Innovations in “Upstream” Care

My last blog was on how today’s medical system fails by not addressing the real needs of our patients and their communities. Here, I highlight three projects that take such an “upstream” approach to healthcare:

Doctors can give prescriptions for medications, but why not a prescription for healthy foods and safer housing? Health Leads employs young people (usually college graduates interested in careers in health) to be advocates who assist doctors in clinics and ERs in connecting patients with community resources. They help with everything from food assistance to job training to legal counseling. They help to “fill” the other prescriptions that people need to achieve better health.

Recognizing that black males have significant health disparities and that outreach and education must start in the community, Project Brotherhood was conceived from a simple idea: give patients free haircuts, and use barber shops as a place to screen and counsel on illnesses such as high blood pressure and STI prevention. Its model of multidisciplinary, culturally competent care incorporates other aspects of social support, including on fatherhood and job support.

 The New York Times just published a story about an “EMS Corps” in East Oakland that specifically recruits at-risk youth and train them to be emergency medical technicians. They provide mentorship for young men who come from backgrounds of poverty and violence, and train them to become professionals who will serve their communities. As the story cites, these men are taught that they aren’t the problem—they are the solution.

These are only some of the some of the many innovations occurring around the country. We need far more interventions that go beyond “band aid” care. In the words of public health doctor Rishi Manchanda (whose recent TED talk I highly recommend), we must change our entire approach to healthcare, away from simply treating the effects of illnesses to targeting interventions to where people live, work, and play—where health really begins.

Going Beyond “Band Aid” Care

When I was a medical student, I worked with an NGO in Rwanda to provide medical care to women with HIV. Nearly all had witnessed their family members murdered during the genocide, and many became afflicted with HIV as a result of rape. Our initial focus was on getting antiretroviral therapy to these women, but we quickly realized that while it was important for them to have access to medications, they couldn’t be healthy unless they also had enough food to eat. They couldn’t stay safe unless they had shelter. They couldn’t be well unless we addressed their psychological trauma.

As an emergency physician working in inner city ERs in St. Louis, Boston, and D.C., I see this same problem every day. My 8-year old patient, Kami, comes in wheezing and short of breath. She has asthma, and two years ago, she lost her inhaler. She and two brothers are staying with her mother’s cousin; lots of people smoke in the house; and she’s missed several days of school. I can give her a breathing treatment and prescribe an inhaler, but how do I help her achieve good health?

Over the last year, I’ve seen 19-year old Byron in the ER three times. The first time, he was stabbed on the arm. It was a superficial cut; he received some stitches. The second time, he got in a fight and broke his hand. I gave him a splint and sent him home. The third time, he was shot twice in the abdomen. I stabilized him and sent him to the operating room. I wonder when he will be back for another violent injury. Is there a better way to help him than to patch him up, piece by piece?

Then there’s Josephine, a 38-year old single mother of four. She was told four years ago that she has cervical cancer. Between her three part-time jobs and taking care of her children, she had no time to see a doctor. Her boss threatened to fire her if she left in the middle of the day. She tried to call a specialist, but they wouldn't take her insurance. By the time she comes to the ER, her cancer had spread to her intestines and her lung. We set her up for treatment, but what does it say about our society that her disease had to progress this far?

Our healthcare system is good at providing short-term fixes for problems. We pride ourselves in having the most advanced technologies in the world. We can provide this excellent care for the few hours the patient is with us in the ER, hospital, or clinic—but then the patient is on her own and back to the same problems, 24 hours a day, 365 days a year. Numerous studies have shown that it’s where we live, learn, work, and play that have a far greater impact on our well-being than the treatment delivered in a hospital.

I chose to be an emergency physician because I want to provide excellent care to everyone, regardless of ability to pay. We in the ER provide a necessary service, but it’s far from being sufficient. We need comprehensive strategies that promote health and target problems “upstream”. We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there—these are Band-Aids, not lasting solutions. Our communities need innovative approaches to pressing issues like homelessness, drug addiction, obesity, and lack of mental health services.

The sage Dr. Patch Adams said that if we treat the disease, we lose; if we treat the patient, we win. To help the patient, we must also address the health of the community.

Over the next several blogs, I will be exploring interventions that show promise in addressing the needs of the patient and their community. I welcome your ideas and suggestions.

