Community Resource Spotlight

Kyra Reed, MD – PGY-2 EM/Peds

The Community Resource Spotlight is a recurring submission intended to highlight community organizations that advocate for vulnerable populations and to also increase awareness about these remarkable local resources.

February Spotlight: CIRCLES® OF SUPPORT

“Family”… “strength”…“ hope for the future”… These were just a few examples of the uplifting rhetoric shared by the members of Circles to describe what the group meant to them. At the weekly meeting, the group was seated in a large circle, of which was a recurrent theme echoed in the vision of this innovative group. There were no socioeconomic barriers in this circle – they had melted long ago into a unifying movement during the process of developing new, long-standing relationships that may not have otherwise come into fruition. As each person shared their reflections on the impact that Circles has had on their lives, it was apparent that I was witnessing the metamorphosis of not only the individuals who had sought a way out of poverty, called “Circle Leaders”, but also that of the “Allies”, volunteers who were paired with Circle Leaders as a pillar of support and guidance. Individuals from different “circles”, or walks of life, were now engaged in candid conversations regarding poverty, violence, and daily life struggles. This inspiring group of individuals are indeed the boots on the ground in the campaign against poverty – and it is working. Watch: Success Story Video

It all starts with dinner. After loading up a plate of a warm, delicious cooking, everyone gathers around the multiple tables for a family style dining experience. This aspect of the meeting is arguably one of the most important pieces – everyone is family, and you sit by someone new every week. Dinner is filled with discussions about one another’s past weekly events, where they are coming from, hilarious stories, and children doodling in their spaghetti sauce. Certainly, this is a family gathering. Following dinner, children are shuttled to the playroom, where volunteers lead interactive games. The volunteers, guests, Allies, and Circle Leaders all bring their children to play together during the meeting –yet another wonderful layer to the Circles’ theme. At the meeting’s conclusion, everyone shares positive, new experiences. There were many victories to be applauded, including job interviews, improved school grades, and graduating from the program. My positive experience that day was being able to learn about this tremendous organization and its truly exceptional members.

The Nuts and Bolts of Circles

Circles is a local and nationwide campaign against poverty using a unique and thoughtful solution – a 16 week course for “Circle Leaders” (underserved individuals from the community) that focuses on self-reflection, employment, finances, and the skills needed to thrive in the community. After completion of the course, Circle Leaders are paired with “Allies”. Allies are volunteers that act as a support system in the transition out of poverty – encompassing the emotional, psychological, and financial aspects of what it means to be impoverished. The result is self-sufficiency, long lasting solutions/relationships, and ultimately breaking the cycle of poverty. How Circles Works

We care for underserved and impoverished individuals in the ED every day.

This is therefore a valuable opportunity to educate ourselves about the lives of our patient population. As advocates for our patients, we have the responsibility to directly engage in our communities and discover the very real cultural, societal, and financial barriers that affect health care. Understanding our patients from this perspective would ultimately lead to improved, thoughtful solutions and subsequently, a higher quality of care. Why not get out there and make a difference in a new and inspiring way?

How can you help?
– Sponsor a poverty simulation for your group: Poverty Sim
Become an Ally
– Volunteer at the weekly meetings: childcare, plan meals and meetings
Provide a meal for one of the weekly meetings
– Donate to Circles

Want to attend a weekly meeting?
– Julian Center Circles: Marie Weise at mwiese@juliancenter.org, or 317-941-2200
– Circles – Back on My Feet: Brian Meyer 317-250-4133

More information:
http://www.circlesindy.org/
http://www.circlesusa.org/
http://www.juliancenter.org/Get-Involved/Circles-of-Support.aspx

Special thanks to the Julian Center and Circles of Support.

Childhood Obesity: An Epidemic Growing By The Mouthful

Bethany Beard, MD

I’ll be the first to admit, chubby babies with mushy Michelin thighs are very cute and fun to squeeze on. I see these kiddos frequently for well child checks and I actually applaud the mother on her job well done to grow and nourish her baby. There is no other time in life when wrist and ankle rolls are cute, so when does this ideal end and become a health concern? At what age is fat no longer preferred? The human body’s future metabolic “programming” can actually be modified by diet and nutrition in early infancy, so maybe that chubby infant shouldn’t be so admired.

America’s children are fat and quite frankly, it’s not cute. This epidemic is spreading through the United States each year. Childhood obesity has more than tripled in the past three decades and statistics from the CDC indicate that obesity in children age 6-11 has increased from 6.5% in 1980 to 19.8% in 2008, and that obesity among adolescents age 12-19 years increased from 5% to 18.1% respectively.

