Run with Your Doc!

On April 9, a large group from Memorial Medical Center (about 70 people!!) including several members of our residency participated in the annual Run With Your Doc 5K, 10K, and 1 mile walk starting and ending on the plaza in the town of Mesilla just west of Las Cruces. The event supports Amador Health Center, one of our local FQHCs. 

Amador Health Center is committed to providing services to those  most vulnerable in our community, believing that every person has the right to health care. It is located on the campus of Mesilla Valley Community of Hope, which provides a range of services including assistance with housing, day care and after school programs for children, a food pantry, a soup kitchen, and health care services. Amador is a comprehensive community health center that welcomes everyone, regardless of background or capability. The mission of the center is to provide access to vital integrated health and wellness services to our community and promote dignity, one life at a time. This mission and vision aligns with our own health equity work in the Southern New Mexico Family Medicine Residency Program. It was a beautiful day in southern New Mexico to get outside, support our the amazing work of Amador Health Center, and spend time together.

Family Medicine Advocacy Summit Actions

Post by Stephanie Benson, Associate Program Director

Physicians are advocates. Even when we don’t realize it or don’t plan for it, our voices are often listened to, even by those who may ultimately disagree with us. We should acknowledge the privilege that our education and training grants us and use it for the betterment of our communities. It is for these reasons a knowledge of policy and willingness to participate in its development are both important for physicians in training. Our program has developed a health policy rotation to teach our residents how to use their voices and engage on local, state, and national levels. As part of this rotation we participate in events sponsored by the American Academy of Family Physicians (AAFP), both the state chapter and the national organization.

One such event is the Family Medicine Advocacy Summit (FMAS). The FMAS is an annual event typically held by the national academy in Washington DC. During the FMAS family physicians travel from all over the United States to learn about advocacy and meet with their Senators and Representatives. The past two years this event has been transitioned to a virtual platform due to the need for COVID safety. We incorporated participation in the FMAS into the Health Policy rotation this past spring I was able to have residents join me for these meetings. Prior to the FMAS the AAFP legislative staff chooses key issues for discussion with the legislators and or their staffers. The staff prepare one-pagers with talking points for each issue guide our conversations.

This past FMAS the AAFP focused their advocacy on three main issues. The first was Medicaid payment for Primary Care. Medicaid payment rates are set by individual states as a percentage of the payments allowed by Medicare. On average nationally, Medicaid only pays about 66% of Medicare allowable. In NM we are in better shape with Medicaid paying 91% of Medicare rates. Still, these low payment rates affect access to care for some of our neediest patients as providers all over the country make decisions to not take Medicaid patients into their practices. This needs to change and federal legislation could require states to pay for at least primary care services at 100% of Medicare allowable. We were able to discuss this issue with both our Senators and our Representatives and encouraged our Representatives to cosponsor HR 1025, the Kids’ Access to Primary Care Act, that would help accomplish this goal.

Second, we discussed telehealth. Telehealth became exceedingly important to patients and providers during the pandemic and the AAFP is joining other medical organizations asking Congress to make permanent certain allowance that were enacted during the pandemic to eliminate geographic and site restriction on telehealth services as these allowances increased access to primary care for poor, marginalized, and rural Americans.

Third, we asked that Congress pass legislation to allow high deductible health plans to waive deductibles for primary care services as the CARES Act had done temporarily for telehealth services. We were able to have productive conversations with healthcare staffs for each of our legislators on both sides of the political spectrum. I look forward to continuing these efforts over the coming year and am excited to share this knowledge and these experiences with future residents.

Addressing Racism in the System: Removing Race-Based Calculations for eGFR

Calls to remove race as a factor in calculating eGFR (estimated glomular filtration rate) are growing across the United States. The use of race in the equation is based on unfounded assumptions that African Americans have on average higher muscle mass than whites. There is no evidence that this is the case.

