Professor Hare: [00:00:00] Hey folks, it’s the Be excited podcast with professor Hare and this morning we have the extreme privilege of having Toni Wilson with us, who is also an assistant professor in physician assistant studies here at the be excited mothership. Welcome to the podcast, Toni.
Professor Wilson: Thanks for having me excited to be here.
Professor Hare: We really appreciate you coming along today. you are a family medicine physician assistant. Tell us a little bit about how you got to this point.
Professor Wilson: Yeah. So I currently practice clinically and family medicine in an outpatient setting. I went to physician assistant school at wake forest university graduated in 2009 and,
Professor Wilson: kind of knew that I wanted to keep perfecting my skills after graduation.
Professor Wilson: And so. I knew that I wanted to do something pretty broadly based and not particularly focused at first. And I really felt like family medicine. played to my skills and what I wanted to do. And [00:01:00] so that’s where I found myself here outside of Pittsburgh, practicing family medicine.
Professor Wilson: I’ve been there for about 13 years now.
Professor Hare: And eventually, this is common to both you and I, and our practice as a physician assistant led both of us into academics at a certain point. And, you know, you’re taught in my class and I think other classes as well before coming to the university of Pittsburgh to teach.
Professor Hare: So now you’re a full-time faculty here with us as well. I think the, one of the things that, that highlights to me is the fact that in physician assistant education, we focus on the generalist perspective with our students. As students make their way through PA education, they find themselves interested or drawn to different specialties in medicine.
Professor Hare: But Our basic tenants of PA education will always be coming from a generalist perspective and really a family medicine perspective. So we can talk about the specific areas like, orthopedic surgery the very detailed areas of endocrine medicine, et cetera, but at its core, we’re teaching the core tenants of family [00:02:00] medicine, which really gives physician assistants a broad base, and the ability to move from one profession, one specialty to another on the be excited podcast, we always talk about the individual profession, but knowing that there is a lot of advising and PA school discussion that goes on along with that coming out of PA school, we often recommend as advisors. And I’m sure you do as well. we think about going into family medicine or emergency medicine or internal medicine, general medicine so that you can
Professor Hare: solidify those skills coming out of PA school and then move to the more specific skills of a specialty further down the line so that you don’t lose track of those. And I’m certainly an example of that, how you can lose track of those if you weren’t too careful. My practice also is family medicine.
Professor Hare: And before I came to the university setting as well, I also was a family medicine, physician assistant but full-time in a different and very different position in family medicine. And so your practice is in a clinic setting in would you describe it as a rural community?
Professor Wilson: So just [00:03:00] outside of the city, I would say so not necessarily rural, but not within the city proper, of Pittsburgh. So maybe suburban, but. It doesn’t feel necessarily suburban either.
Professor Hare: my practice in family medicine is inpatient and is kind of a hybrid between inpatient hospitalist and family medicine and a psychiatric hospital.
Professor Hare: So we’re not the primary diagnosis for any patient there, but we do see all of the variety of presentations there’s always going to be a twist on it in a psych hospital, certainly. we deal with a lot of the sequelae of and complications of medical treatments and some of the issues that patients with mental illness face at higher rates at different times, it certainly is an underserved population.
Professor Hare: But I don’t have a clinic schedule for instance, in my job. I always liken it to being a lifeguard where I have multiple units in most cases. And if there’s an issue with my patients that I’m assigned to on that unit, then I take care of that.
Professor Hare: As the problems arise, we do H and P is on the way in, we do a depart on the way out, but for the most part, [00:04:00] we are not on a schedule. We’re kind of rounding looking for problems, watching vital signs, watching lab work, ordering lab work and medications. And then because those patients don’t get a lot of outside care.
Professor Hare: Sometimes we are also doing some of those screening things like blood pressures, for instance, that they would not normally get in the community or be able to get looking at lab work and seeing small signs of things that may pop up that, that patient’s probably not getting cared for outside of psych and in many cases they’re not.
Professor Hare: that brings us to those moments of, bringing their healthcare back to now, how does your practice differ from that I do on a day-to-day basis?
Professor Wilson: So I certainly do have a schedule that is filled all day long. But so where I practice, it’s a full spectrum family medicine office meaning that we do.
Professor Wilson: Our best to provide as much comprehensive care as we can. So we see children, we see infants, we do prenatal care, and then certainly we see adults and [00:05:00] patients nearing the end of their life.
Professor Wilson: I’m sure similarly to your day, no day is the same in my office. So I’m always seeing something new which makes it interesting.
Professor Wilson: I’m doing preventative care. So patients are coming in for well checks and to talk about what screenings are needed. And then also managing chronic diseases, also just taking care of acute problems. So a patient calls in and they have an acute concern that doesn’t need emergency treatment, certainly we want them to come in so we can evaluate that problem.
Professor Wilson: Treat it if appropriate. And then have follow up. that’s kind of what my day looks like. it’s,
Professor Wilson: following chronic disease, but then also managing acute problems and then hopefully having time to do some education. And I think that kind of goes back to what you were originally saying is that we’re educating students for this generalist approach.
Professor Wilson: And that’s kind of where it even has followed me into from PA school to, [00:06:00] I get a chance to do some education and teaching in collaboration with my patients every day, which is really really what I love.
Professor Hare: that idea of no two days look alike, no two set of circumstances look alike. You know, I had mentioned to you, one of my instructors when I was in PA school back in the day was an orthopedic guy giving us some, knowledge on special testing of joints and things of that nature.
Professor Hare: And. One of the things that he said that stuck with me that day was family medicine, primary care. talking about careers in general with this guy because he was, an interesting character. And he said, family medicine, primary care folks, have to be able to deal with so many different things on a day-to-day basis.
Professor Hare: You have to be essentially a warrior ready to battle with any number of things in those circumstances that show up in your office that day. And it really was one of the things that when I was deciding what I wanted to do longer term after my initial job in physician assistant in orthopedics, I thought to myself, well, what do I really enjoy?
Professor Hare: And as an athletic trainer, I would have student athletes showing up. I would have [00:07:00] faculty, I would have coaches. I would have all kinds of people showing up in my athletic training room and asking me questions about anything from the sublime to the ridiculous and as an athletic trainer, my scope was relatively limited there.
Professor Hare: And I realized that that’s kind of what I enjoyed. I enjoyed that, wide variety of things, and we discussed in a previous episode with Jeff Bright that it really is the Jack of all master of none kind of descriptor, but you have to have a pretty good grasp of all those things.
Professor Hare: You have to be able to recognize conditions. You have to be able to recognize the things that are, the must not miss conditions that patients show up with because you are kind of the quarterback of their healthcare in those moments and family medicine from that perspective, I think is a really big draw.
Professor Hare: It’s one of the reasons why I personally, I think you might agree with this. is one of the reasons why I’m so passionate about family medicine in general, and working with underserved patients as well, and making sure that those patients have access to that kind of care moving forward,
Professor Wilson: Yeah, certainly. I think that it also really drives home the point that we all have to be lifelong learners.
Professor Wilson: And so in family medicine, you are seeing a lot of [00:08:00] different things, different presentations, but different illnesses, or complaints. And so you have to stay on top of your knowledge and continue to build upon that knowledge and treatment, different treatments. Right? So guidelines, I do my best to stay abreast of all of those.
Professor Wilson: And if you think about it, I’m having to stay abreast of hypertensive guidelines, diabetic guidelines, new medications coming out. And certainly it can be overwhelming, but it’s so crucial that we are providing good evidence-based medicine for our patients. I think that that’s certainly an interesting component of family medicine.
Professor Wilson: In addition, just to the relationships you get to build with the patients. And that’s probably. What I care most about. So
Professor Hare: absolutely. And I’m working through preventive medicine with my students in PA school and preventive medicine is one of those things that I put at the very beginning because it provides a solid background for a lot of the things we talk about in the future.
Professor Hare: In some ways I would like that to be the last module in the year, or repeat some of that [00:09:00] information as the last module of the year, because there’s so much of that that goes into day-to-day practice. And, you can’t just have the U S PSTF the United States preventative services, task force app on your phone and look up when somebody needs a colonoscopy or should you be doing a prostate exam or ordering, prostate specific antigen PSA tests for someone, those kinds of things are
Professor Hare: such a part and parcel of your day-to-day practice, that they really do become a part of who you are and what you do with those individual demographics. And so when you walk in the door and see a patient in some ways it starts to tick off a set of boxes in your own head and, you know, it becomes intuitive at a certain point.
