Running head: FINAL NURSING PAPER 1

FINAL NURSING PAPER 16

Final Nursing Paper

Seilin Gonzalez

South University

· Advanced Practice Roles in Nursing:

· Briefly define advance nursing practice and the roles in advanced practice nursing pertaining to clinical practice, primary care, education, administration, and health information. Distinguish between ANP and the APN.

Advanced nursing practice may be defined in regards to either role undertakings or competencies. Saleh, Alameddine & Mourad et al. (2015) assert that when defined based on competencies, advanced nursing practice is perceived as a set skills or capabilities that individuals in such a role must possess. In regards to role, Yee, Boukus, Cross & Samuel (2013) posit that this concept described a multiplicity of various roles, for example educator, clinician, consultant and researcher, rather than a particular distinctive role. It is however notable that as the nursing profession evolves the advanced nursing practice concept is also undergoing transformations.

There are notable differences between advanced nurse practitioners (ANP) and advanced practice nurses (APN). Masters (2015) asserts that one of the most significant distinguishing features is that APNs are the most highly trained/educated registered nurses and they possess either masters or doctorate nursing degrees. Moreover, Martinez-Gonzalez, Djalali & Tandjung et al. (2014) assert that while ANPs may have to work under the supervision of physicians, APNs fulfill roles for example as ordering laboratory test, prescribing medicines, diagnosing conditions and even interpreting lab results, which were initially only fulfilled by doctors. According to Gehring, Schwappach & Battaglia et al. (2013) the main features of ANP include the extensive use of critical thinking, practice transformation and clinical judgment. As a consequence, the main competencies that are commonly associated with ANP role include consultation, research, direct clinical practice, ethical decision making, leadership, guidance and expert coaching. On the other hand, the APN role is

· Describe the advance nursing practice role you aspire and briefly share the experiences and/or qualities you have that have influenced your decision. Include your personal philosophy.

The advance nursing practice role that I aspire is family nurse practitioner. I have always wanted to be a family nurse practitioner because I believe that this role will enable me to deliver high quality care to people of different demographics. As I was growing up, I witnessed someone I knew die a very slow and painful death due to a chronic condition that they had. I somehow felt that the nursing care they received, particularly in their last few days, could have been of higher quality and that the nurses handling their case should have been more compassionate and caring. It was then that I decided I would become a family nurse practitioner.

My personal philosophy as a nurse is based on the first nursing metaparadigm which is person. I am convinced that patients/clients have diverse experiences, perspectives and attitudes towards life and health which must all be considered in the delivery of high-quality care. As such, my principle is to approach each client or patient as a unique person with unique needs.

I possess several qualities which have influenced my decision to pursue a career as a family nurse practitioner. Firstly, my communication skills are exemplary; I am able to communicate through different channels, both verbal and non-verbal, while at the same time ensuring that I get valuable feedback from patients and/or clients. Secondly, I am emotionally stable and with a notable level of emotional intelligence; as indicated by Masters (2015) this quality is a very invaluable one particularly because nursing is a very stressful and demanding career where one may regularly find themself in tragic or highly emotive situations. Thirdly, I am a very empathetic person who reflexively shows compassion and rushes to the assistance of those who need it. According to Blackwell & Neff (2015) this quality will ensure that I am able to identify with patient/clients and consequently deliver high quality care. It is also beneficial in my career as a family nurse practitioner that I am a person who is both versatile and flexible. This means that I can easily adapt to different circumstances, and that I can successfully deliver high quality care to patients and clients of diverse backgrounds.

· Selected Advanced Practice Role:

· Identify the AP you interviewed and summarize the interview, which should/may include (if not in the interview, please address):

The advanced practice role that was interviewed is Angie Riddle who works as a nurse practitioner (NP) at CareHere LLC. CareHere LLC is a private healthcare organization specialized in the delivery of near-site and on-site primary care. Currently the facility has an estimated 200 wellness clinics in different American states. The organization delivers healthcare to more than 335,000 patients/clients across the country. One of the most important discoveries made during this interview is that the career success of any nurse in an advanced nursing role is determined by the degree of their professional fit. Riddle revealed that her professional fit for the NP role is satisfactory because she not only has masters and post master’s educational qualifications but also accreditation from reputable agencies such as the Adult/Gerontology Primary Care Nurse Practitioner Board.

· Examine regulatory and legal requirements for the state in which you plan to practice/work.

I plan to work in Florida State; the agency tasked with regulating nurses in Florida is the Florida Board of Nursing. The Florida Board of Nursing describes an advanced registered nurse practitioner (ARNP) in accordance with s. 464.003 of Florida laws which defines them as “any person licensed in [the] state to practice professional nursing and certified in advanced or specialized nursing practice” (para. 1). The three fields of specialization in nurses which are generally acknowledged in Florida are: certified registered nurse anesthetist, nurse practitioner (NP) and certified nurse midwife (CNM).There are several regulatory and legal requirements which I must satisfy in order to work in the state of Florida. According to Buppert (2017) these regulations govern issues such as education requirements, the authority to make prescriptions, scope of practice, renewal, suspension or revocation of license and standards of practice. In order to practice as a nurse in this state, one must possess both a registered nurse (RN) license and malpractice insurance. Secondly, Swan, Ferguson, Chang, Larson & Smaldone (2015) reveal that it is mandatory to have certification from a relevant specialty board. In regards to academic attainment, nurses practicing in Florida must have finished a post-basic and formal academic program (for at least an academic year) in order to be ready for advanced practice. In addition to this, they must also have graduated from a program which gives them an opportunity to pursue a master’s degree. Buppert (2017) asserts that since the 1st of July, 2006, all nurses desiring to receive advanced registered nurse practitioner certification in the state of Florida must first receive and submit national advanced practice nurse accreditation from a relevant board of nurse certification.

· Describe the professional organizations available for membership based on your selected role.

There are several professional organizations that are available for membership by family nurse practitioners in Florida. Examples of such organizations include the American Association of Nurse Practitioners (AANP), Florida Association of Nurse Practitioners (FANP), Florida Nurse Practitioner Network (FNPN) and the Central Florida Advanced Nursing Practice Council (CFANP). Goolsby & Dubois (2017) assert that membership to such bodies in beneficial for a nurse practicing in an advanced nursing role because enhances networking, policy, professional development, mentorship, engagement and advocacy.

