June: Changed for the Better

As the year comes to and end, I’m starting to process what I will take away from this experience. One of the most valuable parts of this program is my team. Partly because we support each other as we learn and grow and struggle; trying to understand the role of a community health center, how to provide quality care, and define what “quality care” really means. But also for the amazing experiences and interests we are able to share with each other as our relationships have developed, as well as learning from each other in the more formal setting of member lead trainings and individual service projects.

I thought this year would simply be a continuation of what I had done previously – working in community health serving the Latino population. But this year I have developed a much greater understanding of the bigger issues, how those are manifested on an individual scale, and I have grown in compassion towards populations I had previously harbored prejudice towards or simply did not recognize, and can now validate the struggles different populations endure.

Member lead trainings on LGBT health disparities made me realize how uncomfortable and unwelcoming something as seemingly small as the way bathrooms are set up in clinics can be, and how simple changes can break down this barrier. It also made me think hard about the needs of this community as it ages and finding safe and appropriate facilities to care for their health. The mental health training made me recognize my own misunderstandings around mental health issues , and tendency to see the disease, and not the person. Another member’s discussion of her time with the People’s Harm Reduction Alliance and the challenges and condescension IV drug users encounter in the medical system made me want my practice to be a safe place for people to receive the medical attention they need and be treated with dignity and respect.

This experience has not just been my own. My time in clinic has helped me value one-on-one interactions and the importance of listening, and my outreach work has awoken my passion for teaching, but the stories of my teammates have made this year that much richer and that much deeper than I ever could have anticipated. I have allowed myself to be challenged and to grow with the support of those around me and I am coming out a more aware and compassionate person on the other end. I am immensely grateful for the people who chose to challenge themselves this year, and walk with me through our struggles to not just serve those in need, but to make greater changes so that those services aren't a necessary fabric of society.

May: Early Disadvantage

Among the various and invaluable services Sea Mar offers are yearly physicals for high school students of migrant families. As part of the outreach team, I went and gave presentations during the Proyecto Saber class while students were pulled for exams. This class in and of itself is a pretty upstream model of education. It provides support for minority students especially in a predominantly white high school, and is also a way for these students get credit retrieval for classes they may have failed and receive enough credits to successfully graduate. Additionally, it offers an opportunity for students to learn more about their native culture. It places value on where these students have come from in a way that is lacking in today’s public school curriculum.

Our outreach team gave each class an option of what topic they wanted to learn about – chronic diseases, nutrition, mental health, tobacco, or sexually transmitted diseases. Each class period felt more like a conversation with peers than a presentation and reminded me that I am not as far removed from my own high school experience as I may have thought. It also made me recognize a little of my own ageist tendencies. These kids are smart! And many of them have experienced more in their 16 years than I have in my 23.

I had one conversation in particular with a student who made me realize how difficult being a teen can be, especially in a migrant family. The icebreaker for the mental heath presentation requires that everyone to share something that causes them stress. This droopy eyed student shared that family problems on top of balancing work and school were stressful. After the presentation he came up to me, asking about the consequences of drinking a lot of energy drinks. As we talked about sugar content, and the trouble with using energy drinks as a supplement or actual sleep, he revealed to me that his dad was recently injured and he was taking over his father’s night shift to support his family. He would go to work around 11pm, work all night long, come home at 7 or 7:30 and sleep for an hour or so, wake up and come to school. He was failing classes, having anger management issues, and only had one friend who helped keep him awake during class, but no one knew the whole story. “I’m a private person, I don’t want people to finding out about this and start talking about me” he told me, reminding me of how vicious rumors can spread in high school.

I talked with him about some of his options – make sure his teachers were on the same page and working with him to accommodate a schedule that allowed him to sleep and do school work, and to make sure to be in touch with the school counselor about his anxiety and anger issues. But I couldn’t help but feel slightly helpless. His family relied on him for survival. He was carrying way more responsibility at 17 than I ever have. And there wasn’t really any way around it. Who else could work? Who could take care of his siblings if his parents were to take a different job? How else could they make money? Who was going to pay the medical bills? These burdens were falling on his shoulders impacting his mental and physical health as well as his social health – the quality of his education and future prospects for job development and breaking the cycle of poverty his family is in.

