I'm Moving!

I have some exciting news - this blog is moving! The new address is: http://blog.timesunion.com/mdtobe/ .

Through my experiences keeping a blog this summer, I discovered that I very much enjoy writing, and I would like to keep at it. My mom blogs for the Albany newspaper, the Times Union, which covers the entire capital region of New York State. When she passed my summer blog along to the person who manages all of the blogs for the paper, he said he would love for me to move my blog over there. So that's just what I'm doing. Some of the Times Union blogs get tens of thousands of views per month, so this will really give me the opportunity to get my writing out there.

I truly hope that you continue to follow along with my adventures in medical school and visit my new blog!

Goodbye, PSI

I'm feeling bittersweet about my summer project coming to an end. On one hand, I'm excited about moving forward on my journey to become a doctor. But on the other hand, I'm really going to miss all of the patients and the staff of PSI.

As it turns out, the patients in my Health Literacy class actually learned a lot this summer. I'm so incredibly proud of each and every one of them. I gave quizzes at the end of almost every class to check if they had mastered the objective of the day. The patients ended up with an average of 90% on all of their quizzes! During the last class, I gave out surveys for them to take anonymously, and discovered that the patients also subjectively felt as though they had learned a lot. I asked them to rank if they disagreed or agreed with several statements on a scale of 1 to 5. They averaged a 4.75 on the statement "This group helped my ability to read and understand health information," and a 4.76 on the statement "The skills I've learned in this group will help keep me healthy."  I'm so happy about that.

The "Health Literacy" wristbands
I awarded the patients with.

We also had a "party" during our last group together. I handed out their Health Literacy wristbands that I had ordered for them, which they loved. The chef at PSI kindly made us brownies to eat, and we chatted and had a great time. During our conversation, one of the patients asked me a very insightful question: "I know you were here to teach us, but I'm sure you must have learned something this summer too. Can you tell us what you learned?"

I felt unprepared to answer this question. This is the type of question that normally takes hours of brainstorming, writing, editing, and re-writing before I would be able to come up with a perfect answer. However, being put on the spot in front of all the patients somehow provided me with a moment of clarity, maybe because I was just speaking honestly and from the heart. "I learned a lot about AIDS," I began. "But didn't you learn about all that in medical school?" one of the patients asked. "Yes, but reading about AIDS in a textbook is a completely different experience from actually getting to know a person who has AIDS. You can read all about a disease, but you can not really comprehend it until you understand the impact of the disease on actual human beings. Seeing the way in which you all have struggled with and overcome the hardships of AIDS is incredibly inspiring. Your eagerness to get healthy and your ability to persevere through all of the obstacles you have faced in your lives has made you the strongest group of people I have ever met. So, that's what I learned; I hope that answers your question."

The patients were all looking up at me, beaming. They have reinforced my desire to spend my life working to provide high quality health care to those who might not otherwise receive it. Regardless of my specialty, hopefully my experience this summer is just the beginning of a long career of serving the underserved.

Differing Opinions

One of the highest level critical thinking skills is to evaluate - that is, to judge the validity of something and back up your opinion. For one of our last groups together, I wanted to push the patients in my Health Literacy class to accomplish the difficult objective of evaluating a piece from the New York Times. I explained that reading health articles in newspapers and magazines is a great way to maintain the health literacy skills they learned in my group. I chose several recent articles relating to HIV/AIDS, and had the patients answer three questions about the articles:

     1. What is the main point of the article?
     2. Do you think the main point of the article is correct?
     3. Why or why not?

One of the articles I chose for the group to practice with is an Op-Ed by Desmond Tutu called "Obama's Overdue AIDS Bill". The piece calls for Obama to devote more funds to the fight against HIV/AIDS in Africa. Before I taught this class last week, I anticipated that the patients here would unanimously agree with the article, since I assumed they would always be in favor any efforts to eradicate AIDS from this world. My prediction could not have been more wrong.

I gave the patients a few minutes to read this article silently to themselves, then to write their answers to the three questions on their papers. I then asked one of the patients to present their opinion of the article and back it up. She told me that she did not agree with the article, because there are enough people suffering from HIV/AIDS in the United States. This patient's opinion was echoed by many others in the group. Obama needs to take care of the problem at home first, one said. With all of the diamond mines in Africa, they should spend that money to solve their own problems, said another. The United States is just one country, why should we have to provide for a whole other continent?, another patient asked. There was one person in the group who did agree with the article, and she bravely voiced her opinion that since the US has a lot of money, it should contribute to fight AIDS all over the world. However, she was outnumbered by all of the other patients who fiercely disagreed.