· Identify required competencies (domains), including certification requirements for your selected role.

There are four main domains which are needed in a nurse practitioner’s scope of practice; under each of these four domains, are a set of competencies whose mastery and application is fundamental in the successful delivery of care.

i. Domain of professional responsibility and leadership

The important competencies under this domain include: the practitioner’s commitment to practice within an appropriate nursing model, be accountable in their practice, demonstrate and use nursing leadership to influence the health outcomes of clients/patients positively. The Nursing Council of New Zealand (2014) posits that under this domain the nurse practitioner is also expected to participate in processes of policy development, promote health outcome equity in a population, support and promote ethical decision-making and possess and apply an advanced level of knowledge and expertise when making decisions related to the delivery of care.

ii. Domain of management of nursing care

The required competencies under this domain in the role of a nurse practitioner include: skills in diagnostic decision-making and thorough assessment of client/patient health, ability to effectively deliver care in diverse contexts, involvement of client in decision-making processes and the use of theory and application of a formal approach in patient interventions (Saleh, Alameddine & Mourad et al., 2015). A nurse practitioner must also be creative and innovative in patient care, able to use information technologies to enhance their decision-making processes, record and document client participation and evaluation information and able to apply critical thinking in the process of making plans.

iii. Domain of interpersonal and interprofessional care and quality improvement

The most important nurse practitioner competencies associated with this domain are: respect and tolerance for patient diversity, active contribution to clinical collaboration, creation of therapeutic associations with clients and active engagement in processes of quality assurance. American Association of Nurse Practitioners (2014) asserts that under this domain, a competent nurse practitioner must also use evidence-based findings to influence the procurement of facility resources, create and review clinical standards and demonstrate a capacity for risk management.

iv. Domain of prescribing practice

Cotter, Renz, Bradway & Taylor (2013) reveal that under this domain competent nurse practitioners are those who are able to: understand regulations and legislative frameworks that govern practice, access and use third party evidence appropriately always consult and collaborate with client while giving then accurate information regarding their health at all times. It is also notable that as a FNP working in Florida, as in any other part of the country, it is also fundamental that I possess sufficient knowledge and understanding of legal decrees such as Nurse Practice Act, Baker Act and Signature Authority Bill which guide nursing practice (Florida Association of Nurse Practitioners, 2018).

· Describe the organization and setting, population, and colleagues with whom you plan to work.

I plan to work with Jackson South Medical Center in Miami, Florida. Jackson Health System (2018) reveals that this organization offers a diverse spectrum of healthcare services and handles approximately 37,000 emergency cases annually. An estimated 3,400 surgeries are also performed at the facility each year. The setting of Jackson South Medical Center is a notably state of the art because the facility has computerized most of its operation through the integration of information technology systems. The center has 230 certified acute beds and recently unveiled 7 new state of the art operating room suites (Jackson Health System, 2018). The colleagues with who I plan to work with at Jackson South Hospital are amongst the best nationally and globally because according to Jackson Health System (2018) the organization is “staffed by nationally respected, board-certified physicians and healthcare professionals who practice a wide array of specialties and subspecialties” (para. 1).

· Leadership Attributes of the Advanced Practice Role:

· Determine your leadership style

My leadership style is situational leadership style; this model of leadership was created by Paul Hersey and Ken Blanchard as they researched on the management of organizational behavior. Torres-Contreras (2013) asserts that the basic principle of this type of leadership is that there is no best style of leadership that can be applied satisfactorily and effectively in all the different situations that a leader encounters in their organization. As such, this type of leadership is an adaptive one which encourages me to evaluate all my team members, consider the different variables or factors at my place of work and consequently select the type of style of leadership that is best suited for the present circumstances and the goals that we endeavor to achieve as a team. Situational leadership has been very effective for me in different circumstance because it is become increasingly clear that successful leaders in the contemporary day cannot depend only on positional power.

A feasible example of an incident where I applied situational leadership is at Vitas Hospice University where I work as a case manager. One day there was a conflict regarding which team member would handle a particular case because both of the available team members claimed that their workload was too much and that the other should handle that particular case. Although, in other cases I would have applied transformational leadership style to inspire them on the importance of working selflessly to improve patient outcome, I felt that democratic leadership was more suitable. I invited both of them to give their opinions regarding how the issue was to be resolved; at the end, they decided that one of them would handle the current case and the other would handle the next case.

· Define Transformational Leadership and as it relates to your identified leadership attributes that you possess or need to develop

Brewer, Kovner, Djuki, Fatehi, Greene, Chacko & Yang (2016) describe transformational leadership refers to the kind of leadership whereby a leader is charismatic and with the ability to influence their followers to accept and embrace their vision for the organization in order to work together towards attaining set goals. According to Brewer et al. (2016) the transformational style of leadership is built upon four main pillars namely: individualized consideration, idealized attributes, intellectual stimulation, and inspirational motivation. Although situational leadership is my ideal style, there are several leadership qualities that are depicted by transformational leaders which I possess. Firstly anytime I lead I ensure that I have a clear vision of the goals to be achieved; secondly, I possess high-level communication skills which enable me to communicate my vision clearly to all organizational members so that they understand how it is to be actualized; thirdly, is can inspire followers using my charismatic and eloquent nature; lastly, I am a courageous and self-motivated individual who possesses the resilience and determination required to successfully attain set goals.

· Apply the leadership style you will embrace in AP to one of the domains

In AP I will embrace situational leadership. When applied to a domain such as nursing care management or promoting health, this style of leadership is beneficial in several ways. This is mostly because as family nurse practitioner I must work collaboratively with others to ensure successful delivery of high-quality care. Firstly, as indicated by Torres-Contreras (2013), situational leadership will encourage the team members to develop effective workgroups; secondly, since leadership is based on situational factors and circumstances, it will make it for team to establish rapport and bring out the best in each of them.

· Health Policy and the Advanced Practice Role

Based on your program of study, review the literature and address the following:

· FNP/AGNP: Medicare reimbursement for NPs is 85%for the same health care that MDs receive at 100% reimbursement? Please address questions below and state your position on this mandate.

