Block Clerkship Projects

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  Dietary Supplement Education in a Primary Care Setting

  Suleiman Ismael and Mikaela Rodriguez

  More than 50% of American adults use at least one dietary supplement. Despite their popularity, patients and physicians are often unaware of the limited regulation of these products as well as their potential risks and benefits. During our rotation at the Center for Family Medicine in Bangor, Maine, we observed several patients asking about the efficacy and safety of various supplements. Also, many patients wanted to avoid taking pharmacological drugs and inquired about any "natural" treatments to their illnesses. The residents we worked with expressed a lack of confidence in their ability to discuss dietary supplements with their patients. In the overwhelming majority of cases, if a patient did not bring up supplement use on their own, the providers never inquired about it.

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  Caregiver Burden: Finding Resources, Offering Support

  Sarah Johnson

  - Definition: Informal caregivers are unpaid individuals (often a spouse, partner, family member, friend or neighbor) involved in supporting others in activities of daily living.
  - Caregiver burden is an emerging public health issue largely attributed to longer life expectancy that not only increases the number of elderly individuals, but also the level of dependency in these individuals.
  - Despite many formal support services, informal support continues to be the primary source of care for the elderly, dependent and disabled.
  - Unpaid family caregivers will likely continue to be the primary source of long-term care in the United States as the aging population will more than double between the years 2000 and 2030 from 35.1 million to 71.5 million.
  - In 2009, three in ten U.S. households reported at least one person providing unpaid care as a family caregiver.
  - Caregivers report performing housekeeping and personal tasks, running errands, managing medical needs and more.
  - Caregivers spend on average 20.4 hours per week providing care. Those who live with their care recipient spend 39.3 hours per week caring for that person.

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  Health and Community Resources For Older Adults in Chittenden County, Vermont

  Matthew Jordan

  The vast number of resources available to older adults are widely unknown to both health care providers and the older adult population itself.

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  HPV Infection Prevention in Males by Gardasil Vaccination

  Russell Landry

  About 1% of sexually active males in the U.S. have genital warts. Each year 400 males get HPV related cancer of the penis, and 1,500 get HPV related cancer of the anus. 2-3 cases of Genital warts have been reported at Harwood High School (Moretown and Waitsfield), where the school nurse reports 1-3 males students each year seeking information about STIs (including HPV).

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  Alternative Medicine Resources for Primary Care Physicians

  Laura Lazzarini and Angelina Palombo

  Despite the prevalence of patients that would benefit from Complimentary and Alternative Medicine (CAM) at EMMC Center for Family Medicine (CFM), practicing physicians lack sufficient education on CAM and knowledge of community resources to refer their patients to.

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  Concussion Management in Primary Care

  James Levins

  Concussion awareness is a hot topic in youth sports, resulting in increased health care visits. There has been much change in concussion management over the past decade. VT passed a law (Act 68) implementing a concussion management program in schools. Not all primary care physicians are aware of how this law may affect their practice, nor are they all aware of some of the recent changes in concussion management. Improper concussion management can lead to prolonged symptoms, recurrent injuries and long-term sequelae.

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  School Based Yoga Intervention for Childhood Stress Management

  Erica Marden

  Childhood stress can have immediate and long-term negative impacts on physical health, mental health, school performance, self-esteem, and relationships. For children in rural communities there are fewer resources available as recreational and therapeutic outlets for healthy stress reduction. Extracurricular activity involvement also puts significant financial and time burdens on families. There is a particular need to provide children in rural areas with tools to manage stress that can be incorporated into the school day and require few resources. Yoga is an excellent school-based activity that has proven benefits on physical and emotional health for both students and teachers. It has been shown to be effective at improving children's sense of wellbeing and reducing self-perceived levels of stress, and can practiced individually at home without requiring any special equipment.

