History of the Crimson Care Collaborative at Beth Israel Deaconess Medical Center

According to a 2009 MMS Physician Workforce study, patients are now waiting an average of 82 days to see their primary care physicians. With the wait times increasing, many patients who may want to spend more time with their family doctor now resort to the costly option of the emergency room.

Started by Harvard Medical students in 2010, the Crimson Care Collaborative (CCC), a student-faculty clinic, addresses this gap in the healthcare system. At the Beth Israel Deaconess Medical Center (BIDMC), CCC provides specialized care after normal operating hours. CCC-BIDMC focuses on chronic disease management and partners with primary care providers and specialists to serve patients with hypertension, diabetes, and obesity. Every Tuesday evening students and faculty see patients, either recruited or referred by their primary care physician, for their chronic care and various episodic needs.

Students are involved in every step of the practice and develop valuable skills in health care and research. As of 2013, students work in committees ranging from chronic care innovation, which educates patients with chronic diseases, to research, which compiles data on the clinic. In addition, students who are either junior or senior clinicians work with patients directly. Pharmacy students and faculty also counsel patients and make recommendations on their medications.

Look at our website for more about this student-faculty clinic: http://www.crimsoncare.org/

Didactics: August 6th

by Christine Bishundat
Med Ed Committee

Epigastric pain has many causes and can be characterized by different levels of pain. The epigastrium is the area in the upper abdomen that includes organs such as the stomach, pancreas, and parts of the intestine.

A 33 year old male patient comes in with complaints of epigastric pain, pointing to the location of the pain rather than describing it. For the exam, you would focus on the abdomen. Taking vital signs would be a good first step as epigastric pain could mean anything from a mild to critical condition. For example, the cause of pain could be pancreatitis or an ulcer.

If you are administering a physical exam and the patient cringes when you press down on the abdomen, it is called rebound pain. This could indicate that there is a perennial inflammation or if there is something perforated from a previous surgery. It would also be helpful to do a rectal exam. If the patient presents with blood there could be a GI bleed from a perforated ulcer, thus you would want to ask about things that contribute to peptic ulcers such as NSAID and alcohol use.

One pro tip is to have the differential diagnosis at hand to figure out during the exam what things to look out for.

Didactics: July 23rd

by Christine Bishundat
Med Ed Committee 

On Tuesday July 23, 2013 Dr. Elizabeth Housman delivered an illuminating didactic presentation on fatigue. This is a seemingly simple symptom, but what makes it tricky is that there are a number of diagnoses to consider on a differential, ranging from depression/anxiety, diabetes/hypothyroid, renal failure, TB/mono/HIV, to a rheumatology problem to sleep apnea, or perhaps the patient is simply on beta blockers or another medication that is known to cause fatigue. 

Here we have an 85 year old woman with body aches, 10 pounds of weight loss, mild noromocytic anemia, renal failure, high ESR/CRP, and 3 weeks of fatigue. The best thing to do is to take a biopsy to diagnose Giant Cell Arthritis, the histology of which will show vasculitis of medium and large vessels, and distortion of the elastic lamina. We can then give her steroids to suppress the immune system if we're concerned with these rheumatology complications. An ophtho exam shows bilateral uveitis: redness, blurry vision, and eye pain.

Uveitis is actually a rare presentation of GCA. Vision loss in GCA is due to ischemia of optic nerve or retina or ischemia of posterior ciliary arteries. A lot of people with GCA have high platlet count as the thrombocytosis leads to increased risk of vision loss. But then why did she have renal failure? She wasn't eating or drinking much and still taking her Lisinopril medication.  

Key Points:
- Older folks are more prone to giant cell arthritis
- Dehydration with Lisinopril medication is something to look out for!

A New Direction for Weight Loss Care

by Christine Bishundat
Med Ed Committee

Diabetes prevalence is among the highest for chronic disease in Americans. Obesity has a direct role in the foundation of diabetes. It is especially difficult to treat obesity when the steps taken to decrease weight loss relies on patient compliance to lifestyle changes. For severely obese patients, bypass surgery and bariatric surgery have yielded promising results for the long-term treatment of this disease. Through these techniques, interesting findings for weight loss have been uncovered.

Type 2 diabetes is a chain of processes. According to Nicholas Stylopoulos, HMS assistant professor of pediatrics at Boston Children’s Hospital, weight loss treatment usually focuses on the hormone step or fat and muscle section of the chain. Targeting the location of a different pathway in the metabolic system, such as the small intestine, brings us directly to the process that defines obesity.

