The Importance of Understanding Where Patients Come From

Each summer, the incoming class of emergency medicine residents receive an SBIRT training and a tour of the surrounding community to better understand and serve the patients at Boston Medical Center. Below are thoughts from one resident on the day.

Boston Medical Center Emergency Medicine Residents’ Class of 2019: A UNITY TOUR TO MEET THE NEIGHBORS

On June 19th, 2015, the emergency medicine intern class of 2019 set out to discover the neighborhoods they will serve for the next four years. For many interns – several coming from as far as Hawaii and Ireland – it was their first time visiting the streets of Roxbury and Dorchester. Led by Dr. Ed Bernstein and Project ASSERT staff, the community tour was first organized three years ago with two purposes: (1) to visit and learn about the community’s resources; and (2) expose BMC’s newest doctors to the social ills that manifest in ED visits. “We wanted to welcome the interns to not only BMC but the community-at-large…to encourage them to be stakeholders in the community’s health. We want them to get involved and not be afraid to enter these neighborhoods because of rumors they hear…they are now a part of us,” said Ludy Young, a Project ASSERT supervisor of twenty-one years and Dorchester resident. With this notion of service and unity, twelve interns would soon begin a day full of inspiration, reflection, and initiation into the greater BMC family.

The morning began with a presentation on the Screening, Brief Intervention and Referral to Treatment (SBIRT) program at BMC, a public health intervention that has become a national model in addressing substance abuse disorders. The knowledge gained during these morning exercises proved helpful in understanding the role of Hope House, a residential treatment center for recovering substance abusers and the first visit of the day. “Visiting Hope House was a nice way to get exposed to some of the follow-up and transition options that are available for patients suffering with substance abuse issues.

Although there’s clearly a shortage of these kinds of facilities, and not enough high quality rehabilitation programs out there, it’s great to know that there are passionate people who are working to improve the lives of folks who are trying to get clean and make a change in their lives,” said Haley Thun, an intern from Atlanta, Georgia. The visit included the touching testimony of a former user, now clean for many years and expressing his gratitude for Hope House. “I can’t imagine how hard it would be to do the right thing for patients with substance abuse disorders in our ED if it weren’t for programs like this one,” continued Haley.


Fred Newton (c) Director of Hope House, the oldest, and now among the largest residential treatment programs in Massachusetts for adults with substance use disorder (SUD)

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Residents heading into Louis D Brown Peace Institute

After thanking Hope House staff and residents for their generosity and time,   the bus headed straight into the heart of Dorchester to visit the Louis D. Brown Institute. Founded in 1994 after the murder of fifteen year old Louis D. Brown, this non-profit organization is dedicated to educating young people about the value of peace and assisting victims with crisis management services and ongoing support. Louis’ mother, Ms. Tina Chery, is the founder and current president of the organization. Listening to her recount her personal tragedy and subsequent efforts to prevent similar violent acts left an indelible impression on everyone.

“The Louis D. Brown Peace institute provided a nice opportunity for us to get introspective and think about not only our own identities but also those of people in the communities we serve and how violence and trauma are affecting peoples’ lives,” said Jon Santiago, an intern from Boston.

Louis D. Brown Peace Institute's Traveling Memorial for victims of homicide in Boston put faces and stories behind those who tragically lost their lives

Louis D. Brown Peace Institute’s Traveling Memorial for victims of homicide in Boston put faces and stories behind those who tragically lost their lives

Before leaving, all those present were asked to participate in a self-reflection exercise involving a commemorative wall filled with the faces of gun violence victims. “The one particular thing that stood out to me was the wall that they had…it showed all the faces of all the young people my age who had been affected by gun violence. It was reality staring back at you,” said Konrad Karasek, an intern from Chicago, Illinois.


Tina Chery (r), Founder, President and CEO of the Louis D. Brown Peace Institute in Fields Corner.

