History and Physical

Journal Article Summary

Article: Ulipristal acetate versus levonorgestrel for emergency contraception: a randomized non-inferiority trial and meta-analysis

Lancet Journal

• Emergency contraception is used to prevent unwanted pregnancies. This study compared the efficacy and safety of Ulipristal Acetate (a selective progesterone-receptor modulator) with Levonorgestrel for emergency contraceptive.
• This is randomized, multicenter (35 family planning clinics located in the UK, Ireland, and the USA), non-inferiority trail and a meta analysis that used 2221 female participants.
• In the randomized, multicenter, non-inferiority trial:
  • 1104 female participants were randomly assigned to receive a single supervised dose of 30mg Ulipristal Acetate. However, 163 participants were not included in the analysis because of follow up loss, pregnancy occurred before emergency contraception use, or were re-enrolled in the study. Overall 941 participants were included in the efficacy evaluable population.
  • 1117 female participants were assigned to 5mg of Levonorgestrel. However, 159 participants were not included in the analysis because of follow up loss, pregnancy occurred before emergency contraception use, or were re-enrolled in the study. Overall 958 participants were included in the efficacy evaluable population.
• Inclusion Criteria:
  • Women with regular menstrual cycles (24–35 days) seeking emergency contraception within 120 h of unprotected sexual intercourse
  • Women 16 or older in the UK
  • Women 18 years or older in the USA
• Exclusion Criteria:
  • Women who were pregnant breastfeeding, sterilized, fitted with an IUD, taking hormonal contraception, or whose partner was sterilized.
• The main outcome measured was pregnancy rate in participants who received emergency contraception within 72h of unprotected sexual intercourse. Follow-up was done 5–7 days after expected menses.
  • There was a total of 37 pregnancies occurred in women who received emergency contraception within 72 h of sexual inter course; there were 15 (1·8%, 95% CI 1·0–3·0) pregnancies in the ulipristal acetate group and 22 (2·6%, 1·7–3·9) in the levonorgestrel group (OR 0·68, 95% CI 0·35–1·31). Significantly more pregnancies were prevented with ulipristal acetate than with levonorgestrel (p=0·037) in women who received emergency contraception between 72 h and 120 h after sexual intercourse. Ulipristal acetate seemed to prevent more pregnancies than did levonorgestrel, irrespective of the interval between sexual intercourse and treatment.

• Limitations: This is an older study from 2010. It is not a double blind study, instead it is a single blind study (participants were masked to treatment assignment whereas investigators were not). The sponsor of the study was involved in study design, data collection, data analysis, data interpretation, and writing of the report. Women were excluded if they were current or recent users of hormonal methods of contraception; however, emergency contraception is frequently used in women who have missed oral contraceptive pills.

Glasier, Cameron, S. T., Fine, P. M., Logan, S. J., Casale, W., Van Horn, J., Sogor, L., Blithe, D. L., Scherrer, B., Mathe, H., Jaspart, A., Ulmann, A., & Gainer, E. (2010). Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. The Lancet (British Edition), 375(9714), 555–562. https://doi.org/10.1016/S0140-6736(10)60101-8

Site Evaluation Presentation Summary

In my eighth rotation, I had PA Fahim Sadat as my site evaluator. During the site evaluation, I presented three History and Physicals (H&Ps) based on my experience in Ambulatory Care. The first H&P centered around a 28-year-old female patient who complained of red, swollen eyes and blurry vision. A comprehensive eye examination was conducted during her visit, and her visual acuity was found to be unaffected. The potential diagnoses considered included bacterial conjunctivitis, viral conjunctivitis, blepharitis, preseptal cellulitis, and orbital cellulitis. Ultimately, she was diagnosed with bacterial conjunctivitis. She received appropriate treatment measures, and was patient education on ED precautions.

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

One of the most noteworthy patient encounters occurred when a father accompanied his son to grant a social worker HIPAA access to the son’s medical records. The son had visited the urgent care a week earlier due to accidentally getting elbowed in the eye while his father was turning over in his sleep. Despite receiving medical treatment, the son later falsely claimed at school that his father had struck him in the eye, leading to the involvement of Child Protective Services (ACS). 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

Patient education is the process of providing patients with information and guidance about their medical conditions, treatment options, medications, and self-care practices to help them better understand and manage their health. I faced challenges in patient education, but I improved my approach by delving into fundamental topics such as wound healing, drug interactions, and recognizing warning signs. I also occasionally consulted UpToDate on my mobile device, which proved to be a valuable resource.

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

Drawing blood from dehydrated individuals or those with thin veins can be quite challenging. Venipuncture in obese patients, in particular, presents difficulties due to the increased subcutaneous fat layer, which can obscure vein access. To deal with these challenges, I’ve discovered that employing multiple tourniquets or attempting blood collection from the hands can improve the success rate in some cases.

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

In my upcoming rotation, I aim to enhance my skills in patient education, focusing on strategies such as employing the “teach-back” method and tailoring communication to the patient’s educational level. My next rotation will be in pediatrics, which presents unique challenges due to the difficulty in gathering comprehensive medical histories from children and the occasional resistance to physical examinations.

History and Physical

Journal Article Summary

Article: Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial

Lancet Journal

• This is a RCT that focused on comparing three oral anti-hypertensive medications (Labetalol, Nifedipine and Methyldopa) for acute treatment of hypertension in pregnancy.  The 1* Outcome measured was BP control (120-150 Systolic BP or 70-100 mm Hg Diastolic BP) within 6 hours with no adverse outcomes.
• It is a multicenter parallel group RCT; the oral anti-HTN were compared in 2 public hospitals in Nagpur, India.
• Inclusion Criteria: pregnant women at the gestational age of at least 28 weeks with severe HTN (Systolic BP ≥ 160 mm Hg or Diastolic BP ≥ 110 mm Hg) who are able to swallow oral medications.
• Exclusion Criteria: impending eclampsia, active labor, younger than 18 years old, indication for an emergency c-section, known fetal anomaly, history of asthma or actively wheezing, or have signs of heart failure.
• 894 Patients were randomly assigned to receive 10mg oral Nifedipine (298 patients), 200mg oral Labetalol (295 patients), 1000mg Methlydopa (301 patients).
• Results found that for pregnant women with severe hypertension, oral nifedipine retard was more effective than methyldopa at achieving a primary outcome of blood pressure control without adverse events within 6 h when additional medications were used. Oral nifedipine retard and labetalol, as single drugs, were significantly more effective than methyldopa. The frequency of primary outcome attainment was high and maternal adverse events were low in all three treatment groups.
• Labour and delivery outcomes did not vary between groups (2/3 of women in each group delivered by c-section because of failed inductions of labour and FHR abnormalities). The incidence of stillbirth, neonatal death, and neonatal morbidities did not vary between groups.
• However, more neonates born to women assigned to the nifedipine group were admitted to the intensive care unit, primarily because more low or very low birthweight babies were born to mothers in the nifedipine group.
• Implications of the study: For institutions that have limited resources, oral antihypertensive medications can be used for managing severe hypertension. The World Health Organization (WHO) currently includes only intravenous hydralazine and methyldopa in its most recent essential drugs list for addressing severe hypertension during pregnancy. Nifedipine is solely mentioned as a remedy for preterm birth.
• I chose this study because there are not enough studies that directly compared the three most commonly used oral antihypertensives: labetalol, methyldopa, and nifedipine. A Cochrane review of drugs for treatment of very high blood pressure during pregnancy also found insufficient data to recommend a specific drug, and it concluded that the choice of antihypertensive should depend on clinicians’ experience and familiarity with the drug.
• Limitations of the study: it was not possible to mask the participations, study investigators and care providers. Another limitation of the study was their definition of severe HTN, which was defined as Systolic BP ≥ 160 or Diastolic BP ≥ 110. There are multiple categories of hypertensive disorders in pregnancy:
  • Gestational HTN which is new onset Systolic BP ≥ 140 and/or Diastolic BP ≥ 90 after 20 weeks gestation in a previously normotensive individual with no proteinuria, no signs or symptoms of preeclampsia related end organ dysfunction.
  • Preeclampsia which is new onset systolic BP ≥140 and/or Diastolic BP ≥ 90 after 20 weeks gestation with proteinuria, protein: creatinine ratio ≥ 0.3, urine dipstick reading ≥2+.
  • Preeclampsia with severe features occurs with systolic BP ≥ 140 and/or Diastolic BP ≥ 110 with thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, persistent cerebral or visual disturbances.
  • Chronic (Preexisting) Hypertension which is when HTN is diagnosed or present before pregnancy or before 20 weeks of gestation.

