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ON EMPTY Beat burnout and compassion fatigue
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INSIDE PEEK INSIDE THE MIPS PROCESS 6 MANAGE PAIN IN A POST-OPIOID ERA 16 BOOST MEDICATION ADHERENCE 20
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Accreditation transformed. Simplified standards. Redefined process. The Compliance Team (TCT) has pioneered accreditation simplification since 1994. We redefined accreditation processes and standards to make them provider-centric and operations based. Our simplified, comprehensive standards are the bedrock of our nationally recognized Exemplary Provider® accreditation programs. Immediate Care providers embrace The Compliance Team’s unique approach, where we adapt our quality standards to the services you offer. From sign-up to onsite survey, your dedicated TCT advisor will guide you through the accreditation process with checklists and expert-led one-on-one webinars.
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VOLUME 1 ISSUE 2
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COLUMNS 20 CLINICAL CARE: MEDICATION IMPROVING PATIENT MEDICATION ADHERENCE Drugs don’t work in patients who don’t take them.
23 CLINICAL CARE: PODIATRY PLANTAR FASCIITIS: DIAGNOSIS AND TREATMENT 25 NUTRITION REPORT PLANT POWER COVER STORY
Answering patients’ questions about plant-based eating.
CARING ON EMPTY Beating burnout and compassion fatigue
28 FOCUS ON WOMEN’S HEALTH MANAGING MENOPAUSE Recognizing menopause symptoms is the biggest challenge. Use these practical tips to help your patients feel better.
32 SEASONAL SPOTLIGHT OMICRON, HAY FEVER, OR A COLD: WHAT’S THE DIAGNOSIS? DEPARTMENTS
FEATURES
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EDITOR’S NOTE
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GUEST EDITORIAL:
THE CONVENIENT CARE ASSOCIATION
INSIDE LOOK The Merit-based Incentive Payment System Project at MinuteClinic.
16 PAIN RELIEF IN THE ANTI-OPIOID ERA Give your patients the pain relief they seek.
Since the omicron variant shares many symptoms with seasonal allergies and colds, how do you tell the difference?
34 5 MINUTES WITH ...
MEGGEN M. BROWN, MSN, FNP-BC, Chief Nursing Officer, Kroger Health’s The Little Clinic.
Convenient Care Clinician is published 5 times a year by EnsembleIQ, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Subscription rate in the United States: $70 one year; $136 two year; $14 single issue copy; Canada and Mexico: $92 one year; $162 two year; $16 single issue copy; Foreign: $100 one year; $186 two year; $16 single issue copy. Postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Please send address changes to Convenient Care Clinician, 8550 W. Bryn Mawr Ave, Suite 200, Chicago, IL 60631. Vol. 1 No. 1, February/March 2022. Copyright 2022 by EnsembleIQ. All rights reserved.
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EDITOR’S NOTE
Moving in the Right Direction Carrie Adkins-Ali Executive Editor
States with FPA Alaska, Arizona, Colorado, Connecticut, Delaware, the District of Columbia, Hawaii, Idaho, Iowa, Kansas, Maine, Maryland, Massachusetts, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, Washington, and Wyoming States with Limited or Restricted Authority Arkansas, California, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, New Jersey, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas Utah, Virginia, West Virginia, and Wisconsin
As I was working on this issue of Convenient Care Clinician, both New York and Kansas adopted full practice authority for nurse practitioners. Now, in 26 states, NPs can evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—no collaborating physician needed. As Americans increasingly seek the care of NPs, this is welcome news for patients and providers alike. “With FPA, providers do not have to rely on monthly chart audits or arrange visits with their collaborating physicians,” Meggen Brown, chief nursing officer and national health and wellness clinical director, Kroger Health/The Little Clinic, told CCC. “This also helps on the financial side. Providers and companies will not have to take on the burden of paying collaborating physicians and can give back to the NPs completing the work. I truly believe it also gives patients more confidence when the states back their profession.” Another huge win, Brown stresses, is that FPA improves access to care in rural and underserved areas. Some states require NPs to collaborate with a physician whose practice is located within as little as 30 to 50 miles from the NP’s workplace. Many rural areas simply don’t have any physicians in that range. FPA also lets patients see the provider they choose, and for many, that’s an NP. A study published in the Journal of Evidence Based Nursing reported that patients are more satisfied with the care they receive from NPs than physicians and that health outcomes are equal. We’re halfway there, but there’s still work to do. At press time, NP practice is still limited in 24 states. If you’re practicing in one of them, take a few minutes to write to your state representatives to educate them about FPA. (You can find links to locate all your representatives at https://www.usa.gov/elected-officials) Here are some tips on writing effective letters to your representatives: • Identify yourself as a constituent and tell them you’re writing about FPA in the first paragraph. • Explain how FPA benefits the elected official’s particular community. You know more about the benefits of FPA than they do. • Be concise. Limit your letter to one page that addresses one issue. • List three important points. • If applicable, include a personal story. • Be courteous but firm. C
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An EnsembleIQ Publication 8550 W. Bryn Mawr Ave Suite 200 Chicago, IL 60631 Senior Vice President, Publisher John Kenlon (516) 650-2064, jkenlon@ensembleiq.com
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EDITORIAL ADVISORY BOARD Nate Bronstein, MSEd, MPA, MSSP, Convenient Care Association Meggen Brown, MSN, FNP-BC, Kroger Health/The Little Clinic Kristene Diggins, DNP, FAANP, MBA, CNE, NEA-BC, CVS Health Tine Hansen-Turton, MGA, JD, FCPP, FAAN, Convenient Care Association Pete Nordeen, Bellin Health/Bellin FastCare Angela Patterson, DNP, FNP-BC, NEA-BC, FAANP, CVS Health Mark R. Watkins, MD, Kroger Health/ The Little Clinic
CORPORATE OFFICERS Chief Executive Officer, Jennifer Litterick Chief Financial Officer, Jane Volland Chief Human Resources Officer, Ann Jadown EVP, Operations, Derek Estey EVP, Content, Joe Territo
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GUEST COLUMN
BY MIKE CLARK, POLICY DIRECTOR, CONVENIENT CARE ASSOCIATION
Momentum for America’s Silent Health-care Army As of 2021, 781,000 Kansas residents lived in a primary care shortage area where only half of the need for primary care providers was adequately met.1 Now that Kansas has adopted full practice authority, NPs in the state can now help meet that growing demand by being able to practice independently, including prescribing medication without physician oversight. When New York became the 25th state to enact full practice authority, Governor Hochul stated that “New York’s health-care workforce is filled with tremendously talented professionals. … We should leverage the growing skills of the workers already caring for New Yorkers to provide even more care when it is needed most.”2 The majority of states now enacting full practice authority legislation signals a momentum shift in the battle to retire outdated regulations and give tools to an army of talented professionals working in retailhealth settings and other practices across the country. PAs have seen several legislative victories in modernizing their practice over the past year as well, and groundwork is also currently being established to modernize the pharmacist profession.
The retail health perspective remains critical in advancing and replicating promising modernization legislation.
and abroad, from the front lines of the opioid crises to the everenduring gaps of patient knowledge, America’s [NPs and PAs] continue their work, quietly filling our nation’s health-care gaps and bringing us one step closer to a day in which every single American has access to affordable and high-quality care.”3 More than two years of a public health emergency has only further demonstrated the need to equip our front-line health-care heroes with the tools they deserve to meet the mounting challenges of the day. Through recent legislative victories and after nearly three decades of effort, we now have the momentum necessary to ensure that this silent army will not be left unequipped and unarmed by outdated and archaic regulations. A majority of states have enacted full practice authority for NPs. Now, we need to ride this momentum to ensure all states enact this legislative framework. PAs and pharmacists also should be practicing at the very top of what their extensive training allows and ride this legislative momentum. CCA provides a unique perspective in these state-level legislative battles. Retail health sits at the intersection of health-care access, direct consumer interaction, and even local economic development. The retail health perspective remains critical in advancing and replicating promising modernization legislation. As upcoming opportunities arise in states like North Carolina, Texas, and Michigan, we will continue to need your first-hand accounts and narratives as we advocate to lawmakers on the importance of retiring these outdated restrictions and unleashing the full potential of America’s Silent Health-care Army. The momentum is there. We now need to capitalize on it. C
At the onset of the pandemic, we discussed America’s Silent Health-care Army. We wrote that: “Once again, we are witnessing America’s silent health-care army mobilizing to fill the gaps that plague this country. Even before the pandemic was officially declared, this workforce of nearly 450,000 medical professionals was already taking aim and planning its response to an invisible and unpredictable enemy. This is not their first fight either: … this silent workforce mobilized in the face of the floods in Texas and the fires in California. From every natural disaster to the refugee crises here
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REFERENCES 1. Rodriguez S. Kansas Nurse Practitioners Gain Full Practice Authority. Patient Engagement HIT. Published April 19, 2022. Accessed May 9, 2022. https://patientengagementhit.com/news/ kansas-nurse-practitioners-gain-full-practice-authority 2. Brusie C. New York Nurse Practitioners Get Full Practice Authority. Published April 19, 2022. Accessed May 9, 2022. https:// nurse.org/articles/new-york-full-practice-nurse-practitioner/ 3. Bronstein N, Clark M. America’s Silent Healthcare Army. Social Innovations Journal. Published April 12, 2020. Accessed May 9, 2022. https://socialinnovationsjournal.org/editions/issue-60/75disruptive-innovations/3062-america-s-silent-healthcare-army
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FEATURE: BUSINESS INNOVATION
BY ANNE POHNERT, MSN, BSN, RN, FNP-BC; TAMMY TODD, MSN, BSN, RN, CRNP, CPHQ; AND JULIE DAVIS
Inside Look The Merit-based Incentive Payment System project at MinuteClinic The Medicare Access and CHIP Reauthorization Act of 2015 was a game changer for payments to Medicare clinicians by the Centers for Medicare & Medicaid Services (CMS). Most notably, it replaced
CMS’ Sustainable Growth Rate payment system with the Quality Payment Program (QPP). Officially launched in 2017, the QPP rewards high-value, high-quality clinicians with payment increases while lowering payments to those who don’t meet defined performance standards. Its objectives include:
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• • •
Improving Medicare beneficiaries’ health and care. Lowering costs to the Medicare program. Educating, engaging, and empowering patients as members of their care teams. • Advancing the use of health-care information between providers and patients. • Maximizing QPP participation with education, outreach, easy-touse program tools, and support tailored to practices’ needs. Based on practice size, specialty, location, or patient population, clinicians and practices can choose from the Merit-based Incentive Payment System (MIPS), geared for those that provide services to Medicare patients, or the Advanced Alternative Payment Models, designed for those that provide high-quality, high-value care with a focus on a specific population, clinical condition, or care episode. In April 2021, MinuteClinic submitted its first annual MIPS report. Since its inception in 1999, MinuteClinic, which now has more than 1,100 retail medical clinics across 35 states and the District of Columbia, has emphasized the quality, accessibility, and cost-effectiveness of the care it offers, making the decision to participate in MIPS a natural one. MinuteClinic’s Anne Pohnert, MSN, BSN, RN, FNP-BC, director of clinical quality, and Tammy Todd, MSN, BSN, RN, CRNP, CPHQ, senior clinical quality manager, spearheaded the MinuteClinic MIPS integration project. Their experiences should be instructional for other organizations and practices who want to take part in MIPS and the QPP.
Convenient Care Clinician: How did MinuteClinic lay the groundwork for participating in MIPS? Anne Pohnert: We’ve had a quality metrics program for years, and part of evolving is understanding how to stretch the boundaries of quality measurement and improvement. We had met thresholds for certain aspects of previous iterations of the CMS program for individual providers. We’d been tracking CMS changes along with the requirements for submission as part of our quality approach. And so, as we came to understand the specifics of MIPS and saw an opportunity to submit and test ourselves, we talked with our external partners at Epic [a tech company that offers a suite of products for medical center operations, including electronic record-keeping] about what it would take to pull it together and who would be the right person for project manager. Fortunately, Tammy, our quality data and reporting expert, was ready to step in and lead the project.
