CHA Family Medicine Residency

Tufts family medicine residents have "the best of both worlds"


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Synergy Conference: 9/18/14

“Synergy Conference” is a morning resident conference that reviews the common lab and imaging results AFTER a visit to discuss the next steps in the plan, the part that can often be hidden from preceptors.  Faculty contribute with their suggestions and everyone looks up the best-practices and evidence-based decisions for these situations.
35 y/o M presented with 2wks pedal edema, PND, orthopnea, noticed sugars were a little high – restarted Januvia a couple weeks ago
Initially thought maybe his Januvia or amlodipine were causing edema
But then…! Labs showed Cr =14, albumin 2.7, K 5.7
BNP 35,000
Thought to be due to cardio-renal syndrome
Dialysis recommended but pt has declined multiple times
Biggest concern is hyperkalemia -> risk of fatal arrhythmia

38 y/o F s/p gastric bypass with H/H 6.8/26 microcytic
Iron, ferritin low, TIBC high end of normal -> Consistent with IDA
Patient not compliant with PO iron and might not have great absorption of it due to bypass, so IV iron recommended
To set up IV iron transfusions – talk to Drs. Misra or Taylor to get assistance in setting up pts to get IV iron at transfusion center. Have to write Rx for what you want and fax it to transfusion center
However, pt also had low B12
Gastric bypass pts have poor absorption of PO vit B12 due to lack of intrinsic factor -> best Tx is monthly IM B12 shots
Of note, B12 supplementation in patients with low-normal B12 can help with neuropathic pain
However, very high B12 levels (>1200) can also cause neuropathy and other toxic effects

41 y/o F with incidental pancytopenia
WBC 3.3
H/H 9/26
Plts 60
Had h/o IDA, not currently taking iron
Felt a little tired
No EtOH use
Does take a lot of Reglan, which can cause agranulocytosis
Causes to consider: post-viral marrow suppression, hematologic cancer, medication effects, B12 deficiency
Viral marrow suppression should resolve or improve within a couple weeks after viral infection
Plan: add on manual diff, repeat labs, review meds, consider heme referral if pancytopenia persists without clear cause

59 y/o male who said he had a “thyroid problem” in the past
Initial TSH 6.3, normal T4, no sxs
Repeat 4mos later: TSH 22, normal T4, no sxs
Technically supposed to Tx when TSH >10
Plan: Trial of low-dose levothyroxine (25mcg) and see if pt subjectively feels better. Repeat labs 6wks after starting levothyroxine.

-Lauren

We didn’t get into retic counts much – but that could have helped in the two anemia cases. Retic count in the pancytopenia patient could help confirm marrow suppression, if low, or lead to the consideration of hemolysis if high.
PO B12 supplementation always works, except when it doesn’t. People with gastric bypass in particular may not absorb po B12 because of lack of intrinsic factor. There are plenty of B12 1,000mcg capsules, pills, sublingual – but I write it as a prescription so insurance will pay.
Our nurses generally give the B12 shots subcut. It can be given daily in severe deficiency, but usually is weekly for a month then monthly – 1,000mcg.

-George

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CPR in elderly (worth a read)

Take home point: when obtaining code-status on patients, ask them the following question.

“Would you be interested in hearing the statistics from people your age who underwent CPR?”

A 2014 study that compiled the results of thousands-of-smaller-studies of close to half-a-million patients showed that:
More than half of the patients who survived CPR eventually died before hospital discharge.
In an MBTA bus of 50 identical patients who are elderly and received in-hospital CPR:
for 70 to 79 years old: About 9 out of 50 survive CPR and leave the hospital
for 80 to 89 years old: About 8 out of 50 survive CPR and leave the hospital
for 90 years and older: About 6 out of 50 survive CPR and leave the hospital
Data on social and functional outcome after surviving CPR were scarce and contradictory.

MBTA bus

Only about six to nine of you are getting off this bus before its final destination.”
(Disclaimer: this graphic is solely to illustrate the statistic, NOT to include in the counseling of your patients!)

