Tuesday, May 4, 2010

From Jess: Community Health Centers

While we spent most of our time with the Geriatrics residents, Dr. Medrano thought that it would be a worthwhile experience for us to be exposed to the Family Medicine Residency Program so we spent a morning learning about their Community Health Centers. We visited a Health Center in a community in Santiago called Korea.

I thought that by far the most interesting part was the second year experience: essentially each second year Family Medicine resident is assigned a small community in Santiago or the surrounding area and is responsible for the health of that community. The resident sees their patients both in the hospital and in their homes; what better way to really understand your patients? Each resident makes a map of his or her community and denotes with push pins the medical problems that each member of the community has – for instance every one with HTN gets a red pin, everyone with DM gets a green pin, etc. The maps make for a unique representation of the health of each resident’s community. Based on the diseases prevalent in their community, the residents (with assistance from their community health workers) develop educational sessions to improve health literacy and the general health of their community. I loved the maps – here are two of my favorites with close ups of the legends.

I wonder how much better I could care for my outpatients if I visited each of them once in their own homes? I think in addition to demonstrating to the patient that you truly care about them as an individual, you get a sense of whether they have a system for taking their medications, what type of food they have in their fridge, if they have shaggy carpet and exposed wires contributing to their fall risk, the list goes on... I know that we have VNS that can go out into the community and ascertain some of this information for us, but I feel like seeing firsthand how your patients live is pretty powerful. Time constraints of residency make it impossible to see all of our patients in their own homes but when I got back from the DR I was inspired to contact one of our attending who makes home visits to the homebound elderly to set up a few home visits so I can learn more about some of my geriatric patients that I am most concerned about.

Monday, May 3, 2010

From Jess: Consulta (aka Outpatient Clinic)

I spent the first morning in consulta, or outpatient clinic with one of the fourth year geriatric residents. After inpatient morning rounds we slowly meandered downstairs to the first floor where the outpatient clinics are located. The resident that I was paired with, FiFi, picked up a stack of blue and pink cards with patient’s names on them and then we proceed to walk back to the clinic room and call the first patient.

The clinic room was simple. There were 4 chairs, 2 on either side of desk. There were no computers but there were several stacks of unorganized forms on the floor. (When I asked what the forms where for, Fifi told me that she didn’t actually no, she had never needed to use them.) The room had an exam table, a sink and a scale. The air conditioner was on full blast and there was seemingly no way to control the temperature.

We called the first patient. She was a 73 yo woman with pink card and history of stroke, DM and HTN who came to clinic with her husband and her family. Her blood pressure was 130/90. No one in the room (patient, family, or doctor) knew which medications the patient was taking because most patients don’t have a clinic chart. Fifi named some medications for the family and they agreed that HCTZ sounded the most familiar so she grabbed the equivalent of a prescription pad and wrote a script for HCTZ and told her to take one pill once a day. Then Fifi filled out what was essentially an order sheet and told the family the patient should get her fasting glucose checked before the next visit.

After the first few patients I learned most of the basics: the pink card meant the patient had no insurance, the blue card meant that the patient had government insurance. The interview consisted of figuring out what conditions the patient had, what pills they were taking and sorting through the stack of papers detailing lab results for any new or pertinent data. Not one of the patients that we saw that morning had a complaint about pain, no one was dizzy, and if any one had depression or mood symptoms, we didn’t talk about them. The exam was BP, HR, listening to the heart and lungs, and checking for edema. The visit concluded with the resident filling out the prescription form (note that the form only has space for three medications, none of the patient’s were taking more than three pills so we never had to give any patients more than one prescription) and an order form for diagnostic tests (which typically included things like a fasting glucose, BUN/cr, urine dip, and total cholesterol).

Besides the lack of somatic pain complaints, it could have been AIM clinic at least in terms of the diagnoses. The second patient was a 76 yo man with DM and after sorting through the records that he brought with him we realized his fasting glucose was 178 so we started a sulfonylurea. The third and fourth patients just got refills of there antihypertensives (the families of both patients brought in a copy of the prescription from the last visit so we were a little bit more confident about the medications that the patients were actually taking). The fifth patient was an 80 yo man with HTN who had new lower extremity edema and his family volunteered that he had been sleeping sitting upright in a chair for the past few weeks. His BP was 130/90, lungs were clear, and he had 2+ pitting edema to the knees. Fifi stopped his HCTZ and started him on lasix for what was presumed heart failure. No further work up was needed she told me, it would be too expensive and wouldn’t really change what would be offered to the patient. The sixth patient was an older woman who present 10 days earlier with dysuria and had a positive urine dip so was started on ciprofloxacin twice daily. She returned to clinic now with continued symptoms and the results of her urine culture (which was ecoli sensitive to cipro). Some detective work eventually revealed she was only taking the antibiotics daily, she thought the cipro was too strong to take twice a day. The last two patients were 95 and 105 year old, and both suffered from “la memoria”. Fifi asked the caregivers if the patients were eating well enough, sleeping well enough or agitated at night. Both patients were quite pleasantly demented and doing quite well at home with a tremendous amount of attention and dedication from their families. The last family gave Fifi a basket with cheese and crackers to thank her for the care she had provided to their loved one.

After we had seen all 8 of the geriatrics patients who were waiting to be seen, Fifi asked me what I was scribbling in my notebook. I explained I was writing a little bit about each patient and keeping a running list about how things were similar and different between her clinic and AIM clinic; most of them I’ve already touched on above.



*lack of temperature control in the rooms

*no PIC, no attending involvement

*patients and family members often have no idea what medications they are taking

*no patient records

*same diseases (DM, HTN, CVA, MI, dementia)

*many fewer labs ordered, many fewer diagnostic tests

*patients take many fewer medications

*no ancillary staff other than 1 woman who seemed to be registering patients for all clinics

*no continuity, patients see different resident each visit