Surviving in a Tough Market

Published in the June 23, 2011, DiagnosticImaging.com

By Whitney L.J. Howell

Economic times are tough even for radiologists, but attendees of the recent Society of Nuclear Medicine (SNM) annual meeting heard first-hand some strategies for maintaining success.

Andy Savo, a senior imaging specialist with GE Healthcare and a frequent speaker on radiology, offered tips that can strengthen your practice when many patients are delaying diagnostic tests, says Kathy Hunt, president of the SNM’s Technologist Section.

“We asked Andy [Savo] to come and speak because we knew he would provide an upbeat message on how we can best serve our patients during these complicated times,” Hunt says. “Through is presentation, he helped our members reflect on their actions and take a look to see how they impact not only their patients, but other radiologists, as well.”

The current changes in health care present many challenges, she says, and Savo’s recommendations can guide you as you search for your place in the new playing field.

To read the entire article: http://www.diagnosticimaging.com/practice-management/content/article/113619/1888553

Teaching Community-Based Participatory Research

Published in the June 2011 AAMC Reporter

By Whitney L.J. Howell

As she watched the teenagers discuss their new health information database, Tirza Cannon realized why getting communities engaged in their own health care is so important.

The teenagers were unveiling HealthShack.info, a Web site that gives marginalized and homeless young people a safe place to compile and access their medical information. For Cannon, a third-year student at the University of California Davis (UC Davis) School of Medicine, the Web site illustrated how to make the community a true partner in medical research.

“These young people talked eloquently to more than 100 people about how they helped design and implement a system to house medical information,” Cannon said. “That really drove home for me that physicians must be aware of the social, economic, political, and cultural factors influencing their patients.”

HealthShack is an example of a new kind of research that has gained ground over the past decade: community-based participatory research. This method unites investigators with communities to identify health problems, the best ways to study those issues, and how to design health behavior changes that the community is most likely to adopt.

Now, a growing number of medical schools like UC Davis are introducing this research method to their students. The National Institutes of Health and the Centers for Disease Control and Prevention sparked interest in this fledgling field in 2008 when they issued a call for grant proposals in community-based research. Since then, some schools have incorporated community-based research instruction into their curricula through individual studies or full classes.

Still, the method remains a relatively new concept, and finding the right way to teach it has been difficult. In fact, a 2009 study published in Academic Medicine reported that some medical schools and teaching hospitals may be reluctant to accept or encourage community-based research because their investigators have proven success with other methods.

Being familiar with this technique, however, will benefit students as medicine continues to shift its focus to prevention, said Elizabeth Miller, M.D., UC Davis assistant professor of pediatrics and adolescent medicine.

“The amount of didactic instruction that students have received on community-based participatory research has been variable at best,” said Miller, a faculty leader for the HealthShack project. “There’s been very little room in medical education to do this type of thing, but including it is vital because it teaches students early on how to really connect with the people they will serve.”

According to Miller, UC Davis will launch a community-based prevention program in July, in which first-year medical students spend a month tackling child and family wellness issues with community partners.

Jen Kauper-Brown, M.P.H., a director in Northwestern University’s Community-Engaged Research Center, echoed Miller, stressing that community-based research lectures alone are not as effective as real-world training.

“Community-based research is hard to learn in the classroom,” she said. “We have to provide experiential learning models that fuse faculty instruction with days spent working in the community.”

In 2012, Northwestern University Feinberg School of Medicine will introduce a community engagement course series that will place students in a research project, provide on-the-ground training for community-based research skills, and offer students ongoing feedback and support from faculty and peers.

Duke University School of Medicine teaches these concepts to incoming medical students through an interprofessional course in which they learn alongside physician assistant and physical and occupational therapy students, said Mary Anne McDonald, Dr.P.H., assistant professor at Duke’s Center for Community Research.

Students also work in prenatal health and telemedicine programs through the Arizona Cancer Center at the University of Arizona College of Medicine. To help students understand how community-based research is similar to clinical skills, Ana Maria Lopez, M.D., Arizona medicine and pathology professor and telemedicine director, often draws a parallel to a basic medical activity.

