Colon Cancer Detection

>> thank you all for comingback for the second part of public square.i'd like to start with dr. kaufman.we ended our last discussion talking about the importanceof community health workers and the roles they can playin addressing some of these disparities.can you talk a little bit more about that?>> the health system only effects about 10% of whatmakes communities healthy. it's really the socialdeterminants; education,

diet, transportation, socialmarginalization, all of those other factors that arefar more important in health.community health workers spend much more time withthe social determinants than we do sitting in a clinic orin a hospital, so it's critical that we work inpartnership with community health workers.one of the problems is that we've never been trained towork with community health workers, and many tell usthey'll bring patients to

us, but we don't know how towork with them. surprisingly enough, we justfinished a study of 2000 patients who just walkedthrough our doors at the university and first choice,and lo and behold, half of them had a major issue insocial determinants. number one was actuallyaccess to utilities. people wanted moreeducation. they didn't have adequatejobs. transportation was aproblem.

food access.it was totally unknown by the health care system,unless these questions were asked.but when we got this answer, what do we do?so now the university has actually hired communityhealth workers to match what we've heard around the tablehere to address these major problems.>> joaquin, i want to ask you, with that in mind, howis the university shifting how it trains doctors toencompass the realities

we've heard in this roomtoday? >> there is a good amount interms of trying to transform cultural competency withinthe curriculum of the medical school from astandalone product to integrated within the wholesphere of it, and i think that's going to make a bigdifference. it takes a lot of time.and the reason that we saw that is the accreditationagency, lcme for medical schools, has actuallyprescribed that, and i think

that is a huge policy issuethat can change the way that medical schools approachthis. so further changes like thati think would help in terms of medical education.i think in terms of the other disciplines, they'rein some ways a little bit further ahead, nursing andpublic health and other disciplines.>> one thing i wonder is, would it help if we have amillion dr. chacons. i mean, recruiting morenative and latino hispanic

doctors to medical school.>> one thing i was just talking to dr. vallejos, whois the director of admissions at the medicalschool, and she was mentioning a big effect thatthe ba-md program has had in terms of changing thedemographics, and also dr. kaufman has noticed thissince they focus two-thirds on rural communities andone-third on the urban, that we've seen a huge shift inthe applicant pool, and i think that's made a bigdifference.

they apply out of highschool and they actually have a spot kind of reservedfor them in medical school once they graduate.>> i'm curious, i'm going to ask some of our folks whohave been here what you think about these kind ofpossible solutions that we're talking about, if thatwould address some of the issues that you're facingright now. dr. chacon? >> when you speak to ourpatients and our communities, if they had achoice, of course you want

to have great communicationswith your doctor and trust with your doctor, no matterwhere you're at, and part of that trust is that thedoctor looks like you. you know, i am fortunatethat i'm a native physician working in a nativecommunity, and i don't have to be a navajo personworking in a navajo community for nativepatients to tell me things that they otherwise mightnot tell, you know, dr. kaufman, because he'snot from the community.

he doesn't understand thatnative culture way of life that is just ingrained inwho we are. and that's not to saydr. kaufman cannot -- you know, that there won't be atrust relationship there. there certainly would be.we need more native physicians, hispanicphysicians, nurses, at all levels of the field ofprimary care and medicine. the other thing about havingmore diversity, more students coming into theprograms at the university,

is that the faculty and thestaff have to reflect those populations, as well.and the leadership levels. >> we are constantly sittingwith families that their kids are interested inmedical school, they're coming from the rural areas,they're not aware of resources, they're not evenaware of the scholarships. their want is there.and then they bring in other issues, especially in ourmore immigrant communities where they're carrying thefamily.

