Crist

Primary care doctors are in short supply in the United States, and the trend will worsen unless problems with access, pay, and training are addressed. The challenge of making primary care available for all is complex, but using technology, reworking the medical school curriculum, and employing a team-based approach to patient care could be the answer.

The conversation certainly isn’t new, and it continues to happen nationally as physician groups are testing ideas. The best solutions so far are encouraging health professionals to work to the top of their licenses, said a panel of experts discussing the “team-based” approach to primary care at the Association of Health Care Journalists conference held in Boston.
 

more...