“I tell students that working with community partners is a lot like getting the vital signs for an individual patient,” Lopez said. “In order for this research method to work, we have to go talk to them, see what’s working, and change course if we need to based on what they tell us.”

With the growing popularity of community-based research, it is still challenging to ignite medical student interest and make participation feasible, said McDonald. The rigors of medical school and the short length of rotations make it difficult for students to cultivate the long-term relationships that are needed to succeed.

For now, that problem has no clear solution. Getting students excited about the idea that community-based research is the next wave of medical research will depend very much on the faculty role models involved in these projects, said Kauper-Brown.

Even though there is an ongoing debate about what types of research projects can correctly claim that they truly engage the community as partners, exposing medical students to research that immerses them in the community will only have a positive impact, said Doug Brugge, Ph.D., public health and community medicine professor at Tufts University School of Medicine.

“There is no substitute for real-world experience,” said Brugge, who also directs the Tufts Community Research Center and has conducted collaborations with several neighborhoods around Boston. “You can talk or read about working with communities, but you’ll never understand how complex some community’s issues are or how difficult implementing changes can be until you ask questions and listen. Some students are shocked to see that, and it’s an important thing for them to learn.”

Change Agents: Training Doctors as Change Agents for Community and Primary Care

Published in the Summer 2011 Duke Med Alumni News

By Whitney L.J. Howell

When Tracey Spencer enrolled in Duke University School of Medicine’s Class of 2013, supporting a patient’s leg in the delivery room was not the first clinical care image that popped to mind. But earlier this year, that is where she found herself, and she says it is one of the greatest parts of her medical training so far.

“I held my patient’s leg for an hour while she pushed. I never really thought about deliveries taking that long, but 30 minutes into it, her leg started to feel really heavy,” says Spencer, MSIII. “It was my first time seeing a baby delivered, and when I needed to take a break to avoid passing out, they waited on me. The patient was so comfortable with me and really considered me to be a big part of her care team.”

Spencer’s experience is unique among her peers because she is part of a new program for second-year Duke medical students called the Primary Care Leadership Track (PCLT). This academic path is an effort to answer the Association of American Medical Colleges’ recent call for medical schools to  produce more primary care physicians.

As with many aspects of medicine, however, Duke is putting its own twist on things. Rather than  follow the traditional second-year curriculum focusing on inpatient training in the hospital, the PCLT places students mostly in outpatient settings, such as primary care, community, and obstetrics-gynecology clinics. The change gives them first-hand experience in the predominant primary
care settings.

Forming the Program

The past five years have been a time of growing pains for Duke’s primary care and family medicine programs. Since shuttering the family medicine residency in 2006, the school revamped the program, and administrators redoubled their commitment to primary care training. The same enthusiasm arose when faculty began discussing the PCLT, says Edward Buckley, MD, vice dean for medical education.

“Duke’s fundamental educational mission is different from other schools,” he says. “While we do train physicians focused solely on patient care, we also have a commitment to train clinical leaders and scientists who can be change agents for health care at the community and primary care levels.”

In fact, says Barbara Sheline, MD, MPH, PCLT program co-director and assistant dean for primary care, getting buy-in from school administrators and lead faculty took less effort than program coordinators anticipated.

“After we presented our thoughts and plans for the program, the overriding consensus was that this is the way we should’ve been teaching primary care all along,” she says.

Finding five faculty preceptors for each PCLT student was the first step to successfully launching this part of the curriculum. Every student must have a preceptor from each core area— family medicine, internal medicine, psychiatry, pediatrics, and obstetrics-gynecology— so Duke provides faculty development to physicians who do not regularly teach.

Students spend nine months in outpatient clinic training, and they also have the unprecedented  opportunity to rotate through the emergency department. Inpatient training comes by spending nearly three months working in the hospital. Throughout the year, they meet with Sheline every Thursday for instruction and discussion.

Although the PCLT opened with three students enrolled, nearly 200 applicants applied for the six slots available next year, Sheline says. Interest was so great that within 48 hours of posting program information online, coordinators received 96 inquiries. Faculty select students based on a written essay and a separate interview in which program leaders look for applicants with demonstrated or potential leadership skills.