I was so stunned after this discussion. How could I have predicted they would all agree with the article, when in fact the opposite occurred? I expected that the patients here would identify with and feel a connection with the people living with AIDS in Africa, but for some reason, they don't. It seems like the patients view the epidemic in the US as distinct from the epidemic in Africa, not as a global pandemic. Maybe the patients feel as though they have been abandoned by the US government, and our country should not be taking care of people in Africa when they themselves have not been taken care of. Unfortunately, the reality is that AIDS is a global problem, which may never be solved unless different continents can work together cooperatively.

Triple Diagnosis: AIDS, Addiction, and a Psychiatric Disorder

To be eligible to reside at PSI, the patients must have AIDS and substance addiction. Frequently, however, there is a third diagnosis of a psychiatric disorder as well. I remember learning in my psychiatry class in school about the co-morbidity of drug dependence and mental illness; people suffering from drug addiction are over 2 times more likely to have an anxiety disorder and over 4 times more likely to have a mood disorder such as depression. Having a disease with such social stigma such as AIDS contributes to a higher incidence of psychiatric disease as well. So needless to say, the psychiatric nurse practitioner and mental health counselors here are kept very busy.

In my short time at PSI this summer, I have seen many different psychiatric symptoms that are likely indicative of an underlying disorder. To name a few:

• Suicidal ideation. When I asked one of the patients how she was doing that day, she replied, "Still breathing, unfortunately." Concerned, I asked, "Do you really mean that?" She told me that she did.
• Grandiose delusions. One patient adamantly believes that HIV does not exist. He insists that it was invented by the Surgeon General to make money off of antiretroviral drugs sold by the pharmaceutical companies.
• Paranoid traits. One patient here always thinks the world is out to get her. She often refuses to reply to the journal questions in my class, asking, "Why are you trying to pick my brain?". More than once, she has referred to herself and other patients as "guinea pigs" that doctors are using to test out antiretroviral medication.
• Antisocial traits. One patient used to belong to a machete-wielding gang in Puerto Rico, and has done hard time in jail for having dismembered body parts in his car. Despite this, he has no remorse.
• Symptoms of Conduct Disorder. I had the privilege of observing the Anger Management group, in which several patients described the extreme satisfaction they get out of physical aggression towards others.

This may be a chicken and the egg type of situation - which came first, the psychiatric illness, the drug addiction, or AIDS? The Lancet had a great review article last month, detailing the intricacies in treating patients with this triple diagnosis. The article (justifiably) calls for more funding and research in this area to be able to successfully treat these patients who so desperately need the help of the medical community.

Can You Predict Who Will Relapse?

I like to think of myself as a pretty optimistic and idealistic person, though some might just call me naive or gullible. I tend to believe what people tell me, and assume that they have good intentions. This is certainly true for the patients at PSI, although some people on the staff are quick to remind me that many of them used to be big-time drug dealers and criminals, and have retained the tendency to lie and cheat. Now that I have been at PSI for almost the entire summer, I have gotten to see how strong of a grip addiction has on some of the patients here. As they say, addiction is a life-long illness. Even if you are clean, when you're an addict, there is always the temptation to use again and fall back into old habits.

The patients at PSI live at the facility for about a year, during which time they are working toward their recovery. Once they graduate from the program, unfortunately, some patients eventually find their way back to their old lives and addictions. From talking to several staff members at PSI, they believe all of the patients here have at least some chance of relapsing. The vocational educator was describing how it is nearly impossible to predict who that will be. Some of the people who she thought were best equipped to succeed in the community ended up relapsing almost immediately after they left the program. Conversely, people in the program who seemed unstable often ended up doing very well on their own.

One of the students in my Health Literacy class - one of my very best, in fact - was kicked out of PSI for using and attempting to sell drugs inside the facility. I was absolutely shocked when this happened, since she was so intelligent, engaged, and a lovely person all around. Literally the day before she was discovered, I had asked my students to respond to the journal question, "When you graduate from PSI, what could happen that would make you want to use drugs again? What can you do to avoid those triggers?" Her response: "There is nothing that could happen that would make me want to use again." What I didn't know at the time was that she had already been sneaking around inside PSI using and trying to sell, and blatantly lying to me in her journal response. I just couldn't understand how she could have me and other staff members fooled like this. She's the last person I would have guessed would relapse while still at PSI.

There is one staff member, the GED educator, who seems to have it figured out. He has been working at PSI for years, and says there is one quality that is a great predictor of who will relapse: arrogance. In fact, he goes so far as to say he has never met a patient who was arrogant that didn't relapse. That's a strong statement. Maybe it has something to do with admitting that you have a problem that is out of your control. Once you surrender to your addiction, acknowledge it is bigger than you, and admit you need others' help, you're more likely to gain that control back. What are your thoughts? Do you agree?

Health Literacy - The "Newest Vital Sign"?

