Accelerating Change in Medical Education

Hypertension coaches help med students look beyond Rx for high BP

With the recent release of the American Heart Association-American College of Cardiology hypertension guideline, about half of American adults are classified as having hypertension. Yet most of those newly designated as having high blood pressure (BP) will first benefit from nonpharmacological lifestyle changes as well as support to overcome health barriers.

Patients notoriously find lifestyle changes difficult to accomplish and sustain given the prevalence of sedentary workdays, low-walkability communities and cheap, high-sodium foods. And physicians, too, face a challenge in helping patients make such changes, which is why one medical school is training tomorrow’s physicians in this area with an extra helping hand—a “hypertension coach.”

At Eastern Virginia Medical School (EVMS), hypertension coaches interact with students to discuss effective lifestyle interventions and motivational interviewing. They also help to identify other factors that prevent their making those changes such as material insecurities, including no transportation, lack of healthy food in the community or resources to purchase them, health literacy, etc.

The hypertension coaches can help to identify these and link the patient with community resources. Through this additional resource, medical students improve their understanding of how to engage patients in treatment plans for hypertension that go beyond pharmacologic options.

“[Students] are given the opportunity to learn how to ask questions and interact with standardized and virtual patients in a way that enables patients to bring up real life challenges, not just talk about medications,” Lauren Mazzurco, DO, told AMA Wire®. Dr. Mazzurco specializes in geriatric medicine and palliative medicine and is the director for case-based learning at EVMS. The school is a member of the AMA’s Accelerating Change in Medical Education Consortium.

“What they do as far as health behaviors is try to inoculate the students into regularly thinking about lifestyle as something they need to know about their patients,” she added.

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“This project goes beyond providing students with broader educational opportunities,” said Christine Matson, MD, a family physician who serves as the chair of generalist medicine and recent past chair of the Department of ‌Family and Community Medicine at EVMS.

With money left over in a grant, the Virginia Department of Health (VDH) offered funding for hypertension coaches to EVMS. Dr. Matson worked closely with a team of students to develop training modules for the hypertension coaches based on a community health worker’s monograph previously used by the VDH.

The program expanded based on their experience with the clinical skills curriculum and five modules were created, including the basics of hypertension, exercise and healthy diet, motivational interviewing and how to use medications. Students have remained engaged throughout the hypertension coach project, said Dr. Matson.

“We expanded beyond training our two hypertension coaches and we embraced the entire nursing staff in multiple practices,” she added.

Students worked with the nursing staff to present the modules and explain concepts from the AMA’s BP Improvement Program, embracing protocols such as those that help ensure accurate measurement of blood pressure.

“Our major intervention as a practice was to acknowledge the importance of achieving hypertension control  by bringing the patients back within two to four weeks rather than three or six months from now,” Dr. Matson said.

Seven years ago, EVMS faculty member Richard M. Bikowski, MD, started an innovative fourth-year quality improvement elective, through which hypertension was identified as the major focus for students’ engagement as change agents. The students’ active involvement in identifying opportunities to improve blood pressure management grew into the opportunity for experiential learning. Eventually, the BP Improvement Program process and the hypertension coach project merged into one multifaceted, robust collaborative project.

“We have more students who want to take the elective than can be accommodated,” Dr. Matson said. “Using hypertension coaches to effectively identify barriers to success with behavioral change and link to available resources for patients has been replicated for patients with diabetes as well.”

“What doctors should be doing”

The hypertension coaches are just one of several innovative efforts at EVMS that aim to incorporate lifestyle changes into medical education. Another is the use of “virtual families” to help students experience an integrated approach to diagnosis in M1-2 years. Each storyline in this curriculum contains an expanded social history that conveys the multiple factors that influence patients’ health decisions and capabilities. Most portray virtual patients who try to cope with multiple, inter-related complex conditions, with hypertension as a comorbidity that occurs frequently.

“We’re using those cases on a weekly basis with the students,” Dr. Mazzurco said. “The idea is that the patient and the diagnoses are set in the context of their family and community, providing that foundation for discussion.”

EVMS students also have created nutrition modules that equip their classmates to employ dietary discussions to improve health within their communities. Service learning initiatives are part of the curriculum at EVMS that include a focus on choosing healthy lifestyles. Their project develops classes for the community.

“It sets the basis for what doctors should be doing,” said second-year med student Kimberly Ha. “It is good for us to know for our own personal health, but ultimately it is good to know for our ability to educate our patients in the future.”