so in some programs, theyhave actually put in financial packages, likefinancial aid. not financial aid in thetraditional of helping the student, but helping thefamily so that these students can get throughcollege and go forward. >> i think this iscritically important, because if you look at thesocial determinant that probably has the biggestimpact on health, this is graduating from school.and if the attraction is to

get into a health career,because it's a very big employer, that's terrific.but just graduating from school means everything.so i think our investment in educational attainment is ahuge benefit to health. and if we look at thepopulations in new mexico who have the lowest rate ofgraduation from high school, it tends to be the ethicminorities, it tends to be in rural areas.we don't invest enough in those, and we have to ifwe're really serious about

health.>> absolutely. we're working and movingtowards those things, but you can't sacrifice thecurrent generation of patients who need care now.i think that's another thing that has to be done.the existing physicians, the existing medical students,regardless of what their background is, have to beinstructed in cultural competence, how to besensitive to different cultures, because they'regoing to be providing care

to different people, aswell. so it's absolutely crucialthat we bring in the underrepresented groups tofill the health care positions.but they're not going to fill all of them.everybody who's providing health care has to beculturally competent. >> we have, through thecenter for native american health, incorporatedsomething called a student navigator where we havesomebody from the

institution kind of helpnavigate how to get through. but it's from the community,in the community, and can kind of help on both endsof it. so having somebody in theinstitution to help guide those kinds of hurdles andthings that are there. but also, learning what theresources and the obstacles might be in the community,and how to navigate through some of that.so i think that was a great model, and i think if we hadmore of those -- but i think

we see frequently that thatkind of investment is difficult to encouragewithin the institution because you see it as -- itdoesn't generate clinical revenue, it doesn't generateresearch money, necessarily, and it doesn't quite fitinto what the normal model of the institutional missionis. >> go ahead, dr. chacon.>> when i went through medical school, i was one ofthe only few -- out of 300 students there, there wereonly two of us who were

native.going through a cadaver lab, when it's taboo for me to bein a room around dead bodies, basically, to be inthat environment was just totally taboo for me comingfrom the navajo culture. to have to deal with that,there's nobody around at the medical school for me to besafe, to be in an environment, to talk to afaculty member, for them to understand what i was goingthrough. that challenge, i mean, itstill effects me today when

i think about it.that diversity of teaching our students that come in,wherever they're from. they're from new york -->> there you go again. >> having that diversestudent population is that we teach each other, thatwe're in the same classroom, we're sitting side by side,we're at the same table, and that my perspective is heardand respected as much as i'm listening to hisperspective. >> well, i wanted to ask ourhealth workers, because you

seem to be key bridges, andi know comadre does this, as well, right?sometimes you're going into the institutions with thepatients and being bridges. how does that -- is thateffective, or are you respected in your role?>> sometimes as far as going into institutions, we willalso invite a family member, because the family memberlives with the patient. but some people that do livealone, yes, that's when we are there, and that's whenwe do the translation for a

better understanding oftheir medical condition. >> i've been there as apatient, also, and i've been there as a peer navigatorfor comadre a comadre, and the barriers are a lot.a lot. the language, sometimes meas a patient, i have to wait hours for somebody to gointo the room and translate for me, because even when ispeak english, just the fact that they speak to me in myown language, that is what i want.i want the trust there.

it doesn't mean that i don'ttrust the other people, but i feel more comfortablelistening to a doctor that is telling me something andi'm going to understand 100%.>> i've had the opportunity just recently where i waswith a patient, and she went to go see her oncologist,and the oncologist happened to have a spanish-speakingphysician with her. i mean, beautiful spanish.and i saw the difference after the appointment withthe patient, how she felt

more comfortable, understoodeverything that was being said to her, and you couldtell in the face that she walked out with a lot moreinformation that she understood in her language,versus when there isn't someone to interpret forher. they can have theinterpreter, yes, but the actual person being aphysician was a much more effective visit with thedoctor at that point. >> another thing is, a lotof the native people won't

take the time to read whatthe physicians give them. so a lot of us, when we weredoing the health education, we used a visual, because weintake that information better if we see visuals.>> emily, you wanted to say something.>> there's a big drive for culturally congruent orculturally competent care that's being taught at theuniversity level or at the academic level, and what wesee in practice is very different from what they'resaying is being taught.

