Tag Archives: Health Education

Yes, I Can

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I listened to a song about a job interview that went poorly on repeat while I struggled to complete a new workout that I’d written for myself that day. Perhaps the song about the interview resonated with me because I was in my own transition or, perhaps, I just liked the beat. The workout would have been easy for certain versions of my past self. However, recently I’d led a life that didn’t involve intense workouts like this one and, so, the workout was challenging me. “Back to the beginning,” I thought.

I couldn’t ignore the metaphor of my physical fitness and learning medicine because the parallel captured the sentiment I’d been hoping to write about as a reflection of what, exactly, medical school had been like in a broad sense. I’ve had a few months between finishing my medical school classes and starting residency. It’s been a time of celebration and doing things I didn’t have time for during school and won’t have time for during residency. I’ve also taken time to reflect on my medical school experience. “What exactly was the utility of medical school?” I’ve asked myself often during these months of the happy stillness between.

You can guess what medical school was like on a superficial level – it was school. I spent hours studying and hours listening to people instruct me on all kinds of things. I spent more hours practicing skills as varied as suturing cuts shut in the operating room to writing patient medical notes. I attended lectures, engaged in simulated patient interactions, and I worked with real patients and physicians in real hospitals and clinics. I took written exams of various lengths that were proctored by various organizations. Through these actions I learned how the body works and breaks and how we try to make bodies function better with medications and interventions like surgery.

Yet, while learning about the body and how to improve health was the backbone of my medical school learning, it wasn’t the heart of it. The heart of medical school was the exercise of continually starting at the bottom, a place of not knowing much, and climbing to some place of better understanding. Medical school is a lot like the process of doing a hard workout after not working out for a long time and being unable to finish it, then engaging in a few weeks of intent and thoughtful exercise, and finally being able to do the original workout and more.

Medical school taught me that I can learn anything with time and effort. The hardest concepts can be cracked. The first year, I struggled to understand how the body worked. The second year, I expanded my knowledge from how the body worked to how it can go wrong and what we can do about it. Then, years three and four, I learned more about how different specialties in medicine address different diseases and injuries. Each year built on the year prior and then expanded beyond what I knew to things I didn’t yet know. Each time the curriculum expanded I felt like I was starting over. Much like starting in the beginner exercise class and working my way to the advanced class…repeatedly.

I bet you’ve had the experience of riding the rollercoaster of being excellent then falling to subpar and then, through sheer will, climbing to a place of excellence again. And if you have experience doing that in any area of life, then you can imagine what medical school is like. Because it’s just like that. Every month or so you start at the bottom of one area of medicine and climb to the top just to fall again and start the process all over in a different area of medicine.

Medical school is an exercise in being mediocre with a drive to be extraordinary. Each lesson helps move your personal dial from mediocre to better, but there’s a catch. Medicine is founded in science and research and, as such, it’s forever expanding and changing as we (humans) learn more. And so, there is no possible way to ever know everything. To be a physician is to be forever learning while also mastering the knowledge that you explored before. There is no end to medicine, no time when you can’t get better.

Medical school taught me that I can learn anything while I can’t know everything. It taught me not to be intimidated by an obviously hard road, but to take it one step at a time just like I take my plank exercises after a long time not engaging my core. Medical school taught me that experts are built with time and effort. It also taught me that experts remain humble and equally aware of the things they know and the things they don’t know. Medical school taught me that I can do whatever it is I choose to do if I’m willing to put in the effort. The heart of medical school for me was learning that when faced with a challenge to think “yes, I can” instead of “maybe it’ll work out.”

6 Pieces of Advice for Just-Starting Third Year Medical Students

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Now that I know where I’m headed for residency and recently worked with some just-starting 3rd year medical students as a teaching assistant, I feel ready to offer a few practices that helped me through my 3rd and 4th years of medical school. Years 3-4 of medical school are clinical practice years and years 1-2 are academic years, so the transition between the 2nd and 3rd year is challenging for most students.

My survival tidbits aren’t profound, but survival isn’t that profound either.