Using race to calculate eGFR has major consequences for African American patients when the equation results in higher eGFRs for patients who are identified as black.  Disparities in access to kidney transplantation are one example. A patient must have an eGFR of less than 20mL/min/1.73m2 to qualify for the waitlist for kidney transplantation. Using standard equations for eGFR, two patients identical except for assigned racial category may have very different outcomes if they both have a creatinine level of 2.8 mg/dL – a white patient would be placed on the waitlist but a black patient would be ineligible.

What did we do?

Our CMO, also a family physician faculty member in the residency program took this information to the hospital lab director and medical director of pathology and asked for race to be removed from the calculation for eGFR on lab results. She also discussed this issue with the larger hospital corporation, which is now considering removing this calculation in all hospitals corporation-wide. The change was made quickly and without dissention. 

What did we learn?

Public discussion in major medical journals like the New England Journal of Medicine and across many medical professional organizations smoothed the way for rapid action. We also laid the foundation within our residency program to identify and act on institutional racism through placing health equity at the center of our curriculum. And we have leaders willing to act.

SNMFMRP Residents Interactions and Collaborations with PGY1 Pharmacy Residents at Memorial Medical Center

The Pharmacy residency program at Memorial Medical Center has been operating since 2014 and was accredited by the ASHP (American Society of Health Systems Pharmacy) in 2015. The pharmacy residency training focuses on the development of skills necessary to provide optimal drug therapy, function competently on inter-professional teams, and become leaders in the medication use process. We have recently expanded our program to include two PGY1 residents and will expand to include a PGY2 resident in emergency medicine in August 2021.

As pharmacy residents we interact with and work alongside SNMFPRP residents at all stages of their residency in both acute and ambulatory care settings. We have the opportunity to complete two rotations with the FMS (family medicine services) inpatient team, where we round with attendings and residents, and offer medication recommendations to improve patient care. We also work closely with the family medicine residents while at the clinic. We work with our preceptor, Dr. Norris to provide MTM (medication therapy management) visits, as well as provide care to patient with chronic disease states including diabetes, hypertension, and coronary artery disease. We have also had the opportunity to work alongside the family medicine residents by attending and participating in home visits for some of our elderly patients, or patients who are unable to physically come into the clinic.

We have been able to learn so much from the residents whom we have had the opportunity to work alongside but are also able to be a resource to them in all things related to medications. We were each able to provide didactic presentations to the residents regarding pharmacologic treatment of common disease states that family medicine providers encounter including hypertension, type 1 diabetes, and proper use of anticoagulants. 

There is a tremendous level of respect and understanding that comes from learning from and alongside one another as pharmacy and family medicine residents and we hope to continue to encourage multidisciplinary collaboration such as this within our health care system in the years to come.

Community Collaborations: COVID 2 Home Program

This week, I’m highlighting the highly successful COVID 2 Home Program that our community developed in response to the rapid increase in severe COVID-19 cases in our region. I spoke with Dr. Danielle Fitzsimmons-Pattison, the medical director of the COVID 2 Home Program and an FM faculty member in our residency program.

Dr. Fitzsimmons-Pattison emphasized that this program was a community collaboration that has built on existing relationships across a number of organizations including Doña Ana County, our family medicine residency program, Memorial Medical Center, Mountain View residency programs and hospital, Electronic Caregiver, the New Mexico Medical Reserve Corps (MRC), New Mexico State University, and Burrell College of Osteopathic Medicine. These relationships were critical to our ability to stand up the program quickly and respond effectively to community need.

The residency programs at the two hospitals (Memorial and Mountain View) and the New Mexico Medical Reserve Corps, which is a statewide health care professional volunteer organization under the Department of Health, provided the majority of the physicians for the program.

The physicians monitored patients with COVID in the community - at home or in hotels - which freed up beds, particularly for patients who would normally be admitted to the hospital for COVID-19 but have lower (or no) oxygen requirements. Electronic Caregiver provided the technology to support this home monitoring through providing an electronic documentation system and a box with a call button, thermometer, and pulse oximeter. The box also gave the patient verbal recorded instructions about how to use the pulse oximeter.