I am grateful for Proyecto Saber that offers support, the free physicals that Sea Mar provides during school hours, and the school psychologist, but this student’s story exemplifies heartbreaking effects of social determinants of health that inhibit people from being truly and wholly healthy.

May: Culture Shock

A Laotian man sat down at my desk yesterday seeking medication assistance. He is a refugee. He has been living in the United States for about a year, and three months ago "moved" to the South Park neighborhood. I say "moved" because he doesn't really have a home. He has no money and no house, just a friend who would let him stay on his couch, but occasionally will change his mind and throw him out.

He has no money and is trying to manage hypertension and cholesterol. Fortunately his medications are available on the $4 list for some generics, but he can't even afford that. He is plugged in with an Asian Resource Center, but he cannot find work until his health is better. He speaks in a hoarse whisper and doesn't know why he can't speak louder.

As we talked about his inconsistent housing situation, and difficult financial circumstances, he started to talk about life in the United States:

"I am a refugee form Laos. I love America. I am proud to be in America, But in America, you are all by yourself. At 18, you move out of your families house, you are expected to pay for things on your own. You are responsible for yourself. Its different here when you have to pay for things, how you have to pay for things, and who has to pay for them. I'm proud to be an American, but it is a hard life here."

This makes me call into question the individualistic nature of our American culture. We strive for independence from our families, from each other, to make our own story and our own lives. There is social support, but it is created by individuals or some families, not necessarily supported by our societal or governmental structure. Social support and a willingness to help people outside of yourself are values that can be easily lost.

Hearing the story of someone who is deeply struggling to get by shows me how painful this isolation and individualism can be. It helps me better understand the value of community - how it can provide not just social support but can be a tangible resource, a source of sanity, and a vehicle for positive change that everyone deserves be a part of.

April: Community Through Soccer

The charter of the first Community Health Center describes its purpose as serving the not just the medical, dental, and mental health care needs, but providing the social support specific to the needs the community to which it belongs. It is a beautiful model of holistic care that considers not just the individual, but the neighborhood, environment, and society the belong to. Sea Mar has done a great job of doing so in the various communities it is a part of and the many varied services we offer. But I would not have guessed that a soccer team would be considered one of those many services we provide.

Sea Mar's U8 (mostly second grade) soccer team is about to wrap up its first-ever season. The team was birthed from the Childhood Obesity Interest Group and our frustration with the lack of access of low income communities to organized sports. But the goal was not just to make kids run around to shed some pounds. A sports team is more than just physical activity. A sports team helps instill a sense of belonging, teamwork, and personal responsibility. As a coach, I have the opportunity to build relationships with these budding athletes and can help instill in them a value of active living, teaching them responsibility, conflict resolution and how to listen.

This team is not only a positive force for the team members, but also their families. Many parents are getting outside and being active along with their kids. Three Latina mothers have started walking laps around the field together as they watch their kids practice. On game days, we see parents bringing out video cameras and cheering for their child’s team. Families are also learning the value of active living, and are able to support their children and share in this part of their development.

Hopefully these values will continue to grow with the support of the community, and these families will help make this soccer team a sustainable project that can continue to benefiting our South Park neighborhood.

March: More Positivity than I Could Muster

I tend to think of myself as a pretty joyful and optimistic person, but if I had to deal with the mountain of challenges my patients face daily to be healthy, find food, buy medication, and pay rent and bills while unemployed or underemployed - I'm not sure I could maintain my optimism.

The Basic Health plan of Washington state was severely affected by the state budget deficit. More and more patients have been coming to me for help finding affordable medications because they were dropped from Basic Health and can no longer have prescription coverage. As I worked with Diabetic patient and her doctor to find programs that would help her get her insulin, she expressed immense gratitude for the work I was doing on her behalf. She shared that she knew her situation was hard. She has a innumerable worries and challenges. In her own home she lets herself get down about these things and feel the weight of her burdens, but as soon as she steps out her front door she puts on a smile. She has seen how people can carry their negativity and hardships into their interactions with others - being snappy or reclusive - and she won't let herself do that. She knows that life is hard, but she will try and move forward. She will treat people with kindness despite how tired or worried she is.