Professor Hare: Oh, okay. So I need to make sure this individual has had their screenings up to this point and that set of screenings becomes just a part of the way that you operate on a day to day basis.
Professor Hare: obviously if there’s an issue, knowing what to do with that, I think that’s the biggest step for me in understanding family medicine was understanding that need to know what’s the consult, right?
Professor Hare: what’s the referral? Where are we sending this patient next? If they have something that is concerning to you. [00:10:00] And of course that can be such a wide variety of different presentations when that happens. So is hypertension something that you can handle or is it a cardiology consult for instance, or is this an oncology discussion?
Professor Hare: Are we concerned about something, is a dermatology oncology kind of an issue where an oncologist might be the next best step for that particular patient. Knowing that some patients really do need that next step in that referral from family medicine going to sports metaphors is, an easy thing to do sometimes, but I think family medicine becomes the quarterback for a lot of that stuff.
Professor Wilson: Yeah, you’re probably right. And I hadn’t thought of it in that instance, but I think just this whole idea of a team aspect and that’s what we are or what I think of when I think of being a PA and maybe even family medicine then lends to that, is that knowing your expertise and knowing when you also need to call on another teammate provide their expertise.
Professor Wilson: I think that’s what we should all be doing in any kind of interdisciplinary fashion. Where do I need the pharmacist help? Where do I need the physical therapists help? [00:11:00] Where do I need this specialist help?
Professor Hare: on the far end of that, as the quarterback, the ball comes back to you at every play.
Professor Hare: And the maintenance is often referred back to family medicine. The clearance for surgery often brought back to family medicine at that level. so there are two ways in which this relationship with the rest of the world and the rest of medicine works from family medicine. We’re both sending folks out and we’re also seeing them back and helping with the longer-term care.
Professor Wilson: absolutely. my hope is that if I do refer a patient that they see that specialist get guidance the specialist reaches out to me as their primary care provider to kind of close that loop, or I do that, but certainly that they’re coming back to me to help coordinate all of that care. So even I can think of instances where a patient Has a couple of chronic diseases sees a cardiologist sees a gastroenterologist or hepatologist, and maybe they’re not necessarily connecting. But it’s me if you want to call me the quarter back connecting those pieces and [00:12:00] bringing it together to say the cardiologist, wants you want a beta blocker, it looks like the hepatologist prefers this one because of this chronic disease that he or she is managing.
Professor Wilson: I think it’s all about coordination. And for me, it’s really important to make sure that that coordination happens at that the patient understands where all the pieces fit together and hopefully We’ve developed the patient and I a strong enough relationship that they keep coming back to me too, to.
Professor Wilson: help manage that
Professor Hare: I’m guessing that patient rapport is one of the areas where being in a clinic setting and working with folks longer-term and family medicine is of a huge benefit to you. Whereas, you know, in my instance, we have folks who are admitted to the hospital and then will come back at some point.
Professor Hare: to some extent there are relationships that can be developed there. but more often than not, that takes place over the course of say a week. There’ll be inpatient for a certain number of days We will develop that relationship as quickly as possible. Help them to manage whatever’s going on in their health care.
Professor Hare: And then on the [00:13:00] far end of that, we’re sending them home and more often than not sending them to someone like you and family medicine, who has that community perspective for them as opposed to the inpatient setting, which, you know, often patients are, more excited than not to get out of that setting and get home and, self care and care in the community become the primary goal at that point.
Professor Hare: I think that being in family medicine in a clinic setting would be nice. And at the same time, then I go back to psych and, there’s my orthopedic background. I get to be the orthopedic expert there. if someone has a fall or an injury I often would get the call to come and see that patient. So we all have our little specialties that we enjoy. part of the reason why I think you got the initial call to come here and do guest lecturing in my class was your endocrine specialty and your understanding of coagulation and coagulopathies which those are specialties, right?
Professor Hare: So family medicine is a great example of how those specialties still get used in family medicine. And we still have to have some understanding of those things, whether it’s a specialist understanding or not understanding of when it’s an issue and when we need to move it on, when we can handle [00:14:00] it ourselves is one of those big challenges in FM in general.
Professor Wilson: and certainly Jason, if you ever want to come and join the practice, I will take your athletic training, sports medicine orthopedic background, and can certainly call on you to help with some of the cases. Because often we do see a lot of musculoskeletal complaints and family medicine, And really just going off what you said about developing rapport and relationship with patients.
Professor Wilson: I often tell my students when I share that I’m a family medicine provider, the best part of it is that I get to see the whole family sometimes. So I literally am taking care of a kiddo, a neighbor, maybe the mom, a grandma, the father and the goal is get to know them over a years. And so you know, some patients I’ve been in this practice for almost 13 years, I’ve all, I’ve probably seen them for 13 years.
Professor Wilson: And so I think developing rapport is really important,
Professor Hare: one of my favorite moments that I like to tell students is when [00:15:00] I was on a rural medicine in the middle of Montana, it was an NHSC health service Corps rotation in family medicine. it was very much a rural area.
Professor Hare: one stoplight to the roads have been paved within the last year or two before I got there for my rotation. And we went to the grocery store in town. there were two bars, one clinic, and one combination, convenience store, post office, pharmacy that was a rural version of a bodega, I suppose across the streets and.
Professor Hare: My preceptor and I, I lived with him because there’s no other place to stay or live in those kinds of scenarios. And he and I went to the grocery store after our clinic day, that day. And we’re walking through the produce aisle and somebody walked up to him, knew him by name,. had known him for a long time and showed him the rash in the middle of the produce aisle at the local grocery store.
Professor Hare: So those kinds of things, you know, there may be pluses and minuses to that whole familiarity with your, patient population. But it becomes not just seeing families, but also becoming part of that family to some extent, And that is something that in [00:16:00] my setting is missing a little bit, you know, and I’m sure, Jeff Bright would agree. if we’re taking that generalist perspective to his extreme, that’s probably Jeff in critical care, he’s seeing folks and they may only be, even be conscious when he’s with them.
Professor Hare: Which, you know, I think for those of us who are good at dealing with patients and like to develop rapport is. almost a shame that in Jeff’s case that he doesn’t get to put his good patient rapport and people skills into use with those folks. it’s good that those of us who work in family medicine have to really develop those skills if we don’t already have them.
Professor Hare: I think that’s an underappreciated aspect of family medicine is being able to deal with all those things and do it with empathy and care and consideration as it’s happening.
Professor Wilson: Absolutely.
Professor Hare: let’s move toward talking through some cases and family medicine, again, we discussed the fact that
Professor Hare: in orthopedics, you see one module of clinical medicine in the module system and PA school maybe two or three, if you extend some of those, some of that knowledge and an understanding into different modules in clinical medicine, but in family medicine, [00:17:00] it’s so broad that essentially it’s all 15 modules of clinical medicine that we might consider.
Professor Hare: And then some, and so, the list of cases that are high morbidity and mortality, and, I’ll just read through your list that you came up with. And I certainly agree with these hypertension, diabetes, chronic kidney disease, which can result from either hypertension or diabetes or a variety of other things.
Professor Hare: Number four is COPD. So chronic obstructive pulmonary disease or emphysema. And then number five is mental illness and substance abuse issues. So let’s talk about hypertension first. there are a lot of algorithms for these high morbidity and high mortality issues in our country. And worldwide for that matter, because they’re so high morbidity and mortality I assume you’re using the joint national commission eight guidelines for hypertension.
Professor Wilson: Yes, absolutely. So we follow JNC and in terms of evaluating and then managing the patients certainly.
Professor Hare: and do you [00:18:00] consider their cardiovascular risk and score them on those to make determinations for next steps?
Professor Wilson: Most definitely. And to see if in terms of do any changes, need to be made to their medications based on those risk scores.
Professor Wilson: it’s always. Identifying and then managing and monitoring situation for those patients.
