Posts (23)

Mon, Jan 15 10:58am · Hello From the Other Side

By: Kevin Shim

As I sit down to write my thesis I have spent some time thinking about the differences between graduate school and medical school thus far. I want to try to explain them to you using a half-baked analogy with the goal of highlighting (what I think are) some important differences between life as a medical student and life as a graduate student:

Some of us have decided to swim laps. People watch very closely as you swim them, and there are a dozen timers and digital contraptions to capture your speed. You feel pretty miserable when you swim a lot slower than the other swimmers, even though you slap each other on the butt and say good job to each other no matter what. There’s clearly a fastest swimmer who keeps talking about matching into plastic surgery. You know that if you swam more practice laps your time would go down and you would feel better. But the pool is cold in the morning, and you’re exhausted, and ‘Stranger Things’ is far more enjoyable anyway.

Back and forth you swim laps. As soon as you touch the wall on one end you flip around underwater and swim another one. Once in a while, after you’ve finished the pre-set number of laps, you hop out of the pool and immediately check your time. Then you sit down with your coach who tells you to remember that thing-about-the-angle-of-your-stroke you had talked about, provides you one unit of reinforcing feedback, squirts energy drink in your face, and reminds you that your next set of laps starts in 1 week.

Others have decided to swim for a different purpose. You swim in a huge body of water, probably an ocean, but you don’t really know because it’s misty and foggy in all directions and you can’t tell how big it is. Before you slide into the water your coach tells you: just find some new land and you’ll have made it.

By definition, nobody knows where this new land is, what direction it’s in. No one has seen it before, so you don’t really know what you are looking for. You have only a generalized idea of how far away it is (its really far).

Figure 2 – Not the Island You Had Hoped For: The central finding of my thesis publication. There is no improvement in survival outcomes of mice challenged with melanoma when new immune checkpoint blockade therapeutic antibodies are added to our established treatment regimen of Vesicular Stomatitis Virus (VSV) and adoptive transfer of CD8+ T cells (Pmel) (squares, inverted triangles). This is in comparison with a negative control isotype control (ISO) antibody (triangles).

As you slowly begin to swim you encounter a lot of people. Your coach floats by pretty regularly in her canoe and provides generalized tips and ideas about how to find the land, but at some point, you realize that she actually doesn’t 100% know where the land is either. Though she has a great deal of wisdom about seafaring, washing up on the shores of the land she discovered simply isn’t your goal (there is no found-America-second day). “Don’t worry!” she says, “just start swimming, you’ll know it when you find it!”

Often you find other swimmers. They have been swimming for years and are looking for land too. They also have some generalized notion of where the land might be: “swim towards the brightest star you see” or “keep following the wind”, they say. They’re helpful – but you’re not sure you know where they’re going either sometimes. It’s tough to really say that you’re any closer or further from the land than your other friends in the ocean. But you care only somewhat, mostly because you know that everyone has to find their own land and you are quite preoccupied with finding yours.

On some days you furiously freestyle in one direction and you’re filled with the drive and dedication to find the shore. On other days, you grab the log floating past and just hold on to it and float for a while, it’s really the only thing that you can do. Because there are really no landmarks, no sense of the passing of time besides the coming and going of the sun, you can float for days. Or swim for days – only to collapse in a heap on a sandbar to catch your breath and wonder where you even are. Psychologically, it’s horrifying. You have no idea when you will reach the land, and on some days you really freak out because you believe in your heart of hearts that the land really is not there. There’s no way that it could actually exist.

Figure 1 – Adrift: Lying on a log.

Worse though, much worse, is the feeling as you lie on the log – dead tired and ready to cry – is knowing that if you were stronger or had bigger lungs or gills that you could still be swimming. No one is stopping you from still swimming towards getting to the land except your own lack of willpower. Someone tells you to remember work life balance and you throw a seashell at them.

Then, suddenly, you find yourself on shore. Bubbling with pride, you are able to ignore the fact that the island you have discovered is essentially a logical extension of the chain of islands your coach has found (and thoroughly published on in J. Island Disc. 1998-2014). What you have a difficult time forgetting though, is the time you spent floating in the ocean clinging onto a log, or legs burning as you kicked your way towards land.

Each activity (even though they are both swimming) has a different headspace to become lost in, with its own set of joys and challenges. At the end of the day, waking up to practice swimming just 20 more laps is simply a different task than waking up to find your island. Maybe there’s a way to truly understand both, or maybe I’ll just lie on this log a while longer.

Author Bio: Kevin Shim is a 6th year MD/PhD student currently in his 3rd year of medical school who enjoys strategy board games, drinking beers with friends, and Immunology. 

Aug 24, 2017 · Trust in Medicine: From 3 to 83

By: Domenic Fraboni

I’m about to share a story about trust that I learned in an unexpected fashion and from the most unexpected teacher. This unexpected master class in trust was delivered by my nephew. Now, why would any possible readers care about me jabbering on about a 3-year-old that none of you know? The reason being: I think the couple paragraphs that follow run nearly parallel to the trust and therapeutic alliance needed to ensure great, patient-centered care. As a future doctor of physical therapy, I have encountered many instances in the patient room that trust is paramount. Someone who has the strength in their lower extremities to stand and walk but hasn’t been up out of bed for two weeks. An individual who has fallen three times in the past year, twice resulting in hip fractures, and they are terrified to get out of bed after their most recent procedure. A patient who has left sided hemiparesis due to a recent cerebrovascular accident and needs to completely re-learn how to ambulate. These are all (similar to) instances that I have personally encountered, and I have not even been in patient-contact, clinical settings for a complete year. Back to my nephew.