Source:

Easterling, T., Mundle, S., Bracken, H., Parvekar, S., Mool, S., Magee, L. A., von Dadelszen, P., Shochet, T., & Winikoff, B. (2019). Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial. Lancet (London, England), 394(10203), 1011–1021. https://doi.org/10.1016/S0140-6736(19)31282-6

Site Evaluation Presentation Summary

In my seventh rotation, PA Carlos Melendez served as my site evaluator. During the site evaluation, I presented three H&Ps based on my time in Labor and Delivery, Clinic, and GYN. The first H&P was from my time in Labor and Delivery, it involved a 28 year old 30 week pregnant female who presented to triage with complaints of blood in her toilet bowel this morning. During her visit she placed on a continuous external fetal monitor along with toco monitoring. There was no evidence of preterm labor with FFN negative, VE closed/unchanged, and her lower abd pain resolved s/p IV fluids. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

The most unforgettable experience occurred when I witnessed my initial C-section procedure. The patient was categorized as of advanced maternal age and had previously undergone five C-sections. She was scheduled to be induced that day. It’s challenging for anyone to truly grasp the significance of bringing a baby into the world. What left a lasting impression on me was the flawless coordination and collaboration between the pediatric and obstetric teams, particularly as the infant developed respiratory distress syndrome.

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

The most challenging aspect of my role was collecting a detailed medical history from OB patients during their follow-up appointments and aligning it with the required screenings based on their gestational age. I discovered that maintaining a chart is a valuable tool to ensure that patients receive the appropriate screenings according to their pregnancy stage.

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

During this rotation, it was individuals who were reluctant to disclose details about their sexual history or past pregnancies that I found challenging. I observed that some healthcare providers opted for one-on-one OB visits with patients, excluding family members from the room, which I believed was a crucial factor to take into account. Certain patients hesitated to share comprehensive information when their partners, significant others, or family members were present. I also gleaned that emphasizing the significance of confidentiality in certain situations could help patients feel more comfortable.

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

In my upcoming Ambulatory Care rotation, I aim to engage in a greater number of medical procedures and enhance my proficiency in interpreting EKGs. My strategy involves communicating my interest in performing additional procedures to the supervising provider. Along with reviewing videos on EKG interpretation. 

History and Physical

Journal Article Summary

Article: Risk factors for statin-associated rhabdomyolysis

Journal of International Society for Pharmacoepidemiology, 2007

Authors: Schech et al.

• The article focused on finding risk factors such as age, gender, comorbidities, concurrent medication use, dosage, and duration of statin that could lead to statin induced rhabdomyolysis.
• This was a case control study conducted with a cohort of 252, 460 who just started taking statins. A retrospective cohort study was used to identify cases with rhabdomyolysis. 21 cases with rhabdomyolysis induced from statin therapy alone or statin therapy with a fibrate were compared to 200 controls without rhabdomyolysis. All cases were exposed to Atorvastatin, Cerivastatin, or Simvastatin.
• Although the evidence was not as strong, there was also a relationship of developing rhabdomyolysis amongst patients with high statin dosage (especially with Cerivastatin), patients with renal disease, and female patients.
• Overall, the study found patients 65 and older have a 4x risk of developing rhabdomyolysis and needing hospitalization compared to those under the age of 65.
• Some limitations of this article, includes being published in 2007. Since then, Cerivastatin has been discontinued and instead Rosuvastatin became available in 2010. It would be great if this study was redone with the current statins on the market.
• Another limitation is the small number of cases from statin induced rhabdomyolysis, which was 21. Since this is a small sample, it’s hard to confirm a clear association between the risk factors and statin induced rhabdomyolysis. A larger sample would give a clearer answer if there’s increased risk for female patients developing statin induced rhabdomyolysis.
• This article mainly focused on identifying risk factors of developing statin induced rhabdomyolysis, however, it still doesn’t address the other adverse events that occur with statins such as DM, Hepatoxicity, or Myopathy. Further research should focus on recommending statin dosage for patients 65 and older, along with the risk vs. benefit for continued statin treatment in patients 65 and older who develop adverse events.

Citation:

Schech, S., Graham, D., Staffa, J., Andrade, S. E., La Grenade, L., Burgess, M., Blough, D., Stergachis, A., Chan, K. A., Platt, R., & Shatin, D. (2007). Risk factors for statin-associated rhabdomyolysis. Pharmacoepidemiology and drug safety, 16(3), 352–358. https://doi.org/10.1002/pds.1287

Site Evaluation Presentation Summary

My site evaluator for my third rotation was Dr. Davidson. During my site evaluation, I presented 3 monthly evaluation H&Ps from my time in LTC at St. Albans VA. The 1st H&P was a complicated case of a 79-year-old who was admitted to LTC for assistance with ADLs, after being discharged from Mount Sinai where he was admitted for AKI on CKD 2/2 Rhabdomylosis, Uremic Encephalopathy, and Urosepsis. His hospital course was complicated by E. Coli bacteremia. Initially, when I first presented the case, it was hard to follow along chronologically since the patient had various procedures and events that occurred during his course at Mount Sinai. I was given good and clear feedback on how to re-arrange by first starting his HPI with how his status was in the community normally, then talking about the new event/date, then discussing his ED admission and what was found/diagnosed there/his hospital course with any treatments/developments and then discussing his transfer to the VA and his course since that moment. For my second site visit, I presented a case of monthly progress note on a patient who was admitted to St. Albans for short-stay rehab. I also gave prevention on Anemia of Chronic Disease/Inflammation and how anyone who has a chronic illness with microcytic/normocytic anemia should be considered and worked up. In addition, I presented a journal article on the RF for developing Rhabdomyolysis from Statins. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

My time at LTC helped me recognize how vital the patient-provider relationship is in improving the patient’s health. It helped me reevaluate my own encounters with patients. A lot of the residents at LTC do not have social support, instead, it’s the nurses and other healthcare providers that act like their relatives. I saw how a simple handshake and greeting from Dr. Newland, can light up a smile on an 80-year-old wheelchair user. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

It was difficult for me to perform full complete physical exams on a lot of the patients since most were wheelchair-bound, agitated, or A&Ox1. I found it helpful to introduce myself to the charge nurse of that floor, and then informing them I would like to do a physical exam on Mr. X. The charge nurse would then tell me about the resident’s baseline, if they were known to hit staff unprovoked, or if they were currently out. Sometimes the charge nurse would help me distract the patient so I could do a physical exam, which I appreciated. 

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

The hardest patients I had to deal with, were the ones that were known to become physically and verbally assaultive with staff. After talking to Dr. Newland, I learned that some of these patients resort to that because they felt provoked, and sometimes patients can do it unprovoked. For instance, there was a resident who had multiple code 2000s called, where they were physically/verbally agitated and were unresponsive to nurse and provider redirection. However, he later mentioned he was like this because he hated being on a 1:1 observation. Once Dr. Newland switched him from 1:1 to close observation, the resident did not act up again. 

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

For my following rotations, I want to get better at procedures. I had some experience with replacing foley catheters at LTC, however, I want to try using a straight catheter, putting in IVs, and suturing. I also gained a lot of experience with blood draws during this rotation. I understand that each rotation focuses on specific procedures, and I plan on perfecting those procedures at those sites. My next site is Psych and it’s mainly performing a mental status exam along with depression screening. 

History and Physical

Journal Article Summary

Type of article: Systematic Review

Title of article: Efficacy of Treatment of Non-hereditary Angioedema

Published in Clinical Reviews in Allergy & Immunology on 9/27/16

Although this is a foreign-based article from the Netherlands, I chose this article because it’s a great systemic review that used multiple databases National Guideline Clearinghouse, CBO guidelines, Trip Database, the Cochrane Library, PubMed, EMBASE, and Scopus.

61 articles were included in the study. In addition, only articles describing the pharmacological treatment of AE were included. This included both observational studies (case reports and case series) and intervention trials (cohort studies or randomized controlled trials, RCTs). And only articles written in English, Dutch, or German were included so the authors who performed the selection of studies had full understanding of scientific content.

