Site Evaluator: Andrea Pizarro, PA-C

For my site evaluations, I chose to present two very different cases. First, an 82-year-old male was admitted for hematochezia. Second, an 87-year-old female presented with stroke-like symptoms. During our meetings, Andrea worked with me and one other student and had us explain our reasoning for our differential list and plan during admission. One of the things that Andrea did differently was to have us include a section in our H&P titled “Patient Education”. As she mentioned, she knew that we all have experience in school writing a comprehensive H&P. What she wanted to see from us though is that we were also building skills as future providers who could explain a medical diagnosis to a patient in a language that they understood. This is one of the biggest skills that I think we can take out of the clinical year. You learn very quickly that no patient will ever fit a textbook definition, and it is important that we are able to explain what the plan is and why for someone who has never taken a course in medicine. I appreciated her feedback and felt that my second presentation was superior to any that I had given before. This is something I will look to continue to grow to as I move forward throughout the remaining rotations.

My first rotation site was at New York-Presbyterian Queens. Overall, I believe I learned and experienced a lot that will serve as a foundation for the remainder of our clinical year. Internal medicine covers a very broad range of patients and illnesses that requires your ability to expand your thinking as compared to some of the smaller specialties within the medical field. Being in such a large network, I was able to work with a variety of PA’s, all of whom were ready to help a student begin to find their approach when working with patients. For four weeks, I rotated on various floors of general medicine, gaining experience of working up new admissions from the emergency department along with the day-to-day care and eventual discharge. A fifth and final week was spent specifically on the stroke unit, spending time with the neurology team and being the consultant when new patients presented to the hospital with stroke-like conditions.

While on the medicine service, I got a feel for what I believe to be the day-to-day operations of a general medicine floor and the validation that medicine must be a holistic team approach in order to be effective. Consulting any number of specialty services, conference calls with case managers, social workers, and nursing staff to review patients, and working with hospitalist and private attending physicians ensured that no step of patient care went unlooked. During my first two weeks, I found myself apprehensive of stating my opinion and presenting new cases to the team I was on for fear of missing steps. However, taking the constructive criticism I received from both the teams I was assigned and during my site evaluation, I begin to grow confident in asking to be a bigger part of providing care.

One of the areas that I found the most helpful to my ability to keep up with some of the more senior providers was my week of working nights. Because there is generally less staff, management, and visitors on the overnight, the PAs were more available to spend time with any particular case and work through it from start to finish. One of the PAs that I worked directly with would find a new admission and allow me to go conduct an interview before they would and come back to present and discuss. After my presentation, we would work through my initial list of differential diagnoses and discuss what I would do to work up every item on my list. From there, I would need to be able to justify every lab and exam that I ordered as they related to helping the patient get discharged. This is something that was quite similar to our clinical correlations course during the didactic year, except this time it was a real patient with true illnesses on the line.

Finally, spending a week dedicated to a specialty like the stroke team allowed me to see how a workup changes when you are aware of exactly what the problem is. Being able to round with the neurology team, I saw the difference in how patients are presented compared to how they were in either the emergency room or on a conference call. Additionally, I began to understand the importance of a focused H&P, something up to that point, I had not had much experience with. Learning this skill and understanding when a particular set of pertinent positives and negatives are more important than others is something that I will be able to take to the remainder of my rotations.

Looking ahead to my next rotation in ambulatory care, I hope to improve on my ability to take initiative in performing procedures with my patients. Because the ambulatory care center is in a very populated area in Astoria, Queens, I know there will be no shortage of patients for me to learn from. I believe this will also pose new challenges as it will force me to become comfortable seeing such a large volume per shift instead of my assigned 10-15 on the medicine service. In the few that I was able to do during this rotation, I saw my own competence in the skills we learned during didactic year and saw it begin to blend with the knowledge taken from each of our classes.

The two-part clinical correlations course really helped my ability to compile a more extensive differential diagnosis list while expanding my ability to take a thorough patient history. At the beginning of the first seminar course, I found myself mimicking providers I have shadowed in the past to elicit information from our mock patients. As the course continued, in conjunction with our physical diagnosis course, I was able to discover my own particular style of patient interview. As we were exposed to more complex cases, I was able to sift my questions and really use the patient’s answers to guide the workup as opposed to a shotgun questioning approach that is very common in students without the same level of exposure. I believe continuing to mend this style throughout my rotations will prepare me for any field I may work in in the future.

One of the biggest lessons that I have taken from this class is that whether you are a student or provider, you must become comfortable when you are wrong. It is imperative that you use what you have learned constructively to avoid preventable shortcomings in the future. Being able to speak up and explain your thought process is essential in this class and I believe it will be as equally important while on rotations. It is much easier to catch and learn from mistakes while in school and can be the difference in saving someone’s life in the future.

Clinical Scenario: Your orthopedist supervising physician has asked you to help out with the research on a presentation she is to give next week on urinary catheter use in adult post-op total hip replacement patients. 

“In a related question, the unit’s nurse manager has been advocating that instead of placing indwelling urinary catheters, post-op orthopedic patients who cannot use a bedpan should be “straight cathed” (using an as needed straight catheter which is only placed to empty the bladder at that time and then removed).  What can you tell the chief of the service about this question?”

Clinical Question: Does the use of straight catheters as opposed to indwelling urinary catheters reduce the likelihood of infection in female patients over 40 years old?

PICO Elements:

P – postoperative patients

I – straight catheter

C – indwelling catheter

O – urinary tract infection

Search Strategy:

Terms Used

• Indwelling catheter in post-op total hip replacement female patients
  
• Foley catheter in post-op total hip replacement female patients

Databases Searched

• PubMed: Search criteria gave 103 results which were not specifically applied to our clinical question.

• Cochrane: Search criteria gave 7 results which were not relevant at all
  
• Trip Database: Search criteria gave 62 results which were narrowed down to 4 after filtering for randomized control studies

Articles Chosen for Inclusion

1. Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients [Harris et. al, 2018]
   Harris SK, Mitchell EL, Lasarev MR, Attia F, Hunter JG, Sheppard BC. Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients. Am J Surg. 2018 Apr;215(4):658-662. doi: 10.1016/j.amjsurg.2017.11.025. Epub 2017 Dec 14. PMID: 29275909.
   