Guest Post: In a Patient’s Death, My Life Found New Purpose

I am delighted to host this guest blog from Dr. Eric Bing, physician and professor of global health. We share a passion for fighting disparities in health, a passion is deeply rooted in personal experience, and that comes through in this poignant essay.

 

I was a Harvard-educated physician yet I couldn’t save a patient from an easily preventable disease. In her death, my life found new purpose.

Her name was Lorraine. She was abandoned when she was just six weeks old—left alone in a dark building on a cold winter’s morning. Wrapped in only a soiled blanket, she had nothing to soothe her cries. She might have died if not for those cries, for someone heard her and carried the tiny body to the infant’s grandmother. In Philadelphia in the 1930s, neighbors knew everything about each other, and the existence of this child was not a secret. Her grandmother took her in. She had already raised 15 children of her own, so what was one more? 

As a little girl, Lorraine grew up fast. Even with her sharp mind, like many black girls at that time, she had little money and even fewer opportunities. She slept in the crawl space under her grandmother’s stairs. When she was 12, Lorraine began working as a domestic servant, cleaning houses and caring for children not much younger than herself. She later dropped out of school, and while still a teenager began having babies of her own. 

She was so busy taking care of others that when she began having light, occasional vaginal bleeding, she ignored it.  She had already gone through menopause so this was nothing to worry about. But over time the light bleeding became heavy and the occasional occurrence became alarmingly frequent. After an anxious trip to the doctor, tests confirmed that she had cervical cancer, caused by the human papilloma virus she had acquired years earlier.

Lorraine’s life was once again in danger, but this time from an easily preventable disease.

Cervical cancer can be diagnosed in its earliest stages by a simple Pap smear. In developing countries where Pap smears are too expensive, it is being diagnosed using a few drops of vinegar or prevented in girls with a simple vaccination. And it can be treated at an early stage by freezing lesions off, like a wart. But in order for early care and treatment to work, you must not only have access to care, you must use it. And like many women, she did not do that; the needs of others always came first.

By the time her cancer was diagnosed, it had already spread throughout her pelvis. From there it would move to her liver, bones, and lungs before spreading to her brain and taking her life.

I cared for Lorraine until the day she died, however she had cared for me from the day I was born.

Lorraine was my mother. And her death from an easily preventable disease changed my life.

I was a psychiatrist in Los Angeles when my mother died in 1999. Today I am the senior fellow and founding director of global health at the George W. Bush Institute in Dallas and the founding director of the Center for Global Health Impact at Southern Methodist University.

At the Bush Institute, I helped launch, Pink Ribbon Red Ribbon, an innovative public private partnership to combat cervical and breast cancer in Africa and Latin America by increasing access to cancer prevention and treatment. In developing countries, where Pap smears are too expensive, cervical cancer can be diagnosed by putting a few drops of vinegar on the cervix, which is then examined under a lamp. Lesions appear white and can be treated at an early stage by freezing them off.

A recent study from India showed that this simple vinegar test that costs less than $1 can reduce deaths by nearly one-third. There are also inexpensive vaccines that can prevent the viral infection entirely. We can defeat cervical cancer now in simple, cost-effective ways.

The challenge is access.  In Pharmacy on a Bicycle:  Innovative Solutions for Global Health and Poverty, Rice University business professor Marc J. Epstein and I show how even access to care barriers can lowered in developing countries for many diseases, by shifting care to lower-cost providers, focusing on efficiencies, strengthening existing systems and by stimulating partnerships among governments, businesses, nonprofits, entrepreneurs and women of all ages. And, as my mother's death taught me, we must mobilize women to recognize their risk and realize that by protecting their health, they can live to protect the ones they love.

As my mother lay dying in her home in North Carolina, her house was once again full— with people who had been helped and touched by her over the decades. My mother had scoffed at the notion of filling a funeral home with flowers for the dead. "Give me my roses while I can smell them," she had said.  So people obeyed, coming to bid farewell while she could still hear them.

Despite the steady stream of people at her bedside, she fretted in her final days about what she saw as her lack of accomplishment and lasting impact: She was intelligent but uneducated. She was courageous yet lived in fear. She had done nothing with her life, she felt. She had not fulfilled her life's mission.

When she was finished reliving what she thought was a string of disappointments, I began to re-tell her life story—not as she understood it—but as I saw and experienced it as her youngest son.

