Cost-Conscious Care

Editor’s Note: One of the features of completing a clinical rotation at Siloam is learning about “poverty medicine” – delivering cost-conscious care. Andrew Wu, a 4th year Vanderbilt medical and master of public health student recently rotated at Siloam.  Andrew writes of his experience…

Wu, Andrew - VMS-IV - with Dr. Snader 10-2014

Dr. Brent Snader serves as a preceptor to 4th-yr Vanderbilt University School of Medicine student Andrew Wu.

One of my first learning experiences was an opportunity to learn how to practice in a cost-effective manner. A patient needed to be screened for colon cancer, which is normally done with a colonoscopy. However, due to financial constraints for this patient population, the alternative strategy of a fecal occult test was used in lieu of colonoscopy at this clinic. I found it interesting that these “alternative” methods were actually the standard for this particular patient population. In nearly all of my training, I was used to having almost unlimited resources at my fingertips. I could order labs and procedures without thinking much about the cost since they were either allowed for educational purposes or simply because the hospital could afford it. However, practicing at Siloam has allowed me to taste a bit of the reality of the cost behind the medical practice and how to appropriately adjust for it.

Looking for opportunities to give yourself to?

We often blog about medicine being a calling…one, to which practitioners are motivated by God’s tug on their life to pursue.  P.K.Lee - MSF in Sierra LeoneUnfortunately, “a not-so-funny thing happens on the way to the forum.”  Their motivation to practice medicine shifts.  As one of my colleagues often states, “many go into medicine to do good, yet come out of medicine to do well.”  Here is an opportunity to do good…and, possibly get back to that original “calling.”

Doctors Without Borders/Médecins Sans Frontières (MSF) helps people worldwide where the need is greatest, delivering emergency medical aid to people affected by conflict, epidemics, disasters or exclusion from health care. On November 6, 2014, medical and non-medical professionals are invited to a late afternoon presentation from 5-6:30 in Vanderbilt University Medical School’s, Light Hall, Room 208,  to learn more about how they can join Doctors Without Borders’ pool of dedicated aid workers. For readers outside the Nashville, Tennessee area or otherwise unable to make the meeting, more information about opportunities can be found at this link:  http://www.doctorswithoutborders.org/work-with-us

 

No magic solution…

The Siloam Institute offers clinical rotations to nearly 40 health professional trainees annually. Their rotation at Siloam helps them to deepen their understanding of how to engage persons living in poverty, work cross-culturally, and learn how to integrate behavioral health and spiritual care into their practice of medicine.

Click the video below to watch Samaiya Mushtaq reflect on a particular patient encounter stating, “I did not offer them a magic solution to their health problems, but I think they felt a little more healed after that visit.” Samaiya is a fourth-year Vanderbilt medical student who plans to pursue a residency in psychiatry.

Taking a lesson from impoverished nations

Photo Credit: Lwala Community Alliance

Photo Credit: Lwala Community Alliance

Siloam’s Community Health Immersion students worked to train refugee lay health workers for a more effective outreach to the refugee families in Nashville.  This work drew much of its inspiration from successful community health worker programs found in impoverished nations.

In a guest blog at Huffington Post, comments made by James Nardella (Lwala Community Alliance) resonate with our experience here in Nashville.

James writes:  “Scale and efficiency are important to moving health care goods and services….  But, when it comes to addressing the root causes for poor health in many places, scale can be a distraction. Delivering goods and services alone will not motivate people toward health seeking behavior.”  James goes on to point out that, “…health-seeking decisions are made at the family level.”

Read the full post of James’ excellent blog Heirloom Healthcare for the Poor by clicking here.

Lay health workers trained by Siloam students

“I‘m too much glad to see you because you are Nepali.” Greetings like this one from a Nepali man bring joy to 19-year old Anita Nepal who loves helping people in the Nepalese community of Nashville.  Anita, born in a refugee camp in Nepal to Bhutanese parents, was recently trained as a lay health worker by pre-medical students participating in Siloam’s Community Health Immersion program. Nashville’s Nepali community – mostly made up of refugees from Nepal and Bhutan – appreciate the cross-cultural understanding that Anita brings as she teaches within her community on the health topics she recently learned.