Professor Hare: obviously hypertension and diabetes both are a big part of our metabolic risk factors for those patients. And I’ve tell students consistently over the last few years that we’ve gotten to the point where statins are the thing, we used to think about this varied picture. Do we need to put them on nicotinic acid, niacin? Do we need to consider one of our other lipid lowering agents? And the last couple of years, we’ve seen that it’s a plus minus, are they on a statin or are they not on a statin and is their risk score high enough for that to occur?
Professor Wilson: Oh, absolutely. It has. become. Commonplace unless there’s a contraindication or a significant side effect that the patient is experiencing in [00:19:00] terms of certainly diabetes, that they need to be on a statin, unless there’s a contraindication or a side effect oftentimes a patient with hypertension or concern for coronary artery disease that they’re on a statin.
Professor Hare: if they are experiencing side effects from their statin, do you adjust that to a different statin or lower that, or what’s your approach like in that setting?
Professor Wilson: All of the above, I would say it depends on the side effect and identifying that it is coming from the statin. Could we change to a different, Staten? so perhaps
Professor Wilson: kind of plant-based Staton or a lower intensity statin Decreasing the dosage and seeing if they tolerate that. And I think that depending again, on the side effect, it’s a conversation with the patient as to why in general, I’m putting you on this medication, whether that is a statin one to lower your risk of having a stroke or a heart attack keeping your vessels nice and clean and open versus the side [00:20:00] effects.
Professor Wilson: let’s weigh the pros and the cons and have a discussion about whether you ultimately take the medication or not. And I think that’s a general approach I take.
Professor Hare: what’s your most common reported side effect from a statin?
Professor Wilson: Probably muscle aches. Yeah. And it’s not common that I see that complaint, but when it does come up, we really do explore that because I mean, it can be serious and we need to know. But yeah, I would say muscle aches.
Professor Hare: There may be some side effects. We’re going to watch for those. We have things we can do to make that better. But Stanton’s are really a valuable way to wring out some of that cholesterol and the lipids from the bloodstream in general which I think is helpful.
Professor Hare: as far as hypertension there’s so many different medication classes that can go into treatment for hypertension. assuming, no, co-morbidities assuming risk factors are minimal in that patient in your treatment of hypertension, what is your standard start?
Professor Wilson: when I have a student with me in the clinic, we always talk about hypertension and the [00:21:00] different classes of medication. Because while each day is different and family medicine. There are some what we call bread and butter things that you’re going to see. So you’re going to see hypertension a lot and you’re going to see diabetes a lot.
Professor Wilson: we always take some time just to have one-on-one conversation about hypertensive medications going back to your question. usually it’s a thiazide, so hydroclorothiazide is what I would primarily start with. But again, I think it’s looking at that picture and if they don’t have any other co-morbidities, then probably that’s what I would start with.
Professor Wilson: But let’s say they came in and they have diabetes and they’re not already on a medication. Certainly they should probably be on an ACE inhibitor or an ARB to help protect the kidneys. I look at the patient and then really. Talk through the options with them. What are the recommended starting medications here are side effects here, are common side effects or not.
Professor Wilson: So common side effects and then going from there you’re going to probably get [00:22:00] sick of hearing that I come back to the patient constantly because it really, in my mind they have to be given the recommendations and why that is the case. And then we have to come to kind of a mutual patient centered plan.
Professor Wilson: Yeah.
Professor Hare: And along those lines, the ACE inhibitor question, you know, something like lisinopril as a starting point those medications are incredibly inexpensive. And then moving though to something like Losartan, for instance, an ARB and a angiotensin receptor blocker is a much more new.
Professor Hare: Class of medication and it also tends to be much more expensive, they’re getting less expensive over time. And so that family medicine aspect of looking at the medications, looking at the patients ability to pay for those medications, we want to maintain compliance in these patients and, having some backgrounds and understanding of that patient’s relationship, that rapport that you have developed, you can understand their ability to afford that medication, their likelihood to be compliant with that medication and avoiding expensive medications in [00:23:00] some patients is very important.
Professor Hare: And especially if there’s a medication that does the job and doesn’t require that high expense.
Professor Wilson: Yeah, absolutely. I think that, you bring up a really great point that we often see come up in clinic day. is the medication covered? Can they afford it? And then if it is, or isn’t, what can we do on our end, my end to either submit a prior authorization, look for some kind of discount.
Professor Wilson: And certainly if it is a medication that really is indicated needed, we do our best. And, and I think that we do a good job of trying to get that available for the patient, but yeah. Great point. ACE inhibitors are fairly inexpensive the same with like hydroclorothiazide a thiazide diuretic. But that’s always in the back of your mind
Professor Hare: and the reference material.
Professor Hare: I often find it interesting that, especially in current medical diagnosis and treatment as a reference, book or on UpToDate online these references will often note with dollar signs, $4 signs. It’s like a restaurant. The most expensive [00:24:00] restaurant is $4 signs. The least is $1 sign.
Professor Hare: And they will often note that the expense of a medication in physicians, drug reference, or PA drug reference that gives you some background as to what we’re dealing with with the cost for that patient, and if it’s pennies a day then that patient is far more likely to be compliant with it and use it over time.
Professor Hare: If you give them something that they can’t afford they may not use it, which unfortunately to move them maybe to our next. Topic, which is diabetes becomes a major issue for patients, especially our type ones or our long-term type twos who have moved past oral medication into injectable insulins and that the cost for those kinds of insulins.
Professor Hare: And for many of the oral classes that are involved with treatment of diabetes can get really expensive over time.
Professor Wilson: Yeah, certainly some non-insulin types of these newer medications and diabetes insulin is certainly expensive. And then even just thinking down the line C O P D medication can get really expensive inhalers.
Professor Wilson: there’s a lot to think about when you are deciding your treatment plan with a patient.[00:25:00]
Professor Hare: You’re diabetic patients, presumably mostly type two that you deal with on a day-to-day because type one, relatively more rare. I think it’s along the lines of 10% are type one in the diabetes world and you know, more than 90% are, type two.
Professor Hare: Initial recognition of diabetes, is that usually a screening thing for you?
Professor Wilson: Yes.
Professor Hare: A symptom based thing in other,
Professor Wilson: not necessarily. I will sometimes look at this again seeing the patient in the room with me. Do they have some risk factors for developing diabetes?
Professor Wilson: And then that will sometimes prompt the screening in general. we should be screening at a certain age as well. So I think risk factors age is it just a health maintenance item to check a fasting glucose? A family history. So again, back to risk factors, is there a family history and then are they telling me symptoms that could be signs of diabetes, frequency of urination thirst changes in vision dramatic [00:26:00] weight changes, you name it.
Professor Wilson: I think that it can be an easy screening to get a fasting glucose or non-fasting glucose follow-up with some additional testing, typically an A1C in my setting.
Professor Hare: it used to be that the fasting glucose check was the standard. And I’m seeing more and more across the board that HBA one C is being used more and more as a screening tool, probably because it kind of levels things out over time.
Professor Wilson: I know different guidelines say different things, but I would say clinically practicing. If there is enough support to order an A1C, that’s probably what I’m going to go to. Or if we do a screening BMP or they’re coming in for a follow-up and they need a basic metabolic panel, and I see that the glucose is now like 1 46, and that was probably a fasting glucose.
Professor Wilson: Then it’s going to prompt me to say, yeah, I think maybe we should check in A1C. Two, are we potentially seen diabetes or missing diabetes that we need not
Professor Hare: backing up a touch that HbA1C is glycosylated, hemoglobin. And it gives us a picture of what [00:27:00] the average blood glucose have looked like over the past three months.
Professor Hare: And that is it kind of evens out those levels, whereas Most patients don’t come into the clinic fasted and you see some of those initial signs or you, develop a concern for that patients and their blood sugars. And suddenly you are at a point where you decide you need to do blood work. That becomes a not today, or maybe later this afternoon, return for blood work issue.
Professor Hare: I personally go into my primary care physician fasted every time. And the one time that I don’t go into my PCP fasted before a visit She wants to do lab work. So it doesn’t always match up with your expectations or needs in that moment. But I do like HbA1C and that it used to be something that we taught.
