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.

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.

2014 Community Service Award – The Siloam Institute

The Siloam Institute was recently recognized by the Tennessee Medical Association for its work training the next generation of health care practitioners in whole-person care.  Dr. Morgan Wills and Mark McCaw attended an awards ceremony where the video below was shown.

 

Dr. Morgan Wills, President and CEO of Siloam Family Health Center and Mark McCaw, Siloam Institute Director receive the 2014 Community Service Award given by the Tennessee Medical Association.

Dr. Morgan Wills, President and CEO of Siloam Family Health Center and Mark McCaw, Siloam Institute Director receive the 2014 Community Service Award given by the Tennessee Medical Association.

 

Whole-person care…is GRRREAT !

Tony the Tiger recently sought care at Siloam.  Listed as “Tony Tiger” in our electronic health record, Vanderbilt Medical Student Enoch Sizto was given a patient’s perspective on the entire clinic process.  Preparing for his new patient appointment, Enoch remembered to bring his identification (see accompanying photo). Tony Tiger - Enoch Shizto 2-2014

We want our trainees to see that in our attempt to provide whole-person care we need a team committed to making that experience possible.  The best practice examples of whole-person care extend beyond what goes on in the exam room between the patient and the practitioner.  Every staff member plays a role in caring for the whole person…from taking a patient phone call, to check-in, to triage, to the lab, and eventually to check-out…how staff address and care for patients is critically important.

This is not merely a “good customer service” technique, although I certainly do not knock the need for customer service training.  Whole-person care starts with the heart of the individual providing the service.  They must know themselves to be deeply loved creations of God…and, be encouraged by team members and leadership…and, supported by organizational policies and procedures.

Some ways we carry this out at Siloam is hiring staff that understand deeply our mission and can abide by our core values.  It follows with daily moments of renewal of spirit in prayer huddles to seek God’s blessing upon the shift ahead of us.  It is supported by a weekly staff meeting that allows us to form community (team-building) and reflect upon our purpose and study the scriptures.

Making whole-person care “Grrreat!” is not a destination but a process.  We continue to learn as we go.  What systems, processes or people have you experienced that make whole-person care possible in your life?

Optimized for caring

Feussner, Derek - VUMC PGY-II 9-2013 - with Mark McCaw

Mark McCaw, Associate Director for the Siloam Institute, explains the primary care preceptorship program to Dr. Derek Feussner.

Editor’s note: This blog is written by Vanderbilt internal medicine resident Dr. Derek Feussner who recently completed four weeks of training at Siloam.  He writes about his experience…

So often, in large urban medical centers, patients come and go with little focus given to their spiritual, emotional and cultural well-being. As residents at Vanderbilt, we strive to do a phenomenal job taking care of acute medical problems, diagnosing and treating complicated illnesses and performing research to advance medical knowledge. What we often overlook, however, is a patient’s spiritual health.

During my time at Siloam, I was able to see firsthand the direct relationship between spiritual, mental and physical health as it relates to a patient’s entire care. I remember taking care of one such patient who presented for a routine follow-up visit. Based on my chart review of her chronic medical conditions, her normal recent lab work and the appropriateness of her medication regimen, it figured to be a straightforward patient-physician interaction. However, when I entered the room and began speaking with her via an interpreter, it became clear there was much turmoil in her life. She had recently lost her husband and was attempting to care for her young daughter with limited resources and limited social support. Her entire family still resided in her middle-eastern homeland and her contact with them was limited.  Using the skills I had learned through my daily interaction with Siloam’s wonderful medical team I was able to obtain a social work and pastoral consult in one single visit. She met and prayed with our pastor and was set up with resources to obtain medications and care for her daughter. There was nothing specifically wrong with her body’s physiology, but her health was certainly suffering and she was spiritually ill.

Throughout “generic” medical training, residents are taught about religion and how it relates to medicine; about poverty and how it affects patients access to adequate health care – but what we never learn is how to truly care for someone in their entirety. The majority of patients have strong spiritual belief systems and these intertwine entirely with how they perceive illness, medical intervention and prevention of health problems, but as residents we rarely inquire as to patients spiritual needs. Being able to work in an environment where taking a spiritual history is “normal” has opened my eyes to the need for a more holistic approach to patient care. I look forward to carrying this knowledge into my future practice.

Dessert & Conversation with Mary Poplin

Note from the Director–

“The Siloam Institute exists to bridge the gap between academic medicine, the faith community, and the medically underserved.  As trainees at Siloam over the years are well aware, the worldviews of the clinician and patient alike have significant, practical implications for the work of healing.

In addition to training future health professionals to engage at this level (as recounted in stories on this blog), we periodically sponsor lectures or events that foster deeper dialogue around these issues.  With that in mind, we are delighted to co-sponsor an upcoming evening event on Oct. 23rd at Vanderbilt Medical School featuring Mary Poplin, professor at Claremont College and author of Finding Calcutta and Is Reality Secular? 

Whatever your own faith background, we hope you will consider joining us for dessert and provocative discussion about how to integrate personal conviction and professional practice.”

Oct-23 Lecture Flyer

Stress at Home?

This question asked by Dr. Nathan Bullington, a third year Internal Medicine resident completing a primary care rotation at Siloam, opened the door to new insights.

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Dr. Nathan Bullington, Vanderbilt Resident PGY-3

Dr. Bullington writes…

Ms. “H” had labile blood pressures.  A foreign-born, uninsured female in her late 30s with a diagnosis of hypertension was not uncommon.  However, her blood pressure fluctuations throughout the day were not making sense. 

She would sometimes have low readings before her medicine and high readings afterwards.  Sometimes she would have high readings before then drop her systolic blood pressure by 100 points after the medication. 

