1. What differences do you note between the two H&Ps?

The main difference between my first and last H&P is where the physical exam is concerned. For my first H&P there were certain findings I forgot to document. For example, my patient had undergone a caesarian section some years back which left her with a Pfannenstiel scar. I forgot to document this in my physical exam and my professor pointed it out later. on My patient was also s/p thyroidectomy and I forgot to document any findings for this as well. For my final H&P I was more careful with documentation of my physical exam.

2. In what ways has your history-taking improved?  Are you eliciting all the important information?

I believe that my history-taking has improved in terms of time. I remember when I first started writing H&Ps it took me over an hour to get all the history I needed. Although I felt like I was doing a thorough job, I knew that once I officially integrate into the medical field, I will not be able to take so much time for one patient. By the time I had written my last H&P for PD, it only took me 30 minutes to ask all the important question and perform a thorough focused physical exam. I am also able to shift gears in a conversation if I can sense we are becoming sidetracked, I ask questions that are pertinent to the patient’s complaint, and I have developed a flow in how I ask my questions so that I’m not missing anything.

3. In what ways has writing an HPI improved? (hint: look at the rubric scores)

I think that I am much more confident in writing HPIs. For my first HPI, I had to look at previous HPIs that I had written to help me figure out how my sentences should flow in order to sound seamless. For my third HPI, I wrote it as if I were telling a story and just kept my OLDCARTs in mind. I no longer feel like I need to rely on previous HPIs, and I can create the story for my suspected diagnosis with what I write.

4. What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?

When performing a physical exam, I feel more confident evaluating the systems we learned during the first semester. I can confidently perform a physical exam for the skin, head and neck, eyes, ears, nose and sinus, mouth, heart, lungs, and abdomen but I still find myself having to look at my notes in order to perform an MSK exam or a Neuro exam. Moving forward, I would like to practice these exams so I can perform them without referencing my notes.

5. Of course, we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?

As stated above, I believe I need for focus on perfecting my physical exam. I am more confident with certain aspects of performing my physical exam right now than I was over the summer so I believe that this skill will perfect itself as I continue to examine patients and become familiar with what’s normal versus what is not normal. I also want to focus on interpreting EKGs because I find that I still struggle a little where that is concerned.

Policy Brief

To: FDA Commissioner Scott Gottlieb M.D.

From: Arianne Díaz

Date: July 23, 2023

Re: Federal Mandate for Educating the Public Regarding the Dangers of Vaping/Electronic Cigarette Use  

Statement of Issue: What strategies can be implemented to educate U.S. citizens on the dangers of vaping/electronic cigarette use?

Background: Vaping/electronic cigarettes have been implicated in significant health complications among users in the United States. As of 2019, the prevalence of vaping product associated lung injuries has increased substantially, resulting in hospitalization in 95% of cases. Of this 95%, approximately half required intensive care interventions, 20% were intubated, and many died.¹ Insufficient public awareness and misleading marketing of vaping products as a safe alternative to traditional cigarettes have contributed to vaping product associated lung injuries. Without proper education on the dangers of vaping/electronic cigarettes more vulnerable populations will engage in their use and fall victim to their adverse effects.

• Recent data indicates a strong correlation between vaping/e-cigarette use and health complications previously unknown to the public. Consumers of these products experience respiratory complications including cough, shortness of breath, and chest pain. They also experience GI manifestations in the form of nausea, vomiting, and diarrhea as well as constitutional symptoms such as fever, chills, and weight loss. The public’s limited awareness of complications associated with vaping products cause delayed medical care-seeking when users experience these symptoms¹.
• Vaping products regulated by the FDA are dangerous despite marketing claims implying they are a safer alternative to cigarettes. Vaping products containing nicotine may be as addictive as traditional cigarettes. They also contain harmful carcinogens, volatile organic compounds, and heavy metals which lead to lung injury². Chest radiographs in many of these patients depict bilateral pulmonary opacities consistent with those seen in ARDS and other pulmonary disorders. Those who use vaping products are likely to experience chronic diseases common in those who smoke traditional cigarettes such as hyperlipidemia and decreased blood flow through arteries and veins.²
• Adolescents are particularly susceptible to social influence according to a cross sectional study conducted in2016.³ Taking into consideration the increased exposure to e-cigarette marketing via the internet and other forms of media, it is very likely that this vulnerable group will engage in e-cigarette use. Adolescents are also likely to model behaviors witnessed by friends and family members. Increased exposure to the practice of e-cigarette use increases the likelihood that they will imitate these behaviors, especially if they have easy access to vaping products.⁴

Landscape: 

• Regarding the implementation of strategies to educate U.S. citizens on the dangers of vaping/electronic cigarette use, thoughtful consideration must be given to the key stakeholders who will be responsible for developing, executing, and ensuring the effectiveness of these initiatives for the population. The key stakeholders for the administration of this policy include educational institutions such as schools and universities, government agencies such as the FDA, and dispensaries that sell vaping products/electronic cigarettes.