Non-hereditary angioedema (AE) with normal C1 esterase inhibitor (C1INH) can be divided as bradykinin or mast cell mediated, or from an unknown cause. The focus of the systematic review was to provide an overview of the efficacy of different treatment options for refractory non-hereditary AE with or without wheals and with normal C1INH. Therapies were also described for angiotensin-converting enzyme inhibitor-induced AE (ACEi-AE), for idiopathic AE, and for AE with wheals. Patients with ACEi-AE who present to the ED can be treated with FDA label medications or off-label medications. Treatment options include ecallantide, icatibant, C1INH, fresh frozen plasma (FFP), tranexamic acid (TA), and omalizumab.

Key points:

• Hereditary AE caused by C1 esterase inhibitor (C1INH) deficiency, results in the release of the key mediator bradykinin. An increase in bradykinin can also be from ACEi.
• Patients with ACEi-AE generally do not respond to conventional therapy. Pathophysiology suggests that drugs registered for hereditary angioedema (HAE) due to C1INH deficiency could also be effective in ACEi-AE.
• Several drugs are currently available, including:

(1) antifibrinolytic agents such as tranexamic acid (TA)

(2) attenuated androgens such as danazol

(3) replacement of deficient proteins using fresh frozen plasma (FFP)

(4) C1INH concentrates, which inhibit the formation of bradykinin

(5) the selective plasma kallikrein inhibitor ecallantide

(6) the selective bradykinin B2 receptor antagonist icatibant

• In this systematic review, several treatment options for patients with refractory AE were found.
• For acute attacks of AE, several articles described treatment with icatibant, C1INH, TA, FFP, and ecallantide.
• For prophylactic treatment of AE, omalizumab, TA, and C1INH were shown effective, and, with fewer included articles, also progestin and MTX.
• In patients suffering ACEi-AE or an acute attack of idiopathic AE, ecallantide seems to have an effect in a limited number of patients, if any, whereas icatibant, C1INH, TA, and FFP often lead to symptom relief within 2 h, in addition to a good safety profile.

Overall, this systematic review provided an overview of therapeutic options (acute attacks vs prophylactic treatment) in patients with Angioedema with normal C1INH. However, an important limitation to keep in mind is that although patients responded quickly after treatment with icatibant, C1INH, and TA, most of the included studies were not controlled and therefore of lower quality in terms of scientific reliability. There is a need for additional studies with a high level of evidence. The main conclusion of the study, in acute attacks of ACEi-AE and idiopathic AE, treatment with icatibant, C1INH, TA, and FFP often leads to symptom relief within 2 h, with limited side effects. For prophylactic treatment of idiopathic AE and AE with wheals, omalizumab, TA, and C1INH were effective and safe in the majority of patients.

Citation:

van den Elzen, M., Go, M. F. C. L., Knulst, A. C., Blankestijn, M. A., van Os-Medendorp, H., & Otten, H. G. (2018). Efficacy of Treatment of Non-hereditary Angioedema. Clinical reviews in allergy & immunology, 54(3), 412–431. https://doi.org/10.1007/s12016-016-8585-0

Site Evaluation Presentation Summary

My site evaluator for my second rotation was Professor Sajid Mohamed. During my site evaluation, I presented 3 H&Ps that I had written on my patients from my time in Emergency Medicine at New York Presbyterian Queens Hospital. The 1st H&P I presented was a case of a 27-year-old who presented with a complaint of belly pain. The patient already had a history of appendicitis that was treated with antibiotics 6 months ago (not with surgery). His physical exam was notable for RLQ tenderness to palpation, guarding, rebound tenderness, psoas sign was present, and obturator sign was present. My differentials included recurrent acute appendicitis. The plan was to admit the patient for surgery and start him on Ceftriaxone, Metronidazole, and Ketorolac. We had a conversation about how some patients are being treated with antibiotics only for acute appendicitis instead of surgery, but often patients will later have a return episode of appendicitis. 

On my second site visit, I presented a case of a 39-year-old male who had no past medical history and presented with RLQ abdominal pain radiating to RUQ, NBNB vomit, and subjective cells. On exam, the patient had a lot of specific abdominal findings, which made his differentials broad. When I performed the physical exam, the patient was in mild discomfort with hypoactive bowel sounds, diffuse mild pain to palpation, guarding was present, murphy sign was present, psoas sign was present, and obturator was present. Because the patient had all these prominent physical exam findings, his differential included cholecystitis, appendicitis, and cecal volvulus. However, once his labs came back the U/A was notable for cloudy urine with large amounts of RBC and protein with the rest of his labs being unremarkable. A CT of Abd and Pelvis was done, which reported mild Right Hydroureteronephrosis, R Perinephric Edema, and a 3mm R UVJ Calculus. Turns out the patient had a kidney stone. The plan was to start Morphine IV and Zofran. Also to discharge the patient with Tamsulosin and for urology follow-up. This was a great case to discuss because his of wide differentials. A recommendation I got from Professor Mohamed, was that IV Toradol can also be given for kidney stone pain in the ED and additionally upon discharge. In addition, the patient can be discharged with Zofran, since he would also experience nausea/vomiting during the passing of the stone. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

Without a doubt, the ED will always leave a mark on anyone who rotates there. During my first week at the ED, I experienced the pleasure of having bile thrown at me by an altered patient that was not under my care. I learned to pack an extra pair of scrubs since then. The ED is also known for its high-acuity patients. There were a lot of situations that were hard for me to watch; like my 1st code during my shift on the Red Team for a patient that had a lower GI bleed and was on an anticoagulant. It was also hard to see a 1-year-old get stitches on his lip for a laceration repair. As hard as it was to see, it was also amazing to watch the ED providers handle these cases with dexterity. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

It was a challenge for me to figure out which lab orders are relevant according to the ED. Initially, I thought the ED would order extra labs, however, because of cost issues and time constraints sometimes they wouldn’t check Hepatitis B panel for patients with Cirrhosis. I also had a hard time thinking of differentials, however, I found that using the VINDICATE mnemonic worked. I also learned from another provider about the SPIT mnemonic, which helps identify the most Serious, Probable, and Interesting differentials. And the T stands for treatment. 

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

For this rotation I actually found the most challenging patient to not be the patient, instead, it’s their family member. I had a situation where I needed collateral information from the daughter because her mother was Alerted and Oriented x 2 (to person and place). However, I found that the daughter was very a poor historian and when I tried to ask the patient if she felt any pain, her daughter would interrupt and mention her mother wouldn’t understand anything. After I reported my findings to my preceptor, who also went to check on the patient, he noted the daughter was very paternal and domineering. However, he still asked the patient if she felt any pain and told the daughter that even if she had dementia she should still be able to report where it hurts. 

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

For my following rotations, I want to get better at the physical exams. Although physical exams are considered objective, I have a hard time telling if a patient has “true” pain when I palpate their abdomen. I also have to consider, that perhaps their pain is muted because they were already given pain medications. My plan to get better at physical exams is a lot more practice, exposure, and compare my findings to the preceptor. 

I also want to get better at the plan portion for H&P. I’ve gained a lot more experience in taking down a good history. However, I want to get better at knowing the 2nd line pharmacological interventions, knowing the exact dosage of medications, and knowing the absolute contraindications of medications. 

History and Physical

Journal Article Summary

Advances in Alcoholism Treatment

G.R. is a 44 y/o M with severe alcohol dependence. He initially presented to ED two nights ago for intoxication at a train station. He was discharged home after a social worker evaluation; however, he did not go home. He states he went and drank again. Two days later, he was admitted to ED again with alcohol intoxication and epigastric pain. He stated he wants help to quit drinking. Patient was admitted to IM for alcohol withdrawal. I wanted to know what options could be offered to alcohol-dependent patients in regard to quitting so I chose the article “Advances in Alcoholism Treatment.”

Alcoholism Treatment

* There is no single treatment that’s effective for everyone with alcohol dependence.

* Instead, clinicians and researchers propose assigning patients to treatment based on specific needs and characteristics. Such as severity of alcohol involvement, cognitive impairment, psychiatric severity, gender, motivational readiness to change, and social support.