Although NPs and MDs share many duties, for example diagnosing, treating and following up on patients, NPs receive a lower medical reimbursement. While MDs are given 100% reimbursement of standard fees by Medicare, NPs receive 85%. My position regarding this issue is that it is not fair because; the main reason for this is that, as depicted by Phillips (2018), NPs as much time as MDs (or even more) with patients. Moreover, I feel that instead of basing reimbursement on the treating healthcare professional, it should be based on the complexity of each case and the time spent on diagnosing and managing the case.

· FNP/AGNP: What states have NP Full Practice Authority and which states have limitations or restrictions? How does this apply to your state? Please address questions below and state your position on this regulation.

Nurse practice regulations and laws are distinctive to each state. Stanik-Hutt, Newhouse & White et al. (2013) reveal that while some states have the authority to undertake full practice, others have put some limitations in place. The states with full practice are 23; these include: Alaska, Hawaii, Iowa, Arizona, Nebraska, Colorado, Maine, Connecticut, Vermont, Idaho, Oregon, Maryland, Minnesota, Rhode Island, Montana, New Hampshire, New Mexico, Nevada, North Dakota, Oklahoma, South Dakota, Washington and Wyoming. States that have reduced practice authority include: Kansas, New York, South Dakota, Virginia, Utah, Alabama, Michigan, Mississippi, Arkansas, Illinois, Indiana, Delaware, Kentucky, West Virginia, Wisconsin, Massachusetts, Pennsylvania, Ohio and New Jersey. The states with restrictions on practice include: California, Oklahoma, Florida, Georgia, Missouri, North Carolina, South Carolina, Tennessee and Texas.

Practice in Florida, where I intend to work, is restricted. The implication of this is that my capacity to prescribe medication is supervised by either a physician or surgeon. Moreover, I must abide by the dictates of the FL Nurse Practice Act and ensure that I obtain a malpractice exemption or insurance.

· Nurse Executive: What is value-based care and how will it impact decisions made at the executive level relative to nursing and AP nursing? Please address and state your position on the regulation.

Pappas (2013) describes the value-based model of nursing care as that which places preeminence on the relationships and associations between individual nurses and patients/clients, as well as the healthcare services offered. Value based care as notable impacts on both decisions making and nursing. According to Gielen, Dekker & Francke et al. (2014) the most important include: enhanced health in target population, reduction of costs and improvements in the general experience of patients receiving care. As intimated by Pappas & Welton (2015), my position on this issue is that value-based care is best determined using metrics that evaluate the economic and clinical effects of nursing.

· Nurse Informaticists: What law(s) was enacted to regulate health information? Please address questions below and state your position on this regulation.

AHIMA Practice Brief (2014) reveals that health information is regulated through the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule which (effected in April 2003). Other important regulations include the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 which tasked the Federal Department of Health and Human Services (HHS) with ensuring the security, quality and safety of health IT. The Privacy Cat of 1974 and the Confidentiality of Alcohol and Drug Abuse Patient Records Rule also play an instrumental role in ensuring that patients’ medical information and records are protected.

· Nurse Educator: What agency regulates nursing education?  Explain in detail.

According to the American Nephrology Nurses Association (ANNA) (2018) the agencies that regulate nursing education are: state nursing boards and the National Council of States Boards of Nursing (NCSBN). The agencies base their regulation on the dictates of the Nurse Practice Act. Bousso, Poles & Cruz (2014) assert that nursing education and practice is regulated in all American states. Firstly, all nursing schools must receive approval and authorization in the states that they are located. Secondly, nursing schools should be voluntarily accredited by an association that is non-governmental because all graduates must sit for a uniform licensing examination and a computer adaptive test (American Nephrology Nurses Association, 2018).

For the above category chosen, address the following:

· The category chose from the two offered above is nurse informaticist.

· Describe the current policy or trends and determine if it needs to change; if opposed to change state why

Peltonen (2016) asserts that the most notable policies and trends in nurse informatics include those related to big data research, support for clinical decisions, education, patient safety, mobile health and standardized technologies.

· Provide the process required to make the change with key players and parties of interest; support opposition

The policy and trends regarding this role and its regulation have evolved in the last few years due to the action of the HITECH Omnibus Rule which, since 2013, has extended the requirements for information protection or disclosure-and related issues-to business associates (AHIMA Practice Brief, 2014). In order to make changes, therefore, the key players and parties of interest include governmental agencies regulating nursing, professional bodies of nursing and relevant politicians (Kung & Lugo, 2014). Any opposition encountered will be redressed through the use of open communication and feedback channels and the use of both intrinsic and extrinsic rewards.

· Explain how you could lead the effort to make or influence the change in policy or keep the policy the same and the impact in healthcare quality.

The areas of policy I would influence are financing and the integration of telehealth with nursing informatics. This is because reimbursement is fundamental in expanding telehealth. Rather than focus solely on information systems, information nurses must also consider such integration. I would lead the change effort by communicating my vision and desired goal to all relevant parties and involving all direct stakeholders in the process.

· Conclusion

This paper has examined and discussed different issues pertaining to the role of advanced nursing practice. The key points made in this paper include the importance of practicing authority, the role played by government and non-governmental regulatory bodies and the dependence of quality healthcare delivery of nurses’ expertise, competence and commitment to improving healthcare. The different policies and trends in select advanced nursing roles have also been examined.

References

AHIMA Practice Brief (2014). Laws and Regulations Governing the Disclosure of Health

Information. Retrieved from: http://bok.ahima.org/doc?oid=300245#.W4u5aCQzaRl (01 September, date last accessed)

American Association of Nurse Practitioners (2014). Nurse Practitioner State Practice

Environment 2014. Available online at: http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf (21 August 2014, date last accessed).

American Nephrology Nurses Association (2018). Nursing Regulations and State Boards

of Nursing. Retrieved from: https://www.annanurse.org/advocacy/resources-and-tools/state/nursing-regulations (01 September, 2017, date last accessed)

Blackwell, C. W. & Neff, D. F. (2015). Certification and education as determinants of nurse

practitioner scope of practice: An investigation of the rules and regulations defining NP scope of practice in the United States. Journal of the American Association of Nurse Practitioners, 27(10).

Brewer, C. S., Kovner, C. T., Djukic, M., Fatehi, F., Greene, W., Chacko, T.P. & Yang, Y.

(2016). Impact of transformational leadership on nurse work outcomes. Journal of Advanced Nursing, 72: 2879–2893.

