CHC on Martha's Vineyard
--Gina, UMMS '10
4 October 2006
Today was the first day on the Vineyard. We met with some of the people organizing the clerkship, and it became immediately clear both how small and how unique this island is. I am excited about the project, as, until we got here, it was not quite clear what we would be doing. We got a better idea of it this afternoon at the meeting at the hospital, and hopefully it will become more clear tomorrow when we meet some of the other people who are involved in this project. It was interesting to finally see the hospital. It was entirely different from what I had expected. I knew that it was small, but the size created a completely different feeling that I had not anticipated. It is easy to feel lost in the crowd at UMass when walking through the halls of the hospital. Here, however, we didn’t take five steps without being greeted by someone. Everyone at the hospital seemed to be aware of our visit, and were extremely helpful. Just coming in to see someone at the front desk, actually answering the hospital phone and directing people was pretty impressive, as so often you call a hospital and end up with an automated service, or wander the halls without a clue of where to go. I am really excited to be here.
6 October 2006
Our project really started to get underway today, and as Kata and I spent the afternoon researching, two things amazed me. The first related to the book, People and Predicaments. Although this book about Vineyard life was written 30 years ago, it was evident through reading the Island Health Report and talking with the nurse with whom we are staying that many of the situations and issues that people were dealing with 30 years ago are still prevalent today. Tourism is still both the bread and butter and the bane of the islanders’ existence. The summer job opportunities are undeniable, but with them comes the constant comparison of oneself to the rich tourists, their excesses of wealth and material goods, and their leisure activities, including alcohol consumption and drug use.
Another thing that really surprised me was just how unique this island really is. I thought that we would find studies of similar populations, either in remote areas or other resort communities. However, after searching through countless journals and websites, there was little to serve as precedent for our project. Countless references were made to the need for mental health evaluations in a primary care setting in rural areas. Often, in such communities, specialty services are inaccessible or pose difficult barriers. Yet nowhere did we find studies on the efficacy of this, or screening tools to serve as a template for ours. This evidences the importance of our project, to at least begin the conversation of dealing with mental health and substance abuse in a proactive and uniform manner. While the research certainly wasn’t enthralling, it did give me a greater sense of the necessity of addressing the problems facing this community.
8 October 2006
Last night Norlyn, April and I went to a local bar. We were not intending to be working, but found ourselves in the perfect situation to observe the local culture in action. The bar was full of locals, evidenced by the fact that the bartender, the customers, and even the members of the live band all seemed to know each other well. There was a strong sense of camaraderie in the bar, and a huge range of ages and “types” of people all having a good time. Most people there could be classified as “pretty drunk”. One of the most interesting things we saw was a young man wearing a shirt that read “I don’t have a drinking problem: I drink, I get drunk, I pass out. No Problem!” He was very proud of the shirt, and when we asked to take a picture of it, went so far as to pose with his beer next to the shirt.
11 October 2006
Working in the rural health clinic today helped identify an important need that our “universal” screening tool may not meet, at least initially. Out of the five patients that I saw while shadowing the physician’s assistant, three of them were Brazilians who did not speak English. Jacquie, the office manager served as translator for these visits. The rural health clinic is fortunate to have this service for some visits, but as the people at Island Health Access informed us yesterday, there is a shortage of interpreters, and not all of the current interpreters are really adequately trained to serve as medical interpreters, with the unique vocabulary and skills such translation requires.
Kathy, one of the clinic’s nurses, explained that many Brazilian patients show symptoms of anxiety and depression. This is understandable given that many of them must face language barriers, uncertainty of work or housing, new foods and a drastically different climate, as well as the sadness of leaving many loved ones back in Brazil. Our tool, designed to be given verbally, is currently only available in English, so without the aid of translators, it can not be used with the Brazilian population. Hopefully there will be enough translators to help bring this tool to the population, or at least a written translation that Brazilian patients can read in Portuguese and then fill out.
I was really impressed by the work of the PA and the nurse at the clinic. They work really hard, give excellent care to their patients, and spend a lot of time in each appointment. It was refreshing to see that, at least here, medicine takes precedence over volume of patients seen. The creativity of the PA was great to see, as she comes up with many home remedies to help her patients treat themselves, preventing some of them from having to spend a large amount of money on medications, and allowing them to have a role in their own care. She was very open to alternative methods of care, making an effort to learn about the Brazilian medications some of her patients use. This is especially important because in Brazil many prescription drugs, including antibiotics, can be purchased over the counter. Carol Ann’s ingenuity and dedication earn her a lot of respect from her patients, and she deals with many of the patients we are looking to screen for with our tool. There were patients dealing with prescription drug abuse, poly-pharmacy and alcoholism. There was even one patient who came in who had become sober since the last visit. To hear that the tool is something that these health care professionals are open to using was great.