Professor Hare: Don’t do this as a screen, and now it becomes more and more frequently used as that screen because it’s just easier. It doesn’t require fasting. I do tell students that it tends to skew toward the last couple of weeks we tend to see it bump up a little bit in the last couple of days
Professor Hare: to weeks, if the patient has changed their habits from the beginning. So let’s say in the first two months they were, doing a good job of maintaining their blood sugars. And [00:28:00] then recently they have changed their diet. It’s gotten worse over the last week or two, that’s going to have a more significant impact on today’s lab then maybe that first two months of that timeframe.
Professor Hare: talking about diabetes Metformin used to be the only medication of common use when it comes to diabetes, oral treatments, oral medications, specifically for type two diabetics and of course, type two diabetes for my physiology nerds out there and pathophysiology nerds out there type one.
Professor Hare: Diabetes is usually an auto-immune condition. It is usually destruction of pancreatic cells that put out insulin early in life. Usually in the, 12 to 15 is usually the number that I see quoted in a reference sources at which we see development of type one. And then type two diabetes is more of a lifelong process.
Professor Hare: We do see it in the young and increasingly so as the Western diet we’re seeing has moved that into younger ages, but type two, being a longterm process. And the insulin is still being put out at least in the early stages of type two diabetes.
Professor Hare: And later on those pancreatic islet cells.[00:29:00] Secrete insulin start to burn out over time. And because they have to put out increasing amounts of insulin and eventually become essentially worn out in their ability to put out that insulin and the peripheral tissues, the muscle and the fat cells in the body that use that insulin are actually becoming insensitive to the glucose that’s in the system and the insulin that’s being put out by the pancreas at the same time.
Professor Hare: So it’s a relative deficiency of insulin in those moments. And as a result, that’s a much longer term process to develop that type two diabetes. And oftentimes we see those patients. When they present because of that, long-term insidious process they have a lot more symptomatology when they present than we may have realized.
Professor Hare: And it’s hard to pick up some of those more subtle cues. So on the day in which you make that type two diabetes diagnosis with that patient, what is your process look like for the next steps for that patient?
Professor Wilson: absolutely.
Professor Wilson: you know, I think that we have to think about how long has this been going on?
Professor Wilson: Like you said, this [00:30:00] is a chronic long process. So what damage could have potentially already been done that perhaps the patient doesn’t feel doesn’t note, but could be brewing. Certainly we need to make sure the patient has an eye exam to make sure that they’re not diabetic changes like retinopathy in their eyes.
Professor Wilson: We need to make sure they’re not experiencing neuropathy. So numbness and tingling in their hands. Do they have good circulation in their feet? Do they have a sore on their foot because they don’t have much feeling in their foot. Thinking about protecting the kidneys and protecting the heart, that’s why we put a statin, give them a stat.
Professor Wilson: And if they’re diabetic, because diabetes is a risk equivalent for coronary artery disease. meaning that we need to make sure that we’re lowering their risk of having a stroke or a heart attack. It can feel overwhelming I would assume when a patient gets diagnosed with diabetes because now we have kind of a list of things we need to do in [00:31:00] terms of evaluating and make sure there’s not diabetic changes happening in the body. And then here is some medicine that we need to start and that can feel overwhelming. And so do we take this in a step wise approach? I think you have to know your patient and know what they need at that time, but certainly to be mindful that you’re not just treating the sugar at this point, you are treating end organ damage that this sugar is causing,
Professor Hare: and that there’s so many comorbidities associated with diabetes in those scenarios that it can feel overwhelming.
Professor Hare: Certainly for a lot of folks to think about, you know, the diets, the, the therapeutic lifestyle changes that can go into making that better. So it’s not just treating I’ve had students. discussions of diabetes in this program. And you’ve been a big part of that is diagnosis and treatment, which is standard clinical medicine theory pedagogy.
Professor Hare: But there’s also a large component of it. And I’ve had students say, gosh, why we talk so much about complications of diabetes. And it’s because there are so many other things that are going on with diabetes that can present that. It really becomes a big part of that [00:32:00] conversation.
Professor Hare: You’re not just diagnosing and treating and letting them go home in those moments, you’re saying, okay, so we need to get you in for ophthalmology discussions. We need to check your nervous function in the lower extremity, especially, and I’m looking at their cardiac function and all the other metabolic conditions that can go along with that to help them.
Professor Hare: Make that better. What can, what can they do to make that better longterm? And those interventions can be difficult certainly for those folks. So as far as your interventions, as medications what are your common oral medications? So we’re not talking about insulin at this point, we’re talking about the initial, especially type two medications.
Professor Hare: we don’t use oral medications for our type one diabetics at all. We go straight to insulin that’s injected. what are some of your common go-tos these days?
Professor Wilson: certainly Metformin still remains common Sulfonyureas is less common, but again, they can be inexpensive.
Professor Wilson: So seeing what the patient’s needs are and what their co-morbidities are too. So we’re doing more GLP one’s SGLT twos they have new medications out that [00:33:00] are weekly injectables, not insulin. I always want to point out to my patient. This is not insulin, but it’s an injectable weekly medication that is very good for lowering blood sugar, but also has been indicated in chronic kidney disease patients with coronary artery disease or risk factors for the heart or chronic disease of the heart, essentially.
Professor Wilson: So we actually use a little bit more of that and have good outcomes. Patients are happy, satisfied. And then it’s nice if it’s a weekly medication So those are the primary ones. that
Professor Hare: So have you been prescribing a semaglutide Ozempic I think is a, it was one of those that I’ve seen. And that helps also with weight loss my understanding is a 10%, 15% weight loss associated with it, but also as we’re talking about cost earlier, Ozempic has a significant cost associated with it.
Professor Hare: So there’s another example of things that we can do. But again, it can be limiting that economic access to those kinds of medications for anybody a thousand dollars a month for a [00:34:00] medication, there’s a lot of money.
Professor Wilson: Yes. And thankfully they have been covered more and more by insurance.
Professor Wilson: And w is it OSMP or is it another medication in that class? So cost is one issue. The tricky thing is that they’re all different, delivering device mechanisms. as a prescriber, you have to know how to order that medication. the other end of that is to educate the patient, how to use it.
Professor Wilson: And they can be tricky, even thinking about all different inhaler types. Those are tricky to educate the patient in my own practice, where I work. I’m lucky to have pharmacists on staff who can meet with the patient and do some education pieces around that. She does a lot of education around diabetes asthma and COPD medications and just in general medication management, but it can be tricky as the patient to know how to use that’s another challenge. Are you using insulin pens? Are you using a vile As a provider, we have to order the right pen needles. There’s a lot of things to think about. but they are good [00:35:00] medications help with weight loss. They do have some side effects that you need to talk to a patient and contraindications that you need to know your patients so that you’re not prescribing them.
Professor Wilson: If let’s say they have a history of pancreatitis or something like that. if we can drive home to the student, pharmacology is so important knowing these common side effects, contraindications and education, it’s crucial what we teach
Professor Wilson: there’s,
Professor Wilson: a method to the madness and a reason , for these teaching points.
Professor Hare: If you have just out of curiosity. And I don’t know that the answer to this question, myself if you’re going to do a weekly injection for a patient, are you having them come back or are they sometimes being instructed or getting a community member who might be a nurse or somebody in their neighborhood who can help them with that?
Professor Hare: Is that something that you actually take advantage of?
Professor Wilson: For the most part, most of my patients do fine doing this on their own. Once there’s some education, it’s not challenging. The needle is quite small. So most of them, I believe do this on their own. We are certainly happy [00:36:00] to see them back if there needs to be some reteaching retraining or monitoring, but for the most part, they’re doing it on their own.
Professor Wilson: Just reminding them, they need to take it the same day of the week, every week primarily. But yeah, certainly I think that we can. Get other community people involved if needed,
Professor Hare: I think is a point about your particular practice as a family medicine PA is that you have a holistic kind of a whole body approach in your clinic where you have those folks available to help with that kind of education some family medicine folks, especially in those rural areas, you where everything in that practice from the beginning to the end of that patient’s experience maybe an, every nurse around to help with some of those aspects, you know, for phlebotomy and things of that nature.