Bousso, R. S., Poles, K.  & Cruz, D. D. A. L. M. (2014). Nursing Concepts and Theories.

SciELO Analytics, 48(1): 141-145.

Buppert, C. (2017). Nurse Practitioner’s Business Practice and Legal Guide. Jones and Bartlett

Publishers, 125-151.

Cotter, V. T., Renz, S. M., Bradway, C. W. & Taylor, M. A. (2013). Adult-Gerontology Primary

Care Nurse Practitioner Competencies.  Conference: The National Organization of Nurse Practitioner Faculties 39th Annual Meeting.

Florida Board of Nursing (2016). Updated Standards for Protocols: Physicians and ARNPs.

Retrieved from: https://floridasnursing.gov/standards-for-protocols-physicians-and-arnps/ (01 September, 2018, date last accessed).

Florida Association of Nurse Practitioners (2018). Advocacy. Retrieved from:

https://www.flanp.org/ (01 September 2018, date last accessed).

Gehring, K., Schwappach, D. L. & Battaglia, M. et al. (2013). Safety climate and its association

with office type and team involvement in primary care. International Journal of Quality Health Care, 25: 394-402.

Gielen, S. C., Dekker, J. & Francke, A. L. et al. (2014). The effectives of nurse prescribing: a

systematic review. International Journal of Nursing Studies, 51: 1048.

Goolsby, M. J. & Dubois, J. (2017). Professional organization Membership: Advancing the nurse practitioner role. Journal of the American Association of Nurse Practitioners, 29(1): 434-440.

Jackson Health System (2018). Jackson South Medical Center. Retrieved from: http://www.jacksonhealth.org/jackson-south.asp#gref (01 September, 2018, date last accessed).

Kung, Y. M. & Lugo, N. R. (2014). Political advocacy and practice barriers: A survey of Florida

APRNs. Journal of the American Association of Nurse Practitioners, 27(3).

Masters, K. (2015). Role development in professional nursing practice. Boston: Jones & Bartlett Publishers.

Martinez-Gonzalez, N. A., Djalali, S. & Tandjung, R. et al. (2014). Substitution of physicians by

nurses in primary care: a systematic review and meta-analysis. BMC Health Services Res, 14: 214.

Nursing Council of New Zealand (2014). Competencies for the nurse practitioner scope of the

practice. Retrieved from: file:///C:/Users/us/Downloads/NP%20competencies%20December%202012.pdf

Pappas, S. & Welton, J. M. (2015). Nursing: Essential to Healthcare Value. Nurse Leader, 13(3):

26-29.

Papas, S. H. (2013). Value, a Nursing Outcome. Nursing Administrative Quarterly, 37: 122-128.

Peltonen, L. M. et al (2016). Current Trends in Nursing Informatics: Results of an International

Survey. Studies in Health Technology and Informatics, 225: 938-939.

Phillips, S. J. (2018). Improving access to healthcare one state at a time: 30th annual APRN

legislative update. Nurse Practitioner, 43(1): 27-55.

Saleh, S., Alameddine, M & Mourad, Y. et al. (2015). Quality of care in primary health care

settings in the Eastern Mediterranean region: A systematic review of the literature. International Journal of Quality Health Care, 27: 79-88.

Stanik-Hutt, J., Newhouse, R. P. & White, K. M. et al. (2013). The quality and effectiveness of

care provided by nurse practitioners. Journal of Nurse Practitioners, 9(492): 492-500.

Swan, M., Ferguson, S., Chang, A., Larson, E. & Smaldone, A. (2015). Quality of primary care

by advanced practice nurses: A systematic Review. International Journal for Quality in Health Care, 27(5): 396-404.

Torres-Contreras, C. C. (2013). Situational Leadership in Nursing in a Health Institution in

Bucaramanga, Columbia. Enfermeria Clinica, 23(4): 140-147.

Yee, T., Boukus, E., Cross, D., & Samuel, D. (2013). Primary care workforce shortages: Nurse

practitioner scope of practice laws and payment policies. National Institute for Health Care Reform: Advancing Health Policy Research (13).

PICOT Question Worksheet

Name:

Please read the assignment guidelines and rubric. Provide answers to the following:

1) Identify and describe one practice-related issue or concern.  You may choose to build on the practice issue you identified in NR500NP/NR501NP. Provide support for the issue from scholarly nursing sources current within the last 5 years.

2) Explain why the issue/concern is important to nurse practitioner practice and the issue’s impact on health outcomes.  Provide support for the importance of the issue from scholarly nursing sources current within the last 5 years.

3) Define each element of your PICOT question in one or two sentences.

· P-Population and problem (What is the nursing practice concern or problem and whom does it affect?)

· I–Intervention (What evidence-based solution for the problem would you like to apply?)

· C–Comparison (What is another solution for the problem? Note that this is typically the current practice, no intervention at all, or alternative solutions.)

· O–Outcome (Very specifically, how will you know that the intervention worked? How you will measure the outcome?)

· T–Timeframe (Timeframe involved for the EBP initiative/target date of completion.)

Construct your PICOT question in the standard PICOT question format (narrative) and define each letter separately, such as:  

· P =

· I =

· C =

· O =

· T =

· PICOT Question written in full:

References

0320 RB/KK

For this assignment, you will select a disease of your choice and conduct a detailed analysis of that disease, exploring it from a balanced traditional and alternative health perspective.

Begin by searching the Center for Disease Control (CDC) website Diseases and Conditions Index to choose a disease or condition of interest to you.

Next, review the website for Healthy People 2020 for information related to the disease or the disease category (e.g., mental health for ADHD).

In your paper, discuss the following:

• Prominent aspects of this disease
• Current data and statistics related to the disease
• Health disparities related to the disease
• Prevention strategies including complementary and alternative health therapies
• Contemporary research and clinical studies related to the disease
• An analysis of the pathophysiologic effects of stress related to the disease
• Evidence-based stress management interventions that might help with prevention or cure

The paper should be between 3–4 pages.

Incorporate at least three scholarly sources within the paper. Sources should be no more than three years old.

Use proper APA format to cite and reference sources.