   
2. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis [Zhang et. al, 2015]
   Brosnahan J, Jull A, Tracy C. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev. 2004;(1):CD004013. doi: 10.1002/14651858.CD004013.pub2. Update in: Cochrane Database Syst Rev. 2008;(2):CD004013. PMID: 14974052.
   
3. Overuse of the indwelling urinary tract catheter in hospitalized medical patients [Jain et. al, 1995]
   Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995 Jul 10;155(13):1425-9. PMID: 7794092.
   
4. The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty [Garbarino et al., 2020]
   Zhang W, Liu A, Hu D, Xue D, Li C, Zhang K, Ma H, Yan S, Pan Z. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One. 2015 Jul 6;10(7):e0130636. doi: 10.1371/journal.pone.0130636. PMID: 26146830; PMCID: PMC4492963.
   
5. Treatment of urinary complications after total joint replacement in elderly females. [Carpiniello et. al, 1988] 
   Carpiniello VL, Cendron M, Altman HG, Malloy TR, Booth R. Treatment of urinary complications after total joint replacement in elderly females. Urology. 1988 Sep;32(3):186-8. doi: 10.1016/0090-4295(88)90381-0. PMID: 3413910.

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Harris et. al (2017)	Retrospective Cohort Study	General surgery patients from 2006-2015	Frequency of hospital-associated UTIs in surgery patients after recommendations for reducing indwelling catheter days.	Females had significantly higher risk of HA-UTIs   While number of straight catherterizations increased, there was no significant change in HA-UTIs	Hospital policy only looked to reduce indwelling catheter days, did not account for provider education of placement and best infection prevention practices. Did not account for initial indwelling catheter days of patients with CA-UTI after policy implementation
Zhang et al. (2015)	Meta Analysis	1771 post total joint othoplasty patients	compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.	No significant difference in the rates of UTIs between foley and intermittent catheters   Lower rate of POUR in the foley group vs the intermittent group	No precise definition of POUR even amongst urologistsBecause only 9 RCTs were used, it became impossible to stratify according to surgical site.Unable to identify whether the two groups were comparable with respect to the use of opiates and antibiotics because most authors did not report sufficient data in this regard.
Garbarino et al. (2020)	Retrospective Cohort Study	7306 THA patients across 15 hospitals between Nov 28, 2016 – April 1, 2019	Incidence of infection in various post operative bladder catheterizations.	A significantly higher risk of developing UTI’s was seen in patients with both indwelling and intermittent catheters.   A lower risk was seen in the use of indwelling alone and an even lower risk was associated with intermittent catheterization.	Since the patient data was collected via EMR, patients who sought external follow up were usually lost. However, most infections were seen during the initial stay and this lowers the risk of missed data. The study was also unable to gather the exact duration of urinary bladder catheterization Sample was collected based on billing codes which may have been erroneously added (coding error within 15 different institutions)
Jain P. Parada (1995)	Prospective Cohort Study	202 ICU patients	Infection vs. No Infection after use of indwelling catheter	Continued catheterization was found to be unjustified in 47% of patients ( causing complication).	Results recorded by human observer → human error is a possibilityNo parameters on gender or ageLimited to one hospital setting → may skew results based on procedures performed in the hospital and demographic of community
Carpiniello, et. al (1988)	Randomized control study	77 patients undergoing total joint replacement	Incidence of urinary tract infection and retention	-Patients who received an indwelling Foley catheters preoperatively and for 24 hours postoperatively had a reduced incidence of infection as opposed to patients who received straight catheterization in the recovery room alone	Small sample size of 77 patients Study was performed in 1988, over 20 years ago Limited to patients receiving spinal anesthesia only, not general anesthesia Patients were given prophylactic antibiotics for 3 days post-op which were not controlled. They were given either clindamycin or cefazolin

Conclusions:

In postoperative patients, indwelling catheters demonstrated to increase the risk of infection. In contrast, intermittent or straight catheters demonstrated a lower risk of infection and is the recommended treatment option.

Clinical Bottom Line:

• The category of research question was risk of infection.

• 5 studies were critically appraised.
  
  • 1 prospective, 1 retrospective, 1 randomized controlled trial, 1 meta-analysis, 1 cohort study]

• 4 out of the 5 articles showed the indwelling catheters presented with the risk of infection.

To: Senators Kristen Gillibrand and Charles Schumer
From: Matthew Lemieszewski, PA-S
Date: July 18, 2021
Re: Proposed federal action to expand access to and coverage of telemedicine

Statement of Issue:

According to The Annals of Family Medicine, 45% of physicians receive patients through physician referrals annually. However, many primary care providers are unaware as to whether the specialist is being utilized by the patient. From limited providers in rural areas to patients with limited mobility, there are many barriers to receiving in-person care. One of the largest challenges faced during the COVID-19 pandemic was finding safe and effective ways to treat patient’s without COVID conditions for their many illnesses and comorbidities without putting them at risk for catching the virus. In their efforts, twenty-two states enacted temporary orders to enhance private insurance coverage of telemedicine in 2020.

• According to the CDC, during the first quarter of 2020, the number of telehealth visits increased by 50%, compared with the same period in 2019, with a 154% increase in visits noted in surveillance week 13 in 2020, compared to the same period in 2019. During January-March 2020, most encounters were from patients seeking care for conditions other than COVID-19.
  
  
• Jefferson Health, the second largest health system in Philadelphia found that diverting patients from unnecessary Emergency Department visits through telehealth platforms saves providers $1,500 per patient encounter.
  
  
• Concerns over the liability of telemedicine providers extends to civil, penal, and disciplinary liability. Coupled with a lack of unified legal framework for telehealth care can lead to a discouragement of use.
  
  
• Socioeconomic factors such as employment and income may inhibit some individuals from using telemedicine due to costs if they are not available as a service in a federal program.

