Monday, September 22, 2014

At the Heart of It All...

Tonight I watched one of my favorite movies, Something the Lord Made, for what is probably the fifth or sixth time.  Yes, I really love this movie.  If you haven't seen it--watch it.  Briefly, it is the story of Vivien Thomas, the black carpenter turned dog lab cleaner turned lab/surgical assistant to Dr. Alfred Blalock.  Thomas was at Blalock's side the whole time in devising the blue-baby operation, which is now known as the Blalock-Taussig operation.  This operation has saved the lives of countless babies born with Tetralogy of Fallot over the years.

In the past when I've watched the movie, the racial and gender issues have come to the forefront (blacks and women, as in Thomas and Taussig, weren't exactly accepted by the good old boys at Johns Hopkins).  Tonight, something different came to the forefront.  I was watching the movie for the first time on DVD (versus VHS-yes, our family has some TV/electronic antiques), and there was some written text at the end...about how this operation in 1944 was the beginning of the field of cardiac surgery.

Wow.   That's huge. CABGs (bypasses), valve procedures, congenital defect repairs...these are the bread and butter of cardiac surgeons these days.  Still certainly major procedures, but fairly common. And it started in 1944.  Taussig had observed and cared for many cyanotic young patients as their pediatric cardiologist and provided the diagnostic acumen needed, Blalock was brave enough to operate on the previously untouched heart..and Thomas' skilled hands and intelligent mind guided the development and execution of the procedure.

As I watched the movie, with its depictions of "old-time medicine"--ancient oximeters, IV fluids in glass bottles, hand-operated blood pressure made me think of how much medicine has changed since the days of Blalock, Taussig, and Thomas.  The heart is no longer uncharted medical and surgical territory.  New technology makes it possible to perform longer and more complex cardiac surgical procedures on patients.  Transplants can be performed to give patients new hearts and second changes at healthy lives.

So many changes in heart surgery since Blalock, Taussig, and Thomas paved the way back in 1944.  It is nothing short of incredible. And yet the main ingredients from their work....intelligence, diagnostic ability, ingenuity, perseverance, skilled and steady hands, and brave and caring hearts...are still applicable and relevant today--in heart surgery, and in medicine as a whole. No pun intended, those ingredients are still at the heart of it all.

Thursday, September 18, 2014

Serving in the Danger Zone...

A few nights ago, I saw Access to the Danger Zone a movie about Doctors Without Borders.  Poignant, and sometimes gruesome, medical scenes were interspersed with commentary about the organization, its logistics, its neutrality.  After the movie there was a panel Q&A of returned volunteers, and the matter-of-fact attitudes and the enthusiasm for the work were impressive.  I am not sure who scheduled the movie, but that person could not have picked a more appropriate time, given all of the current international health crises.

Doctors Without Borders volunteers routinely serve in danger zones around the world.  Somalia.  Afghanistan. Sierra Leone and other Ebola countries.  Refugee camps. Natural disaster areas. They may put their own lives at risk while serving.  Today on Twitter, just two days after seeing the movie, while scanning my usual public health sources of news I saw a Tweet that a Doctors Without Borders volunteer had a confirmed case of Ebola.  Yikes.

My heart--filled with admiration--goes out to the Doctors Without Borders volunteers.  They go where few other groups can or will go, into the most dangerous places with the most unsettled political situations, to provide critical medical care.  They run feeding centers that save the lives of critically malnourished children.  They also provide other services; the movie showed a program at an African hospital for pregnant women; the women can come and stay there during their pregnancies and be kept safe and healthy.  They receive the medical care and the social support they need, and deliver their babies at the hospital.

It would be nice if our world didn't need Doctors Without Borders.  If every nation had a strong medical and public health infrastructure in place to face emergencies, to address epidemics, to implement testing and treatment programs, and to educate individuals and communities around prevention.  If there weren't the wars, if there weren't the violence and the fleeing of refugees, if there weren't natural disasters affecting high poverty countries.   Wishful thinking!  It seems like Doctors Without Borders is almost more necessary than ever now.

Like I said, that movie couldn't have been timed better!


Monday, September 15, 2014

Two Kinds of Public Health....

For the past month or so, I have been on a break.  Not summer vacation like I used to have in my teaching days. And not a break that involved traveling.  A break from one of the kinds of public health in my life, a one-evening-a-week volunteer activity in which I work with Latino kids and families in a family literacy program.

To be honest, I thought it would be really nice to have that particular evening free for a while, to have a little more time to play outside on beautiful end-of-summer evenings.  