Alcoholics Anonymous & the 12-Step Program

* Alcoholics Anonymous is a fellowship of people who come together to solve their drinking problem. It doesn’t cost anything to attend A.A. meetings. There are no age or education requirements to participate. Membership is open to anyone who wants to do something about their drinking problem.

* 12 Steps is based on the premise that turning one’s life and will over to a personally meaningful “higher power.” In the 12 steps program, sobriety or recovery depends on the admission of powerlessness with respect to alcohol or other substances of abuse. The model called for an individualized treatment plan with active family involvement in a 28-day inpatient setting and participation.

* Patients with low psychiatric severity were best suited to 12­step facilitation therapy than those treated with cognitive–behavioral therapy (these patients had more abstinent days).

Behavioral Therapy

* The behavioral treatment integrated aspects of cognitive–behavioral therapy, motivational interviewing, and 12­step facilitation. It also included general behavioral principles like reinforcement and punishment, coping skills training, and brief interventions.

* In cognitive behavioral therapy the concept of self-efficacy (belief in one’s ability to abstain from alcohol) plays a prominent role in relapse prevention. Also, a person’s expectations regarding the effects of alcohol are identified and challenged during CBT interventions.

* In coping skills training and relapse prevention, there is a primary focus on identifying high­ risk situations for drinking and then building a repertoire of coping skills to help patients approach risky situations without using alcohol.

Medications

* Naltrexone helps to reduce the craving for alcohol after someone has stopped drinking.

* Acamprosate is thought to work by reducing symptoms that follow lengthy abstinence, such as anxiety and insomnia.

* Disulfiram discourages drinking by making the patient feel sick after drinking alcohol.

* Other types of drugs are available to help manage symptoms of withdrawal.

Combining Medications and Behavioral Interventions

*  Patients who received naltrexone, behavioral therapy, or both demonstrated the best drinking outcomes after 16 weeks of treatment.

* Acamprosate showed no evidence of efficacy, with or without behavioral therapy.

Choosing the most appropriate treatment for a given patient remains a challenge. The delivery of alcohol treatment, whether that treatment is medication, behavioral therapy, or a combination of both, can be facilitated by the use of communication tools such as the telephone, e­mail, and the Internet. Among the applications being used are Internet and computer program–based screening instruments (e.g., www.AlcoholScreening.org), online social support groups, Internet­ based interventions, telephone contact, e­mail, and text messaging. There is also a technology, called A­CHESS (Addiction Comprehensive Health Enhancement Support System), which is designed to provide coping competence, social support, and autonomous motivation. It’s often provided to patients as they leave residential treatment.

References:

Huebner, R. B., & Kantor, L. W. (2011). Advances in alcoholism treatment. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 33(4), 295–299

PDF Attachment

Site Evaluation Presentation Summary

My site evaluator for my first rotation was Professor Fahim Sadat. During my site evaluation, I presented 3 H&Ps that I had written on my patients from my time in Internal Medicine at North Shore University. The 1st H&P I presented was a case of a 43-year-old female who presented with a complaint of difficulty breathing. The patient already had a history of cardiomyopathy with a reduced ejection fraction of 20% and AICD. Her physical exam was notable for 12-14cm JVP, 2+ BLE Pitting Edema. My differentials included acute HF exacerbation, PE, Pulmonary HTN, and Pericardial Effusion. I did not include Cardiac Tamponade because the patient’s vital signs were within normal range. The patient was admitted for acute HF exacerbation and was started on Lasix 40mg IVP BID. The plan also included strict I&Os, daily weight measuring, and to replete Mg and K. For my 1st H&P, we had a long discussion on the differential diagnosis for this case, the pathophysiology of decompensated heart failure, and on the adverse effects of loop diuretics. I got some feedback on including lab values and imaging results. In addition, he recommended that I address all of the patient’s PMHx in the assessment and plan, not just the active complaints. 

On my second site visit, I presented the second H&P which was a case of a 44-year-old male who had a history of severe alcohol dependence and presented with stomach pain x 3 days. On exam, pt was agitated and in mild distress with diaphoresis, had fine hand tremors, and had epigastric tenderness to palpation but was otherwise stable. Differentials included Alcohol Dependence Withdrawal, Pancreatitis, PUD, and Alcohol Induced Gastritis. This time I included labs and imaging, and interestingly enough for this case Lipase was 118. The plan was to admit the patient for alcohol withdrawal, and give lorazepam, thiamine, and folic acid. For the abdominal pain, alcoholic gastritis vs gastric ulcer was considered. Hence, a trial of Carfate was recommended with a CT Abdomen and Pelvis ordered. In addition, the CIWA monitoring protocol was ordered to assess the severity of his withdrawal symptoms. For future site evaluations, my plan is to become more familiar with the different scores that are used in clinical practice. I was vaguely familiar with the CIWA protocol, but there are a lot more scores and criteria that I can learn about. In addition, one of the biggest areas that I can work on is learning the pathophysiology of certain diseases and learning the mechanism of action for drugs. I find reading or watching videos about the pathophysiology and then trying to connect it to the clinical signs or symptoms, helps me understand the disease process better. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

Starting off, the first rotation in clinical year will always be a memorable one. My first rotation was at North Shore University in Internal Medicine. Initially, I had a hard time adjusting the first 2 weeks with trying to make sense of the hospital structure, hierarchy, and the roles of the different teams. During my time there, the one thing that stood out to me was how patients were constantly being checked in on by the medical team and how they were constantly updated and included in the medical team’s care plan. I was really impressed with the professionalism of the medicine team and how efficiently they worked, especially when they were faced with a high patient volume from the recent nurse strike. The most memorable patient encounter I had, was with an 80-year-old man who was admitted for fungemia and bacteremia. The first time I met him, he was delirious and in a lot of pain. In my eyes, I was unsure if he would get better. To my surprise the second time I came across him, he was doing much better and recovering. However, now he was being worked up for infectious endocarditis but because of his old age he refused surgery, and that’s when the palliative care team became involved. This case was a perfect reminder of respecting the patient’s autonomy in refusing medical care. I will always feel like I did not learn as much, since there will always be something new to learn. Although I was in Internal Medicine, thanks to PA Dawn Coburn I had opportunities to see a Cardiac Catheterization, TAVR, Mitral Clip Surgery, Endoscopy, and Colonoscopy. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them

This is my 1st rotation, so there is a lot to learn and improve on. I gained a lot of experience with handoffs. Typically, when I prepare handoffs to providers I update them on any change in the patient, on any pertinent labs/imaging, and on the pending consult recommendations. I’m still learning how to give presentations and focused H&Ps. Procedural-wise, I realized I was quite sheltered in regards to practicing phlebotomy on dummies. The reality is, patients will often have veins that are difficult to access. Most of the time the veins are not superficial and they will roll. In addition, if the patient is elderly or dehydrated it adds another fun layer of challenge with collecting blood. My plan to get better at phlebotomy is to practice more with nurses; the nurses are pros and give great feedback.

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

I always struggle with getting history from altered patients. In my mind, I assumed it would be impossible to get information from patients that have dementia or delirium. However, during my time there I realized that was not true. Patients with dementia can still tell you if they are in pain or point toward the area that’s causing them discomfort. While working with the PA Dawn Coburn, I learned that even if some of the patients can’t speak, you can look at them and tell if they are in distress. That’s why before starting rounds, we would go see the patients just to get “eyes” on them. 

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

I want to get better at patient education and giving informed consent to the patient. Informed consent is based on giving the patient all the treatment options and telling them about the risk and benefits. One way, I can work on this is by learning about the different treatment options by reading up on them on UptoDate or asking other providers. It would also help to improve my assessment and plan, review other provider notes, and listen to conversations providers have with patients as they discuss informed consent. 

Comparison to Beginning Clinical Correlations I in the Summer

• What’s New?

Overall, it’s easier to go through the cases now that I am familiar with all of the physical exams that can be done. Initially, I only knew about physical exams that included the skin to the abdomen for Clinical Correlations I in the summer. I got better at demonstrating a focused physical exam and developing differential diagnoses. Also, in Clinical Correlations II there was more exposure to scenarios regarding trauma/high acuity patients. 

• What Skills I’ve Developed?