As we made our way to Merengue – a well-known Dorchester restaurant serving the best Dominican food north of the island – Joyce Stanley of Dudley Main Streets gave the interns a tour of Roxbury. After experiencing waves of immigrants, the now largely African-American neighborhood “serves as the heart of Black culture in Boston.” Despite a wave of violence in the 1980’s, many parts of the neighborhood are now flourishing as a result of investment and numerous urban initiatives. By the time we arrived at Merengue, bellies were starving for arroz blanco con habichuelas. Various representatives from the community spoke about their respective organizations – from tackling health disparities to LGBT healthcare issues – as food was served. Representatives from BMC’s nursing and social work departments also spoke of their roles and growing collaboration with the ED residents.

With food comas pending, the interns made their way back to BMC motivated by the day’s event. Many felt more connected and aware of the city’s challenges after the tour. “I think that it was an extremely useful experience to participate in that trip. After going to (medical) school in Boston, it was nice to see the world beyond our bubble in the South End. I rarely explored the neighborhoods south of BMC, but it is impressive to see how vibrant and diverse the communities are,” said Konrad. Others were able to place their new job responsibilities and the challenges faced by patients in a public health context.

Daniel Resnick-Ault, an intern from Brookline, Massachusetts said, “It’s one thing to care for patients in the hospital environment…but it’s another thing to see where they come from and understand the context of their social situation. You gain perspective.”

The community tour gave the intern class of 2019 a new-found sense of purpose and service. As they embark on their careers, it’s hearing the stories of patients that will provide perspective as they carry on with the daily grind of residency. Walking through the streets of Boston and meeting advocates across the city was an inspiring first step in the journey that awaits.


By Jonathan Santiago, MD (PGY 1)

The Brief Intervention Experience: A Student Perspective

Dr. Bernstein taught a public health class over the summer called Merging Clinical & Population-Based Perspectives in Public Health Practice: Tension & Resolution. As part of the class the students learn brief interventions via a training in the Brief Negotiated Interview (BNI).  They then spend time in the BMC emergency room with Dr. Bernstein screening for unhealthy behaviors and providing intervention. One student, Colbey Ricklefs, wrote about his experience:


Conversations and Collaborations:


Colbey Ricklefs, MPH

At a superficial glance, it would seem that public health and clinical systems are at odds. Public health focuses on the population while clinical medicine focuses on individuals; public health systems adopt an “upstream” preventive approach, while clinical medicine systems exist “downstream” as curative systems. However, as Dr. Edward Bernstein would argue, health is dependent upon these two systems collaborating to promote a continuum of exceptional care both at the individual- and population-level.

During the Summer 2015, Dr. Bernstein taught a course through the School of Public Health entitled SB808 – Merging Clinical & Population-Based Perspectives in Public Health Practice: Tension & Resolution. With his role as a professor at both Boston University School of Public Health and School of Medicine, in addition to serving as an Attending Physician at the BMC Emergency Department, no one better than Dr. Bernstein knows how to accomplish this harmonious marriage between the two disciplines.

Meeting twice per week from May to June, the course is equally intensive and informative. I signed up for the course as pre-medical student that had already obtained my Master’s degree in Public Health, looking for ways to translate the public health advocacy into clinical medicine. With some phenomenal guest speakers from BMC ED and beyond, we delved into contentious topics that have drastic real-world consequences.

In one of our first sessions, we learned how to interview patients through Brief Motivational Interviewing, a practice that has proven effective during Emergency Department visits at BMC. From a training video featuring Dr. Bernstein himself, the class engaged in collaborative strategies to address intrinsic motivation for destructive behaviors, ensuring that we maintain the patient’s autonomy. With this new skill in our toolbox, we individually shadowed Dr. Bernstein in the BMC Emergency Department and tested the strategy ourselves.

And it worked wonderfully. I interacted with an individual that had several concurrent addictions, but had presented to the ED while high on heroin. We asked him what he liked about the drug, and he responded with the expected response that it takes his pain away. We then asked him what he did not like about the drug, and in a moment of clarity, he shared that his addiction had distanced him from his family and made him feel more isolated. In that particular moment in his life, he was not ready to seek treatment to address his addiction, and initially refused a referral to Project ASSERT. However, we had planted the seed in his mind in an effort to resolve his ambivalence. I realized immediately that this conversation would have ended differently had we approached him with a patronizing tone, stating that “drugs are bad and you shouldn’t do them!”