Policy Options:

• Modernize  payment policies while improving management by reimbursement parity between telemedicine and in-person services. Because there is a lack of a universal definition of virtual care delivered, there is also a lack of standardization in approaches to payment. Currently, Medicare does not pay for training or education, and limits payment to real-time audio or video encounters between providers the patient.
  
  
  • Advantages: Incentivizes providers to adopt telehealth into their practice which will lead to overall lower costs of care as patients will not see a provider in person for every ailment, saving money on unnecessary labs typically performed during face-to-face visits.  
    
    
  • Disadvantages: Because of the ability to extend the reach of those who can utilize telehealth services, this leads to a higher potential for overuse, which can take up time that providers could be spending with patients who actually do need care. Additionally, virtual visits require less clinical effort when compared to patients seen in person. As the number of patients grows significantly, this can lead to levels of burnout of providers which can also increase the chance of medical errors.

• Employ state level reciprocal licensing and credentialing allowing out-of-state physicians to render care. This would work with state Medicaid offices to expanding coverage for remote care services.
  • Advantages: Allows more accessibility and expedition of telehealth in rural and underserved communities by seeing a provider not in your area. Creates a unified system in line with the initial licensing process for physicians and mid-level providers.
    
    
  • Disadvantages: Putting providers at risk for lawsuits across state lines on the grounds that medical advice given may be negligent or cause injury. It is possible that a lawsuit in one state is not covered by the provider’s home state malpractice insurance.
    
    
• A partnership with the Federal Communications Commission to increase broadband access to underserved urban and rural areas. Working with the nation’s largest internet providers, providers can receive federal funds to increase their ability to deliver care electronically to the 23% of Americans who currently do not have a wired broadband connection.
  • Advantages: Enabling video and audio services to patients allows for quicker access to a provider while saving on time, transportation, and costs. Being able to see a provider to review exam results or conduct some parts of a physical exam, this gives patients the opportunity to speak privately with a provider when there may not be one accessible where they live. In situations that are deemed medical emergencies, the provider would be able to alert local 911 to get people the treatment that they need in person.
    
    
  • Disadvantages: The financial obligation of getting access to all Americans has been estimated around $80 billion by the FCC, these funds would have to be collected in a way that congress sees fit. Further, increasing access to the internet can lead to increased anxiety and decreased mental health as patients being to self-diagnose based on symptoms they put onto a medical website.
    
    

Policy Recommendations: According to the most recently available US Census, by 2030, all members of the baby boomer generation will be older than age 65. With the current size of this population, that will mean that one in every five US residents will be retirement age. Doximity, the nation’s largest physician network predicts that by 2023, as much as $106 billion of current US health care spending could be on virtual services. Due to these facts, it is imperative to fix the payment policies of the system before expanding it to individuals currently unable to access it. Working with elected officials to require reimbursement parity and waive cost sharing will not only incentive providers to adapt to the world of telemedicine but also ensure that our older generation will be able to continue to obtain the care that they need. Employing efforts to ensure more individuals can afford this care will in turn lead to less unnecessary trips to hospitals and private practices which will save time, money, and resources, all things of utmost value in the world of healthcare.

References:

• Doximity , 2020, 2020 State of Telemedicine Report: Examining Patient Perspectives and Physician Adoption of Telemedicine Since the COVID-19 Pandemic, c8y.doxcdn.com/image/upload/v1599769894/Press%20Blog/Research%20Reports/2020-state-telemedicine-report.pdf.
  
  
• Eron, Lawrence. “Telemedicine: The Future of Outpatient Therapy?” OUP Academic, Oxford University Press, 15 Sept. 2010, academic.oup.com/cid/article/51/Supplement_2/S224/383896?login=true.
  
  
• Jin, Michael X, et al. “Telemedicine: Current Impact on the Future.” Cureus, Cureus, 20 Aug. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7502422/.
  
  
• “Policy Changes during COVID-19.” US Department of Health and Human Services: Telehealth, telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/.
  
  
• Powell, Rhea E, et al. “Patient and Health System Experience With Implementation of an Enterprise-Wide Telehealth Scheduled Video Visit Program: Mixed-Methods Study.” JMIR Medical Informatics, JMIR Publications, 13 Feb. 2018, www.ncbi.nlm.nih.gov/pmc/articles/PMC5829457/.
  
  
• “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic – United States, January–March 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Oct. 2020, www.cdc.gov/mmwr/volumes/69/wr/mm6943a3.htm.
  
  
• United States, Congress, Office of Strategic Planning and Policy Analysis, Paul De Sa. Improving the Nation’s Digital Infrastructure , 2017. www.fcc.gov/document/improving-nations-digital-infrastructure.

COVID-19 Response Paper

On January 21, 2020, the first case of the 2019 novel coronavirus was confirmed in the United States in a man from Washington State. Initially, many public health and government officials believed that the virus would not be a threat to national security (Schwellenbach, 2021). This belief quickly diminished as the death toll surpassed 10,000 only 75 days later on April 6^th (Brewster, 2021). As the United States continues the ongoing battle of recovering from the COVID-19 pandemic, professional research and media on both sides of the political aisle spend day-in and day-out dissecting every response effort made from the pandemic’s infancy to where we are today. Under two separate administrations, we have seen many differences in the ways that the virus has been handled. Looking retrospectively and through a global lens, there are many things that the United States could have done either sooner or completely different in an effort to soften the loss of now over 600,000 American lives. From closing travel borders earlier to demonstrating more fiscal responsibility, the United States will be dealing with the public health and economic aftermath of this virus for years to come. However, the one area that I believe our government failed the most was with the lack of transparency in creating policy which led to severe distrust among the public.

Beginning in March 2020, New Yorkers looked to the daily briefings from both state and federal players such as Governor Andrew Cuomo and Dr. Anthony Fauci. The two who were revered as heroes to the populations they served have been criticized for their tendencies to change policies in place on a whim ambiguously citing expanding evidence without providing the sources of their research that guided their decisions. Veiling the evidence-based foundation for policies being pushed made it much more difficult for the public to gauge what was being done. This led to an inability to assess actions that may have been poorly crafted and even hazardous. When health authorities come out with one rule after another without clear, evidence-based validation, their advice comes off as illogical and impulsive. That tears away public trust and makes it tougher to implement rules that do make sense, for this current pandemic and for any future public health issues we may face in the future. In the virus’ infancy in the United States, the Centers for Disease Control and Prevention botched the early messaging on masks by recommending they be used only by health workers; while the Trump administration did not pass any recommendation at all. If, however, the studies used to create these guidelines had been cited, the eventual complete shift towards masks being worn by all would have been viewed as far less uninformed and could have led to higher levels of acceptance as the virus continued to spread.