Interest in this topic began during my undergraduate study of nutrition. I learned all about flavonoids, phytochemicals, biochemical nutrient metabolism, blah, and blah; however, nutrition’s real life importance did not come to fruition until later in my career. At a nearby table in the Riley cafeteria sat a morbidly obese toddler, roughly three years old. The child was accompanied by what appeared to be some sort of health coach. I observed the “coach” help the child count green beans, carrots, and apples as if to re-program her mind about healthy foods and appropriate portion sizes. I assumed she worked at Riley’s POWER clinic, which was established for overweight and obese children. Shortly thereafter, before the food was gone, the woman took everything away and said “ok, that’s all for now. Let’s go”.  I put my cheeseburger down. My emotion was initially sadness, then it was later followed by motivation to learn more about childhood obesity and it’s harms on today’s youth.  

So what’s the big deal with childhood obesity and what impact are we seeing across the country? Childhood obesity results in multiple health related illnesses including hypertension and hyperlipidemia, diabetes, worse asthma control, sleep apnea, and mental health disorders such as depression and body image issues. As emergency physician’s we are seeing these children present more commonly with lower extremity injuries, commonly knee pain and sprains, compared to their normal weight for age peers. Obese children perform worse academically and miss approximately 4x more school days than their classmates. They also sleep worse. Probably the most startling statistic is from a study in 2005 which shows that if obesity continues at the current rate, children of today’s generation will have a shorter life expectancy than their parents for the first time in over 100 years! In addition, these children present challenges in the health care setting. Obese children are more difficult to obtain IV access and intubation, their belly rolls limit the sensitivity of ultrasound, and there are dosing difficulties for both medication and defibrillation during resuscitation. Aside from numerous co-morbidities, the heath care system also feels the impact of childhood obesity, as these children are 3x more expensive compared to the cost of normal weight children.

Obesity results from a combination of a little genetic and mostly multifactorial environmental influence. Some influences include a lack of education on what’s healthy and what’s not, limited access to healthy food, and sedentary lifestyles as technology and television viewing increases. Another challenge is that our nation’s schools have limited resources. School lunches lack fresh fruits and vegetables and due to budget cuts, physical education was reduced leaving the majority of elementary schools without daily gym classes. The biggest contributor to childhood obesity, in my opinion and that of expert researchers, is the parents of these children. As a mom, I realize that it is both cheaper and easier to warm up prepackaged chicken nuggets, hotdogs, cookies, etc. I get it; especially when parents are busy and on a budget. However, the quality and quantity of food a child receives is controlled by the parents and directly impacts a child’s weight.

The chance that an obese child will grow into an obese adult is 70%; therefore, it is our job as physicians to identify these children early. One study suggested targeting obesity at six months of age as these infants were most likely to remain obese at their two-year visit. Although there is no strict age cut off, most pediatricians and researchers believe that obesity should not be diagnosed before two years of age. The first step is to simply target those children at risk. This can be achieved by calculating a BMI on all children who present to a primary care clinic or the emergency department. With electronic medical records, this should already be calculated when both height and weight are submitted. The next step is to identify those with BMI 80-94% which will classify the child as overweight. Those with a BMI >95% are obese.

The consensus of obesity experts in the National Association of Children’s Hospitals and Related Institutions (NACHRI) Obesity Focus Group recommends that identification of obesity and treatment should occur in all inpatient and outpatient settings in a children’s hospital. Promotion of healthy behaviors at the hospital is also encouraged. Change is currently underway at Riley Hospital, as McDonalds will soon be replaced with healthy food options and Andrew Luck’s ‘Change the Play’ campaign was established to promote the importance of physical activity and wellbeing.

Cornerstones of obesity treatment are focused on promoting a healthy diet and increasing physical activity, along with parental involvement and support. Emergency department visits are an opportunity to have discussions with patients and families about weight loss and encourage regular follow-up with their primary care physician for monitoring. Exciting initiatives are also supported nationally. In 2010, three events occurred: Michelle Obama’s “Let’s Move” campaign, the Patient Protection and Affordable Care Act, and the White House Task Force on Childhood Obesity report. Together as physicians and advocates for children’s health, we can combat the childhood obesity epidemic, make a positive impact on their adult health, and hope for change in generations that follow. 

Resources:

-Arpilleda, Joyce C. “Managing Childhood Obesity in the Emergency Department”. Pediatric Emergency Medicine Practice: 9 (2012), 1-15.