so we've seen some goodexamples of what should be happening.having an actual spanish-speaking physician,that's a great example. but what we see in thetextbooks is stuff like, native people don't like tomake eye contact. that's a classic example ofwhat we see in the nursing texts.or i see, when i go on a tour of a floor with anurse, they'll say, we're practicing culturallycongruent care, we have very

large rooms so when ournative patients come and they have all their familyhere, we can fit them all in the room.well, that is nice, but who are you talking to when youhave this family? that's just the first step.so the way that the chrs are really helping out isthey're helping direct the care here.they're helping to slow down the conversation so thatwhen the clinician walks into the room, theconversation doesn't take

place in three seconds andthen they're out of there. they're saying, whoa, whoa,whoa, you need to slow down and you need to have thisconversation at our pace. >> dr. kaufman?>> a lot of the interventions with communityhealth workers are in the comfort zone of theclinician's. it's our turf.it's our hierarchy. we move in and out at ourpace. but we've begun to see thatthere are community health

workers who actually runclinics, and they supervise, where we're outside ourcomfort zone. and one of the best examplesthat we've learned the most from is in the internationaldistrict, and it's specifically forundocumented immigrants. the one population that'snot going to receive any benefit from the affordablecare act, but they're a vital part of our community.no patient leaves that clinic unless they gothrough a exit interview

with a community healthworker. over half the patients, thecommunity health worker comes back and says, theydidn't understand what you said, they can't afford themedicines you prescribed, you sent them to a placethat has no interpreters, could you change this.or worse, which is more embarrassing, you didn'tunderstand what the real problem is.because that trust, as part of an exit interview, wascritical.

so we're scratching ourheads and thinking, wait a minute, half the patients inour regular clinic at the university probably don'tunderstand what we're saying and they're just nodding.so we do have to change the location of where wepractice and learn to really respect what this powerfulrole of a community health worker is.>> you mean the physical location?>> absolutely. >> it would be wonderful tochange those power

relationships where thecommunity health workers, the promotors and navigatorsare a critical part included in the team, they're notjust, you know, well, let's get that chr or promotors tofind that woman that can't come to the biopsy. but howabout, not the afterthought, how about at the front andcenter. and i think that that'swhere i see a challenge with us, is that we see thatthere isn't that desire to invest.>> but then the

doctor-patient connectionneeds to be there, too. they come in with aclipboard and say, okay, ms. bird, your hemoglobin,your this and that, your vitamins, your calcium,they're all okay. and one time, i just satthere like this. i put my hand like this, andshe didn't even -- like the door opened this way, and iwas sitting there, and the counter was right there.she laid her book on it and read it, and then -->> she didn't look at you?

>> and then silence.she turned around, and i said, good morning, doctor.and then, you know, i told them that i was just waitingfor you to start talking to me, you're standing theretalking to the clipboard. >> dr. espey, some doctorsdon't react well when patients speak up.>> they don't. >> is there anything --we're talking about a lot of cultural shifts here.>> it is critical to elevate the role of community healthworkers and chrs in the

clinical setting, but ithink there's an enormous opportunity, especially incancer prevention. a third of cancers, roughly,are due to inadequate physical activity, obesityand poor diet. and there's an enormousopportunity for prevention where the community healthworker, chr profession, can really have a huge impact.>> you know, a lot of these things not only can thechrs address, but if we stand in solidarity betweensectors, like education and

health and the policymakers,to talk about the basics, you know, the stress that'screated because a parent can't have a job that allowsthem to pay for healthy food, or you know, they haveto work three jobs just to make ends meet, to make therent payment and to make the utilities, those things havethe greater effect on the stress levels, which alsoeffect how your body deals with illness.>> dr. chacon, you could see a patient and recommend,like you need to eat five to

seven fruits and vegetablesa day and go out and exercise.what do you do when that's not a reality that they canmeet, necessarily, if they are facing some of those?>> i think it really takes a great understanding from theprovider level, what is available and what isn't.what's realistic. i can tell them everythingabout how to live and eat more healthy, but unless wecan address some of these other issues, these socialdeterminants, then, you