It has become universally accepted that evidence must be provided and accepted when guidelines are made by public health agencies. For example, the Centers for Disease Control and Prevention gives detailed information from published research studies on the science behind the practice and benefits of hand-washing. Due to the fact that the COVID-19 pandemic is much more complex, it poses many more hurdles when it comes to passing recommendations, given the volume of new research and the pace at which it is becoming available. Even today, finding reputable sources of information is a difficult task as much of the available research online has gone up before being assessed and scrutinized by reviewers for a scientific journal. While many of the recommendations have not stood the test of time over the last year with evidence continually changing, arguments will continue to be made in deciding which studies should be used to drive public health policy forward.

Now a year and a half into the pandemic, much research has been done to point out which countries successfully implemented a response strategy and aimed to see how the countries that did not have the same success can look to them for guidance should the need arise in the future. One country that should be seen as the quintessential model is New Zealand. According to John Hopkins to date, New Zealand has had 2,768 cases of COVID-19 that led to a mere 26 deaths (John Hopkins, 2021). Given the country’s relatively small population size of 4.92 million people, this number should be adjusted to be considered for comparison. Given the United States’ population of 328.2 million, following New Zealand’s unified strategy at curbing the virus would only have proportionally worked out to 184,758 cases; far less than the near 34 million cases we have seen. Digging deeper into what exactly New Zealand did to eliminate cases to the best of their ability, there are many points that the United States can use to learn from. Particularly, the country’s response to closing borders swiftly and strictly has proved to be a life-saving effort.

Beginning on March 14^th 2020, border controls had been implemented stating that anyone entering New Zealand must self-isolate for 14 days. Within 5 days, on March 19^th, the National Party announced that the country’s borders would close to all except citizens and permanent residents for the first time in their history. In a week’s time, the country moved to full lockdown and gave all citizens two days to relocate to their lockdown premises, only allowing essential workers to leave home. After 78 days, on June 9^th 2020, the country lifted all restrictions on work, school, business, and domestic travel as there were no active cases in the country (McGuinness Institute, 2021). After three months without transmission, five individuals tested positive for the virus and the country reinitiated restrictions over the country. Less than a month later, restrictions had once again been lifted, with this only occurring one final time from February to March 2021.  

The significance of the timeline of New Zealand’s response is that it came as a unified evidence-based model. Members of conflicting political parties did not view these decisions through a partisan lens, but of one that was for the best of the country as a whole. Conversely in America, declarations of emergency were left up to individual states to decide. It was not until April 11, 2020 that Wyoming become the final state to request a disaster declaration. Many policies were released as guidelines and many places in the country did not exercise strict stay-at-home orders. Had the virus not been politicized in this country as was feared by the World Health Organization, and all parties approached the handling from a united front as our country states we are, there is no telling how many lives could have been saved.

Now as we enter the late summer one year later, we continue to see many of the same problems continuing to lurk here in the United States. As the growingly popular delta variant of the virus now ranks as the most prevalent strain domestically, Los Angeles County is recommending that individuals wear masks inside, regardless of vaccination status, to prevent the spread, mere weeks after the state finally lifted restrictions and eased their guidance on wearing masks. This recommendation comes despite a study done by Public Health England in June 2021 in which of 14,019 cases of the Delta variant, the BioNTech/Pfizer and Oxford/AstraZeneca vaccines were found to be 96% and 92% effective in preventing hospitalizations, respectively. Additionally, the chief scientist at the World Health Organization, Soumya Swaminathan says that “the most important priority just now is to scale up vaccination coverage in all countries” (Mancini et al., 2021).

As the United States continues all efforts to defeat this virus, the time has come for politicians on both sides to put down their arms and explain to the American people the exact steps that need to be taken to allow our lives to fully return back to normal. In this, the government must trust the public in creating a more transparent dialogue with all evidence-behind policies, or fear of being seen as a totalitarian government. Explaining exactly why actions are being taken will allow Americans to look at the facts and understand that the wellbeing of the whole is greater than the sum of its parts. Tackling this virus together is the only way that a very divided country can come out of this united.

References

• The American Journal of Managed Care. (2021, January 1). A Timeline of COVID-19 Developments in 2020. AJMC. https://www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020.
• Brewster, Jack. “U.S. Surpasses 10,000 COVID-19 Deaths.” Forbes Magazine, 6 Apr. 2020, www.forbes.com/sites/jackbrewster/2020/04/06/us-surpasses-10000-covid-19-deaths/?sh=1693e36f2565.
  
  
• “COVID-19 Map.” Johns Hopkins Coronavirus Resource Center, coronavirus.jhu.edu/map.html.
  
  
• “COVID-19 New Zealand Timeline.” McGuinness Institute, 7 July 2021, www.mcguinnessinstitute.org/projects/pandemicnz/covid-19-timeline/.
  
  
• Mancini, Donato Paolo, and John Burn-Murdoch. “How Effective Are Coronavirus Vaccines against the Delta Variant?” Financial Times, 9 July 2021, www.ft.com/content/5a24d39a-a702-40d2-876d-b12a524dc9a5.
  
  
• SARS-CoV-2 Variants of Concern and Variants under Investigation in England, 11 June 2021. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/993879/Variants_of_Concern_VOC_Technical_Briefing_15.pdf.
  
  
• Schwellenbach, Nick. “The First 100 Days of the U.S. Government’s COVID-19 Response.” Project On Government Oversight, 29 Dec. 2019, www.pogo.org/analysis/2020/05/the-first-100-days-of-the-u-s-governments-covid-19-response/.
  