-Golan, Moria. “Targeting Parents Exclusively in the Treatment of Childhood Obesity: Long-Term Results” Obesity Research. 12 (2004) 357-361

-Pomerantz, Wendy J. “Injury Patterns in Obese Versus Nonobese Children Presenting to a Pediatric Emergency Department”. Pediatrics. 125 (2010) 681-85

-Prendergast, Heather M. “On the Frontline: Pediatric Obesity in the Emergency Department”. J Natl Med Assoc. 103 (2011). 922-25

-Scheff, Sue. (2011, Mar 1). 10 Frightening facts about childhood obesity. Retrieved Jan 10, 2013 from http://www.examiner.com

-Vaughn, Lisa M. “Obesity Screening in the Pediatric Emergency Department”. Pediatr Emer Care. 28 (2012). 548-552

Challenges of Foster Care

Terez Malka, MD

I click open the x-ray viewer.  After 4 years in emergency pediatrics, I am not really surprised that a tibia fracture underlies the bruised ankle I unexpectedly encountered on physical exam.  Yet I audibly gasp as the chest x-ray loads.  The torso in question belongs to a chubby little cherub of a 3 month old in room 11, brought in for red eyes.  I begin to count the fractured ribs—1, 2, 3, 4, 5.  I pause.  That’s just the left side. 

His 17 year old mother sobs as the caseworker takes her son from her arms.  “He smiles when you kiss his face,” she calls as she’s escorted out of the ED, “and he likes it when you read him books.  Someone has to read him books.”  She looks towards me.  I look down.

She admits to the social worker that she gets overwhelmed.  His father, also 17, has a short temper.  He works third shift, she works days.  They pass the baby off.  I don’t ask when they sleep.  “Having a baby,” she whispers, “is harder than I thought.” 

I want to tell her not to worry.  I want to tell her he’s in good hands, that he’s safe now, that someone will read to him and kiss his face and make him smile.

I don’t tell her about the toddler twins I admitted last week, profoundly dehydrated after days of not being fed by their foster parents.

 I don’t tell her about the preteen I saw just hours ago, pushed out a second story window by her foster mother during an argument. 

I don’t tell her that, on average, a child will spend 3 years in the foster care system and traverse through three placements before reuniting with their family.  That he may be walking, talking, and calling someone else “mommy” by the time she’s able to navigate the court system and regain custody.

Statistics on abuse within the foster care system are nearly impossible to find, though anecdotes abound.  Just last week, an 11 year old foster child was found handcuffed on his front porch with a dead chicken hung around his neck.  In 2003, a Pennsylvania foster mother was arrested after her foster daughter died of asphyxiation when duct tape was used to enforce a time-out.   An inquiry into the Trenton, New Jersey foster care system inspired by that case, found that up to 1 in 5 children within their foster system were abused at a foster home. 

In Indianapolis, the Department of Child Services (DCS) has undergone budget cut after budget cut over the past decade, $100 million in 2011, $16 million in 2012, and,  most recently $10 million in 2013.  The national turnover rate for DCS caseworkers is above 20%, with low salary, inadequate support, and excessive workload cited as the most common reasons for leaving.   In my own encounters with DCS as a prospective adoptive parent, my caseworker changed three times over a 12 month period, with our final caseworker never responding to our emails.  The social worker teaching our parenting course readily admitted at the start of our class that she had no experience with children, but had taken the job to cover until the position was filled.

I see extraordinary foster parents at my job every single day and have the honor of working with caseworkers who commit their lives to caring for and protecting children.  I also witness the consequences when the system fails the very children it is charged with protecting.

So I don’t tell the young mother that her son is safe, that he’ll be cared for, that he’ll be back with her soon.  “I’ll read to him,” I promise her. 

Sources:

  1. http://www.ibj.com/agency-blames-caseworker-turnover-on-pay–scrutiny/PARAMS/article/35724
  2. http://www.cdc.gov/violenceprevention/childmaltreatment/datasources.html
  3. http://www.nj.com/politics/index.ssf/2013/10/some_child_welfare_reform_gains_stalling_monitor_says.html
  4. http://www.pbs.org/wgbh/pages/frontline/shows/fostercare/marr/
  5. http://abcnews.go.com/WNT/story?id=130266
  6. http://www.foxnews.com/us/2013/11/17/north-carolina-foster-parents-arrested-after-child-found-handcuffed-with-dead/

Capturing a Moment: A Reflection on Mental Health and Emergency Medicine

“’Lisa’s’ Story” is a recollection of a patient encounter experienced by Kyra Reed. Kyra is a PGY-2 in the Emergency Medicine/Pediatrics Residency Program at Indiana University and a member of its Advocacy Track.

