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.

Getting a Job as an Addict

As I described in an earlier post, the vocational educator at PSI invited me to help facilitate the "transition groups" she leads. These groups are designed for the patients who are getting ready to graduate from the treatment program and need to learn practical skills to help them succeed once they reenter society. This week, the transition group focused on filling out a job application and preparing for a job interview. As if the job market weren't tough enough already, many of the patients here face additional obstacles to finding employment. First of all, they have all been unemployed for at least the year they have lived at PSI. Many have not graduated from high school or earned a GED. Some have been fired from previous jobs for performance issues or drug problems. The majority have been incarcerated at some point in their lives, and some have serious charges, like felonies, on their criminal record.

During the group, the vocational educator gave the residents advice for how to address negative aspects of their background on the job application and in the interview. Here are some of my favorite tips:

• Do not offer any information that was not specifically asked about. For example, if a job application asks if you have been convicted of a felony in the last 5 years, but your felony was 7 years ago, it is perfectly acceptable to answer 'no' and leave it at that.
• Whenever you can, try to make the reason you were terminated from your previous job sound as neutral as possible. For example, if several people were let go at the same time as you, you can state the company was downsizing. If you moved to a different state after you were fired, you can say that you relocated. If you did not get along with your supervisor, you can say you were let go for political reasons. You can stretch the truth, but whatever reason you give must have some truth to it in case your new employer checks up on you.
• If asked directly about negative information by an interviewer, you should acknowledge it, briefly describe it, and then move on to talking about something positive. For example, "Yes, I was laid off from my previous job because of a drug problem. At that time, my addiction caused me to be late or absent frequently. However, I have been clean and sober for two years now, and I have a reference from my treatment program that states my attendance and punctuality have been perfect."

I am impressed by this advice. I think they are all great strategies to help the patients present themselves in the best possible light. At the same time, I am trying to view this situation from an employer's perspective. If I had two equal job candidates, except one was an addict with a criminal record, and the other was neither of these things, I think I would be inclined to pick the latter. If you didn't take the time to get to know the patients - how they are truly reformed, and very kind, hard-working individuals - I can see how you might be disinclined to hire them. The patients here are going to have to work incredibly hard to show future employers how dedicated they are, perhaps by first interning or volunteering at the company where they want to work. Hopefully their employers will see the potential that I see in them, and these patients will be able to support themselves and lead sober, healthy lives.

Rx: Optimism

In order to live at PSI, the patients must have a dual diagnosis of full-blown AIDS (not just HIV), as well as substance addiction. Other psychiatric diseases, such as major depression, are also very frequently co-morbid conditions with AIDS and addiction. As I mentioned in a previous post, the majority of the patients here have also spent time in prison. You would think that the patients here, having all of these odds stacked against them, would be jaded, hardened, and unhappy. But you'd be wrong.

An example of a journal response written by one
of the patients in my Health Literacy group.

Many of the patients here have incredibly positive attitudes, despite the myriad hardships they have experienced. For example, the patients love to write about their recovery in their journal responses (see the example on the right). They welcome me every day with an enthusiastic Good morning, Marianne! when I enter the building. They offer to help me carry my materials from class back to my office. They tell me about their goals to become HIV peer educators, mechanics, or bus drivers in the future. They even share their good news about their health with me.

One patient in particular is perhaps the most optimistic person I've ever met. This is remarkable, considering she was born with intellectual disabilities, she started hanging out with the wrong crowd as a teenager and got hooked on drugs, and then she was infected with HIV when she was raped during her twenties. She is enrolled in my Health Literacy class, but frequently becomes frustrated and pulls me aside during class, asking if she can come in later for extra help. Our tutoring sessions together tend to take a while since she is a fairly slow learner, but she always leaves with a smile on her face. Last week, she stopped by my office, and I assumed it was for extra help on the material we learned that day. Instead, she simply came in my office and handed me a piece of paper, grinning ear-to-ear. I looked at the paper, and on it was her latest T cell count, which was very high. It's because I've been focusing on my recovery, she told me. She may well be right - a quick Google search shows that there has been a multitude of studies linking optimism and better health outcomes. Maybe we should all take a cue from this patient and others like her at PSI, and adapt a more positive outlook on life.