After taking Emergency Medicine, I feel like I’m more acquainted with trauma cases. Especially in regards to what’s the next best step, for example in patients that are suspected of having meningitis you give them IV antibiotics first before doing blood cultures or any workup. In that same scenario, I’m also familiar with the best order regarding imaging, which would be a CT scan and then Lumbar Puncture. 

• What Was Surprising or Challenging?

The main thing that I struggled with was cases where you can’t obtain a proper history from the patient. For instance, scenarios with pediatric patients or delirious patients. Those cases were a good reflection of how difficult it may be to obtain a good history from real-life patients.  

• Where I Need More Work During Clinical Year?

Looking forward, there will always be stuff I can improve on. I still struggle with thinking about the risks and benefits of clinical procedures, in the case of a foley catheter it may discourage a patient’s mobility and may even lead to clots. I haven’t had much experience with admission orders or discharge notes either. I could also hone my skills in developing comprehensive treatment plans.

• What resources did you find most helpful – which ones will you use going forward in the clinical year?

I mainly used different textbooks like Current Medical Diagnosis & Treatment, Quick Medical Diagnosis & Treatment, and Harrison’s Internal Medicine from Access Medicine. If I needed information on how to work up a disease I would refer to UptoDate. 

• What have you learned about yourself through this class?

I learned about the areas I need to work on, which I already mentioned above. I liked working as a group and coming together to discuss the different diagnoses. While one tip given to us was to work our way from “head to toes” I definitely had moments where I would skip over “an arm or leg” but then thankfully a classmate would go back to it. 

• Have you changed your opinions/beliefs about any aspects of practice as a result of this course?

Initially, I didn’t understand what social workers did nor what a critical role they play especially with patient care. They can assist with coordinating transport for patients, acquire walkers/wheelchairs for patients, and help with post-acute care facility placement such as nursing facilities. Social workers, discharge instructions, and follow-up care are all essential to improving patient care.  

• What would you advise the students in the class behind you about this course?

Participation is the main root of this class. Don’t be afraid of saying the wrong diagnosis and it’s alright to go down the rabbit hole in regard to the scenarios.

HPPA 514 Biomedical Ethics Ethical Argument: Autonomy v Nonmaleficence

Heba Fakir

6/24/22

I chose the journal article What Should Physicians and Chaplains Do When a Patient Believes God Wants Him to Suffer. The scenario presents a patient that requires surgery but refuses post-operative analgesics because “God wants me to be in pain.” The provider explains to the patient that being on analgesics will help him decrease his risk of getting post-operative pneumonia, as the post-operative pain can prevent patient from breathing properly from the pain. [1]

This is case of autonomy versus nonmaleficence principles. Autonomy is an ethical principle in medicine. It is based on the patient’s right to make their own choice in regards to their medical care; in autonomy the clinician advises the patient based on best practices and experience and the patient has the power of self-determination. The patient has the right to freely accept or reject the clinician’s recommendations. Patients have the ultimate responsibility in decision making, and clinicians would respect the patients preferences. Even so, it is important to note that in autonomy, clinicians are not required to adhere to inappropriate demands by the patient. Nonmaleficence is another ethical principle in medicine that refers to not harming patients. In medicine, this primarily means to prevent further injury or reduce risks of complications. [2]

In the scenario described, the patient choosing to forgo post-operative analgesics because of his religious beliefs is based on the ethical principle of autonomy. Whereas, the clinician’s concern on the risk of pneumonia if the patient refuses post-operative analgesics is based on the ethical principle of nonmaleficence. 

The purpose of medicine is to relieve suffering. However, we can still try to accommodate the patient’s beliefs and maintain the clinician’s professional boundaries. When deciding between 2 ethical principles, like autonomy v nonmaleficence, it is not necessary that 1 principle is prioritized in every situation. In this case, if withholding the analgesics decreases the success of the operation, undermines post-operative recovery, or endangers the patient’s health then I believe the physician should refuse the patient’s request. However, if withholding the analgesic does not upset the patient’s health then the physician should respect the patient’s autonomy even if they disagree with it. Also, if the provider’s main concern is post operative pneumonia then there are some actions that can be taken to prevent it like using prophylactic antibiotics or giving the pneumococcal vaccine prior to surgery. [3] [4]

There’s also the helpful role of the chaplain, that help in a situation like this. Chaplains are certified religious leaders that provide spiritual care in non-religious organizations like healthcare facilities, or, even in the military. Chaplains can understand and even open up the patient’s religious reasoning to different alternatives. They can discuss alternative understandings within the patient’s religious beliefs. Chaplains should not be inclined to the physician’s judgment, instead they should attend to the patient’s spiritual good. In addition, providers have another route which would be involving the patient’s family, friends, or community into the clinical discussion.

Overall, in ethical situations like this there is not one ethical principle that prevails over the other. The provider must be courteous and try to accommodate that patient’s choice to respect their autonomy. The provider must exhibit patience to understand and explore the patient’s reasoning regarding their refusal for treatment. At the same time, the provider cannot take on requests that contradicts the provider’s professionalism.

References:

[1] AMA Journal of Ethics, 2018. What Should Physicians and Chaplains Do When a Patient Believes God Wants Him to Suffer?. 20(7), pp.613-620.

[2] Jonsen, Winslade, W. J., & Siegler, M. (2015). Clinical ethics : a practical approach to ethical decisions in clinical medicine / Albert R. Jonsen, Mark Siegler, William J. Winslade. (8th ed.). McGraw Hill.

[3] Garly, M. L., Balé, C., Martins, C. L., Whittle, H. C., Nielsen, J., Lisse, I. M., & Aaby, P. (2006). Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ (Clinical research ed.), 333(7581), 1245. https://doi.org/10.1136/bmj.38989.684178.AE

[4] Uptodate.com. 2022. UpToDate. [online] Available at: <https://www.uptodate.com/contents/pneumococcal-vaccination-in-adults> [Accessed 19 June 2022].

Medical Ethics Group Project

The Impact of Workplace Bullying in Healthcare

Lily Jacobs, Heba Fakir, Amanda Rogers

Nia Grant, Shaindel Pinsky

Course: Biomedical Ethics

Instructor: Professor McGarry

July 15th, 2022

The AMA defines workplace bullying as “repeated emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target” (Carlasare et al., 2021). The two main categories of bullying include overt and covert behaviors. Overt bullying includes “extreme micromanaging, verbal criticism, name-calling, insults, and direct threats” (Edmonson et al., 2019). This type of bullying is easily recognizable, yet still continues due to organizational dysfunction and poor management or lack thereof. Covert bullying is considered “passive aggressive” and includes actions such as rumors and gossip, anonymous cyberbullying and other microaggressions. 

When team members are subjected to this type of disrespectful behavior, especially if it is continual, it can result in absenteeism, depression/anxiety, burnout, isolation, suicidal thoughts, and may even cause disease conditions such as fibromyalgia or cardiovascular disease. It can completely destroy a safe workplace and create an unhealthy team dynamic. Members will be less likely to express their patient care concerns or ask for help due to fear of not being taken seriously or being bullied again. As a result, poor patient satisfaction rates, an increase in medical errors, and an increase in preventable adverse outcomes may occur. Therefore, it is crucial for team members to report incidents and for organizations to provide sufficient resources to address such issues. Everyone is responsible and everyone should be equally held accountable. Even if people are not actively participating in the behavior, remaining silent breaks the trust, respect, equity, and support that is expected within a team. Commitment to providing a better work culture that is safe and respectable, will ultimately help create a high-functioning medical team, thus leading to better quality patient care. 

Medicine has a culture of hierarchy, which makes the workplaces more susceptible to bullying. It often occurs in high-stress settings with heavy workloads and low job autonomy. Among the groups most bullied are nurses and medical residents (Edmonson et al., 2019). Nurse bullying has now become commonplace. Studies have shown that it can start as early as in nursing school, only to continue into clinical rotations, and then finally into one’s job. The article “Our Own Worst Enemies- The Nurse Bullying Epidemic” by Edmonson, et al. addresses these issues and states that 60% of nurses leave their first job in the first 6 months due to the bullying behavior of their coworkers, which are in fact mostly other nurses. The bullies range across the nursing workforce spectrum and are not limited to gender, age, or experience level. Older nurses bully the younger nurses on their lack of expertise, the younger nurses bully the older nurses on physical limitations, male nurses bully female nurses and vice versa, and nurses with a higher level of education bully those who have a lower degree or certification. In fact, even nurses in managerial roles may emulate the same leadership style of fear and intimidation as their bosses did with them, thus precipitating a never ending toxic cycle.