Professor Hare: it sounds as if your clinic is very full body oriented and very comprehensive in its approach to those kinds of care and which is great. Not always possible,
Professor Wilson: definitely not always possible. And we’ve tried to be mindful of really how can we support the entire person and who do we need and what do we need for.
Professor Wilson: that [00:37:00] Even I’ll give you a good example. a lot of my patients, transportation is difficult and so transportation to go see an ophthalmologist for a retinal screening can be challenging. we actually have a retinal camera in the office, so it is a camera.
Professor Wilson: We had one of the first in the area, but now they are being utilized much more over, this Pittsburgh metropolitan area.
Professor Wilson: so it’s a retinal camera that takes pictures of our patients, eyes who have diabetes. This then the picture is like the vasculature of these eyes. We can send that image to an ophthalmologist or an ophthalmology team who looks at those images and then can send a report back. that has been fantastic at identifying these diabetic changes for our patients.
Professor Wilson: And it doesn’t replace a full exam for a patient. Certainly doesn’t do that. But For the population that I work with, this is really crucial because if, we can at first identify an issue, we can then help to connect them into care.
Professor Hare: So moving from telemedicine [00:38:00] to photo medicine, to speak
Professor Wilson: Yeah. And we started maybe with that photo medicine. So,
Professor Hare: yeah. And interestingly enough, it’s something similar to what you would see with an EKG. You have this thing that you can actually fax to somebody and they can take a look at it and report back to you. It looks like this is an issue. This is not an issue. You know, it’s helpful to have folks in specialty services who can help you make those kinds of decisions.
Professor Hare: But that’s a really helpful step in that direction. the next one you have on the list is chronic kidney disease. And again, often a result of those first two hypertension and diabetes tell me about a common way in which you would approach a course for a common chronic kidney disease.
Professor Wilson: I put that on in terms of morbidity and mortality, because it is so linked to hypertension and diabetes that oftentimes we see kidney function start creeping up or worsening, and one, we need to know what the underlying cause is. And then again, when it’s important to refer to a kidney specialist and nephrologist to start managing and seeing those patients.
Professor Wilson: [00:39:00] It’s really kind of noticing when the creatinine, when the bun is starting to creep up asking them, well, what medications are you taking? What over the counter medications are you taking like an NSAID.? And then again, making sure that we’re identifying it before it is at a stage where it is advanced kidney disease or end stage renal disease.
Professor Wilson: And now the patient is on dialysis. because We certainly want to avoid that if we can,
Professor Hare: at all possible. Yeah. And that’s I think hopefully a future episode the podcast, we’re going to try to get some renal PAs in. And what I have found is renal PAs primarily have a split between clinic and dialysis.
Professor Hare: And so dialysis is a huge part of renal medicine. And avoiding getting to that point, hopefully that preventive medicine aspect of family medicine becomes more, well, it does become more important and hopefully can intervene. We can intervene before we get to that point, make changes to medications help the patient with those kinds of lifestyle changes that they might need to make to avoid that next step in those situations.
Professor Wilson: Absolutely.
Professor Hare: [00:40:00] do you work with dialysis clinics on patient care in those scenario?
Professor Wilson: yes, I think for me, it’s really important to have that connection with a specialist. in some instances I have patients who I’m managing their hypertension and they have chronic kidney disease.
Professor Wilson: And so we’ll have that discussion. They’re seeing a nephrologist having some communication, whether that’s through the electronic medical record or a phone call where we need to make some adjustments to the hypertension medicines monitoring the kidney function and really kind of like a joint effort.
Professor Wilson: that’s the most rewarding when you can have this joint effort with the specialist, with the nephrologist to really provide the best care for the patient. So it doesn’t happen All the time, but I can tell you it does happen. And for me, that’s really
Professor Wilson: important. Yeah.
Professor Hare: in my inpatient family medicine scenario, we have patients who are in the hospital for a period of time and we have to send them to dialysis say three times a week.
Professor Hare: And oftentimes we’re, ordering the labs and the dialysis folks [00:41:00] and the kidney service across the street are looking at those labs and making determinations. Sometimes I’m calling them and saying, this person’s pressure is up today. They seem to have a lot of extra volume. And of course their kidneys aren’t capable of getting rid of that extra fluid or electrolyte or whatever it might be in their system at that moment.
Professor Hare: asking them for some advice on those things, and it also helps to have those folks on board when we’re making medication decisions. we’ve got these two medications. This one is Okay for the kidney it’s usually not, great for the kidney any one of those medication additions.
Professor Hare: But then the question of, this one’s really kind of kidney toxic. There’s never a toxic, or we need to avoid that one because it’s going to bump that BUN and Creatinine up if they start that medication. So it really is helpful to have the kidney service on board for those kinds of discussions and really some advice on how to handle those things.
Professor Hare: And then sometimes when the pressure gets up, when the patient has fluid loaded for, for whatever reason we can send them over and, add what on there and those moments. So it’s kind of the advantage of being inpatient for us as we have that care available when we need it. And they’ve established care already.
Professor Hare: Cause [00:42:00] they’re seeing them three times a week. It’s really a nice nice. may not be the word there, but it is a helpful adjunct to our care and that hospital to be able to do that. And then, so the next one COPD and presumably this is almost exclusively a smoker issue in our patients.
Professor Hare: So that, that preventative medicine side of things obviously is one of the big ones here. And then eventually we have to deal with the potential complications of that. So tell me about COPD and what a patient looks like for that.
Professor Wilson: Sure. for the most part a major risk factor is tobacco use being in Pittsburgh though, certainly, steel mills common and work in the steel mills just exposure to different fumes and so forth.
Professor Wilson: But a patient often comes in complaining of. a chronic cough. So if we’re thinking chronic bronchitis persistent cough, mucusy, cough that kind of maybe is always there. And then has these exacerbations or spikes up where they, feel like it gets worse or shortness of breath [00:43:00] that they notice with activity primarily as the first presentation.
Professor Wilson: perhaps they’re doing yard work that they used to do without any type of break. And now they’re having to take a break. Or sometimes we just notice it on imaging. They’ve gotten an image for one reason or another, that notes, emphysema. Really what we strive to do is one recognized tobacco use disorder asking the questions about chronic cough, shortness of.
Professor Wilson: breath, And then getting pulmonary function tests to see if that gives us objective finding of COPD ideally that’s what should be happening.
Professor Hare: How often do you see industrial occupational exposure type? C O P D. Assuming we don’t have an alpha one antitrypsin deficiency, which causes in some genetically predisposed individuals more COPD.
Professor Hare: And at an earlier age, how often do you see Those kinds of occupational or industrial exposure is causing that kind of COPD presentation?
Professor Wilson: I don’t see it necessarily often. I think what’s important [00:44:00] as a provider, we need to remember to ask those questions are there exposures do they do welding? what do they do in their occupation or in life is the cause for the exposure. I would guess pulmonary medicine sees this more often and is treating it more often. That’s my guess, but in family medicine, it’s often because of a long history of tobacco use.
Professor Hare: Okay. obviously you’re concerned about exacerbations in those patients that can lead to things like pneumonia. So how do you talk to patients about that pneumonia risk and the possibility of next steps for those folks when it comes to pneumonia?
Professor Wilson: Yeah, I think that’s where preventative medicine comes back into play.
Professor Wilson: So getting their pneumonia vaccine if they’re a smoker that is indicated and again, continually providing education and support and tobacco use Decrease in hopes for complete cessation is really what I try touch on and drive home. And then in addition to the pneumonia vaccine, influenza vaccine is really important.
Professor Wilson: [00:45:00] just to frame it in your lungs are not as healthy as someone who is not smoking potentially, and that we need to protect you from developing these severe illnesses that can lead to significant change in your life, if not death
Professor Hare: what is your playbook for tobacco cessation, nicotine dependence?
Professor Hare: Do you have something that is a go-to for you or , do you use the entire , from CBT to Chantix?
Professor Wilson: Yeah, do. I try to see where the patient’s at first. And so. have you thought about quitting
Professor Wilson: Yeah. Tell me about that. And then oftentimes they will bring it up to like I’m ready to quit and I’m like, great.