  
• Signé, Landry. “A New Approach Is Needed to Defeat COVID-19 and Fix Fragile States.” Brookings Institute , 21 Apr. 2020, www.brookings.edu/blog/future-development/2020/04/21/a-new-approach-is-needed-to-defeat-covid-19-and-fix-fragile-states/
  
  
• World Bank. (n.d.). Understanding the COVID-19 Pandemic through Data. World Bank. https://datanalytics.worldbank.org/covid-dashboard/#section-indicators.

• World Health Organization. (2020, July 15). New Zealand takes early and hard action to tackle COVID-19. World Health Organization. https://www.who.int/westernpacific/news/feature-stories/detail/new-zealand-takes-early-and-hard-action-to-tackle-covid-19.

Addressing Cultural & Religious Diversity in Medicine

As the world we live in continues to diversify and the long-standing inequalities in the health status of people from culturally diverse upbringings become more evident, there has been a challenge issued to health care providers and their organizations as a whole to view cultural diversity as a priority in providing the highest level of patient care. The patients we treat come from an immense range of cultures and religions that each have different needs, health beliefs, and behaviors. Additionally, patients often have different backgrounds than their provider which can lead to incongruent care based on religious differences, gender issues, and cultural practices that influence medical decisions. A lack of both provider diversity and cultural competence has led to health disparities amongst different sociocultural groups, especially those considered to be a minority. By addressing diversity in medicine, we can begin to understand the determinants of those disparities and make equitable care improvements to the patient-centered model.

Although there have been pushes across the healthcare industry to promote higher levels of cultural competence among providers in the past two decades, there has not been much evidence that the influence on patient treatment outcomes have been significantly superior. The Centre for Forensic Behavioural Science out of Swinburne University in Victoria, Australia wanted to explore how professionals perceived their own cultural competence levels in their care, the degree in which they believe their work addresses cultural disparities, and to analyze the level of training these professionals have had concerning cultural awareness.

By delivering surveys to providers across three major health care systems and one university student health center in the United States, this study allowed researchers to understand how providers at different levels differed in their capacity to identify and overcome the obstacles of caring for patients from an array of backgrounds and cultures.

While a majority of the study participants conveyed confidence in their own ability to meet the needs of multicultural patient populations, a majority also confessed to not having undergone any previous cultural training in their education or from their employer. This overconfidence may symbolize a misrepresentation between truly addressing the cultural needs and the everyday experiencing of challenges when working with minority patients. One of the most popular answers received via the survey was that providing interpreters was the best way to provide effective cross-cultural care. This shows one of the biggest misconceptions with healthcare disparities, which is that effective culturally competent care was a matter of communication rather than a multifaceted institutional framework.

While communication is an effective first step, both cultural and religious competence in medicine is important to create a trusting, respectful, and collaborative dialogue between providers and patients. By establishing that dialogue, providers can carry out shared decision making and bring quality care to patients. Religious practices may have an influence on patients’ diets, on which medications they can take, on the gender preference of their provider, and much more. Additionally, many patients turn to their faith when making a decision regarding their medical care, or to relieve any anxieties (Swihart et al., 2021). For many individuals, religion and spirituality are central factors in their lives, being an essential part of their identity. Without religious competence, patients are at risk of receiving poor quality of care, having negative health outcomes, being dissatisfied, and losing trust in healthcare. Providers should tailor evaluations and treatments in efforts to provide and improve patient-centered care and meet patient’s needs.

Examples of clinically significant views various religions hold include the following: In Islam, handshakes or contact between genders, pork, shellfish, and alcohol are prohibited. A same-sex practitioner is required unless the situation is an emergency. Jehovah’s Witnesses refuse any blood products. In Sikhism, cutting hair on any part of the body is prohibited. Christian Scientists believe that prayers are more effective as a remedy than medicine is (Swihart et al., 2021). There are many more religions and beliefs, along with their respective views that exist. Without knowing such religious values, providers may unintentionally come across as insensitive and display healthcare as an unsafe environment. One study established 80 percent of patients claimed that physicians rarely gave them a chance to discuss religious or spiritual issues (Dillard et al., 2021). Discussion, support, and acknowledging different religious views and giving the patient the opportunity to discuss their beliefs can better the relationship between patients and providers (Swihart et al., 2021). This can further improve the assessments and interventions which ensue.

When possible, by integrating prayer or culture into treatment or management, the patient-provider relationship strengthens, fewer medical errors are made, and patient-centered care improves (Swihart et al., 2021). Patients have moral rights with respect to their evaluation and treatment. In efforts to build a therapeutic alliance with patients, providers should respect the cultural or religious background which patients identify themselves with and upon which they form their life decisions. 

When it is not solely a problem of ineffective communication, providers must look deeper when they aim to understand the vast array of patients that they serve. This idea includes the notion of understanding the long history your patients have within the local community. Racial essentialism is a belief that all individuals in a race are only distinct due to their genes. This belief has lingered into medicine, has shaped certain clinical decisions, and is the basis of many studies. However, race and culture are very complex, particularly in the case of  Native American and Alaskan Indians. The development of their culture is based off of its history which is comprised of relocation, genocide, and exploitation, but the current racial and cultural identity of American Indian and Alaskan Indians has developed based on federal policies. This racial and cultural  categorization is still used as a biological marker by clinicians to understand increased or decreased risk of illnesses. In order to make clinical decisions providers use research and data; However, the misclassification of a culture can exacerbate health disparities. This can lead to underreporting of mortality and morbidity in Native American and Alaskan Indians populations and can lead to worsening health disparities. 

Fetal alcohol spectrum disorder (FASD)  is claimed to be a genetic condition among Native Americans. However, researchers do not account for particular historical, political, or sociocultural factors that lead to FASD. The use of race and culture as a basis to make clinical decisions poses certain limitations. Data and studies fail to take into account both the complexities of cultures from different tribes and use genes to determine differences against certain illnesses. There are several different tribes within Native American and Alaskan Indian people, yet the data provided classifies these distinct groups as a single racial group. By not being aware of the different tribes and the different values which exist among the tribes, providers fall short of providing culturally competent care and become more inclined to make assumptions. By making these assumptions, clinicians can make errors in diagnosing, treating, or drive patients away from seeking care. Such an assumption is seen with the FASD, linking it as a “Native American” condition. The weak and ambiguous data can cause overestimation or underestimation of the patient’s disease risk. The social inequities present between Native Americans and Alaskan Indians are visible in the data that impacts the decision-making process of providers. 