CCC: What are the essential keys to success with MIPS? Tammy Todd: Because it’s such a broad and complex project, you have to build a very strong project team and connect the key partners. There’s the clinical aspect—you need to be able to interpret the clinical elements that are required—but there’s also the technical aspect around submitting data. We have an internal IT team as well as an external Epic
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At a Glance •
MinuteClinic’s Anne Pohnert, MSN, BSN, RN, FNP-BC, and Tammy Todd, MSN, BSN, RN, CRNP, CPHQ, share their experiences with the Merit-based Incentive Payment System (MIPS).
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MIPS is one of two options under CMS’ Quality Payment Program
electronic health record support team who supported the project. Anne Pohnert: Another essential is building your understanding of CMS and all the requirements. Tammy did a great job of reviewing the QPP resources, attending webinars and learning everything possible about the program. It helps for one person on the team to develop the expertise and oversee the entire process. Tammy Todd: CMS resources are so vast, so supportive, and so easy to access. The Electronic Clinical Quality Improvement Resource Center site at ecqi.healthit.gov really offers robust educational resources on the technical component, as well as resources for the health provider to learn more. This site is an excellent resource, as well as qpp.cms.gov.
CCC: Who did you draw on within MinuteClinic and Epic to put together your dream team? Tammy Todd: It’s essential to have leadership sponsorship and commitment to the project. Our executive sponsors included the president of MinuteClinic, the chief nurse practitioner officer, the medical director for quality and patient safety, and the senior director for payer relations. Key program partners included provider credentialing, payer enrollment and medical coding, payer relations, enterprise analytics and reporting, clinical practice, and members of the internal MinuteClinic Epic electronic health record team who were already working with Epic. External Epic partners included their technical solutions engineers and other personnel who specialize in supporting clients with developing quality measure reporting for programs such as MIPS.
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FEATURE: BUSINESS INNOVATION
CCC: How were you able to get MinuteClinic practitioners engaged in supporting the program and not just seeing it as more paperwork or data entry? Anne Pohnert: We were able to leverage our existing and very robust internal clinical-quality dashboard, which is providerfacing and is an important tool for communicating performance of quality care and improvement over time. [Our clinicians are already] familiar with it, so linking it to the new project made sense. Our practice is becoming more primary-care enabled, and as our providers are delivering this expanded type of care, we’re engaging with them and supporting them so that they continue to be successful, not only with existing metrics but also with these new metrics that are more nationally and not just internally driven. Tammy Todd: MinuteClinic offers an internal provider communication website which is leveraged to house all clinicalquality resources, including the MIPS-related work. Creating tip sheets, additional provider training, and provider access to an Epic-MIPS provider dashboard has been a focused strategy to enhance provider engagement. One of the most essential aspects of MIPS success is enhancing provider knowledge of what the measures mean, and describing proper documentation workflows to achieve success. We also explained the patient benefit—that it’s not only CMS rewarding companies but also making a better outcome for the patient. That was already part of our strategic educational plan, because patient experience is a very important aspect of our work here in the Quality Department—if we can improve on that with the work we’re doing with MIPS, we certainly want to leverage that.
Tammy Todd: In our first year, we were focused on learning the MIPS reporting process, identifying the quality measures to report, building the quality reporting framework in Epic, and mapping the clinical documentation behind the quality measures. Now, we’re looking for where we can expand success with metric outcomes and where we can build even greater success. We have some existing services for which we already deliver a lot of the components of the MIPS measures, but we need to optimize the documentation workflow to drive success with these metrics. We’re also getting a better understanding of why companies get back the percentage that they do from CMS. A lot of people I work with at Epic who are really good in terms of MIPS say it’s a big question mark—you submit the MIPS data as directed, but there are so many variables to consider in terms of how the scores are calculated, that it is often hard to predict the outcome. For example, cost is assessed and adjusted for by CMS directly after submission. In 2021, MIPS distributed 20% of the score for cost, so this variable may have a strong impact on outcomes. In 2020, the cost measure was neutralized for all practices due to COVID-19, so it will be an important indicator for MC MIPS success in 2021.
CCC: The CMS site mentions further improvements to come in 2023. Is there a learning curve every time the parameters change? Tammy Todd: I would definitely say there’s a learning curve, but the approaches that CMS is trying to implement are thoughtful. They’re trying to reduce the burden of data submission. The process is so data-driven that if you don’t have the infrastructure to be able to submit that data, it’s going to be a barrier.
CCC: What did you learn in year one that you applied to year two? Anne Pohnert: Submitting data each time gets you very familiar with the process, so it’s not as daunting as it was the first time around.
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Traditional MIPS “Traditional MIPS” is the original framework available to eligible practices for collecting and reporting data. Performance is generally measured across four areas, some of which might be inapplicable or weighted based on the type of practice. For instance, NP- and PA-facing practices, such as MinuteClinic, are currently excluded from the “performing interoperability” reporting category, so the “quality” category takes on a greater weight for them. There are four performance categories: 1. Quality. This category assesses the quality of the care a practice or organization delivers based on performance measures created by CMS as well as medical professional and stakeholder groups. Participants pick six quality metrics that best fit their practice. 2. Improvement Activities. This assesses how participating organizations improve their care processes, enhance patient engagement in care, and increase access to care. Participants choose activities appropriate to their practice. 3. Promoting Interoperability. This assesses how well a practice promotes patient engagement and the electronic exchange of health information using certified electronic health record technology. 4. Cost. This assesses the cost of the patient care provided by practices. Participating organizations and practices submit the data collected on the first three categories during the performance year in an annual report. CMS collects and calculates cost metrics based on an organization’s Medicare claims to determine the cost of the care provided to qualifying patients. The four performance categories are assigned scores and added together to calculate the MIPS final score, which determines the payment adjustment applied to the organization’s Medicare Part B reimbursements. Each MIPS performance year begins on January 1 and ends on December 31. If an organization is eligible for MIPS, it must report the data it collected during the calendar year by March 31 of the following calendar year. Payment adjustments based on the submitted data for services provided are applied to Medicare Part B claims from January 1 to December 31 of the following performance year.
CCC: What’s your advice for practices that want to attempt to participate in MIPS? Tammy Todd: Planning is essential. Allow at least six months before the MIPS reporting cycle to lay all the groundwork. Build the project plan, build the team, build the knowledge, register on the QPP portal, and then you will be prepared to report the following year. Find your internal point person to serve as your quaterback. Connecting and collaborating with the various teams is essential to the success of the project. That’s especially valuable if there’s personnel turnover at your external partner’s organization, which we experienced late in the first year of the project. The more stability you can build within your internal project team, the better. If you don’t have a relationship with an outside team to support your work, a consultant is an option, but it’s costly, so you’d have to weigh that cost/benefit ratio. Anne Pohnert: You have to understand your strengths as an organization and what types of measures make the most sense for you. Have a good understanding of how your reporting is set up so that you will have confidence that you’re reporting accurately. If you’re already measuring quality, tracking data, and using it in a productive way to support high quality in your practice, think of submitting to MIPS as taking it to another level. Tammy Todd: If you select measures within MIPS that you’re already tracking and are successful with, you can build on that success right out of the gate. I also want to make the point that you have to go into a project as large as this with a long-term commitment. It can’t be something that you’re going to do for a year to see how it goes—the first year is just the first building block. You’re constantly learning and expanding knowledge that, in turn, should trickle down to your providers to have a greater impact on the quality of outcomes for the patient.
CCC: Can a smaller practice be as adept as a company as large as MinuteClinic at implementing MIPS participation? Tammy Todd: A smaller practice can certainly do this well and, in some regards, it may be easier because their data volume would be lower. Also, CMS is in the process of creating the MIPS Value Pathways, a subset of measures and activities that can be used to meet MIPS reporting requirements beginning in the 2023 performance year. CMS is trying different approaches to reduce the burden of reporting on smaller practices. C
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COVER STORY
BY LESLIE GOLDMAN, MPH
CARING ON EMPTY Beating burnout and compassion fatigue
In 2014, Kathryn Reed, MS, PA-C, EMT-P, RYT, was a paramedic working in McKees Rocks, Pennsylvania, watching patients die one after another due to opioid overdose. After earning her physician assistant (PA) degree, she then began working on an acute inpatient behavioral health floor in a Veterans Affairs hospital, treating the physical ailments of young, mentally ill, often suicidal patients. While there, a colleague gave her advice that has stayed with her ever since: “You have five paid weeks off a year. Take them or else you’re going to get burned out.” Burnout Symptoms Several years later, the phenomenon Reed’s colleague was referencing has reached epidemic proportions among health-care providers. It has a constellation of symptoms:1,2 • emotional exhaustion • a reduced sense of competence • depersonalization (including emotions such as cynicism and apathy) • loss of perspective that one’s work is meaningful. Burnout syndrome affects more than half of all U.S. clinicians, per a 2019 study in The American Journal of Accountable Care.3 That includes nurse practitioners (NPs) and PAs, both of whom experience the debilitating, sometimes career-ending syndrome in rates similar to that of physicians.1,4
Consequences of Burnout Burnout carries significant consequences, and not just for clinicians, who experience elevated levels of stress, anxiety, and depression5; higher rates of alcohol and drug abuse, and suicide3; and lower job satisfaction. It also affects patients, who are more likely to fall victim to medical errors when treated by a burned-out provider.3 Besides potentially compromising patient safety, burnout also fuels significant financial loss when it drives health-care providers to leave their jobs. Employers, on average, spend approximately $250,000 to replace an NP or PA.6 Considering that half of the 3,680 providers who responded to the Center for Healthcare Leadership and Management 2018 PA and NP Workplace Experiences National Summary Report have quit their job at least once due to burnout, stress, or a toxic work environment, this phenomenon of career-related exhaustion is a real threat.7 Compassion Fatigue Compassion fatigue (CF) is another modern-day scourge with similar consequences. Distinct from burnout (though the two may co-exist and share overlapping symptoms),8 CF happens “when you give and give until you ‘give out’ and become numb to caring,” explains Chelsia Harris, DNP, RN, FNP-BC, executive director
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At a Glance
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Burnout can cause elevated levels of stress, anxiety, and depression; higher rates of medical errors, alcohol and drug abuse, and suicide; and lower job satisfaction.
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Compassion fatigue (CF) is distinct from burnout, but the two may co-exist and share overlapping symptoms. CF occurs when health-care providers “give out and become numb to caring.”
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Therapy, social support, exercise, and laughter can all lower stress and help some of the symptoms of burnout, but they’re not enough on their own.
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Health-care leaders must address the systemic issues that are causing high rates of burnout and CF.
