Whitney Howell

Healthcare. Politics. Family.

Medical Schools Develop Programs to Grow Primary Care Pipeline

Published in the November 2015 AAMC Reporter

By Whitney L.J. Howell

With a looming doctor shortage, several medical schools are launching programs and curricula to help encourage students to pursue primary care careers. The hope is that students will have more time to develop a career interest in disciplines such as family medicine, internal medicine, and general pediatrics.

According to an AAMC study released in March, the United States will face a shortage of up to 90,000 physicians by 2025, with a deficit of up to 31,000 primary care doctors. Much of the shortage can be attributed to a growing and aging population that will require more of both primary and specialty care.

“We know fewer trainees are going into [internal medicine], but we’ve been working to improve the lifestyle and reimbursement for [internal medicine] and, more broadly, primary care,” said Ann Nattinger, MD, general internal medicine (GIM) chief for the Medical College of Wisconsin (MCW). “But improving reimbursement and redesigning the field won’t do anything without students. We must have a pipeline of bright, motivated medical students and residents.”

Encouraging primary care

Rowan University Cooper Medical School opened doors to its first medical school class in 2011. Already, institution leaders are focusing on promoting primary care and augmenting the number of providers.

In July, Cooper received a $1.75 million grant from the Health Resources and Services Administration Primary Care Training and Enhancement program to bolster primary care training. According to Vice Dean Anne Reboli, MD, funding will support faculty development, as well as a new three-year, competency-based curriculum.

Within the curriculum, which will begin in 2016, students will train in patient-centered medical homes (PCMHs) with a variety of primary care providers.

“We’re convinced students need the ability to respect and understand the role of other providers,” Reboli said.

Cooper students also run a primary care clinic where they learn about barriers to care and provide services under faculty supervision. The clinic operates four days a week, and each student works three hours weekly.

At Duke University School of Medicine, students who are interested in primary care can enroll in the Primary Care Leadership Track (PCLT), which increases exposure to primary care. During clinical training, students follow the same patients throughout the year and complete coursework in health literacy and community engagement. Students who enroll in PCLT sign a letter of intent to pursue primary care and receive a scholarship of $10,000 annually. If students do not remain in primary care, the scholarship reverts to a loan.

Students at the Texas Tech University Health Sciences Center can choose to complete medical school in three years through the Family Medicine Accelerated Track (FMAT), enabling graduates to enter the workforce a year earlier and save a year of tuition. Students also receive scholarship support. The program leads directly to a family medicine residency at one of three Texas Tech programs in the state. According to FMAT reports, more than 90 percent of family medicine residents continue practicing in primary care.

In addition to efforts originating at individual medical schools, the Society for General Internal Medicine (SGIM) is encouraging more students to enter primary care with its ProudtobeGIM campaign, which launched in October. According to MCW’s Nattinger, a ProudtobeGIM’s project leader, the program aims to make primary care more attractive. Twenty medical schools applied for funding, and six were selected to create and test innovative methods to increase GIM interest among first- and second-year students.

“We want to learn what works with different kinds of students so we’re ensuring we can speak to a broad group of medical students across the country,” Nattinger said.

Medical speed dating

It is an exciting time for primary care, noted Paul O’Rourke, MD, MPH, GIM fellow at Johns Hopkins Medicine and ProudtobeGIM liaison. The Affordable Care Act, new payment models, and the advent of PCMHs provide opportunities for medical students to observe how primary care physicians are contributing to delivery reforms and make it vital to bolster the number of GIM doctors.

In a novel approach to expanding the physician pipeline, Johns Hopkins used a speed-dating model. On Oct. 30, students rotated through five groups of primary care providers—faculty and roughly 25 alumni community physicians—to discuss five topics: GIM clinical opportunities; GIM research; leadership, advocacy, and public health; medical education; and work-life balance. The event offered opportunities for interactive student-provider discussions about life as a primary care physician.

In addition, O’Rourke said, the school is designing a mentorship program to pair faculty and students with similar interests. Alongside three annual social events, students will have ongoing chances to learn from faculty, seeing how primary care providers can improve outcomes and lower costs.

“We’re passionate about GIM and feel honored to be in this position as the quarterbacks of patient care,” O’Rourke said. “We have a unique role to be there for patients during crises and minor ailments.”