I told her that I believed that her life's mission was to unleash passion and purpose in the lives of those she touched. Not only had she raised five children who went on to careers in business, education and medicine; she had applied her quick mind, hearty laugh and steel backbone to helping anyone she came across who was in need.

She taught us that love is what creates a family. She helped us see that a good heart must be coupled with hard work in order to succeed. Those that she had helped were now helping others, and they would in turn help others, and they, still others. Through others, her spirit would live on, continuing to change the world.

As we spoke, I could see a shift occurring within her as she sat there quietly. Softly, a warm smile filled her face, as though she was looking in the mirror and for the first time loved the woman she saw. 

My mother died in my arms, leaving the world far more peacefully than she entered it. In her death, my life found new purpose.

Eric G. Bing is the co-author of "Pharmacy on a Bicycle: Innovative Solutions for Global Health and Poverty" and senior fellow of global health at the George W. Bush Institute. He is also a professor global health at Southern Methodist University and founding director of the Center for Global Health Impact.

A version of this article originally appeared in the LA Times, June 23, 2013, as A cancer that need not kill, by Eric G. Bing.  It is reprinted here with permission of the publisher.

A Young Emergency Physician Appreciates the History of U.S. Emergency Medicine Through the Lens of China’s ERs

I’m a young emergency physician, part of the “new breed” that’s always known emergency physicians to be residency-trained and emergency medicine (EM) as a well-respected field. Being a leader in the American Academy of Emergency Medicine, I often hear of our organization’s leaders speak about the struggles they had in establishing our specialty, but I didn’t have a sense of what they actually went through. Why is that they so dislike the term “emergency room” and cringe at the reference to “ER doctors”?

It took a visit to China for me to even begin to understand the reasons. In August-September 2012, I traveled back to the country of my birth to study the current state of medical education here. My trip traversed 9 provinces and involved visits to 14 medical schools and over 50 hospitals.

Being an emergency physician who is interested in healthcare systems, I was particularly curious to visit the Emergency Departments there (we prefer this term and the abbreviation “ED”s to ERs for reasons I’ll speak about later). What I found is quite far from the EDs I know. In fact, everywhere I visited, from rural provincial hospitals in Inner Mongolia to major inner-city teaching hospitals in Beijing, had an emergency ROOM. That’s because patients were literally seen in a giant room, with beds pushed against walls and (if they are lucky) a curtain to divide the rooms. Extra patients were lined up along hallways, often six-deep.

Many places had triage to service, meaning that patients were triaged to a specific area to be seen by specialists who came through the ER. So internists would see patients designated as having medical problems, surgeons would see patients thought to have surgical problems, etc. If the patient turned out to a different problem than was initially decided, a long discussion would take place before the patient was transferred to the correct part of the ER.

Since China is a densely populated country, many hospitals had serious issues with overcrowding. Not surprisingly, the biggest problem seems to be with patients waiting for a hospital bed—basically, boarding.

“Do you often see patients waiting for a bed for 24 hours?” I asked a doctor in a major Beijing hospital.

“24 hours? We are lucky if there’s a bed in 72 hours!” He went on to describe the difficulties he had with admitting an elderly woman with heart failure, diabetes, kidney problems, and liver cancer who came in with difficulty breathing. The cardiologists refused the patient, saying the problem was the kidney. The nephrologists declined, saying diabetes or cancer was the underlying problem. Oncology and endocrine stated the chief complaint was not mainly their issue. General internal medicine said the patient was too complicated. As a result, the patient stayed in the ED for the entirety of her care—a total of 30 days.

The emergency physicians I met attributed the problem of boarding to the lack of respect for the specialty. Though EM is a specialty in China, and there are EM residency programs in some cities, it is considered to be a specialty of last resort—for those physicians cannot make it in other fields. Most EDs are divisions that exist only under the auspices of “real” departments such as surgery and medicine. Attendings working in the ED are scorned by others, and fights over airway, chest tubes, and other procedures are frequent occurrences.

Hopefully, my fellow young American physicians are wondering what kind of backwards environment I’m describing, but many reading this column are probably thinking that this description is not too far from the reality they knew. Indeed, the road to becoming a specialty involves predictable stages. My generation takes it for granted that we are part of excellent training programs and will be specialists in a well-respected medical field. But it wasn’t long ago that our predecessors fought the same battles that China faces now, of specialty recognition, admission privileges, scope of practice, etc.