After a brisk knock on the door, I entered the room of a young female patient who was at the office for her eighth grade physical exam. It was the time of year for school physicals, and the schedule at the underserved, rural clinic in which I was working as a medical student through the Rural Medicine Program at Indiana University, was absolutely filled for the day. Introducing myself to the 12 year-old patient, “Lisa”, she said hello and made eye contact only briefly. As I began the encounter with light-hearted comments about the upcoming school year, Lisa began fidgeting with her rings and massaging her arms in a nervous manner. Lisa reported that she felt dizzy sometimes and that she has nearly passed out on multiple occasions. Cautiously guiding the conversation, I attempted to see if there was something more she wanted to share with me. Noting her thin frame and very low BMI, I said “You know, even though starting a new year at school can be fun, it can also be quite scary – with new classes, teachers, and students. I was always nervous the first week of school. Do you feel the same way?” Lisa contemplated for a moment and then softly replied, “I am really scared.” “Is there anything in particular about school that worries you?” I asked. After a few moments, Lisa began crying and stated, “Yes… I’m fat and everyone knows it.”

Subsequently opening up about her habits, which included restricting food gradually over the past year and exercising five hours daily, Lisa confided that she wanted help. With no insurance, however, the search for resources proved to be challenging. I was eventually able to locate a specialist on a sliding scale fee that was a two-hour drive away. Providing Lisa with a journal, I encouraged her to chronicle her journey through recovery. We have kept in touch since, and now many years later, Lisa is working on being healthy and happy. She has held several student conferences in which she has shared her story and helped other students with similar issues. She aspires to be a pediatric psychiatrist.

It is an encounter such as this that I reflect on often as I continue through training. It is not the typical story of a large scale event, catastrophe, or a shocking incident in the emergency department that one may hear or think of when discussing important moments in their medical career. This story is a relatively subtle one, yet to me was truly striking because of that very aspect. Taking a moment to sit and truly communicate with a patient can provide an opportunity to capture a moment where a seemingly straightforward, everyday school physical exam suddenly becomes a catalyst for a transformative moment in one’s life. Now, Lisa has touched the lives of so many others with her story, creating a wave of positive change. For me, this encounter sparked an interest that will continue throughout my medical career. Physicians in particular see patients at their most vulnerable moments, and these opportunities should not slip through the cracks. How many others can we catch in that moment?

I could not help but wonder…
— Is Lisa’s story just the tip of the iceberg?
— How prevalent are mental health disorders in adolescents (depression, anxiety, eating disorders, etc)?
— Are we missing an opportunity to identify these patients?
— Is there a difference in prevalence between rural and urban settings?
— Does the resource distribution reflect the need in these areas?

What does the data tell us?
Pediatric Mental Health Fast Facts(6):
– Suicide in the U.S. currently ranks as the 4th leading cause of death for 10-14 year-olds and the 3rd leading cause of death for 15-19 year-olds
– This accounts for 11.3% of all deaths in the latter age group in 2006.
– More than half of adolescents 13-19 years of age have suicidal thoughts
– Nearly 250,000 adolescents attempt suicide each year
– Up to 10% of children attempt suicide sometime during their lives.
– 83% of adolescent patients who had attempted suicide were not recognized as suicidal by their primary care physicians

Fourteen million children and adolescents, or approximately greater than 1 in every 5 children suffer from mental health disorders in the United States(1,5). This prevalence suggests the need for a useful detection method of these children and adolescents in order to appropriately identify and treat mental health disorders, including anxiety, depression, and eating disorders. The American Academy of Pediatrics (AAP) recommends regular screening of children and adolescents in the primary care setting(5). However, for adolescents who had attempted suicide, 83% of them had not been identified as having suicidal ideation by their PCP(6). So how can detection improve? Since children and adolescents are seen in larger numbers in the primary care setting during annual school physical examinations, this seems to provide an excellent opportunity to screen for mental health disorders that may have not otherwise been detected. This will be the start of the focus of my project on assessing prevalence of mental health disorders in underserved areas, both urban and rural. The next step will be to assess resource availability in relation to the objective need.

So, how does this impact Emergency Medicine?
It suggests that we have an opportunity to intervene. The data indicates an increasing incidence of pediatric psychiatric emergencies and unrecognized suicidal ideation in adolescents, which is in conjunction with an already underdeveloped outpatient mental health infrastructure in many communities(6). This is particularly true for rural areas. These patients utilize emergency departments, whether they are acutely in crisis, or involved in risky behaviors leading to trauma, substance abuse, or suicide attempts. Rotheram-Borus et al reported that “fewer than 50% of adolescents seen for suicidal behavior in the ED were ever referred for treatment, and, even when they were referred, compliance with treatment was low.”(7) I think we can do better.