Policy Options

• Creating a federal mandate focused on educating consumers of vaping products about their adverse health effects. In the United States, all establishments that participate in the distribution and sale of alcohol possess a surgeon’s general warning. This warning serves the purpose of cautioning child-bearing persons from drinking alcoholic beverages during pregnancy because of the risk of birth defects.⁵ Establishments that sell alcohol are also mandated to display a government warning stating that the consumption of alcoholic beverages impairs the ability to drive a car or operate machinery and may cause health problems⁵. Similarly, cigarette packs and advertisements are required to display the adverse health consequences of smoking cigarettes. For this federal mandate, all vaping products/e-cigarettes would require a warning highlighting the potential health consequences of vaping. As of 2018, these products simply possess a label stating that nicotine is an additive chemical yet there is no mention of the potential side effects of using e-cigarettes⁶.
  • Advantages – Clearly displaying the adverse health consequences of vaping products/e-cigarettes may discourage their use among the population. One of the reasons why individuals engage in e-cigarette use is because they are unaware of the associated risks. Since these individuals are unaware, they tend to forego medical care until their symptoms become severe or life threatening. If the manufacturers of these products were required to clearly highlight the symptoms associated with vaping products, their consumers would at least be aware of when medical care is warranted before their symptoms become more serious. Another reason why consumers of vaping products engage in their use is because they were originally marketed as a safer alternative to traditional cigarettes. If the public were aware of the dangers associated with these products, they may seek other harm reduction methods before resorting to using e-cigarettes.
  • Disadvantages – Regarding the modification of labels on vaping products to accurately reflect their associated risks, the language used to convey this information must be considered. Although majority of residents in the United States speak English as their first language, English is not the official language of the United States. Massive influxes of individuals from various parts of the world have managed to diversify the population, especially in large cities. Because of this, it is important to consider which languages will be used on these warning labels. These labels would serve little to no purpose if they cannot be read by a good chunk of the population. Additionally, a general label would not target populations who are more likely to experience adverse outcomes due to e-cigarette use such as those with pre-existing pulmonary conditions.

• Reinforcing a restricted federal mandate which requires businesses that sell vaping products to confirm the age of the buyer. According to the FDA, under the T21 law retailers in the United States are not allowed to sell tobacco products to anyone under the age of 21. This law applies to cigarettes, smokeless tobacco products, cigars, pipe tobacco, and electronic nicotine delivery systems such as e-cigarettes⁶. National trends indicate that younger populations are now engaging in e-cigarette use, some starting as young as even 14 years old. Adolescent populations are more sensitive to the effects of nicotine and are more likely to experience memory and concentration issues which impact their ability to learn. The nicotine in these products may also induce dependence and become a potential gateway for other forms of substance abuse. This mandate requires for more stringent adherence to T21 laws.
  • Advantages – Reinforcing a pre-existing law would help mitigate e-cigarette use in adolescent populations. Although T21 was passed in 2019, many retailers do not strictly adhere to the policies requiring them to ID individuals who seek to purchase tobacco products. By reinforcing this law via a tracking system that would force vendors to document the age of everyone that purchases tobacco products, younger populations would be discouraged from attempting to buy vaping products/e-cigarettes. This can be achieved by scanning IDs to ensure their authenticity, similar to other establishments that scan IDs before allowing patrons to enter and purchase alcohol. Sanctions would be placed on establishments who do not scan the IDs of customers who purchase tobacco products.
  • Disadvantages –Adolescent populations would still be able to access vaping products/e-cigarettes via other means. It would be very difficult to implement sanctions on establishments that do not ID their customers unless there was someone always monitoring them. Additionally, adolescents can simply ask friends or family members who are ≥ 21 years of age to purchase these products for them. Furthermore, adolescents who appear older than they truly are can easily purchase vaping products/ e-cigarettes.