Van Gijn, MS., et al. (2014) The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review. Age and Ageing. 43: 456–463

Abstract
Background: physicians are frequently confronted with the question whether cardiopulmonary resuscitation (CPR) is a medically appropriate treatment for older people. For physicians, patients and relatives, it is important to know the chance of survival and the functional outcome after CPR in order to make an informed decision.
Methods: a systematic search was performed in MEDLINE, Embase and Cochrane up to November 2012. Studies that were included described the chance of survival, the social status and functional outcome after in-hospital CPR in older people aged 70 years and above.
Results: we identified 11,377 publications of which 29 were included in this review; 38.6% of the patients who were 70 years and older had a return of spontaneous circulation. More than half of the patients who initially survived resuscitation died in the hospital before hospital discharge. The pooled survival to discharge after in-hospital CPR was 18.7% for patients between 70 and 79 years old, 15.4% for patients between 80 and 89 years old and 11.6% for patients of 90 years and older. Data on social and functional outcome after surviving CPR were scarce and contradictory.
Conclusions: the chance of survival to hospital discharge for in-hospital CPR in older people is low to moderate (11.6– 18.7%) and decreases with age. However, evidence about functional or social outcomes after surviving CPR is scarce. Prospective studies are needed to address this issue and to identify pre-arrest factors that can predict survival in the older people in order to define subgroups that could benefit from CPR.
Keywords: CPR, geriatrics, inpatient, prognosis, systematic review, elderly


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Ancillary Services

 

What: Family Planning and Health Education
Who should come: Patients who want to discuss anything related to sexual or reproductive health.
Some of the services the Health Educator can provide are:
-Starting a birth control method
-Access to emergency contraception (like Plan B)
-Pregnancy testing and pregnancy options counseling
-Sexually transmitted infections testing and prevention information
-Talking about sexuality, sexual identity and gender identity
-Talking about relationships in a safe space
Where: Malden Family Medicine Clinic at 195 Canal St., Malden MA
When: Mondays, Tuesdays and Fridays 9:00-5:00; Wednesday and Thursday 9:00-1:30
Who to contact: If you would like meet with the family planning health educator, please schedule an appointment at the front desk or call 781-338-0500.

 

What: Nutrition counseling provided by a registered dietitian
Who should come (and Why):  Nutrition is an important of a healthy lifestyle.  A registered dietitian works with clients to assess their dietary intake and identify area where change is needed.  Nutrition counseling assists all ages to make and maintain the needed dietary changes, helping to improve overall health. People of all ages with different medical conditions and nutritional questions may benefit from nutrition counseling provided by a registered dietitian.
Where: Malden Family Health Center
When: Wednesday 12pm-6pm, and Thursday 9:30am-4pm
Who to contact (and How): Please call 781-338-0500 to schedule an appointment with the registered dietitian.  All clients, except pregnant women, need a referral from primary care provider.

 

Pharmacotherapy
Hours:
Monday 8:30-12 pm and 1:30-4:30 pm
Tuesday 9am-12 noon and 1:30 to 5 pm
Wednesday 9 am-12pm and 1- 7 pm
Thursday 9 am-12 pm
Friday 8:30 am-12pm and 1pm-4:30 pm
What: anticoagulation, Diabetes, hypertension, cholesterol, asthma and medication management. Extensive patient education on disease state, goals of therapy and medications is provided during appointments.
Who should come (and Why): Any patient who needs help getting blood sugars, cholesterol, blood pressure or asthma under control. Patients who will benefit the most are patients who need help managing their medications, have medication related problems, problems with taking their medications, patients who are taking too many medications or recently discharged from the hospital, reduction of pill burden or problems affording medications.
Where: of Malden Family Medicine Clinic at 195 Canal St., Malden MA
Who to contact (and How): please ask your PCP to refer you or call or call the clinic to speak to Alexandra Santamaria.

 


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Integrative, Complementary and Alternative Medicine

Acupuncture with the New England School of Acupuncture

“Our program is distinguished by its concentration in Japanese Acupuncture Styles (JAS), including Shakuju Therapy, an approach based on non-insertive needling technique. JAS relies on exquisite sensitivity in palpatory techniques, taught by pre-eminent senior faculty from Japan and the United States. Programs are academically rigorous, with a strong core of small-group, hands-on practice of our craft.”
“Chinese Herbal Medicine (CHM) is also distinctive at NESA. Taught by expert herbalists trained in China and the United States. CHM relies on a clinical tradition honed from generations of practitioners. The study of CHM is the task of a lifetime, to manage safe and effective use of traditional Chinese herbs for modern patients.”