I stopped our conversation to ask how her home life had been going. 

“Do you have new stress at home?” I asked.  Immediately her eyes welled with tears and she began crying uncontrollably.  She was having immense difficulty with her son’s behavior along with strong feelings of guilt. 

Thankfully, she was open to meeting with Siloam’s behavioral health consultant and praying with the staff pastor before leaving.  This eliminated the need for any new medicines or medicine changes.

It is not unusual for our residents, students, and staff practitioners to ask one more question – perhaps a rephrased one – that opens the door to deeper pain within our patient’s life that is negatively affecting their physical health.  With this new insight, they are better able to direct a plan of care that addresses the patient as a whole person

I am not the Healer

Lydia Rice recently completed a two-month primary care rotation at Siloam as part of her family nurse practitioner training at Vanderbilt University School of Nursing.  She writes…

I walked into the patient’s room, thankful for the interpreter beside me. However, negotiating a language barrier sometimes seems less intimidating than navigating cultural differences.

FNP student, Lydia Rice, consults her preceptor.

FNP student, Lydia Rice, consults her preceptor.

In this case, both potential obstacles were blessings. Having an interpreter allowed me to gather my thoughts between sentences.  Differing culturally gave me a unique perspective on this woman’s circumstance… and somehow allowed me to connect a little more with her heart.

We’ll call her Sara.  I met her less than half-way through my student nurse practitioner rotation at Siloam.  My preceptor had already told me a little about her history; in the clinic that day for a follow-up visit, she suffered not only from several chronic health conditions, but had also been plagued for years by depression, shame, and isolation. She had come to the U.S. from a very different culture over a decade before, but her family has returned to her home country, and she has experienced estrangement from her cultural community here.  In her deep isolation, she finds support only from her counseling services and her practitioners at Siloam.

Our conversation began with assessing her physical illness, but it quickly became apparent that the deeper, persistent emotional issues were causing the majority of her distress. She told me she prays and seeks spiritual comfort, but she lacks a community where she feels welcome and she voiced a void that her religion has not filled.  Beneath her striking traditional garb, her eyes reflected a haunting, hollow pain.  I wanted to do something, to fix it, to heal her.  We talked. I listened. We even prayed.  After quite some time, she left the clinic.  As she squeezed my hand in parting, I knew it had been an important encounter for both of us.  Yet I still felt so helpless.

Then my preceptor reminded me that only God can truly heal.  We can be witnesses to this healing, perhaps even play a role in it.  Yet we do not enact it.  And God is working in people’s lives outside of our small encounter or ability to affect them.  I pray that he is working in and healing this woman.  Because I cannot.  But – much as I would like to stubbornly pretend otherwise – I am not called to be the healer, only to carry her to Him.  And, perhaps, she taught me that only this Healer can heal me, too.

Muslims and Gelatin-based medications

Guest blogger, Elisa Greene, Pharm.D., is an Assistant Professor in the Belmont University College of Pharmacy.  Through a collaborative agreement with Belmont, Dr. Greene dedicates half of her time to caring for patients and precepting pharmacy students at Siloam.

Elisa Greene cropped

Elisa Greene, Pharm.D., counsels a patient on medication.

Anyone who has spent time at Siloam is aware of the variety of cultures, religions and languages represented in our patient population. We all desire to provide the highest quality of care. However, despite our best efforts at cultural competency and effective use of interpreters, we often overlook an important aspect of cross-cultural care: dietary restrictions.

Common dietary considerations include variations in blood sugar during Ramadan and other times of religious fasting, vitamin D deficiencies due to all over body coverings reducing sun exposure, and vitamin B deficiencies in Vegan diets that many refugees follow. An additional, less well known, restriction involves gelatin. Gelatin (stearic acid) is derived from beef or pork products and is an ingredient in almost all medications that are in capsule form. It is sometimes, although less commonly, present in tablet formulations, as well. For our Muslim patients, ingestion of pork is forbidden by their religious convictions. As you can imagine, this often results in a therapeutic challenge for clinicians!

Consider this case encountered by Dr. Kristin Martel (a staff physician at Siloam)…

“I had a Somali patient with severe hypothyroidism who returned for a follow up visit with continued complaints of the same symptoms. She admitted to not taking the thyroid medication I had prescribed. She revealed her fears that there was, in fact, gelatin, in some of the levothyroxine tablets. The patient was relieved when she heard that I could specify gelatin-free formulations of this medication. Since then, she has been more consistent with taking her medicine.”

This case illustrates the importance of considering whether dietary restrictions, and specifically the fear of products containing gelatin, are functioning as a source of non-adherence with medical therapies. Identifying this concern allows for development of alternative treatment plans. Gelatin-free products are often available, but require extra research into the inactive ingredients. In general, choosing tablet forms of medications instead of capsules for Muslim patients, when possible, can minimize gelatin exposures.Capsules

Resources are available to aid in this effort. Here is an excellent website* for identifying inactive ingredients in medications. It can be helpful for those seeking to avoid a substance such as gelatin, lactose, or red dye # 40. Also, a quick Internet search displays many commercially available gelatin-free forms of fish oil, an over the counter medication used to lower cholesterol.

Whole-person health care in general—and care offered by Christian believers in the Incarnation in particular (God among us in the life of Jesus)—should seek to meet the patient where they are.  Whether or not we agree with some of the specific convictions of our patients, we nonetheless need to acknowledge and respect them.  By creating an open, nonjudgmental atmosphere where potential barriers to care can safely emerge, the setting is optimized for healing. Assuming there is no harm to the patient from the proposed alternative, and that it doesn’t cause the clinician to violate her own integrity, we ought to seek to meet and treat patients on their own terms as much as possible.

* www.medicines.org.uk/EMC