In no particular order:

  1. Use a sunrise light alarm clock. You’ll be surprised how waking to light transforms even the grimmest before-sunrise wakeups.
  2. Have a pump-up song and listen to it as you arrive at the hospital each morning. Switch up the song as frequently (or infrequently) as needed to ensure it helps you put on your game face…every…single…time…you…enter…the…hospital.
  3. Work hard, do all your work and beyond, and then strive to leave if you aren’t needed. Of course, only leave if you’re done with your work and it won’t compromise your grade or learning. I call this practicing self-dismissal. You’ll have plenty of time to be in the hospital at all hours during residency and at least you’ll be meagerly paid then, so go home when you’re done during medical school.
  4. Fight for moments to eat if they aren’t given. Try to eat all the food groups, just like you teach your patients to do. I know eating properly seems impossible at times, but anemia and other diet doldrums will make learning harder.
  5. Periodically take a moment to remember why you went into medicine in the first place – it can be a literal moment. This is most important during those periods when you aren’t sure you will survive. You will survive and there’s a reason you went to medical school so try to remember it.
  6. During the busiest rotations you can’t sleep enough, see friends, exercise enough, and study… so pick the two most important ones each busy rotation. It doesn’t have to be the same two each rotation. Know that there are slower rotations where you can do all these things, but sometimes you simply can’t have it all.

That’s it. You got this.

I Don’t Think That Thought Process Means What You Think It Means*

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One day on rounds (the time when physicians, residents, and students discuss the day’s plan for each patient they’re caring for) I commented on a patient’s amazing carpenter veins (colloquial term for veins on the back of the forearm which tend to be prominent in people who work with their hands). Having once put in IVs for a living, it’s hard to shake my deep appreciation for a good vein when I see one. The physician leading the team and a resident both stopped and asked, “What do you know about carpenters?” They asked this as if I couldn’t possibly know anything about people who are carpenters. It was a joking question which is common in medicine when calling out someone’s knowledge gap.

I was completely dumbstruck by their assertion that I couldn’t have interacted with many carpenters in my life. After a long pause, I mumbled something about having put in IVs as part of my work before medical school where I had many carpenter patients with these veins. I was confused because sometimes I forgot that many people assume all med students have no experience outside of university classrooms and have doctor parents, or at least white-collar parents. If I had been less taken aback, I would have told them I know a lot about carpenters in a happy, matter-of-fact tone.

My father is a carpenter. My stepfather and mother don’t call themselves carpenters but they both do a lot of carpentry as part of their regular lives and as part of their work. I, myself, have helped build houses, furniture, and theater sets. In fact, one of the more memorable childhood photos of me depicts an elementary-aged me hammering a bolt into some floor beams. In double fact, my first work was in carpentry helping my parents build our house and working on paid building projects. Which is to say, short of being a carpenter, I feel confident calling myself an expert in what the life of a carpenter is like (without even mentioning all the carpenters I’ve cared for as patients since I started working in healthcare as an EMT years before medical school).

As humans we make many assumptions because it helps us organize the world – for better or for worse. Physicians are trained to come to quick conclusions and identify disease patterns almost as quickly as their patients decide if they like their new doctor or not. This is why your doctor will often only ask four questions before they decide how to investigate your knee pain – their experience has taught them how best to understand medical situations and make a strategy for those situations in a 15-minute appointment. Obviously, there are many medical situations where more than 4 questions are needed, but I say this as an example of how physicians are trained to make even more assumptions than the average person already does.

Often, the assumptions physicians make about medical symptoms are helpful because they lead to quick recognition of life-threatening medical conditions so they can be addressed in time to save someone’s life or allow the physician to develop a reasonable method for exploring the situation further in the confines of an overburdened, short-for-time system like the US medical system. But, as we all hopefully know, assumptions are dangerous when they come to making conclusions about whole persons. Note the difference between assumptions about symptoms versus about people. It’s assumptions about people that lead to biases.

It’s assumptions that play a role in the dark side of healthcare – like black people having their pain undertreated or receiving inferior medical treatment and transpeople receiving poor medical care (Google these if you want to know more, there’s plenty of data. There are also numerous other examples of disparities in health stemming from biases and assumptions about people).