Pacing Problems

It's been a little while since I gave an update on how my Health Literacy class has been going. In a word, it has been wonderful. The averages on the quizzes have been around 90%. Attendance is still somewhat spotty, but many patients will come to me on their own if they missed a class to make up the work. The patients are very willing to do the work during group, even when we're doing something kind of boring.

It's always more interesting to discuss what has not been going so smoothly, however. Tuesday was the first day all summer where we didn't finish what we were scheduled to in class. Our objective was to summarize a story about a patient's journey with HIV/AIDS. For you non-teachers out there, a good lesson goes through an entire "lesson cycle," which includes five steps:

My easel with a typical agenda
showing the lesson cycle.

1. Opening. You communicate the importance of the day’s objective and thereby engage the students.

2. Introduction to New Material. You model the new skill. This is abbreviated in my agenda as "I do."

3. Guided Practice. The students have an opportunity to practice the new skill in groups or pairs while I monitor their progress and provide feedback. Abbreviated as "We do."

4. Independent Practice. Students practice their new skill on their own so I will know if they have mastered the day’s objective. Abbreviated as "You do."

5. Closing. In my health literacy class, this usually takes the form of a journal entry reflecting on what we learned.

This way of planning a lesson was drilled into my head during my time with Teach For America, and I still use it for every one of my health literacy classes! Like some would say, I drank the Teach For America Kool-Aid. But like I mentioned, unfortunately, we didn't make it through all five steps of the lesson cycle on Tuesday. First of all, we didn't start class until 10 minutes into our allotted 45 minute time slot. Then the objective (summarizing a story) was just way too hard to fit into one class. We only got through the Guided Practice, and some people did not even finish that.

I never have been very good at pacing my classes so that what I have planned takes exactly the right amount of time. Usually, I err on the side of planning too much for one class (which I think is still better than the opposite situation, where you finish early and then don't know what to do with the students for the end of class). I'll never forget how I felt on my very first day in a classroom, in June 2007, at Scarborough High School in Houston. I was teaching ninth grade algebra in summer school, to students who already had an entire year of algebra but had failed their class. For my first lesson, I planned on reviewing how to solve one step algebraic equations (such as x+ 6=10). Imagine the horror I felt when I went through several examples, and was getting blank, confused stares back from the students. I tried to break it down as much as I could, explaining that to solve x+6=10, you had to first subtract 6 from both sides, but even that didn't make sense to them. That first day, I ended up having to teach them things that should be intuitive to ninth graders, like how a number minus itself equals zero. Needless to say, we didn't come close to getting through the lesson I had planned that day.

So here I am, more than three years later, and I still have not mastered the art of pacing a lesson. However, I'd like to think I've improved since my very first day as a teacher. I just need to remind myself what is and is not feasible to accomplish in a 45 minute period. Luckily, I've already planned on reviewing summary a couple more times, so all is not lost. The patients here will learn to summarize by the end of the summer!

The Face of the Epidemic

Another staff member at PSI noted that most of the patients are Latino or African American, which she said "reflected the face of the AIDS epidemic." I thought that this was an interesting comment, and it made me curious to see just how true this was. I checked out the statistics on the website for the Center for Disease Control and Prevention (http://www.cdc.gov/hiv, my source for all statistics in this blog post). Then I calculated the racial makeup of PSI. Interestingly, the demographics of PSI did not reflect the racial/ethnic breakdown of the prevalence of HIV in this country. As you can see from the charts below, there are disproportionately more Black and Hispanic/Latino people living at PSI than there are living with HIV in the United States. Additionally, there are very few white people at PSI, while they make up over one-third of people with HIV in this country.

Why doesn't the racial makeup of PSI match that of the HIV/AIDS epidemic?