 

Integrative Medicine Clinic
What:  One morning a week when patients who are referred are seen by a family physician who is trained in Integrative medicine and osteopathic manipulation techniques (OMT) . These are long appointments so that we can discuss the many factors that may influence your health and well-being.
Who should come (and Why):
– Patients referred by their doctors for a more holistic approach to a problem, Patients who may be interested in using modalities other than conventional medicine, such as herbs or mind-body techniques,
-Patients who could benefit from an osteopathic approach to physical pain or issues like repetitive injuries
Where: at Malden FMC
When: Wednesday mornings
Who to contact (and How): Your doctor can refer you or ask the front desk.

 

Join Dr Randi Wertheimer and Dr Lisa Yeung on a journey towards peace and relaxation by participating in the Malden Family Medicine Center’s Stress Reduction Group. We are all confronted with stress and adversity in our lives, and we offer this group as a way to build resiliency and learn calming and relaxing techniques to improve your happiness and over all well-being. If you are a Malden Family Medicine Center patient, and are experiencing stress in your life, we hope that you will join us every Tuesday starting September 2014 from 9:00-11:00am.

 

CHA Yoga:

When: Monday through Thursday
Time: Early morning, afternoon and evening classes.
Where: Cambridge , Somerville, Whidden, Assembly Square.

Interested in Yoga, but not quite sure if you are ready? Speak with your CHA Provider to learn more and receive your discount code. Your first class is always free. Receive a patient discount for all future classes with a referral from a CHA provider.

 


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Group Visits

What: Living Well with Diabetes! A Group Visit
Who should come: for Patients with Diabetes, English-speaking
This is a new kind of appointment where a group of people meet monthly with a doctor, nutritionist, pharmacist and other staff.  We work together to learn ways to control diabetes through nutrition, exercise, stress reduction and medications.  Members meet as a group and one-on-one with the doctor to address any personal health needs.  We look forward to seeing you at our next meeting! Healthy snacks are provided.
Where: Conference room A/B of Malden Family Medicine Clinic at 195 Canal St., Malden MA
When: Thursday
Who to contact: If you would like to attend, please call 781-338-0500 to RSVP with our front desk staff..

 

What: Patient Advisory Council (PAC)
Who should come (and Why): All patients and family members of patients at MFMC who are interested in collaborating with other patient partners and staff to improve the experience and care provided at Malden are encouraged to contact the PAC.  The group regularly provides feedback to clinic leadership and staff on proposed clinic projects as well as generates new ideas for improvement based.  Some projects currently in process include creating a friendlier and cleaner waiting room, improving the MyChart experience and developing ways to better communicate to patients changes occurring at MFMC.
Where: Malden Family Medicine Center – Conference Room A/B
When: 3rd Wednesday of each month, 6-7:30pm; Dinner is provided!
Who to contact (and How): Please contact the front desk for details.  Member recruitment happens on a yearly basis.

 

What: Wellness group
Who should come (and Why): Any English-speaking adult patient who is interested in being well!  In collaboration with a physician, nutritionist and other Malden patients, we discuss practical healthy eating and exercise strategies for weight loss and overall health.  The group often cooks simple snacks and meals together, engages in low-impact exercise such as walking or yoga (tailored to individual abilities) and sets goals for healthy behaviors.  Gain knowledge, techniques and motivation for healthy living.
Where: MFMC – conference room TBD
When: 1-2 evenings per month
Who to contact (and How): please let the front desk know if you are interested in joining the group.  Enrollment will likely occur for an 8-12 week block.

 

(On hiatus)
Join Dr Randi Wertheimer and Dr Lisa Yeung on a journey towards peace and relaxation by participating in the Malden Family Medicine Center’s Stress Reduction Group. We are all confronted with stress and adversity in our lives, and we offer this group as a way to build resiliency and learn calming and relaxing techniques to improve your happiness and over all well-being. If you are a Malden Family Medicine Center patient, and are experiencing stress in your life, we hope that you will join us every Tuesday starting September 2014 from 9:00-11:00am.