We young emergency physicians need to thank those who came before us for making our specialty what it is and paving the way for us. For creating the emergency DEPARTMENT (rather than the ER) staffed by emergency physicians (rather than ER docs). For ensuring safer and better care for our patients.

We must also recognize that while many problems have been resolved, many remain. Overcrowding and boarding continue to be problems in EDs across the U.S. There are continuing challenges to our scope of practice, and other specialties still question our abilities. Vocal groups still insist that there are other ways to become “certified” emergency physicians through alternative boards. The corporate practice of medicine remains a real issue for practicing physicians.

It’s imperative for young emergency physicians like myself to continue to find value for our specialty. China’s EM leaders have found creative solutions around their overcrowding and scope of practice by starting “E-ICUs” (emergency ICUs) and transitional care units (transition from E-ICU to home) and staffing “emergency inpatient” and observation units. As we look to the future of EM, we should be aware of our history, work to overcome ongoing problems, and continue to advance our specialty and improve healthcare, in the U.S. and internationally.

This article was initially published in AAEM’s Common Sense magazine. I welcome your comments!

For Students and Residents: a Guide to International Emergency Medicine

International emergency medicine (IEM) is one of the most popular subspecialties in emergency medicine. Among other medical specialties, international medicine is just as popular. As a senior resident, I have seen many a medical student or junior resident light up when I discuss IEM. But even though IEM is a great buzzword, it can mean different things to different people. Does it refer to a clinical rotation to see how EM is practiced in other parts of the world? How about developing emergency systems, or providing humanitarian relief? Where does research or teaching fit in? In my first president's column, I want to share my passion for IEM with you by providing some guidance and advice that I wish I had gotten when I was first drawn into IEM.

Unlike some of my IEM colleagues who were born to do international work, I had my heart set on a career in domestic health policy. It wasn't until medical school that I was exposed to international health. A fellowship at the WHO made it clear that the issues I was working on in the U.S. were magnified many times over in other countries. Geneva was an eye-opener, but I felt a need to work "on the ground", so went to Rwanda to do fieldwork on gender-based violence and subsequently to the Democratic Republic of the Congo and Burundi as a journalist reporting on war and health.¹ Through this exposure I saw the urgent need for research to understand systems and evaluate interventions, and decided to go to the U.K. for two years to study economics and policy. I came into residency with more tools and a stronger passion for IEM research. Now, entering my fourth year, I have conducted systems design and evaluations in several countries,^2-4 a healthcare workforce evaluation in South Africa,^5-7 and a global health professional study.⁸

Everyone’s path in IEM is different, and I share my background with you so that you can see my circuitous path in this journey. Students and residents often ask about getting involved with IEM and what things they should consider in building an IEM career. Here are some thoughts:

1) The only way to know whether or not you will like something is to try it. If you are new to international work, find an opportunity and jump on it. Don't be picky about location or type of experience. Many schools and residencies will have an international rotation. Most likely it is a one-month clinical experience, but occasionally it is a research project (e.g.,  studying malnutrition) or an educational opportunity (e.g., teaching point-of-care ultrasound). There may be a relief mission that needs your help. Some of my residency classmates went to assist with the disasters in Haiti and Japan. These were not things that they planned, but they jumped on opportunities that came up. Explore multiple options. Your own program is the most natural place to start, but also look elsewhere in your university. The American Medical Student Association has medical student elective listings. AAEM/RSA is also establishing an international rotation database. Keep your eyes and ears open and ask other residents and attendings to be on the lookout for you.

2) There has been a lot written in recent years about "medical tourism".^9,10 While this phrase conjures up unpleasant connotations, and sustainability in international programs is very important to think about, don't discount experiences because of your own (unnecessary) guilt. International rotations are important for your exposure, and whether you end up doing international work or not in your career, your experience will be instructive for you and good for your future patients. Find your own way to meaningfully learn and to contribute.

3) Once you’ve had experience with IEM, decide whether it is something that you feel passion for versus something that you would like to do only occasionally. There is no right or wrong answer--don't feel guilty if your experience showed you that you don't want to live in war-torn countries forever. Be honest about what you like doing and how you think international work will fit into your career. What attracts you most about the work? Does clinical work excite you while research bores you? Are you happiest doing impact evaluations from the comfort of your own home? Would you want to do these things occasionally, or do you love them so much that you need to build it into your career?