Similar to nurse bullying, the prevalence of bullying among medical students and residents is a cycle of abuse that starts from the very first day and continues through and after residency. This cycle is an ongoing loop and often starts again with the residents who were once bullied, reciprocating such behavior when they become attendings. In recent years, the media and various literature has revealed an alarmingly high rate of bullying among medical students, most commonly by the hands of physicians and surgeons. A presumption exists that one must be tough to have a job in medicine, however this presumption fuels an environment of mistreatment and bullying because it is often used to defend and justify the mistreatment of medical students. In 1990, a landmark study was published in the Journal of the American Medical Association (JAMA) which addressed the incidence, severity, and significance of abuse in medical students. The study found that 56.4% of the 519 participants reported being mistreated during some point in medical school and 49.6% of the participants that reported abuse claimed that the most serious abuse will always negatively affect them in some way. 

More recently, a 2006 study was published looking at the ongoing mistreatment among medical students. Out of the 2316 participants from 16 different U.S. medical schools, 85% of students reported being harassed or belittled, 13% of which described an incident that they would categorize as “severe.” Along with many other studies, they all share a common theme, a strikingly high rate (at least 50%) of bullying and harassment among medical students. One study in Sydney evaluated ten current or recently graduated medical students using semi-structured, in-depth interviews regarding their experiences of bullying in clinical settings. Six themes were identified amongst the interview transcripts that provide some insight into how medical students perceive the medical field, the most common one being hierarchy. All ten of the participants identified that a “hierarchy” exists in the workplace and that abuse of this hierarchy is what leads to bullying and a toxic workplace. This study revealed another issue, the lack of reporting mistreatment and bullying. Participants attributed their feelings of being unable to report incidents of bullying to the hierarchy and fear of any rebound effect, stating that senior physicians were unapproachable because they were “self-important, sexist, uninterested, too busy, or participants feared verbal abuse” (Colenbrander et al., 2020). Five participants stated that if they did experience bullying they would not report it because they do not believe any action would be taken. Additional barriers to reporting bullying included a lack of knowledge about available resources, lack of assurance of confidentiality, and a fear of impact on career. The mistreatment and bullying of medical students has long-lasting physical and mental consequences for future physicians that have the ability to affect future patient care. And still, workplace bullying within the medical student population is a very prevalent, yet underrepresented issue in the current day. 

With the alarming number of reports surrounding workplace incivility and bullying amongst healthcare workers, there have been lots of efforts to limit its presence within the medical community. According to an article published in Acta Biomedica regarding nurse bullying, it states that many facilities have institutionalized preventative and proactive practices such as increasing the awareness of workplace bullying amongst hospital staff, providing nurses with conflict management skills, implementing a zero tolerance strategy to abuse, and expressing healthcare workers conduct codes (Bambi et al., 2017). A systematic literature review of seven publications was conducted to analyze the efficacy of these preventive measures by measuring three different outcomes: nurses’ turnover, rate of bullying, and direct confrontation between target and perpetrator. After careful analysis, researchers concluded that just a single application of these measures to completely combat bullying amongst nurses and other hospital staff was ineffective. 

Recently, there has been an increased need to add innovative and “creative” solutions to address the problem–one of those surrounding the concept of emotional intelligence. The article written by Bambi et.al, (2017) explains that a deeper understanding of the four components of emotional intelligence is a starting point to mitigating stressors and managing emerging conflicts. Some authors propose focusing on a “Peace and Power” strategy, which is founded upon the ideas of “reflection and action” and “building a sense of community” in an attempt to make the perpetrators more aware of their words and actions. Furthermore, solutions of workplace bullying should involve organizational leadership, with measures put in place to detect its presence early on. The article states that the starting point to detection includes analyzing “absenteeism rates and group cohesion rates” as well as “performing general surveys on work environment climate.” A journal article published on Nurse Outlook proposes an implementation incentive strategy for institutions, including a method of factoring the level of nurse bullying into the calculation of value-based incentive payment (Castronovo et al., 2015). 

Education is another way in which workplace bullying can be addressed. One of the issues with workplace bullying is the incognizance of what qualifies as healthcare bullying, how to report it, and how to address it. In the article by Leisy et al. (2016), it was noted that after reviewing studies on resident knowledge, only half of the residents were aware of the reporting process regarding healthcare bullying. Healthcare workers and students, often, see harassment and intimidation as a “functional educational tool” ​​(Leisy et al., 2016). Pimping is a prime example of this–initially and for a long time it was seen as a reasonable method in teaching. However, pimping is now under scrutiny as a form of mistreatment through humiliation. It’s important that residents, medical students, nursing students, and PA students be aware of resources available for addressing lateral violence. Suggestions and guidelines can be found in “Procedures for Addressing Complaints and Concerns against Residency/ Fellowship Programs and Sponsoring Institutions,” “Institutional Requirements for Resident/ Fellow Learning and Working Environment, ” and “Distinguishing Between Concerns and Formal Complaints” from the Accreditation Council for Graduate Medical Education (Leisy et al., 2016).

Leadership is also another key and crucial factor in defining a just and safe culture in an organization. Supervisors can encourage collegiality and supportive relationships which can lessen stress and increase worker retention; hence the importance of placing supportive, impartial, and available physicians in supervising roles. Whereas, having an unsupportive or inadequate physician supervision can allow mistreatment to continue to occur in our medical training system without opposition. Creating a supportive system that can prevent workplace bullying through mentoring physicians-in-training may also be effective. A mentorship relationship can provide support for residents, nursing students, and PA students and also reduce harassment and belittlement rates during medical training ​​(Leisy et al., 2016). 

Institutions can benefit from having a bullying and mediation committee. Many hospital policies address illegal harassment and discrimination, but not gray areas like bullying and intimidation. The bullying and mediation committee approaches every mistreatment case as a manageable problem, along with having a zero tolerance system for combating bullying by: educating all team members on professional behavior, code of conduct, the process of disciplinary action, the detrimental effects of bullying, and creating systems for monitoring any unprofessional behavior. The committee must review and mediate any of these situations, create a definitive protocol for reporting workplace bullying/mistreatment along with an anonymous reporting system (that will alleviate the fear of retaliation), and determine penalties following the mistreatment. 

Lastly, there should be a focus on creating a culture that emphasizes patient safety, models professionalism, enhances collaborative behavior, encourages transparency, values the individual leader, eliminates hierarchical authority, and has zero tolerance for abusive/demeaning behavior. It was suggested that emphasizing interdisciplinary team based care during training can combat workplace bullying, since a team based mentality can lessen the hierarchical nature in medicine. As advised by a medical resident on how to prevent bullying, healthcare workers should “keep in mind that patient safety is our number one priority” and to keep our ego at the door while respecting each team member for their skills ​​(Leisy et al., 2016).

In conclusion, bullying in the workplace is detrimental to the work environment, and as a result of that, patient care. Nurses and medical students are just two examples of populations within the medical field who may experience bullying, however all healthcare providers may be subject to this at some point in their careers. As future physician assistants and healthcare workers, it is important to bring these issues to light, help mitigate these situations and advocate on the behalf of ourselves and our colleagues.  Though some studies may have shown lack of effectiveness in single implementations to control workplace bullying, multi-policy implementations with focus on emotional intelligence and team building can be beneficial. Additionally, promoting an attitude of inclusiveness, teamwork and collaboration amongst healthcare teams can ultimately establish cohesiveness and minimize conflict. Other ways to combat the situation include, education on how to identify and report lateral violence in the workplace, developing a bullying and mediation committee, and electing supportive healthcare mentors for students. Although there may still be some time before seeing the effects of these potential implementations, we can all agree on the seriousness and magnitude of this issue as one that warrants continued conversation and prompt intervention.

Works Cited

Bambi S, Guazzini A, De Felippis C, Lucchini A, Rasero L. Preventing workplace incivility, lateral violence and bullying between nurses: A narrative literature review. Acta Biomed. 2017 Nov 30;88(5S):39-47. doi: 10.23750/abm.v88i5-S.6838. PMID: 29189704; PMCID: PMC6357576.