November 21, 2015 Posted by | Education, Healthcare | , , , , , , , , , , , | Leave a comment

In Radiology, Turnaround Time is King

Published on the Nov. 13, 2015, DiagnosticImaging.com website

By Whitney L.J. Howell

In today’s health care environment, radiology is being asked to be the Medical Six Million Dollar Man – the specialty is expected to be better, stronger, and faster than before. And, integral to that achievement is the quickest radiology report turnaround time possible.

The quest for the most rapid turnaround time (TAT) isn’t new – in many ways, it’s been the Holy Grail of radiology for nearly a decade. But, there’s a growing number of tools now available that are designed to shave away the amount of time it takes a radiologist to read a study and return his or her diagnosis to a referring physician. The question plaguing providers – and industry experts – is how fast is too fast?

“Turnaround times are variable. Some tests require 15 minutes to read, such as chest X-rays for pneumonia or CT scans for brain bleeds, and others require longer,” said Eric England, MD, radiology assistant professor and residency director for the University of Cincinnati College of Medicine. “The biggest issue is that this is being used as a way to measure the quality of radiology services. Rather than the quality of the report, more emphasis is placed on the turnaround time.”

According to a 2013 Imaging Performance Partnership TAT survey of 86 hospitals, imaging centers, children’s hospitals, and academic medical centers, hospital and practice leaders rank efficient TATs among their highest priorities – assigning it a 5.7 and 5.5 out of 6 rating, respectively.

The emphasis placed on TAT has already sparked changes, based on survey results. Between 2009 and 2012, reading times for non-advanced imaging in all care settings dropped by 54.5%. For example, emergency department (ED) TAT dropped from an average of 2 to 4 hours to between 30 minutes and 2 hours; inpatient times from same day to 4to 8 hours; and outpatient from 24 hours to 4 to 8 hours. Making these changes is vital to demonstrating radiology’s impact and importance, study authors wrote.

“Ensuring radiologist performance on fundamental aspects of reading and reporting is a critical starting point for radiology group leaders looking to remain competitive and demonstrate value to hospital partners,” authors wrote about the survey results.

To read the remainder of the article at its original location: http://www.diagnosticimaging.com/practice-management/radiology-turnaround-time-king?cid=tophero

November 13, 2015 Posted by | Uncategorized | , , | Leave a comment

Sustaining Employment with Arthritis

Published on the Nov. 11, 2015, Rheumatology Network website

By Whitney L.J. Howell

Not only can the presence of disability-accommodating workplace policies help workers with arthritis stay in the jobs longer, but proactively using the policies can enhance job performance, according to a small study.

Based on Centers for Disease Control and Prevention data, 20 percent of American adults have some form of doctor-diagnosed arthritis. In addition to pain and joint stiffness, arthritis is also responsible for job absenteeism, productivity losses, fatigue, and difficulty sustaining throughout the day.

In a presentation given on Nov. 11 at the 2015 ACR/ARHP Annual Meeting in San Francisco, Calif., Monique A.M. Gignac, M.D., an affiliate scientist with the Toronto Western Research Institute, discussed how workplace policies accommodating disability needs can improve job performance and how physicians should encourage patients to research and utilize those resources when necessary.

“When an employee has a flare-up, he or she might need to draw on the policies, but they won’t always be a drain on employer resources,” she said. “That’s an important message for workplaces to hear.”

Results showed participants without access to policies experienced more pain, fatigue, and health variability. Those who proactively used policies before any crises exhibited greater productivity and fewer health disruptions.

Among participants, 500 with arthritis and 500 without, two-thirds said their workplace met their accommodation needs, and 16 percent said their needs were exceeded. Twenty percent reported unmet needs, and 8 percent said their workplace had no accommodation policies in place. Of the workplaces with policies, 75 percent had three or more policies available, and most were low-cost solutions, such as flex time, ergonomic equipment, or modified job duties, Gignac said.

According to study results, one-fourth of participants never used disability workplace policies, and three-fourths used only one or two, she said.

(The study was funded by the Canadian Institute for Health Research.)

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/adults-arthritis-want-stay-workforce

November 11, 2015 Posted by | Healthcare | , , , , | Leave a comment

Adults with Arthritis Want to Stay in the Workforce

Published on the Nov. 11, 2015, Rheumatology Network website

By Whitney L.J. Howell

Proper medical treatment can keep people with arthritis in the workforce longer, a large study of individuals with arthritis and those without the condition showed.

