Imaging Among the Underserved: Utilization and Expenditures in a Student-Run Free Clinic.

OBJECTIVE: To determine imaging utilization and expenditures among an underserved population at a student-run free clinic. METHODS: This was a retrospective review of billing records for all radiology studies performed over a 4-year period at a student-run free clinic supervised by physician faculty. All imaging services were outsourced through either direct payment by the clinic to a local imaging group or through in-kind donations. Radiology studies were grouped by modality and diagnostic category. Data were analyzed to determine overall and average imaging utilization and expenditures. RESULTS: Across the 4-year study period, 413 radiology studies were performed with a yearly average of 103 (SD = 16). During this time, 192 (46%) ultrasounds, 123 (30%) radiographic studies, 40 (10%) MRIs, 37 (9%) CTs, 8 (2%) interventional procedures, and 5 (1%) nuclear imaging studies were obtained. Overall, expenditures were $157,888 with a yearly average of $39,472 (SD = $1982). In-kind donations accounted for $138,508 (88%) of expenditures. Across the 4-year study period, utilization increased by 15% with less than 1% increase in expenditures. DISCUSSION: Ultrasound was the most common imaging modality used. Overall imaging utilization was considerably less than that of published data in an ambulatory setting.

Outcomes from the Health Resources and Services Administration's Dental Faculty Development Program.

PURPOSE/OBJECTIVES: While the Commission on Dental Accreditation (CODA) requires programs to conduct faculty development, implementation of faculty development activities vary widely. Faculty development programs can enhance teaching, research, and leadership skills needed to transition from clinical practice to teaching. In 2012, the Health Resources and Services Administration (HRSA) funded 6 institutions to plan, develop, and operate programs for training oral healthcare providers who plan to teach in general, pediatric, public health dentistry, or dental hygiene. This performance study examines the results of the dental faculty development programs. METHODS: After the 5-year grant program (2012-2017), we used descriptive analysis to examine annual performance data including trainee demographics, faculty development activities, post-completion intentions, and course development activities. RESULTS: Nearly 300 trainees participated across 6 funded grantees; the majority were female, aged 30-49 years, and non-Hispanic White. For those who completed, 80% intended to teach. Common faculty development activities included community-based training, curriculum enhancements, Web-based training, and interprofessional education methods. Faculty development modalities included faculty seminars, Master's degrees, and mentoring. Pipeline activities, online resources, and continuing education supported dental students and providers moving into academics. CONCLUSIONS: Faculty development better prepares individuals to compete in academic environments and develop faculty. Community-based programs may utilize faculty development to recruit community preceptors and achieve calibration. HRSA investment in faculty development programs builds resources and infrastructure to promote continuing engagement in clinical education, research, and administrative skills. Future research is needed to establish the impact of faculty development initiatives on practice change and patient outcomes.

Universal depression screening, diagnosis, management, and outcomes at a student-run free clinic.

OBJECTIVE: Student-run free clinics (SRFCs) are now present at most medical schools. Reports regarding SRFCs have focused on the infrastructure of established clinics, characteristics of the patient populations served, and their contribution to patient care. Few studies discuss their role in preventive medicine and even fewer discuss mental health care. This study examined the outcomes of a medical student-run universal depression screening, diagnosis, and management program at two SRFC sites. METHODS: Medical students implemented a universal depression screening, diagnosis, and management program within the electronic health record during routine adult primary care visits utilizing the Patient Health Questionnaire-2 (PHQ-2) as an initial screening tool, with a protocol to administer the Patient Health Questionnaire-9 (PHQ-9) if the PHQ-2 score was ≥3. This is a retrospective medical record review of visits from August 13, 2013, through February 13, 2014, to assess this program. RESULTS: Overall, 95.8 % (206/215) of the patients received either the PHQ-2 or the PHQ-9. Among the 174 patients without a previous diagnosis of depression, 166 were screened (95.4 %), of which 33 (19.9 %) had a positive PHQ-2 score of ≥3; 30 (of 33; 90.9 %) appropriately received a PHQ-9. Nineteen (of 166 screened; 11.4 %) previously undiagnosed patients were confirmed to have depression. Fourteen patients had two or more PHQ-9 tests at least 4 weeks apart and eight (57.1 %) had a clinically significant improvement, defined as PHQ-9 score decrease of ≥5. The prevalence of depression diagnosed prior to the implementation of this program in this cohort was 19.1 % (41/215) and after was 27.9 % (60/215). CONCLUSIONS: This study demonstrated that medical students with faculty supervision can successfully implement a universal depression screening, diagnosis, and management program at multiple SRFC sites, identify previously undiagnosed depression, and work with interdisciplinary support services to provide treatment options, leading to a clinically significant improvement in depression severity.