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COVER STORY
of Lipscomb University’s School of Nursing in Nashville, Tennessee, and an expert in compassion fatigue. This is an unconscious self-preservation technique that strikes clinicians who are “continuously exposed to trauma and seeing an exponential amount of loss,” like they have during the COVID-19 pandemic. It renders one “unable to love, nurture, care for, or empathize with another’s suffering.” Causes of Burnout and Compassion Fatigue The National Academies Press’ (NAP) “The Future of Nursing 2020-2030:Charting a Path to Achieve Health Equity” cites factors such as excessive workloads, staff shortages, and extended shifts as contributors to nurse burnout, while “chronic and intense patient contact, prolonged stress, a lack of support, high workload” and other pressures can trigger CF.1 But that’s not all: Pandemic effects. Serving on the front lines of the pandemic has driven up burnout rates,9 with sources of burnout-producing stress stemming from witnessing numerous deaths, the uncertainty of how to care for patients, social isolation, fear of spreading the virus to loved ones, severe staff shortages, and more.1,10 Nurses working at retail clinics and in inpatient hospital care have been hit especially hard, with 59% and 76% of them, respectively, having treated COVID patients.10 Dr. Harris says colleagues working in retail health and urgent care have reported CF after months of attempting to educate thousands of patients on proper masking protocols and vaccination, only to be ignored and asked for experimental treatments recommended by friends and family. Documentation burden. Electronic medical records, excessive documentation demands, and the pressure to bill in high volumes all contribute as well, says Tim Cunningham, RN, DrPH, FAAN, vice president of practice & innovation at Emory Healthcare in Atlanta and co-author of “Self-Care for New and Student Nurses.” Scope of practice. “A lot of state and federal laws had to shift to allow us to operate at the top of our scope, and some of those regulations have stayed, which has been a silver lining. But that also means many of us were … working more hours, interfacing with more patients, and being utilized at the tiptop of our practice in settings that didn’t have enough providers,” Reed adds. Racism at Work Systemic racism fuels burnout and CF as well. Reed, a biracial woman and founder of the National Society of Black Physician Assistants (NSBPA), says that being a provider of color in a mostly white field can take a toll on one’s mental health and career satisfaction. During the George Floyd protests of 2021, she says, she was followed into work by a police officer on Blackout Tuesday, even though she was
Leadership Needs to Change the Culture Health-care leadership needs to walk the walk when it comes to prioritizing clinician wellbeing. Here are a few strategies that can help. Adaptive staffing. During a recent American Medical Association webinar titled, “COVID-19 and Rethinking Wellness,” the chief wellness officer of Chicago’s Rush University Medical Center, Bryant Adibe, MD, recalled receiving a consult from a team leader who reported their team was experiencing excessive stress and a 30% increase in workload volume likely related to COVID-19. “What the team needed was not wellness tips and tricks,” Dr. Adibe said. “[It needed] an adaptive staffing plan— one that would allow for a flexible, temporary increase in staffing to meet that 30% increased demand so that their load would be more manageable.”1 Stick with essentials. Pruning away tasks that don’t improve patient care, reducing charting burdens, and improving the user-friendliness of health information technology are three other examples of carving out room for clinicians to better attend to patient needs while also taking care of their own.2 Create safe spaces at work for staff to retreat to when stressed. Leaders need to trade “draconian policies around rest and relaxation” for “resilience rooms or wellness zones so staff can take a few minutes to breathe, stretch, read, cry, hydrate, or nap,” says Dr. Cunningham. Wellness rooms
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an easy reporting system that allows for anonymity. “Taking the concerns of their teams seriously can build rapport and create an environment that brings folks from diverse backgrounds together,” she says. Dr. Cunningham would like to see an end to the still commonplace practice of allowing patients to make requests regarding their health-care providers’ race. Mayo Clinic, he notes, has adopted a progressive policy, now stating: “We won’t grant requests for care team members based on race, religion, ethnicity, gender, sexual orientation, gender identity, language, disability status, age or any other personal attribute.”7
can be existing areas, such as a dining or meeting room, that are repurposed and outfitted for self-care endeavors. Outdoor spaces work as well. Robust literature shows that time spent in nature is mentally and emotionally healing. Peer-to-peer support. Dr. Kaushik endorses peer-to-peer coaching sessions to give clinicians the chance to feel heard, swap tips, and commiserate. •
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Minute Clinic provides colleague interest groups that provide outlets for special interests and focus on individualized professional practice, says Kristene Diggins,DNP, FAANP, MBA, CNE, NEA-BC, from CVS MinuteClinic. “These groups help prioritize personal life and allow providers to develop goals professionally that can support a group vision and strategy in times of stressful work.” Kroger Health has initiated conversations with team members to address the multiple issues and concerns that they are facing, says Meggen Brown MSN, FNP-BC, and developed a strategy to provide peer support on “mind, movement, and nutrition.” At the University of North Carolina at Chapel Hill, the Peer Support Program connects providers with trained volunteers for support following adverse patient events, patient losses, or verbal or physical assaults from patients or visitors.3,4 Johns Hopkins Medicine’s confidential peer-support program, RISE (Resilience in Stressful Events), provides similar “inperson psychological first aid and emotional support” to health-care professionals and has been replicated in more than 30 U.S. hospitals in the past six years.5-6
Address racism. In terms of addressing burnout stemming from systemic racism, Reed would like to see clinic and hospital leadership institute zero-tolerance policies and procedures for discrimination, harassment, and microaggressions, including
Provide mental health services. To support clinicians through the pandemic, the American Nurses Foundation launched a national wellbeing initiative to provide nurses access to a menu of mental health and wellness-related resources designed to help manage trauma and mitigate burnout, including peer-support video chats, a narrative expressive writing program, and a smartphone app that connects nurses one-on-one to a trained support giver 24/7.8 Kroger Health partnered with Magellan Health to provide free mental health services to its employees, Dr. Brown says. The very existence of such endeavors sends the message to staff that they matter, Dr. Cunningham says, noting that, “When people feel heard, and their needs are being met, they’re less likely to feel burnout.”
REFERENCES 1. American Medical Association. How the last year has forced rethinking on physician burnout. Accessed December 9, 2021. 2. American Medical Association., Bryant Adibe, MD, discusses rethinking wellness during COVID-19. Accessed December 9, 2021. https://www.ama-assn.org/practice-management/physician-health/ bryant-adibe-md-discusses-rethinking-wellness-during-covid-19 3. Rush University Center for Clinical Wellness. Accessed December 9, 2021. https://www.rushu.rush.edu/rush-experience/student-services/ center-clinical-wellness 4. University of North Carolina. Integrated Emotional Support Program. Accessed December 9, 2021. https://www.med.unc.edu/ psych/wellness-initiatives/integrated-emotional-support-program/ 5. University of North Carolina. Peer Support Program. Accessed December 9, 2021. https://www.med.unc.edu/psych/ wellness-initiatives/peer-support-program 6. Johns Hopkins University. Caring for the caregiver. Accessed December 9, 2021. https://www.hopkinsmedicine. org/armstrong_institute/training_services/workshops/ Caring_for_the_Caregiver/ 7. Wu AW, Connors C, Everly, GS, Jr. COVID-19: Peer support and crisis communication strategies to promote institutional resilience. Ann Intern Med. June 16, 2021. Accessed December 9, 2021. https://www.acpjournals.org/doi/10.7326/M20-1236 8. Warsame RM, Hayes SN. Mayo Clinic’s 5-step policy for responding to bias incidents. AMA Journal of Ethics. June 2019. Accessed December 9, 2021. https://journalofethics.ama-assn.org/article/ mayo-clinics-5-step-policy-responding-bias-incidents/2019-06
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wearing scrubs and had her hospital ID around her neck. “That same day, a patient came in saying, ‘We need to kill all the [racial slur] protesters.’ It’s exhausting having a lack of support, lack of mentorship, lack of seeing myself represented in my colleagues, lack of a sounding board.” Asian providers have reported verbal and physical abuse in the wake of COVID, too. Internationally educated nurses contend with racism and discrimination as well, according to the NAP.1 Add to that the fact that many Black and Latin clinicians feel the pressure of the “Minority Tax,” the unspoken burden placed on employees of color to do the heavy lifting when it comes to creating awareness of workplace diversity.11
If we, as leaders, push nurses to practice resilience but do nothing to address systemic problems such as staffing, the electronic health record, and incivility in the workplace, then we are missing the boat.
“We’re doing all we can for patients, and you’re also asking us to create cultural and systemic changes within the institution,” Reed notes, adding that she knows of one Black PA who quit medicine to work at Trader Joe’s because “she felt unappreciated in a system that doesn’t seem to prioritize the lived experiences and mental health state of any providers, and specifically minority providers. It’s all cumulative and over time, it can create burnout.” Finding Fixes Dharam Kaushik, MD, an associate professor of urology and a urologic oncologist at the University of Texas Health San Antonio, says the first step towards finding solutions is recognizing that burnout and CF exist. Whether you’re a student, doctor, NP, or
PA, the message ingrained early on is: “There is no room for complaining, and you’re expected to have empathy for everyone else but not yourself. You can take vacation days, but there are no wellness days off.” This mindset, he says, is damaging and can breed burnout and CF. Clinician Self-Help Personal stress management strategies—while not enough to address the issue of clinician burnout on their own—can provide meaningful relief from feelings of burnout and CF.12 Therapy Working with a therapist gives you the opportunity to vent, judgment-free, and can also teach you to challenge and reframe unhealthy or unproductive thoughts. (“I’ve lost my touch” becomes “I’m doing the best I can under difficult circumstances.”) Cognitive behavioral therapy and acceptance and commitment therapy are two proven methods to help address anxiety, depression, and burnout.13,14,15 Pandemic-related changes in telehealth mean that you can now teleconference with your therapist from your living room couch, eliminating some of the traditional barriers. Don’t let outdated stigma surrounding therapy deter you: One out of every six Americans tried therapy for the first time in 2020, joining the one-third of Americans who either continued or returned to it.16 Dr. Harris notes that non-traditional types of therapy, like art therapy and pet therapy, offer similar benefits, too. (She recently took up painting for just this reason.) Find your Village Reed recommends finding a support system, whether that’s friends and family who can lend an ear, or by joining a specific caucus of your health-care professional organization. “Finding your community helps you see past the misery of that day and look more broadly at the impact you are making,” Reed says. “You can interact with like-minded individuals who give you the energy and strength to keep pushing on as well as remind you to take breaks.” It can also help you find a mentor and networking opportunities. Exercise Jogging, dancing, basketball, Spinning, tennis, yoga: Exercise has the ability to reduce stress, improve sleep, and trigger the release of feel-good endorphins.17 Research suggests that working out may also help ease burnout by offering a distraction from stress, reducing a person’s physiological sensitivity to chronic stress, and boosting resilience,18 which has been shown to serve as a sort of antidote to burnout while improving compassion satisfaction.19 Dr. Harris calls compassion satisfaction the joy and satisfaction one feels from working as a professional caregiver, “the opposite of compassion fatigue.”
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Laughter Laughter is wonderful, stress-relieving medicine. It promotes relaxation, improves self-esteem and energy levels, and cuts through anxiety.20 As a board member of Clowns Without Borders who has performed in Sierra Leone, Turkey, Haiti, and more, Dr. Cunningham has witnessed this first-hand. Whatever you find funny—live comedy, spending time with your most amusing friend, tuning into a humorous podcast—seek it out. Still, running along the lake and binge-watching The Office reruns, enjoyable as they may be, aren’t enough to cure burnout. “Personal resilience is only one small piece of the puzzle,” Dr. Cunningham recently wrote in the American Journal of Nursing. “If we, as leaders, push nurses to practice resilience
but do nothing to address systemic problems such as staffing, the electronic health record, and incivility in the workplace, then we are missing the boat.”21 He notes that leaders say, “To fix your burnout, you just have to meditate more,” but health-care providers don’t have time to meditate. The organizational culture needs to shift, he says, so that self-care is not just a possibility, but a priority. See the sidebar for more information on how leaders can address burnout. C
REFERENCES 1. National Academies of Sciences, Engineering, and Medicine 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press. Accessed December 9, 2021. https://doi.org/10.17226/25982. 2. UNC School of Medicine Psychiatry. Integrated Emotional Support Program. Accessed December 9, 2021. https://www.med.unc.edu/ psych/wellness-initiatives/integrated-emotional-support-program/ 3. Melnyk BM. making an evidence-based case for urgent action to address clinician burnout. The American Journal of Accountable Care, June 2019;7(2):12-14. Accessed December 9, 2021. https://www. ajmc.com/view/making-an-evidencebased-case-for-urgent-actionto-address-clinician-burnout 4. Essary AC, Bernard KS, Coplan B, et al. Burnout and job and career satisfaction in the physician assistant profession: A review of the literature. National Academy of Medicine. 2018. Accessed December 9, 2021. https://nam.edu/burnout-and-job-and-career-satisfaction-inthe-physician-assistant-profession-a-review-of-the-literature/
12. To ensure high-quality patient care, the health-care system must address clinician burnout tied to work and learning environments, administrative requirements [news release]. Washington, DC: National Academies of Sciences, Engineering, and Medicine. October 23, 2019. Accessed December 9, 2021. https://www. nationalacademies.org/news/2019/10/to-ensure-high-qualitypatient-care-the-health-care-system-must-address-clinicianburnout-tied-to-work-and-learning-environments-administrative-requirements 13. Anclair M, Lappalainen R, Muotka J, Hiltunen A. Cognitive behavioural therapy and mindfulness for stress and burnout: a waiting list controlled pilot study comparing treatments for parents of children with chronic conditions. Scand J Caring Sci. 2018;32(1):389-396. 14. Sampson M, Melnyk BM, Hoying J. Intervention effects of the Mindbodystrong cognitive behavioral skills building program on newly licensed registered nurses’ mental health, healthy lifestyle behaviors, and job satisfaction. JONA. 2019;49(10):487-495.