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  Community Resources for Elevated BMI in Downeast, ME

  Nicolas Monte

  The US is currently mired in a decades-long battle against an epidemic of obesity. ­According to the CDC 69.2% of the US population over the age of 20 is either overweight or obese. As primary care clinics move towards becoming “Patient-Centered Medical Homes” the need exists to provide adequate and specific educational materials.­While a great wealth of educational resources exist to inform patients about the nature and pathogenesis of individual diseases, access to specific local treatment tools is lacking. Although nearly all clinicians screen patients for elevated BMI and provide general information about general healthy habits, this is often the limit of the discussion.Time restrictions on appointment length hinders the ability of the clinician to adequately provide recommendations about how/where patients may work to reduce their BMI.

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  Managing and Treating Allergic Rhinitis in the Primary Care Setting

  Leah Novinger

  Screening and appropriate treatment of allergic rhinitis in the primary care setting is a challenge for providers due to time constraints. Providers in the practice desired more information about where in the community to refer patients with persistent allergic rhinitis and what information or test results they should send those specialists.

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  Fluoride supplementation: recommendations in the primary care office

  Dwight Parker

  Physicians in a Vermont family practice setting tend not to be very familiar with CDC/AAP/AAD recommendations regarding fluoride, especially when it came to rural areas in Vermont not on town or public water. Questions include: What are the pros and cons of fluoride supplementation? What are the indications for supplementation? How does one go about testing their well water? Which towns have fluoridated water, and what are their levels? What doses are recommended, and what options are there for treatment?

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  Common Naturopathic Therapies for Chronic Conditions

  Jordan E. Perlman

  Complementary and Alternative Medicine has started to achieve greater public prominence – many patients report satisfaction and believe these therapies are cost effective. Allopathic physicians are largely unfamiliar with the supplements prescribed by naturopathic doctors, and have trouble integrating these therapies into traditional treatment plans. Patients are not trained to evaluate the safety or efficacy of their medication regimens, and rely on their primary care physicians to provide that service -– even if the majority of their "medications" are supplements recommended by an "alternative" provider.

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  Creating a Guide for Patient Self-Management of Weight Loss (For Management of Diabetes)

  Kelsey Preston

  In my first week working with Dr. Flynn, I saw more patients coming in with a diagnosis of diabetes than those without; this is likely untrue, but it certainly felt like that. I realized how big of an issue diabetes really is, and hoped to work on a project targeted towards diabetes. While I noticed medical and medicinal management of patients with diabetes was adequate, there was a large gap in patient self-management of their diabetes – they followed their prescriptions, but did not seem to have changed other aspects of their lives, most importantly, their diets.

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  Improving Vaccination Rates in Bangor, ME

  Noah Quinlan and Whitney Thomas

  Providers believe vaccination rates at EMMC Center for Family Medicine can be higher. A resurgence in some preventable diseases is likely due to decreased immunization rates. While other preventable diseases have not seen a resurgence, the potential for outbreak exists if immunization rates remain low. Factors contributing to low immunization rates are misinformation, lack of awareness, cost, inconvenience, and infrequent office visits by adolescents.

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  Addiction Burden and Resources for Patients in Connecticut

  Jacob Reynolds

  Nationally, the US has 60 million smokers, 14 million dependent on alcohol, and 14 million illicit drug users. One quarter of Americans over 15 have physiologic dependence on at least one addictive substance. A quarter of all deaths in the US are caused by addictive substances: alcohol, tobacco, drugs. There are an additional 40 million injuries and illnesses per year. Locally, one Connecticut therapist reports sending 30 of her patients under age 22 to in-patient treatment for opiate abuse.

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  Providers’ Views on Transition of Healthcare for Youth with Developmental Disabilities

  Cordelia Y. Ross

  Problem: Youth with DD have conditions that may limit their ability to function, with resulting social, emotional, or behavioral sequelae, and experience difficulty transitioning from child to adult health care. Also, adult providers may lack training and comfort level in working with patients with DD. For example, youth with ASD need an adult provider who understands autism but doesn’t see every health or behavior problem as a result of autism.