Now, the assumption that I, a medical student, hadn’t interacted with carpenters before was erroneous on the part of my supervising physician and resident, but it doesn’t compare to disparities in care secondary to biases and assumptions. I brought those up in the previous paragraph to illustrate some of the ways assumptions infiltrate medicine beyond what I experienced and beyond their helpfulness in identifying diseases quickly.

What my situation does show is that the mental picture that many people in the US (including physicians themselves) have of who US doctors are is a bit out-of-date. There was a time when almost all doctors were white men, and many were from doctor families. And, today, the percentage of white male physicians is still greater than the percentage of white males in the population. And, separate category, there are still many medical students who have doctor parents or white-collar parents. Yet, while this is true, it is also true that things have changed a lot in medicine.

Today, there are more women than men enrolled in US medical schools. There is also a growing contingency of doctors and medical students who aren’t Caucasian (check out this article). There is also a growing percentage of medical students who will be the first doctors in their families (check out this article and this data)

There was a time when most physicians became physicians without ever leaving school – they’d pass from high school to college to medical school to residency. Today, the average age of people starting medical school is 24, which means that they took 1-2 years off from school somewhere along the pipeline. And that’s the average, meaning a significant portion of people starting medical school are older than 24; people like me, I was 29.

All this is to say that who medical students are now is different from what most of our older patients and seasoned physicians have seen most of their lives. For example, as the carpenter story suggests, my teaching physicians thought I was naiver than I am and had a different background than I do. As a different example, as a female medical student my older patients (mostly the men) think I’m a nurse. I find this particularly ironic and amusing because my husband is a nurse; he has no interest in being a doctor and he is a far better nurse than I ever would or could be given my nature.

Looking at the modern world of medicine and the medical world we want for our future, it’s time to check our assumptions about medical students and reevaluate who they are because their backgrounds may surprise you. And to disclose one of my biases, I think the diversifying of the physician force is awesome and, perhaps more doomsday, the only way we’ll solve many of the medical profession’s problems.

*Attempted The Princess Bride reference, not sorry because Inigo Montoya summarizes my thoughts more often than I would like to admit

Teaching Sex Ed

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I never imagined myself teaching sex education before Paraguay. But since late August sex education, focusing on HIV prevention, has been the center of my work world. And, it is some of the most gratifying work I’ve done in my ever-elongating life. What I enjoy most is watching how my students giggle more knowingly rather than awkwardly and show greater confidence as we work through sexual health topics. During my first class, my students wouldn’t say words like “penis,” but now they can tell me exactly how and for what one uses a condom with only a slight smirk betraying underlying tension.

Just like in the States, many families and schools in Paraguay skim or entirely skip sex education because adults are embarrassed or don’t know how to discuss the topic with youth. As a result, “sex education” is learned through experiment. It’s not that experiment is entirely bad but when it comes to sex, experiment without some basic knowledge and protection can often lead to unwanted pregnancy and sexually transmitted disease.

Because I’m using a program that focuses on HIV prevention, I talk about condoms a lot. As you know, they are the only form of birth control that prevents pregnancy and STDs. Just like in the States, condoms are under utilized in Paraguay even though they are widely available and often free. You might ask, “Why?”

Unlike in the US where there is a poisonous link between condoms and religion in some circles, the officially Catholic country of Paraguay, for the most part, does not view condoms as a negative thing. Myths and mistaken beliefs about condoms are one reason many Paraguayan men are reluctant to use condoms. Myths like one can not feel pleasure during sex when using a condom. Another, and perhaps more important reason, is that many people, both genders, are too embarrassed to talk about sex or get information about how to protect themselves that they just go for it. It takes confidence to get a condom and then ask your partner to use it. And, that’s where I think sex education enters the picture.

Sex education is partly explaining how things work, like how to use a condom, and telling what resources are available, like the different forms of birth control. But, I think almost more importantly sex education is a time to clear the air and help young people become more comfortable talking about their bodies. I like to think that my students don’t only learn how to protect themselves from HIV, but also become self-advocates so that if faced with a partner who asks them to take a sexual risk they don’t like they can stand up for themselves. One can know about all forms of protection and the ins-and-outs of sex, but if one is too nervous to say what he or she wants in the moment it does no good.