13 October 2006
The interviews that we have actually had over the past couple of days have opened up some important issues with counseling on the island. One of the things that I have heard multiple times is that there are serious shortages on the island; shortages in interpreters, counselors, appropriate facilities (i.e. detox. and crisis stabilization units), and a three month waiting list for beds at Vineyard House, an organization that Hazel Teagan gave us great insight about during our interview this morning. If our tool is successful, there will be a greater need for all of these services on the island, as a number of people who are not being treated now may end up entering the system. Hopefully a concurrent task with increasing screening for mental health and substance abuse issues will be a process to increase services on the island, and to establish a much better connection to the non-English speaking populations. There are multiple AA meetings that occur around the island regularly, yet none of these are offered in languages other than English, meaning that many people are without a potential support system. Today was also the first day when I really began to think about follow-up to our study. There will need to be an assessment of the tool’s effectiveness, ease of use, prevalence of use by professionals, and areas which will need to be improved. The tool will be useless unless we can see it s impact on the community. Just as the island changes from season to season and year to year in terms of its population and its changing needs, any tool will have to withstand these changes or be adapted in order to remain current and effective.
16 October 2006
Today it was back to work after a couple of days of simply enjoying the island and being immersed in the island culture. Although, in a way we never really stopped thinking about our project and would talk about it as we saw different things in our travels. The island was drastically different this weekend than it was last weekend, the holiday weekend. There were far fewer tourists, the whole island felt quieter and sleepier, and many of the stores that had had open doors and huge SALE signs during the week were closed, locked, adorned only with a “thank you, see you next spring” sign. In a way, it struck me as really sad, to see such a change in the towns, and while I realize that it is this calm that the locals look forward to all summer, I can see how the island would become a difficult place to be throughout the long winter. It would be hard not to feel isolated at times.
In coming back to work on our project, we worked to refine the tool, the companion to the tool, and our presentation. Having only two of us at each interview meant that we came back with very different suggestions for how the tool should be adapted, and had to reconcile these suggestions to create a tool that was at once simple and comprehensive, generic and yet informative. We had a lot of conversations about the project and the tool, with different opinions, and differing influences based on which interviews we had conducted. It was very hard to come to a consensus, and the group had some issues figuring out how to really adapt the tool and presentation. In order to prevent making the tool and the scoring more complex, we had to compromise, brainstorm, and rethink our priorities. When we finally finished, there was a sense of relief at having come to a final decision, and having created something that many of our interviewees stated they would find useful in their practices. That for me was so important, knowing that there is potential for a future for our tool, that we weren’t doing a project that would just sit on a shelf once we leave the island. It would have been a valuable learning experience either way, but having the project affect more people than just ourselves was the ultimate goal for us when we came here.
17 October 2006
We finalized and presented our project today. This morning’s discussion with Suzanne and Murray really helped to identify the things that worked for us, and the things that can be improved upon next year. I didn’t expect Murray to be there this morning, so it was a really nice surprise to see him. We were all asking each other if we thought that other clerkships resulted in such tight connections, and I don’t think that that is the case. We spent so much time together; working, debriefing, exploring, and the island is such a small place, that it was inevitable that once we started digging into the community, it would become a part of us. It is clear in the islanders. The tribe’s health executive asked us if we thought that the next health report would look worse in terms of mental health issues and substance abuse, assuming our tool is successful. It will, and I can understand how no one on the island wants it to be seen in a bad light. But it is the only way to initiate change, to get funding for this change, and will inevitably draw the community closer together as everyone gains a better understanding of themselves, each other, and the problems that the island must tackle together. We met a lot of people who have been fighting for health care change, and I think that if anyone could be successful in such a venture, they certainly would be the ones. Unfortunately it will be without Murray. The continued connection with UMass should help to ensure that the project does not die on the table, and I think that next year’s group will have a lot of possibilities for study and improvement upon what we have created. It was, for me a more powerful experience than I ever could have expected, both in the work that we accomplished, and that which we saw others so completely involved in. Coming back home will be a somewhat rude return to reality
18 October 2006
We said goodbye to Norlyne and April over breakfast at The Black Dog this morning. Over the two short weeks that we were here, we formed a really solid working relationship, one that survived debates, disagreements, and drastically different backgrounds. It made me realize how isolated we are in the med school from the nursing students. We will all be working more closely with nurses than with doctors in our future careers, and it would be great to have classes with them, or at least social events together. It should not be a relationship initiated on the job, and it is probably why there are a lot of clashes and power-lording in doctor-nurse relationships. I hope that more programs are developed to cater to this, either in more of a PPS format or even in standard lecture settings, because it is really apparent to me that the two groups have much to offer one another.
It was sad to leave the island, even amidst the clouds and drizzle. Going back to the real world means going back to the grind and routine of classes, and while there are aspects of it that I missed, overall this was truly a prefect escape from everything. I felt totally immersed in Vineyard life, from running around the island, meeting so many people, to exploring the health care system, and living in some ways like a resident of the island. I don’t think we could have done the work we did without being quite so immersed