“Many of the Nepali people do not understand the health care system in America,” says Anita who works full-time in housekeeping at a local hospital. They struggle to know how to make appointments to see a doctor or how to get medicine from a pharmacy because as Anita says, “… in Nepal there were no appointments or prescriptions…you just show up and ask for what you need.”

“I learned many things – I can help many…”

For Siloam’s six-week Community Health Immersion program, pre-medical students were recruited from around the country to live in a refugee apartment complex in southeast Nashville where they trained nine lay health workers like Anita from the neighborhood. Training topics included preventative care like oral health, nutrition, and exercise, along with health navigation topics like how insurance works and the difference between an emergency room and a primary care clinic. Beyond learning how to teach lay health workers, the pre-medical students also explored how to see the vocation of medicine as a calling and to see how to care for patients as whole persons as Jesus did.

The pre-medical students’ work with the lay health workers is making a lasting impact.  The oral health topic alone made an immediate impact on Anita’s family of five who were resettled a year ago in Nashville after spending 21 years in a refugee camp in Nepal. “We did not know about dental floss or how many times each day to brush our teeth or for how long,” Anita says. “Now we do. I learned many things – I can help many Nepali and Bhutanese people.”

Lay Health Workers and CHI Students pose outside their apartment - 2014 - cropped

Pre-medical students and lay health workers pose outside following a training session. Lay health workers include (L-R) Samson Sarki from Bhutan (in turquoise), Paulos Ezekiel from Eritrea (in purple), and Anita Nepal from Nepal (in blue and red). Pre-medical students (L-R back row) include Will Davies, Stewart Goodwin, Kenny Namkoong, Frances Cobb, Caleb Huber, Will Tucker, along with Reinie Thomas (kneeling), and Lauren Roddy (in blue on right). Pre-medical student Chelsea Travis is behind the lens!

Off with a bang!

It has been quiet this week since our nine CHI participants (7 pre-meds and 2 directors) left town after spending an exciting six-weeks with us on a Community Health Immersion.  As we celebrate our nation’s independence this weekend, let’s also celebrate the ministry of presence that our freedoms allow us to carry out.  Check out this video that the students put together as a celebration of how God is moving in their lives as they prepare to be future physicians:

Helping Without Hurting

Guest blogger Lauren Roddy, one of seven students in this summer’s Community Health Immersion, writes…

35 For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.”

These verses from Matthew 25 are just one example of how we, as Christians, are explicitly called to care for and minister to the poor.  The participants in this year’s CHI Program and the staff at Siloam are seeking to answer this call, but what if our best efforts to help are actually hurting those in poverty?  What if our desires to be the hands and feet of God are preventing others from doing the same?

“What if our efforts are hurting those in poverty?”

The CHI Program, in addition to providing opportunities to shadow Siloam staff and directly engage in community outreach, has several settings in which the students can begin to discern what their future service in medicine will look like.  One such forum is a 6-week small group study on the book When Helping Hurts by Steve Corbett and Brian Fikkert.  The book offers a framework for rethinking not only how we address the needs related to poverty but also to redefine the term completely.

Instead of thinking about poverty in terms of a lack of material wealth, When Helping Hurts challenges us to think of it as a product of broken relationships – with our own being, others, God, and the rest of Creation.  Therefore, true poverty alleviation is a process in which both the materially poor and non-poor work together to rectify each of our broken relationships.  The goal, therefore, of working with the materially poor is to reconcile these foundational relationships and in such a way that all are empowered to perform the work in God’s kingdom that they are meant to do.

What good is relief if we’ve crushed the confidence

needed for true development?