 

Family Planning and Religion

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HouseOne of the topics about which I will teach here is family planning. Before coming to site, I was concerned about the topic because of how polarizing it is in the US. I worried that there would be as much religious rhetoric against contraception and teaching sexual health in Paraguay as there is in the US. Paraguay is a Catholic country and I wondered if some of the same denial of basic health realities was present here as in the US. It is not.

Family planning and sexual health in Paraguay is not a subject cramped by religion. It is awkward and hard to talk about, just like in the US, but not because of religious beliefs. I find it awkward because of the power relationships between men and women here. And, well, because it’s just a hard subject to discuss eloquently.

In Paraguay, birth control pills and condom are free and offered at every public health clinic in the country. To get birth control pills a woman simply needs to go to the health clinic, request them, and present her ID. Sexual education is taught in many schools. I like to think Paraguay is transitioning to a family model that allows women to have the number of children they want when it makes sense for them. Paraguay isn’t there yet, but it’s on its way.

One thing I find particularly interesting about the relative ease of discussing family planning in Paraguay is that abortion is illegal. Period. Having one national set of laws in Paraguay that governs actions related to family planning makes it easier than in the US to know what can be said and can’t be said when teaching.

Drinking: Underage and Driving

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DawnDrinking is just as common in Paraguay as it is in the US. The difference? Paraguayan private and public organizations haven’t sunk as many millions of dollars into raising public awareness about alcohol safety. The result? People are getting harmed.

You’ll see 15-year-olds get drunk in front of their parents, with beer their mother bought. You’ll see drunks finish their drink and hop on their motorcycle or in their car. Few people talk about the fact that driving is impaired by alcohol consumption, and fewer wear seat belts (ever) or opt out of riding vehicles operated by people under the influence.

You know there’s a reason why you’re not supposed to start drinking too young: it can affect brain development. As for drunk driving—if you’ve ever been sober while riding in a vehicle operated by someone who’s been drinking you already know it’s terrifying. According to one report, Paraguay has one of the highest motorcycle-related mortality rates in the Americas, with a rate of 2.5 deaths per 100,000 from 1998-2010. And according to another report, one of the highest traffic injury-related mortality rates in the Americas.

I get that people just want to have fun. But, do responsibility and fun have to be mutually exclusive? I think not.  My quandary: How can I help transmit this message in Paraguay? More difficult still: How can I help encourage behavior change to improve drinking safety?

Where Public Health Fits Into the Health Picture

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ClimbingParaguay and Health Care

Every country has it’s own way of trying to protect its citizens’ right to health. In Paraguay, there is universal health care. This means that consults and medications are free. Well, at least that’s the idea. Most people have access to doctors and nurses trained in family medicine, but things get complicated when it comes to medications and access to specialists.

Every medical facility in Paraguay doesn’t always get all the medications it needs for its patients. (Paraguay is working to decentralize its medical system with the hope to reduce some of the bureaucracy that might be contributing to these shortages.) As for specialized care, it’s unsustainable for every health clinic to have specialist in all areas, so they are centralized regionally in hospitals and health centers.

These limitations sometimes mean individuals go without the medications or care they need. Public health has a role to play to help relieve strain on the health care system by helping people lead healthier lives in the first place.

Barriers to Medicines and Specialized Care When They Are Not Available in Local Clinics

The main barrier is access. When a local clinic doesn’t have a needed medication patients must either buy it or find a public health facility that has the medication.

For families where money is short or income is unreliable, it means individuals go without their medications—a scary thought in a land where hypertension and diabetes are leading conditions.

Traveling to another medical facility might also be out of the question. It costs money to travel—whether by bus, by dirt bike, or by car. What’s more, it takes time that individuals might not have. For those who work, they can’t be absent from their jobs. And, for those who are looking after a house, there’s food to cook, children to watch, and clothes to wash.