5. Burnout a ‘growing problem’ for physician assistants, reports JAAPA [news release]. Philadelphia, PA: Wolters Kluwer; August 27, 2021. Accessed December 9, 2021. https://www.wolterskluwer.com/ en/news/burnout-growing-problem-for-physician-assistants
15. The Ohio State University College of Nursing. MINDBODYSTRONG an evidence-based program for clinicians. Accessed December 9, 2021. https://nursing.osu.edu/offices-and-initiatives/ mindstrongtmmindbodystrong#mindbodystrong
6. Roberson J. Survey uncovers ways employers can enhance the PA workplace [news release]. October 4, 2019. American Association of Physician Assistants. Accessed December 9, 2021. https://www.aapa.org/news-central/2019/10/ survey-uncovers-ways-employers-can-enhance-the-pa-workplace/
16. McNally V. Shocking number of Americans say 2020 pushed them to try therapy for the first time. SWNS Media Group. September 6, 2021. Accessed December 9, 2021. https://swnsdigital.com/ us/2021/01/shocking-number-of-americans-say-2020-pushed-themto-try-therapy-for-the-first-time/
7. Center for Healthcare Leadership and Management. PA and NP workplace experiences. National summary report. May 8, 2019. Accessed December 9, 2021. https://www.chlm.org/wp-content/ uploads/2019/05/2018-CHLM-PA-NP-Report-Review_May2019. pdf?uuid=e856b5d8d848df65
17. The Anxiety and Depression Association of America. Physical Activity Reduces Stress. Accessed December 9, 2021. https://adaa.org/understanding-anxiety/related-illnesses/ other-related-conditions/stress/physical-activity-reduces-st
8. Weintraub A, Geithner E, Stroustrup A, et al. Compassion fatigue, burnout and compassion satisfaction in neonatologists in the US. J Perinatol. 2016;36:1021-1026. https://doi.org/10.1038/jp.2016.121 9. Kaushik D. Medical burnout: Breaking bad [news release]. Washington, DC: American Association of Medical Colleges. June 4, 2021. Accessed December 9, 2021. https://www.aamc.org/ news-insights/medical-burnout-breaking-bad 10. Frellick M. Nurse burnout has soared during pandemic, survey shows. Medscape. December 24, 2020. Accessed December 9, 2021. https://www.medscape.com/viewarticle/943091#vp_2 11. Rodriguez JE, Campbell ML, Pololi L. Addressing disparities in academic medicine: What of the minority tax? BMC Medical Education. 2015;15(1):6.
18. American Psychological Association. Working out boosts brain health. March 4, 2020. Accessed December 9, 2021. https://www.apa. org/topics/exercise-fitness/stress 19. Thapa D, Levett-Jones T, West S, Cleary M. Burnout, compassion fatigue, and resilience among health-care professionals. Nursing & Health Sciences. 2021; 23(3):565-569. Accessed December 9, 2021. https://onlinelibrary.wiley.com/doi/epdf/10.1111/nhs.12843 20. Shattla S, Mabrouk S, Gehan A. Effectiveness of laughter yoga therapy on job burnout syndromes among psychiatric nurses. Abed International Journal of Nursing. 2019(6)1: 33-47. 21. Cunningham T. The burden of resilience should not fall solely on nurses. AJN. 2020;120(9):10-11. Accessed December 9, 2021. https:// www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key= pdf_00000446-202009000-00002
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FEATURE: PAIN MANAGEMENT
BY JULIE DAVIS
Pain Relief in the Anti-Opioid Era Give your patients the pain relief they seek
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Pain erodes overall quality of life by impairing the ability to work, play, or simply manage the activities of daily living. It is the most common symptom that drives patients to seek immediate care, says Rosemary Carol Polomano, PhD, RN, FAAN, professor of pain practice at the University of Pennsylvania School of Nursing in Philadelphia. Guiding Principles When patients with pain get to your clinic, they’re uncomfortable and frustrated and may be expecting medications they’ve received in the past, namely opioids. But the foundation of acute pain management is now nonopioid medication and other, nondrug techniques. February 2021 marked the culmination of a two-year project spearheaded by the American Society of Anesthesiologists (ASA) aimed at curtailing opioid abuse. Fourteen medical groups developed guidelines to help decrease an overreliance on opioids, increase access to care, and promote widespread education on pain and substance-use disorders. It established guiding principles that are based on multimodal and multidisciplinary approaches to pain management, including nonpharmacologic interventions, the use of validated pain assessment tools to guide and adjust treatment, and an emphasis on individualized care and education. Role of Opioids The guidelines don’t remove opioids from the arsenal of pain management tools, but they do redefine their role as a short-term solution. “There will still be times when an opioid is used—for a patient passing a kidney stone, for instance, or recovering after surgery—with right-sized dosing and monitoring,” says David M. Dickerson, MD, chair of the ASA’s committee on pain medicine and medical director of Anesthesia Pain Management Services at NorthShore University Health System in Evanston, Illinois. “Using a multiprong approach to pain means that the core of pain control is with modalities that can still be used when any course of opioids is over,” he explains. Pain-Management Modalities The foundation of acute pain management is often acetaminophen, but a patient may need a second layer of pain treatment, such as a topical numbing agent, muscle relaxant, or heat, ice, and elevation. Within convenient-care settings, here are the most helpful pain management modalities. Over-the-counter Analgesics Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Brufen, Advil, Motrin, Nurofen) and naproxen (Aflaxen, Aleve, Anaprox, EC Naprosyn, Naprelan) are often the first line of treatment for short-term use. NSAIDs are meant to be taken at the recommended dosage for a fourto six-day period. The longer patients take NSAIDs, the greater the risk of cardiovascular issues, gastrointestinal dysfunction, kidney problems, and increased bleeding time. “It’s always important before prescribing any
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At a Glance •
Fourteen medical groups joined together to develop guidelines to help decrease an overreliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders.
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The guidelines don’t remove opioids from the arsenal of pain management tools, but they do redefine their role as a short-term solution.
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Nonopioid pain-relieving treatments may include OTC medications, steroids, anticonvulsants, antidepressants, heat, cold, and transcutaneous electrical nerve stimulation.
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Exercise and diet play an important role in pain management.
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Several evidence-based mind-body techniques that activate descending pathways from the brain to the site of the pain can be helpful.
analgesic to know the patient’s health history, especially any hepatic, gastric, or renal issues,” says Dr. Polomano. Acetaminophen (Tylenol, Paracetamol, Panadol, Aceta) can cause liver toxicity if taken for too long or in dosages that are too high. The American College of Gastroenterology notes that healthy people should take no more than 1,000 mg of acetaminophen per dose or 4,000 mg per day. If a patient has liver disease, acetaminophen intake should not exceed 2,000 mg per day. Healthy people should also avoid taking 3,000 mg of acetaminophen daily for more than three to five days. Patients should undergo liver-function testing, avoid drinking alcohol, and include the drug on their medication list any time another health-care provider asks what drugs they take regularly. Steroids For acute pain, such as back pain that radiates down the leg, a short course of steroids can help decrease inflammation and pain. But these drugs shouldn’t be prescribed long term because of their side effects, says
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FEATURE: PAIN MANAGEMENT
Grant Chen, MD, associate professor of anesthesiology and chief of chronic pain services at McGovern Medical School at UTHealth, Houston. Anticonvulsant Drugs Pregabalin (Lyrica) and gabapentin (Horizant, Gralise, Neurontin) can help with neuropathic and muscular pain. A small study published in October 2021 in The Korean Journal of Pain explained that pregabalin seems to work by interrupting “the immune system’s role in the pathogenesis of neuropathic pain.” These drugs are relatively safe, but not all patients respond to them, notes Dr. Chen. Antidepressants Drugs such as duloxetine (Cymbalta) and venlafaxine (Effexor) can help with neuropathic pain. You may need to explain to patients that you are not suggesting that their pain is caused by depression, but that these drugs can affect how the brain perceives pain. Start patients at a lower dose to reduce the risk of side effects, such as sedation or dizziness, and then increase as needed. Make sure your patients know that they should follow up with you if they are not experiencing relief within four to six weeks: A dosage increase or medication change may be needed. “These drugs need to be titrated slowly, especially if the patient is older and if the drugs contribute to sedation,” Dr. Polomano says. Heat and Cold Temperature and pain travel on the same nerve fibers. A cold compress is one of the most effective approaches to reduce drivers of pain, like inflammation, says Dr. Dickerson. For some conditions, such as a pulled muscle, heat might be more helpful. Advise patients to follow a pattern of 20 minutes on and 20 minutes off. Creams Over-the-counter products like Salonpas, Icy Hot, lidocaine cream, and diclofenac gel can provide relief. Both lidocaine patches and diclofenac are also available in prescription strength if needed, says Dr. Chen. Transcutaneous Electrical Nerve Stimulation (TENS) These at-home units send low-voltage electrical signals that either interrupt the nerve signals to the brain or stimulate the production of endorphins. A study published in the Journal of Pain Research found that using a wearable TENS device reduced disease impact, pain, and functional impairment in people with fibromyalgia. Participants with higher pain sensitivity exhibited larger treatment effects than those with lower pain sensitivity.