Review the rubric for further information on how your assignment will be graded

Copyright © 2019 Wolters Kluwer • All Rights Reserved

CASE STUDY

You are working with Dr. Stephanie Lee at her family medicine clinic. Dr. Lee tells you, “The next patient, Mrs. Payne, is a 45-year-old cisgender female who is here for a health maintenance exam. It looks like she hasn’t had a visit for over five years. When you’re talking with Mrs. Payne, I’d like you to find out if she has any current concerns, update her past medical history, and do a brief review of systems. Then, come on out and tell me what you’ve discovered and we’ll both go in to do the physical exam together.”

You introduce yourself to Mrs. Payne and begin obtaining her history:

Medical History:

“Do you mind if I ask you a few questions to find out how you are doing?”

Mrs. Payne says, “That sounds fine.”

“What brought you in today?”

“I feel fine, but I know I should get checked out since it’s been a while and I need to have a Pap test and mammogram.”

“I would like to update your medical history. Do you have any chronic medical problems?”

“Well, I don’t really have any medical problems.”

“Have you had any operations?”

“I had my tubes tied shortly after the birth of my last child.”

“Are you on any medications, or are you allergic to any medications?”

“I take an occasional Tylenol or ibuprofen for pain or headache and a multivitamin. I’m not allergic to any medicine as far as I know.”

Social History:

“Have you ever smoked?”

“Yes, I’m afraid I do smoke a pack of cigarettes a week. I keep trying to quit, but I just never seem to be able to do it.”

“Do you drink alcohol?”

“No, I don’t drink any alcohol at all.”

“Have you ever used any recreational drugs?”

“I never tried any illegal drugs. My friends have smoked marijuana but I was always too afraid to try.”

“How much do you exercise?”

“I used to try to walk at lunchtime, but I don’t do that anymore. It just seems like I’ve been too busy to have time to exercise.”

“Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?”

“No, I feel safe.”

Family History:

“How is the health of your family members?”

“My father has high blood pressure and my mother has mild arthritis, but both are in good health. My two sisters are healthy.”

“What about your extended family?”

“I don’t know how my grandparents died, but I think one of them had diabetes. My mom’s sister has breast cancer but is doing well after surgery and chemotherapy.”

Mrs. Payne asks you, “Does having an aunt with breast cancer increase my risk of developing breast cancer? My aunt was diagnosed with breast cancer when she was about 70 years old.”

You were able to reassure Mrs. Payne that the risk is increased only if there is a history in a first-degree relative, such as a parent or sibling.

OB/GYN:

“How old were you when your periods began?”

“Around 13 or 14.”

“Are your periods usually regular?”

“They have always been regular until the last year, when my menstrual flow has decreased.”

“Can you describe what you mean?”

“My cycles have lengthened and the flow has decreased. I think I might be having hot flashes once in while, too. I’m wondering if I might be going through menopause.”

You tell Mrs. Payne you would like to address this issue in more detail when you return later with Dr. Lee.

“Have you ever had an abnormal Pap test?”

“I had one abnormal Pap test seven or eight years ago. Dr. Lee did a test and took some samples but everything turned out normal. I had another Pap test one year later that was normal. I then had another normal one a few years ago, right?”

“Right. You mentioned having a child. How many times have you been pregnant?”

“I have been pregnant three times, and I have three children.”

When you ask Mrs. Payne about health maintenance, she says she has never had a mammogram. She tells you, “One of the big reasons I’ve been putting off coming to see Dr. Lee is because I know she will recommend a mammogram. I think I should have one since my aunt had breast cancer and all, even though we just discussed how that shouldn’t increase my risk. But a friend of mine told me her mammogram was very painful. I have done breast self-exams, but not very often. I did notice some tenderness the last time I did my exam.”

You respond, “Let’s talk more about mammograms with Dr. Lee when she comes in. Are there any other issues you’d like to cover today?”

Mrs. Payne indicates that she’s discussed all her concerns with you already. You excuse yourself while Mrs. Payne changes into a gown for her physical exam.

After presenting Mrs. Payne’s history and vital signs to Dr. Lee, the two of you knock on the door and reenter the room. After greeting Mrs. Payne, Dr. Lee asks if she minds if you perform the physical examination with Dr. Lee observing. Mrs. Payne assents.

Physical Exam

Vital signs:

· Temperature is 37 °C (98.6 °F)

· Pulse is 81 beats/minute

· Respiratory rate is 12 breaths/minute

· Blood pressure is 128/72 mmHg

· Weight is 81.6 kg (180 lbs)

· Height is 168 cm (66 in)

· BMI is 29 kg/m2

General: Mrs. Payne is a well-appearing 45-year-old female.

Head, eyes, ears, nose, and throat (HEENT): All unremarkable. Teeth are in good repair with several fillings and some tobacco staining noted.

Neck: Normal-sized thyroid with no nodules. Trachea is in the midline.

Cardiovascular: Normal S1 and S2 with no murmurs, gallops, or rubs. Pulses are palpable and equal throughout.

Respiratory: Clear with good respiratory excursions. No palpable lymph nodes are noted in the cervical or inguinal regions.

Musculoskeletal: Good muscle development and normal range of motion of all joints.

Neurologic: Cranial nerves are intact; normal strength and sensation; reflexes are equal and symmetrical; normal gait.

Performing a Breast Exam

Although breast exam is not a recommended screening test, it is important to know how to perform it in a patient with symptoms.

A good breast exam consists of both visual inspection and palpation.

Visual inspection:

With patient sitting upright on the exam table, have her lower her gown to her waist so the breasts can be fully visualized.

· Look for symmetry in shape and assess skin changes, including any erythema, retractions, dimpling, or nipple changes.

· Ask the patient to lift her hands overhead to accentuate any retraction or dimpling.

Palpation:

For the palpation portion of the exam, ask patient to lie back on the exam table and place her hands over her head, thus flattening the breast tissue on the chest wall.

· Carefully examine each breast using a vertical strip pattern.

After you have finished the breast exam, you examine Mrs. Payne’s abdomen.

Abdomen:

No hepatosplenomegaly, tenderness, or masses.

Dr. Lee then explains to you the correct technique for a pelvic exam, as Mrs. Payne is due for her Pap test.

Dr. Lee next inspects the cervix and vaginal walls for lesions or discharge before obtaining cytology. “Now I’m going to obtain a sample,” she tells Mrs. Payne.

TEACHING POINT

Obtaining a Pap Test

One common method for collecting the Pap test is to use a spatula and cytobrush, though there are single-collection products available for this purpose as well.