The whole crew! Perfect day for a boat ride. PC Emma Tenge

I was lucky enough, just recently, to spend a gorgeous, summer day with my entire “Modern Family” out on the lake. The day was packed with all sorts of festivities including a delicious brunch, pontoon cruising, taking a dip in the lake, and even some tubing behind the boat. However, I am not writing today to tell you another story about my unique family. I learned a vital lesson during this extra humid day out on the Minnesota water. Even more interesting, my teacher was my three-year-old nephew. He managed to sprinkle in a valuable toddler-led seminar about trust among all the lake activities.

Initially, my nephew, Jasper, was terrified at even the thought of going in the water. We slowly worked our way down the boat ladder. As soon as the water got above his knees, he would scurry back to safety. I nearly succumbed to the fact that we would not achieve our end goal of getting him tubing behind the boat. However, we slowly progressed to going in the water up to his waist, then chest, but I could not get him to let go and swim around with me. Hmm…. What to do?

At this age, Jasper is able to understand basic sentences, so I said to him, “Jasper, if you let go of the ladder, I promise that the life jacket will hold your head above the water.” With odds of zipping around the lake on the tube looking grim, Jasper finally let go. The effect was almost instant. Jasper felt the buoyant life jacket holding him up and knew that his precious head was safe from the treacherous water he so adamantly feared. In a matter of 10 minutes, we had him doggy-paddling around the boat, going for dolphin rides on my back, and even blowing bubbles in the water with his mouth. Jasper wasn’t satisfied. After his uncles briefly demonstrated to him that tubing behind the boat was not as dangerous as imagined, he joined us! During the entire ride, he did not tell us to slow the boat down once; in fact, he kept giving the thumbs up to say “faster.”

Look mom, no hands! My nephew Jasper, younger brother Gino, and me tubing out on the lake.

Research completed in 2000 concluded that, although the importance of trust in the patient-clinician room cannot be questioned, much of our understanding of trust relied in large part on anecdotal evidence from enthusiastic physicians. More recent research, done by Street et al, identified “seven pathways through which communication can lead to better health include[ing] increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions.” The pathway that most resonates with me among that list is enhanced therapeutic alliances. This is because some of the most recent research, coming from within the realm of physical therapy and rehabilitation, showed that the patient-therapist alliance can have a positive effect on treatment outcomes. The trends in the research are clear; communication, and specifically trust, can make worlds of difference in your patient’s medical experience and overall quality of care.

Here is my plea to all trainees and current health professionals in the field: Take the extra minute. Be there for the patient and their questions, concerns, sorrows, and fears. Come down to the patient’s level in your delivery of their care. Make sure they understand what is being done to their body and have a voice in those decisions. Yes, this model may take 2, 5, or 15 extra minutes in a patient’s room, but it may make all the difference in that patient’s quality of care and health care experience. It does not matter if your patient is 3 or 83, trust in their medical provider is important to them, and the communication styles needed to earn that trust is can be very diverse between patients across the entire lifespan. Never underestimate the role trust can play in medicine… or the lessons you can learn from a 3-year-old on a pontoon boat.

Acknowledgements: I want to thank my nephew Jasper for bringing me this amazing lesson and helping me further realize the diversity of communication styles that exist between patients and across the lifespan. I also want to thank the patients that I work with every day who are consistently my greatest educators in the art of communication.

Author Bio: Domenic is currently a 3rd year Doctor of Physical Therapy School student in the Mayo Clinic School of Health Sciences. Right now he is working at Saint Marys Hospital out of the 1-Domitilla physical therapy office seeing a mixture of general medical, orthopedic/trauma, and cardiac/vascular patients over the course of a 12-week clinical education experience. From here, Domenic will go to Fargo, ND to work in a Sanford Hospital in an Outpatient Neurology setting.

Jun 14, 2017 · My "Modern" Family

By: Domenic F. Fraboni

 

I want to talk about that ugly “D” word that wreaks havoc on so many families every year. “We’re getting a divorce.” The words my mom and dad shared with me at the kitchen table during my senior year of high school. My world flopped on its head in an instant. How could this be happening at this time in my life? When I was about to fly the coop and go into the big bad world on my own? Where would this leave our family? What will holidays, birthdays, or even funerals look like? I want to tell you about my family during this period and where we landed after this tsunami wave of divorce swept the household.

We live in a country in which 90% of our population gets married before the age of 50. However, roughly 40-50% of marriages end in divorce, with the divorce rate in subsequent marriages tallying even higher. The United States also boasts one of the highest divorce rates internationally. Why is it that divorce is so prevalent in our country? I think the answer to why can encompass a vast spectrum of reasons. In this post, I am not attempting to generalize divorce or say some separations aren’t warranted. There are many instances in which separating may be the best option for the wellbeing or safety of one or both partners and their kids. Because of this, I am going to stick to my parents’ divorce story. The most appropriate place to start is with a brief intro to my family. Let’s hop in the hot tub time machine and travel back to the 1990’s.

I want everyone to imagine a family. Disclaimer: It is going to be a stereotyped, nuclear, “American” family. The type of family image that has been perpetuated by popular media and television since media began. I’m talking about the families from the likes of The Wonder Years, All in the Family, The Cosby Show, Everybody Loves Raymond, and even The Simpsons. I’m talking a mom, dad, 2.2 kids, dog, cat, and two-car garage in a suburban home. Other than the fact that we lived in a pleasant, conservative country town, and I had two brothers, that would just about sum up the family dynamic in my early life. My father was a family physician specialized in OB/GYN and my mother was the chair of the Princeton School Board (she participated in many other boards and political realms for that matter) and was the volunteer extraordinaire.

My “pre-divorce” family.

My parents were like many others: taught us to say our please’s and thank you’s, made us eat our vegetables, and tried providing any potential opportunity that they could for my brothers and me to find joy. My parents were also incredibly active in exposing us younglings to a wealth of diverse experiences. I remember bringing books to the local Princeton Laundromat to the “give one, take one” library for families looking for children’s books. We would go and help stock food shelters when the trucks came in and did monthly ditch clean up around our outback neighborhood. As my brothers and I grew up, we began falling into our preferred activities and had a fair amount of success doing so in our high school and community. So, what in the actual heck went wrong to tear apart my “picturesque” family? Back in the time machine to return to the dinner table.