Exercise Lifestyle changes can have an important impact on pain relief, but these changes aren’t quick fixes. They take dedication and time. “The main lifestyle change is to be more active in whatever way you can,” says Dr. Chen. “Exercise can help patients lose excess weight and strengthen muscles around painful sites.” Dr. Chen finds tai chi to be particularly effective. Even right after surgery, he encourages patients to move, especially when they are in the hospital and receiving pain medication. “The worst thing is lying in bed and letting muscles atrophy,” he says. “Injections and medications cover up pain but don’t change the body structurally. Doing physical therapy and strengthening the core can really help with long-term pain relief compared to short-term office treatments.” While exercise is important, “you need to know the pain syndromes that need rest vs. those that need increased mobility to prevent further pain. For example, if the patient has shoulder pain, there are some conditions that benefit from musculoskeletal immobility for a short time and others that need immediate mobilization. Sending a patient to an ambulatory physical therapy setting as an adjunct to analgesics is appropriate,” says Dr. Polomano. A physical therapist can tailor an exercise program to pain and may use other modalities, including ultrasound and massage. Water exercise can make exercise less painful as well. Diet According to research published in Pain and Therapy, diet may play a supporting role in easing pain. The theory is that chronic pain stems, in part, from oxidative stress and inflammation, conditions that are linked to diet. The standard American diet has been linked to “increased postprandial oxidative stress in the short term and chronic elevation of oxidative stress markers in the long term.” This is most likely because it increases free radicals and hinders the antioxidant defense system. Switching to a low-carbohydrate diet or Mediterranean diet can reduce pain in some patients. “Some people find that including turmeric in their diet may also help to decrease inflammatory pain,” says Dr. Chen. Developing a Plan To provide the best care, first evaluate the person and their pain. When a patient comes to your clinic, you may have only limited knowledge of that person’s history, which can make it challenging to diagnose and treat their pain. The first step, then, is to evaluate the pain in the context of other symptoms and determine whether the pain is acute or chronic. Acute pain can come from identifiable sources—strains, pulled muscles, herpes zoster, or a recent surgery—or it can be
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Mind-Body Techniques Several evidence-based mind-body techniques that activate descending pathways from the brain to the site of the pain can be helpful. Acupuncture. “Although used for a variety of ailments, in the West, acupuncture has a history of treating mostly pain. It is completely natural, safe, and effective in that all it’s doing is stimulating the body to heal itself,” says Judith Woolf, MAc, LAc, a licensed acupuncturist in Ridgefield, Conn. “By targeting specific points, we can stimulate the immune system and release endorphins and other chemicals like serotonin and norepinephrine, which help ease pain,” she says. “It not only treats the pain, but also brings blood to the area to promote healing.” Acupuncture can be combined with other modalities. Mental health therapy. “Pain is a physical and emotional response to potential or current tissue damage. … Pain can get into the patient’s head to the point where they focus on pain and nothing else,” says Dr. Chen. Strategies such as cognitive behavioral therapy can help patients understand where their pain comes from, how it manifests, and how to manage the anxiety that comes with it. You can research evidence-based treatments in the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine publication Acute Pain Management: Scientific Evidence. It’s available as a free download at https://www.anzca.edu. au/resources/college-publications/acute-painmanagement/apmse5.pdf
more mysterious. A patient may complain of low-back pain, but determining the actual source of the discomfort can be complicated: Is the pain from a joint, a muscle, a herniated disc? Does it stem from an acute injury? Or could it be an exacerbation of a chronic problem? “Then you can maximize multimodal analgesia—combining different classes of drugs, such as nonopioids, acetaminophen, and an SNRI [serotonin-norepinephrine reuptake inhibitor], for instance, with different mechanisms that target pain by different pathways,” Dr. Chen notes. While acute pain often responds well to nonopioid treatments, chronic pain is more challenging to address. Helping
a patient resolve a chronic pain condition requires a different approach and often starts with getting them an exact diagnosis. That can mean referring them to a pain specialist. As a convenient-care clinician, your role is to help guide patients to the care they need. “You have the ability to recognize when a patient is not recovering and when to involve a pain specialist. Many pain specialists come from other medical specialties, such as anesthesiology, emergency medicine, rehabilitation, or even psychiatry. What they all have in common is that they take a 360-degree approach to addressing pain. Medical Interventions Pain specialists have an arsenal of treatment options to help relieve chronic pain, many of which patients may not be aware of. • Nerve blocks. These injections of local anesthetics or other medications can help short-circuit nerve pain or pain from a muscle spasm. • Noninvasive brain stimulation. According to research published in Pain and Therapy, the two most commonly used technologies, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), relieved pain symptoms in 97.1% and 81.4% of neuropathic pain patients respectively. • Radiofrequency ablation. This procedure uses an electric current created by radio waves to short circuit the nerves that transmit pain signals. Relief can last for up to one year. • Neuromodulation. This umbrella term refers to a number of treatment modalities that reroute pain signals. They include spinal cord stimulation, which uses a pacemaker-like device that replaces the pain with a more tolerable sensation; implanted systems that allow spinal-pain patients to deliver medication directly to the painful area at the press of a button; and sacral, brain, peripheral nerve, and peripheral nerve field stimulation. Neurostimulation can help pain from a nerve injury, slow healing after surgery, and the burning pain caused by diabetes. “There’s a 70 to 80% response rating in patients for whom it’s appropriate,” says Dr. Dickerson. • Interspinous spacers. These small implants can restore 1 centimeter of height to spinal areas affected by degenerative issues such as herniated discs and spinal stenosis, in which narrowing pinches nerves and causes pain. The procedure is minimally invasive but must be performed by a specialist with specific training in the procedure. • Future trends. Research into other procedures, such as regenerative medicine using stem cell implants, is ongoing, says Dr. Chen. But for some patients, only surgery will correct abnormalities responsible for their pain. It may be the answer for people who can no longer tolerate their pain level, for whom a condition has caused disability or severely affected daily living, or when everything else fails to help enough. C
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CLINICAL CARE: MEDICATION MANAGEMENT
BY MARK MCGRAW
Improving Patient Medication Adherence
At a Glance •
Three-quarters of adults taking medications are nonadherent in at least some way.
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Patients may not understand the need to start or continue taking a medication, particularly for an asymptomatic condition.
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It’s important to consider the cost and availability of the medication you’re prescribing.
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Partner with your patients, working with their preferences to choose the optimal medications to treat their conditions.
Thirty-two million Americans use three or more medications daily, and 75% of adults taking medications are nonadherent in at least some way. Thirty percent of prescriptions are never filled, and 50% of medications for chronic disease aren’t taken as prescribed. Those figures are from studies conducted before the pandemic — current rates may be even higher.1 A host of factors contribute to this problem, says Daniel Reichert, MD, medical director for the department of family medicine at Loma Linda University Health, California. He recommends talking to your patients about any barriers they face. You can address those concerns before they leave your clinic and develop “trusting relationships to influence [patients’] attitudes about taking the medications.” Here’s a look at the most common barriers and how to address them. Medication Misunderstandings Patients may not understand the need to start or continue taking a medication, particularly for an asymptomatic condition. Go over every medication and explain what it does, why it’s important, and why they should take the full course as prescribed, says Kelly Gibson, CRNP, an NP at Howard County General Hospital, Columbia, Maryland.
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Explain why patients should finish antibiotics even after they feel better, for example. If you prescribe a medication for a nontraditional use, such as an antidepressant for pain management, make sure the patient understands that the medication has more than one use and that you’re not suggesting their illness is “all in their head.” When replacing an old medication with a new one, make sure the patient understands the change. Gibson also notes that she makes sure the pharmacy has the correct information so patients can easily fill their prescriptions. Cultural Factors Medication adherence rates are typically lower among patients who belong to a racial minority or are socioeconomically disadvantaged.2 Across a wide range of illnesses, “beliefs regarding the necessity of a medication, and the level of concern about taking daily medications, differ among cultural groups,” Elizabeth L. McQuaid, PhD, ABPP, and Wendy Landier, PhD, CRNP, wrote in Cultural Issues in Medication Adherence: Disparities and Directions.2 “As an example, empirical surveys demonstrate that African American patients with HIV/AIDS have high levels of concern regarding antiretroviral treatment and HIV infection. Data from one large survey showed that, relative to other racial/ethnic groups, African Americans more frequently endorsed the belief that HIV is a manmade virus, and more often agreed with the statement that those who take antiretroviral medications are ‘human guinea pigs.’”2 Similarly, political affiliation is linked to mistrust of COVID-19 vaccinations and treatments. Ask patients if they have any concerns about medications and open a discussion about whether those concerns outweigh the potential benefits. Affordability It’s important to consider the cost and availability of the medication you’re prescribing, says Alexis Chauvette, CPNP, PC, a nurse practitioner with Lehigh Valley Health Network in Allentown, Pennsylvania. Approximately 39% of the 1,029 people who responded to a GoodRx survey reported that they reduce or skip medication doses because of prescription costs.3 Moreover, 37% said that paying for their regular prescription was difficult, 21% reported declaring bankruptcy or taking on debt because of prescription costs, and 21% reported struggling to pay for basic needs like housing and food because of their medication costs. The Kaiser Family Foundation reports that the people most likely to face difficulties affording their medications include those who take at least four drugs monthly (35%), those who have monthly drug costs of $100 or more (58%), those who are in fair or poor health (49%), and those who have annual incomes below $40,000 (35%).4 Further, a 2021 report noted that Medicare and other insurance plans are increasingly shifting drugs into higher formulary tiers, making previously affordable medications too expensive for patients to refill.5
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Patient Preferences Partner with your patients, working with their preferences to choose the optimal medication to treat their condition, says Alexis Chauvette, CPNP, PC, a nurse practitioner with Lehigh Valley Health Network in Allentown, Pennsylvania. “There are a lot of questions we can ask … to ensure success in medication compliance,” she notes: • Is the form of the medication tolerable? A liquid medication may be more convenient for some pediatric patients, while a dissolvable may be a better option for others. Not all adults can swallow pills, especially if the pills are large, so talk to patients about whether a medication can be cut or crushed for easier swallowing and what alternative forms of the medication are available. • Is the dosing frequency manageable? It’s easier for patients—adults and children alike—to take one or two pills each day than it is to take three or four. • What kind of adherence aids would be helpful? Simple tools like pill organizers and phone alarms can help patients remember to take their medications. Patients have reported that 30-day pillboxes, packets of medications for each dose time, and longer prescriptions from physicians and pharmacies all help them better adhere to their medications regimens.6 • You can also suggest that patients tie medication time to a routine activity, like toothbrushing or another bedtime ritual.
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CLINICAL CARE: MEDICATION MANAGEMENT
BY MARK MCGRAW
Before you write prescriptions, ask patients if they are concerned about paying for them and discuss any more-affordable options that may be available. Insured patients can call their insurance companies to check on copays and may be able to use drug-manufacturer coupons to lower their costs. Uninsured patients can visit websites like GoodRx to compare the price of a medication across a variety of retail stores.
DRUGS DON’T WORK IN PATIENTS WHO DON’T TAKE THEM. — FORMER SURGEON GENERAL C. EVERETT KOOP
reported difficulty organizing medications and self-administering the correct medication at the prescribed time.6 Inability to Pick Up Medications In the aforementioned study, people with mobility impairments reported difficulty getting to the pharmacy to fill prescriptions.7 Travel may also be a barrier for people who don’t drive or have access to alternative forms of transportation. A growing number of pharmacies now offer prescription delivery so patients don’t have to travel. Creating a Connection The real challenge begins when a patient goes home. Before patients head home to pick up a new prescription, Gibson suggests allowing them time to ask questions and making sure they know they can always call you—even after they get home. C
REFERENCES
Fear of Side Effects Patients may see friends or family members experience side effects, or they may be influenced by inaccurate information from social media or other news sources. Talk to patients about potential side effects and how to manage them from the beginning. For example, if you prescribe an antibiotic that tends to cause nausea, discuss also prescribing antinausea medication, Gibson notes. “If patients know what to expect, they are more likely to either accept the side effects or agree to try to treat them.” Concomitant Conditions Conditions such as depression, anxiety, substance abuse, and cognitive or physical impairment can make it harder to take a medication as prescribed. Depressive symptoms have been linked to poor adherence to anti-epileptic medications, oral medications for cancer, and asthma drugs.2 Cognitive impairment is a risk factor for poor antihypertensive medication adherence, even in patients without dementia.7 A survey of patients with a variety of disabilities found that squeezing eyedropper bottles and opening childproof bottles are major barriers across groups. People with vision impairments
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1. Mollison C. Concerns about medication adherence grow amid COVID-19 pandemic. Pharmacy Times. April 3, 2020. Accessed December 22, 2021. https://www.pharmacytimes. com/view/concerns-about-medication-adherence-growamid-covid-19-pandemic 2. McQuaid EL, Landier W. Cultural issues in medication adherence: disparities and directions. J Gen Intern Med. 2018;33(2):200-206. doi:10.1007/s11606-017-4199-3 3. Nguyen A. Survey: Americans struggle to afford medications as COVID-19 hits savings and insurance coverage. GoodRx Health. March 22, 2021. Accessed December 22, 2021. https://www.goodrx. com/healthcare-access/drug-cost-and-savings/ survey-covid-19-effects-on-medication-affordability 4. Poll: nearly 1 in 4 Americans taking prescription drugs say it’s difficult to afford their medicines, including larger shares among those with health issues, with low incomes and nearing Medicare age. News release. Kaiser Family Foundation. March 1, 2019. Accessed December 22, 2021. https://www.kff.org/health-costs/press-release/pollnearly-1-in-4-americans-taking-prescription-drugs-say-itsdifficult-to-afford-medicines-including-larger-shares-withlow-incomes/ 5. Avalere Health. Generic drugs in Medicare Part D: trends in tier structure and placement. May 22, 2018. Accessed December 22, 2021. https://accessiblemeds.org/sites/ default/files/2018-05/Avalere_Generic_Tiering_White_ Paper.pdf 6. Fain B, Farmer S. Medication adherence for older adults with disabilities: technical report TechSAge-TR-1701. Georgia Institute of Technology. 2017. Accessed December 22, 2021. https://smartech.gatech.edu/bitstream/handle/1853/58509/ techsage-tr-1701.pdf 7. Cho MH, Shin DW, Chang S, et al. Association between cognitive impairment and poor antihypertensive medication adherence in elderly hypertensive patients without dementia. Sci Rep. 2018;8(11688). doi:10.1038/ s41598-018-29974-7
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CLINICAL CARE: PODIATRY
BY MAUREEN SALAMON
Plantar Fasciitis: Diagnosis and Treatment At a Glance •
Plantar fasciitis is the most common cause of heel pain.