• Establishing optional state mandates through the U.S. Department of Education to integrate education on the dangers of vaping/electronic cigarette use into the curriculum. It is imperative to reiterate that younger populations engage in vaping/e-cigarette use due to a lack of awareness about its adverse effects. According to the Department of Education, tobacco, drug, and alcohol use prevention is included in their curriculum and aims to equip students with the decision-making skills necessary to resist group influence.⁸ The curriculum, however, does not explicitly include a section regarding the dangers associated with e-cigarette use. The curricula should be modified on a state-by-state basis to reflect the level of intervention required in schools that will successfully mitigate nicotine use in young populations.
  • Advantages – There are various means of incorporating vaping/e-cigarette education into the curriculum. Teachers may lead discussions in classrooms that encourage dialogue about e-cigarette use. Students may be assigned group work/projects regarding the consequences of e-cigarette use which will be shared amongst their peers, facilitating easy dissemination of accurate information amongst students. Schools may also encourage volunteer speakers to conduct assemblies, providing students with firsthand accounts of the consequences of vaping. Lastly, faculty at school can address the issue of e-cigarette use at PTA meetings to provide parents with the necessary skills to talk to their children about vaping and its associated risks.
  • Disadvantages – Teachers would need to be trained to lead discussions regarding the consequences of e-cigarette use amongst students. This training may interfere with pre-existing curricula that must be covered before the end of the school year. Not all teachers or students teach/learn at the same pace therefore the time required to effectively educate children on these health consequences would be variable. Finding volunteer speakers may also prove difficult considering the rising cost of living. Many guest speakers may want to be compensated for their time and schools would have to figure out how to incorporate this into their budget. Finally, not all parents attend PTA meetings. Parents have varying work hours and may be unable to be present for these conferences or may not speak the language being used at these conferences which discourages them from attending.

Policy Recommendation

            With the recent upsurge in e-cigarette use amongst younger U.S. populations, establishing optional state mandates through the U.S. Department of Education to integrate education on the dangers of vaping/electronic cigarette use into the curriculum should be highly considered to address the statement of issue. Children attending primary and secondary school (K-5 and 6-8) spend most of their formative years at school. School is where many children learn to socialize, develop their sense of self, and establish a moral compass that will dictate their actions for years to come. Educating younger populations on the adverse effects of vaping decreases the likelihood that they will engage in these behaviors even if others around them use these products. Teachers responsible for leading class discussions can receive training on how to properly do so by attending seminars after school. An advance notice of at least 4 weeks will be provided to ensure it does not conflict with any pre-existing plans. Additionally, schools with limited budgets can hold tournaments, bake sales, and other fundraising activities to help pay for any guest speakers that desire to be compensated for their time. Lastly, schools can mail brief summaries of topics discussed at PTA meetings which will cover strategies on how to talk to children about vaping/e-cigarette use. These pamphlets will be summarized in the languages most spoken in that school district (ie: English, Spanish, Haitian-Kreyòl). I believe this recommendation is likely to be successful to educate U.S. citizens on the dangers of vaping/ electronic cigarettes.

Sources:

1. Fitzpatrick ME, Prendergast NT, Rivera-Lebron B. E-cigarette or vaping product–associated lung injury (EVALI). In: Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR. eds. Current Medical Diagnosis & Treatment 2023. McGraw Hill; 2023. Accessed July 22, 2023. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=3212&sectionid=269162608

• How smoking affects the heart and blood vessels. National Heart Lung and Blood Institute. Accessed July 23, 2023. https://www.nhlbi.nih.gov/health/heart/smoking.

• Knoll LJ, Leung JT, Foulkes L, Blakemore SJ. Age-related differences in social influence on risk perception depend on the direction of influence. J Adolesc. 2017;60:53-63. doi:10.1016/j.adolescence.2017.07.002

• Dale S. Mantey et al. E-cigarette marketing exposure is associated with e-cigarette use among US youth. Journal of Adolescent Health. April 12, 2016. Accessed July 22, 2023. https://www.sciencedirect.com/science/article/abs/pii/S1054139X16000641?casa_token=lMAmTGDRcBcAAAAA%3Aoyd3rYEOdlwHpv9ZPYgw-N7Kpson54zD03n9g58VXwsDPdpyLb7wdLPHNbreTdD8vOFQtwDYhQ

• The Federal Register. Federal Register :: Request Access. Accessed July 23, 2023. https://www.ecfr.gov/current/title-27/chapter-I/subchapter-A/part-16.

• Products C for T. “covered” and Ryo/ Cigarette Tobacco Labeling & Warning statements. U.S. Food and Drug Administration. Accessed July 23, 2023. https://www.fda.gov/tobacco-products/labeling-and-warning-statements-tobacco-products/covered-tobacco-products-and-roll-your-own-cigarette-tobacco-labeling-and-warning-statement.

•  Products C for T. Tobacco 21. U.S. Food and Drug Administration. Accessed July 23, 2023. https://www.fda.gov/tobacco-products/retail-sales-tobacco-products/tobacco-21#:~:text=No%2C%20the%20law%20does%20not,under%20the%20age%20of%2021.

• Health Department sounds the alarm on e-cigarette use among NYC middle school students. Health Department Sounds The Alarm On E-Cigarette Use Among NYC Middle School Students – NYC Health. Accessed July 23, 2023. https://www.nyc.gov/site/doh/about/press/pr2019/e-cigarette-use-among-nyc-middle-school-students.page.