What are the barriers in the ED to recognizing and referring these patients?
— Time, time, time. These at-risk patients take time to identify, especially when the visit reason seems unrelated and the department is bustling.
— Education. Paucity of mental health education for medical staff and ancillary support inhibits recognition of these patients. Also, lack of awareness of available resources leads to ineffective referrals for follow-up.
— Resource availability. Lack of access to the necessary resources continues to be an issue, for both inpatient admissions and outpatient referrals. This is especially the case in the rural setting, when the nearest resource may be two hours or more away.
— Patient priorities. Should I pay for mental health services or pay the electric bill? Factors such as being able to afford the gas money and the day off of work in order to follow up in clinics are huge for these patients and their families. The priorities relative to the patient’s situation can ultimately result in a lack of follow-up.

What we can do in the ED:
– Always consider a mental health disorder, even if the chief complaint seems unrelated
– Take the extra minute to ask follow up questions if concerned (SBIRT – Screening, Brief Intervention, and Referral to Treatment)
– Familiarize oneself with the available resources in the community
– Advocate for these patients – increasing education, awareness, and policy changes
– Ask about patient barriers, and involve social work if available
– Reinforce the importance of treatment of mental health issues, keeping in mind the rate of serious outcomes, including suicide
– Consider phone call after discharge if concerned for ability to follow up

A final reflection:
By continuing to keep our eyes open to the needs of others, we can have a valuable impact. Understanding one another on this basic level spans gender, geography, culture, and income. We have an incredible opportunity in medicine to contribute to this cause in a multitude of ways. So, capture your moment – no matter how subtle it may seem. The outcome may be inspiring.
Thanks for reading!

LINKS
IUSM Rural Medicine Program

REFERENCES

1. Behavioral health screening and referral in the pediatric office. Swartz J. King HS. Rider EA.
Pediatric Annals. 40(12):610-6, 2011 Dec.

2. Brief mental health screening questionnaire for children and adolescents in primary care settings.
De la Osa N. Ezpeleta L. Granero R. Domenech JM. International Journal of Adolescent Medicine & Health. 21(1):91-100, 2009 Jan-Mar.

3. Incorporating mental health checkups into adolescent primary care visits. Allen PL. McGuire L. Pediatric Nursing. 37(3):137-40, 2011 May-Jun.

4. Mental health screening of adolescents in pediatric practice. Husky MM. Miller K. McGuire L. Flynn L. Olfson M. Journal of Behavioral Health Services & Research. 38(2):159-69, 2011 Apr.

5. American Academy of Pediatrics. IMPACT Fact Sheet: Improving Mental Health in Primary Care Through Access, Collaboration, and Training (IMPACT). Available at: http://www.aap.org/commpeds/dochs/mentalhealth/docs/IMPACT%20Fact%20Sheet.pdf.

6. Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical
Services System: The Committee on Pediatric Emergency Medicine
Pediatrics 2011;127;e1356; originally published online April 25, 2011; DOI: 10.1542/peds.2011-0522

7. Rotheram-Borus M, Piacentini J, Van Ros- sem R, et al. Enhancing treatment adher- ence with a specialized emergency room program for adolescent suicide attempt- ers. J Am Acad Child Adolesc Psychiatry. 1996;35(5):654 – 663

A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

In 2010, Dr. Howard Brody wrote:

“the best rebuttal to the antireform argument that all efforts to control medical costs amount to the ‘government getting between you and your doctor’ is to have physicians, not ‘government,’ take the lead in identifying the waste to be eliminated. Mark Twain said, ‘Always do right. This will gratify some people and astonish the rest.’ Today, meaningful health care reform seems to be in danger of taking a back seat to special-interest pleading and partisan squabbling. If physicians seized the moral high ground, we just might astonish enough other people to change the entire reform debate for the better.”

Dr. Brody made an argument for specialty societies to take the lead and develop a list of tests or procedures that are commonly ordered but according to current evidence do not provide meaningful benefit. Many specialty societies joined the Choosing Wisely Campaign and have released their “Top 5” list but ACEP was notably absent from this movement.

We discussed ACEP’s absence from this list at our last advocacy meeting and unanimously agreed that Emergency Medicine should be part of the Choosing Wisely Campaign. Fresh off the heels of this discussion we discovered that ACEP had reversed their decision. They are now a partner in the campaign and plan to reveal their list of “top 5” tests or procedures that should be questioned or discussed and not just routinely ordered.

An article, just released, in the American Journal of Emergency Medicine establishes the case for why it is important for emergency physicians to be stewards of our available resources and to take the lead in establishing what areas of care should be examined for opportunities to reduce costs.

In the article “A ‘Top Five’ list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care,” Drs. Venkatesh and Schuur discuss their recommendations for an approach to developing this top 5 list and the path forward after development of this list.