"Negativity won't get you anywhere. You have to smile." She said.

She inspires me to put my own challenges in perspective, and start each day with a smile.

February: Graduation

My first patient graduated from the Hypertension Case Management program! This program is set up so that patients can take their blood pressure regularly, and try start to seeing relationships between their exercise, stress level, what they eat and drink and how it has an effect on their blood pressure. Simultaneously we set goals together and I call monthly to follow up.

Mariposa has lowered her blood pressure significantly, and has been able to maintain a healthy 123/80 for a few months now. I've discussed with her in previous follow ups that it was time to start thinking about exiting the program. This would mean that she would need to return the loaned blood pressure cuff to clinic. Though possible, she asked that I give her more warning before she exited so that she could save up for a few months in order to buy her own blood pressure monitor. Her doctor had told her to check her pressure every day. Her heart is her life and she wants to take care of it. She was proud of her progress and insistent on still being able to take her blood pressure so that she could keep it in control and stay healthy. I asked my supervisor if we could make an exception for Mariposa. She couldn't really afford a blood pressure monitor, but was willing to try and make this financial sacrifice in order to take care of her health. Inspired by her motivation, I was allowed to let her keep the monitor. When I called Mariposa to let her know that I would no longer be making follow up calls, but she was able to keep her monitor - with the one condition that she must return it if she ever stops using it - she was immensely grateful and assured me that the monitor would continue to be put to good use.

People no longer will no longer "exit" the Hypertension Case Management Program as I had previously thought. They will "graduate" having learned the value of taking care of your heart.

February: "Quiero compartir una estadistica contigo"

"I'd like to share a statistic with you" Is frequently the introduction to many of the outreach team's presentations. "Immigrants arrive in the United States with the best health in the nation, but in just 5 years, they come to have the poorest health in the nation. How could that be?"

I sat down with a patient today to talk about participating in our upcoming diabetes group classes entitled Tomando Control de su Diabetes, or Taking Control of your Diabetes. During our conversation, It became clear that diabetes was the least of her struggles. She was nervous of finding the location - which is two blocks from our clinic. She told me about a time when she had an appoinment in a new clinic and would wander the same city blocks over and over looking for the building, scared to stop. Nervous and frustrated, she eventually took a turn off the main road and hunched down in the ally way and sobbed. She would hear people approach and be overcome with fear that they would harm her. All she could do was pray. Pray and cry. Eventually she calmed her self and just went home. But now she only goes to the places she already knows, using bus routs she is familiar with, and will spend hours in our clinic trying to get all of her needs so she doesn't need to go elsewhere. To try and make it to the Diabetes group visits was too much to handle.

The anxiety and fear of living in a new and foreign place is overwhelming. Leaving her home out of financial necessity to live in a place that has no feeling of home or community has allowed terror to permeated her life. It has worsened her physical an mental health and stunted her social interactions. Its no wonder that immigrants, who may have come to the US happy and healthy, are stripped of their health within only a few years.

December: The Power of Laughter

Sexual Health, albeit important, is not the easiest thing to talk about. Especially with a room full people who don’t know each other, aren't familiar you, and come from a culture that historically doesn't talk very openly about this subject. This made our health outreach team more than a little apprehensive about giving the presentation that the Mexican Consulate staff specifically asked us to give on Sexual Health around the holidays. We were very mindful about the how we presented this information and trying to create a light hearted and open environment so that people would be comfortable and receptive to the information we presented.

We started with an ice breaker: We handed out cups filled with little pieces of paper - mostly white, but a few cups were full of yellow, red, or orange paper - and had everyone stand up. The group was asked to talk with at least three other people and ask a simple question: "What's your name?" "Where are you from?" "How long did you have to travel to get to the consulate today?" As each questions was asked, the pair exchanged a bit of paper from each of their cups. The outreach team participated to try and break down the barriers between the three "Gringas" presenting and the other participants. Once we explained that this was a model of the transmission of sexually transmitted infections, the room erupted with laughter and pointing of fingers, a few red faces, and a lot of surprise - mostly for us who were not expecting the metaphor to be so well received. We asked how people felt who had started with only white paper and then by the end had a mixture of colors - indicating they had received an STI, as well as those who had started with colored paper (STIs) and didn't know they'd had an infection. The participants openly talked about their feelings of dissapointment and being tricked.