Native Americans and Alaskan Indians are not the only groups who have felt the negative impact of cultural disparities in healthcare. The culturally centered group known as E-WORTH (Empowering African American Women on the Road to Health) based out of New York City demonstrated what the impact of good communication can do for an individual’s well-being. In this randomized clinical trial, it was set out to determine the effectiveness of a cultural group-based HIV and STI intervention by comparing findings to a control group. 

Black women who had a history of drug use and were enrolled in community supervision programs in New York City were randomly assigned to each group. The control group had a single 30-minute session for HIV testing and information versus the E-WORTH group that had an hour session for HIV testing and orientation followed by four 90-minute group sessions per week for 12 months. The study ran from the years 2015-2019.

Results showed that E-WORTH participants had 54 percent lower odds of testing positive for an STI at the 12-month assessment and reported 38 percent fewer acts of condom-less vaginal or anal intercourse with a male partner compared to the HIV streamlined intervention control group.

Limitations of this study include the control group not being in a group-based setting which is needed to determine the effectiveness of group settings alone versus cultural-based group settings. There were other limitations in the statistical analysis such as not accounting for risk-behaviors with participants who had same-sex partners.

Community Supervision Programs include parole, probation, or alternative-to-incarceration programs in the United States, which have an increased number of HIV/STI cases for black women compared to other cultural groups, illustrating the importance of this study. An intention-to-treat approach was used; therefore, the statistical analysis was based on the group that participants were originally assigned and did not consider alternative treatment that may have been received thereafter. Accordingly, results should be interpreted as prospective effects of treatment policy instead of prospective effects of specific treatment.

The results from the E-WORTH study suggest that cultural group-based medical interventions may be more efficacious than non-culture centered individual interventions even after accounting for the limitations of that study. This model should be studied on other cultural or religious groups with specific risk-reduction needs such as those of Native American and Alaskan Natives. If similar results are replicated, it would further demonstrate the benefit of applying culturally targeted risk-reduction as a standard practice in preventative medicine.

It is not questioned that, regardless of a provider’s depth of cross-cultural knowledge, the importance of cross-cultural awareness has become universally accepted. However, thematic analysis of the study showed that there was a need for interventions that acknowledge the value of cultural awareness-based approaches, while also investigating the practicality of more thorough competence and safety training for all providers. Providers themselves come from different cultural and religious backgrounds and have different levels of cultural or religious competence. As mentioned, having a majority of providers confess to not having undergone training in education or in the workplace merely indicates the absence of recognition, acknowledgement and exploration of patients’ religiosities which are necessary to address the diversity in medicine and bring about a culturally and religiously sensitive care. 

References

• Dillard, V., Moss, J., Padgett, N., Tan, X., & Kennedy, A. B. (2021, June 15). Attitudes, beliefs and behaviors of religiosity, spirituality, and cultural competence in the medical profession: A cross-sectional survey study. PLOS ONE. https://doi.org/10.1371/journal.pone.0252750.
  
  
• Gampa, V., Bernard, K., & Oldani, M. J. O. J. (2020). Racialization as a Barrier to Achieving Health Equity for Native Americans. AMA Journal of Ethics, 22(10). https://doi.org/10.1001/amajethics.2020.874.
  
  
• Gilbert L, Goddard-Eckrich D, Chang M, et al. Effectiveness of a Culturally Tailored HIV and Sexually Transmitted Infection Prevention Intervention for Black Women in Community Supervision Programs: A Randomized Clinical Trial. JAMA Netw Open. 2021;4(4):e215226. doi:10.1001/jamanetworkopen.2021.5226
  
  
• Jackson, C. S., & Gracia, J. N. (2014). Addressing health and health-care disparities: the role of a diverse workforce and the social determinants of health. Public health reports (Washington, D.C. : 1974), 129 Suppl 2(Suppl 2), 57-61.  https://doi.org/10.1177/00333549141291S211
  
  
• Shepherd, S.M., Willis-Esqueda, C., Newton, D. et al. The challenge of cultural 

competence in the workplace: perspectives of healthcare providers. BMC Health Serv Res 19, 135 (2019). https://doi.org/10.1186/s12913-019-3959-7

• Swihart, D. L., Yarrarapu, S., & Martin, R. L. (2021). Cultural Religious Competence In Clinical Practice. In StatPearls. StatPearls Publishing.

HPPA 514 – Biomedical Ethics – Summer 2021 – Ethical Argument Essay

Every day, patients around the country exercise their right to autonomy when making decisions about their medical care. Included in this right is the ability for patients to make the conscious choice to not receive treatment. Today, one of the most debated topics within the medical community is whether or not this right should include a patient’s choice to end their own lives. Physician-assisted suicide, also referred to as aid-in-dying (AID), occurs when “a physician provides “the necessary means and/or information” to facilitate a patient’s choice to end his or her life.” (Dugdale, Lerner, & Callahan, 2019). While some states and countries have begun to legalize this practice, many still oppose the idea as it conflicts with a physician’s duty of nonmaleficence along with the risk of abusing this practice with individuals looking to end their lives. As medicine continues to advance and patients are living longer than ever before, I believe that under particular circumstances, a patient is within their rights to decide when they wish to die and no other opinion should trump this autonomy. 

As we have learned, the four core concepts of biomedical ethics include patient autonomy, beneficence, nonmaleficence, and justice. As medicine has shifted from a paternalistic model to shared-decision making model, the patient’s right to autonomy has become a center focus when it comes to an individual’s level of treatment. When the conversation surrounds aid in dying however, many feel that a physician has an obligation to deny any request of the nature. I do not believe that medical ethics should have the ability to set limits on a sound-minded patient’s autonomous request. If a competent patient were to develop an illness for which there was no cure and only leads to agony and suffering, the patient should be allowed, and within their rights to end life on their own terms. Making this decision alleviates the patient of the agony and suffering their illness will create for them, reduces the use of resources within the healthcare system, reduces the financial hardship that is ultimately passed on to the individual’s family, and most important, allows the patient to die with dignity while they can still recognize themselves. Before any execution however, I believe the caring physician must utilize the resources available to them to ensure that this patient is of sound mind, free from any illnesses that can affect one’s judgement.