As bariatric surgery has been around for a few decades, the effects of rapid weight loss have been observed, but only now have researchers begun to take a closer look at what goes on in the small intestine. This type of surgery has revealed that the transporter GLUT-1 appears and its mechanism helps to decrease the presence of glucose in the small intestine. As glucose contributes heavily to obesity, the reduced glucose environment created is highly efficient in weight loss.

Gastric bypass surgery removes a great quantity of gastrointestinal microbiota that effectively aid metabolism. Patients report being less hungry with help from an altered level of hormones that contribute to appetite. Changing the amount and type of gastrointestinal microbiota directly lowers metabolic weight and supports a rapid rate of weight loss. The processing of glucose by short-chained fatty acids in the small intestine accelerates, leading to the rapid rate of weight loss.

Thanks to these findings, it is becoming more apparent that one does not need to be severely obese to get the same benefits of bypass surgery or bariatric surgery. If an outpatient procedure for the small intestine can be developed, the diabetes treatment for primary care centers could become more effective and dramatically alter chronic care statistics.

Didactics: July 16th

July 16th's didactic was an interactive discussion led by resident preceptor, Dr. Lindsay Hintz. Our talk focused on an article published this month in Health Affairs detailing why patients of low socioeconomic status (SES) favor going to the emergency room over their primary care physician. 

The study, which interviewed 40 patients of low SES in Philadelphia, found that for patients the main perceived benefits of the emergency room are better accessibility (in terms of cost, resources, and transportation) and more trust in the quality of services. Some patients gained secondary benefits from the emergency room as it was a place of respite that offered social support.

In order to address the barrier low SES patients face, changes must be made. For example, primary care settings can try to emulate the emergency room's "one-stop shop" services and invest in community health workers to address some of the patients' social support needs. 

To learn more about this study you can read the article here:

Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care

Link to another interesting article relating to primary care published this month in Health Affairs:

States With The Least Restrictive Regulations Experienced the Largest Increase in Patients Seen by Nurse Practitioners

Surveys

Hi all,

If you haven't done so already, please fill out this super quick 7-question Smoking Cessation Survey.
Smoking Cessation Survey

In addition, if you are interested in the nutrition course detailed in the last blog post, please fill out this 10-question assessment before starting.
Nutrition Assessment

Please fill them out by Sunday, August 4th. 

Thank you!

Nutrition: Introduction

Many of you might have already read our emails detailing a free online diet and disease course taught by Katie Ferraro, Assistant Clinical Professor of Nutrition at UCSF. It is a great tool to learn about the appropriate nutritional needs for patients concerned with weight management, heart disease, and diabetes.

We hope you are learning a lot from it so far and if you have not gotten a chance to sign up there is still time! 

Reminder: Before starting on the videos, please take this short 10-question online assessment by Sunday, August 4th for research purposes:
Online Assessment

And to enroll in the **FREE** course please go to the following website:
Nutrition for Health Promotion and Disease Prevention course

 

For 3 weeks, we will provide a weekly list of recommended videos to address your top concerns. Here are the recommended videos for the first two weeks:

Week 1 (total time, ~53 minutes)

1) Why Study Nutrition? (12:22)

2) Meal Planning Around the World (12:00) 

• Features My Plate and Harvard's Healthy Eating Plate guidelines

3) Determining Individual Nutrient Needs (12:23) 

• Features Harris-Benedict Eqn, Mifflin-St. Jeor (for overweight/obese) Eqn, and Shortcut: Calories/kg Method

4) Dietary Supplements (16:58)

• Features upper limits and introduction to contraindications/drug interactions

Week 2: Heart Disease and Diabetes (total time, ~1 hr 10 mins)

Heart Disease videos (time, ~36 mins)

1) Therapeutic Lifestyle Change (13:44)

2) Dietary Fats and Heart Disease (15:54) 

• Features saturated fat guidelines; info on meat and milk; reference to Harvard Fats and Cholesterol  handout (to improve lipid profiles)

3) Hypertriglyceridemia Management (7:46)

• Features dietary guidelines to follow if triglycerides are outside normal range

Diabetes (time, ~34 mins)

1) Physical Activity and Weight in Diabetes (10:38) 

• Features research about metformin/Diabetes Prevention Program and pre-diabetes/impaired glucose tolerance

 3) Meal Planning for Diabetes: Part 1 (10:40) 

• Features eating guidelines for dealing with hypoglycemia ("Rule of 15") and sick day management

4) Meal Planning for Diabetes: Part 2 (12:43) 

We hope you find these videos useful and we'd love to hear some feedback!