Using the combination involves two steps: First, the spatula is rotated several times to obtain a sample from the ectocervix. The cytobrush is then inserted into the os and rotated 180 degrees.

Care is taken to make sure that the squamo-columnar junction (the area of the endocervix where there is rapid cell division and where dysplastic cells originate) is adequately sampled.

The sample is then placed into a liquid medium.

Using the liquid-based system over the conventional Pap test technology allows for later testing of the sample for the presence of human papillomavirus (HPV) if the Pap comes back abnormal.

Currently two liquid-based systems are approved by the FDA. You should check with your lab to find out which system is preferred.

Once the sample is obtained, let the patient know the speculum is about to be withdrawn.

Then, withdraw the speculum slightly to clear the cervix, loosen the speculum and allow the “bills” to fall together, and continue to withdraw while rotating the speculum to 45 degrees.

Performing a Bimanual Exam

Screening for ovarian cancer with a bimanual exam is not recommended, but it is the technique you would use should you need to do the exam for a symptomatic patient.

First, explain to your patient what you are going to do.

Next, apply lubricant (e.g., K-Y jelly) to the index and middle fingers of your nondominant gloved hand and insert them into the patient’s vagina.

Move cervix side to side (laterally) to ensure that it is nontender and mobile.

Place your non-gloved hand on the abdomen just superior to the symphysis pubis, feeling for the uterus between your two hands. This gives you an idea of its size and position.

Then, moving your pelvic hand to each lateral fornix, try to capture each ovary between your abdominal and pelvic hands. The ovaries are usually palpable in slender, relaxed patients, but are difficult or impossible to feel in obese patients.

Mrs. Payne’s cervix is freely moveable and nontender, and her uterus is normal in size and position. Her ovaries are not palpable.

“Everything is fine,” Dr. Lee tells Mrs. Payne. “We’re going to leave the room for a minute and give you a chance to get dressed, and then we can talk some more when we come back.”

When you have left the room, you tell Dr. Lee that you are a little confused about when Pap tests are recommended, so she reviews the guidelines with you.

Cervical Cancer Screening Guidelines

In 2012, the ACS, the USPSTF, the American College of Obstetrics and Gynecology (ACOG), and the American Society for Colposcopy and Cervical Pathology (ASCCP) came to a consensus on cervical cancer screening.

Since that time, many organizations have updated their recommendations to include the use of high-risk HPV (hrHPV) testing alone. The frequency of testing and age of first use varies.

In 2018, the USPSTF updated their guidelines to recommend that:

· At age 21: cervical cancer screening should begin.

· Between ages 21 and 29: screening should be performed every three years with cytology alone.

· Between ages 30 and 65: screening can be done every five years with high risk HPV (hrHPV) testing alone, every five years with cotesting (hrHPV and cytology), or every three years with cytology alone.

Since that time, many organizations have updated their recommendations to include the use of high risk HPV (hrHPV) testing alone. The frequency of testing and age of first use varies.

Importantly, it should be noted that the new guidelines stipulate that certain risk groups need to have more frequent screening. They include patients who have compromised immunity, are HIV positive, have a history of cervical intraepithelial neoplasia grade 2, 3, or cancer, or have been exposed to diethylstilbestrol (DES) in utero. (DES is a nonsteroidal estrogen that was given to pregnant females to prevent miscarriages. However, it was linked to clear cell adenocarcinoma of the vagina and its use was discontinued in 1971.)

Patients older than 65 years who have had adequate screening within the last 10 years may choose to stop cervical cancer screening. Adequate screening is three consecutive normal Pap tests with cytology alone or two normal Pap tests if combined with HPV testing.

Patients who have undergone a total hysterectomy for benign reasons do not require cervical cancer screening.

While you are in the hallway waiting for Mrs. Payne to get dressed, you and Dr. Lee discuss breast and cervical cancer screening. She asks you, “What constitutes a good screening test?”

Characteristics of a Good Screening Test

1. Accuracy (high sensitivity and specificity)

2. Able to detect disease in an asymptomatic phase

3. Minimal associated risk

4. Reasonable cost

5. Acceptable to patient

6. There is an available treatment for the disease

The Pap test fits into the definition of a good screening test because the test is relatively inexpensive, easy to perform, and acceptable to patients.

Cervical cancer has a long asymptomatic preinvasive state (often a decade or more), and there are effective treatments for preinvasive disease.

Although the Pap test has a sensitivity of only between 30% and 80% and a specificity of 86% to 100%, cancer deaths from cervical cancer decreased markedly in the U.S. after the Pap test was introduced.

Based on Mrs. Payne’s history, you and Dr. Lee have determined that she is at average risk for breast cancer. Dr. Lee tells you that the recommendation regarding when to perform screening mammography varies.

“We all struggle to keep up with the constantly changing recommendations,” Dr. Lee tells you. “I follow the USPSTF guidelines. They review cancer screening as well as health maintenance issues in general. The USPSTF guidelines are strictly evidence-based and probably eliminate some of the bias brought to the table by specialists. A nice feature of the USPSTF guidelines is that they also review the guidelines from other organizations.”

Dr. Lee further observes that, in Mrs. Payne’s age group, even though the most common cancers are breast, lung, and colorectal cancers, screening for them is not necessarily suggested.

TEACHING POINT

Recommendations for Breast Cancer Screening Mammography

Most guidelines do not recommend routine mammography for females younger than 40 unless they fall into a high-risk category, such as females with a known BRCA mutation.

TEACHING POINT

Shared Decision-Making in the Setting of Conflicting Guidelines

Part of a clinician’s job is to help patients make informed decisions that incorporate their personal and family history/risk factors and personal health beliefs. Clinicians need to be aware of the different guidelines. It is important to present the pros and cons of different recommendations and guide patients in a shared decision-making process. In situations where there are differences in recommendations, it is important to get the patient’s input.

Dr. Lee tells you that breast-related concerns like lumps and discharge are common in primary care practice.

TEACHING POINT

Evaluating a Breast Lump

First, take a good history from the patient, including:

· Precise location of the lump

· How it was first noticed (accidentally, by breast self-examination, clinical breast examination, or mammogram)

· How long it has been present

· Presence of nipple discharge

· Any change in size of the lump (especially ask whether the lump changes in size according to phase of the menstrual cycle)

The next step is a thorough breast exam: Certain characteristics on physical exam increase the suspicion of malignancy.