Accepted students receive a $10,000 scholarship to offset the cost associated with pursuing the often lower-paid primary care positions. If students decide to enter a different specialty, the scholarship reverts to a loan.

How It Works

While PCLT students begin the same curriculum as their classmates, taking basic science courses during their first year, they also discuss patient cases with other health care professions students. They branch away further as second year students by learning in different environments. Instead of spending the majority of their time with hospital inpatients, these second-year students rotate through outpatient clinics.

Each week, they spend half-days shadowing their preceptors, taking patient histories, and learning to hone their diagnostic skills. Time spent in the clinics gives students the benefit of one-on-one time with faculty, says Bruce Peyser, MD, PCLT co-director from internal medicine.

“Second-year students naturally need more time and supervision than fourth years, and in many cases they’re starting from square one. They can’t find a lymph node or aren’t skilled enough to hear a heart murmur,” Peyser says. “But working alone with a doctor means they get more time to make sure they’re doing things correctly and we, as faculty, can take time to really show them things and make sure they understand or can ask questions.”

In addition to observing patients with their preceptors, PCLT students also get their first taste of being a “real doctor.” They are required to compile their own panel of patients—a group of individuals whom students follow through the health care system as they need and receive services. For instance, if a primary care provider refers a patient to a specialist, the student would accompany the patient to the appointment as a patient advocate and to provide an extra continuity of care layer.

Having an individual panel of patients gives PCLT students a first-hand glimpse into the life and  responsibilities of a practicing provider far earlier than any of their peers.

“I don’t think even fourth years or residents get the same continuity with their patients,” says  Christopher Danford, MSIII, who chose Duke over other medical schools specifically for the PCLT program. “All three of us have had a patient we’ve been close to die or get a new diagnosis of cancer. And on the other end, we’ve been able to deliver babies. That’s a very emotionally charged experience.”

The Centering Program through Lincoln Community Health Center offers PCLT students the opportunity to follow pregnant patients through their health care experience. Together with a nurse midwife, the students work with a group of women throughout their pregnancies, providing prenatal care and leading Program discussions. The students are present for the births— many delivering the babies—and they follow mother and baby to postnatal care.

“It’s wonderful for the women to get to know the students and have them at their births,” says Trish Payne, a certified nurse midwife who serves as a PCLT preceptor. “These women walk into the hospital to have their baby and instead of seeing a stranger, they see their medical student.”

The program is too new to provide longitudinal data on the benefits of having medical students involved in prenatal care, but Payne says she anticipates the Centering Program women will not only be more likely to listen to and follow the students’ advice, but they will also be at a lower risk for a C-section because they will be less frightened in the delivery room.

The Program ’s Next Steps

Real-world primary care training continues for PCLT students in the third and fourth years of medical  school. During the third year, according to program co-director Sheline, students must complete a research project in collaboration with the Duke Center for Community Research that focuses on a community or population health issue facing Durham residents, such as diabetes in the African- American population.

“This is the year where students will really see the health care system through the patient’s eyes,”   Sheline says. “They will work with groups already looking at health issues Durham cares about while receiving training in community and population clinical leadership.”

The PCLT fourth year will be similar to the traditional fourth-year curriculum. Students will choose a variety of electives designed to increase their primary care proficiency, including a sub-internship and a critical care elective. Additionally, PCLT students must complete a four-week long capstone course that will better prepare them to work in a patient-centered medical home.

Another View of Health Care

Even though they have only finished the program’s second year, the three PCLT students have already achieved one of Duke’s goals—they are far more aware of what it means to be a patient in today’s health care system.

“It’s been most interesting to see the transition of care as a patient goes from different practice to  practice. I’ve realized that many patients have trouble getting to and from appointments because of transportation issues, and I’ve seen them struggle to make their co-pays,” says Cassandra Kisby, MSIII. “I know our classmates don’t see that because they’re transferring from service to service rather than rotating with the patient.”

The effect so far—on student and patient—has been positive, says co-director Peyser. The need for strong leaders in primary care is especially great as the health care system faces a time of substantial transition. The continuity of having students in the clinic is also comforting to patients.