When patients have to travel to a regional facility for care they face the same challenges as accessing medications. It’s not uncommon for local health care providers to use their personal money and vehicles to help people see specialists. But, that is limited because it puts stress on health care providers beyond their normal work and their vehicles may not fit everyone who needs to see a specialist.

There’s no silver bullet for resolving barriers preventing people from the health care they need. But, one thing is for sure; the more we can do to help prevent illness the better off individuals will be. That’s why health education and providing individuals with advice on how to lead healthier lives makes a difference.

Why Am I in Paraguay: Peace Corps Goals

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A Paraguayan viewI know the Peace Corps and its work sounds abstract, being hard to explain is one of the many challenges of international development. Before leaving for Paraguay, many people asked what I would be doing and I couldn’t tell them. Here is my post-training attempt to define my work as a volunteer.

The Peace Corps Goals

  • To help the people of interested countries in meeting their need for trained men and women
  • To help promote a better understanding of Americans on the part of the peoples served
  • To help promote a better understanding of other peoples on the part of Americans

Cultural Exchange

The first job (and inevitable outcome of a job well done) of Peace Corps volunteer (PCV) is cultural exchange. Cultural exchange means learning about your host country’s culture and sharing about the culture of the US.

As a PCV, I’ve lived with a host family almost 3 months now and will live with one for almost 5 months when all is said and done. Living with a host family gives me the chance to learn what Paraguayan family life is like, eat tons of Paraguayan food, and ask endless questions about social events, pastimes, and beliefs. On the flip side, it also allows my host family to ask billions of questions and allows me to combat myths about the US, share my music, share American food, and offer a new perspective.

Of course, this exchange isn’t limited to my host family or the time I will live with them. Through all my interactions with community members, including people just seeing me do what I do, we are exchanging culture. Also, this blog, conversations with friends in the US, and all the stories I will tell when I get back to the States work toward the cultural exchange goals.

Health Education and Public Health

As a community health volunteer my work toward helping Paraguay develop skilled men and women involves raising awareness about health issues and working to improve health environments. The community health sector goals in Paraguay are:

Goal 1: Improve hygiene and environmental health practices

  • Dental health: I could teach why brushing your teen is important and how to brush properly. It is normal in Paraguay to see children with visible rotten teeth and for people to be missing some or many of their teeth.
  • Hand washing and parasite prevention: I may teach kids how to wash their hands correctly and parents how to recognize if their children have parasites. The main types of parasites found in Paraguay are giardia, roundworm, and hookworm.
  • Sanitation Practices (trash management and potable water): There isn’t trash collection in most places in Paraguay so most families burn or burry their trash. Water pollution can be a problem in some areas of Paraguay because of sewage management and livestock, among other things. Many people don’t think twice before throwing trash on ground.
  • Cook Stoves: Many families in Paraguay use open fires to cook. The Peace Corps has developed several wood cook stoves that when built can improve cooking efficiency, reduce the risk of burns, and reduce respiratory problems aggravated by breathing smoke.

Goal 2: Reduce the risk of non-communicable diseases (NCD)

  • Non-communicable diseases education: NCDs are diseases that can’t be passed from one person to another. Some of the most common NCDs in Paraguay are diabetes, hypertension, and obesity.  I could provide general information about these diseases and teach about nutrition and exercise as a way to control and prevent NCDs.
  • Gardens: I’m planning to have my own veggie garden, help my school have a school garden, and work with anyone who wants help making their own veggie garden. Gardens are a great opportunity to promote healthy eating and diversify the veggies available to families.

Goal 3: Reproductive Health:

  • Life Skills: I will work with youth to help them expand their decision-making and problem solving skills, critical and creative thinking abilities, communication and interpersonal relationship strategies, self-awareness and sense of empathy, and stress and emotional strain coping strategies.
  • Sexual and Reproductive Health: I may talk to youth about what sex is, STDs, and family planning strategies.
  • HIV/AIDS: As part of reproductive health, I could work to educate youth about what HIV is and how it is transmitted. Also, through this work I can hopefully help reduce discrimination against people who are living with HIV.