Not only are people of color disproportionately affected by HIV (Blacks/African-Americans and Hispanics/Latinos make up 12% and 15% of the US population, respectively), but they are also disproportionately represented at PSI. Why should this be? Is it that there are relatively more people of color living in New York City? Is it that whites are less likely to enroll in treatment programs? I truly do not know the answer to this question, but I plan on informally surveying the people I work with, who I'm sure have greater insight than I do. I'll publish an update to this post afterwards. In the meantime, readers, what are your thoughts?

Update 7/21/10: After talking to my co-workers and doing a little internet research, I may have found a partial explanation.  Shockingly, 97% of people who are incarcerated in New York City are Black or Hispanic (http://www.nyclu.org/content/state-of-drug-policy-and-addiction-new-york-city-and-reform-of-rockefeller-drug-laws). Keep in mind that the majority of people admitted to PSI have come from prison and are mandated here by a judge. So, that is likely a major contributor to the racial breakdown of PSI.

HIV+ And Healthy Without Meds?

In addition to teaching the Health Literacy class this summer, the medical director of PSI asked me to help her complete a formal assessment of all 66 of the patients' health literacy levels to be included in their medical charts. I have been calling patients to my office one by one to give them the assessment, which consists of basic questions about health knowledge and HIV. For example, one of the questions I ask the patients is to recall all of the medications they are currently taking to treat their HIV. I then check what they have told me against their medical records to see if they answered correctly.

Yesterday, as I was completing an assessment with one of the patients, he told me he wasn't taking any medication to treat his HIV. At first I thought he was joking or mistaken, but he asserted that he has made the decision not to start antiretroviral therapy (against medical advice). Trying to hide my disbelief, I asked him why. He explained that he did not want the side effects from the medication, was not afraid of dying, and that he would pass away when God decided it was his time to go. He said he was diagnosed as HIV+ in 1996, and has been relatively healthy since (although, to live at PSI you must have full-blown AIDS). I asked him if he had any children, to which he responded that he had a 24 year old daughter. As a 24 year old woman myself, I told him I would want to see my own father live as long of a life as possible. He made the counterpoint that he didn't wish to extend his life if his daughter would have to watch him suffer and care for him for a longer period of time, and restated that God knew what was best for him and his family.

This patient has had the virus for at least 14 years; the average person will become very ill or die within 8-10 years of contracting HIV if untreated. Although the patient attributes his health to God's work, I think it is probably because he is what is called a "long-term nonprogressor." These people usually 1) have receptors on their T cells that do not easily bind to HIV so that it is more difficult for HIV to infect T cells, or 2) possess a specific immune protein that allows their immune system to more easily detect when HIV proteins are being made inside of cells. Both of these are due to beneficial mutations in the patient's DNA, and long-term nonprogressors can live with HIV for years and years without being affected by the virus.

As a medical student, it is hard for me to understand people who don't seem to care about improving their health when given the opportunity. And as an agnostic, it is hard for me to understand people who leave things up to "God" rather than take action to solve problems on their own. I found myself becoming incredibly frustrated with this patient's unwillingness to take medication, and this person is not even MY patient! I know that when I am a doctor, many of my patients will be non-adherent to their treatment and ignore my advice. I will have to learn how to effectively deal with this, so that my future patients are as healthy as possible and I can maintain my own sanity.

Back On Track

After an incredibly refreshing vacation visiting family and friends, I'm back, hard at work at PSI. My Health Literacy class resumed yesterday, with a great deal of success! A huge heat wave hit NYC yesterday, with temperatures in the triple digits. Since the location where I usually hold the class is not air-conditioned, I was a little worried that it would be cancelled on me again. I was not about to let that happen, so I made sure I could hold my class in a space with AC.

Yesterday our objective was to "look up information about HIV/AIDS medication side effects in a table." First we went over what the different side effects were, so the residents became familiar with medical jargon like "hepatotoxicity" (liver illness) and "lipodystrophy" (changes in fat distribution). Then I showed them how to read a table by first reading the column and row headings, then tracing over with your finger to find the correct information. The table we used was no joke - it was a pretty complicated and packed with information (see below, from http://www.health.state.ny.us/publications/9408.pdf).  I would ask them things like "Name 2 medicines that can cause both rash and sleeping problems," a daunting task for someone that is a struggling reader. The residents earned an average of a 95% on the quiz! They keep pleasantly surprising me with the hard work they put into the assignments I give them.

