At 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. This is her story.

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.

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Juliana Macri has just joined PCP as a Clinical Innovation Fellow.  Once a Washington health policy researcher, she made the journey to primary care clinical innovation from the outside in. Here’s her story.

By Juliana Macri

My discovery of primary care innovation made me certain I wanted to attend medical school.
 
After college I took a policy research position at the Health Policy Center of the Urban Institute, a non-partisan think tank in Washington, DC. I was interested in how governmental, political and economic structures influence social programs and knew I wanted to be involved in improving health care, though I didn’t know the best way. 
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A family practice nurse makes the case for health care professionals to use social media to ensure they have a say in the inevitable change in health care.  

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

The first time I ever heard of Twitter was in 2008. CNN was running a segment about a graduate student in Egypt who had been arrested. He let his friends and network know of his arrest via Twitter. It was, undoubtedly, this action, this getting the word out, that facilitated his quick release. Two years later, Egypt underwent a revolution that was driven in part by social media and which many have dubbed the Twitter Revolution.
 
Social media has changed the way we view and interact with the world. The tool has given a previously unprecedented power to individuals and small groups. This is a power many health care groups and professionals could benefit from, but only some are harnessing.

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Lack of access to primary care is exacerbated by the fact that most providers can only bill for an in-person visit while many patients may wish they could just ask a health professional a quick question by phone or email.  Here, in this piece from our archives that first ran in 2010, David Margolius, M.D., demonstrates the impact that 30 minutes of phone triage per day can make.

By David Margolius, M.D.

In the Department of Public Health (DPH) clinics in San Francisco, CA, demand for doctor's appointments far outweighs supply. This has been especially dramatic in clinics that have switched to “open access” scheduling, an innovation that allows patients to schedule same-day or next-day appointments. Open access is meant to eliminate long waits for appointments, but the reality is that often dozens of patients call for a limited number of appointments. Fifteen minutes into each day, receptionists have to tell patients that there are no more appointments available.

In January of this year, as part of my work with the Center for Excellence in Primary Care at the University of California, San Francisco, I teamed up with one of these open-access clinics, Southeast Health Center, to work on their access issue. Other DPH clinics had piloted telephone visits to reduce demand for face-to-face appointments but had had a hard time sorting out which patients or issues were appropriate for a telephone visit. Still, we knew that many patients had issues that could be resolved over the phone, maybe even some of the patients that called after all the appointments for the day had been booked. So that month, I helped the Southeast team try to replace denied appointment requests with team-based telephone visits. After a few weeks of trial and error, our team came up with a nice system.
 

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After the clinic where she practices transformed to a patient-centered medical home, this nurse has found that while staff are on board with the changes, patients - whose buy-in is key to the model's success - are sometimes a tougher sell.

By Amberly Killmer, R.N.

My patient and I had spent most of the 45-minute appointment discussing the challenges of living with diabetes and some ways that he could begin changing his eating and exercise habits. I started to wrap up the visit and asked him, “Which of these changes can I follow up with you about next week?” He looked at me incredulously and said, “You are supposed to tell me what to do: I’m not a doctor!”

I am not a doctor either, but as a nurse, my role as patient care provider, advocate, and educator does not mean I simply tell patients what they should do. The primary care clinic where I work has implemented innovative care strategies as part of the Patient Centered Medical Home Initiative (PCMH). These changes are exciting and challenging and put us on the front lines of a national movement. Every member of the team at my clinic is key to our model as each one has a role to play in the patient’s health journey. 

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When med students asked Dr. Matthew Mintz what the future held for primary care practice, Mintz didn't always know what to say -- until now.  Here he lays out the future of primary care as he sees it under the Affordable Care Act.

By Matthew Mintz, M.D.

As a physician who teaches medical students, I am often asked for career advice. Medical students are by nature smart and ask very good questions. “Will I be able to pay off my student loans if I choose primary care?” “Will I have a balanced lifestyle if I decide to go into primary care?”

I try to be both encouraging and realistic.  However, far too often I have found myself telling students that the future of medicine, and primary care in particular, is not clear.

That is no longer true.

The future of health care, and particularly primary care, is now very clear.

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On an ER rotation -- which she thought should have been the most exciting rotation of all --  this med student knew more than ever that she wanted to form long-term relationships with patients through the practice of primary care.

By Jennifer Stella, M.D.

As a third-year med student, I was doing an ER shift when the call came through our dispatch: 56-year-old man, status epilepticus, being flown in from Yosemite, 10 minutes out. I watched the residents snap into a semi-ordered chaos. Ten crucial minutes. Prepping the trauma bay. Anticipating acute management, who was going to do it, half-tying the yellow paper gowns. Anyone who had looked tired didn’t anymore.
 
We raced in the elevator to the roof. Helicopter. Residents, attendings, me. The airlift paramedics I’d come to know by face, name, and the way they ran. Patient transferred, team moving in formation with the stretcher, bag masking and rushing downstairs to rapid-sequence intubate, medicate, and try to save him. It’s the stuff TV shows are made of.
 
And I was bored. 

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After text messages significantly improved outcomes for patients after discharge from the ER, this doc sees the potential for texting between patients and providers to coordinate and streamline primary care, too.

By Freeman Favors, III, M.D.

A couple of months ago, one of our PAs in the ER at Banner Thunderbird Medical Center received a text from a distressed patient, stating that he couldn’t handle life anymore, and was contemplating suicide. The PA immediately notified the nursing supervisor, who both contacted the patient and sent police to the patient’s home to bring the patient back to the hospital, where the patient then received successful psychiatric treatment.

This was all possible because we have a system for following up with the patients post-discharge from our ER via text message.

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Inspired by clinical innovations he learned about during his tenure with the Obama Administration’s Comparative Effectiveness Research program, Amol Navathe wished there was a forum to share such practices with clinicians who could benefit from them.  That’s why he and a colleague launched a journal for just that purpose. The first issue of Health Care: The Journal of Delivery Science and Innovation comes out in late June.

By Amol Navathe, M.D., Ph.D.

We have all heard the chants about our nation’s broken health care system and its path to unsustainability. In one of the most frustrating paradoxes, our country is home to the world’s best doctors, brightest researchers, top medical schools, and latest medical technology, yet it is not home to the best health care nor the best outcomes for patients.  Not to even mention the soaring costs.  In my former position in the Obama Administration as Medical Officer and Senior Program Manager of the $1.1B Comparative Effectiveness Research (CER) program, I had the opportunity to build a national strategy to improve the evidence upon which we base patient care decisions. 
 
This would include evidence that compares treatments, ways to diagnose disease, and also the systems and processes we use to deliver health care.  As we funded project after project and interesting preliminary results came to bear, we realized there wasn’t a health system and academic community built around sharing these best practices. 

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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. 

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