Physicians should be aware that a growing number of patients, including those with arthritis, are interested in working beyond traditional retirement age, study authors said. And, there is a clinical need to ensure treatment helps them get back to work.

In a presentation given on Nov. 11 at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., Monique A.M. Gignac, M.D., an affiliate scientist with the Toronto Western Research Institute, discussed how individuals living with arthritis have the same desires to remain in the workforce as do their counterparts who don’t have the chronic condition.

“Perhaps we need to provide clinicians with resources, policies, and practices about success stories of how people have managed to sustain in the workplace,” she said. “They can provide education and information to patients looking to continue working.”

According to study results, there were no differences in retirement expectations between individuals with arthritis and those without. Both groups expected to retire from their current jobs at age 64, she said, and 60 percent of them said they plan to return to work full-time or part-time at something else for several more years. In fact, she said, 11 percent of both groups indicated they had no intention of ever retiring.

This concept – retiring from one career to take a job in another field – is called bridged retirement, and it’s becoming more common, Gignac said. Based on results from 631 individuals with arthritis and 538 without it, participants with arthritis reported less fatigue, greater job satisfaction, less productivity loss, and less absenteeism in the second-career jobs than did individuals who never left the workforce.

(The study was funded by the Canadian Institute for Health Research.)

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/adults-arthritis-want-stay-workforce

November 11, 2015 Posted by | Healthcare | , , , , | Leave a comment

It’s Not Enough to “Tell” RA Patients to Exercise: They Need a Challenge

Published on the Nov. 11, 2015, Rheumatology Network website

By Whitney L.J. Howell

Improving physical activity could be an effective tool in decreasing fatigue associated with rheumatoid arthritis, according to a small study.
Fatigue is universally associated with rheumatoid arthritis, as well as depression, poor sleep and obesity. Physical activity can mitigate these problems, meaning increased movement could positively impact rheumatoid arthritis-associated fatigue.
In a presentation given on Nov. 11 at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., Patricia Katz, MD, professor of medicine at the University of California at San Francisco, discussed how increased walking is enough to be beneficial. At study’s end, participants experienced no increase in rheumatoid-arthritis activity, but they did see a marked decreased in tiredness.
“For years, people with rheumatoid arthritis experiencing fatigue have been told they should rest more,” Katz said. “This research flies in the face of that advice. Resting more is probably the opposite of what they need to do.”
Ninety-six participants were divided into three groups: (1) education-only (2) pedometer and (3) pedometer with step targets. Group 1 received only a Centers for Disease Control and Prevention booklet about incorporating exercise into daily routines. Group 2 monitored their steps, and Group 3 was challenged to increase their steps by 10 percent each week for 21 weeks. Both groups received phone call follow-ups at 10 weeks and 21 weeks.
Overall, the median baseline step count was 3,710, fewer than 5,000 daily steps is considered sedentary. At the study’s end, Group 1 saw virtually no change in their number of steps, but experienced a 38 percent drop in fatigue. Group 2 increased their steps by 87 percent and decreased their fatigue 54 percent. Group 3 augmented their steps by 159 percent and saw their fatigue dip by 48 percent. The PROMIS Fatigue short-form was used to assess fatigue levels.

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/it%E2%80%99s-not-enough-%E2%80%9Ctell%E2%80%9D-ra-patients-exercise-they-need-challenge

November 11, 2015 Posted by | Healthcare | , , , , | Leave a comment

Treatment Can Reduce Pericarditis in RA

Published on the Nov. 10, 2015, Rheumatology Network website

By Whitney L.J. Howell

Taking anakinra, a drug that treats rheumatoid arthritis, can significantly reduce pericarditis in patients with highly inflammatory disease and elevated CRP protein, according to a small study.

Among acute pericarditis instances, recurrence occurs in 30 percent of cases. Most patients with recurrent cases don’t respond to or can’t tolerate NSAID, corticosteroid or colchicine treatments. But, for those with a history of high fever, elevated CRP level and pleural effusions, anakinra can be highly effective.

In a presentation given on Nov. 10 at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., Antonio Brucato, MD, an internal medicine specialist with Hospital Papa Giovanni XXIII in Bergamo Italy, discussed the role anakinra plays in controlling the interleukin-1 family cytokines responsible for regulating immune responses and inflammation, particularly in patients with high-disease activity.