Those of you not familiar with these concepts may be shocked to hear phrases like “our poverty” and “our broken relationships”, but through this process, I’ve learned to recognize the places in my own life where relationships have been broken.  When Helping Hurts advocates for poverty alleviation that focuses on building on the God-given assets already present within individuals and communities.  In my own life, I often am afraid to “brag” about my assets, talents, and ideas, and as a result, fail to fully achieve what I am made to do.  Imagine how much more debilitating that fear must be for someone who has been made to feel as though their lack of material wealth makes them worthless.  To then tell this person that we have all of the answers to fixing their poverty strips them of the already limited power they have.  What good is relief if we’ve crushed the confidence needed for true development?

Lauren Roddy is a rising junior in the pre-medical program at Baylor University in Texas.

Lauren Roddy is a rising junior in the pre-medical program at Baylor University in Texas.

Framing poverty in terms of relationships just makes sense to me now.  Not only do we belong to a relational God, but medicine is also such a relational field.  Our primary focus should always be on the empowerment of our patients.  A piece of this certainly is restoring physical health, but helping others (and ourselves) feel empowered and purposeful is how real growth occurs.  I hope that my friends and family will consider reading the book, engaging in conversation with me about these ideas, and holding me accountable to living this out!

“Share the gospel at all times, and when necessary, use words.”

– St. Francis of Assisi

Empowering the Impoverished

Guest blogger Kenny Namkoong, one of seven students in this summer’s Community Health Immersion, writes…

Teaching is not a forte of mine.  Public speaking in itself frightens me.  However, those were the requirements coming into the CHI program.  I had to be a teacher to lay health workers from the refugee community.  I also had to speak in front of the staff of Siloam Family Health Center.

“Thankfully, I was wrong.”

Initially, the lay health worker training seemed like a huge obstacle.

CHI participant, Chelsea Travis, works with lay health workers.

CHI participant, Chelsea Travis, works with lay health workers.

I felt like I did not have enough knowledge to teach anyone.  Training the trainer, a time where the Siloam staff taught us healthcare-related information, was informative but it included overwhelming amounts of information.  How was I supposed to teach all of this information to people who had limited English?  Would they even appreciate the training?  I approached the training with skepticism and with the mindset that belittled the trainees.  Thankfully, I was wrong.

“…the tension and worry turned into excitement.”

I was assigned to the first group that presented.  We were in charge of introducing the curriculum and conducting the first lesson.  With the total of 4 lessons, my fellow CHI participants divided up the health-related topics broadly into health navigation, oral health, insurance, and nutrition.  Since my group was first, it was difficult to know what to expect.  However, as the lesson got underway, the tension and worry turned into excitement.  These people were ready to learn. 

The individuals from 5 different countries (Burma, Bhutan, Somlia, Iraq, and Eritrea) were very prepared to learn from us in order to help their respective communities.  They were eager to absorb the information being taught by us.  I felt obliged to improve myself so that I could help the lay health workers become more educated.

The purpose of the community lay health worker training is so that we can relieve the impacts of poverty within the population represented by the lay health worker.  Siloam Family Health Center’s goal is to go beyond its four walls and provide healthcare to those outside of its building.  The lay health workers are a good way to provide preventive care measures to each of the five different communities.  Instead of prescribing medicine and diagnosing symptoms, the usage of lay health workers will benefit the overall health of the refugees and immigrants before things get out of hand.

 “A man’s heart plans his way, but the Lord directs his steps.” 

After finishing all of the training for the refugees, I realized one thing: God is in control.  We planned and executed.  We did all we could in order to educate the workers.  However, if God were not in the midst of our fellowship, I think it would have been a failure.  “A man’s heart plans his way, but the Lord directs his steps.”  -Proverbs 16:9 (NKJV).  Its an amazing thing to see individuals from 5 different countries gathered in a small apartment living room in the middle of Tennessee.  Unbelievable.  God works when He is ready.

CHI participants teach lay health workers about nutrition and exercise.

CHI participants teach lay health workers about nutrition and exercise.