Relapse Prevention

Last week I had the privilege of observing a "transition group" that prepares the residents of PSI for various issues they'll face once they are living on their own in the community. This series of six classes is led by the vocational educator, who kindly asked me to help with the group. The topic for the first meeting was "Avoiding Triggers in the Workplace."

All of the residents of PSI are addicts. Even though to live at PSI they can not be currently using drugs, they still struggle with addiction and carry that diagnosis for the rest of their lives. I was completely unaware of the difficulties that addicts face in a place as seemingly innocent as at their job. As a group, we discussed what could happen at work to make someone want to use again, as well as what solutions to those problems could be. Some of the common workplace triggers to use include:

• Pay day. When an addict is handed a check, it can be hard to resist cashing it in to buy drugs. To avoid this, you can immediately hand their check over to a trusted friend, or set up direct deposit to distance yourself a little from the money.
• Having too much free time or too little supervision on the job. Being bored at work and having no one there to watch you can lead to temptations to use on the job. To avoid this, you can ask your supervisor for extra tasks to pick up, or attend meetings that you aren't necessarily required to be at.
• Working long hours or having too much supervision on the job. This can lead to stress and pressure to perform, which can lead to a desire to use. To avoid this, you can politely turn down tasks your supervisor asks of you, or kindly tell your supervisor you would like the opportunity to work more independently.
• Office holiday parties. There will be lots of alcohol and possibly drugs around, and co-workers may even unknowingly pressure an addict to drink. To avoid this, you can show your face to the VIPs at work, and then tell co-workers you have other plans and can't stay at the party.

I was fascinated by our discussion. It is so important for people to be sensitive to these issues, and I feel very privileged to have had the opportunity for the residents to teach me about the struggles they face.

Off To A Rough Start

Perhaps the biggest challenge I will face this summer is going to be scheduling. The residents have a very busy schedule every day, attending different meetings, doctor's appointments, and groups, which frequently interfere with coming to my class. Nearly one-third of the residents were absent for last Tuesday's class, so I met individually with the residents who were absent to tutor them in what we had learned and have them do their make-up assignments. This just doesn't seem like a sustainable system for the summer, however.

We came to another bump in the road on Thursday, which was Staff Appreciation Day. My supervisor invited me to come even though I had only been working at PSI for a week. Since the entire rest of the staff was going, I felt like it would be rude and anti-social to stay behind. To be brutally honest, the celebration was at Orchard Beach and they were having a make-your-own-sundae station, so I was pretty much sold from the get-go. The only problem was I'd have to postpone my Health Literacy class until Friday. Luckily there seemed to be an open slot in the schedule that I could move my class to on Friday at 11:00 AM. Unfortunately, Friday at 10:45 AM my supervisor came into my office to tell me there was a mandatory meeting for all residents at 11, and I would have to cancel my class. I was pretty upset. Especially when I actually attended the mandatory 11:00 meeting, and saw that it was basically just a forum for the residents to ask individual questions to staff members.

To make matters even worse, I'm taking a very poorly-timed vacation this week. So basically we had two Health Literacy classes, then stopped the classes for the next week and a half. I'm wondering how many residents will even bother showing up to class the rest of the summer, now that I have proven to be unreliable and inconsistent. One of the residents even said to me, "They always do this to us! We're finally taking a class we like, and then they take it away from us!" I tried to explain to her that this would merely be a pause in classes, and they would take place regularly every Tuesday and Thursday for the rest of the summer. She seemed doubtful.

I have some problem-solving to do. How can I make sure that mandatory meetings don't pop up throughout the rest of the summer? How can I prevent doctor's appointments and the like from being scheduled at the same time as my class? How can I gain back the residents' trust?

So, This Is Hard

After my first day of actual teaching yesterday, I realized there will definitely be some unique challenges to working with the population at PSI. I want to start out by saying that I absolutely love working with them. The best part of my job is having the privilege of interacting with the patients here. They're a fun and rowdy bunch, which can definitely be a positive thing since it leads to thought provoking discussion and insightful questions about their disease. We will be facing our fair share of obstacles, however.