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Procedure Clinic

What:  Vasectomy, a family planning option for men who desire elective, permanent sterilization
Who should come (and Why): above
Where: Malden Family Medicine Clinic
When: Counseling can by done at any routine appointment with Dr. Jean S Whitten, Procedures are done on Friday mornings
Who to contact (and How): Call MFMC front desk to schedule counseling appointment, no referral needed

 

MFMC PROCEDURE CLINIC REFERRALS

Dermatology Procedure Clinic:
Wednesday morning and Friday afternoon

  • Punch, excisional and shave biopsies
  • Sebaceous cyst removal
  • Lipoma excision
  • Toenail removal
  • I&D abscess (if acuity / timing works)
  • Foreign body removal (if acuity / timing works)
  • Cryotherapy
  • Skin tag removal

GYN Procedure Clinic
Tuesday morning and Thursday afternoon
All patients must have a counseling appointment with a provider prior to scheduling an gynecologic procedure appointment. Please call 781-338-0500 to speak to our front desk staff or talk to your doctor about your needs.

  • IUD insertion
  • IUD removal only if missing strings
  • Nexplanon (implant) insertion and/or removal
  • Endometrial biopsy – check with GYN preceptor if unsure if indicated or AFP article on Abnormal Uterine Bleeding in Premenopausal Women: http://www.aafp.org/afp/2012/0101/p35.html
  • Colposcopy (preferred for Thursday afternoon) – check new ASCCP guidelines before referring; check with GYN preceptor if unsure
  • Cervical polypectomy
  • Vulvar biopsy
  • Bartholin’s cyst / Word catheter placement
  • Diaphragm fitting


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Behavioral and Psych Services

Integrative Medicine Clinic

What:  One morning a week when patients who are referred are seen by a family physician who is trained in Integrative medicine and osteopathic manipulation techniques (OMT) . These are long appointments so that we can discuss the many factors that may influence your health and well-being.
Who should come (and Why):
– Patients referred by their doctors for a more holistic approach to a problem, Patients who may be interested in using modalities other than conventional medicine, such as herbs or mind-body techniques,
-Patients who could benefit from an osteopathic approach to physical pain or issues like repetitive injuries
Where: at Malden FMC
When: Wednesday mornings
Who to contact (and How): Your doctor can refer you or ask the front desk.

What: Wellness group
Who should come (and Why): Any English-speaking adult patient who is interested in being well!  In collaboration with a physician, nutritionist and other Malden patients, we discuss practical healthy eating and exercise strategies for weight loss and overall health.  The group often cooks simple snacks and meals together, engages in low-impact exercise such as walking or yoga (tailored to individual abilities) and sets goals for healthy behaviors.  Gain knowledge, techniques and motivation for healthy living.
Where: MFMC – conference room TBD
When: 1-2 evenings per month
Who to contact (and How): please let the front desk know if you are interested in joining the group.  Enrollment will likely occur for an 8-12 week block.

 

Join Dr Randi Wertheimer and Dr Lisa Yeung on a journey towards peace and relaxation by participating in the Malden Family Medicine Center’s Stress Reduction Group. We are all confronted with stress and adversity in our lives, and we offer this group as a way to build resiliency and learn calming and relaxing techniques to improve your happiness and over all well-being. If you are a Malden Family Medicine Center patient, and are experiencing stress in your life, we hope that you will join us every Tuesday starting September 2014 from 9:00-11:00am.

 

CHA Behavioral Medicine and Psychiatry

If interested, ask your PCP to place referral.

Cambridge Health Alliance: Outpatient Mental Health @ Central Street:
26 Central St.
Somerville, MA
(617) 591-6033
Details: Most languages available with specialty team or translator

MINDFULNESS STRESS MANAGEMENT  GROUP        For Trauma Survivors
WHAT: This group will provide an understanding of the ways that stress  impacts one’s mind, body, emotions, spirit,  and relationships. It will offer skills for managing the stressors of everyday life; focusing on  health (nutrition, sleep, physical well being), self-compassion and relief from the symptoms that interfere with everyday functioning.
WHO: Prerequisites: commitment to sobriety, safe living situation, no active suicidality/self harm/or psychosis, ability to listen in a group.
WHEN: Group to meet for 8-10 weeks; Wednesday Afternoon (time TBD); at Central Street Health Center; WINTER 2015
HOW: To make a referral: Fill out a VOV group intake form (with your therapist)