This experienced resonated with what we had learned in class. To discuss the opioid epidemic in the state and at BMC, we had guest lectures from Colleen Le Belle RN, CARN, Program Director BMC Office Based Opioid Treatment Program and Hilary Jacobs, , from the MA. Department of Public Health. We learned about the necessary collaboration between public health and clinical medicine to respond to the opioid emergency: prevention, intervention, treatment, and recovery support. Each step involves both public health professionals and medical clinicians to ensure a healthy community.

In the next class, Joan Whitney from the Healthy Gloucester Coalition supported these notions and argued that compassionate care is good business for health systems. Echoing the Brief Motivational Interviewing strategy, she asserted, “You don’t give people motivation. You tap into it.”

Perhaps framing these conversations and perspectives is the most important theme from the course. During a guest lecture from Hanni Stoklosa from HEAL Trafficking, we addressed the need for trauma-informed, compassionate care at each stage of the healthcare interaction. Shifting the traditional paradigm can remarkably alter the dynamics of the interaction between the patient and the healthcare infrastructure. “Why did you do this to yourself?” should become “help me to understand why,” and “what’s wrong?” should become “what’s happening to you today?” While seemingly subtle linguistic changes, the effects are profound at the individual-level that help to address population-level public health concerns.

It was quite the whirlwind of a semester, but encouraging to witness the successes of current public health/clinical medicine mergers at the community-, city-, and state-level. I speak for many of my classmates in stating that this course was invigorating, and we left with a call to action to seek collaboration between the disciplines. I would like to personally thank Dr. Bernstein for his fearless leadership in pioneering this field.

I would also like to take the opportunity to formally recognize our other fantastic guest lecturers including: EM/PGH faculty Drs. Judith Bernstein (Co-Course Developer), Jon Olshaker, Gabrielle Jacquet, Thea James, Ricky Kue, Kalpana Narayan, Ryan Sullivan, Judith Linden, Elissa Perkins, Judith Bernstein and James Feldman; Project ASSERT (Ludy Young and Maria Champigny of the After Midnight and John Cromwell of the Overdose Education and Naloxone Distribution Program); the VIAP team (Kendall Bruce, Donald Osgood, Rustin Pendleton and Elizabeth Dugan; Jennifer Masdea (BU SPH BNI ART); Georgia Simpson-May, Director of Health Equity, MA DPH; the BMC Interpreter Service (Elida Acuna Martinez and Carlos Fuentes), Maureen McMahon (BMC Director of Emergency Preparedness), Rita Nieves (BPHC), Joan Whitney; Lisa Capoccia (Suicide Prevention Resource Center) and Maryann Frangules (Massachusetts Organization for Addiction Recovery). Thank you all for participating in an unforgettable semester and for illustrating a balanced merger between public health and clinical medicine.

SBIRT and Adolescents

A recent journal article outlines two models for adolescent SBIRT in federally qualified health centers. Looking forward to the results of the study!


Innovative SBIRT delivery method

A great partner of the BNI ART Institute Dr. Edwin Boudreaux of UMASS Memorial Medical School Departments of Emergency Medicine, Psychiatry, and Quantitative Health Sciences recently published an article on RBIRT (Remote Brief Intervention and Referral to Treatment).  After an in-hospital screening, the BIRT part of SBIRT is performed through the RBIRT call-in service and uses a computer guided program for clinicians to perform a brief intervention. The program generates a "dynamic referral" for the patient that is tailored to the patients specific needs which is then sent to back to the hospital and the patient to use. With the brief intervention and referral often a major barrier to implementation, this seems like a promising innovation. For more details, check out the article:


The Emergency Department and Overdose Prevention

Boston Medical Center Responds to Opioid Overdose Epidemic and Public Health Emergency

The Boston Opioid Overdose Education and Naloxone Distribution (OEND) programs began in 2006 when the Public Health Commission (BPHC), passed a regulation that authorized intranasal naloxone distribution by trained, nonmedical public health workers and EMS personnel under a standing order from Dr. Peter Moyer, the EMS Medical Director. In 2007, Massachusetts’ Department of Public Health adopted a similar program, and now provides free nasal naloxone rescue kits and training to community based programs. OEND includes identification of risk behaviors and training in such measures as rescue breathing, calling 911, using naloxone and remaining with the victim until emergency responders arrive.