Professor Wilson: Tell me more. When are you ready? Ready to quit? Have you set a date yet. What do you think that you would like to use to help you quit? What have you tried in the past, but certainly medications we will prescribe as well as giving support, encouraging them to call the PA quit hotline. Right? So there’s lots of resources.
Professor Wilson: It’s not easy to do. And I reinforce that.
Professor Wilson: I heard [00:46:00] somewhere that any kind of habit takes multiple tries, and to quit. And so I reinforce, okay. It sounds like you quit in the past and you quit for a month. That is fantastic. is just because you started back up. That’s not a reason not to try again.
Professor Wilson: Oftentimes we have to try multiple times to quit a habit. So let’s keep at it and really encouraging them. You quit for a whole three years. Great. let’s get there again. I think to me, those are some of the most satisfying moments when you can really help someone to find that it’s life altering to stop smoking.
Professor Hare: Not just the long-term implications, but you know, the cost of smoking and the, social costs sometimes of smoking can be significant. One of my favorite moments in my rotations in PA school, again, out in Montana, and I’m sitting with my preceptor, we’re talking about next patient.
Professor Hare: Who’s about to come in. She’s a long-term patient. And he’s like, yeah, I’ve been trying to get her to quit smoking for a long time. And she literally burst into the room, ran across the room and gave him a gigantic hug and was just so happy because he had been working with her for so long [00:47:00] to try to get her to stop smoking.
Professor Hare: And she’d been trying it. different ways to make that happen. And the day that I happened to be there in the room, on the day, when she really felt comfortable saying I feel good about this now, I don’t feel like I’m about to lapse back. I’m not going to walk out the door and Jones for that cigarette so badly that I’m going to need to have a cigarette.
Professor Hare: I feel like I’ve finally gotten to that point and that was a great moment, and my preceptor obviously was extremely happy, pretty much in tears in that moment because of the significant shift that that patient had been able to make and he’d been able to, to help her to get to that point.
Professor Hare: And so that’s a really special moments that family medicine gets that you might not see in a lot of other specialties, to be honest.
Professor Wilson: Absolutely. and it’s nice to be there for those moments or to hear when the patient has made that shift, if they come back and share that with you and really a credit to the patient for doing the hard work.
Professor Wilson: And I think it’s always important that we remember
Professor Wilson: whatever occupation we’re doing, but certainly in medicine, we could plant seeds. and you might not see it grow, but it could grow later. And I think that’s the important thing.
Professor Hare: [00:48:00] that leads us to the last one on the list for our discussion of cases and that’s mental illness and substance abuse, which is broad categories.
Professor Hare: Folks that I work with a lot in my setting and family medicine and psych hospital mental illnesses, one of those things. Do you feel like you need to screen for it, or is it more often that they are presenting to you with discussions about those things?
Professor Wilson: it’s definitely important to screen for mental illness.
Professor Wilson: And we do have protocol in our practice for a screening yearly if not more often for depression. And sometimes patients present with that chief complaint, but I tell my students too, that it’s your job to keep your differential broad. When a patient comes in with a complaint sometimes patients present with physical complaints that can be because of physical cause, but not always. And so you need to recognize to how his mood playing into all of this so that the patient can get care. Now, instead of later down the road, when you can improve quality of [00:49:00] life instead of waiting or not thinking of it, and it’s a long time down the road and they’ve been suffering.
Professor Hare: Yeah. It was teaching thyroid conditions And of course, thyroid conditions can lead to depression, like symptoms, anxiety, like symptoms, whether it’s low or high thyroid levels. But the discussion led to fatigue and tiredness being one of the most common presentations in family medicine,
Professor Hare: when you think about how tired many people are on a day to day basis, it’s an easy thing to think about yourself. But if a patient’s presenting with fatigue and tiredness, clearly that’s a, level that, maybe they didn’t have previously, and maybe there’s been a change there, but the number of differential diagnoses that can go into fatigue is so large and encompasses almost every body system that, there is including the cardiac, the lungs, blood vessels.
Professor Hare: The endocrine system certainly is very wrapped up in energy as is the neurologic system, psychiatric conditions like depression and anxiety can really play into fatigue and energy levels insomnia sleep issues, which can be linked back to things like obstructive sleep [00:50:00] apnea.
Professor Hare: The list is significant. So having that approach to those kinds of conditions and those. Presentations where you work through your lab workers, CBC CMP BMP is something that we talked about, the TSH, which is a common screening lab we do in psychiatry. But I think it’s often done in family medicine as well, because you need to know whether that patient has a good thyroid function.
Professor Hare: If it may be impacting their ability to function, to sleep on a day-to-day basis as well. And TSH is, the easiest spot in that entire feedback loop, that negative feedback loop that thyroid hormone presents to them, to their brain to, make that determination. then maybe move on to other labs to determine if there is another process going on there.
Professor Hare: So it’s a good example of areas where we can do a quick and Relatively easy lab on our end and really screen for a variety of things in that setting. Infection could also be causing those kinds of fatigue that broad approach to those things and figuring those things out again, that’s the warrior mentality when you’re approaching patients and having that broad set of differentials can be significant and difficult
Professor Wilson: [00:51:00] I was just going to add, so I love that you brought up that, the chief complaint of fatigue, so right there your differential is quite broad with that. Do some blood work ask those questions and then in terms of screening or thinking more about, could this be depression then add in the PHQ nine or some kind of depression screen, or ask questions about that so that then you can rule that out.
Professor Hare: What percentage of mental illness patients would you say. You treat in-house versus sending along to a psychologist or a psychiatrist for
Professor Wilson: great question. in general, and I’ll speak for myself. I feel pretty comfortable treating depression and anxiety in terms of medications recommending behavioral health therapy and even perhaps we try one or two medications for depression and we need to switch or try a third.
Professor Wilson: So I feel pretty comfortable trying a couple of different depression, medications, but then when we’ve not had improvement [00:52:00] in mood for the patient, I think then that’s when, for me it’s time to say, okay, I think we need to get someone else on board to give their impression, their suggestion bipolar.
Professor Wilson: I typically have a patient see a psychiatrist for that. Unless they’re coming to me as a new patient, they’ve been stable on medications. But if this is a new presentation or worsening of their symptoms, usually have them see a psychiatrist, same with schizophrenia
Professor Hare: organic psych illness.
Professor Wilson: Yeah. Yeah.
Professor Hare: brain chemistry, very, very much wrapped in brain chemistry that is not in any way situational, really.
Professor Hare: Right. So we have those, ups and, and life situations that impact can put someone who might be otherwise slightly inclined toward depression. Puts them further into that spectrum of depression or anxiety in the opposite direction, and really can, be more of a transitional diagnosis where shorter term medications might be helpful for them.
Professor Hare: And then moving on to the longer-term medications for those who really do need [00:53:00] longer-term care I think that it’s great that family medicine works with these kind of diagnoses. Often, because we want to see mental illness as, as just that as illness and disease states not failing on the part of the patients, you know, and I think that’s been a significant battle in mental health and psychiatry, I don’t like even like the term behavioral health, to be honest with you, because it implies that there’s a behavior that can be changed on the part of the patient. That is a simple answer to that particular issue. So psychiatry and mental illness, I like those terms far better because they really do point out that there are things that need to be addressed in that patient, not ignored or, saying, you know, well, you just need to brighten your attitude or change the way you approach things.
Professor Hare: And, While some folks might benefit from that we will always need to take these seriously as we’re presented with.
Professor Wilson: Yeah, absolutely. And I think just like any other condition this is an illness. We can treat it in a multitude of ways. And then just like, I would refer to a [00:54:00] nephrologist for a patient who has severe, kidney disease.
Professor Wilson: if this is out of my comfort zone or out of my scope of practice in terms of treating mental illness like schizophrenia or bipolar, then I’m going to refer to a specialist and that’s what needs to happen. And I think, we could spend a whole nother episode of podcast on this, but connecting them with care is really important and it can be challenging challenging, especially in this time when.
Professor Wilson: There’s not enough providers. And so I really maybe take the extra step to help make sure that connection happens because it it needs to happen. and in terms of connecting with the psychiatrist or a
Professor Hare: therapist.
Professor Hare: And you read my mind, you know, this is where PAs make this possible. I think not to overstate it, but the number of practitioners in that office, the ability to see patients on a day-to-day basis.