Carlasare, L. E., & Hickson, G. B. (2021, December). Whose Responsibility Is It to Address Bullying in Health Care? AMA Journal of Ethics Volume 23, Number 12: E931-936. Retrieved from  https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2021-11/cscm4-peer-2112_0.pdf 

Castronovo MA, Pullizzi A, Evans S. Nurse Bullying: A Review And A Proposed Solution. Nurs Outlook. 2016 May-Jun;64(3):208-14. doi: 10.1016/j.outlook.2015.11.008. Epub 2015 Nov 22. PMID: 26732552.

Colenbrander, L., Causer, L. & Haire, B. ‘If you can’t make it, you’re not tough enough to do medicine’: a qualitative study of Sydney-based medical students’ experiences of bullying and harassment in clinical settings. BMC Med Educ 20, 86 (2020). https://doi.org/10.1186/s12909-020-02001-y

Edmonson, Cole DNP, RN, FACHE, NEA-BC, FAAN; Zelonka, Caroline BS Our Own Worst Enemies, Nursing Administration Quarterly: July/September 2019 – Volume 43 – Issue 3 – p 274-279 doi: 10.1097/NAQ.0000000000000353

Leisy, H. B., & Ahmad, M. (2016). Altering workplace attitudes for resident education (A.W.A.R.E.): discovering solutions for medical resident bullying through literature review. BMC medical education, 16, 127. https://doi.org/10.1186/s12909-016-0639-8

Preventing Unintentional OTC Medication Misuse

Description of the Public Health Program

            Medication misuse occurs when a drug is taken in a way or at a dose other than what is directed on the packaging. The U.S. Food and Drug Administration (FDA) and individual states closely regulate prescription medications that are dispensed to the public such as with the iSTOP program in NYS and DEA licensure, but there is more leniency when it comes to over-the-counter drugs (OTC) and less regulation on what is being advertised to the public. The majority of OTC medications are generally safe to use, but some products such as Dextromethorphan (DMX), a cough suppressant, and Loperamide, an anti-diarrheal, contain active ingredients that can be accidentally misused if directions are not followed correctly (Department of Justice, 2020).

In 2005, the FDA issued online warnings about DMX use, following increased reports of teen deaths. Although the warning included consequences of abuse such as brain damage, seizures, loss of consciousness, irregular heartbeat, and death – unintentional misuse still remains an issue. According to the 2020 National Survey on Drug Use and Health, 0.9% (2.4 million people) of adolescents aged 12 to 17, 1.2% of young adults ages 18 to 25, and 0.8% of adults ages 26 and older misused OTC cough and cold medicines within the year. While the percentages seem insignificant at first glance, there is a significant increase in drug misuse numbers compared to the year prior which only consisted of 223,000 adolescents, 389,000 young adults, and 1.8 million adults aged 26 or older (SAMHSA, 2020). 

Our proposed public health program targets the gap in drug education, with a focus on individuals purchasing and/or taking drugs with potentially high risks, but are often overlooked due to their OTC status. These individuals consist of adolescents and adults, including parents and caregivers of young children. While there are many stakeholders, we believe that the pharmaceutical industry (consisting of pharmacists, pharmacies, pharmaceuticals) as well as drug advertisement companies will play a major role in successfully carrying out such a program and ultimately further commit to protecting the safety of the public. 

Development & Dissemination of Interventions

            There are many possible interventions that can help prevent accidental OTC medication misuse. The most beneficial interventions focus on patient and parent education, reinforcement by pharmacies, and proper advertisement of the benefits and adverse side effects of medications by pharmaceuticals.

1. Patient & Parent Education

Patient education is arguably one of the most beneficial ways to empower patients in taking control of their health and achieving better health outcomes. There are many different OTC medications that treat the same symptoms, often making it confusing and overwhelming for the patient. Patients do not have immediate access to their providers, nor do they think of utilizing the pharmacist for help. Therefore, we need to make sure there are available resources at the hands of the patient located on the shelves of medications. Resources should outline the differences between each drug treating that particular symptom and clearly state drug interactions or any adverse effects. This is especially important for once-prescribed drugs that have now become OTC, as there still may be active ingredients that could harm the patient.

• If young adults or children are unintentionally abusing OTC drugs, they may be obtaining them from their medicine cabinets. Hence, we encourage parents to keep medication bottles capped and out of reach from young children, especially if they are not needed on a daily basis.
• We also encourage parents to appropriately dose OTC medications when their children are sick. It is understandable that parents may not know the exact dosing of childhood medications, so it is important to educate parents on readily available resources such as the FDA’s Division of Drug Information, where pharmacists are readily available to respond to questions about drugs for the U.S. public.
• Patients may unintentionally combine multiple medications at the same time, unaware of adverse health consequences. For example, if a patient has a cough they may take NyQuil (Acetaminophen, Doxylamine Succinate, DXM) along with an additional Acetaminophen pill or an additional antihistamine pill. The patient believes they are simply treating their symptoms, however, many medications can have additive or synergistic effects leading to toxicity. In an effort to educate our patients, placing large-print, colored labels on medication bottles and providing workshops for community members about the different ways OTC medications can be misused will prevent patients from overdosing. Lastly, due to the diverse communities we serve, having instructions in multiple languages will be beneficial to those whose first language is not English.

2. Reinforcement by Pharmacy/Drug Stores

According to FDA public health expert Mary E. Kremzner, pharmacists “help people get the maximum benefit from the drugs they need to take, with the least amount of risk” (FDA, 2022). Agreeing with this sentiment, incorporating pharmacy staff to our public health program is essential, as they are the first point of contact for individuals during the purchase of OTC medications. Proper training and reinforcement by pharmacies and pharmacists could serve as an avenue to decrease OTC misuse.

• Pharmacists should provide brief education on the instructions and side effects of drugs patients are purchasing. Within a hospital setting, pharmacy technicians have demonstrated positive impacts by obtaining medication history and conducting medication reconciliation for patients (Sansgiry et al, 2016). By expanding the role of pharmacists and pharmacy technicians to be more proactive in managing OTC medications, providing oral and written medication information, and further developing trust with all patients, we can ensure patients will not misuse OTC medications.
• Pharmacies can also reinforce patients from misusing OTC drugs by having a shared patient record. For instance, implementing a system that allows for the patient to be “carded” for every OTC drug purchase they make allows for increased awareness by the patient and detection of whether they have made similar purchases in the past. This could also potentially reduce “pharmacy shopping” because pharmacists will be able to view patients who have purchased several of the same drugs. Once implemented, pharmacists or pharmacies who fail to comply with these standards should be fined.
• Lastly, another step pharmacies can take to raise awareness on OTC medication abuse, with the help of pharmaceutical and advertisement companies, is to place “quick facts” pamphlets next to the drugs or posters at the pharmacy counters and in waiting areas.

3. Pharmaceuticals & Proper Advertising

Consumer advertisement of drugs allows for greater awareness of available treatment and better discussions between patients and healthcare professionals (FDA, 2015). In order to ensure consumers are acquainted with the various safety concerns of OTC drugs, drugs must be properly advertised and geared towards the literacy of the general public. People who have low health literacy and limited English proficiency are twice as likely to report poor health status (Agency for Healthcare Research and Quality, 2020). Thus, the way OTC drugs are currently advertised should be revised.

• Currently, the advertisements for OTC drugs are much less regulated than prescription drugs. This difference is likely due to the federal agency in charge of respective advertisements. The FDA regulates advertisements for prescription drugs, whereas OTC drugs are regulated by the US Federal Trade Commission (FTC). As such, the FTC presents with fewer regulations, where they hold drug advertisements to the same standard as other consumer products. We suggest that OTC drug advertisements should equally focus on the safety concerns and drug contraindications, along with the benefits. This is crucial because OTC drug advertisements are the driving factor in how patients make their medication selection.
• Since the FTC regulates non-prescription drug advertisements, we also recommend more regulation on what information is included; paying close attention to medication indications, adverse effects, and contraindications. In preparing advertisements, we also recommend the use of larger fonts and language that is easy to understand on all drug labels to make it easier for people in the general population who may have poor health literacy. Further steps may also include labeling of dosing information and instructions in different languages.