Boston Medical Center (BMC) patients have been the beneficiary of these city and state policies and programs. The BMC-ED OEND program began in September, 2009 in partnership with the BPHC, MA DPH and the South End Healthy Boston Coalition. From January, 2013 through July, 2015, Project ASSERT, an ED based team of peer licensed alcohol and drug counselors (LADCs) /Health Promotion distributed 594 nasal naloxone rescue kits to patients identified through bedside screening and physician and nursing referrals--twice the number of kits distributed during the first two and one half years of the OEND program. This increase in distribution was sparked by a meeting between the BMC President Kate Walsh and the Boston Public Health Commission Director that resulted in the enactment of a hospital policy to assure that patients at risk for opioid overdose are offered education and naloxone free of charge in the ED. The policy was intended to enable other clinical providers to distribute NNRK after Project ASSERT ceased hours of operation (9am-11pm daily). Under a standing order protocol, rescue kits were tubed down from the inpatient pharmacy to the ED for patients to take home at discharge. Dr. Alexander A Walley, the Medical Director of the MA DPH OEND pilot program, provides his license so that naloxone can be distributed as a standing order throughout the state, including in the BMC ED and from the outpatient pharmacy.

Support and funding from state, city and hospital policies, are necessary as system-wide and contextual factors, but not sufficient for widespread NNRK distribution and sustainability, which depend on local adoption and implementation. We did not collect data on how many patients were eligible or the number that were approached. Over a two year period 2013 and 2014, Boston EMS transported 1167 patients to BMC for narcotic related illnesses and 3435 ED patient were discharged with ICD 9 diagnoses of opioid poisoning and or opioid use disorder. The latter included patients with injection opioid related infections, symptoms of mental status change and withdrawal and those seeking treatment placement /detox which was not always available. If we use this contextual data as denominator for the number of patients who received NNRK (n=594), we can estimate that only about 15% of ED patients “at risk for overdose” were documented to have received NNRK. The results of this program to date reflect an ongoing struggle to motivate patients to receive naloxone kits and education and for providers and system leaders to engage with patients in a new way and overcome barriers to distribution. .

We are working on learning what we need to know to improve our performance. Last summer a team from the Department of Health Policy and Management at the BU School of Public Health under the leadership of Dr. Mari-Lynn Drainoni and the EM Research Section partnered to conduct a qualitative study of the facilitators and barriers to implementation. Preliminary results from the interviews with nurses, physicians, pharmacists and Project ASSERT staff revealed general support for policy goals but multiple barriers to distribution:

Patient barriers included lack of receptivity to NNRK, patients not accompanied to the ED by a supportive other who might be present at a future event to administer naloxone, and many individuals who were not open to learning about overdose prevention but just wanted to leave and address their withdrawal symptoms after an overdose reversal in the ED or the field. Many patients were initially hesitant to accept rescue kits because they feared that they would be at risk for arrest or police harassment for possession of naloxone if they called 911, and remained at the scene. Additionally a significant number of patients had received NNRK.

Staff barriers included unfamiliarity with policy, lack of clarity regarding responsibility for education and distribution, lack of consensus about which patients are appropriate for NNRKs.

Process barriers included: unclear method to obtain the kit, confusion around the legality of a standing verbal order, lack of integration of NNRK into the EMR, and difficulty tracking data about distribution. Staff suggestions to improve uptake included uniform and targeted training, role clarification, integration into EMR and restructuring implementation.

In response to these findings, we implemented a change in the EPIC EMR’s common order panel that enabled the physicians to electronically order NNRK, an order that goes directly to our night ED pharmacist who distributes the kits, and together with nursing, and evening SW provide patient training and education. The EMR fix simplified the process and eliminated the need for the standing orders paper forms as specified in the original policy. In addition the night social worker was crossed-trained in OEND, and now works collaboratively with staff and pharmacy to reach more patients. During house staff orientation, Dr. Lauren Nentwich together with Project ASSERT staff provided NNRK training for over one hundred new interns.