· For example, the presence of a single, hard, immobile lesion of approximately 2 cm or larger with irregular borders increases the likelihood of malignancy.

Diagnostic tests:

· If it feels cystic, aspiration can be attempted and the fluid sent for cytology. Fine needle aspiration is a procedure family physicians can do in the office.

· If it feels solid, mammography is the next step.

· Ultrasound can be helpful in distinguishing a solid mass from a cystic lesion.

Follow-up:

If the workup suggests that the lesion is benign (which the vast majority are), close follow-up with regular breast exams and mammography is indicated.

Next, you and Dr. Lee review breast cancer screening. The most commonly used screening tool is mammography. Physician breast exam has not been shown in studies to meet the screening criteria.

TEACHING POINT

Breast Cancer Screening Studies

Dr. Lee asks, “What other important health maintenance issues do we need to address?”

You suggest checking Mrs. Payne’s immunization status. You both review Mrs. Payne’s chart and then visit the CDC immunization information website (PDF). Seeing that Mrs. Payne’s last tetanus shot was over 10 years ago, you recommend she get a Tdap now. Also, since she is a smoker, you recommend she receive the pneumovax vaccine today. She should receive a flu vaccine every fall.

“Okay. Is there anything else we should talk with Mrs. Payne about when we go back?” You feel you should address Mrs. Payne’s smoking, her excessive weight, her lack of exercise, and osteoporosis prevention. Dr. Lee agrees.

TEACHING POINT

Immunization: Tdap

Tetanus, diptheria, and acellular pertussis (Tdap) should replace a single dose of Td for adults age 19 through 64 who have not received a dose of Tdap previously.

When you reenter the room, Dr. Lee reassures Mrs. Payne, “Your physical exam was normal. However, I have several suggestions and recommendations I would like to discuss with you. But first let’s talk a bit about menopause, since I’m told you have some concerns.”

TEACHING POINT

Menopause

Timing

On average, patients with ovaries reach menopause at age 51, but menopause can start earlier or later. A few patients start menopause as young as 40, and a very few as late as 60. Those who smoke tend to go through menopause a few years earlier than nonsmokers. The timing of an individual’s menopause cannot be predicted. Only after a patient has not menstruated for 12 straight months can menopause be confirmed.

Perimenopause

The gradual transition to menopause is called perimenopause. The ovaries don’t abruptly stop; they slow down. During perimenopause it is still possible to get pregnant. The ovaries are still functional, and ovulation may occur, although not necessarily on a monthly basis. Perimenopause can last from two to eight years.

Symptoms

Menopause affects each person differently. Some reach menopause with little to no trouble; others experience severe symptoms that drastically hamper their lives. Menstrual irregularity is the hallmark of perimenopause. Patients should be advised to call their clinician if their menses come very close together, if the bleeding is heavy, or if the bleeding lasts more than a week.

Other perimenopausal symptoms due to estrogen deficiency include:

Hot flashes: Hot flashes are brief feelings of heat that may make the face and neck flushed and cause temporary red blotches to appear on the chest, back, and arms. Sweating and chills may follow. Hot flashes vary in intensity and typically last between 30 seconds and 10 minutes. Dressing in light layers, using a fan, getting regular exercise, avoiding spicy foods and heat, and managing stress may help.

Vaginal dryness: This can make intercourse uncomfortable. A water-soluble lubricant may be recommended. A patient’s libido may also change.

Mood swings: Mood swings, especially depression, are common during perimenopause and menopause. Patients should let their clinician know if they are experiencing this, so that resources and support may be found.

Dr. Lee asks you if Mrs. Payne has any risk factors for osteoporosis. “Yes,” you reply. “She is a smoker.”

TEACHING POINT

Recommendations for Osteoporosis Prevention

Before menopause, estrogen offers some protection against heart disease and osteoporosis. This protection is lost when estrogen levels ebb with menopause.

Calcium Intake

Calcium supplementation for osteoporotic fracture prevention has raised concerns that it may increase the risk of atherosclerotic vascular disease and kidney stones. However, it is unclear from the present data whether intake of dietary calcium versus calcium supplementation increases cardiovascular risk or the risk for kidney stones. A USPSTF 2018 recommendation statement concluded that current evidence is insufficient to assess the risks and benefits of calcium and vitamin D supplementation for the prevention of fractures in premenopausal and noninstitutionalized postmenopausal patients. Therefore the USPSTF is currently recommending against 1,000 mg or less of calcium and 400 IU or less vitamin D supplementation in community-dwelling postmenopausal patients.

At this time the most prudent recommendation would be to try to increase intake of dairy and try to include weight-bearing exercises such as walking into a daily routine.

TEACHING POINT

Recommendations for Osteoporosis Screening

· For females 65 and older, screening with dual energy x-ray absorptiometry (DEXA) is recommended.

· For females under 65, the USPSTF recommends using the World Health Organization’s  Fracture Risk Assessment Tool  to risk-stratify. Screening with DEXA is recommended if the risk of fracture is greater than or equal to that of a 65-year-old White female without additional risk factors (9.3 percent over 10 years). These recommendations are being reviewed by the USPSTF.

· Dr. Lee moves on to the next topic. “I’d like to talk next about your weight,” she tells Mrs. Payne. “By losing 5 to 10 percent of your body weight, you can significantly reduce your risk of diabetes, hypertension, and cardiovascular disease.”

· “How do you feel about your weight at this point?”

· “I weigh too much. I would feel better physically and emotionally if I could only lose about 10 or 20 pounds. But I don’t know where to start.”

· “Well, we are here to help you with that,” offers Dr. Lee. Can you tell me what you would eat in a typical day?”

· Mrs. Payne lists her daily diet for you: “Well, I usually skip breakfast because mornings are so chaotic, plus I know I don’t really need to eat more than I do. For lunch, I eat a sandwich or leftover pasta, an apple or orange, and I drink water. I also have a weakness for a couple of cookies after lunch to keep me going through the day. For dinner, I try to cook lean meats, and we usually have rice with it. Again, I drink water. My family likes strawberries and blackberries. We try to eat something like that when it’s available. And, we have cake or ice cream for dessert. At night, while I’m watching TV is my weakness—I’ll often eat some chips or have another helping of dessert.”