The authors begin by pointing out that if we as emergency physicians do not take the lead in being stewards of society’s resources and taking responsibility for health care costs, private insurers and government regulators will certainly fill that void and impose policies on the specialty. Furthermore, they argue that we have an ethical obligation to address the cost of care in our departments and that we as emergency medicine experts should define where we can limit testing and in the process demonstrate the value of emergency care.

The first step is to identify overuse. What are the tests, treatments, and disposition decisions that don’t change the care we provide? For example, 37% of all ED patients have a CBC drawn during their ED visit with little evidence that this test affects care. The authors argue that instead of actually doctoring which they say is “emphatic listening, physician examination, and clear communication,” we are too frequently using technology as a crutch. Other areas of overuse that could be targeted were identified. These include CT imaging which has seen a 330% increase in use since 1996 with no increase in diagnostic yield, antibiotics for upper respiratory infections and bronchitis, and IV fluids and medications. A recent study that has been accepted for publication showed that 50% of IVs inserted in an ED were unused.

Another issue the authors took up was the ability of the ED to serve as a definitive site of care. Interestingly, only 6% of patients are discharged without a recommendation for planned follow-up when there is no evidence that the majority of these follow up visits are needed. Most conditions seen in the ED are self-limited and can be treated as such. We as emergency physicians can ease the burden of a significant portion of primary care usage by providing complete diagnosis, treatment and education for conditions that don’t require follow up care.

The authors next addressed barriers to emergency physicians participating in cost reduction. A common cited reason for over-testing is legal concerns, however there is no good evidence that additional testing, or “defensive medicine” provides any medico-legal protections. The authors acknowledge that many hospitals may put pressure on physicians to maintain admissions and a certain level of testing as this is a major contributor to revenue. In the end, emergency physicians should advocate for a patient-centered model of care and a payment system that rewards patient-oriented outcomes and reducing health care spending as opposed to continuing the status quo.

The answers to many of the issues raised may not yet be known and more research needs to be done. However, the creation of a top five list will also help to stimulate research priorities and will likely lead to many more identified opportunities to reduce health care costs while improving emergency care.

It is becoming more clear that if we do not lead the effort to identify areas of overuse within our specialty others will step in and do it for us. It is likely not in our best interest or our patients to have these changes imposed upon us by others whose interests and expertise are different from ours. This article provides a good framework for identifying our “top 5” list and is something we all should read and consider as we try to provide the best care we can for our patients.

For more information, check out the linked papers in the resource section!

Advocacy Track Workshop: Health Literacy

The IUEM Advocacy Track hosted a workshop entitled “Health Literacy in the Emergency Department: Barriers and Solutions” with the help of our resident expert Jill Sracic and invited guest panelists from the School of Nursing and The Indiana Center for Intercultural Communication. The turnout, passion, and creative conversations about integrating improved patient communication for better health outcomes was inspiring. At one point. Dr. Carol Shieh from the School of Nursing said, “I feel better about my daughter being a second year medical student knowing that there are doctors out there like you.”

According to the 2004 IOM Prescription to End Confusion:

“More than a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic, and conceptual knowledge. Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health. At some point, most individuals will encounter health information they cannot understand. Even well educated people with strong reading and writing skills may have trouble comprehending a medical form or doctor’s instructions regarding a drug or procedure.”

At the end of the session, everyone generated a personal learning point that they planned to incorporate into their practice immediately. Here they are:

1) Stop asking people, “Do you understand?” to end the discharge instruction process. They will usually say yes even when they mean no.
2) Anticipate cultural differences instead of waiting for them to be a problem. Educate yourself on cultures commonly seen in your ED.
3) Talk about the discharge plan on the first visit. That way when you come back, they have had time to think about it.
4) Understand “cultural humility” even in truly emergency situations. What we do can have lasting impact even beyond medical management.
5) Explain how to take medicine then ask the patient to explain it back.
6) Be aware of the differences between us and our patients and try to bridge the gap.
7) The more you know, the more humble you become.
8) Edit discharge instructions.
9) Add a question to the end of the discharge instructions about the content to assess understanding.
10) Verify new medications with the patient and one more person.
11) Communication is not one size fits all.
12) We should try to have a better understanding of a patient’s healthcare environment. (Home, primary care, transportation, etc.)
13) Don’t think only about patients with poor health literacy as deficits. Try to see the strengths they have as well.

Resources:

http://www.healthinfotranslations.org

Indiana Center for Intercultural Communication
http://liberalarts.iupui.edu/icic

Check out the IOM document in the Resources section!

“Caring for patients from different cultures” by Geri-Ann Galanti

LaMorris Crawford – Treating the Impoverished

In the world of emergency medicine, we care for many people who live in poverty. There are many reasons but largely this is due to the fact that we turn no one away. We will see and care for anyone who walks into our department, whether or not they can pay. For those who chose a career in emergency medicine, not choosing who we see was an attractive feature of EM. We are the safety net of medicine and we’re proud of it. The reality of this, however, is that we confront the challenges of caring for those in poverty every day and we are not always equipped to provide optimal care.