After allowing everyone to laugh and relax, the group was primed to pay attention to the information we had to offer. When our presentations were done and the team was packing up, the consulate staff said they'd never heard so much laughter and participation during a presentation about STIs. Our team really had a way with breaking down barriers and helping people be involved in the learning and teaching process. This was not only a testament to our enthusiasm as presenters, but to the people we are presenting to. They key is being able to connect. Something about our outgoing demeanor and smiling faces made the participants more comfortable. Taking any opportunity to make them laugh and let them breath a little easier made them much more receptive to the information we had to offer, and hopefully made them think seriously about their personal sexual health. Healthier individuals make a healthier community, and a little laughter can go a long way in helping that happen.

December: Face to Face

It is not always easy to connect with the patients participating in my hypertension case management project. I am supposed to call with patients who have been lent home blood pressure monitors each month to follow-up on their blood pressure readings and self management goals. Surprisingly I have a found that more than a few of the nine patients participating prefer to make the extra trip into clinic and do our check-in face to face. I had been playing phone tag with one patient in particular for a few weeks. He happened to come into clinic one day for a follow up with his primary care doctor, and wandered up to my desk as he was waiting to be registered. “Are you Erin?” he asked tentatively. Recognizing his voice form our previous phone conversations I said “Why yes I am, and you must be Ron.* Its so nice to put a face to a name.” He was just as pleased to match a face to the voice that left him messages each month. I asked if he had time to check in after his appointment with the doctor, and he returned a while later ready to talk. He had a complicated medical case and was not keeping good track of his hypertension due to other worries and problems. Throughout our conversation I tried hard to pick out the things he was really concerned about that may be a good place to start. He was not really willing to pick one goal to work on, but was recognizing that there were many things that could change. I empathized with his complicated situation and encouraging him to take things one step at a time. We were able to make one goal that he would be willing to revisit when we checked in January after he’d had some testing done for his other health concerns. We had a wonderful conversation and he felt very comfortable sharing his worries with me. I knew he would respond well with a little more encouragement and could handle a little more push to make some small lifestyle changes the next time we talked. As he stood up to leave my desk, we talked about our next check in. He said “you know, I’d really prefer to come in and talk with you in person if that’s possible. It really was a pleasure meeting you.” I guess a little personal connection can go a long way.

*Name changed to protect patient confidentiality

November: Patient Advocacy

My identity as a patient advocate and future physician go hand in hand, but I have had some interactions with doctors in my clinic that contradict that ideal.

A patient came in needing help with Labor and Industry paperwork that required a letter from the doctor stating her treatment plan in order for her to continue getting her payments. The paperwork had been faxed to the provider a week or so previously and the patient asked the doctor about it during her visit, but she was sent to the "social worker" to have this paperwork filled out. The paperwork explicitly required information directly from the doctor, and was not information that any other clinic staff could fill out. The patient was very distressed. She was frustrated with the quality of care she was receiving as well as very concerned about being able to pay her bills.

As I worked with medical assistant to make sure the doctor wrote the letter, she explained that he often tries to have other clinic staff do this kind of work. He doesn't like to be bogged down with paperwork and simply passes it off. How frustrating that a physician who's entire job is to care for his patients would stop so short of providing complete and quality care!

I expected to be allies with providers to make sure patients had everything they needed. I did not expect to have to advocate for my patients so much within my own clinic.

November - Pride: one of the few things left to hold onto

One patient who I see on a regular basis has really made Sea Mar his home. This is in part because he has been coming here so long that the clinic staff treats him more like that quirky uncle than a patient, and in part because he is homeless and really has no place else to go in South Park. I am like the gatekeeper of his home. He will walk in the door, raise a hand and shout "How's it goin, Miss Erin?" then continue forward seating himself in the chair in front of my desk and hand over one of the many tattered business cards of social support services that are the thread holding the remaining fabric of his life together.