Clinical ethics shows that the respect for autonomy is a subset of a larger principle known as respect for persons. One implication of respect for persons is acknowledging the “moral right of every competent individual to choose and follow his or her own plan of life and actions.”  (Jonsen, Siegler, & Winslade). And while a physician’s recommendation aligns with a patient’s request a majority of the time, where is the line drawn where the physician’s moral compass should decide whether or not a patient will live and suffer as opposed or die in peace. If the patient is capably making this request, I would argue that the physician is in fact practicing beneficence as opposed to nonmaleficence as the patient is looking for a way out of the suffering.

Arguments against the aided death practice range from moral and ethical to pragmatic. One line of the Hippocratic Oath, one of the most well-known Greek texts which states, ‘I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan…’ In the practice of aid in dying, some view the core concepts of autonomy and nonmaleficence are in direct conflict but, under the circumstances, feel that the latter can override the former. In this conflict, why should the principle of nonmaleficence take priority solely because it aligns with the physician’s moral compass? If our patient completely understands the nature of what they are requesting, as explained by the physician, this no longer is posed as an illusionary conflict between the two core concepts.

An individual’s unalienable rights are to life, liberty, and the pursuit of happiness. I believe one’s right to die should be protected under our 14^th Amendment. Taking away this right is limiting a mentally competent patient’s right to exercise autonomy. This practice is not a true issue of autonomy versus nonmaleficence as individual’s are making educated and reasonable requests to their physicians in an effort to escape potential harm, pain, or suffering. If a provider truly upheld their duty to nonmaleficence, one would not allow their personal moral dilemmas conflict with an ill patient’s wishes towards seeking peace.

References

• Dugdale, L., Lerner, B., & Callahan, D. (2019 Dec). Pros and Cons of Physician Aid in Dying. Yale Journal of Biology and Medicine, 92(4): 747-750.

• Jonsen, A. R., Siegler, M., & Winslade, W. J. (n.d.). Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine 8th Edition. 2015: McGraw-Hill Education.

• Shinall Jr, M. C. (2018). The Evolving Moral Landscape of Palliative Care. Health Affairs, 37:4, 670-673.

What differences do you note between the two H&Ps?

The biggest difference I noticed between my first and last H&Ps was that my last H&P had a much smoother flow that developed over the two semesters. This is particularly evident in the HPI, showing how I have become more comfortable in my own writing style.

In what ways has your history-taking improved?  Are you eliciting all the important information?

Though my history taking has improved as I demonstrate a greater familiarity with what follow-up questions need to be asked, having patients that needed the assistance of an interpreter showed me that I need to be as specific as possible when looking to get relevant information on my patients. I feel that I was able to better formulate follow-up questions for both pertinent positives and negatives with my last visit of the semester. I think this comes additionally with having more time in the classroom and understanding how to dig a little deeper.

In what ways has writing an HPI improved

The main difference I noticed was the improved fluidity. During my first visit, I felt extremely apprehensive about asking my patient “too many questions,” and I may have missed some important information. By the time I had my final visit, I felt much more comfortable approaching a stranger and getting all of the relevant information to help them in the best way that I could.

What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

I feel very confident about performing a physical exam of what we have learned up to this point. I would still like to improve in the speed of my physical exam, which is where I feel I have the most room to grow. Right now as I go through each system I find myself stopping to run down a checklist in my head to make sure I have not missed any aspect of each exam. Overall, I feel I am strongest in my technique in making patients feel comfortable when I approach them for an exam.

Of course, we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

My biggest area would be to continue taking a full history and doing a review of systems. If you listen to what a patient tells you, they can often tell you exactly what is wrong before you even begin a physical exam. I am very comfortable with speaking to patients, but knowing how to keep a medical conversation flowing is a skill that I am looking forward to working on in the fall and as we move closer to our clinical year.

Identification:
March 23, 2021 – 9:30AM
MK, F, White, DOB 12/8/43, Single, Flushing, NY

Informant: Self, reliable
Referral Source: Self
Chief Complaint: “I have fallen several times at home recently and now I am constipated x 4-5 days”

History of Present Illness:
MK is a 77yo COVID-negative female with a PMH of HTN and surgical history of left mastectomy and left lobe lung resection presented to the ED for frequent falls and constipation x4-5 days. States that she has +LOC during these falls and she recently hit her face. Patient lives alone and reports she cannot care for herself anymore. Patient otherwise denies fever, SOB, chest pain, cough, abdominal pain, N/V, and urinary symptoms.

Past Medical History:

• HTN x 17 yrs
• Breast cancer – surgery in 2018
• Lung cancer – surgery in 2016
• Cellulitis – diagnosed on admission, previously untreated
• UTI – diagnosed on admission, previously untreated

Past Surgical History:

• Left  simple mastectomy, November 2018
• Left lower lobectomy, May 2016

Medications:

• Anastrozole 1mg, PO Q.D
• Docusate-Senna 2 tablets, PO bedtime
• Doxycycline 100mg, PO Q12H
• Enoxaparin 40mg, subcutaneous, Q24H
• Levaquin 500mg, IV Q.D
• Metoprolol Tartrate 25mg, PO Q12H

Allergies:

• Penicillin: hives
• Sulfamethoxazole: hives
• Strawberry (Food): hives

Family History:

• Mother: Deceased (unknown age), HTN, breast cancer
• Father: Deceased (unknown age), unsure of medical history
• Brother: 86yo, denies medical history

Social History:

• Habits:  Denies alcohol use, quit smoking cigarettes 20 years ago with 25-pack year history
• Travel: Denies any travel in the last 5 years
• Marital history: Never married, lives alone
• Occupational history: Retired office job for 15 years
• Home situation: Lives alone, home aid occasionally comes to assist with shower and cleaning
• Diet: Coffee, premade frozen foods. On low sodium diet while admitted
• Sleep patterns: Will not sleep in bed out of fear of falling, sleeps in reclining chair
• Exercise: Limited – walking around apartment unit
• Sexual history: No longer sexually active

Review of Systems:

• General: Admits bilateral leg weakness from sedentary lifestyle. Denies loss of appetite but eating less due to constipation. Denies fever, chills, fatigue, recent weight gain of loss.
  