“We were impressed to see how quick and immediate the effect of anakinra was on patients with severe, acute and inflammatory disease,” he said. “It allowed for the prompt discontinuation of other drugs.”

Anakinra showed itself to be effective and safe, he said, with the most common side effect being a mild injection-site skin reaction.

In the double-blind study conducted in three medical centers, 21 patients were divided into two groups – a placebo group and an anakinra-treatment group. Between June 2014 and June 2015, pericarditis recurrence occurred in nine out of 10 participants in the placebo group and in two of 11 anakinra-treatment participants. The median time to a flare-up among the placebo group was just over 48 days.

After a patient achieves remission, Brucato said, they should complete a gradual anakinra taper, reducing the dose by 100 mg/week until they drop to 300 mg/week. They should, then, reduce by another 100 mg/week every two-to-three months.

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/treatment-can-reduce-pericarditis-ra

November 10, 2015 Posted by | Healthcare | , , , , , , , | Leave a comment

How Do Your Patients Perceive Pain?

Published on the Nov. 9, 2015, Rheumatology Network website

By Whitney L.J. Howell

A significant portion of patients with rheumatoid arthritis don’t feel they have effective communication with their rheumatologists, according to a small qualitative study.
Patient perceptions of pain and fatigue can differ from clinical markers. Knowing this can encourage rheumatologists to take patient responses into account when designing treatment plans.

In a presentation given on Nov. 10 at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., Mayo Clinic rheumatologist John M. Davis III, discussed how frequently patients report severe rheumatoid arthritis symptoms that exceed the objective markers their rheumatologists observe.

Results suggest patients experience a disconnect with their doctors, friends and family members that contributes to the psycho-social burden of disease. The findings can help providers recognize patients who feel their concerns aren’t being heard, he said, as well as open the door to more transparent patient-physician discussions.

“The sense is if we engage with patients and are attentive to their unmet needs, in terms of complaints and coping with symptoms,” he said, “we’ll have a better sense of what’s going on with patients.”

Based on patient responses through the Clinical Disease Activity Index, the pain visual analog scale, and the Patient Health Questionnaire-9, patient-physician discordance appears in 33 percent of clinical encounters even though not all patients are dissatisfied with their doctors. Patient-physician concordance is defined by a >25-mm absolute difference in these global assessments of their disease activity during the patient’s most recent rheumatology appointment within the previous four weeks.

Patients who report discordance also report high levels of fatigue, pain and difficulty with activities, he said, even though the number of swollen joints and CRP protein levels don’t indicate the same level of disease activity.

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/how-do-your-patients-perceive-pain

November 9, 2015 Posted by | Healthcare | , , , , | Leave a comment

Physical Therapy in Knee Osteoarthritis Relieves Physical and Financial Pain

Published on the Nov. 9, 2015, Rheumatology Network website

By Whitney L.J. Howell

Individuals with knee osteoarthritis can benefit more from intensive physical therapy paired with subsequent booster sessions than from a shorter period of concentrated physical therapy, according to a recent study.

While this strategy is a deviation from current practices, it has been shown to improve outcomes, as well as lower costs. Longer periods of face-to-face work with a physical therapist could also encourage patients to exercise more, helping them maintain health benefits.

In a presentation given on Nov. 8 at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., University of Pittsburg physical therapy assistant professor Allyn Bove, discussed the comparative differences between treating knee osteoarthritis patients with short, concentrated periods of physical therapy or with extended physical therapy services augmented by booster session.

“A lot of physical therapists would like to have regular follow-ups with patients to adjust home exercise programs and talk about best strategies to manage knee osteoarthritis,” she said. “It would be much like having a conversation about chronic disease with a primary physician or scheduling regular dental appointments.”

Three hundred participants completed a two-year study and were divided into four groups: 12 exercise-only visits; 9 exercise-only visits with three boosters, spread over 12 months; 12 exercise-only session, plus manual therapy; and, 9 exercise-only therapy, plus manual therapy, plus three booster sessions.

Based on patient-reported outcomes, Healthcare Utilization Project data, and the Medicare physician fee schedule, physical therapy with booster session produced the greatest effectiveness at the lower cost, Bove said. Exercise, manual therapy and booster session cost the least, and exercise-plus-booster cost $1,061 more with a gain of 0.082 Quality-Adjusted Life Years.