“We’re getting a divorce.” Again, dread and despair flooded my entire 6’2” being. However, the next sentence out of their mouths was one we may not have been expecting: “I am gay,” my dad followed up. The remainder of the night was filled with more explanation, loads more questions, enough alligator tears to supply the Nile, and a bucket of ice cream to pass around between the family. It wasn’t until weeks (potentially months) later that I realized how lucky I was. Lucky? No, you did not read incorrectly. I said lucky.  I’ll try to briefly explain to you why.

During the three to four years prior to this announcement, you could cut the tension in the Fraboni household with a knife. Arguments would spark out of nowhere. Resentment could be felt between my parents if you stood close. Chores left undone were punishable by solitary confinement in the dungeon. Okay, that last one is an exaggeration, but I once offered to clean the dishes to prevent a fight between my father and older brother. I couldn’t remember seeing my parents show affection to one another for a stretch of years.

I found out that night at the dinner table that my mom and dad had been going to marriage counseling during this entire four-year period. My mother stayed by my father in order to help him find himself and what he needed to be happy in life. It was my mother, the rock, who did not say “get out of my (expletive) house you (expletive)” when her husband of 25 years told her he thought he was sexually attracted to men.

My mom and the three dads at one of my college football games together.

This is why I am lucky. I feel scenarios like this generally do not play out in this manner. I learned many lessons about life through this experience. I learned that kindness, respect, acceptance, love, and forgiveness can mend shattered relationships and even save lives. Without the example that my parents set across those four years, I don’t know where my family would be now. Yes, I am generalizing the situation a bit. There are many more details of happenings between my mother and father that I won’t be sharing to protect the sanctity of their privacy, but hopefully this gives you a little sense of the situation.

Let’s fast forward to present day and see what’s going on in the Fobbe-Fraboni Chronicles. It’s been over six years from the fateful dinner that rocked our family, and I’m proud (and fairly shocked) to say my family is closer than ever. Never did I think that I would find myself on a houseboat with my mom, her boyfriend, my dad, his boyfriend, my brother, his wife, and my gay younger brother (oh yeah, he came out to the family three years later too). Never did I think that my mom would be standing up as the matron of honor (or best woman, whichever you prefer) for my dad as he married his now husband, Alex. Never did I think my parents and both their partners would come to watch my college football games together, and make the three-plus hour drive north to do so in a single vehicle. Yes, our new “Modern Family” unquestionably still faces challenges. I believe that it is through the example my parents set that we are able to navigate these challenges much better than we may have in the past. With love, respect, acceptance, and forgiveness.

Yeah, my family contributed to the fifty-whatever percent of marriages that end in divorce. But this experience helped me realize not all divorces need to end in complete destruction of the family dynamic, especially because of the Blended families are all the rage these days. Now, instead of exemplifying the nuclear family, my household has joined the likes of The Brady Bunch, Full House, and Modern Family. And I love it.

My Modern Family!

 

Acknowledgements: I need to send a huge thank you to my family. They have always been there for me and my dreams, and now I know that they always will be, no matter how they look.

 

Author Bio: Domenic is a third year Doctor of Physical Therapy student at the Mayo Clinic School of Health Sciences. He is currently in a 12-week clinical rotation at 1-Domitilla and hopes someday to work in a private outpatient setting that serves a variety of patient populations.

May 4, 2017 · Providing Physical Therapy in Rural Honduras

By: Jordan McGowan

In February of 2017, I traveled to Honduras with other members of the physical therapy program from the Mayo Clinic School of Health Sciences: one professor and 3 students. Our mission was to meet up with functional therapy students at the university in Tegucigalpa, Honduras and travel with them to a clinic to provide care to patients who would not otherwise be able to receive treatment. It was by far one of the most influential experiences I’ve had in my life.

The first couple days were unlike the rest, as we stayed in Tegucigalpa. We flew in on Friday, settled into our hotel, and ate at a Honduran restaurant to explore the local cuisine. On Saturday, we attended a conference at the Universidad Nacional Autónoma de Honduras.  It was a great way to get introduced to what the students in the program are learning and to get familiar with some of the students before heading to the ranch. We left for Rancho el Paraiso on Sunday. We traveled in a bus with the entire group, which consisted of about 25 Honduran students, 2 doctors, 3 physical therapists, 1 medical resident and 4 American students. In a typical day at the ranch, we would wake up around 5:45am and eat breakfast at 6:15. There was a devotional (meant to bless the ensuing/proceeding week of patient care) on Monday and Friday before we saw patients in the clinic at 7:30. The clinic consisted of a waiting room and approximately 8 treatment rooms in a ring with an outside courtyard in the middle.

Two Mayo DPT students and a Honduran functional therapy student working in the clinic. PC: Sam Nelson

In the clinic, we were divided into groups of 4-5 under the direction of 1-2 physical therapists and/or a doctor.  I was excited to be placed on the pediatric team, because my patient population consisted of kids! I was responsible for examining and evaluating patients and prescribing them interventions. We worked together as a team to do this, but as the only American PT student in my group, I had a unique perspective that I could express in each case. This team dynamic was one of my favorite aspects of the experience. In my group, I had 4 unique lenses that were being used: a medical doctor, a pediatric physical therapist, the Honduran students’ perpectives, and my own. After treating patients in the morning, we would go to lunch at 12. Meals were fantastic at the ranch, consisting of a lot of meat, soda, rice, beans, and fruit!