Professor Hare: And then when that moment comes along in which there needs to be more discussion, there needs to be a more in-depth. We’re going to spend some more time with this and make this possible for that patient. Give them next steps that are [00:55:00] palpable, usable, next steps for them, physician assistants and the team approach to medicine when it comes to.
Professor Hare: Mid-level providers APPs, PAs, NPS adding us into that mix provides more comprehensive care in those moments and better care in those moments as opposed to we need to refer this patient on because as a solo practitioner, I’ve got to get to my next room I think that’s incredibly important. And of course, substance abuse is the one of those things where we really do need to look to the next level with our patients. obviously we never want to detox a patient for instance, in family medicine or primary care kind of environment, because detox can be deadly in some situations, detoxing from medications should be something that we pass along to psychiatry and, substance abuse specialists . Do you see a lot of that particular aspect of things?
Professor Wilson: Yes. In terms of where I practice, we actually treat opioid use disorder. So we have providers who have gone through the training and are licensed to prescribe some medications to help with [00:56:00] this.
Professor Wilson: I think there’s also this understanding and learning to, if there is detox that needs to happen, what’s the best environment for that. So do they need to be in an inpatient setting where they can be closely monitored and then transitioned to our outpatient setting to continue on medications or continue in some kind of supportive environment?
Professor Wilson: So not all family medicine practices do this. I think it’s going to become more common because there is a strong need. And there is a strong need in the community that I practice in for. Medication assisted treatment for opioid use disorder, we could, again, also talk about substance abuse in general, but I think going back identifying mental illness, identifying diabetes, also identifying substance abuse, That it’s a hard thing for a patient to bring up and discuss. Whether, they feel that they want to bring it up, but whether they do or not, I think that if I go back to talking to the students, we bring up, it’s important to take a social history and it really is for so [00:57:00] many reasons.
Professor Wilson: And one of those reasons is to screen for substance. abuse.
Professor Hare: In our program, we have worked with the pharmacy program at the university of Pittsburgh to help create and work with the mental health folks to create the SBIRT program which is substance abuse, brief intervention referral for treatment.
Professor Hare: That’s what SBI R T stands for. And that is the early recognition and the first steps in that process. And that we use a lot of audit and assist style
Professor Hare: paperwork, for lack of a better term. We’re checking those boxes and scoring that patient’s responses to their willingness to change for instance, and their readiness to move to next steps. And then we also have developed in the year, since that SBIRT program was started with Peru and the pharmacy folks, that’s an NIH grant started and funded program that has now transitioned to the individual schools that teach it.
Professor Hare: And we have a whole bunch of schools here at Pitt use that SBIRT program and teach it. Now, MAT is the next logical extension of that, where medication assisted treatment for opiate abuse for a variety [00:58:00] of other substances can also be lumped into that abuse, potential issue. And so our students come out with the SBIRT program and the mat certifications, which even if they don’t use it, they’ve now got those skills too, when they see it with a patient regardless of what area of medicine they work in, you’re going to see patients who have addiction issues no matter where you work, whether it’s in a psychiatric hospital, whether it’s in family medicine human, see those kinds of issues in specialty services like orthopedics and dermatology.
Professor Hare: Knowing what you’re looking at with that patient, knowing how to approach that patient and then realizing that if everybody, including their physical therapist, their occupational therapist, their PA, their pharmacist, everyone in the chain. Recognizing and giving them the same message about drug use and their potential need to stop using that and why that might be important, really helpful, really a kind of an adjunct that really it’s underappreciated that interprofessional approach to those kinds of substance issues that we can all help with and deal with.
Professor Hare: And then the mat side of things obviously providing [00:59:00] them with medication to help them to get off of those medications, to detox and withdrawal from those medications over time without the extreme amounts of discomfort that would come along with that, and often make those patients more likely to relapse and continue to their substance abuse habits.
Professor Hare: So one of the things that I’ve really appreciated about being here is Pitt’s willingness to allow us to use those adjuncts in the classroom to teach those folks, here at , be excited, mothership as I like to call it. So next, thinking about all of those things, those five elements.
Professor Hare: We talked about family medicine being the quarterback. And as a result, when we talk about must not misdiagnosis, and, you know, that’s the term that I use with my students, but those are the conditions that are high morbidity. So dysfunction causing and high mortality or cause of death conditions in family.
Professor Hare: Medicine must not misdiagnoses are across the board. We, we see them almost every day. In some ways it may be a longer term, must not miss. It may not be an acute setting. And every day, a family medicine practice an acute condition that could cause morbidity or [01:00:00] mortality, but there are so many of them that they get wrapped up in that primary care and family medicine background.
Professor Hare: You listed out a couple for me, I think I might’ve added DVT to that list. Those things that you have to know and recognize and know what to do with when you see them. Tell me about a couple of the ones that stick out to you.
Professor Wilson: when I talked about my day and you have like a cute visits, you need to not miss infection that can be happening or brewing PE or DVT.
Professor Wilson: You need to know when to refer to the emergency room and you can’t do all of the care in the outpatient setting that can be challenging. Sometimes because certainly we don’t want to send a patient to an emergency room, but sometimes they need it. We can’t manage it in an outpatient setting. They might need to be admitted.
Professor Wilson: So there are, must not misses for acute PE DVT, MI, infection. So myocardial infarction heart attack. stroke.
Professor Hare: pulmonary embolism is one that we talk about a lot because it’s got such a varied presentation. We talked about it [01:01:00] last week with Jeff, the great masquerader or, you know, the, the great pretender, because it can look so many different things.
Professor Hare: And, when I introduced this concept to students, I say, okay, so here’s this patient, it looks like chronic bronchitis. They have a cough, they’re a little short of breath. They may not have much in the way of pain or anything that pushed them in that direction, but it looks like chronic bronchitis.
Professor Hare: And if you just assume that that diagnosis is chronic bronchitis or bronchitis, I should say and that they have an upper respiratory infection you miss wha t should be a must not miss. And you ask the history and physical exam questions and, do the exam elements as common in your class with history and physical exam.
Professor Hare: Those history questions become very important. So then in the next slide we add the history that’s been taken. And the history that’s been taken is that they flew home from Australia over the last week and spent,, 24 hours, essentially in a plane seated and not moving around much.
Professor Hare: And that caused a blood clot and the blood clot went to the lungs and that’s a pulmonary embolism. So knowing having that history and having that full question set [01:02:00] family medicine really is where history and physical exam lives in my mind, because we’re not focused, right? We’re catching all of those things all the way back to the review of systems and the very general questions about, do you have chest pain?
Professor Hare: Do you have shortness of breath? Those kinds of things really bring those back.
Professor Hare: And then the DVT issue, the lower extremity thing, which can lead to a multitude of these conditions, not least of which is pulmonary embolism and stroke, cerebrovascular conditions of that sort.
Professor Hare: So those must not misdiagnoses. You’ve had some exposure to, obviously in your years of, family medicine care with patients. Do any of those stick out to you?
Professor Wilson: Certainly. I think there’s, there’s been times when things have come up and, you shouldn’t have missed them or thankfully perhaps I didn’t miss them.
Professor Wilson: One example is a patient who called in complaining of some nausea, sweating, vomiting, and thought they had the stomach bug. And so immediately you think, okay, they need to be on a brat diet. Maybe they ate something. or.
Professor Wilson: some kind of GI virus, but that’s why it’s important to look at what the history of that patient is.
Professor Wilson: And so this [01:03:00] particular patient was diabetic, uncontrolled had them come in they need to be evaluated one what’s their sugar. are they having these symptoms because they’re in diabetic ketoacidosis, may be thinking broad broad differential, but bringing that patient in and then asking, like you pointed out the history and the review of systems.
Professor Wilson: So crucial, and I asked the patient, are you having any chest pain? And they said, actually I am. But I thought that was just kind of like from this vomiting and so forth, did an EKG. They had ST elevation. They were having acute myocardial infarction. So that’s when you, then start thinking now we need to activate and get things going.
