MD/PhD students share their skills at a free clinic to benefit patients with diabetes

March 2, 2017

A version of this article, by Jamie Williams, first appeared on the UNC Health Care website.

Anna Kahkoska (left) and Nick Brazeau

Anna Kahkoska (left) and Nick Brazeau

Anna Kahkoska and Nick Brazeau, students in the MD/PhD program at UNC Gillings School of Global Public Health, have developed an innovative approach to patient care. They work at the Open Door Clinic, a free clinic in Burlington, N.C., where a number of patients with diabetes are treated. The clinic is staffed by students from UNC’s schools of medicine and public health, Elon University and Alamance Community College.

Kahkoska is a doctoral student in nutrition, with a minor in epidemiology. Brazeau is an epidemiology doctoral student.

Two years ago, Kahkoska and Brazeau took a direct leadership role in the Diabetes Maintenance and Prevention Program. There, they were responsible for coordinating a monthly endocrinology clinic for patients with diabetes who were referred from the general clinic for specialized care.

What started as a way to do some good in the community while also gaining valuable clinical skills quickly transformed into something much larger. When they began working at Open Door, Brazeau said, the continuity of care was lacking. Patients would come to clinic one month, and then miss several subsequent visits due to changes in work hours, child-care responsibilities or other issues. When they did come back, they were frustrated with long waits.

The two decided a change was needed. They wanted to develop a model that would help address the patients’ clinical and social needs, but also give them an incentive to return to clinic each month.

With the help of faculty mentor John Buse, MD, PhD, chief of the Division of Endocrinology and executive associate dean for clinical research at the medical school, and Laura Young, MD, PhD, and Joe Largay, PA, from UNC Endocrinology, they developed a plan for introducing group visits for diabetes patients at the clinic.

The shared medical appointments would allow patients to have more direct interaction with clinicians and with each other. The resulting conversations empower patients to share information about their experiences and allow clinicians to identify themes worthy of further discussion.

“Our faculty mentors have been incredibly supportive,” Kahkoska said. “Offering diabetes care in a free clinic is challenging, especially given the flux of students, rotating staff and variability in attendance. Completely changing the model of care in such a way that takes all of those factors into account is very challenging, and there has been a lot of brainstorming, troubleshooting and discussion involved.”

Introducing such a radical change caused some apprehension among members of the clinic staff, and even Brazeau and Kahkoska said they weren’t sure how it would go.

“These are patients from all walks of life with very different life experiences,” Brazeau said. “Our biggest fear was that we would put 10 people in the room and just hear crickets.”

The opposite happened.

“It has been incredible to see how much the patients have given of themselves,” Kahkoska said. “We do the legwork required to get patients in the room together, but once they are there, there’s not a whole lot we have to do to facilitate discussion. I’ve been surprised and moved by how generous people are in sharing their stories and how focused they are on listening to and helping each other. It’s inspiring.”

The nature of the group visits provides a forum for shared experiences and support, but also a high level of accountability.

“If one person in the group is having success meeting his or her goals and has found some strategies that work, modeling that for the other patients can be really effective,” Kahkoska said. “But the biggest shift we’ve seen is that patients come back to shared medical appointments. For many patients, the group-visit model is more engaging and enjoyable than an individual appointment, and as a result, we have fewer ‘no-shows’ at the clinic.”

In addition to the social support, the group appointments have provided clear clinical benefits. Since beginning the group appointments, many patients have experienced reductions in HbA1c levels. HbA1c measures the average level of glucose in the blood over the previous three months. Sharing strategies and discussing common barriers – combined with the accountability of the group – has helped motivate patients to take the steps needed to monitor and manage their glucose levels, begin exercising or take a close look at their diet.

Kahkoska and Brazeau said that the Open Door project has allowed them to weave together both sides of their training.

“We can combine the tenets of public health best practices with the clinical skills that we are learning in medical school,” Kahkoska said. “This project has helped me to understand both my research and my clinical goals in a deeper way.”

This is the second year in which Kahkoska has worked with Elizabeth Mayer-Davis, PhD, Cary C. Boshamer Distinguished Professor of nutrition and medicine and chair of the Gillings School’s Department of Nutrition.

“In addition to Anna’s tremendous work on my research team, which is focused on Type 1 diabetes in youth and young adults, she somehow finds time to do this fantastic work at the Open Door clinic, working with low-income adult patients with diabetes,” Mayer-Davis said. “She’s amazing!”

Kahkoska and Brazeau want to see this model expanded to other community clinics and augmented to include students from other health disciplines such as nursing, dentistry, nutrition and allied health sciences.

“As a future provider, I have become more empathetic to the broad range of issues our patients face,” Brazeau said. “This experience also has been a crash course in everything that goes into providing holistic patient care – especially in an underserved environment. We hope that through expanding this program, more patients can benefit from this model, and more students can have the same transformative experience that we’ve had.”

Funding support for the implementation of medical group appointments was provided through the Albert Schweitzer Fellowship.


Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or