Empower People to Take Ownership of Their Health

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Public Health

The heated debate about U.S. health care focuses largely on health insurance and health care access. Of course, these two aspects are appropriate for the policy debate—there are few who would say our current system is optimal with regard to either, and many who say it’s not acceptable. But from a public health prospective, I can’t help but think of a slightly more humble part of the future of health in the U.S. –mainly the everyday tools everyday people can use to take ownership of their health. Two tools are of particular interest to me: the Internet and health tracking.

It’s not to say that Internet information or personal health tracking can replace medical professionals and their care, but it is to say that the health of the individual goes beyond medical visits and consultations with health care professionals. Many of us who do visit the doctor and the dentist may already know this—the forceful suggestions to exercise at least 4 times a week and to floss everyday remind us that maintaining our health is not just the responsibility of medical professionals.

It’s true that individual people can take ownership of their health on a daily basis. There are tons of health education initiatives trying to help people do that by providing them with information and specific steps they can take. What makes these initiatives both strong and weak is that they focus on one specific aspect of life that can improve health, like quitting smoking or exercising.

But, what if health education in the U.S. taught people how to find out about health conditions and healthy actions instead of focusing on disseminating the facts about conditions and healthy actions?

The Internet: A First Source of Health Information

According to a 2013 Pew Internet report, 35% of U.S. adults reported going online to try to diagnose a medical condition they or someone else had. Of these, 46% said their findings made them think they needed help from a medical professional and 38% said the condition was something they could take care of at home. In addition, 41% of the adults who used the Internet to form a diagnosis said that a medical professional confirmed their diagnosis.

What I find fascinating is that of adults who looked for health information online, 77% started their search on a search engine and only 13% said they started on a site that specializes in health information.

This leads to several questions:

  • How can we make the Internet, as a whole, a better source of health information?
  • How can we help individuals develop good online searching skills that will lead them to accurate health information online?
  • How can we make online health information easier to weed through?
  • How can we ensure that the most helpful, accurate, and credible sources of online health information come up when people search for health information?

Many health organizations are already putting health information online—not just research organizations but also doctor’s offices that allow you to view your medical records online.  But, putting information online is not enough. Empowering individuals to find health information on their own is going to also require helping people learn how to navigate the sea of information and creating tools that organize and sort that information.

Tracking Health: Health Empowerment

According to a 2013 Pew Internet report, 69% of U.S. adults track one or more health indicators (e.g. weight, exercise, or diet). Adults are more likely to track health indicators if they have one or more chronic health conditions. People have different ways of tracking these conditions—49% of adults reported tracking their health mentally, 34% reported tracking their health on paper, and 21% reported using technology to track their health.

What’s more, 63% of those who reported tracking their health also agreed with at least one statement of impact including: their tracking changed their approach to maintaining their (or someone else’s) health, caused them to ask their doctor questions or get a second opinion, and impacted a decision about treatment for a illness or condition.

Much like with Internet health information, personal tracking can provide individuals with knowledge about their health before they visit a health professional. The prevalence and impact of health tracking indicated in this report lead to several questions:

  • How can we help people become better at tracking their own health?
  • How can we develop tools to help people keep better track of their health?
  • How can we develop tools that not only track health but also provide analysis of the tracking results?

Access to technology can help individuals track their health, according to the same Pew Internet report one in five smartphone owners has a health app, but it’s not the only important piece to effective health monitoring. Providing people with the knowledge of what aspects of their health are most important to track and the skills to track those aspects with consistency is another key piece to the puzzle.

Health Ownership

Tools like the Internet allow individuals to find health information on their own and tools like health trackers empower individuals to monitor their own health. While online information and health trackers abound, the challenge with these tools is their usability and accessibility. The usability of these tools not only depends on the tools themselves but on individual’s skills and confidence in using the tools. The accessibility of the tools is about how an individual is going to find the tools when there is so much information online and so many different ways of tracking health.

As we look forward to improving public health, it may be worth shifting our focus from pushing information about specific conditions and actions to teaching skills that help individuals effectively find health information on any condition and track their health on their own.  It’s not enough to just push the facts, we need to empower individuals with health knowledge and skills so they can take ownership of their health.