4) Consider the other interests that you have to balance. International fieldwork is hard to find time for in residency, but it might be even more challenging with a young family. Know how your significant other feels about your work. This is a continuing conversation for me and my husband, a South African native who I met in the U.K. Initially, we thought that we would spend two months every year abroad, but this is difficult to manage in both of our careers right now. It took me a while to realize that not everything I want has to be done at this very moment. Perhaps this is the time to focus on your family and your clinical work. IEM opportunities will be there when your life settles down. Perhaps later on, you and your family might consider a year or two abroad, or you may be able to take a job with greater travel flexibility. Think about how you want to balance your IEM interest at this point in time and be flexible to change.

5) Don't discount related work in the U.S. I have come full circle in this regard by starting in domestic health policy, falling in love with IEM, then coming back to U.S. policy. There are huge problems with access to care and health inequities in the U.S., and what you learn through your international experiences will inform your work here - whether it's in policy, advocacy, community activism, or your clinical work. Many international interests can be built into your domestic work and vice versa. If you have an interest in EMS, you can develop your expertise in the U.S. first and then do projects abroad. If you have experience with teaching mid-level providers internationally, you can design similar programs in the U.S. The options are limitless!

6) Build and nourish your network. Identify mentors as early as possible. Seek out those you admire and follow their career paths. Read their work. Ask for advice from those who have IEM careers and those who don't--their perspectives will be just as important for you. Women, it may help to find identify female mentors as women face a unique set of challenges. The Academy of Womenin Academic Emergency Medicine is a great resource, and this year it is offering free membership to residents.¹¹ Along the same lines, build your peer group. IEM is a small world, and your peers will encourage and inspire you throughout your professional lifetime.^8,12

As my mentors have taught me, a successful IEM career necessitates thinking outside the box—and keeping an open mind and open eyes and ears. Speaking of being open, now is the perfect time to get involved! Don't discount any opportunities. Now is the time to make a difference, in the U.S. and internationally, with our profession and most importantly with our patients.

References:

1. The New York Times. Two For the Road Blog. Available at http://twofortheroad.nytimes.com. Accessed 1 June 2012.

2. Wen LS, Oshiomogho JI, Eluwa GI et al. Characteristics and capabilities of emergency departments in Abuja, Nigeria. Emerg Med J. 2011; Nov 2. [Epub ahead of print]

3. Wen LS, Anderson PD, Stagelund S et al. National survey of emergency departments in Denmark. European Journal of Emergency Medicine. 2012; in press.

4. Wen LS, Char DM. Existing infrastructure for the delivery of emergency care in post-conflict Rwanda: an initial descriptive study. Af J Emerg Med. 2011; 18(8): 868-71.

5. Wen LS, Geduld HI, Nagurney JT et al. Perceptions of Graduates from Africa’s First Emergency Medicine Training Program. CJEM. 2012; 14(2): 97-105.

6. Wen LS, Nagurney JT, Geduld HI et al. Procedure competence versus number performed: a survey of graduate emergency specialists in a developing country. Emerg Med J. 2011; Oct 21. [Epub ahead of print]

7. Wen LS, Geduld HI, Nagurney JT et al. Africa’s first emergency medicine training program at the University of Cape Town/Stellenbosch University: history, progress, and lessons learned. Acad Emerg Med. 2011; 18(8):868-71.

8. Wen LS, Greysen SR, Keszthelyi D et al. Social accountability in health professional education. Lancet. 2011; 378(9807): e12-13.

9. Jesus JE. Ethical challenges and considerations of short-term international medical initiatives: an excursion to Ghana as a case study. Ann Emerg Med. 2010;55: 17-22.

10. Van Hoving DJ, Wallis LA, Docrat F et al. Haiti disaster tourism—a medical shame. Prehosp Disaster Med. 2010;25: 201-2.

11. Society of Academic Emergency Medicine. Academy of Women in Academic Emergency Medicine. Available at: http://www.saem.org/academy-women-academic-emergency-medicine. Accessed 1 June 2012.

12. Morton MJ, Vu A. International emergency medicine and global health: training and career paths for emergency medicine residents. Ann Emerg Med. 2011;57: 520-5.

Portions of the article will appear as part of the American Academy of Emergency Medicine's Common Sense magazine. I serve as the President of AAEM/RSA. These opinions represent my own and not of AAEM or AAEM/RSA.