Increasing Women’s Healthcare Access at a Student Run Free Clinic by Creating a Women’s Health Coalition

Introduction/Problem: The Indiana University Student Outreach Clinic (IU-SOC) was established to bridge gaps in primary care-based medical, dental, social and legal services to uninsured and underinsured Indiana residents. A bimonthly women’s clinic was later created to provide medical care to those with obstetric and gynecologic needs. Even with the introduction of a women’s clinic, mammogram referrals were not always being conducted, Pap smears were being deferred, and sexually transmitted infections (STIs) were not being treated appropriately. Here, we describe how the concept of the women’s clinic was expanded to a multidisciplinary coalition of medical students and a certified OB/GYN physician advisor dedicated to women’s health to address women-specific concerns. Methods/Interventions: A 62 person team was created ​to address each of the needs we identified in the clinic regarding women’s health. This team consisted of a finance chair, volunteer chair, clinic managers (CM), patient navigators (PN), appointment coordinators (AC), WH liaisons, education specialists, and quality improvement (QI) researchers. Eleven team leaders were created to assist with managing the different elements of the growing team. Results: Fifty-eight patients were referred to the WH PN team to help assist patients obtaining higher level care, 11 of which were successfully referred to date. Eight pregnant patients were seen at the clinic this year, an increase from six over the past three years combined. Fifty-six pap smears were completed this year, an increase from 37 over the past five years combined. STI, HIV, and hepatitis testing was performed on 281 patients, an increase from 149 from the past five years combined. Thirty-one patients were referred to a new twice monthly WH clinic to be evaluated by an OB/GYN or obstetrics-trained family medicine provider not previously accessible at the clinic. Labetalol, RhoGAM, and glucose tolerance tests were added to clinic resources to improve prenatal care. Protocols were written for sexual assault, abnormal uterine bleeding (AUB), dysmenorrhea, HPV, and medications approved in pregnancy to standarize patient care. A new microscope was obtained to improve the ability to perform wet mounts. Conclusion: With the creation of the WHC, our volunteers have bridged gaps in medical care. Important and prevalent female reproductive and sexual health issues, like AUB, IPV, cervical and breast cancer screenings, and others are handled with the appropriate level of urgency and thoroughness they require. Nearly equally as important, we have trained and built a community of students who are passionate about women’s health ensuring sustainability

Implementing Scheduled Women’s Health Clinics at Free Student Outreach Clinic

Introduction/Problem: Since 2009, Indiana University Student Outreach Clinic (IU-SOC) has served the underinsured and uninsured members of the Indianapolis community. Many barriers to care exist within this community, from low income to lack of documented immigration status. One of the most concerning vulnerable populations observed was pregnant patients. Five years ago, the IU-SOC addressed this via creation of Women’s Health days on Saturdays every other month and in 2020 by creating an as needed prenatal clinic. However, the need still existed for general, non-prenatal women’s health concerns, which led to the expansion to a twice monthly general women’s clinic staffed by a board-certified obstetrician-gynecologist (OB/GYN). Methods/Interventions: In April 2021, twice monthly scheduled clinics were implemented for two hours on Wednesday evenings staffed by OB/GYNs or obstetrics-trained family medicine physicians. Additionally, the team available on Wednesday clinics expanded to include a women’s health specific clinic manager, women’s health patient navigator to facilitate referrals, and women’s health education specialist to address low health literacy. Results: In 2021, 15 women’s health clinic days have been hosted since April,expanding beyond prenatal patients and resulting in increased volume of this clinic. There were a total of 36 patient encounters from 31 different patients including eight pregnant patients. Other chief concerns addressed at the clinic included: infertility/preconception counseling, abnormal uterine bleeding, pelvic pain/mass, vaginal itching, dyspareunia, and preventive women’s health visit. Six patients received pap smears and sexually transmitted infection (STI) screening. Low pap smear and STI screening rates at the women’s health clinic are attributed to the presence of women’s health fourth year student representatives at general clinic days ensuring most patients receive pap smears and STI screenings prior to referral. Conclusion: We implemented a twice-monthly, referral-based women’s health clinic in 2021 that has successfully provided care for 31 different patients including eight pregnant patients for a variety of chief concerns and preventive care encounters. The presence of a certified OB/GYN has ensured appropriate management of prenatal and primary care women’s health issues. Consistent provision of women’s health care services helps to mitigate the many barriers to women’s health care in our Indianapolis community

Hyperprolactinemia Secondary to Paliperidone: Considerations for Women of Childbearing Age

CASE DESCRIPTION: A 27 year old female with past medical history significant for schizoaffective disorder, borderline personality disorder, major depressive disorder, and catatonia was admitted following a suicide attempt. During her admission, she revealed that she has had a persistent delusion of believing she was pregnant despite not being sexually active in several months and having multiple negative pregnancy tests. After the patient was started on paliperidone, she stopped menstruating, further perpetuating this delusion. The patient also expressed concerns for infertility in the future. CONCLUSION: Paliperidone has a high incidence of hyperprolactinemia which can lead to reproductive concerns including menstrual irregularity and infertility. These side-effects highlight the critical need for shared decision making in discussions about fertility in patients with psychotic disorders. Further complicating this issue is the significant increase in psychosis risk during the perinatal period. There are other alternatives that exist and may be better options for some patients but changing medications to oral options should be balanced with medication adherence needs. CLINICAL SIGNIFICANCE: Through shared decision-making, the selection of antipsychotic maintenance therapy should consider a variety of patient and physician goals. A younger age of initial psychotic break has strong indications for reproductive counseling, which should remain consistent with patients’ goals and be reassessed as goals evolve throughout their lifetime. Patients who struggle with medication adherence may benefit from long acting injectable antipsychotic medications. However, some of these injections, like paliperidone, can cause hyperprolactinemia and contribute to infertility. Prolactin levels can be monitored and lowering medication doses can be effective for mitigating hyperprolactinemia. There are oral medications available that have a lower chance of causing hyperprolactinemia. However, oral only medication options must be balanced with patient medication adherence concerns