After lunch, we would most often divide into larger groups to go treat patients in the community. We would hop into 12 person vans and travel up to 30 minutes to different locations. It was rewarding to see patients that otherwise did not have the means to get to the clinic on their own. Due to the larger group size, my responsibilites during these expereinces were slightly less, but I was still able to give my opinion as to what should be done with patients and learn from the entire group. When we got back frm these experiences, we would often play soccer for a couple hours before supper. I had to be on top of my game, as the majority of the Honduran students were really good! Supper was at 6pm and was always delicious.

The fantastic four Mayo students that traveled on this Honduran adventure. (Left to Right – Kayla, Samantha, Heather, Jordan) PC: Samantha Nelson

One regret I have about the trip was that I would regularily sit with the American students and staff. If you are thinking about taking part in a similar experience, I would recommend getting out of your comfort zone and sitting with those from different countries whether or not you understand their primary form of communication! Every group washed dishes one night of the week, and afterwards, we would gather for a reflection of the day at 7:30. These reflections were meant to share interesting cases that each group had been exposed to during the day, to increase our awareness of what the other groups were seeing and doing. We would then go back to the dorms, chat, play guitar, shower, and go to bed.

During this experience, I grew both personally and professionally. I would say the majority of my personal lessons came from the Honduran students. For their education, they have 3 years of extra education beyond high school until they are permanently in the clinic. If I were to compare their confidence and knowledge to what I knew 3 years out of high school in my junior year of college, it wouldn’t even be a contest; they are very professional and knowledgable. I admired their confidence with the patients and their ability to connect with patients immediately. It taught me that I should surely be confident with what I know, as it creates an invaluable connection with patients. If patients see me as confident, they will be much more likely to adhere to my recommendations and thus, improve. Another thing I admired, which I have already alluded to, was their ability to forge personal relationships with everyone they met. There was often a language barrier between me and the students, and though I consider myself pretty good at Spanish, I was sometimes still out of the loop. Despite all this, every student I met was able to make me feel like they were my best friend in the world. I was inspired by their desire to get to know me personally. I aim to employ this in the future to new and old relationships in my life.

Mayo students and their professor playing soccer with some functional therapy students. PC: Sam Nelson

Professionally, I would say I learned most from the doctors and PT’s.  I learned a significant amount about how to interact with pediatric patients from the doctor in my group. He taught me how to provide the best care even when children were not in the mood (crying and screaming)! It was good to watch the dynamic between the doctor and physical therapist in my group, as they had very different lenses, yet respected each other’s opinions and ideas. Furthermore, I admired the staff of HOI’s resolve to treat the patients who really needed to be treated. I sometimes thought that we could treat more patients if we just stayed in the clinic and let the patients come to us, instead of going out to the community to treat 1 patient. However, it was a good lesson in patient care to treat the patients who desperately needed treating, even if it’s not the most efficient or easiest. In America, we often strive for efficiency. It does not often make sense economically to treat a certain patient when we can treat two others in the same time frame. However, I will strive to put my patients before my own desires to provide the best care I can in the future.

This experience allowed me to grow immensely. It provided me with new lenses that I can use to treat patients to the best of my ability, I was able to learn about different cultures, I was given experience working with diagnoses that I may not see in the U.S., and I was able to apply the knowledge I have learned at Mayo to help others in need. I cannot adequately express my gratitude for having been given this wonderful adventure.

Author Bio:  Jordan McGowan is a second year Doctorate of Physical Therapy student in the Mayo Clinic School of Health Sciences. Other than having a promising future as an incredible Doctor of PT, Jordan likes to unicycle, play frisbee, and compose music… all at the same time.

Apr 27, 2017 · I Now Pronounce You Man and Muxe

 

By: Domenic F. Fraboni

 

The following is a fictional vignette:

I have a penis. Well, I was born with one, I guess. The sex organs I was born with would make you think I am a man. However, I identify as a woman who is attracted to what most would call “traditional” manly men. Furthermore, the activities that I like to participate in when I have leisure time are traditionally masculine activities. I love playing basketball, going fishing and hunting, working on home improvement projects, and four wheeling. Sometimes people find my situation confusing. I just think that my self-identity is unique, as is every single person’s self identity on our planet. 

The above scenario is something that is not talked about nearly as often as it needs to be in today’s medicine. The woman that I described in the previous paragraph identifies some of the differences in how people describe gender. She has described for you her biological sex, gender identity, gender expression, and sexual orientation. These are just four of the many facets that help us to define self. Last month, on March 8th, I was fortunate enough to be a part of an incredible session that helped the attendees dig into gender. Anna Schettle and Dr. Cesar Gonzalez (their bios can be found below) led a cultural competency session called “Transgender affirming care in medical settings: Where cultural competence meets evidence-based practices.” They helped those in attendance explore a few questions: Where did gender come from? How can our language and culture influence our perception of culture? What is the prevalence of those that identify with the LGBTQ+ community? How can we as medical providers better prepare ourselves to give the highest quality of care to a very gender diverse population?

Diagram trying to decode the different aspects of gender and self-identity. PC: Dr. Gonzalez’s slideshow

Before the session began, I had the opportunity to prod the minds in the crowd. Echocardiography student from Mayo Clinic School of Health Sciences, Lauren Emerson, said hands down that this topic required continued discussion. She found herself in clinical experiences where providers had not known how to react towards, treat, or handle a patient who does not align with a binary gender. I then turned to Erin Mason, a Physician Assistant Fellow in Emergency Medicine, who stated she observed similarly unfortunate scenarios. Erin followed up by saying that her colleagues did not want things to be awkward in these instances. They even express that they want to better understand how to treat gender diverse individuals. Perhaps they do not have sufficient “experience” with this population. Erin hopes to work with Dr. Gonzalez to develop an educational program for providers to broaden their education on gender diverse medicine. Okay, lets get back to the talk.

