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ACEs Champion Dana Kwitnicki — An ACEs Tale of Two Counties

 

Growing up in suburban New Jersey, Dana Kwitnicki, a physician assistant, says she always wanted to be in health care. Her dad is a dentist, her mother a teacher, and she grew up with several other family members also in medicine.

Kwitnicki learned about becoming a PA while attending Northeastern University in Boston, MA, where she earned a degree in health sciences. After undergraduate school, she earned a Master’s in Physician Assistant Studies at Philadelphia University through a vigorous two-year academic curriculum, including clinical rotations during the second year. In 2015, she boldly decided to move to California after passing her the national boards exam to start her career and to experience the “California lifestyle” she always dreamed of living. Her first job was in the specialty of gynecology/women’s health at Planned Parenthood in Watsonville, CA. However, she always knew that she wanted to practice family medicine, which is the field she works in to this day. 

final- Dana Kwitnicki (1)“I love treating the whole person—the patient’s acute concerns, chronic disease, mental health issues, physical exams, and seeing patients in all stages of their life. Family medicine is so broad, I believe it is one of the most challenging fields in medicine to practice because you need to know it all—each and every body system and every speciality—and know when it is appropriate to refer to the specialists. Not a day in the office is ever the same in primary care.” 

Kwitnicki applied for and accepted a one-year fellowship to work at Shasta Community Health Center (SCHC) in Redding, in northern California, after her first job in women’s health. Shasta County, she learned, is one of the highest ranked counties in California for childhood abuse. Dr. Sean Dugan, a pediatrician who works at SCHC, played a pivotal role in educating the local community of this and about ACEs and its severe long-term health effects.

ACEs is a term that comes from a landmark study that showed how widespread childhood adversity is. The CDC-Kaiser Permanente Adverse Childhood Experience Studyof more than 17,000 adults, which was first published in 1998, linked 10 types of childhood adversity —such as living with a parent who is mentally ill, has abused alcohol or is emotionally abusive—to the adult onset of chronic disease, mental illness, violence and being a victim of violence. Many other types of ACEs—including racism, bullying, a father being abused, and community violence—have been added to subsequent ACE surveys.

The ACE Study found that the higher someone’s ACE score—the more types of childhood adversity a person experienced—the higher their risk of social, economic, health and civic consequences. The study found that most people (64%) have at least one ACE; 12% of the population has an ACE score of 4 or higher. Having an ACE score of 4 nearly doubles the risk of heart disease and cancer. It increases the likelihood of becoming an alcoholic by 700 percent and the risk of attempted suicide by 1200 percent. (For more information about how this works and about the full complement of ACEs science, go to ACEs Science 101. To calculate your ACE and resilience scores, go to: Got Your ACE and Resilience Scores?)

Although Kwitnicki says SCHC did not use the standard 10-point ACE screening questionnaire, Kwitnicki and fellow clinicians used the HEADSS Assessment tool when screening adolescents during their well child exams; this is a screening tool that encompasses a broad overview of the adolescent’s psychosocial history. In addition, the county has been educating community members about ACEs science for several years.

Kwitnicki said it was distressing and heartbreaking to hear the high childhood trauma statistics in the local community.

“There is a lot of childhood trauma that goes undetected for years,” she says. “And if you look at the child’s ACEs score, it makes sense that they have so many physical and mental and emotional health problems later in life. 

“If the ACEs screen is not part of a routine visit, they might be undiagnosed for years, and it would be hard for patients to disclose that information later in life the longer these questions are not addressed. It is different doing an ACEs screen for a minor vs. a young adult…the whole dynamic is different. If a parent is in the room with the child or adolescent, I believe the patient is less willing to disclose personal information about their psychosocial issues.”

Quite often she dealt with cases of childhood abuse and neglect, as well as newborns who were from mothers with drug addictions. Several times she did need to file a complaint with Child Protective Services and, unfortunately, sometimes CPS was unable to handle cases because they had to triage those that were considered most important. 

“Kids don’t have authority to make their own health choices nor can they advocate for their own health without their parent or guardian’s permission,” says Kwitnicki. “A lot of the time, you feel powerless even if all the appropriate clinical steps are taken. If CPS doesn’t make a case and if a child doesn’t have other external support, such as a teacher or friend, I can only do so much to help them.”

Kwitnicki now works for One Medical, a private, primary care practice that is in the SF Bay Area. She now sees mostly adults and some teenagers from time to time. 

“It is a very different population than my first two jobs,” she says. “There are significantly less psychosocial environmental factors that affect patients’ health. Generally speaking, patients have more financial, food, environmental and family stability with this population of patients.” 

Since the COVID-19 epidemic began, Kwitnicki says, “I have read national statistics of domestic abuse and child neglect being alarmingly high since people are confined to their homes whether or not they feel safe in this environment. Mental health issues at my practice, including depression and anxiety have definitely increased since the pandemic started.

“One Medical has been astounding at adapting to these changing times with rapidly changing protocols, work flows, implementing COVID-19 testing sites, and telemedicine for our patients. There has never been a dull moment for me since the pandemic started, but I am grateful each and every day, for my health and ability to do what I love to do by practicing medicine.” 

How does the PA handle the increased stress?

“I am taking it one day at a time,” she says. “I am grateful for my job, my employer, One Medical, and being able to be an essential worker, to help the greater good of my community and the general population. We are all in this together.”  

And we are grateful to Kwitnicki and other PAs for doing essential work to safeguard our health during these times.

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The first sentence in paragraph 10, "If the ACEs screen is not part of a routine visit, they might be undiagnosed for years," suggests the critical importance of a comprehensive medical history, gathered routinely.  Ordinarily this is avoided because it is so time consuming, hence costly, and mostly does not seem to relate to the symptom bringing patients in.  In my former Department of Preventive Medicine at Kaiser Permanente in San Diego, we circumvented this by having patients fill out our very lengthy medical history questionnaire at home.  We then passed it through a digital scanner that picked up and organized all the Yes answers ib a 2-3 page laser printout that took 2-3 minutes to read before meeting the patient.  The results were extraordinary as you can see in the 2 attachments.  What we learned enabled us to identify and treat underlying basic causes rather than just the symptom at hand.  In a 135,000 patient study, an outside data analyst found that this led to a 35% reduction in office visits and an 11% decrease in ER visits the following year compared to their prior year.  This has multi-billion dollar implications for the cost of medical care.  It has now led 23 State Legislatures to provide funding to encourage the routine collection of ACE histories in medical practice.  There is resistance, however.

I believe that providing an even more advanced version of the patient's medical history questionnaire on the internet at no charge, and having patients provide identifying information only after they disconnected, would enable those who wished to provide this critical information to their physicians, and significantly advance their medical care as well as the practice of medicine.  

If anyone with experience in this type development and its funding would be interested in helping it happen, please contact me.  

If you would like more information about the ACE Study, simply search 'Adverse Childhood Experiences Study' on the internet and YouTube and you will be delighted by what you learn.

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