Just as BMC ED needs a hospital-wide collaboration and continuous quality monitoring and improvement to extend the reach of NNRK, Massachusetts and the nation needs all its EDs and hospitals to implement OEND programs. In 2014, Massachusetts reported 1246 deaths over twice the death reported in 2012 and the trend continues in the first quarter of 2015 with 312 deaths. Despite great strides, we face the reality that opioid addiction is a challenging, highly stigmatized complex bio-psycho-social problem that we are only beginning to address in the medical setting. Opioid overdose education and naloxone distribution and referral to quality modalities of treatment including constitute strategies on the demand side of the equation. However, as a society and professionals we will be less than effective if we neglect the supply side--the market place of narcotic prescriptions and diversion and the highly organized industry of street sales of opioid and heroin. Prescriber education, and the use of the Prescription Monitoring Program, and pharmacy drug take back programs are additional strategies. We need to bring together science, medicine, public health and law enforcement to comprehensively address this epidemic. We have made important strides, yet there’s still much work to be done and our nation’s emergency departments have an important role to play.

SBIRT and Feedback: Getting it Right

In the brief intervention part of SBIRT, we teach people to give feedback as a way to educate patients on drugs and alcohol, consistent with the tenants of motivational interviewing: respecting the patient’s autonomy and building a shared agenda toward behavior change. We recommend using “elicit-provide-elicit” when providing any feedback or health education.

The first “elicit” is two pronged: one, asking permission if it’s ok to talk about the issue and two, eliciting what the patient may already know about it.

For example, a patient screens positive for risky alcohol use:

“Do you mind if we talk a little about the effects of alcohol on your health?”

This gives a patient a “voice and a choice” in their healthcare visit. The patient may say no and we have to respect that. And, quite frankly, if a patient doesn’t want to talk about it, you can tell them all kinds of scientifically sound and thought provoking things about alcohol and health but they will probably not hear you.

This is followed by:

“Great. What do you already know about the way alcohol effects your health?”

This is the first “elicit.” We are eliciting from the patient what they may already know about the effects of alcohol on their health. They may more than you may think. Knowledge alone doesn’t always translate to action or change. You may also learn what is important to the patient in terms of their health and some of the things that may be related to their reasons for change. Perhaps most importantly, the patient feels good about contributing their own ideas to the visit and feels a sense of ownership in their own care. Feeling good about something and having a positive experience does all kinds of wonderful things for our confidence and desire to take action. I think this can’t be understated.

The “provide” part is also two pronged. First, asking permission if it’s ok to share something you (the provider) know about the effects of alcohol. Then, providing the feedback in the form of easy to understand health information that is relevant to the patient. You may even expand on some of the topics they brought up to be especially pertinent to the patient.

Continuing with our example:

“Is it ok if I share with you some things about alcohol use and your health?”

Again, this functions as a way for the patient to have some autonomy and feel good about their visit. If you’ve got this far in the conversation, the likelihood a patient says no is pretty slim but it’s still important to ask.

"We know that drinking 4 or more (F)/ 5 or more (M) in 2hrs or more than 7(F)/14(M) in a week or use of illicit drugs can put you at risk for illness and injury. It can also cause health problems like [insert medical information].

This is a pretty generic feedback example but you can see the point. We will do a post, or maybe a couple posts, on specific education around different types of substances and the health effects. A lot of hesitation in discussing alcohol or drugs with a patient comes from being unfamiliar with the topic or unsure of what exactly to say. Medical and behavioral health training doesn’t mean someone understands everything about alcohol and drugs. For all the daily news we see about heroin in Massachusetts, it’s still a relatively unfamiliar subject for a lot of people. Not to mention, the drugs are constantly changing and can be geographically or culturally specific.

The last part, the second “elicit” in our strategy, asks what that patient thinks about the health information you provided.

To finish our example:

“What are your thoughts on that?”