  National Need: 1 in 6 children in the U.S. has a DD. Each year, almost half a million of these children transition into adulthood. As for ASD, 1 in 68 children (1 in 42 boys) meets ASD diagnostic criteria.

  State Need: In Vermont in 2006, 540 children and adults with ASD (with 126 in Chittenden County alone) were being served by the Vermont Community Mental Health and Developmental Services programs. Since then, the number of children with ASD has grown approx. 20% per year.

  Community Need: Hinesburg Family Practice currently sees 11 patients with a Code 299 diagnosis (pervasive developmental disorders) per year. These patients accounted for 25 visits during FY 2014. The patients range in age from 5 to 53 years (median age: 17 years).

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  Identifying and Coping with Adolescent Anxiety

  Merima Ruhotina

  Anxiety disorders, which include panic disorder, generalized anxiety disorder, post-traumatic stress disorder, phobias, and separation anxiety disorder, are the most common class of mental disorders present in the general population. These disorders have a negative impact on the quality of life in a number of areas of functioning, including academic performance, social interactions, self confidence, and ability to enjoy daily life experiences and may impact future emotional health. Approximately 20% of youth ages 13 to 18 experience severe mental disorders in a given year. Almost one-half of youth ages 8 to 15 with a mental illness received no mental health services in the previous year. At Colchester family practice, all practicing physicians have a multitude of adolescent patients with a wide spectrum of anxiety disorders.

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  Creating Patient Instructions for Community Health Resources

  Kevin Saiki

  In the US, more than a third of adults are obese as well as 17% of children. A recent report estimates the annual cost of obesity in Maine amounts to approximately 452 million dollars. Additional reports estimate the cost of obesity to the entire country lies somewhere between 10-30 billion annually.

  Encouraging patients to have healthy diet rich with whole grains, fruits, and vegetables, and to maintain regular exercise (150 minutes a week) are effective ways to combat higher BMIs and to stave off associated hypertension, coronary artery disease, type II diabetes, and dyslipidemia.

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  Medicare Part D: Avoiding the “Donut Hole” and Cost-related Medication Nonadherence

  Daryl Selen

  Problem: Studies have shown that only ~50% of patients with chronic conditions take their medications as prescribed. Patient nonadherence can be due to forgetfulness, desire to avoid adverse side effects, and high costs of medications, particularly in patients with low incomes, multiple chronic health problems, and no prescription coverage. Attempting to reduce medication costs by taking less than prescribed dose does not allow for full therapeutic benefits, and may put patients at increased risk for declining health. Consequences of cost-related nonadherence (CRN) and underuse: increased ED visits, psychiatric admissions, nursing home admissions, and decreased health status. In patients with asthma, medication nonadherence has led to increased hospitalization rates and other adverse outcomes. Up to 88% of patients with asthma do not properly follow their inhaled medication regimen. CRN behaviors are influenced by financial pressures and polypharmacy. However, physicians and other members of the health system may prevent these behaviors by fostering trust, prescribing cheaper medications, and providing access to prescription assistance programs.

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  Health Insurance Coverage and Young Adults

  Cameron Sikavi

  - Young adults have the largest percentage of uninsured citizens of any age group in the United States. According to the CDC, 38.4% of the uninsured population in 2013 was between the ages of 19 – 34. This equates to 27.2% of 19 – 34 year-olds in 2013 not having health insurance.
  - In Connecticut, 18-34 year-olds represent by far the largest demographic of those uninsured, at 43.3% , more than double the rate of the second highest uninsured demographic (45 – 54 year olds, with an uninsured rate of 19.2%). Unfortunately, this remains significantly higher than the national average.
  - Danbury in particular has a total uninsured population of 34.0%, which represents the fourth highest percentage of uninsured citizens of all cities in the state.