“Without fail,” Peyser says,” the patients who agreed to have Chris [Danford] as part of their care ask for him and want him in their appointments.”

MRI/PET Machines Hit Mainstream

Published on the June 8, 2011, DiagnosticImaging.com

By Whitney L.J. Howell

Design and structure improvements in PET and MRI scanners could soon alter how you practice nuclear medicine. These changes have made combining the scans for clinical treatment a possibility, according to a presentation at this week’s Society of Nuclear Medicine (SNM) annual meeting in San Antonio.

The PET/MRI combination scanner first appeared in the mid-1990s in mouse-model cancer research conducted at the University of California-Davis (UC-Davis), but using it clinically has been impossible until now. Not only have MRI magnets distorted colors and images from nearby PET scanners, but there also hasn’t been enough space inside an MRI to accommodate a PET.

Those problems no longer exist. Using LCD screens instead of CRT screens in PET scanners prevents image distortion, and installing higher-performing gradients frees up space – 70 cm rather than 55 cm – to install a PET inside an MRI, says Bruce Rosen, M.D., Ph.D., radiology professor at Harvard Medical School and director of the Athinoula A. Martinos Center for Biomedical Imaging at Massachusetts General Hospital. The wider space also reduces anxiety for patients who are claustrophobic.

Given these changes, companies, including Siemens and GE, are now working to commercialize combination scanners.

“It’s important that the technology is now advanced so these scans can play well together,” says Rosen, who delivered the SNM’s PET/MRI presentation. “Running tests simultaneously lets radiologists diagnose a problem and see how it’s working real-time. It can also save patients the inconvenience of having tests at different times.”

To read the rest of the story online: http://www.diagnosticimaging.com/molecular-imaging/content/article/113619/1875482?CID=rss&cid=dlvr.it

 

Treatment and prevention in the ‘buckle’ of the stroke belt

Published in the Spring 2011 Carolina Public Health Magazine

By Whitney L.J. Howell

During the last 20 years, North Carolina has edged toward the top of an ignominious list. The state currently has the sixth highest incidence of stroke mortality in the nation. There’s no time to waste in turning this trend around.

Annually, 27,000 North Carolinians suffer strokes; one dies every two hours. These statistics led researchers to label certain North Carolina counties as part of the “buckle” of the Stroke Belt, which runs through the southeastern United States. Stroke risk in the region is two to three times greater than the national average.

Recognizing stroke risks and symptoms and providing appropriate and timely treatment are critical to preventing stroke and lessening its long-term impacts. For more than a decade, UNC Gillings School of Global Public Health researchers have dedicated themselves to reducing the impact of the nation’s third highest killer. They identify “best practices” in stroke treatment and prevention, help hospitals implement quality of care improvement programs, and train medical personnel to recognize and respond quickly to stroke symptoms.

“We want to improve patients’ care – wherever they may be – should they have a stroke in North Carolina,” says Wayne Rosamond, PhD, epidemiology professor and principal investigator for the North Carolina Stroke Care Collaborative (NCSCC).

The NCSCC works with 56 of the state’s 102 hospitals, from Henderson County’s Park Ridge Health in the west to Carteret County General Hospital in the east. Participating hospitals range from the 25-bed Transylvania Medical Center to Pitt County Memorial (745 beds, affiliated with East Carolina University’s Brody School of Medicine), Duke University Medical Center (989 beds) and Greensboro-based Moses Cone Health System (529 beds).

With Centers for Disease Control and Prevention funding, the collaborative created an interactive database so that a hospital’s stroke care performance can be monitored and compared to similar facilities. Each month, NCSCC hosts webinars for stroke experts to address specific quality improvement topics, and they assist hospitals in giving emergency medical technicians and caregivers advanced education in both identifying and reacting appropriately to a stroke.

NCSCC annually awards up to 12 grants to fund initiatives that meet individual hospital needs. For example, for 2009–2010, Catawba Valley Medical Center received $15,000 for a stroke nurse coordinator. NCSCC also collaborates with the Registry of the Canadian Stroke Network. In February, the NCSCC joined with UNC’s Department of Emergency Medicine to participate in a seminar, presented at the International Stroke Conference 2011, about integrating a stroke registry into EMS data sources.