The effect of involvement in a student-run free clinic project on attitudes toward the underserved and interest in primary care.

METHODS: The authors designed a survey instrument to examine the effect of involvement in a student-run free clinic project (SRFCP) on medical student self-reported attitudes toward the underserved and interest in primary care. From 2001-2010, first-and second-year medical students in an introductory service-learning elective course rated each of 15 statements on a seven-point Likert scale pre/post survey. Wilcoxon's signed rank test was performed on all matched pairs and an intent-to-treat analysis included unmatched pairs. RESULTS: The response rate was 97.9%, with 914 of 934 students enrolled participating. Significant increases were seen in each of the 15 items in matched pre/post survey pairs, N = 433 (47.4%), or with an intent-to-treat analysis, N = 914 (p ≤ .002 for all). CONCLUSIONS: This study found that medical student involvement in a SRFCP improved student knowledge, skills, attitudes and self-efficacy with the underserved, interest in work with the underserved after graduation, and interest in primary care.

Clinical outcomes of diabetic patients at a student-run free clinic project.

OBJECTIVES: Our objective was to determine if the quality of care of diabetic patients at a Student-Run Free Clinic Project (SRFCP) meets the standard of care, is comparable with other published outcomes, and whether pertinent diabetic clinical indicators improve over time. METHODS: The authors conducted a retrospective chart review of diabetic patients at three University of California-San Diego (UCSD) SRFCP sites from December 1, 2008 to December 1, 2009 (n=182), calculated the percentage who received recommended screening tests, percent at goal, and compared these to published outcomes using Fisher's exact tests. Baseline measures were compared to most recent values using paired t tests. RESULTS: The percentage of patients who received recommended screening tests (process measures) was blood pressure (BP) 100%, HbA1c 99.5%, creatinine 99.5%, LDL 93%, HDL and triglycerides 88%, microalbumin/creatinine ratio 80%, and ophthalmology exam 32%. Intermediate outcomes included: 70% of patients were at LDL goal <100, 70% had microalbumin/creatinine ratio <30, 61% of males were at HDL goal %gt;40, 47% of females at HDL goal>50, 52% with triglycerides <150, 45% had BP <130/80, and 30% of patients had HbA1c <7. Mean HbA1c, LDL, HDL, triglycerides and blood pressure improved significantly over time. CONCLUSIONS: Diabetic patients at UCSD SRFCP reached goals for both process measures and intermediate outcomes at rates that meet or exceed published outcomes of insured and uninsured diabetics on nearly all measures, with the exception of ophthalmology screening. Glycemic control, cholesterol levels, and blood pressure improved significantly during care at the UCSD SRFCP.

Medical student perceptions of the educational value of a student-run free clinic.

BACKGROUND AND OBJECTIVES: Many medical schools have student-run free clinics (SRFCs), yet their educational value has not been well studied. We performed a one-time cross-sectional survey to assess medical student perceptions of the educational value of an SRFC at their institution. METHODS: The authors designed and validated a survey instrument including six statements on a 5-point Likert-scale. The questionnaire was distributed from February through May 2010 to all students enrolled at the University of California San Diego (UCSD) School of Medicine as part of a larger yearly, anonymous, internet-based survey regarding their experiences at the institution. RESULTS: The response rate was 66.5% with 347 of 522 eligible students participating. Ninety percent agreed or strongly agreed that the SRFC was a valuable educational experience, mean score: 4.51 on a scale of 5. Eighty-two percent agreed or strongly agreed that the teaching was excellent, mean score: 4.23. Students agreed or strongly agreed that the SRFC improved attitudes toward working with underserved patients (72%, mean score 3.99), helped students stay connected to sense of purpose, (71%, mean score 3.98), improved overall sense of well-being (67%, mean score 3.88), and influenced their decision to come to UCSD (52%, mean score 3.37). Eighty-four percent of qualitative responses in a free text comment box were positive (46 of 55). CONCLUSIONS: To the authors' knowledge, this is the first study to report the perceptions of an entire medical student body of a SRFC at their institution. The majority felt that this was a valuable educational experience.

Addressing the health needs of the underserved: a national faculty development program.