His situation broke my heart a little further right before Thanksgiving. As temperatures dropped, he came in each day with a new layer of clothes and with a little less excitement in his greeting. His usual smile started to droop and the glimmer in eye grew dimmer and dimmer. I searched for housing downtown, but without a guarantee that he would have a place to sleep, he didn't want to make the trek to the city.

One day it was finally dropping below zero and emergency shelters in the city center were opening up. I urged him to go to City Hall, but he pushed back, not wanting to have to wait in line for hours just to be kicked out early in the morning. "But it's a warm bed" I pleaded with him. He replied "Its not a bed. Its a cot on the floor." I had no response. He was desperately trying to hang onto his last shreds of dignity. He would rather sleep with blankets under the bridge than wait in line to be packed into a dirty, smelly room with other people without homes hoping for a few hours of warmth on the City Hall floor.

There was nothing I could say to convince him to go. I can make the resources known, but protecting your pride when you have nothing else is sometimes a bigger priority.

October - First Presentation at the Consulate

We were full of nerves and excitement at our first presentation at the Mexican Consulate. The Health Education team nervously practiced our parts in Spanish, hoping to sound natural and fluid as we tried to get the important information we wanted to share across to the room of people anxiously waiting for their documents.

There were a few bumps in the road as other groups showed up scheduled to present, but we rolled with the punches and waited our turn. Finally it was time to go. The audience started out fairly quiet and hesitant o participate, with the exception of one woman. She sat in the front row with her husband with her eyes wide and eager to contribute to the conversation about Diabetes, Hypertension and High Blood Pressure. She was the first to volunteer when we offered free testing for those three conditions with our nurse. On the other hand, there was a man who sat in the back with a sly smile who just kept quiet, not quite buying what we were talking about. Throughout the presentation, he became a little more vocal. He asked questions, participated in a demonstration, but still did not want to get tested. As our Diabetic Educator spoke about Diabetes, our Champion poked her bright eyes around the corner of the testing room and displayed her bandaged finger for all to see, proud of getting her blood sugar checked and encouraging others to do the same.

As the discussion wound down, and we asked the last time for people interested in getting their blood sugar, blood pressure, and cholesterol checked, our quiet friend and his sly smile reluctantly shook his head and raised his hand. Empowered not only by the knowledge we imparted, but by the actions and advocacy of his peers, he checked his sugar, which was high, and was referred to out clinic for follow up - something so simple that will help him live a longer and healthier life.

October - Hypertension Case Management

Today I enrolled my first patient in our hypertension case management pilot program.

As she sat down at my desk, wide-eyed and overwhelmed by her disease, I could see her pressure rising along with her anxiety. She recently buried her son, and has had over 5 family members die due to high blood pressure. I asked what she knew about the disease, and she said not much. She was told she had it about 6 years ago, but felt fine so didn't worry about it. I could see her putting pieces together as I gave simple explanation of what blood pressure is, and what having high blood pressure for a long time can do to your body. As she began to comprehend the risks of uncontrolled high blood pressure, she was more and more willing to take charge of her disease. With the support of her daughter she was ready to make a change. When I asked about what has inspired her to change and how I could best support her, the tears started to well up in her eyes. Still struggling with the recent death of her son, and the social isolation of living with an absent niece, she was grateful just to have someone who would walk with her through her struggle to survive this disease. With support and knowledge she was encouraged and empowered to manage her blood pressure. The silent yet heartfelt thank you spoken through tear-filled eyes reminds me why I have chosen to serve others and inspires me to continue to walk along side my patients in their struggles to lead healthy lives.

Another Year Gone

My year of service with AmeriCorps/HealthCorps is almost over and I haven't written a word since orientation last September... WOOPSIES!

This year has been full of growth to say the least, and I truly do want to share my journey with you all. As I start to get everything ready for the new Patient Navigator in my last four weeks with Sea Mar Community Health Centers, I'm starting to reflect on what this year has meant to me and what I will take away from this experience.

But before I process too much, I wanted to share some of the things I've done. Throughout the year we are required to report "Great Stories" each month showing the work we've done and what we've learned. These are ultimately used as a promotional tool for our program, but as I weed through them I thought I'd post a few so people can have a better sense of the things I've done this year.

So keep your eye out - the next few posts will be a few of my "Great Stories" from this year.

Enjoy!