Researching the Literacy Rates of Patients after Diabetes Education on A1C tests and Blood Sugar Levels
Advisor: Ms. Alexis Parker
Internship Location: Washington Hospital Healthcare System
Onsite Mentor: Mr. Shekar Srinivas
According to the National Institutes of Health, from 2016 to 2017, 25% of the patients that visited the Emergency Department were reported for coming in for diabetes-specific ED visits. With the rise in diabetes related E.R. visits, there is a need for a larger focus on a specific field of medicine, preventive medicine, which promotes preventive health care to improve well-being. The goal is to ultimately prevent disease, disability, and death. My research aims to focus on two aspects of preventive medicine, disease education programs and regular screenings. Specifically, diabetic related health literacy of diabetic patients is an essential focus in preventing further complications for diabetic patients. Diabetic related health literacy refers to the “extent to which patients with diabetes have the required skills and abilities to seek, understand, analyze, communicate, and enumerate diabetes-related information both in the healthcare environment.” After conducting comprehensive diabetes education sessions, I aim to survey diabetic patients’s comprehension of their specific cases of diabetes and factors that contribute to the exacerbation of their diabetes. I expect my findings to illustrate the effectiveness of practicing preventive medicine in a curative medicine setting. This may inform the development of the diabetes education program in the current healthcare system, equip physicians to further personalize their treatment plans, and enable them to further serve as an educator for preventive medicine.
Project Blog
Week 0: An Introduction to Diabetes Education
Hi, my name is Aashirya, and welcome to my Week 1 Senior Project Blog! In this first blog, I will go over some background information, details of my project, and an introduction to my advisors.
*Photo sourced from Adobe Stock Photos
According to the American College of Preventive Medicine, preventive medicine promotes preventive health care to improve patient well-being. The goal is to ultimately prevent disease, disability, and death. Specifically for diabetes, the eight leading cause of death in the United States, preventive medicine is significant to prevent further complications. My interest in diabetes education sparked when I was young, where I observed the sense of normalcy of diabetes being a common disease in many families. I watched as my grandparents had to prick themselves with needles to regularly monitor themselves and their sugar levels. After shadowing an emergency physician, I started to think about the perspective of the patients, how knowledgeable they were about their own case of diabetes and whether they were taking steps to prevent further complications and following a regular routine. I want diabetic patients to understand the types of diabetes, what A1C tests are, and steps to control their blood sugar including meal planning and monitoring their glucose levels. This study equips physicians with data to gauge patients' knowledge of their personal involvement in their treatment plan, and will allow them to take action in personalizing their treatment plans and role of an educator for preventive medicine.
*Photo sourced from Adobe Stock Photos
In this project, I will randomly select a few patients with various conditions of diabetes and conduct diabetic education and management educational sessions. During the appointment, I will be going over their A1C test results, blood glucose monitoring, and general tips regarding nutrition and exercise. I will be lecturing for around 10 minutes, and will be asking 4 - 5 comprehension questions right after in the same appointment room. In the following day, I will be sending out a survey measuring the literacy/comprehension that diabetic patients had of the educational material in my lecture and whether they have an increased understanding of how to look after themselves as diabetic patients and new steps they will take to avoid new complications. Incorporating the BASICS program at the Washington Hospital Diabetes Outpatient center in my research, a comprehensive curriculum that covers everything a person with diabetes needs to know to live successfully with diabetes, I hope to raise awareness about diabetes and foster open communication between patients and their physicians.
For this project, my internal advisor is Ms. Parker, and my external advisor is Dr. Srinivas. Dr. Srinivas is an emergency physician at Washington Hospital Healthcare System who has over 12 years of experience in emergency medicine.
For my plan next week, I aim to read scientific material on preventive medicine in the curative medicine setting, and on diabetes education and management. I will start preparing the necessary diabetic education and management lesson plan prior to my first shift as well as the survey to be presented to diabetic patients.
Thank you for reading, and stay safe and healthy out there!