In the very beginning of the summer, I met with the medical director of PSI to gain her input on my project. I outlined my ideas for the Health Literacy curriculum, and she added that she would like me to include a lesson on the "Newest Vital Sign". It consists of a Nutrition Facts label followed by six questions relating to the label. It is meant to be used by physicians as a screening tool for their patients' health literacy levels, completed at each patient's first visit. It is called the newest vital sign since heath literacy levels may be just as important to health care decisions as a patient's heart rate and blood pressure.

The Newest Vital Sign test was developed because of the lack of rapid and valid health literacy assessments physicians can use with their patients. Older tests include the TOFHLA (Test Of Functional Health Literacy in Adults) and the REALM (Rapid Estimate of Adult Literacy in Medicine). The TOFHLA consists of reading a passage and answering questions about it, which is too time-consuming for most clinical settings. The REALM consists of simply reading a list of medical terms aloud, but being able to pronounce words doesn't necessarily imply comprehension. In contrast to older tests, the Newest Vital Sign assessment only takes about 3 minutes, and asks patients to interpret health information, not simply read it. For these reasons, I do think that the Newest Vital Sign test is an improvement on the previously developed tests. The questions include:

The label used in the 
Newest Vital Sign Assessment.

1. If you eat the entire container, how many calories will you eat?

2. If you are allowed to eat 60 grams of carbohydrates as a snack, how many servings of ice cream could you have?

3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day?

4. If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?

5. Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. Is it safe for you to eat this ice cream?

6. Why or why not?

A score of 0-1 indicates a high likelihood of limited health literacy; 2-3 indicates a possibility of limited health literacy; 4-6 almost always indicates adequate literacy. Although it is more practical than the TOFHLA and more valid than the REALM, I'm still not convinced that the Newest Vital Sign assessment is a great predictor of health literacy levels. First of all, the first four questions all test the same basic math skills. If a patient can't do mental math, they would automatically receive a score of a 2 or less. Additionally, getting #6 right depends on having answered #5 right. And perhaps most importantly, does the ability to understand a Nutrition Facts label necessarily reflect the ability to comprehend all health-related information? The literature shows a mixed response to this question, with some studies showing that it is a valid assessment, with others arguing that it may miss the mark.

I apologize for the digression; after all, I wasn't using the Newest Vital Sign as a test of my students' health literacy levels. Rather, the medical director asked me to use the activity to teach the patients about nutrition. When I was first presented with this idea, I felt overwhelmed because of the difficulty of the questions asked on the test, combined with the patient's low literacy and numeracy skills. I met with both the GED teacher and the nutritionist here to get their opinions on how I could most effectively teach the math skills needed to complete this assessment. I ended up giving the lesson last week, and it went great. First we practiced doing similar types of calculations from Nutrition Facts labels, and then I gave them the Newest Vital Sign test at the end of class. They earned an average of 82%, which is considered true mastery from a teacher's perspective (and adequate literacy from the test writer's perspective). The patients here are so hungry for knowledge and work so hard for me. It seems like whatever work I give them, they continue to exceed my expectations.

Medicaid Budget Cuts at PSI

Because of recent cuts to the Medicaid budget, PSI has recently been subjected to a number of changes. Medicaid pays for the patients to live at this facility, including their medical care, food, and housing (the total is over $400 per day). PSI is also legally classified as a nursing home, so it must follow the government's nursing home regulations and restrictions as well.

About five years ago, the government mandated that Medicaid would not pay for a nursing home patient's cost of living if they had to leave to go to the hospital within the first 30 days of their admission. This ruling is especially harsh at PSI, where patients are actually the sickest when they enter the facility. When patients first get to PSI, their T-cell count may be extremely low, making them susceptible to life-threatening opportunistic infections. This means that patients are often admitted here, get very sick soon after, and have to be discharged from PSI only to be re-admitted days later after their hospital stay. This procedure saves Medicaid money since they are not paying for two beds simultaneously (one at PSI and one at the hospital), but it is a huge hassle for the patients and staff here.

Last week, more budget cuts led to additional restrictions on when patients can leave PSI and still be covered by Medicaid. Patients who have been here for a while are given privileges such as leaving the facility to visit loved ones. Medicaid used to cover 18 of these visit days per year, but recent changes has limited it to 10 days. Any more time that patients spend visiting family and friends is paid out-of-pocket by PSI. Additionally, recent regulations have limited the total number of hospital days that Medicaid will pay for to 14 days per year. For patients as sick as ours, this is quite unrealistic, and PSI will likely end up paying the extra $400 per day for patients who need to spend more time in the hospital.

The staff of PSI is still unsure of how to handle these changes. Some solutions that staff members have discussed include discharging patients any time they go to the hospital in case their stay is unexpectedly long, or decreasing the total length of the treatment program here so that patients will not exceed their allotted time out of the facility. These solutions are far from perfect. Unfortunately, all of these restrictions imposed on PSI by the government are not in the patients' best interest - what should be Medicaid's top priority.