Fostering Leadership in a Student-Run Free Clinic Medical Executive Board and Across Interdisciplinary Partners.

Background: Being a member of a healthcare executive board requires a unique sense of resolve and passion for service. Not only are these leaders operating a student-run free clinic, but they are also full-time professional students while balancing extracurricular activities to discern their healthcare vocation. Board members feel pulled in many directions, resulting in imposter syndrome and possibly untapped leadership potential. Leadership succumbing to this pressure in 2021 might have resulted in the permanent closure or dysfunction of a clinic after COVID-19 required closure for one year. This study will discuss the interventions employed by the clinic’s Chair, Vice-Chair, Women’s Health co-chairs, and Operations chair to overcome the burden felt when faced with reopening a large, interdisciplinary, free clinic serving approximately 34 patients per weekly clinic day. Though fostering interpersonal relationships best encompasses the theme with which the above leaders encouraged hope during a time of global suffering, relationships were encouraged through multiple discrete interventions forming camaraderie and trust within and between interdisciplinary executive boards. Interventions: Medical Executive Board: In anticipation of the added pressures of reopening the clinic amid COVID-19, the Chair took special care to create a culture of collegiality and mutual vulnerability by facilitating various ways to ‘check-in’ with her board. She hosted preterm and midterm check-ins with each leader to discuss their vision for their role on the board. The Chair and Chair-elect also hosted the clinic’s first annual leadership retreat to support each member in finding their leadership style, and in turn, becoming familiar with their colleagues’ leadership styles. The Chair and Chair-elect will also perform exit interviews with all graduating board members. Partners: Reopening during the pandemic meant reorganizing the entire clinic flow and limiting the number of volunteers present. As a result, many interdisciplinary partners could not participate in the initial reopening and had to be brought in slowly throughout the year. Partner participation was encouraged by monthly meetings with all partners (regardless of clinical presence), and an active group chat with leaders. The Vice-Chair also emphasized alternate means of participation. Some partners organized winter clothes and food drives, while others fundraised for the clinic. All partners were encouraged to develop telehealth plans. The fall partners’ retreat fostered community, during which all partners brainstormed 2022 goals. Results/Conclusion: Medical Executive Board: As a result of the above interventions, clinic leadership not only reopened the free clinic but fulfilled many years-long goals, which include rolling out a weekday telehealth protocol, serving record numbers of patients during a time of immense need, publishing the inaugural clinic-wide monthly newsletter, and formulating the clinic’s first-ever mistreatment policy. The leadership retreat inspired our Women’s Health Coalition to host a retreat; a check-in with the Women’s Health chair led to a midterm co-chair election to sustain the coalition long-term. Finally, the Operations chair spearheaded changes to clinic flow to avoid COVID-19 outbreaks–in doing so, she inspired a record turnout for this position at the 2022 elections. Partners: By the end of 2021, all interdisciplinary partners had resumed in-person care. However, the regular monthly meetings, alternate projects, and retreats fostered community and interest in the clinics even when all could not physically participate

Pre- and post-conception planning in autoimmune disorders

Background: Autoimmune diseases are often multisystem, requiring many specialists. However, there are no clear recommendations for many of these disorders for planning pregnancy and preventing exacerbations. Intervention: Little time is devoted to patient counseling about contraception or care antepartum, intrapartum, and postpartum. Contraception and many first-line interventions can have varying effects in different diseases, which can be further complicated by multiple diagnoses. Many of these disorders also can have postpartum complications, making follow-up essential. Results:Systemic lupus erythematosus (SLE) is known to cause exacerbations during pregnancy and has serious adverse outcomes for both mother and baby. Active disease is associated with higher rates of preterm birth, pre-eclampsia, thromboses, fetal loss, and neonatal lupus. Patients are at increased risk of these complications with a history of lupus nephritis, cessation of hydroxychloroquine, and primigravidity. Multiple sclerosis (MS) has lower rates of relapse during pregnancy, but higher rates in the first postpartum year. This has been attributed to the rapid increase in progesterone during pregnancy improving symptoms, while the rapid decrease after pregnancy promotes relapses. Additionally, neonatal morbidity does not increase as a result of MS. For other autoimmune diseases such as Sjögren's Syndrome or Grave’s Disease, the clinical picture may be complicated by the physiology of pregnancy, but is unclear whether pregnancy exacerbates the autoimmune component of the disease. Conclusions: Pregnancy and contraception could improve or worsen symptoms in autoimmune diseases, even up to a year postpartum. There is a significant gap in practice guidelines regarding contraception and pregnancy despite many diseases’ onset during childbearing years. Pregnancy and contraception counseling should be part of initial conversations at diagnosis to prepare women