There are several barriers as we care for those who live in poverty. Some are unavoidable and need system wide changes. Some, however, come from our own lack of understanding. For this reason we held a workshop about poverty. Our goal was to learn more about the people for whom we provide care. Perhaps this would lead to us providing better care. If not, at the very least, perhaps through a greater understanding of poverty we will also have a greater compassion towards those we encounter in the ED.

In order to accomplish our goal we invited LaMorris Crawford. Crawford was born in Altgeld Gardens on the South side of Chicago. He grew up in a high poverty neighborhood where crime and drugs were the norm. Crawford says that he became a product of his environment, active in gang culture and drug trade. After seeing many of his friends and family end up dead or in jail he knew that he had to make a different life for himself. He completed an associate degree at a local Community College and went on to not only get a Bachelor’s degree but also completed his Master’s in Organizational Leadership. LaMorris now speaks regularly to athletes, sports teams and groups like ours.

Feedback was clear that Crawford’s talk was thought-provoking and challenged how we care for those in poverty. First and foremost he encouraged us to get to know our patients. This doesn’t need to take long but asking a simple question to get to know someone beyond their physical need connects us to them as people and we no longer identify them by their chief complaint. Getting to know our patients not only creates more fulfilling interactions for us but also shows that we care. If our patients leave feeling like they were cared for, it leaves a lasting impact no matter what their body feels like.

Crawford also discussed Assets. He explained that the assets, or what is important to us and vital to our existence, can be so vastly different for those in poverty compared to those in the middle class or living in wealth. Having an understanding of this causes us to remove our preconceived notions of how we think our patients should act or what we think should be important to them. Through a greater understanding of what motivates our patients and what is important to them, we can work alongside them to find the best solution to what ails them instead of feeling like they don’t care or don’t want to do what we think is best for them.

Everyone who was at the poverty workshop was enriched in some way. LaMorris did an amazing job at taking a topic that can certainly be complicated and presenting it in a way that helped us have a better understanding and gave us tools to better care for our patients.

We are grateful to LaMorris for sharing his life experiences with us and giving us insight into the lives of so many of the patients that we see every day. Taking a few extra seconds to show that we care for our patients as people and understand that their daily priorities are different from ours will not only lead to a greater job satisfaction but also to better and more fulfilling patient care.

Check out the presentation at:
LaMorris Crawford – Approaching Poverty

Please join us on September 12 at 6pm for our next Advocacy Track Workshop where we will be focusing on Health Literacy!

Testimonies to Senator Miller

Today Dr. Lindsay Harmon, IUEM grad and current faculty, testified in front of Senator Miller and Committee about a new bill addressing opioid abuse in Indiana. Dr. Harmon addressed specifically the chronic pain program at Methodist hospital and how opioid abuse is handled in the emergency department setting. Other testimonies from previous opioid abuse victims, addiction psychiatrists, pediatricians and other task force members provided enlightening views on how this national issue affects other areas of medicine and the community.

Please visit the following link for more information:
http://www.nabp.net/news/indiana-medical-board-to-adopt-emergency-opioid-prescribing-rules-at-request-of-state-legislature

Choosing Wisely: Advocacy Track Meeting Update – 8.14.13

This week we discussed the national campaign Choosing Wisely and emergency medicine’s role. The campaign’s goal is to have each specialty choose five evidence based decision rules to improve patient outcomes and cut-down costs. ACEP had initially been reluctant to join the campaign due to litigation concerns, but just announced they will now be participating. Our track would like to contribute and will be coming up with our own Choosing Wisely decision rules for the year.

Read more below:

http://www.acep.org/choosingwisely/
www.choosingwisely.org/

Can you come up with five evidence based decision rules?

The Rising Cost of Health Care

Have a discussion about health care recently?  Did rising costs come up?  Of course it did.  Emily McIsaac, an IUEM R3, discusses her perspective as an emergency medicine physician:

My mini rant

When I had that ceremonial sash (I believe it is actually called a hood), placed over my head by my father at my medical school graduation, I had little to no idea that suddenly becoming a doctor was now going to grant me the title of the health care expert and frankly I had no idea how much I didn’t know.  It is now the end of my intern year, and though I have gathered an enormous amount of clinical experience, there is still an area of medicine that I am rather ignorant about: costs.

According to a recent report released by Milliman Medical Index and published by Forbes magazine, the average health care costs for a family of four with a PPO insurance plan is over $20,000.  That is with insurance.  Imagine the costs for a family without insurance with a catastrophic health event.