But...I miss it.  I miss being with the kids while their parents are occupied with the hard and important work of learning English.  I miss the reading, the art projects, the pretend play, and the walks to nearby parks with playgrounds.  My teacher self misses trying to figure out which skills kids have and don't have as we read and write with them.  Most of all, I miss knowing that with the help of staff and volunteers and community programs, families are able to learn and grow together.  I miss doing this particular kind of public health.

Some of you are probably saying "huh?!?"  You're wondering how learning English, how playing and doing art projects, are public health.  When they happen in a program that serves two generations, that provides education for whole families in a community context...they are public health.  Big time.  I've blogged about two-generation programs before, and I won't reiterate it here--suffice it to say I am a major fan.  

The public health that I do during the day and the public health that I do in the evenings are different. This break from the evening-volunteer-public-health has made me realize just how much I value that public health.  Which is why I can't wait to see the kids and families again soon (even the rowdy kiddos).  I can't wait to have both kinds of public health in my life again.

Tuesday, September 9, 2014

The Art of Being a Patient...

I thought that I was more or less used to being a patient.  After all, not only have I been a patient of my own doctors over the years, I've been raised by doctor-parents who provided clinical care for patients. And I know how to navigate the health care system, courtesy of public health grad school.

Enter being a patient in an large academic health center.  Where the cast of characters includes more than individual doctors with years of practice experience under their belts with whom it's possible to have long-term doctor-patient relationships--which is what I'm used to.  In academic medical settings, the cast expands exponentially to include medical students and residents at all levels of training. 

Being a patient when med students and residents, along with senior physicians/attendings, are in the picture is a little...different.  You may have to give a history more than once--in detail, because med students and residents tend to ask lots of questions.  You might get examined more than once.  You might experience different ideas about tests and procedures needed.  You may have to be very explicit and crystal-clear about certain issues. Among other things.  There's definitely an art to being a patient under med students and involves being a patient patient (no pun intended).

I know that these medical students and residents will someday be real doctors, caring on their own for patients--maybe even for me or my family and friends.  And I know that the docs in my family were all med students/residents at one time, and developed their skills on patients during training.  I don't object (so far) to med students and residents practicing and learning on me...honing their history-taking skills, performing exams, etc.  It's actually really cool to see a  competent and caring doctor-in-training and to be able to tell that he/she will make an outstanding doctor someday. In my mind, giving med students and residents the chance to practice on me is a  fair trade for being able to receive excellent academic health center care. 

But while the med students and residents practice their evolving clinical skills on me, I am going to have to practice my evolving patient patient skills on them.  It's a two-way street.

Sunday, September 7, 2014

Back to My Roots...

Every once in a while I head back to my see family and friends, to hit favorite restaurants, and to relax.  When I go back, it reminds me of my medical and public health roots.

Because my hometown is the place, where, as a child and teen and young adult, I watched my doctor-parents in action...answering numerous beeper pages, doling out copious amounts of medical advice at all hours over the phone while on call, making occasional housecalls (and hockey rink calls), and caring for patients in a clinic and hospital.  It is where I became fluent in the language of medicine, learning it from the doctor-parents and various doctor-friends.  It is where I did my first public health advocacy work, around the hot issue of the day--tobacco.  It is where I spent several years working and volunteering as an interpreter, helping patients and doctors to communicate with each other and connecting patients to community resources.  It is where I worked as a teacher, and learned about the interconnections between schools and community that are needed for healthy kids.

I live and work now in a very different medical and public health environment.  Academic medicine, grants and contracts, strong and longstanding public health networks, etc.  I've become reasonably accustomed to this environment, and can now converse somewhat fluently in its unique languages and dialects.

Even a short trip back to my hometown, though, makes me head down medical-and-public-health-memory-lane.  It takes me back to my roots, and reminds me of the medical and public health lessons and values that I learned while growing up, working, and volunteering there. I've discovered that there's a vast gulf between the community clinical medicine around which I was raised and the academic medicine that I live in now as a patient and a professional.  I've also discovered that you can't take the community public health out of a girl who spent years working at the community level, no matter what.

I don't ever want to, or plan to, forget the lessons and beliefs learned and the advocacy performed and the connections made.  I don't want to forget the awesome mentors and role models, the challenges of working with a diverse and impoverished population, and the energy inherent in community health projects.  I can be just a little stubborn (just ask my brothers), and I'm holding on pretty tightly to the things I learned over the years.

Some people are eager to shed their roots, to completely forget where they came from, to start completely fresh.  Not me.  I'm more than happy to be reminded of my medical and public health roots.  It's a good thing because they are good roots.

Tuesday, September 2, 2014

Three years and counting

This month marks three years of blogging, which is really hard to believe.  When I think of all the public health and health policy events since the fall of 2011, namely the upholding and implementation of the!  I'm lucky that I've been a blogger during such exciting times, and even luckier that family and friends have bothered to read my random ramblings and occasional rants and raves.