· “Alright, you are making some excellent choices by eating two fruits a day, choosing lean meats, and drinking water. I would like to continue to see you doing these things.”

· You tell Mrs. Payne about some additional nutritional approaches to a healthier diet.

· “Do you think you could try any of these changes?”

· Mrs. Payne says, “I could start eating breakfast, buy whole wheat stuff, and decrease my desserts to three servings weekly.”

· “That would be excellent,” Dr. Lee concludes. “Let’s follow up on these goals at our next visit.”

·

Dr. Lee reminds Mrs. Payne that increasing her physical activity would also assist weight loss.

· “What type of activity do you enjoy?”

· “I used to walk during my lunch hour, but I’ve gotten away from it. I could start doing that again.”

“Now I’d like to talk about smoking,” continues Dr. Lee.

“Have you thought about quitting?”

“I’ve tried to quit smoking a few times but was never able to make it stick. I’d like to quit for good.”

Turning to you, Dr. Lee says, “It sounds like Mrs. Payne is at the ‘preparation stage’ according to the transtheoretical model for change.”

Mrs. Payne declines assistance with medication to help her stop smoking.

When discussing smoking cessation, it is a good idea to start with the five “A’s”: ask, advise, assess, assist, arrange. With Mrs. Payne, you have asked and assessed. Fortunately, Mrs. Payne is interested in quitting, but typically you would want to advise as well. Since Dr. Lee has noted the patient is in the preparation stage but does not want to use medication, you can provide her with some of the other smoking cessation strategies below. Make sure to arrange for follow up!

“Now, I’ve just got a few more loose ends we need to tackle at this appointment. Since your last tetanus shot was over 10 years ago, I’d like you get a Tdap shot today. In 10 years, you will need a Td.”

Dr. Lee turns to you and asks,

“Is there any blood work we should order on Mrs. Payne today?”

“I think a lipid profile and fasting glucose would be indicated.”

Dr. Lee agrees.

“I’d like you to schedule a follow-up appointment so we can go over your lab results and your progress with your lifestyle goals,” She tells Mrs. Payne.

Dr. Lee asks her, “Do you have any questions about our recommendations?”

“No, you both have answered all my questions. I am going to try to start eating breakfast regularly, increasing my exercise, and try getting out and walking daily. I’ll work on cutting back smoking as well. Thanks for all your help,” Mrs. Payne says as she shakes hands with both of you and heads out the door.

On your last day with Dr. Lee, you see Mrs. Payne is on the schedule to follow up on her lab results. Before going into the room, you review her results with Dr. Lee:

Fasting glucose: 86 mg/dl

Lipids:

· Total cholesterol 183 mg/dl

· HDL 52 mg/dl

· LDL 121 mg/dl

· Triglycerides 137 mg/dl

Using her blood pressure from her initial visit and current cholesterol results, the atheroslerotic cardiovascular disease (ASCVD) risk calculator shows that Mrs. Payne’s 10-year risk is 2.6 percent. For more required information about risk factors for ASCVD, read the  Aquifer Cholesterol Guidelines Module .

Pap test results: Satisfactory; with evidence of ASC-US; HPV negative on co-testing.

Dr. Lee reviews with you the current way cervical cytology is reported via the Bethesda System. Since you know that infection with specific types of HPV is required for the development of cervical cancer and high-grade cervical lesions, you are reassured by the fact that Mrs. Payne’s Pap is negative for HPV. You and Dr. Lee also take a look at the recommendations to follow-up on Mrs. Payne’s Pap test results. Because of her ASC-US and HPV negative findings, the current recommendation is to retest in 3 rather than 5 years. (See guidelines below).

The Bethesda System for Reporting Cervical Cytology

Using this system of reporting, cervical cytology pathology results are given in three categories:

1. Specimen adequacy

In order to be “adequate,” the Pap test must contain over 5,000 squamous cells and have sufficient endocervical cells. (Endocervical cells are columnar epithelial cells found just proximal to the squamo-columnar junction, the site of beginning dysplastic changes.) If they are present, it shows that you have sampled the transformation zone, and therefore the specimen is “adequate.”

2. General categorization of results

Is there any evidence of intraepithelial lesion or malignancy?

3. Interpretation of results

Either the Pap is negative for intraepithelial lesion or malignancy, or there is evidence of epithelial abnormalities. Epithelial abnormalities are further divided into four categories.

· Atypical squamous cells (ASC): Some abnormal cells are seen. These cells may be caused by an infection or irritation or may be precancerous.

· Low-grade squamous intraepithelial lesion (LSIL). LSIL may progress to a high-grade lesion but most regress.

· High-grade squamous intraepithelial lesion (HSIL). This is considered a significant precancerous lesion.

· Squamous cell carcinoma.

You and Dr. Lee enter the room and greet Mrs. Payne. She says she had already received the report that her mammogram was normal. Dr. Lee also tells her that her blood sugar was normal and that her cholesterol was at the recommended level. She tells her that her Pap test had only a mild abnormality but that there is little risk of cancer and recommends a repeat co-testing in three years. She would not recommend waiting for five years, as she did with this Pap. Mrs. Payne thanks you both for the good news.

Aware that Mrs. Payne has a young daughter, you volunteer to tell her about the HPV vaccine.

The CDC notes that as of 2017, only the 9-valent will be available in the U.S. Another important change is that the HPV series is considered complete after two doses in patients who receive the first dose before age 15 and the second dose at least five months after the first (ideally six to 12 months apart). See  an overview of the HPV vaccine recommendations for clinicians .

The vaccines can be expensive, and patients should be advised to check with their individual insurance carrier about coverage.

Dr. Lee notices Mrs. Payne’s weight: “I see that you have lost two pounds since your last visit.”

“Well, I tried. I have taken your advice and started to eat breakfast and have cut back on sweets and portion size. I have been able to walk three times a week,” replies Mrs. Payne.

“Good job! Keep up the good work,” applauds Dr. Lee.

Dr. Lee poses her last question: “And how are you doing with smoking cessation?”

“Great! I’m down to only one or two cigarettes a day! By the next time you see me I may have stopped smoking altogether!” Mrs. Payne exclaims.

Dr. Lee offers encouragement and says she would like to see her again in three weeks to monitor her progress.

Mrs. Payne thanks you both and says she will really try to continue to make the changes to her lifestyle.

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