The session began with a video based in the Southern Mexican city of Juchitan. Understanding of gender in Juchitan has evolved a bit differently than in most cities in the United States. In Juchitan, they have a third gender, muxe. Many muxes are assigned male at birth, but consider themselves a woman (aka their gender identity). However, as the documentary went on, others said that they define themselves as a muxe and do not fit the “stereotypical” muxe mold. The muxe term is one that just allows them to know who they are, how they identify, and what this identification means to them. In other words, muxe in Juchitan seems to have given this region a gender diverse outlet that most other areas do not have. I hope no one found the title of this piece to be heterosexist or heteronormative. I just wanted to use this example of cultural gender diversity to show that there are many different ways in which gender is understood and socially practiced globally. This short Central American documentary acts as a small example of how culture and language have functioned as a catalyst for the evolution of gender. How can our society impact the development of how we collectively understand gender in our country? I daresay we could come up with a laundry list.

One of the main topics of discussion was health care best practice for the LGBTQ+ community. It is well documented that those who identify with this group have markedly higher prevalence of some health conditions. Of those that identify as transgender, 47% currently experience depression (general population 8.7%) and about 41% of them attempt suicide across their lifetime (2.4% in the general population). There also tend to be higher rates of sexually transmitted infections in the gender diverse population. These statistics may not mean a whole lot out of context. However, it tells me that something may be going astray in the health care management of those who are not straight cisgender individuals.  In fact, the rates of access between the general and transgender populations are very similar. What can we do to help improve healthcare for the queer population?

Minority stress can be another factor resulting in the health disparities found in the LGBTQ+ population. PC: Dr. Gonzalez’s presentation

Why is it that these individuals have had such a bad go at it in the realm of medicine and healthcare? This could be because for years (and still today) they have been seeking care from within a system that only understands medicine through the scope of male and female. What is the first question most people are asked when they fill out medical forms? My guess is it looks something like this – Sex: Male Female. It is unspoken microaggressions like this that can immediately put a sour taste in a gender diverse individual’s mouth. In addition to the many homosexual, bisexual, and transgender microaggressions seen in medicine, it was only in 1992 that homosexuality was removed as a mental disorder by the World Health Organization. Now I’m not very old, but that is within my lifetime. Furthermore, transgender identity is currently listed as a classification under mental disorders in the ICD-10 codes… We wonder why there are higher rates of depression, self-harm, and attempted suicide among these patient populations. To me it is easy to see why while operating within this system that disaffirms their existence.

“What now?” you may ask. The goal of “treatment” is to help relieve the “dysphoria” surrounding patients as they explore their own gender. Here at Mayo, as a leader in world-wide inclusive medicine, we must educate ourselves on teaching self acceptance and affirmation, social transition, cross hormone therapies, and/or potential surgical procedures that these patients may need. In an American society that has more individuals that identify as transgender than have diabetes mellitus I, we should behoove ourselves to meticulously understand how to treat this population. We can add these tools to our clinician tool belts in order to educate these patients and their parents or loved ones on all the options available. After all, those trans youth with supportive parents are one third as likely to experience depressive symptoms and almost 14 times less likely to attempt suicide in a calendar year. Piggy backing on that little fact, 80% of those who undergo hormonal therapy and genital reconstructive surgery have an improved quality of life.

To me the data rings clear. I hope that all out there in the Mayo community can join this team to help create a thoughtful, inclusive, and evidence based medical approach for ALL patients that walk through our doors. We can take a page out of the Mayo Brother’s book for that one.

 

“Within its walls all classes of people, the poor as well as the rich, without regard to color or creed, shall be cared for without discrimination” –Dr. William J. Mayo (October 09, 1912).

 

Acknowledgements: Huge thank you to Ms. Schettle and Dr. Gonzalez for giving such an enlightening educational session on transgender medicine. Also, thank you to Pete and Mayo Clinic School of Health Sciences for coordinating and advertising this event.

 

Presenter Bios:

Anna Schettle, LICSW, MSW, is a Licensed Independent Clinical Social Worker at Mayo Clinic’s Transgender and Intersex Specialty Care Clinic (TISCC). She completed her undergraduate degree in Social Work, Gender and Women’s Studies, and Lesbian, Gay, Bisexual, and Transgender Studies from The University of Wisconsin in 2011 and earned a Masters of Social Work Degree from the University of Central Florida in 2013. While Ms. Schettle’s background includes clinical social work experience within a variety of multidisciplinary inpatient and outpatient hospital departments, her current role focuses on providing individual and family therapy to transgender and intersex patients, coordinating patients with open and inclusive community-based services, advocating for patient rights, and serving as a resource for allied health professionals. Ms. Schettle’s education, passion, experience, and identity within the LGBTI+ community positively impacts her understanding of and work with transgender and intersex partners.

 

Dr. Cesar A. Gonzalez, PhD, LP, ABPP, is board certified psychologist and is and assistant professor of psychology and family medicine at Mayo Clinic. His clinical practice and community involvement in transgender health has spanned over 14 years and includes over 400 psychological assessments among transgender and gender diverse individuals.

In 2010, Dr. Gonzalez completed his research and clinical postdoctoral fellowship in human sexuality at the University of Minnesota, where he specialized in transgender health. His research activities are focused on topics pertaining to minority stress and transgender mental health. He is an editorial board member of the International Journal of Transgenderism and served as faculty at the University of Minnesota Medical School’s Program in Human Sexuality. In 2014, Dr. Gonzalez was nationally recognized by the American Board of Professional Psychology for his dedication to multiculturalism and diversity in professional psychology.