Dr. Fitzsimmons-Pattison noted that Memorial and Mountain View residents wer integral to this process, working alongside MRC volunteers in monitoring patients from one to multiple times a day telephonically. The overall feedback was very positive.

For example, one patient sent our program director an email commending our residents for their work in caring for her while she was in the COVID 2 Home Program. She said: “This program is the most amazing program and I truly believe that it is saving lives every day.  The doctors I spoke with were the most caring and patient individuals I have ever encountered.  There were a couple of days where I was not sure what I even told the doctor, and I feel they sensed that and called an extra time that day just to make sure I was doing better…I want you to know that all of the team was amazing.”

Thankfully, numbers of patients hospitalized with COVID-19 in our community has dropped to the point that we no longer need the program. During its existence, the COVID 2 Home program served over 200 patients, meaning that 200 beds in our hospital were available to others who needed them. While we were certainly stretched during the height of our COVID-19 cases, this program kept our hospital from being overwhelmed. This is the kind of work we are able to do when we look outward towards our community and work in collaboration to meet community needs.

Palliative Care During COVID-19

Dr. Stephanie Benson, Associate Program Director in Family Medicine is currently completing a master’s degree in palliative care. The post below is part of a reflective essay she wrote several weeks ago for one of her classes during a time when COVID-19 cases and hospitalizations were increasing rapidly in our community. She highlights the work she and others in our program are doing to care for patients and for each other in this very difficult time.

The past two weeks I have had trouble focusing on anything else but COVID-19. Our small five-person palliative care team has been extraordinarily busy given the surge of cases we have seen. I have personally witnessed more death in the past two weeks than I have seen probably in the last five years. We now have two refrigerated trucks sitting outside our moderately sized, about 199 bed, hospital to hold the bodies of the deceased because the morgue and local funeral homes are at capacity. It is all difficult to put into words. I have tried to focus on the small wins. Last week we successfully got five patients home with hospice to pass away peacefully with their families despite needing bipap and/or very high flow O2. Our team has been thanked repeatedly by the intensivists, the hospitalists, the ID doc, and the nursing staff throughout the hospital for our help. It is rewarding, humbling, and terrible all at the same time. I am trying to keep things in perspective and work on maintaining my own wellness while looking out for the wellness on my team. As the leader I feel responsible for their wellbeing. This past week I started having individual members of my team rotate away each day and take a break from the hospital. It was beneficial. I hope to set up some sort of schedule to do this consistently every week. Our local daily case numbers continue to rise, and we know that there is a delay between when case numbers rise and when hospitalizations rise. I am trying to pace myself and be attentive to the long game. I know we are just getting started and there is more to come.

One area of impact I did not realize we would have immediately is on the wellbeing of the nursing staff. The first couple of days we were consistently present on the COVID units it struck me how I could almost hear the staff exhale, like soldiers suddenly getting reinforcements. It did not take long to figure out that the simple act of sharing the burden of talking with patients and families, most of which had fallen to the nurses, was a great relief to them. In addition, intentionally and genuinely asking a member of the staff how they’re holding up, genuinely listening to their answers, and then acknowledging with them the madness around us, has been of more benefit to them than I ever would have expected. The moral injury we all feel has been one of the most difficult things to manage. It is contrary to our morality to tell family of a dying person that they cannot see them or touch them one last time. It is demoralizing to see and hear people I know from the community continue to act irresponsibly and dismiss the seriousness of the situation. I told a friend recently that it is like being in a war zone while others outside dance and sing like nothing is wrong while bombs explode all around us. I have used a great deal of what I have learned from this program in the last couple of weeks and I am certainly better for it. I am comforted by the purpose I feel in the work we do and by helping those who have no hope of recovery pass away peacefully according to their wishes. I wish it were not so many.