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The majority of patients can find relief with over-the-counter (OTC) analgesics and stretching.
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Night-time splinting is no longer recommended.
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Recovery takes about two to three months for most patients.
Each year, millions of people in the United States are treated for plantar fasciitis (PF), the most common cause of heel pain. Fortunately, the majority of them can find relief with conservative treatments and over-the-counter (OTC) remedies, making retail health clinics one-stop solutions for PF care. Causes and Consequences Plantar fasciitis is caused by inflammation of the plantar fascia, the thick and fibrous tissue that runs from the heel to the toes and supports the arch of the foot. Repeated and excessive strain on the tissue can produce many small tears, resulting in irritation and inflammation. Left untreated, PF can turn into chronic heel pain that significantly impairs everyday activities like walking. Changes in a patient’s gait can cause additional ailments in the foot over time, as well as in related regions like the knee or hip. Clear Signs The hallmark symptom of PF is stabbing pain in the heel when a patient first gets out of bed in the morning.
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CLINICAL CARE: PODIATRY
BY MAUREEN SALAMON
Approaches to Avoid
A clinical exam is usually sufficient to diagnose plantar fasciitis, says Shanna Chapman, DNP, APRN, FNP-BC, a retail health clinician and the region 7 director of the American Association of Nurse Practitioners. X-rays and other confirmatory imaging tests are needed only when a patient might have another source of heel pain, such as a fracture or arthritis. During the exam, watch for tenderness while pressing on the bottom of the patient’s foot, just in front of the heel bone. Applying pressure there will “send [the patient] through the roof,” says Nathan Miracle, MS, an assistant professor in the department of physician assistant studies at Missouri State University. Pressing the patient’s foot and toes toward the shin will produce that pain as well. Conversely, the pain will decrease when the patient points their toes down. Gold Standard Approaches The gold standard for treating PF consists of nonsteroidal anti-inflammatory drugs and regular foot stretches. Directing the patient to take OTC ibuprofen or naproxen is usually a good first step, but tailor the dosage and duration to reduce the risk of side effects, such as heartburn, nausea and, less commonly, high blood pressure, liver and kidney damage, and gastrointestinal ulcers. The second half of the treatment regimen is regular stretching of the arch of the foot and the Achilles tendon. Dr. Chapman suggests instructing patients with PF to roll their affected foot over a cold or frozen water bottle for 20 minutes three to four times per day. The American Academy of Orthopaedic Surgeons (AAOS) offers three additional stretches to share with PF patients:1 • Lean forward against a wall with one leg in front of the other. Straighten the back leg and press the heel into the floor. Bend the front knee. Hold the stretch for 15 to 30 seconds. Repeat with the other foot—even if only one foot is affected. • Place the ball of one foot on the edge of a step, with the other foot solidly on the same step. Slowly drop your weight into the heel of your foot and push the heel down. Hold for 15 to 30 seconds and repeat with the other foot. • Sit on the floor and place both legs in front of you. Wrap a towel around the ball of the affected foot and pull it toward your body. Hold for 15 to 30 seconds and repeat with the other foot. The AAOS recommends performing each of these stretches three times daily.
Not all OTC products are created equal when it comes to treating PF. Miracle advises skipping topical analgesics such as diclofenac sodium creams and gels. “They’re not likely to produce any benefit because of the deep structural placement of the plantar fascia,” he explains. Similarly, having patients use devices like night splints to stretch the plantar fascia and Achilles tendon while sleeping is no longer recommended. Though formerly a favored treatment, Dr. Chapman says that recent indepth studies conclude that night splints are “not as helpful as originally thought.”
Dr. Chapman recommends gently suggesting that overweight patients attempt to lose weight. She finds that guiding patients to conceptualize excess weight as a household item, like a gallon of milk, can help motivate patients to begin and persevere in weight-loss regimens. Follow-Ups and Further Treatment When using conservative treatments and OTC remedies, you can expect about nine out of 10 patients to show improvement within two to three months.1 “I would follow up with patients within a few weeks to a month to see if there’s improvement, but they need to understand it will probably take two to three months to see dramatic results,” says Miracle. Make sure patients’ expectations are realistic. If patients are still experiencing significant heel pain after three months, they might benefit from corticosteroid injections into the plantar fascia. However, Dr. Chapman and Miracle agree that, at this point, it’s prudent to refer patients to a podiatrist or other specialist experienced with such a course of treatment. Miracle explains that “this injection is one of the most painful done in orthopedics, so having a skilled clinician is important.” What’s more, “Corticosteroids can start breaking down the heel bone if they’re done too much,” Dr. Chapman adds. A podiatrist can also discuss with the patient if and when surgery may be indicated. C
Supplemental Pain Management To further reduce pain, especially in patients with flat or high arches, Dr. Chapman suggests recommending shoe inserts like soft rubber heel lifts, cups, and wedges. She adds that many pharmacies offer patients machines to measure their arches, allowing them to find inserts that suit their feet. Since carrying extra pounds can exacerbate plantar fasciitis, CONVENIENT CARE CLINICIAN
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REFERENCE 1. American Academy of Orthopaedic Surgeons. OrthoInfo basics — plantar fasciitis. OrthoInfo. 2019. Accessed Jan. 19, 2022. https://orthoinfo.aaos.org/globalassets/pdfs/planterfasciitis.pdf
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NUTRITION REPORT
BY BILL GOTTLIEB
Plant Power Answering patients’ questions about plant-based eating
At a Glance •
A plant-based diet is strongly associated with reductions in disease risk and severity across the spectrum of human illness.
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A plant-based diet is not necessarily a vegetarian or vegan diet.
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People can get plenty of protein from plant-based foods.
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Small changes can make a big difference.
What do you say to a patient who asks you why they should eat a plantbased diet? For one clinician, the answer is simple: Why not? “A plant-based diet is strongly associated with reductions of disease risk and severity across the spectrum of human illness,” says Joshua Levitt, ND, a naturopathic doctor in Hamden, Connecticut, and a clinical preceptor for the Yale School of Medicine. Here is a partial list of the benefits: • Plant foods deliver a bounty of phytonutrients (compounds that research suggests improve the health of cells, organs, and bodily systems), vitamins, minerals, and fiber. • A plant-based diet decreases chronic inflammation, which may lower the risk of osteoarthritis, Alzheimer’s disease, cancer, and many other conditions triggered by inflammation. • It improves the composition of gut microbiota—the trillions of friendly and unfriendly bacteria that live in the digestive tract. A healthier gut microbiota has been linked to better digestion, stronger immunity, and improved mood.
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NUTRITION REPORT
BY BILL GOTTLIEB
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Eating a diet rich in vegetables, beans, whole grains, fruits, nuts, and seeds can lower blood pressure and LDL cholesterol, reducing the risk of heart attack and stroke. • High-fiber plant foods help patients feel full without delivering a lot of calories—so they can help with weight loss and maintenance. • Beans, vegetables, and nuts balance blood sugar, helping to prevent or reverse prediabetes and type 2 diabetes. • A plant-based diet can improve energy levels and sleep, adds Amanda Adkins, MD, an internist with NorthBay Healthcare in Fairfield, California. “If there ever was a panacea—one remedy that works for every disease—a plant-based diet is pretty close,” says Dr. Levitt. Make It Easier for Patients Even though a plant-based diet is good for you, patients might find it hard to imagine including more of these foods in their diet. You can reassure them that it’s easier than they think. “For one thing, a plant-based diet is not a vegetarian or vegan diet,” explains Dr. Levitt. “Plants are the base of the diet—the foundation—but that leaves plenty of room for foods that aren’t plants.” To help your patients think about this in practical terms, ask them to visualize a plate. Rather than a steak with a little bit of potatoes or asparagus on the side, tell them to reverse the ratio. Let plants be the center of the meal, and meat the accessory. “Eating a plant-based diet doesn’t mean you’ll never eat meat again,” says Dr. Levitt. “You can be a plant-based omnivore just by making plants the majority of your diet,” agrees Keith Ayoob, EdD, a nutritionist and registered dietitian at the Albert Einstein College of Medicine in New York City. “And it doesn’t have to be done instantly.” Patients can make changes gradually and consider their likes and dislikes. Here are some tips to help patients get started: Go Big on Beans The best way to start getting more plant foods into the diet is with legumes such as beans, peas, and lentils. Bean-rich diets are strongly associated with a lower risk of cardiovascular disease, diabetes, and overweight. In fact, research shows that for every ounce of beans added to the daily diet, longevity increases by nearly 10%. There are many varieties, and the easiest to start with are black beans, pinto beans, white beans, and garbanzo beans, says Dr. Levitt. You can buy them canned, so preparation is minimal. They’re inexpensive. And they work in a variety of dishes, like soups, stews, and salads. With a little spice and sauce, you can have a world of culinary options—turn white beans into an old-world Italian dish,
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Smart Supplements While a plant-based diet is remarkably healthy, people who follow a strict vegan diet (one that excludes all animal-based products) may benefit from dietary supplements. · Vitamin B12 levels are often low in vegans, who can increase levels by eating B12-fortified foods or taking a supplement. The recommended intake is 2.4 mcg per day for adults, 2.6 mcg per day during pregnancy, and 2.8 mcg per day while breastfeeding. · Omega-3 fatty acids. Studies suggest that vegetarians and vegans have up to 50% lower blood and tissue concentrations of two long-chain fatty acids, EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid), than omnivores. Omega-3 supplements are available as fish oil or, for vegans, algae oil. · Calcium and vitamin D. A study published in The American Journal of Clinical Nutrition in May 2021 reported that though women on a vegan diet have a higher rate of fractures, taking calcium and vitamin D supplements eliminated that elevated risk.1 Highcalcium plant foods include dark leafy greens, nuts, seeds, soy foods, seaweed, lentils, and beans. Good food sources of vitamin D include fortified milk substitutes and mushrooms.