Getting the patient’s feelings on the information is essential. It gives you a measure of where the patient is at with their potential to change and also gives the patient a chance to put into their own words what may or may not resonate with them in terms of their reasons for change. This flows quite naturally into the next part of the BI - assessing readiness for change.

Take a look at the brief negotiated interview (BNI) to get the full context of feedback in the brief intervention.

More addiction and the brain

Take a look and listen to this interesting story on the wiring of our brains and where addiction fits in. Could mindfulness be a way to rewire the rewiring??

How Addiction Can Effect Brain Connections?

Empathy revisited

We often find ourselves judging people with addictions.  On the commute to work, we shake our heads at the man on the train who can't seem to get a grip (literally) because he's been drinking early and falls on to a fellow passenger. He doesn't even say sorry. The stigma is real - I work in this field, and my own biases come out when I see a pregnant woman smoking or putting that fifth bag into her bag.  I am aware of it and try to check it, but its there and its not always easy to put aside. But if we go back to that Sesame Street video for a second and try to feel what that person is going through, maybe we can develop empathy for that person. I'm sure she doesn't want to be drinking with a baby on the way. I'm sure she's been lectured about what she's doing to that child. It must be hard. But sometimes it's hard not to get mad at her even though we know its not our place. We feel like we're getting mad for that unborn child, right?

In  trainings and sometimes at meetings, I always ask the question - can you teach the empathy (I usually say you can't because I like to play devil's advocate). I've got a lot of interesting responses over time - both in the yay and the nay. But one common one that says, yes you can teach empathy, and the one I really believe in is listening to and understanding people's stories. Narratives teach us a lot and help us understand. Even fictional stories and understanding motivations and experiences of a character can establish new understanding. Sometimes if we just try to understand what that's person's going through (quickly, yes, I know about the American health system), if we just try to hear their story even if all it might not be true or has an angle to it or is all over the place and we don't have time for all over the place, maybe we can take better care of our patients. I have no evidence or odds ratio to prove this but I've been a human for awhile so I guess there's that.

Anyway, the point of all this rambling is to share a story I read recently that addresses the very bias I owned earlier in the post.   I'm sure you've heard similar and there may be more powerful ones out there but I found it appropriate because just earlier on the morning that I read it, I saw a pregnant woman nodding out, almost falling to the ground outside Andrew Station. I shook my head in disgust and kept walking. Then, as if a blessing, I came in to work and someone sent me a link to this story. Its a story of addiction and also of recovery.  Knowing that its hard to make changes immediately and on demand, that addiction is a disease and that recovery is possible helps me deal with my own biases.

Enough's the link:


BNI Core Values: Empathy

This is the first in a series of posts on what we think about when we think about a good brief negotiated interview (BNI). Empathy is a word that often comes up when we ask trainees what they think is important when having a conversation with a patient about making important changes in their lives. And we agree, just a little empathy goes a long way in giving the patient a "voice and a choice" in their care. But what is empathy? Like most things, an old trustworthy source is better at explaining things than we can...

Naloxone Distribution in the Emergency Room

In the past couple of years, we have been working on ways to increase Naloxone distribution in the emergency department - a seemingly perfect match of public health and best clinical care. Project ASSERT is able to distribute rescue kits to patients who are at risk for overdose as well as parts of their social networks through a Massachusetts Bureau of Substance Abuse Services (BSAS) funded pilot to get Naloxone and overdose education out in communities across the state. Through collaborative efforts between BMC leadership and the Boston Public Health Commission, BMC has also developed a policy to maximize efforts in getting Naloxone into all patients who have overdose d or at risk for overdose.
Recently, our director Dr. Edward Bernstein presented these efforts as part of a Office of National Drug Control Policy (ONDCP) and American College of Emergency Physicans  (ACEP) webinar title Naloxone Distribution from the ED for patients at-risk for Opioid Overdose.  You can download the slides below which also include presentations from ONDCP acting director Michael Botticelli University of Washington ED faculty member Dr. Lauren Whiteside and University of Washington researcher Caleb Banta Green, PhD, MPH, MSW.

ACEP_ONDCP Naloxone Distribution Webinar