 

Valuable Websites for Additional Information:

Gay & Lesbian Medical Association: http://www.glma.com

MN LGBT Therapists:: http://www.lgbttherapists.org

National Center for Transgender Equality: http://www.transequality.org

Out Front Minnesota:: http://www.outfront.org

PrEP Locator: https://preplocator.org

World Professional Association for Transgender Health: http://www.wpath.org

Author Bio: Domenic Fraboni is a second year Doctorate of Physical Therapy student at the Mayo Clinic School of Health Sciences. One of his goals is to do whatever he can to advocate for culturally competent and evidence based care for all patients. Please feel free to email Domenic if you want to chat about different aspects about cultural competency or even colaborate on a post about care surrounding a different population, please feel free to reach out to him.

Apr 7, 2017 · Do Not Oversimplify MLK’s Complex Legacy

A very belated Martin Luther King Day post

By: James H. Lee 

A couple of months ago, I was tasked with reporting on the Office for Diversity’s Martin Luther King Jr. Day event – “Content of Character, Color of Skin; Has Dr. King’s Dream Been Realized?” One lengthy name for an event, but I hoped that the length of the title was justified by the complexity of the hour-long talk. What was Dr. King’s legacy, and how did it affect how we see race today? How has Dr. King’s message transformed since he was assassinated on April 4th forty-nine years ago?

The discussion was opened up with Dr. Eddie Greene introducing the panel and then reading a few quotes from a prepared list. It was great to remember how Dr. King was a phenomenal orator and writer with an uncanny ability to sum up grand truths in short statements – a true literary magician, instilling hope and courage in thousands of people at a time. But I couldn’t help but feel that Dr. King’s legacy was cheated somehow by simply reading pithy excerpts from his various speeches and letters – it is dangerous to reduce an entire individual to thirty or so intentionally elegant sentences without understanding the surrounding historical context.

At the MLK Memorial in Washington DC. ~PC James Lee

Now, to be fair, this criticism is coming from someone whose favorite quote is from MLK – “The arc of the moral universe is long, but it bends towards justice.” (Sends shivers down your spine, doesn’t it?) But I was never simply content to accept the quote as a quote – I continued to delve into the history. I researched how the quote came from a Baccalaureate speech at Wesleyan University in 1964 and how the quote was used in previous ministers’ sermons (e.g. Reverend Seth Brooks in 1934, Rabbi Jacob Kohn in 1940) before its “debut” in Middletown, CT. I read about the context of the Civil Rights Movement at that time and what may have inspired Dr. King to use those words at that time.

People love to abbreviate history into quotations. “Four score and seven years ago.” “I have a dream.” “Ask not what your country can do for you.” Quotes are full of buzzwords and emotions, but they are also a lazy way of understanding someone’s legacy. In the future, I hope that no one walks away from a list of quotes satisfied. There should always be more exploration and navigation into the history of the words.

Which brings us to the meat of the discussion. The four panelists (Aiyana Batton, Domenic Fraboni, Dr. Michael J. Joyner, and Dr. Latasha Smith) introduced themselves and immediately dove into what Martin Luther King meant for them. How has Dr. King’s message affected them today?

Hearkening back to the previous point of digging deeper into history, one of the more provocative points involved talking about the flaws of Dr. King. It is easy to simply remember Dr. King as a saint who could do no wrong, one who brought forth a universal message that rang true with the heartstrings of Americans. We tend to purify and idolize the people whom we admire, emphasizing the cleanest aspects of these people. But then we forget that Dr. King had familial strife. He engaged in sex outside of marriage in spite of his vocation. He was likely against LGBTQ marriage in spite of the fact that one of the chief organizers for the Civil Rights Movement, Bayard Rustin, was a gay man. By pursuing the history of Dr. King’s life, the panelists argued that we are not degrading his legacy, but rather giving context to the man who gave us his words. Dr. King’s legacy was not a simple one, and to give it full justice, one needs to understand the good and bad parts of the man that made the legacy a realizable one for the American people.

More MLK Jr. Memorial pics. ~PC James Lee

There were some other powerful points made by each of the panelists. Ms. Batton remarked on how she saw how Dr. King’s messages affected her consistently as a young black woman in school. Mr. Fraboni discussed about how the legacy that King left also affected his life as a white male in a relatively racially homogenous place. Dr. Joyner examined privilege and how much more complex racial and socioeconomic privilege are today in the melting-pot of America. Dr. Smith mentioned the various challenges and rewards of working as a black woman in a STEM field. The panelists brought forth stories from their peers, superiors, families, friends, and themselves and thrust them into the complex discussion that was forming around us. The panelists trekked through quite an expansive terrain of what Dr. King’s legacy means today in a less black-and-white America, how Dr. King would be pleased or disturbed by the progress (or lack thereof) since his death, and how a Trump administration reflects (or really does not reflect) the visions of Dr. King. The generational divides between the panelists showcased how various generations (Baby Boomers vs. Gen Xers vs. Millennials) took racial justice for granted. How much of Dr. King’s legacy was centered on race, and how much of it was dedicated to intersectionality – gender, socioeconomic status (aka poverty), age? Clearly, the legacy of Dr. King is a multifaceted one that lends itself to multiple complex narratives in people today, nearly fifty years after his death.

Nearly one month after the event at Mayo, I happened to be visiting the Martin Luther King Jr. Memorial in Washington, D.C. with a close friend from college. The memorial is an architectural feat that acts as Dr. King’s quote book. As my friend and I strolled through the memorial and spent time analyzing various quotes, I felt frustrated with how oversimplified the memorial seemed. King’s legacy could not simply be wrapped up in a few words. The memorial did not seem to encourage critical thought, but rather, it seemed to quash it by distracting us with inspirational “quotes of the day.”

James in Washington DC at the MLK Jr. Memorial.

We should not fall into that trap. We should never cease finding new questions and accepting difficult answers. We should never simply accept “truths” handed to us by society or various individuals. Thoroughly understanding history is the only way to think critically about the political and legal systems in place today.

King’s legacy is not a simple one. It’s not confined to “I Have a Dream.” And only by asking and answering sophisticated questions can we begin to fully respect and appreciate how Dr. King changed America for the better.