REFERENCE 1. Thorpe DL, Beeson WL, Knutsen R, Fraser GE, Knutsen SF. Dietary patterns and hip fracture in the Adventist Health Study 2: combined vitamin D and calcium supplementation mitigate increased hip fracture risk among vegans. Am J Clin Nutr. 2021;114(2):488-495. doi:10.1093/ ajcn/nqab095
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NUTRITION REPORT
BY BILL GOTTLIEB
black beans into a South American specialty, pinto beans into a Mexican meal, and garbanzo beans into something tasty from the Mediterranean. Vegetables and Fruits You often hear the phrase “fruits and vegetables” in describing a plantbased diet. But for optimal health, advise your patients to emphasize vegetables and eat fruits mostly as a snack or dessert. Patients should strive to include vegetables of a variety of colors in their daily diets. A vegetable’s color (orange for carrots, red for tomatoes, green for broccoli, etc.) is often indicative of which phytonutrient it contains, and phytonutritional diversity is beneficial. Nuts and Seeds “Eating nuts and seeds in their whole and minimally processed form is strongly associated with decreased risk of chronic disease—particularly heart disease,” says Dr. Levitt. Emphasize minimally processed nuts and stay away from Nutella and Skippy. Particularly good sources of healthy fats are almonds, walnuts, flax seeds, and chia seeds, according to Dr. Adkins. Get an Oil Change Your patient might think vegetable oils are a big part of a plantbased diet: They’re made from vegetables, right? But soybean and canola oils are highly processed and deliver unhealthy amounts of omega-6 fatty acids, which are proinflammatory. For cooking, patients should favor extra-virgin olive oil or coconut oil.
Spice It Up Ounce for ounce, spices can provide more nutrients than vegetables, fruits, nuts, seeds, and grains. Plus, adding spices can make any plant-based meal delicious. There are many prepared spice blends on the market, Dr. Levitt points out. Try them on vegetables and grains, and in soups and stews. Eat Clean Meat For optimal health, encourage your patients to look for meat from animals that were raised in a healthy way—grass-fed, free-range, or wild—rather than on a factory farm. “Increase the quality and decrease the quantity—and fill in the gap with plants,” Dr. Levitt says. Avoid Processed Plant and Other Foods Dr. Levitt isn’t a big fan of highly processed meat substitutes, like the Beyond Burger. “For health, it’s best to eat minimally processed plants in their whole form,” he says. “One big mistake I see patients make is replacing meat with meat substitutes full of sugars, salt, and fat,” agrees Dr. Adkins. She also sees patients on a plant-based diet eating french fries, chips, sugary cereals, and other unhealthy foods. She asks patients to get a plantbased cookbook for more ideas on what to eat. Bestsellers in that category include The Complete Plant-Based Cookbook and Forks Over Knives: The Cookbook. Let Your Insides Adjust It’s not uncommon for people who up their intake of plant foods to experience a week or two of extra gas or bloating as their bowels adjust to increased levels of fiber. To ease discomfort, advise patients to temporarily decrease the amount of plant food they’re eating while they adjust. Taking a digestive enzyme with meals or a daily probiotic can help as well, Dr. Levitt says. Don’t Worry About Protein In general, an adult only needs about 10% of their calories to come from protein, and eating a variety of vegetables, beans, legumes, whole grains, and nuts will easily meet that requirement, Dr. Adkins says. There are also a variety of plant-based protein powders available. Tell Yourself a New Story Among the main “pushbacks” to a plant-based diet you may hear are: “I don’t like vegetables,” or “I’m just a meat-and-potatoes person.” Dr. Levitt says (that) those are just stories patients tell themselves—ones that can easily be rewritten. He tells patients, “If you’re willing to accept the possibility you could become a vegetable person, it’s very possible to do so—because human beings are remarkably adaptable.” C
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FOCUS ON WOMEN’S HEALTH
BY JULIE DAVIS
At a Glance •
For about one in five women, menopause symptoms— primarily hot flashes and night sweats—are so severe that they affect relationships, work, sleep, and mood.
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Many women may not realize that symptoms like heart palpitations and anxiety can be related to menopause, too.
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By being familiar with symptoms that could suggest menopause, convenient care clinicians can help women find symptomatic relief and guide them to the right specialists.
Managing Menopause Symptoms Recognizing menopause symptoms is the biggest challenge Most of the 6,000 American women who reach menopause each day experience one or more symptoms. For about one in five women, these symptoms— primarily hot flashes and night sweats—are so severe that they affect relationships, work, sleep, and mood. Unfortunately, too few women get the right help. Many doctors minimize or dismiss the symptoms that women are willing to bring up, while there are other symptoms that women are too embarrassed to discuss, and some that may not be recognized as stemming from menopause. Further, “there are not a lot of OB-GYNs who do menopause, and women don’t
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know where to find someone who does,” says Stephanie Faubion, MD, the Penny and Bill George Director for Mayo Clinic’s Center for Women’s Health and medical director for the North American Menopause Society (NAMS). That’s where convenient care clinicians can step in. By being familiar with the symptoms that could suggest menopause, you can help women find relief from the symptoms and guide them to the right specialists. Unexpected Symptoms While hot flashes are well-known signs of menopause, many women may not realize that symptoms like heart palpitations and anxiety can be related to menopause, too. “Women may have joint aches, palpitations, weight gain—a cluster of symptoms might be related in part to aging and in part to menopause,” says Dr. Faubion. Adding to the confusion, research published in Menopause in September 2021 highlighted the fact that many women start to experience symptoms earlier than expected, during the late reproductive stage and before menstrual cycles become irregular.1 “Patients experiencing symptoms in their late 30s are often told they’re too young to get menopause symptoms, that it’s all in their head—that’s very destructive,” says Wen Shen, MD, assistant professor in the Johns Hopkins Medicine Department of Gynecology and Obstetrics, clinical director of the Menopause Consultation service and co-director of the Women’s Wellness and Healthy Aging Program. “A lot of women will blame themselves and say, ‘I’m going crazy’ rather than, ‘these symptoms are driving me crazy.’ That’s a terrible state of mind to be in.” At any age, women need to be taken seriously so they can get relief from bothersome symptoms. Here’s a look at the most common issues. Vaginal Dryness For some women, the only symptom of menopause is vaginal dryness, which can cause pain during sex, but only 9% of women who experience vaginal dryness get treated for it, notes Dr. Fabion. While most women will bring up hot flashes with their doctor, they often don’t talk about vaginal dryness. If they did, they’d learn that there are several strategies that may help. Over-the-counter vaginal moisturizers. Some products create a biofilm that can moisturize for two to three days. This can provide pain relief during sex, when sitting hurts, or when there’s discomfort any time urine gets close to the vaginal opening. Vaginal products with hyaluronic acid have been shown to help the skin retain water content. Prescription drugs. If there is still pain when having sex, a patient might benefit from a prescription option that can help restore the layers of skin within the vagina, such as low-dose vaginal estrogen, available in a cream, ring, table, or insert; a vaginal
Get Certified in Menopause Management To fill in knowledge gaps, the North American Menopause Society offers health professionals continuing education courses on menopause, as well as certification in the field of menopause management. Find out more at https://www.menopause.org/forprofessionals/ncmp-certification
insert of prasterone, also known as DHEA, (Intrarosa); or oral ospemifene (Osphena), a once-daily, nonhormonal pill.2,3 It’s important to discuss side effects, such as changes in Pap test results with prasterone, and drug interactions, as well as an increased risk for a condition that could lead to uterine cancer, with ospemifene.4,5 Urination Issues Low estrogen levels can lead to urinary urgency, incontinence, and multiple nightly awakenings. Start by suggesting that your patient stop drinking any liquids after dinner and consider referring to a urogynecologist. An ultra-low-dose vaginal estrogen medication can help some women, while those with stress incontinence may benefit from physical therapy to treat pelvic floor dysfunction. Sleep Trouble According to research published in Medicina, sleep difficulties affect about a third of women during the menopausal transition and increase to up to 56% of postmenopausal women.6 Women may have trouble falling asleep, wake up several times, not get enough sleep, or develop sleep apnea. Since sleep deprivation is a risk factor for cardiovascular disease, diabetes, obesity, and neurobehavioral dysfunction, it’s important to address it. Women may be able to improve sleep with lifestyle changes. Recommend daily exercise,
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FOCUS ON WOMEN’S HEALTH
BY JULIE DAVIS
life and those who had premenstrual syndrome or premenstrual dysphoric disorder or postpartum mood disorders are at the highest risk. Treatment options include hormone therapy, antidepressants, and cognitive behavioral therapy. Mind-body therapies such as yoga, meditation, and breathing exercises may also improve mood when added to other treatments.
avoidance of caffeine, a cool and dark bedroom, and turning off electronic devices well before bedtime. Hormone therapy and other medications may also enhance sleep quality. Consider referring patients to a sleep specialist if these measures don’t help. Depression and Anxiety Because of the huge roller-coaster action of hormones, one of the first symptoms many women experience is anxiety with heart palpitations, says Dr. Shen. “First, make sure the patient doesn’t have any cardiac issues going on. Then, consider that it’s perimenopause,” she says. If a patient is still cycling on a very regular monthly basis, you can see if a short-term trial of low-dose birth control pills helps resolve symptoms. “Depression is more tightly tied to perimenopause than menopause,” says Dr. Faubion. “We call it the window of vulnerability in terms of mood.” Women who experienced depression earlier in
Brain Fog Problems with concentration and memory can be part of menopause. According to a report by neurologist Gayatri Devi, MD, that was published in Obstetrics & Gynecology Gynecology, it’s important to identify the cognitive changes related to menopause so that symptoms aren’t mistakenly attributed to a neurodegenerative disease and can be addressed appropriately.7 Some proven brain-boosting interventions include losing any excess weight, regular exercise, following the Mediterranean diet or Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, and learning new things to stimulate the brain. Improving sleep and decreasing stress are also helpful since lack of sleep and stress overload can make brain fog worse.8 Vasomotor Symptoms Seventy-five to 80% of women are affected by vasomotor symptoms. Hot flashes can last up to 10 years or even longer and vary widely in degree—they’re mild for some, severe for others. The standard treatment is hormone therapy (see sidebar), but there are alternatives for women who can’t or don’t want to use HT: • Cognitive behavioral therapy and hypnosis might reduce the perception of hot flashes and night sweats.9 Both techniques might also help improve sleep. • Tracking how things like weather, smoking, caffeine, spicy or sugary foods, alcohol, tight clothing, and stress
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Hormone Therapy Hormone therapy (HT), when started within 10 years of menopause, can ease hot flashes, improve sleep, and reduce all-cause mortality and the risk of coronary disease, osteoporosis, and dementia, according to a review in Climacteric published in February 2021.1 Further, it can ease vaginal dryness, night sweats, and bone loss.2 Many women and clinicians, however, are reluctant to use it because a study published in 2002 linked HT to breast cancer and heart attack.3 Researchers have since learned that the link only exists when HT is started 10 or more years after menopause. Beginning therapy earlier is safer.
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Though the findings were ultimately corrected, many clinicians have not received adequate training to feel comfortable prescribing HT. Furthermore, “Present-day hormones are very different from the one hormone therapy that was used when the 2002 study was done” says Wen Shen, MD, assistant professor in the Johns Hopkins Medicine Department of Gynecology and Obstetrics, clinical director of the Menopause Consultation service, and co-director of the Women’s Wellness and Healthy Aging Program. “Overall, it’s much safer in regards to breast cancer and high blood pressure.” “The benefits of HT outweigh risks for most women in their 50s when started within 10 years of their last period,” adds Stephanie Faubion, MD, the Penny and Bill George Director for Mayo Clinic’s Center for Women’s Health and Medical Director for The North American Menopause Society.
