H&P/ SOAP notes:
Journal Article and Summary:
There is growing evidence that supports the uses of advanced and innovative technologies, such as telehealth, to monitor and manage people with diabetes at a distance. Studies suggest that telehealth has the potential in improving HbA1c for patients living with diabetes but the overall magnitude of effect is unclear due to variable results. Thus this study was conducted as the first systematic review of systematic reviews and meta-analyses of RCTs to assess the evidence of the effects of telehealth interventions on glycemic control in patients with type 2 diabetes.
They included only studies that were systematic reviews/meta-analysis of RCTs in adults >18 years diagnosed with type 2 diabetes and compared standard outpatient care versus other remote patient monitoring (RPM) with HBA1c as an outcome. Patients also had to transmit electronically or verbally of self-monitored blood glucose (SMBG) readings. A total of 29 unique RCTs were analyzed from the four systematic reviews and/or meta-analyses. Half the studies had automatic transmission of SMBG using either an application on a phone or telehealth unit connected to internet. Others would report blood glucose logs by telephone or input data via the web by phone or computer. Patients were also given feedback of blood sugar readings via automated messages, human calls, personalized feedback via message, a call only if necessary, or videoconferencing.
Based on the primary effect of telehealth on HbA1c, the studies found a statistically significant improvement in HbA1c in the telehealth group when compared to usual care group. Additionally one study found that feedback by interactive telephone calls with a healthcare provider or researcher to be associated with the greatest improvement in HbA1c. Also a significant reduction in HbA1c was reported to be associated with Asian ethnic groups, small study sample sizes, and patients with a baseline HbA1c level of 8% or higher.
Site Evaluation Presentation Summary:
For both the mid and final evaluations, it was conducted via telephone. It had been a while since I spoke with Professor Malavet so we spent some time catching up and discussing how the COVID-19 pandemic had effected out lives. We then proceeded to talk about the family medicine practice I was rotating at. I had informed him that the office gets very busy but the preceptor had trusted me to give me autonomy and see patients and perform physicals exams on. Also I had the liberty to come up with my own assessments and follow up on the patient’s chronic problems like diabetes or hypertension. I presented one full history and physical and five drug cards at my first evaluation and then an additional two H&Ps with five drug cards and an article (summarized above) at my last evaluation. He provided feedback on my first H&P timely so I used his suggestions to improve my documentation. We also spoke about different disease processes and types of diagnostic imaging like a blood scan, which I had no idea was. He explained that in patients with a GI bleed a GI bleeding scan is an imaging test that can help detect the origin of their gastrointestinal bleeding. During the test, blood will be drawn from their vein. The drawn blood will be mixed with a radiopharmaceutical called Technetium-99m. A special camera, called a gamma camera, is used to take pictures of the abdomen after the blood cells are reinjected. Meaning the RBCs are tagged and when the patient undergoes scans the tagged blood can be located, especially if there is a bleed. The test however is longer about 2-3 hours compared to a CT scan, but also offers benefits like lower radiation risk, and good for children and pregnant moms. We also discussed the types of procedures available, mostly venipunctures, finger sticks, EKGs, and vitals. I was also able to review a variety of patient reports from labs and imaging to consult notes.
Typhon Log:
Self-Reflection:
Coming from emergency medicine and going into my Family Medicine rotation I thought it was going to be slower pace and more mundane. However it was face pace yet comprehensive and I had more independence. Advice I got from previous students was that it could get overwhelming but the staff was very kind and patient. I was also fortunate my classmate, Melinda was able to give me a few pointers on the workflow and a brief training on how to use their electronic medical record, eClinical Works (eCW). I met with Melinda the Friday before my start day and she gave me a quick tour and told me about her experience and how to utilize eCW to make visits faster. This allowed me to be more proficient since day one and the preceptor, Dr. Dairo was very appreciative of this. Dr. Dairo was friendly, nice, and you could see she cared for her patients and had great rapport with them. The patient population consisted of middle aged to elderly men and women who were predominantly African/African-American, Hispanic and Guyanese.
From my first day I was an eager beaver and after watching her work with a few patients, I began to see patients myself. Throughout the rotation she gave me a lot of independence and I was able to take a patient in and work up their chief complaint, albeit a lot of patients presented for follow-ups on their chronic conditions such as hypertension, diabetes, hyperlipidemia, and anemia. I documented the HPI, did medication reconciliation, obtained medical, surgical and social history, as well as complete the ROS. Furthermore I would conduct a focused or detailed physical exam and document my findings. I would present them to the doctor when she came into see the patient and we would work together on the assessment and plan. Yet as the rotation progressed I was able to complete my own assessments and plans and make referrals, and assist to refill medications. I was grateful for the experience and she would always give good feedback and we had brief teaching moments on certain patient visits.
One patient that stood out to me was a 48 year old El Salvadorian male who had presented to the office for the first time to establish care and reported that he had not seen a doctor in over 2 years. He had complained of unintentional weight loss of almost 20 pounds over the past year. He denied any change in diet, or taking any medications and denied any active exercising. He was a, slim, neatly groomed, appropriately dressed, good hygiene, and seated in no apparent distress. So in my head I was thinking of differentials for unintentional weight loss, with no significant history. The big one that always comes to mind is cancer, and then there was hyperthyroidism, poor nutrition, tuberculosis, diabetes mellitus and a Psychiatric disorder like depression. Of the following the easiest test to do in office was a blood glucose fingerstick, and lo and behold it was 486. Even postprandial this is considered high, and since it was a random blood glucose level >200, I immediately knew it was due to diabetes (DM). So unfortunately for him I diagnosed him with DM and he was subsequently started on Metformin 500 mg BID, Glyburide 2.5 mg daily, and prescribed a glucometer to measure daily sugar. He was then educated on the importance of adherence and told to avoid concentrated sugars. He was also educated on use of a glucometer and target ranges as well as tracking glucose levels. He was then asked to bring in blood glucose log on next visit. Diet and exercise was also reviewed with patient and information sent to MyPortal. Furthermore labs were drawn to rule out other causes and screening of diseases like hepatitis and tuberculosis. I was also able to see him on a 2 week follow up visit and he reported taking his medication, however insulin was also started since his Hemoglobin A1c was found to be >14.0. Additionally he required further workup based on his lab work, which can be seen on my attached H&P #1.
All in all I enjoyed the rotation and valued being able to discuss/address patients medical problems. I felt respected as part of their medical team and liked being able to follow up with them on subsequent visits. Although family medicine can get hectic and very busy, it is a worthwhile pursuit. I would recommend this rotation site to other students and also recommend learning eCW beforehand.
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