Evaluation & Maintenance

We expect pharmacies to provide us with bi-yearly reports as well as updates on educating their community members on adverse side effects including potentially life-threatening effects that can occur when consuming high doses of OTC drugs. If pharmacies fail to comply with these standards, then they will be fined and will receive additional training. We hope to translate these bi-yearly reports into quantitative data, in which we can determine the effectiveness and success of the interventions outlined above. We also hope to use these reports to determine which communities may require additional support. If these interventions are a success, we hope to continue their practice and assess their effectiveness via yearly reports over the next five years.

References

Administration, E. D. & Department of Justice, U S. (2020). Drugs of Abuse, A DEA Resource

Guide: 2017 Edition.

Agency for Healthcare Research and Quality (AHRQ). (2020, November). The SHARE

approach—health literacy and shared decision making: a reference guide for health care providers. AHRQ. https://www.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-4.html

Center for Drug Evaluation and Research. (2015, June 19). Prescription Drug Advertising |

Questions and Answers. U.S. Food and Drug Administration.

https://www.fda.gov/drugs/prescription-drug-advertising/prescription-drug-advertising-questions-and-answers

Center for Drug Evaluation and Research. (2015b, October 23). The Impact of

Direct-to-Consumer Advertising. U.S. Food and Drug Administration. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/impact-direct-consumer-advertising#:%7E:text=DTC%20ads%20help%20patients%20have,condition%20that%20the%20drug%20treated

Royal Pharmaceutical Society of Great Britain. (2021). The pharmacy team’s role in reducing

harm and preventing drug deaths. https://www.rpharms.com/recognition/all-our-campaigns/policy-a-z/drug-deaths-and-the-role-of-the-pharmacy-team

Sansgiry, S., Bhansali, A., Bapat, S., & Xu, Q. (2016). Abuse of over-the-counter medicines: a

pharmacist’s perspective. Integrated Pharmacy Research and Practice, Volume 6, 1–6. https://doi.org/10.2147/iprp.s103494

Shi, C. (2011, October 1). Abuse of Over-the-Counter Medications Among Teenagers and Young

Adults. American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2011/1001/p745.html

Substance Abuse and Mental Health Services Administration. (2021, October). Key Substance

Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. Department of Health and Human Services.

To: Brian Kavanagh of the 26^th Senate District

From: Heba Fakir

Date: 7/17/21

Re: Federal and Local Mandate for Affordable and Accessible Dental Coverage by Insurance Providers

Statement of Issue

74 million American families do not have dental insurance, and many are unable to afford the full cost of basic dental care. Instead, many would prefer to forgo dental care. High dental costs are a considerable challenge to Americans, especially for those from low socioeconomic backgrounds. What federal and local policies can be implemented to make dental coverage more affordable and accessible?

Background

Oral healthcare is often considered a separate entity from other chronic medical conditions, however, oral healthcare is intertwined with chronic medical conditions like Diabetes or Heart Disease. Despite that, there is a lack of access to dental care. Studies report 80% of residents in major metropolitan areas, have inadequate access to affordable dental care. New York is ranked 30 out of the 50 states in terms of dental wellness. It is recommended that dental cleaning be done twice yearly, however, this can cost between $75 and $200 per person. About 2/3 of people who have dental insurance get it through their employers as a separate add-on to health coverage. And for those without employer-provided plans, it can be impossible to pay for dental care out of pocket. In addition, Medicaid coverage of adult dental services varies state by state and doesn’t include all forms of dental care. Also, the consequence of poor dental health does not end at affecting health, it can also affect employment and school attendance.

Landscape: Key Stakeholders

American Dental Association, Health Insurance Industry, Federal Government, State Government, Democratic and Republic Politicians, Labor Unions, Workers Associations, American Medical Association, American Nurse Association, American Academy of PAs

Policy Options

• Have a federal mandate that backs inclusion of universal dental coverage with health insurance, this would include coverage for preventive and restorative dental services regardless of age or medical illness. Preventive dental care includes regular oral exams, teeth cleaning and routine x-rays. Restorative dental care includes dental fillings, dental crowns, dental bridges, dental implants, and root canals.
  • Advantages: This will make it easier for clinicians to coordinate care with dentists since dental programs will be in the same provider network. Dental coverage and access will increase for patients leading to a healthier population. This will also help reduce the financial costs for medical illnesses associated with dental care.
  • Disadvantages: Insurance companies can regulate dental procedures and decide on dental reimbursement rates. If the fees are insufficient for dentists, this may lead to dentists being unwilling to participate. In addition, there will be longer wait times for dental care because of declining dentist to population ratio. This will not cover cosmetic dentistry. Insurance rates may increase.
• Have state and local mandates that focuses on preventative care by creating interdisciplinary partnership between dentists and healthcare providers. This can occur by providing dental services at medical offices or hospitals. Also, increasing access to dental therapists and hygienist will help promote preventative dental care.
  • Advantages: This is less costly than the federal mandate and this will lead to better quality of care by making it easier for clinicians to coordinate care with dentist. It also helps address dental health disparities by expanding access to dental care. The more dental therapists and hygienists available will allow for decreased waiting periods.
  • Disadvantages: There will be an increase demand for dental providers, amongst the already a declining dentist to population ratio.There may be an over-referral of patients. Healthcare providers and dental providers may be unwilling to participate. This will not address dental care affordability challenges.
• Have optional work mandates that allow employees a paid dental leave 1-3 days per year.
  • Advantages: This will significantly reduce patients’ out of pocket preventative dental care expenses.
  • Disadvantages: This a limited policy that would only cover the working population. It would not be able to cover long term dental procedures like restorative dental work Employers may regulate what preventative dental procedures are allowed.

Policy Recommendations:

With dental care becoming more unaffordable and inaccessible, many Americans are choosing to forego seeing a dentist. Hence, the importance of having dental care reform. I believe enacting the federal mandate, which includes dental coverage into health insurance, will quickly make dental care more accessible. This option will allow for coordinate care between healthcare providers and dentists, leading to better quality of care and reducing medical problems related to poor oral care. It’ll also help expand access to dental care.

However, this option can allow insurance companies to increase insurance rate, and to regulate dental procedures including reimbursement rates. There’s also the drawback of longer wait times for dental care because of declining dentist to population ratio.

I suggest to combat this, that the federal government mandates a standardization of dental procedures and reimbursement rates. As for the increasing insurance rate, the federal and local government must find a way re-allocate funds, like from the military to the healthcare service. And to counter the low supply of dentists, I suggest that there be incentives like grants for students in dental schools.

Sources:

Bertolami C. N. (2011). Access to dental care: is there a problem?. American journal of public health, 101(10), 1817. https://doi.org/10.2105/AJPH.2011.300271

Biordi, D. L., Heitzer, M., Mundy, E., DiMarco, M., Thacker, S., Taylor, E., Huff, M., Marino, D., & Fitzgerald, K. (2015). Improving access and provision of preventive oral health care for very young, poor, and low-income children through a new interdisciplinary partnership. American journal of public health, 105 Suppl 2(Suppl 2), e23–e29. https://doi.org/10.2105/AJPH.2014.302486

Kanzigg, L. A., & Hunt, L. (2016). Oral Health and Hospital-Acquired Pneumonia in Elderly Patients: A Review of the Literature. Journal of dental hygiene : JDH, 90 Suppl 1, 15–21.

Naughton D. K. (2014). Expanding oral care opportunities: direct access care provided by dental hygienists in the United States. The journal of evidence-based dental practice, 14 Suppl, 171–82.e1. https://doi.org/10.1016/j.jebdp.2014.04.003

The Many Costs (Financial and Well-Being) of Poor Oral Health | College of Dentistry | University of Illinois Chicago. (2019, August 6). The Many Costs (Financial and Well-Being) of Poor Oral Health | College of Dentistry | University of Illinois Chicago; dentistry.uic.edu. https://dentistry.uic.edu/news-stories/the-many-costs-financial-and-well-being-of-poor-oral-health/

Vujicic, M., & Fosse, C. (2022). Time for Dental Care to Be Considered Essential in US Health Care Policy. Journal of Ethics | American Medical Association. Retrieved 17 July 2022, from https://journalofethics.ama-assn.org/article/time-dental-care-be-considered-essential-us-health-care-policy/2022-01.