REFERENCES 1. Langer RD, Hodis HN, Lobo RA, Allison MA. Hormone replacement therapy - where are we now? Climacteric. 2021;24(1):3-10. doi:10.1080/13697137.2020.1851183 2. Hormone therapy: benefits & risks. North American Menopause Society. Accessed January 20, 2022. https:// www.menopause.org/for-women/menopauseflashes/ menopause-symptoms-and-treatments/ hormone-therapy-benefits-risks 3. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.
affect affect hot flashes allows women to take measures to reduce exposure to those triggers. Losing excess weight can ease symptoms. Moving more can help. Sedentary behavior can increase the likelihood of nighttime hot flashes, according to preliminary results of a new study of pre-, peri-, and postmenopausal women presented at the 2021 NAMS Annual Meeting. Mindfulness and acupuncture may provide small but real benefits. Keeping a bedside fan and a glass of ice water nearby can reduce the disruption of night sweats. Don’t put too much stock in supplements. Neither red clover nor black cohosh have shown benefits in clinical trials, despite anecdotal reports of benefits.10,11 C REFERENCES 1. Coslov N, Richardson M, Woods NF. Symptoms experienced during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey. Menopause. 28(9):1012-1025. 2. Labrie F, Archer DF, Koltun W, et al. Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause. 2018;25(11):1339-1353. 3. FDA approves Intrarosa for postmenopausal women experiencing pain during sex. News release. U.S. Food and Drug Administration. November 17, 2016. Accessed January 20, 2022. https://www.fda.gov/news-events/press-announcements/fdaapproves-intrarosa-postmenopausal-women-experiencingpain-during-sex 4. Intrarosa. Drugs.com. Updated August 24, 2021. Accessed January 20, 2022. https://www.drugs.com/intrarosa.html 5. Ospemifene. University of Michigan Health. Accessed January 20, 2022. https://www.uofmhealth.org/health-library/d08070a1 6. Gava G, Orsili I, Alvisi A, et al. Cognition, mood and sleep in menopausal transition: the role of menopause hormone therapy. Medicina. 2019;55(10): 668. 7 Bilodeau K. Sleep, stress, or hormones? brain fog during perimenopause. Harvard Health Publishing. April 9, 2021. Accessed January 20, 2022. https://www.health.harvard. edu/blog/sleep-stress-or-hormones-brain-fog-duringperimenopause-202104092429 8. Hot flashes. Mayo Clinic. August 31, 2021. Accessed January 20, 2022. https://www.mayoclinic.org/diseases-conditions/ hot-flashes/diagnosis-treatment/drc-20352795 9. Kanadys W, Barańska A, Błaszczuk A, et al. Evaluation of clinical meaningfulness of red clover (Trifolium pratense L.) extract to relieve hot flushes and menopausal symptoms in peri- and post-menopausal women: a systematic review and meta-analysis of randomized controlled trials. Nutrients. 22021;13(4):1258. 10. Black cohosh: fact sheet for health professionals. National Institutes of Health: Office of Dietary Supplements. Updated June 3, 2020. Accessed January 20, 2022. https://ods.od.nih. gov/factsheets/BlackCohosh-HealthProfessional/
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SEASONAL SPOTLIGHT
BY CHRIS ILIADES, MD
Omicron, Hay Fever, or a Cold: What’s the Diagnosis? The COVID-19 omicron variant shares many symptoms with seasonal allergies and colds, so how do you tell the difference? When the flu season started last year and the delta variant of the coronavirus was still around, it could be hard to tell the difference between COVID-19 and the flu. Both could make you feel seriously ill, with symptoms like fever, cough, shortness of breath, muscle aches, and severe fatigue. For a few people, the flu could be deadly, and the delta variant was deadly for many more. As we head into spring and summer, the delta variant has been replaced by the omicron variant, and the flu has become much less common than seasonal allergies. For most people, omicron is more like allergies or a cold than delta was, although omicron can still be dangerous for unvaccinated people. So how do you tell the difference? What tests should you use to make the right diagnosis?
At a Glance •
Colds, COVID-19, and allergies often have overlapping symptoms.
•
When a patient presents with these symptoms, take a thorough history to tease out clues as to which condition may be present.
•
If the symptoms and a physical exam do not lead to a diagnosis, diagnostic tests may be needed.
Similar Symptoms Early data shows that cold-like symptoms are the most commonly reported symptoms for people with omicron:1 • Runny nose. • Headache. • Fatigue, ranging from mild to severe. • Sneezing. • Sore throat. The ailment is more likely to be a cold if your patient has additional symptoms such as fever, cough, aches and pains, and congestion.2 Allergy Symptoms Omicron and colds are both caused by viruses that can be easily spread from person to person—usually by droplets coughed or sneezed into the air. Seasonal allergies, or “hay fever,” have a completely different cause. They are an immune system reaction in which normally harmless pollens in the air trigger an attack by the immune system, which treats the pollens as foreign invaders, attacking them much like it would a virus.3 The most common symptoms of hay fever are: 3 • Itching of the nose, eyes, throat, and mouth. • Sneezing. • Stuffy nose. • Runny nose. • Tearing. • Dark circles under the eyes. Symptoms that are not caused by hay fever are severe fatigue, aches and pains, and fever. Sore throat is rarely caused by allergies. On the other hand, colds and omicron do not cause itching, tearing, or dark circles under the eyes.2 You should also suspect seasonal allergies if your patient has had similar allergy symptoms in the past at the same time of year. When spring allergies start depends on where you live. In general, if you live in an area where trees and grass grow in the spring, spring allergies usually start when trees start to bloom. They continue into the summer as the grass starts to grow and pollinate. Later in the summer and fall, weed pollens become common.4
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Treatment Options Cold: Patients probably won’t need any treatment for a cold other than over-the-counter cold medicines. COVID-19: In the absence of risk factors, no treatment is necessary. But if a patient has a weak immune system, is unvaccinated and over age 65, or is vaccinated and over age 75, consider an intravenous dose of monoclonal antibody.
Diagnosis When a patient presents with these symptoms, ask when they started and how long they’ve lasted. Ask about any history of allergies and if the patient has been in contact with anyone who’s had similar symptoms.4 If the symptoms and a physical exam do not lead to a diagnosis, diagnostic tests may be performed. Omicron can be diagnosed with two COVID tests. Both can be performed with a nose or throat swab:1,5 • Nucleic acid amplification tests— most commonly, PCR tests—are the most accurate, but they must be sent to a lab, and receiving the results may take a day or two. • Antigen tests are point-of-care tests that yield results in about 15 minutes. These tests occasionally fail to detect infections, producing a false negative. Diagnosing allergies has two purposes. A diagnosis can confirm that symptoms are due to allergies and also tell you what the patient’s allergies are, which can help the patient avoid them or help an allergist treat them. For allergy diagnosis, there are two testing methods:4,6 • Skin testing uses a prick, scratch, or injection under the skin to expose the patient to a tiny amount of an allergen. If the skin reacts with redness or swelling, it confirms the allergy. • RAST or IgE testing. A blood sample is sent to a lab to measure the allergic response to different allergens. Consider that a patient may have more than one condition. C
Seasonal Allergies: The best treatment for hay fever is avoiding pollen during the allergy season. Advise patients to limit outdoor activities when the pollen count is high. (Check the National Allergy Bureau for allergy counts in your area.) Short-term treatments include antihistamine pills, antihistamine nasal spray, steroid nasal spray, and nasal decongestant pills. Long-term treatment of hay fever is called immunotherapy. This therapy exposes the immune system to small amounts of allergens and slowly builds up the exposure over time until the patient’s immune system learns to control the allergy. Traditionally, immunotherapy consists of just allergy shots. A newer option is sublingual immunotherapy, which is instead a regimen of allergy tablets placed under the tongue.4,6
REFERENCES 1. Iacobucci G. Covid-19: runny nose, headache, and fatigue are the commonest symptoms of omicron, early data show. BMJ. 2021;375:n3103. doi:10.1136/bmj.n3103 2. Mayo Clinic Staff. COVID-19, cold, allergies, and the flu: what are the differences? Mayo Clinic. Published March 3, 2022. Accessed March 30, 2022. https://www.mayoclinic.org/diseases-conditions/ coronavirus/in-depth/covid-19-cold-flu-and-allergies-differences/ art-20503981 3. American Academy of Allergy, Asthma & Immunology. Hay fever / rhinitis. Accessed March 30, 2022. https://www.aaaai.org/ Conditions-Treatments/Allergies/Hay-Fever-Rhinitis?msclkid=0168 add8af6c11ecb5b6c40617ee805a 4. Bartolome S. Which COVID test is best? Pros and cons of coronavirus detection methods. UT Southwestern Medical Center. Published September 3, 2020. Accessed March 30, 2022. https:// utswmed.org/medblog/covid19-testing-methods/?msclkid=efe872 a2af8d11ec958a22278c9d58a4 5. Cleveland Clinic. Allergy testing. Updated July 2, 2021. Accessed March 30, 2022. https://my.clevelandclinic.org/health/ diagnostics/21495-allergy-testing?msclkid=5efa8625af9a11ecbf51b a905c7199ce 6. National Institutes of Health. Therapeutic management of nonhospitalized adults with COVID-19. NIH | COVID-19 Treatment Guidelines. Updated February 1, 2022. Accessed March 30, 2022. https://www.covid19treatmentguidelines. nih.gov/management/clinical-management/ nonhospitalized-adults--therapeutic-management/
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BY CARRIE ADKINS-ALI
MINUTES WITH ... Meggen M. Brown, MSN, FNP-BC, Chief Nursing Officer, Kroger Health’s The Little Clinic What led you to convenient care, and how has your career evolved since you began? Meggen M. Brown: After graduation, I thought I was destined to be in emergency medicine. It was my passion as an RN, and I loved the continuous challenge each day brought. However, as I was applying, I kept seeing positions seeking cutting-edge providers who wanted to truly run their own practice in the newest sector of the health care industry. This, of course, intrigued me, and I applied. Once I interviewed for the Little Clinic and took a tour of the clinic, pharmacy, and store, I was hooked. I truly loved that I could run my own clinic and had a plethora of resources around me, from OTC products to a pharmacist at my fingertips. After two years working in the clinic and building trusting relationships with my patients and peers, I was promoted and became an advanced clinical provider in the Louisville, Kentucky region. One year later, I was again promoted to regional clinical director over the Columbus and Dayton regions of The Little Clinic. In 2015, I was promoted to southern region national clinical director, overseeing multiple states, and then moved to my current role as chief nursing officer in late 2020. What was the most surprising patient interaction you’ve had? MMB: I found a malignant mole between a teenage patient’s toes during a sports physical. This interaction was a few years ago while completing a routine sports physical on a 17-year-old male. As I was finishing my assessment, I asked the patient to take off his shoes and socks so I could complete his assessment. With a puzzled look, he said that he has been getting physicals for years, and no one had ever examined his feet. While he was a bit reluctant and embarrassed due to his feet being a touch malodorous, he removed his shoes and socks. There appeared to be no abnormalities at first, but as I spread his fourth and fifth toe, I noticed a dark, irregularly shaped mole. I immediately referred the patient to a dermatologist’s office, where it was diagnosed that he had stage 2 melanoma. Several days later, the patient’s mother came to see me and stated that she and her family were beyond grateful for the referral and assessment, as it most likely saved her son’s life. The moral of the story is to never take shortcuts and treat every single patient fully, as you never know if they will have the opportunity to be fully examined or seen by a provider. What epiphany have you had in your career? MMB: Early in my career, I wanted to prove myself, so I would take on every task I could to show my worth. I had to admit to myself that I can’t do it all nor will I never know everything. It was difficult for me to admit, and I always felt like I should
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do or know everything to succeed. The more I fought my anger and frustration for not knowing how to accomplish certain tasks, the more difficult it became to complete them. I realized that if I changed a few of my habits and trusted those who worked alongside me, my work and my overall happiness in my position would improve. Once I opened up and let myself ask for help, I was actually promoted. You truly are only as good as those around you, and once you embrace that, you will soar. What inspires you? MMB: Many things inspire me, but, if I had to pick just one, it would be seeing someone overcome adversity or beat the odds. This is within business, sports, politics, health, and more. It inspires me to also try to give my best shot at all I do, including being a mom, wife, and leader. Inspiration is a driver, and I hope to continue to find it in the stories of others. Perhaps one day, my own story can be an inspiration for someone else. Is there a book that you think all convenient care clinicians should read? MMB: A book that I have truly connected with recently is Dare to Lead by Brené Brown. This book speaks to what we, as providers, should embody as leaders. It is a quick and powerful read that discusses how we must be OK with being vulnerable, living our values, building trust, and leading with courage. C
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5/12/22 3:43 PM
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