I just figured out how to "label" blog posts (it only took me three years to learn this trick), and as I was doing it, it brought back memories of my public health and health policy journey over the past three years.  I went from community educator and Spanish interpreter to working at the public health system level.  I went from a very rural area to an urban, capital city (AKA hotbed of health policy) environment.   Along the way, I've gained some public health patience and maybe even a little wisdom, met a bunch of skilled and passionate professionals and advocates...and blogged through it all.

Thinking back, this blog started as my way of educating non-health policy people about health policy.  Very quickly, as health policy heated up in our state and nation, it continued to have an education function but also became my moan and groan, to grumble and mumble, but most importantly to speak out as an advocate.  Blogging life is different now for me, because I no longer work directly in communities.  I no longer have "war stories", and no longer deal with concrete situations that get my health policy advocate self all up in arms. Thus, blogging has become more of an abstract art, but one I look forward to continuing! 

I'm hoping some really awesome and amazing health policy and public health topics come up in the news and I can blog about them this month (how about a Medicaid expansion in our state?!?  I wish!).  For now, I need to thank some people:
  • The family members who have read almost every blog post I've ever written during the past three years--and who occasionally provide fodder for posts (yes, I someday owe my young nephew royalties on the posts related to the costs of infant well-checks). They have also put up with my computer-hogging tendencies when I'm blogging.

  • The friends who read my posts and humor my public health and health policy obsession.  Especially the few who are equally obsessed.

  • The authors of the medical/public health books on my shelves--Atul Gawande, Darshak Sanghavi, Siddhartha Mukherjee, Paul Farmer, etc--for putting words together in incredible ways to tell inspiring medical and public health stories.  Oh yes, and authors like Nicholas Kristof who truly "get" public health and provoke my thoughts with their articles.  Hoping someday to be half as good as they are.

  • The patients and families, community members, colleagues, physicians and health professionals, students, and others who have taught me so much.  I never realized just how much I've learned and how many public health and health policy "teachers" I've had until I started blogging about it.  Obviously--and luckily, "school" did not end when I got my MPH!

Wednesday, August 27, 2014

Scary numbers: what do we do?

Today I saw research results that freaked me out.

The research study looked at the long-term impacts of children of their mothers' Gestational Diabetes Mellitus (GDM).  For those who don't know,  GDM a type of diabetes that occurs during pregnancy.  We know certain things about it:  Uncontrolled GDM increases moms' risks of preeclampsia and of future Type 2 Diabetes.  It increases babies' risks for high birth weight (macrosomia) which can increase the risks of labor and delivery problems, neonatal hypoglycemia, preterm birth, and  childhood obesity and Type 2 diabetes as adults.  (For more information on GDM, visit the American Diabetes Association website or Mayo Clinic's website.)  The good news is that controlling GDM, with diet and/or insulin, can improve health outcomes for mom and baby.

 As an interpreter, I went through a phase when I interpreted for several women with GDM.  These women happened to be following their specialist doctor's recommendations to the letter, checking  blood sugars at home religiously and using insulin as instructed (and the regimens were not simple). They were eager for their babies to be born so that they would be done with the GDM, the strict diet, and the insulin.  I, however, had mixed emotions.  On one hand I could completely understand their eagerness to be done with everything.  Who wouldn't feel this way?  On the other hand, my health policy brain knew that after delivery and the six week postpartum period, these Latina  immigrants would no longer have access to covered medical care.  No more pregnancy Medicaid.  Knowing that having had GDM they were at increased risk for Type 2 diabetes, I couldn't help but wonder...when and where would they get their follow-up blood sugar tests?  Who would counsel them about their risks, and provide nutrition information?  Who would provide high quality interconception care?

Back to the research study.  This study looked at 255 obese adolescents.  210 (82.3%) had not been exposed to GDM while in utero, and 45 (17.7%) had.  Of those not exposed to GDM in utero, only 8.6% had impaired glucose tolerance (IGT) or Type 2 diabetes.  Of those exposed to GDM in utero, 31.1% had IGT or Type 2 diabetes as determined by repeated oral glucose tolerance tests (OGTT).

31.1%.  That's almost 1/3 of the adolescents in the study who had been exposed to GDM in utero being at risk for Type 2 diabetes or actually having it.  Years after they were born.  Yikes.  This study is not the 'be all, end all,' but it's scary.

What do we do--not just to treat, but to prevent GDM in the first place?  I don't pretend to know the answers to this, though I definitely think that access to Medicaid coverage before, between, and after pregnancies for noncitizen immigrants could help by increasing access to ongoing care, at least for this population.  What else do we do?  We better figure it out, because with numbers like these...we have to do something.  ASAP.