Two of the residents I teach have mild mental retardation. One has such poor vision that she cannot see the letters on the worksheet. One doesn't read a word of English, and can barely speak it. One decided five minutes in that she wasn't going to participate, but she didn't want to leave the room either and instead walked around loudly bothering the other residents. One proclaimed in class yesterday "I hate reading," to which I responded, "Well... this is a literacy class, so we're going to be doing a lot of reading."

Unlike teaching high school, I can't threaten the residents with consequences like detention or a deduction in their participation grade. The residents attend my class completely by their own free will, which is amazing. Also unlike teaching high school, about 10 minutes before class was done there was a large group of people waiting to cross through the area where I teach to go outside and take a cigarette break. Needless to say, this caused quite the distraction when they walked through my classroom, right as the residents were working on their quiz for the day. This 3:00 smoke break will happen at the end of every one of my classes.

Our objective for the day was to be able to read and answer questions about a paragraph on HIV/AIDS drugs. The average reading comprehension score on their diagnostic was a 65%. Amazingly, the average quiz score was an 86%, meaning they grew 21 percentage points in just one class! (If I discount the scores of the 2 residents with severe disabilities, the average jumps to a 93%). I'm so incredibly proud of each of my students. Hopefully their reading skills will continue to grow as the summer progresses.

My First Class

I put a sign up sheet on the door to my office, made an announcement to all of the PSI residents about my class, and crossed my fingers that people would sign up. As I was sitting in the office planning the final details of my first class, I could hear a group of them congregating outside my door.

"What's this sign up sheet for again?"

"It's the class that white girl was talkin' about!"

"Oh yeah! We get a certificate at the end!"

I couldn't help but laugh to myself. The residents I'll be teaching already remind me a lot of my students in Houston. For one, being known as "that white person." And secondly, how excited the residents got about receiving a certificate for my class. No matter your age, external rewards seem to be a good motivator. Hopefully in time they will start to value what they're learning in my class to become internally motivated. As it turns out, there may be a legitimate reason the residents (most of whom are middle-aged) remind me of my teenage high school students. Another member of the education staff of PSI told me that when addicts stop using drugs, they remain "stuck" at the same developmental level they were at when they started using. For many of the residents of PSI, this was when they were in high school.

I ended up getting over 20 people to sign up for my class this past Thursday, which I viewed as a huge success. The first item on the agenda was introductions. I reminded them of my name (I haven't been referred to as 'that white girl' since, I believe) and defined 'Health Literacy' as the ability to read and understand health information. Then I gave them their pre-test for the medication unit. I thought there was a possibility some would walk out when I announced I was giving a quiz, but they all went along with it! Afterwards, I had them sign a contract saying that they would attend class and work their hardest. I also had them write their first journal assignment, in which they described what they wanted to learn from my class, their goals, and anything else I should know about them. All of the residents gave very thoughtful responses and to my delight, want to learn about some of the topics I was already planning on covering.

To wrap up class, I told the residents they could ask me anything they wanted. One woman asked me if there were any differences between women's and men's health, besides the obvious anatomical differences. I told her that in fact, many diseases have different symptoms, prevalence, and course in women and men. Next, a transwoman raised her hand and asked, "How does this affect me, since I have male chromosomes, but women's hormones?" I was so impressed by this intelligent and insightful question, and told her the truth - that I didn't know, because there was not much research done on trans health. This led to a great discussion of the biases that transpeople and people living with AIDS face, and how society did not respond to the AIDS epidemic until upper-class and straight people were diagnosed. The residents got so fired up by the discussion, and I really want to include some reading assignments on social justice later on in the curriculum.

Overall, great first class!

Here Goes Nothing

Today is the big day - I'm teaching my first Health Literacy class. I spent all day yesterday at PSI getting ready and outlining my plan for the summer. I decided the class will be broken down into four units - Medication, Adherence, Wellness, and Understanding Your Disease. For today's class, I'm going to be giving them a diagnostic quiz for the Medication unit (I'll give them the same quiz after I teach the unit so I can directly measure my impact). We're also going to have a discussion about what to expect from my class, and we're going to set up our folders. Should be a fun day, as long as they don't mind taking the quiz.