However, ensuring that patients receive appropriate services is only part of the stroke-prevention equation, says June Stevens, PhD, nutrition and epidemiology professor and nutrition department chair. Health care providers also should focus on helping individuals tackle obesity – a substantial, preventable stroke risk factor.

“Obesity increases the risk of stroke, because it raises the likelihood of high blood pressure,” Stevens says. “In fact, we’ve found that if you have a significant weight gain over an extended period of time, your risk is substantially higher than if you maintain your weight.”

In a soon-to-be published study of 15,000 people from North Carolina, Mississippi and Minnesota, Stevens and her colleagues found that a 10- to 30-percent weight gain between age 25 and middle age resulted in a 29 percent increase in stroke risk. Individuals who gained more than 30 percent of their body weight had a 64 percent higher risk. These results were compared to individuals who maintained their weight within 3 percent of the initial measurement.

“People already know obesity isn’t healthy,” Stevens says. “They also need to know about evidence that shows they’re at high risk for stroke – so they can do something about it.”

To read the story online: http://www.sph.unc.edu/images/stories/news/cph_2011_spring/documents/howell_stroke.pdf

Swa Koteka ‘It is possible’ to prevent HIV

Published in the Spring 2011 Carolina Public Health Magazine

By Whitney L.J. Howell

Even without engaging in risky behaviors, young girls and women who live in South Africa have a 1-in-3 chance of contracting HIV.

Audrey Pettifor, PhD, assistant professor of epidemiology at UNC Gillings School of Global Public Health, launched a study in March 2011 to examine the factor known to have the greatest impact on reducing HIV infection risk – education. Pettifor partners with University of the Witwatersrand researchers  Catherine MacPhail, PhD, and Kathleen Kahn, MD, PhD.

Audrey Pettifor, Ph.D., assistant professor of epidemiology at the UNC-Chapel Hill Gillings School of Global Public Health

“We know young girls who finish high school are four times less likely to become infected with HIV than those who don’t complete school,” Pettifor says. “Condom use and number of partners simply don’t explain the high levels of HIV infection we observe in young South African women.”

To keep girls in school, Pettifor and her team will randomize 2,900 young women and their  parents/guardians to receive a monthly cash transfer, based on whether they attend school 80 percent of the time over the next three years. Then, they will determine whether girls receiving the cash  transfers are less likely than girls in the control group to become infected with HIV.

The study, funded by the National Institute of Mental Health and the National Institutes of Health’s (NIH) HIV Prevention Trials Network, also will measure HSV-2 (genital herpes), sexual behavior, mental health, school outcomes, socio-economic status and other key social factors. It is referred to locally as Swa Koteka, which means “it is possible” in the native language, Shangaan.

Educating girls is only half the battle, however, Pettifor says. Cultural norms that impinge upon a woman’s right to resist sex or insist on condom use also have to change if young women’s HIV risk is to be decreased. Therefore, half of the young women’s villages also will be randomized to receive an intervention focused on changing negative gender norms and HIV risk among men ages 18 to 35. The team partners with a local nongovernmental organization, Sonke Gender Justice, which aims to challenge and reshape negative gender norms in South Africa.

Pettifor also directs two NIH-funded pilot projects in Lilongwe, Malawi, to help those with acute HIV infection (AHI) lessen the likelihood of transmission. AHI is a highly infectious phase of the disease.

One of Pettifor’s projects, co-led with Amy Corneli, PhD, of FHI,* will compare the effect of four intensive counseling sessions in the first two weeks after AHI diagnosis to standard counseling in reducing transmission risk to partners.

In the second project, co-led with Bill Miller, MD, PhD, UNC associate professor of epidemiology and medicine, Pettifor’s team will compare effects of three interventions – antiretroviral treatment for the first 12 weeks after infection, in combination with intensive alone and standard counseling.

“This is a behavior change intervention through which we’re asking people to change behavior for a defined and short period of time,” Pettifor says. “If we get them through this really risky time, then we can talk about a longer-range risk reduction plan.”

To read the story online: http://www.sph.unc.edu/images/stories/news/cph_2011_spring/documents/howell_HIV.pdf