According to study results, she said, it would cost $13,000 in medication costs, follow-up visits, and additional services to achieve the same healthcare benefits seen with physical therapy sessions that include booster sessions spread out over a 12-month period.

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/physical-therapy-knee-osteoarthritis-relieves-physical-and-financial-pain

November 9, 2015 Posted by | Healthcare | , , , , | Leave a comment

Q&A: Writing the Book on Radiology Reports

Published on the Nov. 9, 2015, DiagnosticImaging.com website

By Whitney L.J. Howell

For radiology and radiologists, their most significant work product is the radiology report. It provides guidance to referring physicians and plays an integral role in the design of a patient’s treatment plan. However, providers haven’t had much guidance on how to optimize the reports they produce in recent decades.

To change that and offer more clarity, Curtis Langlotz, MD, PhD, professor of radiology and medicine at Stanford University Medical Center, wrote The Radiology Report: A Guide to Thoughtful Communication for Radiologists and Other Medical Professionals, which was released last week.

Diagnostic Imaging spoke with him about why the book was necessary, the information he provides, and the impact he hopes the publication will make.

What was the impetus behind writing this book?

Considered as a whole, radiology reports are awful. Plenty of data in the literature backs up that claim: there is an appalling rate of clinically significant errors, reports that don’t answer the clinical question, dissatisfied clinicians, unnecessary hedging, and just a general lack of clarity. I wanted to help radiologists get better.

Most of my career has been focused on the radiology report in one way or another, and I found myself often lamenting the sorry state of affairs. One of the biggest problems was the lack of a comprehensive resource for radiologists, which leads to poor training and limited skills.

Then around 2005, it finally dawned on me that nobody else was going to write the book, so I probably should. I started collecting relevant literature, reporting pitfalls, and speech bloopers, and began thinking about how to organize the material. Writing doesn’t come easily to me, and style guides can be pretty dry, but it became a fun challenge to make the material interesting.  That was easier for some parts of the book than for others. I will leave it to the reader to judge whether that worked out.

To read the remainder of the story at its original location: http://www.diagnosticimaging.com/pacs-and-informatics/qa-writing-book-radiology-reports

November 9, 2015 Posted by | Healthcare | , , | Leave a comment

Methotrexate Frequently Prescribed Incorrectly

Published on the Nov. 9, 2015, Rheumatology Network website

By Whitney L.J. Howell

Methotrexate is frequently prescribed incorrectly in the United States, a recent study found. It’s under-dosed, prescribed for inadequate time periods, and is rarely switched to the subcutaneous version before biologic are initiated.

If methotrexate was better appropriated, rheumatoid arthritis could be better controlled and it could produce significant cost savings.

In a presentation given on Nov. 9 at the 2015 ACR/ARHP annual meeting in San Francisco, Calif., James O’Dell, M.D., University of Nebraska Medical Center rheumatology division chief, discussed how methotrexate is prescribed to treat rheumatoid arthritis and whether it can be used more effectively.

The study pulled health information from Symphony Health Solutions, including demographic characteristics, switches from oral to subcutaneous methotrexate or a biologic with or without concomitant methotrexate, timing of any changes, dosing at the time of changes. Researchers concentrated on patients who received an ICD-9 diagnosis of 714.0 or 714.30 and initiated methotrexate treatment in 2009, following their outcomes through 2014.

Out of 35,640 individuals, 15,599 (43.8 percent) received continuous oral methotrexate, and 17,528 (49.2 percent) added or switched to a biologic agent. Seven percent switched from oral to subcutaneous methotrexate.

Analysis showed that switching to subcutaneous methotrexate prevents the need for or extends the time to the addition of a biologic. More than 40 percent of rheumatoid arthritis patients who started oral methotrexate switched to or added a biologic within 90 days after a median dose of 15 mg/week.

Of those who switched to subcutaneous methotrexate, 71 percent remained on the same treatment for three years, adding a biologic after 289 days. The average time of progression to a biologic was longer for patients who switched to subcutaneous methotrexate (823 days) than those who switched to oral methotrexate (170 days).

To read the article at its original location: http://www.rheumatologynetwork.com/acr2015-rn/methotrexate-frequently-prescribed-incorrectly

November 9, 2015 Posted by | Healthcare | , , , | Leave a comment


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