Last night I was introduced to all 66 of the residents of PSI at their nightly meeting. They gave me such a warm welcome, complete with applause! I can't wait to get to know each and every one of them.  I'll let you know how it goes today.

By the way, here's a picture of the front of PSI, if you were curious what the place looks like!

5 Things I Learned My 1st Year of Med School

I'm taking a break from discussing my summer project, because I feel the need to reflect on this huge thing that happened yesterday - I finished my first year of med school. I heard somewhere that a first year med student learns 10,000 new facts, which seems about right. Somewhere in between all of the cadaver dissections, lectures, shadowing, and labs, I learned some lessons that can't be found in any medical textbooks.

1. People will get naked in front of you. I mean this both figuratively and literally. I was shadowing a doctor during one of the first weeks of school, and the doctor was about to give a physical exam. The elderly female patient simply started removing all of her clothing, and I had this urge to look away before I realized that I was supposed to look. In addition, during practice patient interviews for my courses, patients revealed things about their personal, psychiatric, or sexual history that they may not even tell their spouses or their best friends. When you are wearing your white coat, patients will automatically trust you and have faith that you know what you are doing. Who am I to have earned this privilege to hear and see the most intimate details of people's lives?

2. Medicine is messy. As a wise doctor once said to me, "Med students choose their specialty based on which body fluid they least hate to put their hands in." When I was shadowing a Cesarean section, the doctor let me hold the suction tube to suck up the excess blood (similar to what you'd see at a dentist's office to suck up excess drool). I was doing a great job as she was masterfully slicing through the layers of skin, fat, and muscle to get to the uterus. Then, the intern turned to me and said, "Get ready to suck." A half second later, the doctor nicked the amniotic sac, and it was suddenly like trying to suck up a waterfall with an eyedropper. After moments of futile trying, the doctor hastily grabbed the suction away from me and did it herself. The intern was right - I did suck.

3. To the patient, this is a big deal. No matter how many appendixes you have removed, or how many times you've had to break the news that the fetus has Down Syndrome, the patient is experiencing one of the most significant events in their lives. I have heard enough patient stories now to know that some doctors forget this fact. When I was facing some health problems of my own this year, I was having a simple procedure done that I knew (from a med student's perspective) was not a big deal. However, as a patient, I was scared out of my mind. I realized to be a good doctor is to be able to see things from the patient's perspective.

4. Ignore the gunners. For those of you not in med school, a gunner is a med student who is an obnoxious overachiever. They probably said they wanted to be an orthopedic surgeon or dermatologist on the first day of med school. They probably started studying for their MCAT as freshmen in college. They look at you with disdain when you tell them you don't like to read the textbook or didn't study last Saturday night. Although difficult, I had to learn to ignore these people to preserve my sanity. I had to get over the fact that it is truly impossible to learn all of the material presented. There are 3 more years of med school for a reason - we're not expected to have everything memorized the first time around. It was much more worth my time to maintain good relationships with friends and family and to relax on the weekends than it was to study. Balance is essential.

5. I am in the right place. This past year has been the most fulfilling and rewarding year of my life. I have had so many moments where I have just known that this is where I am supposed to be. For the first time in my life, I don't feel like the goal of what I'm doing is to get to someplace else. I'm already here.

Why Health Literacy?

I thought I'd share with you how I became interested in the topic of Health Literacy. For those unfamiliar with the term, health literacy is the ability to understand and interpret health care-related information and services in order to make good decisions and adhere to treatment. Better health literacy is known to be correlated with more positive health outcomes in patients living with AIDS, like the residents of Project Samaritan. In fact, one study found that the number one determining factor in AIDS outcomes is the level of health literacy! (AIDS outcomes meaning the amount of virus particles in your body, survival time after diagnosis, etc.) I very strongly believe that health care is a right, and it is abhorrent that one's education level should determine one's quality of health.