The authors developed a three-week faculty development program, "Addressing the Health Needs of the Underserved" (funded by Title VII), and later incorporated a year long Fellowship in Underserved Medicine. This article describes these programs from 1999 to 2007, focusing on participants, curricula, outcomes, and potential impact.Participants (n = 107) in the three-week faculty development program came from 29 states and Puerto Rico, with more than 25% from underrepresented minorities in the health professions. The program focused on three skill sets: creating and sustaining community programs and partnerships; core faculty development/academic skills; and personal and professional renewal. Outcomes measured with follow-up surveys and interviews in 2003 revealed that since their participation, the first 53 participants to complete the program had created 30 new or modified residency curricula, 19 new student curricula, and 7 new student-run free clinic projects. Pre-post measures from 2003 to 2007 identified an overall 46% increase in skill confidence, with the greatest increase reported for designing a promotora (community lay health promoter) program. Participants expressed particular satisfaction with becoming part of a national community of scholars in the field of underserved medicine.For the year long, on-site Fellowship in Underserved Medicine, four of the first six fellows who completed the fellowship were former University of California-San Diego Student-Run Free Clinic Project student leaders who left San Diego to complete family medicine residency and returned to complete the fellowship. All six currently work with underserved communities as their primary focus, five in the United States and one internationally with Doctors Without Borders.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The UCSD Student-Run Free Clinic Project: transdisciplinary health professional education.

In the face of the serious problem of lack of access to health care in the United States, with over 45 million uninsured,1 there exist many models of collaborative local programs serving the uninsured. One such approach is the student-run free clinic, small projects managed by health professional students, supervised by licensed health professionals, offering free health services to those without health access. The purpose of this article is to describe the UCSD Student-Run Free Clinic Project, its history, mission, partners, clinical services, curriculum, funding, replicability, outcomes, elements of success, transdisciplinary nature, and hopes for the future.

Management of cluster headache.

Cluster headache, an excruciating, unilateral headache usually accompanied by conjunctival injection and lacrimation, can occur episodically or chronically, and can be difficult to treat. Existing effective treatments may be underused because of underdiagnosis of the syndrome. Oxygen and sumatriptan have been demonstrated to be effective in the acute treatment of cluster headaches. Verapamil has been shown to be effective for prophylaxis. For cluster headache completely refractory to all treatments, surgical modalities and newer interventions such as the implantation of stereotactic electrodes may be useful. Patients should be encouraged to avoid possible triggers such as smoking or alcohol consumption, especially during the duster period. The intensity of duster headache pain leads to ethical concerns among researchers over the use of placebo, making randomized controlled trials difficult. As new technology and genetic studies clarify the etiology of duster headache, it is possible that more specific therapies will emerge.

Gibberellin structure and function: biological activity and competitive inhibition of gibberellin 2- and 3-oxidases.

Some gibberellin (GA) analogues, especially with C-16,17 modifications of GA(5), can inhibit growth of plants apparently by acting as competitors with the endogenous substrate of GA biosynthetic enzymes. Here, we directly confirm the competitive action of GA derivatives but also show that some analogues may retain significant bioactivity. A recombinant 3-oxidase from pea, which converts GA(20) to bioactive GA(1), was inhibited by GA(5), and 16,17-dihydro-GA(5) derivatives, especially if the C-17 alkyl chain length was increased by up to three carbons or if the C-13 hydroxyl was acetylated. Genetic confirmation that GA(5) analogues target 3-oxidases in vivo was provided by comparing the growth response of a WT (LE) pea with a 3-oxidase mutant (le-1). Two pea 2-oxidases that inactivate bioactive GAs, were inhibited by GA(1) and GA(3) but were generally insensitive to GA(5) analogues. alpha-Amylase production by barley half-seeds in response to GA analogues provided a method to study their action when effects on GA biosynthesis were excluded. This bioactivity assay showed that 16,17-dihydro GA(5) analogues have some inherent activity but mostly less than for GA(5) (5-50-fold), which in turn was 100-fold less active than GA(1) and GA(3). However, although C-17 alkyl derivatives with one or two added carbons showed little bioactivity and were purely 3-oxidase inhibitors, adding a third carbon (the 17-n-propyl-16,17-dihydro GA(5) analogue) restored bioactivity to that of GA(5). Furthermore, this analogue has lost its capacity to inhibit stem elongation of Lolium temulentum (Mander et al., Phytochemistry 49:1509-1515, 1998a), although it strongly inhibits the 3-oxidase. Thus, the effectiveness of a GA derivative as a growth retardant will reflect the balance between its bioactivity and its capacity to inhibit the terminal enzyme of GA biosynthesis. The weaker growth inhibition in dicots including pea (approximately 10%) than in monocots such as L. temulentum (>35%) is suggestive of taxonomic differences in the bioactivity of GAs and/or their effects on GA biosynthesis.