know, i've spent all my timetalking and doing all of these things that it's -- sothen i will address what else is going on.what are the stressors in your life.what is preventing you from doing some of these things.how do we help, you know, and facilitate gettingsomeone healthy. >> we started a mens andwomens group. some of the questions, orsome of the things that the health workers talked aboutwas, we're forgetting how

when people, when our eldersgrew up, they were healthy. diabetes was not around.cancer was not around. what did they do then versuswhat we have now. so i know in the mens group,i'm just going to share a little bit of what they weretalking about, is they're going to go back totraditional planting. hunting, they hunt for theirfood. they walk to go get theirwater. so they're doing theeducation from the young

kids to elders, and in theirgroup, they have a variety of people that areparticipating. so, you know, if we go backto how we lived before, i think it should make adifference, and it'll be a little bit betterunderstanding of where we are at now that we have allof these cheetos and sodas, and not exercising.>> going back to the comment that dr. chacon made abouttelling these people, eat healthy food and stuff,that's a huge barrier, but

imagine the barrier now withthis new law that they want to implement, taking awaythe driver's license from the undocumented people.what are ladies going to do? what are they going to dowhen they have to go for chemotherapy?how are they going to drive if they don't have driver'slicense? who's going to drive them?their husbands? their husband is probablyundocumented, too, and he can't drive either.so they don't have driver

license, how they going tosave their lives? so i was thinking thatbefore making all these huge decisions, they need to seethat we are human beings, you know.>> when i first got diagnosed and surgery, i wasbombarded with information. i didn't know i had anavigator. i didn't know i had a casemanager. so family members or chrsgo with you, because you're bombarded with all kindsof -- i made so many

mistakes, i made wrongchoices. so that's what i want to do,you know, educate people. you have choices.and ask, ask, ask. >> ask, ask the doctor.>> what would be the most effective solutions that wecould implement now? >> if a group of peoplewould but together a binder and list all the resources.we tried to look for resources so we can referpeople to pick up a box of groceries, or we help ourwomen with gas cards for

them to be able to go totheir appointments. so i personally think, had ibeen given a binder telling me this, you could do thisif you do that, i think it would have given me a betteridea as to what i could do, and what was out there inthe community to help me to focus on my health.>> it does seem like the community health workers canbe -- they're already acting in that kind of role, theway you described in the clinic here, dr. kaufman.so is it a matter of

integrating them more intothe health system? >> i think one of theadvantages now is that there is a payment source that wenever had before. for those who are onmedicaid, now the way managed care companies maketheir money is to keep people healthy.what a concept. that's why they're investingin community health workers, social determinants.it's the kind of change and incentive that we never hadbefore, because if we did

things in prevention, wedidn't get paid for it. now they have to investin it. so i think we have to lookat different strategies where you have kind of thewind at your sails. some of the big funders nowcan support this where they never did before.>> is this because of the affordable care act?>> because of the affordable care act.>> we brought this up like 20 years ago, but we wereshoved to the side.

what we were told is, youknow, the professional, the doctors, the nurses, thelpns, the pharmacists, all those are licensure.that was a blow below the belt, you know, to ourchws, chrs and promotors, because they saidthey're not licensed, they're not professionals.well, to heck with you, you know, we're the ones thatyou're going to come full circle to.>> you were on the forefront long before public policycaught up with you.

i want to thank you all.i'm going to give carmengloria the final wordbefore we leave. >> i believe that everybody,it doesn't matter where they're coming from, theyneed to be treated with respect.they need to be treated with dignity.we need the right to communication with ourdoctors and our health care system.we need partnership. we need help.so, i been there and it's

really hard, so i hopeeverybody can open their heart and say, these peoplereally need help. not only to get betterphysically, but also psychologically, becausewhen cancer comes, it doesn't come -- it's justnot only the person that gets the sickness, it's theentire family. and we are there, and weneed you guys. thank you.>> thank you very much. i appreciate you all comingto talk about this.