With the support of the Middlesex Alumni Association Internship Stipend, I was able to explore my interest in rural health by working and living in Hawaii this summer. During the month of June, I worked with Dr. Kelley Withy, Professor at the University Of Hawai’i John A. Burns School Of Medicine, and Director of the University of Hawai’i. Project ECHO was launched in New Mexico in 2003 as a way to give primary care physicians (PCPs) in rural and underserved areas the skills and confidence to treat patients with hepatitis C in their own community. Before Project ECHO, PCP’s would generally refer their patients with hepatitis C to specialist for care, but it can be hard or impossible for patients from rural areas or with limited resources to access distant specialists for routine care. And so, Project ECHO established a model where a team of hepatitis C specialists at a “hub” site presents a brief lecture about an aspect of hepatitis C care and serve as a sounding board for care management when a participating PCP at a rural “spoke” success, and Project EHCO has since expanded to hundreds of sites across the country and to many different disease topics. The University of Hawaii runs three Project ECHO topics: behavioral health, geriatrics, and endocrinology.
My task for the summer was to design an evaluation that could assess what kind of impact Project ECHO has for the Hawaii clinicians that participate. By taking part in the weekly secure video-conferencing sessions, speaking with ECHO Hawai’i team members, and reviewing the literature published on Project ECHO to date, I was able to identify what the specific needs and limitations of ECHO Hawai’i are. For instance, ECHO Hawai’i has a high proportion of social work participants compared to physician and nurse participants. Any evaluation therefore needs to appreciate how different types of participants utilize the knowledge gleaned. The diverse sites and of ECHO Hawai’i participants do not all use electronic medical records, so tracking patient labs and progress notes is virtually impossible. With these challenges in mind I worked with Dr. Withy to design a survey that assesses multiple possible domain of Project ECHO’s impact, uses an individualized measurement of practice change, and presents a low time-burden for participants to complete. We launched the first survey a few weeks after I returned to MA. While additional information is needed from follow-up surveys and the planned annual focus groups, preliminary results suggest the evaluation design is capable of assessing Project ECHO’s impact and could easily be adopted by other Project ECHO sites as part of their evaluation effort.
During my time in Honolulu, I also had the opportunity to work with Dr. Deborah Birkmire-Peters, Program Director for the Pacific Basin Telehealth Resource Center, to help set up a directory of telehealth services available in the state of Hawai’i. I learned a lot from Dr. Birkmire-Peters about what role the Pacific Basin Telehealth Resource Center (PBTRC) plays in Samoa, Guam, Commonwealth of the Northern Marana Islands, and the freely associated states (Republic of Palau and the Federated States of Micronesia). This area spans 5 time zones and includes both US citizens and individuals from foreign countries that the US has treaty obligations to provide health care for. This was the most interesting (and relevant) history lesson I’ve had since Doc Freiberg’s US History class!
After focusing on the Project ECHO evaluation in June, I moved to what is colloquially called the Big Island. Technically, the Big Island is the island of Hawai’i, but this can be confusing since the islands as a whole are generally referred to as Hawai’i. The Big Island has a land mass larger than all of the other Hawaiian islands combined and a population less than 1/5 the size of Oahu (the island that Honolulu is on). The population density of the Big Island is approximately 37 people per square mile, which is roughly the same as that of Maine, Kansas, Oregon, and Utah but pales in comparison to Massachusetts’s population density of 839 people/sq. mile (according to 2010 US census data). While on the Big Island, I observed primary care physicians at the VA clinic in Hilo. I had the chance to see parts of the small town medicine I am drawn to. Patients recognized a doctor or nurse’s last name and immediately knew what part of the island their family grew up in. I also saw the challenges that island medicine presents. Specialists are typically flown in once a month to spend time seeing patients from the different islands, and it is not uncommon for patients to have to fly to Honolulu to get the care they need.
The Kilauea eruption was ongoing while I was stationed in Hilo, which is approximately 33 miles north of the volcano. I listened as patients described how they had been evacuated from their homes and were making do in the meantime staying at temporary shelters, crashing on family member’s couches, or renting if they had the means for months on end as they wondered when the eruption would finally stop. There was a lot of anxiety and uncertainty, however, around what would happen once the eruption subsided. Nearly everyone recognized it would probably never be possible to live in their homes but were uncertain about where their next home would be given that their homes no longer had any monetary value. I also witnessed the intersection of veterans with PTSD, many of whom I learned thrive under high pressure situations, and a natural disaster. Many of the patients at the VA sprang into action when the volcano started to erupt, volunteering to help save people’s possessions and making the area safer for other inhabitants who had not been evacuated. These patients put themselves in harm’s way, exposing themselves to dangerous levels of sulfur dioxide and the hazards of a constantly evolving natural disaster site, but reported feeling more at ease with their PTSD symptoms than they had in a long time.
The Kilauea eruption was ongoing while I was stationed in Hilo, which is approximately 33 miles north of the volcano. I listened as patients describe how they had evacuated from their homes and were making do in the meantime staying at temporary shelters, crashing on family members’ couches, or renting if they had the means for months on end as they wondered when the eruption would finally stop. There was a lot of anxiety and uncertainty, however, around what would happen once the eruption subsided. Nearly everyone recognized it would probably never be possible to live in their homes but were uncertain about where their next home would be given that their current homes no longer had any monetary value. I also witnessed the intersection of veterans with PTSD, many of whom I learned thrive under high pressure situations, and a natural disaster. Many of the patients at the VA sprang into action when the volcano started to erupt, volunteering to help save people’s possessions and making the area safer for other inhabitants who had not been evacuated. These patients put themselves in harm’s way, exposing themselves to dangerous levels of sulfur dioxide and the hazards of a constantly evolving natural disaster site, but reported feeling more at ease with their PTSD symptoms than they had in a long time.
Spending the summer in Hawai’i working with rural clinicians and delving in to a research project focused on how telehealth can address some of the challenges of rural health was a transformative experience. Traveled 5,000 miles away from home to spend two and a half months by myself unsure of what to expect. I had the best adventure I could have hoped for exploring the beauty of the Hawai’ian mountains and beaches, meeting local people and Native Hawaiians, and eating the freshest tuna and most refreshing shaved ice all while strengthening my telehealth that I can continue to work on for my remaining three years of medical school. I presented the preliminary results of my project at the University of Massachusetts Medical School *MMS) Summer Research Poster session and hope to present an updated poster of the MetaECHO conference in New Mexico in March. In addition, I have begun to work with other Project ECHO team members on putting together a systematic review of the literature published on Project ECHO since 2012 and developing a database that can be used to log articles at they co out in the future. I have also harnessed the can-do energy and rural health enthusiasm that this summer sparked in me to plan the inaugural Rural Health Scholars retreat at UMMS this fall. I am immensely grateful for the Middlesex Alumni Association for making this