Bio: James Lee is a first-year medical student at the Mayo Clinic School of Medicine interested in pursuing Child and Adolescent Psychiatry. He loves music, dogs, and cheese a lot.

Acknowledgments: Thank you to the Mayo Clinic Office for Diversity for hosting the MLK Jr. event, as well as the moderator Dr. Eddie Greene and panelists Aiyana Batton, Domenic Fraboni, Dr. Michael J. Joyner, and Dr. Latasha Smith for their contributions to the discussion.

Mar 31, 2017 · Who's Driving This Thing?!

By: Domenic Fraboni

The story of a group of

 Doctorate of Physical Therapy (DPT) students who take command of a full-court, Special Olympic basketball team in its inaugural year and the invaluable lessons, memories, and skill set the experience brought to their health care education.

Just as they did last year, the crew of Mayo Physical Therapy students took on the duty of coaching some of the most talented Special Olympic basketball athletes in the Rochester area. This is the same team that took home the championship in their Division of half court basketball at the State Games the year prior. This is the same team that did not lose a single game the entire year. This is the team that could have easily gone on to repeat in this season if they so chose to. However, in a Michael Jordan-esque move, the players decided they wanted something new. They were over this 3-on-3, half court version of basketball that they had seemingly mastered. It was time to move on to bigger and better things: full court, 5-on-5 basketball.

To comply with the teams wishes, the Rochester Area Special Olympics (RASO) registered a second full court team for the first time. The other full court team has been ballin’ it up at the full-court level for some time now, and they were more than thrilled to have some up and coming competition in the area. The greatest twist of events came when they were choosing who should coach this newly formed bunch of scrappy full-courters. They tapped in the DPT students that have been constantly looking for more opportunities to deepen their involvement over the past year with this amazing organization. The DPT Students gladly accepted the challenge. With a team of 13 athletes at the ready, it was now time to get to work.

Coach Nick schooling up the athletes on the bench before he subs them into the game.

With a staff of seven DPT coaches, all of which had experience in playing and/or coaching, the PT students figured this would be an easy gig. Right? Wrong! What they didn’t initially realize was that none of these individuals had played organized, full court basketball before (with the exception of a couple players). They also quickly understood that the skill level range and spectrum of intellectual ability differed greatly among the 13 players. Where some of the athletes could be coached on the in-game nuances like pick and rolls, back door cuts, zones and presses, or a run and jump, others on the team would need to be reminded that they can’t pick the ball up and dribble again right away. I believe it is within these differences that the DPT students were able to grow tremendously as coaches, but also as future health professionals.

Breaking it down before tip off!

More about that growth as future health professionals later. For now, basketball. The first few practices were not the prettiest. The players weren’t used to having to run up and down the court. Some could not dribble with their left hand. Some could not really dribble well with either hand! Passes were all over the place. Drills proposed by the coaching staff were slightly too complex and did not run very smoothly. The athletes with slightly lower basketball ability would get lost in the shuffle during the scrimmage time at the end of practices, and this was frustrating for both them and the coaches. How could this be fixed? The coaches went back to the basics. After that, practices always began with fundamental drills like dribbling, passing, and basic shooting. The team was split up into small groups of similar ability so that they could be coached to their level, and the coaches found that 3-on-3 scrimmage would work better so each player could get more time with the ball. Things were actually coming together. Then game the first day of competition: Area Games.

Area was held at Gustavus Adolphus College (thanks Gusties!) on February 12th. The Rochester Flyers full court team had two games against Division 3 opponents. The first started out kind of rough. The other team jumped out to a 12-2 lead and needed to be calmed down before rallying back to lose only by 5. The second game was another story. The Flyers jumped out to a very early lead and never looked back, winning by about 30 points. The best part of that game was the very end. There were two players on the team that hadn’t scored yet. Our goal was to get them to put the ball in the hoop. With 45 seconds to go, on of the best players on our team (and someone who values scoring points himself above all else) got the basketball with an open layup. Instead of shooting the ball, he turned to his side, passed to his teammate who hadn’t scored yet, and they shot and made the basket. Proud coaching moment right there.

A lot was learned during these first two games. There were many ways in which our team could improve, but also our team never played better than when it played together and utilized the skill set of everyone that was a part of our basketball family. Since earning second place at the Area games, our team has gone on to receive the 2nd place prize at the Regional basketball games at St. Olaf College and 1st place for Division G at the State basketball games at St. Thomas. In our championship game at State, every single player on our team scored a basket. Now I call that a team victory. If you would have any interest in getting in some Special Olympics coaching experience yourself, you can sign up here or get in touch with me at Fraboni.domenic@mayo.edu.

Team photo after winning State!

Time to hop back to health professional growth and development. Every single person that walks into our exam room for physical therapy will have a different story. They will have a different profession, different cognitive ability, different preferred learning style, different barriers to learning, and ultimately will need to be taught very differently than the person who was in the exam room with us for the previous appointment. Just as these thirteen athletes were so beautifully different in the way we needed to coach them, so we will need to differently teach and treat each patient we ever encounter. The soft skills and knack for patient interaction I feel I have gained as a coach over the past six years is something I could not do without in my practice. I think every medical professional, future or current, could greatly benefit from working with individuals with varying levels of intellectual ability. They could also have a darn good time while doing it.

Author Bio: Domenic Fraboni is a second year Doctor of Physical Therapy Student in the Mayo Clinic School of Health Sciences. He has coached Special Olympic athletics for the past six years in basketball, track and field, power lifting, volleyball, and flag football.

Acknowledgements: I need to just thank the Rochester Area Special Olympics for allowing our students to coach this team and to all of the athletes for the passion and effort they bring every week to practice and competitions. I also need to thank all the other amazing classmates of mine that helped coach the team! we rocked it.