As part of my residency training, the residents spend about half of their time at a county institution.  Most patients do not have insurance and only some can get on the state aid program.  At some point in my training, I quickly realized that someone was paying for patient care and it certainly was not an insurance company or likely the patient.  That CT scan I ordered was coming out of the taxpayer’s money- that doesn’t seem fair.  But it also isn’t fair that my patient can’t qualify for insurance to help pay their bill.  Or they can’t get in to see a primary care doctor regularly to control their diabetes so they are stuck coming to the emergency department for higher cost treatment.

Health care expenditures accounted for 17% of the GDP in 2008 and is estimated to rise to 19% by 2017.  It is a major concern as this level of growth is unsustainable.

What is The Affordable Health Care Act?

On March 23, 2010 President Obama signed a bill that is expected to comprehensively reconstruct the way health care insurance works in the United States.  This also includes several reforms to improve health care costs.

Recently, The Center for American Progress, held a panel discussing the Affordable Care Act.  The panel addressed the changes already made and future changes that are to be enacted soon, specifically pertaining to cost effective care.

The panel included several physicians and policymakers who were involved with drafting the bill.  The panel members extensively discussed various test areas and their success as well as future plans.  Specifically, they brought up a few terms that I feel need definition before further discussion.

Alternative Quality Contracts

Program enacted by Blue Cross and Blue Shield of Massachusetts in 2009 that took primary care providers and provided them a base fee for patient care and also provided bonuses for savings and health targets reached.  This plan suggests they reward for quality and efficiency instead of volume.

Accountable Care Organizations

Groups of hospitals and physicians made responsible for a group of Medicare patients.  In theory, the organization would be paid a flat fee per patient and its job would be to minimize patient costs.  The more money that it saves, the more money the group makes.

Bundling

Transferring from a fee for service payment model to what is described as a bundled charge.  This would take a diagnosis such as congestive heart failure exacerbation and make a standard charge for the admission and recovery.  Per the panel, this is already done for many operative procedures but could also be applied to diagnosis like depression.

What does this mean for Emergency Medicine?

As the panel alluded to, a major goal of the new care plan is to decrease “unnecessary” ER visits and the rate of readmission.  The over-arching theme seems to be to place the provider and healthcare network with more responsibility in the long term care of the patient.  In order to do this, the provider/group would be financially rewarded for a healthier patient.   Not only would this include the PCP, but also the rehab sites, and nursing homes.  The plan would encourage communication between the patient’s health care resources.

In the emergency department this would hopefully mean less chronic health exacerbations or noncompliance visits, which would obviously significantly reduce patient load.  The panel also mentioned providing 24/7 primary care access through ancillary health care staff.  Traditionally, this burden has been carried by emergency departments for after hours and weekend care.  Although in theory this is a great idea, it is hard to imagine it in practice.  With the lack of primary care providers, the emergency department will still be the only option for non-ideal hours of care.   It is also unclear how emergency medicine will fit within the ACO model.

The panel did not specifically explain the intricacies of the bundled payment model, and it is hard to imagine how this will apply to emergency medicine.  Will the emergency medicine fee be an allotted amount based on the diagnosis?  Will emergency physicians be rewarded for communicating with primary care providers and working to keep patients from admission?  Since emergency medicine is a shift-based specialty based on single visits, it may take some creativity to integrate the specialty in the new system.

One more comment- during the panel, one physician cited that only 10-15% of emergency room visits are true emergencies.  It is clear that emergency departments are overused for a variety of what may seem to be primary care complaints.  I am not convinced that only 10% are true emergencies, but do agree that many can be treated with less expensive care.  Consider an uncontrolled diabetic.  Many of these patients get admitted for diabetes education and glycemic control.  What if this patient could be given fluids and insulin in the department and then sent home with follow-up the next morning this their PCP? Or their PCP could communicate with the emergency medicine physician/nurse/midlevel provider to make adjustments to their regimen that day, thus reduce another health care visit and possibly prevent future ones.

The problem is access to care and the efficiency of care provided.  Increasing communication and a patient centered focus will be pivotal in the change.  However, legislators must also remember that health care is a business.  People must be rewarded for the changes they make both in practice and their commitment to their patients.  The financial incentives surrounding reimbursement will have to adjust to not only be more effective but also profit enhancing.  As the panelist alluded to, this may mean more intermediate providers, electronic communication, data analysis for patient care improvement, and incentive structures to decrease costs specifically admissions.  Emergency medicine will be expected to become more involved with these changes, though the exact role remains unclear.

If you are curious about the Affordable Care Act please visit the website:

http://www.healthcare.gov/law/index.html