This brings me to the reason I became interested in health literacy in the first place. Before I enrolled in med school last fall, I was a high school teacher for 2 years with Teach For America (http://www.teachforamerica.org/). TFA is an organization that recruits recent college graduates to teach in low-income schools for two years, with the goal of closing the achievement gap. Learning that only 1 in 10 children growing up in poverty will graduate from college, or that the average student in a low-income community performs as well as an eighth grader coming from a higher income area, made my blood boil.

After graduating from college, I moved to Houston, Texas where I taught ninth grade science at Jefferson Davis High School (see the picture of me in action in my classroom). About 90% of the students at Davis qualify for free or reduced lunch. Many of my students were several grade levels behind in math and reading. I also began noticing that my 15 year old students had health problems that I had thought were predominantly disease of older people - high blood pressure, cancer, type 2 diabetes. It was then that I started making the connection between poverty, education, and health, which put me on the path to medical school.

As a Teach For America alum and a medical student, I have a particular interest in the intersection between health care and education. Teaching my Health Literacy class this summer is bound to be an incredible experience. I can only hope that my students will learn as much from me as I know I will learn from them.

Baby steps

It's official, I will be teaching a Health Literacy class this summer. I met with the brilliant education team at Project Samaritan this afternoon, and after a THREE HOUR long meeting, we established that my class will likely exist on some level. Not a huge amount of progress, but still, hooray!

I am truly looking forward to working with the patients this summer. When I stepped into the elevator on my way to the meeting, I was greeted with a big smile from one of the residents who wanted to know all about who I was and why I was there. The residents aren't used to seeing unfamiliar faces around the building, since there are only 66 of them and about 20 or so staff members. When I explained my class to her, she said she would love to sign up - my first future student! I also happened to run into one of the residents whom I had met in the fall, when I was shadowing. I met him on the day he was admitted to Project Samaritan, when he was dying from AIDS, addicted to heroin, and sentenced by a judge to enroll in the program (or else go to prison). He looked so much healthier than I remember him, and he told me proudly that he was entering his last phase of treatment and would be graduating from the program soon. As you can see, Project Samaritan is amazingly successful at getting patients who have hit rock-bottom to be healthy and prepared to re-enter society.

Next step: start planning my curriculum. I'm going in on Tuesday to introduce myself to the residents and try and recruit students for my class. Any thoughts on how to make Health Literacy sound downright fascinating?

Welcome!

I am so incredibly excited to begin writing my first-ever blog. Full disclosure: I have zero writing experience. In fact, I am totally a left-brained kind of person. Right now, I'm just finishing up my first year of medical school at Columbia University College of Physicians & Surgeons. So why, might you ask, am I blogging?

This summer is the so-called "last summer" for us med students, since from the fall on I will have school and work straight through for the next, oh, 60 years of my life. Being at an academia-focused medical center like CUMC (Columbia University Medical Center), the majority of students decided to spend their precious last summer months doing research. To be candid, our med school completely pushed us in this direction. I, however, couldn't stand the thought of being cooped up in a lab all summer, when I don't even know what area of medicine I'm interested in yet. I decided to apply for a fellowship through the Arnold P. Gold Foundation for Humanism in Medicine. For reasons I'll save for a future post, I have an intense passion for education and social justice, and I designed a project where I will be teaching health literacy at Project Samaritan in the Bronx. Project Samaritan is a residential treatment center in the Bronx, where people living with AIDS and substance addictions live and rehabilitate. They offer a holistic treatment program, including health care, substance abuse treatment, and educational classes. I had shadowed there for one of my med school classes this past year, and I knew I wanted to somehow get involved there during the summer.

By some miracle, I was awarded a Gold Fellowship, and I landed my dream summer job! Part of the requirement for my fellowship is that I write a blog about my experience. I was looking for an excuse to start a blog, so I was thrilled to hear about this. I can't wait to share my journey through this summer, and beyond, with you. I have a meeting with the folks at Project Samaritan tomorrow to plan how my health literacy class will be structured. I'll keep you updated!