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  Improvement in Diabetic Care

  Richard Smith

  Over the years, steps have been taken to 'streamline' the process when it comes to diabetic management in the Village Primary Care (VPC) practice. As more and more outcomes are monitored, it is important to both identify the shortcomings of the practice as far as diabetic management, and attempt to implement processes to ensure better outcomes. VPC is doing well in many areas (LDL/BP/BMI), but is lacking in monitoring and implementing certain areas of diabetic management: Recommending and tracking eye exams, HbA1c, Micro albumin, Foot exams.

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  Increasing awareness of Adverse Childhood Experience (ACE) and the benefits of inquiring about ACE

  Maya Son

  Adverse Childhood Experiences (ACE), including childhood abuse/neglect, household dysfunction, and exposure to other traumatic stressors, have a large impact on health costs as well as social services, education, juvenile justice. Impact of ACE crosses socioeconomic boundaries. In 2011, the Vermont Department of Health reported that 58% of VT adults had experienced at least 1 ACE, and 17% of VT women had four or more ACEs.

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  Opiate Abuse in Brandon, VT: Empowering Support Systems

  Raj Thakrar

  Primary care physicians and emergency physicians have reported a surge in opiate abuse within the state of Vermont. It is being labeled as a public health epidemic and crisis, with a 2013 mortality rate of almost double what it was in 2012. There are several factors that play a role in why Vermont has seen such a growth in opiate abuse, from easy access to opiate dealers in major urban cities such as New York, Boston, and Philadelphia to a decrease in law enforcement coverage in rural areas of the state. One major element, and the focus of this project, is the lack of communication and awareness of resources for family members of abuse victims. Opiate abuse does not only affect the victim, it also affects their relationships, families, and friends. The major barrier to family members and friends seeking emotional, physical, spiritual, and mental support is the stigma that surrounds opiate abuse. If people don’t talk about the issue, this barrier cannot be overcome. There needs to be more information available to families, so they may seek out the appropriate resources and support needed to make strides towards helping their loved ones through their addiction’ This lack of communication among families in the community also contributes to the public health problem and the stigma of substance abuse; it results in a vicious cycle.

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  Advocating Powerhouse Fruits & Vegetables

  Christine Tran

  Fruits and vegetables are great, but they are not all created equally. In 2014, the Centers for Disease Control and Prevention published a study on which fruits and vegetables contain the most nutrients for preventing cancer, diabetes, and heart disease.

  The top 41 have been named "Powerhouse Fruits and Vegetables."

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  Using Local Resources to Build Strong, Healthy Families

  Cornelia Willis

  Although obesity rates across all demographics continue to climb annually, when separated into income levels, the prevalence of obesity in poor adults and children are rising at a greater rate than middle class individuals. A recent publication by the Food Research and Action Center (FRAC) compiled a list of data points that indicated that, while the trend is gradually slowing, rates of severe obesity are about 1.7 times greater in children coming from families whose incomes fell below the poverty line than equal counterparts in the middle class income bracket. High fat, high carb foods are often the staple of a lower income family based on the assumption that they are more affordable, easier to prepare, and more time effective to gather, prepare, and consume. Because the cycle of poverty can be hard to escape, the cycle of high fat, high carb consumption is also passed on to subsequent generations. Unfortunately low income residential areas have a record of being "food deserts" where nutritious and fresh food is hard to find or overly expensive.

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  Alcoholism Self Assessments, Thomas Chittenden Health Center

  Casey Wilson

  In the clinic we frequently see patients with self-admitted heavy drinking who are often in various stages of denial about their problems with alcohol. All the pamphlets and handouts available to patients at Thomas Chittenden Health Center and at Fletcher Allen Health Care are for patients who have admitted they have a problem with alcohol. These patients with admitted problems are the minority of patients with admitted heavy drinking. The patients who have not admitted their problem with drinking need a way to reflect on how their drinking is affecting their lives.