Professor Wilson: And, EMS got some oxygen on them, gave them aspirin. They went straight to the hospital to the cath lab. In this case I got a call a couple of hours later, I think from the interventional cardiologist who said, you know, the patient was kept got a stent and they’re doing well now. I think that this hammers [01:04:00] home, the question of history and physical is so important, knowing your patient, knowing past medical history is crucial.
Professor Wilson: and so make the plug for Y H and P class is important and how we use it every day. And I think Jason, going back to the question of must not miss in family medicine or primary care medicine. That’s why preventative medicine is really important too, because. it’s for a reason. getting mammograms, we’re trying not to miss breast cancer, cervical screening.
Professor Wilson: Colonoscopies. So we’re doing, due diligence to make sure we’re screening for these conditions can be life altering. if I can add that to the must not miss, it might be different in terms of what Jeff Bright presented too, but you know, it can man, it can encompass so much.
Professor Hare: it is.
Professor Hare: And I think that’s a great point to make. I think that one of the things that our students get surprised by is the importance of screening, certainly. And the amount of [01:05:00] information that is in that content, certainly for them it feels daunting. I think.
Professor Hare: So we also talk about the difference between the preventive services task force, the us PSTF and the American cancer society recommendations.
Professor Hare: And so parsing the difference between the American cancer society, whose goal. And I will never tell you that this is a bad goal for them to have, is to eradicate cancer, right. And screenings are a big part of that. I think the USPSTF takes a slightly more public health perspective on that kind of discussion.
Professor Hare: Does screening actually prevent deaths and morbidity and mortality in our patients. I think students are often surprised that there are some recommendations from the USPSTF’s specifically that do not recommend things like clinical breast exams, clinical or self exams for breast or testicular exams because
Professor Hare: of the amount of stress places on the patient and the lack of evidence that there are significant gains to be had in the mortality rate for those patients. [01:06:00] it’s controversial. So the ACS and the USPSTF’s are my two examples because ACS is always going to skew toward more testing, more screening, more question, asking more examinations in imaging.
Professor Hare: Whereas the USP STF is doing so much. Consideration of whether that is helpful adjunct for that individual patient and what issues that’s going to cause that patients, the the issues with a prostate biopsy, for instance, you know, there’s a lot of potential morbidity, some nerve damage other issues that can come from that they are taking into consideration.
Professor Hare: Whereas ACS is more about the testing screening and finding an eradicating cancer which again, you know, both of those are two sides of the same coin. Do you use the USPSTF’s or ACS more in those scenarios?
Professor Wilson: I think that you bring up a great point. So what I do and my approach is I. Kind of Summarize or explain what different guidelines suggest. So there’s lots of societies that would have [01:07:00] guidelines that may be slightly different from one another. And so when I see a patient, I say, hear recommendations and hear recommendations from different groups or different thoughts.
Professor Wilson: And then where does that align with the patient and the patient’s desire and why are these recommendations being made so that they can take that into play? I think that goes back to evidence-based medicine is this whole idea of you have clinical expertise, you have best knowledge evidence in terms of the literature and then you have to have the patient input too, right?
Professor Wilson: It has to be all three. So what do we see in clinical practice? What do we draw from the literature? The best, evidence in terms of research out there, but then really where does that patient come in? So that’s how I present it. And that’s where what I also present to the student is you have to have this discussion with the patient and put it in terms of the patient, right?
Professor Wilson: A colonoscopy may not be [01:08:00] what, a patient who has multiple chronic diseases. Some of them end stage that they need to have at that moment. If their life expectancy is not great, however, the discussion should happen. And maybe that is something that needs to happen. And again, things can change and patient approaches, patient decisions can change over time.
Professor Wilson: So it’s really important to go back and review those recommended screenings. Why we do. them, What the patient decision is and coming really a patient centered focus. So, yeah. Hope that answered your
Professor Hare: Yeah, absolutely. I appreciate that. that is our discussion of the USPSDF recommendations for instance includes the strength of recommendation.
Professor Hare: So an a from the USB STF is a very strong recommendation that we have evidence that this helps save lives. And it prevents morbidity and mortality in our patients. what gets me about that particular recommendation is the last statement in that recommendations description. Yeah.
Professor Hare: [01:09:00] Offer this service, it’s not order this service it’s offered this service. So we’re still having that conversation with the patient about their willingness to do so. And that it has to include the patient input on those be less strong, have a conversation with the patient, make personalized decisions, C: even more so. This may or may not help the patient. They need to know that it may be more risk than reward in this case. And so we need to talk to them about that balance and for them as an individual, what does that mean for them? And of course, D not recommended you know, again, you might talk about it with the patient, but you are less likely to order that.
Professor Hare: And then I is, we just don’t, we just don’t have sufficient evidence. And one thing that I like to point out to my students is the official USPSTF’s recommendation for diet and exercise, therapeutic lifestyle changes is I. Which, you know, again, should never be taken as I, okay. We won’t do that. We won’t make those recommendations.
Professor Hare: But diet and exercise as, as far as morbidity and mortality goes and, and the likelihood that the patient’s going to take that up, the stress that [01:10:00] might cause the patient, those kinds of things is less well-defined. And so, as a result, it’s an I, but again, I think most primary care and family medicine practitioners are gonna say, yeah, diet and exercise are a good thing, you know, and, and pay at least some, some thoughtfulness when it comes to those things is, is incredibly important.
Professor Wilson: And I always remind the students that this is discussing screenings. And certainly this does not mean that we don’t check a PSA for instance, on a gentleman who is presenting. with Hematuria or nocturia or changes in urination. So again, this is screenings and and I think that’s important to point out and sometimes we forget.
Professor Hare: I always kind of back up that conversation a little bit as we get toward the end of it, because students, I can see looking around the room, they’re looking at me like what? We’re not telling patients, or we’re not even doing clinical breast exams. It’s not recommended. And I say, don’t forget, that’s a screen.
Professor Hare: Right? we’re and the definition of a screen is testing something.
Professor Hare: Lack of [01:11:00] symptomatology. There’s no signs or symptoms that, that patient has that particular condition and we’re looking for it. We’re going after it. And those, those conditions have a higher bar. Those are things that we might not see otherwise, you know, the hypertensions.
Professor Hare: So we do hypertension screens on patients to make sure we know if their blood pressure is elevated, because they’re not going to know that on their own. And those situations and those breast exams, testicular, self exams, things of that nature are less fruitful in that they often cause patients significant.
Professor Hare: Stress. And we do a lot more biopsies and we do a lot more tests and imaging than we probably need to do in those scenarios because of the concern of the patients. Right. And that, that patient’s concern. We’re not as concerned, but again, we’re now we’re ordering a lot of imaging or a biopsy for that patient.
Professor Hare: And that can be a stressful for that patient. So not to say that this is not something that should be done. But it is something that we have to have a thoughtful approach to. again, you know, you think about the number of things we have to think about in family medicine and that you think about in your family medicine practice.
Professor Hare: it really is. It goes from acute to chronic, to the must, not miss to the [01:12:00] long-term care to the rapport and relationships that have to be developed with patients. The next steps and the knowledge of what is available in your community and where you can send those patients in those moments, which again is another really important aspect of that care.
Professor Hare: Hmm.
Professor Wilson: Thank you.
Professor Hare: Any other thoughts.
Professor Wilson: Oh, we could probably talk forever,
Professor Wilson: but
Professor Hare: indeed we could. Well,
Professor Wilson: I think we covered good material, so
Professor Hare: Yeah, I love it. And I think obviously I, I know where you live, so to speak. So I may come down the hall and and talk to you about doing a future episode and talking about our students and the way that we deal with these things from a PA school perspective may certainly be a part of that.
Professor Hare: So I really appreciate your time. So many thanks to our esteemed guest today, Tony Wilson, PAC, always a pleasure to hang out. Thanks so much for your time today. That’s it for now? Be sure to check out the podcast web. Www.be excited, hq.com for more episodes, show notes and transcripts of the episodes.
Professor Hare: Email us at contact. Be excited. [01:13:00] That’s one [email protected]. With questions, comments, or future show suggestions. And of course, follow us on Facebook and Instagram at be excited podcast for news new episode notifications maybe an occasional picture of a couple of people sitting at a desk. Recording an episode.
Professor Hare: Thanks for listening and remain excited.