  
• Skin, Hair, and Nails: Admits rash with erythema on lower right leg. Denies any other changes in texture, dryness, or discolorations.
  
  
• Head: + bruising under left eye from most recent fall. Denies any headaches, vertigo, or lightheadedness.
  
  
• Eyes: Does not use corrective vision, denies any visual disturbances, photophobia.
  
  
• Ears: Admits muffled hearing in left ear due to excessive cerumen. Denies any pain, discharge, tinnitus, or use of hearing aids.
  
  
• Nose/Sinuses: Denies discharge, epistaxis, or obstruction
  
  
• Mouth and Throat: Denies bleeding gums, sore tongue, sore throat, and does not use dentures.
  
  
• Neck: Denies swelling, stiffness, or decreased range of motion.
  
  
• Breast: Denies any lumps, nipple discharge, or pain on right breast.
  
  
• Pulmonary: Denies dyspnea, SOB, dyspnea on exertion, cough, wheezing, cyanosis, orthopnea, PND.
  
  
• Cardiovascular: HTN controlled by medication. Denies chest pain, palpitations, edema, irregular rhythms.
  
  
• Gastrointestinal: Admits severe constipation for 5 days, given docusate-senna on admission. Denies dysphagia, pyrosis, flatulence, abdominal pain.
  
  
• Genitourinary: Foley placed on 3/16 to monitor diagnosed UTI. Denies any dysuria or change in color, or flank pain.
  
  
• Sexual history: Not sexually active, denies history of STIs.
  
  
• Menstrual and Obstetrical: Menopausal for 15+ years. Never pregnant.
  
  
• Nervous: Admits loss of consciousness from falls and weakness on right leg prior to each fall. Denies any seizures, headache, sensory disturbances, change in mental status, or memory loss.
  
  
• Musculoskeletal: Admits bilateral knee pain with activity. Denies history of arthritis.
  
  
• Peripheral Vascular: Admits to intermittent claudication bilateral legs with right > left. Positive erythema on right leg. Denies coldness, varicose veins, edema.
  
  
• Hematologic: Denies history of anemia, blood transfusions, DVT/PE. Visible bruising noted from falls.
  
  
• Endocrine: Denies polyuria, polyphagia, polydipsia, heat/cold intolerance, goiter.
  
  
• Psychiatric: Denies feelings of depression, sadness, anxiety, SI, previously seeing a mental health professional.
  
  
  

Physical

General Survey: 77yo female, A&O x3 with a larger build sitting up in bed watching tv and finishing breakfast. Does not appear in any distress.

Vitals:

BP	Left Arm	Right Arm
Seated	132/70	136/78
Supine	138/78	148/84

• Pulse: 84bpm, strong, regular
  • EKG obtained from nurse: normal sinus rhythm
    
    
• Respirations: 18breaths/minute, unlabored
  
  
• O2 Sat: 99% on room air
  
  
• Temperature: 36.8C (98.2F) oral
  
  
• Height: 68 inches
• Weight: 88.2kg (194lb) weighed
• BMI: 29.5

Skin: Warm and dry, no masses or lesions. Slight erythematous rash on right leg below the knee. Slight bruising under left eye from fall and on left hand from phlebotomy access. Good skin turgor bilaterally.

Nails: No clubbing. Capillary refill < 2 seconds bilaterally on upper and lower extremities

Hair: Average quality and distribution of hair. Negative for seborrhea upon scalp inspection.

Head: Nontender to palpation throughout. Small bump on left frontotemporal region from previous fall. Denies any associative pain.

Eyes: Symmetrical OU. Sclera white, cornea clear, conjunctiva pink.

• Visual acuity uncorrected: OU: 20/30 OD: 20/40 OS: 20/40
• Visual fields full OU. PERRLA
• Fundoscopy: Red reflex intact OS. Patient bothered by light, would not allow exam to continue beyond reflex or at all OD. Would look for a cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, or exudates.
  
  
  

Ears: Symmetrical and appropriate size. No masses, lesions, or trauma on external ear. No discharge but moderate amount of cerumen in left ear. TM’s pearly white / intact with light reflex in good position AU. Auditory acuity intact upon whisper test. Weber was midline. Rinne shows AC > BC AU.

Nose: Symmetrical. No masses, lesions, or trauma. Septum was midline on external inspection.
Patient would not allow for internal inspection of nose. Would look for pink nasal mucosa, no septum deviation, and foreign bodies. No discharge on anterior rhinoscopy

Sinuses: Nontender to palpation and percussion over bilateral frontal, maxillary, and ethmoid sinuses.

Mouth:

• Lips: Pink and dry, no cyanosis or lesions. Patient would not allow palpation for any of the oral exam as she just finished eating. Would expect non-tender to palpation.
  
  
• Mucosa: Pink; well hydrated. No masses or lesions noted.  Non-tender to palpation. No leukoplakia.
  
  
• Palate: Pink; well hydrated.   Palate intact with no lesions; masses; scars.  Non-tender to palpation; continuity intact. 
  
  
• Teeth: Good dentition  with no obvious dental caries noted.
  
  
• Gingivae: Pink; moist.  No hyperplasia; masses; lesions; erythema or discharge.

Non-tender to palpation.

• Tongue: Pink; well papillated with no masses or lesions. Non-tender to palpation.

Neck:

• Neck: Trachea midline with no masses, lesions, scars, or pulsations noted. Non-tender to palpation.  No stridor noted. 2+ Carotid pulses and no cervical adenopathy noted.
  
  
• Thyroid – Non-tender; no palpable masses; no thyromegaly