The hard part starts now.  What kind of help can we with the newly trained lay health workers give to the community?  Can we make a difference?  Will it be enough?  Although there are many questions to answer, we put our trust in God.  We approached the outreach to empower the lay health workers, not just to pat ourselves in the back.  We train to raise leaders who can help bring an end to poverty: financially, socially, and physically.

Rich in Poverty

Guest blogger Will Davies, one of seven students in this summer’s Community Health Immersion, writes…

I thought it was another normal day at Siloam.  The health care providers were supplely moving about the clinic, tending to each of their patients (including any unscheduled walk in patients).  Interpreters were turning the confusing syllables of patieLoneliness - blackednts who spoke no English into relatable language for the health care providers.  And as if the administrative staff had personally learned from God, himself, when he formed the world, they too brought all sorts of chaos into order.

It’s here that our team has seen how Siloam isn’t just restoring the health of those who live in financial poverty, but they are bringing down the Kingdom of God to their patients, helping restore different types of poverty as well.  For we live in a world stricken with poverty.  Relationships with loved ones, our self-image and worth, the creation around us, and our relationship with God can all exist in poverty.

And our CHI team has been lucky enough to join with Siloam and fight against these different types of poverty.

 “…a refugee…sat hunched over from pain…”

Two weeks ago I found myself in a clinic room with two people: a refugee, and one of Siloam’s health providers whom I was shadowing.  What could have been a simple check up was made trying, for our patient, a refugee who had no insurance, has no family in the States, and to make matters worse. . . spoke no English, sat hunched over from pain caused by constipation.

Yes, medicine could help this patient, and I’m sure it did.  But he needed more.  In fact, the physician’s prescribed treatment was instructed to his case worker:  “Find some people to stop by his apartment, spend some time with him, and help cook him a healthy meal!”

You see, it wasn’t a problem of financial poverty.  This patient suffered from poverty of all sorts of other relationships!  Having been in the states less than two weeks with no family, no friends, and no one to be with, there was plenty of room for restoration.

My having grown up in a financially blessed family, society, and Church, it is easy to view poverty in one way: the lack of material possessions.  As a church, it can be easy to give materials away to the poor, pray blessings over them, and call it a day.  This method of help is easily measured and has a nice ring to it: “We went to this poor area of town, gave away certain material gifts that can help improve the resident’s lives, built a certain amount of homes for them to live better lives in, and oh ya- we also provided them food because they were hungry.”

“…he called his disciples to a life of greater financial poverty…”

Those are good and needed things. . .but only sometimes because this type of aid only helps with financial poverty.

What about the relational poverty that our neighbors are living in?  As Christians, we are called to love people relationally as well as financially.  It’s not glorious to forsake your own life, fight for other people’s lives spiritually, and equip others to do the same.  But that’s what Christ did.

When Christ called his disciples, he didn’t walk up to them, seeing that they were poor, hand them some extra change, or even build them a better house!  In fact, he called his disciples to a life of greater financial poverty!  What!? Wow.  And asking them to live life with him, he revealed to them who God was.  He fought for their lives spiritually, and because of it, the poor became rich, and followed him.

“…he happens to live in our neighborhood!”

Will Davies is a rising junior at the University of Tennessee. He is among seven pre-medical students committing their summer to a Community Health Immersion in Nashville.

Will Davies is a rising junior at the University of Tennessee. He is among seven pre-medical students committing their summer to a Community Health Immersion in Nashville.

So last week, as our group was rewinding after a day at the clinic, the same patient from the clinic happened to run into us because he happens to live in our neighborhood!  Wow, it’s amazing how the Lord sets things up.  As we invited him into our house, he looked much better than previously, but still spoke no English.  And it’s here where our CHI team was able to start to love him, know him, and bless him.  We are not great at it, but it’s a beginning.  And as we will get to know him more over our next few weeks, I pray that the spirit of God will move through him and us, and our poverty of relationships will be restored.