Jan 26, 2017 · Health Disparities: Equity vs Equality

By: Margaret O. Akinhanmi

“What does health disparity mean to you?” This was the first question asked by the instructor of the Mayo Clinic Center for Clinical and Translational Science (CCaTS) course, ‘What Every Researcher Needs to Know about Health Disparities’. Our instructor, Dr. Joy Balls-Berry, gave us a few minutes to answer this question. My answer was akin to the definition that most people think of when they hear the words ‘health disparity’. I simply stated that health disparity is defined as differences in healthcare treatment and access. The formal definition as stated by the Center for Disease Control (CDC) is as follows: “Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” When one really breaks down this definition of health disparities, it can mainly be attributed to a certain group of individuals, particularly minority populations. Geographically secluded and underprivileged areas have high volumes of minorities. While violence and subsequent injury are not exclusive to these populations, they are seen to occur at greater rates here. The need for proper healthcare is therefore essential to these areas but access is limited because of low socioeconomic status, thus leading to the vicious cycle of the disparity of health and lower quality of care.

What sticks out to me in the formal definition of health disparities is that these are preventable differences. If it’s so preventable, why hasn’t it been eliminated yet? In my opinion as a student, the answer to this tough question is a combination of a long history of mistrust between minority populations and large medical institutions. The problem with lack of access is not only due to the inability to physically see a healthcare professional or financially afford it, but also an innate discomfort and lack of belonging in these large institutions. This issue is layered with the history of who was permitted to access medical institutions, while it also reflects those who could provide the best care when these institutions were being developed. History also tells us that the minority individuals that attempted to access any kind of care were often mistreated and/or under treated, leading to tragic events such as the Tuskegee Syphilis Experiments. The Tuskegee experiments are one of many examples that contribute to the uneasiness and mistrust that minority populations experience and exhibit today. Like any relationship, the trust must be rebuilt to look ahead to a brighter future of eliminating the disparities being faced by these communities.

Rebuilding this relationship begins with understanding these populations and their needs through researchers and engagement with the community members. Dr. Claire Pomeroy, President of The Lasker Foundation and expert researcher, stated during a talk at the Mayo Graduate School Symposium last year that it is the responsibility of researchers to be advocates for health disparities research. No matter the field of research, scientists should strive to include diverse individuals in their studies and grants to eliminate health disparities. In addition to inclusion, scientists must also strive to comprehend the needs of the community and involve these individuals from the beginning to the end of all research studies. This principle of research is called community engaged participatory based research. In this model, the researchers form relevant research questions and work alongside community members to address the specific needs of that community. Community members are involved from the genesis of the research objective to the point at which the results are disseminated through appropriate venues such as public meetings, radio, and peer-review journals.

A group of Mayo Clinic physical therapy students immersing themselves in an international experience in Honduras, both deepening their education and helping to provide for an area with large amounts of health disparity.

While every researcher may not be called to exclusively conduct community engaged research studies, it is possible to be involved by simply being an advocate, as Dr. Pomeroy stated. During our graduate research, we can be advocates by maintaining the knowledge of how our work will eventually impact the community. As students at Mayo Clinic, we have the privilege of being able to see our work in action in the clinic. We should take advantage of this through occasional immersion in the clinic either through meeting with patients relevant to our research or discussing our work with physicians and its impact on their work. Additionally, engaging with the community (through volunteerism or social activities) outside of our research facilities will allow community members to put a human face to the large research/medical institution that can be intimidating to many. When researchers and healthcare professionals engage with the community that they work to help, bridges are built that allow certain minority populations to feel more comfortable accessing proper care. This will then positively impact recruitment efforts for important research studies to be conducted. It is equally valuable for students that are engaged in various other types of medical education (Medical School, School of Health Sciences, Nursing, and Continuing Education) to participate with patients, physicians, and community members as well. Cultivating relationships and reminding oneself of the positive effects of our work plays a crucial role the eventual elimination of health disparities.

While reducing health disparities is a positive step, complete elimination of it is the ultimate goal toward health equity for all. Truly eliminating disparities means achieving equity for all individuals regardless of race, religion, sexual orientation, or socioeconomic status. Equity is reached when patients receive the appropriate care necessary for their medical condition or situation. Equity distinctly differs from equality. Equality refers to applying the same solution to different cases, while equity examines each case carefully and applies the appropriate solution for each case. For example, in the illustration below, each person has an equal number of boxes in the ‘equality’ panel. However, an equal amount does not fit the needs of each person. The ‘equity’ panel shows appropriate distribution of the boxes to fit each person’s specific need. In this age of personalized medicine, true equity is becoming more possible. There are initiatives all over the U.S. taking action to make health more equitable. To join in these actions, we as researchers and future healthcare professionals must consistently immerse ourselves in underprivileged communities and surround ourselves with diverse populations. We will then be able to include these individuals in our studies to fully eliminate health disparities and work toward the goal of true equity for all.

Photo Credit: http://interactioninstitute.org/illustrating-equality-vs-equity/%5B/caption%5D

[caption id="attachment_2655" align="alignright" width="169"] Margaret O. Akinhanmi PC: MOA

Author Bio: Margaret is a third-year PhD student in the Clinical and Translational Science track at Mayo Clinic Graduate School of Biomedical Science. Her thesis work incorporates epidemiology and clinical genetics to tackle a health disparity in Bipolar Disorder. In her spare time, she enjoys spending time with friends and traveling to places that she has never been before. In the future, she hopes to be part of a research team whose goal is to eventually improve clinical outcomes and eliminate health disparities. With translational research being such an emerging field, she is eager to see where it will take research and medicine.

Acknowledgements:

Mayo Clinic

Center for Clinical and Translational Science (CCaTS)

Joy Balls-Berry, PhD, Office of Community Engaged Research

Claire Pomeroy, MD, Lasker Foundation

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