Week 1: Creating Educational Material for Diabetic Patients in the E.R.
Welcome to my Week 1 Senior Project Blog!
This week, I delved into the world of night shifts in the Emergency Room, and I observed the dedication needed to be a night shift healthcare worker.
In this blog, I will walk you through my journey of creating educational material for diabetes patients. Under my external advisor, Dr. Srinivas, I was able to create many drafts, and refine them to create final drafts.
For my diabetes educational sessions next week, I worked to create an infographic, handout, and comprehension questions.
Infographic:
For my infographic, I started off by spending a few hours this week researching diabetes through resources like the CDC and the American Diabetes Association. After researching, I narrowed my infographic to the following topics:
What is Diabetes
Type 2 Diabetes
Causes and Effects of Diabetes
A1C Tests
A1C Tests vs “Relative Risks for Complications”
With these topics in mind, I proceeded to add elements of big font, a colorful background, visual images and focused on adding comprehensible language for the patients reading this infographic.
While making this infographic, I had faced difficulty in finding graphs comparing A1C levels and the following complications: Cardiovascular Disease, Retinopathy, Nephropathy, and Neuropathy. To resolve this issue, I created my own graph combining two graphs I had found online. At the end, I listed definitions for these conditions for patients to refer to.
Handout:
In my handout, I focused on making information accessible for meal planning and fitness for diabetic patients. Through sources like the CDC and UCSF Health, I researched the “Plate Method”, a meal plan that includes balanced meals filled with starchy and non-starchy vegetables as well as carbohydrates, in which diabetic patients are recommended to follow. Additionally, I added a sample menu that diabetic patients can follow as a guide. On the back of the handout, I added a fitness section detailing examples of moderate-intensity activity that diabetic patients are recommended to engage in. Lastly, I included types of exercises that diabetic patients should implement such as aerobic exercise and resistance exercise (strength training).
Comprehension Questions:
For my comprehension questions, I created 5 questions to test the patients’ knowledge before the educational session and after the educational session. The questions included tests on knowledge about diabetes, A1C levels, relative risks and complications, and food & fitness. I refined these questions to be easily understood and digestible.
As I prepare to implement these educational resources in the E.R. next week, I am eager to interact with patients and teach my first educational session next week.
Stay tuned for more updates on my work in the E.R.!
Week 2: Collecting Data & Learning Experiences in the E.R.
Welcome to my Week 2 Senior Project Blog, everyone!
This week, I worked on syncing my circadian rhythm to the timings of my shifts in the E.R. and refining my educational material.
Throughout this week, I finalized my educational handouts, as shown above. Also, I was able to finalize my comprehension questions, adjusting them after having an educational session with a diabetic patient. After completing the comprehension questions, I worked to complete my survey to be sent after my educational sessions with patients.
By collaborating with my external advisor, Dr. Srinivas, I was able to a devise a change in my current surveying method. During the remainder of his E.R. shifts, when seeing a diabetic patient, my external advisor offered to also conduct educational sessions using my material and comprehension questions. This change would allow us to increase our survey sampling size for my project.
Throughout this process, I have learned the patience required when collecting data for scientific research projects. While waiting for diabetic patients to enter the E.R, I have made sure to expand my knowledge of medicine and healthcare in many ways. For instance, I was able to converse with an E.R. technician and learn an introduction to reading electrocardiograms (ECGs). In this introduction, he taught me how the numbers and letters on the ECGs represent different angles of the heart, and how the ECG’s can help indicate abnormal heart rhythms and heart disease.
Lastly, I had the pleasure of getting to know a fourth year medical student attending medical school in California. Our conversation ranged from her experiences in medical school, her experience doing clinical rotations, differences between M.D. and D.O schools, and how fourth year medical students will find out whether they matched to residency next week, the next step in training to become a doctor. She shared her insights in her decision to specialize in pediatrics, and emphasized the value of not having “tunnel vision” and being open minded to various medical specialties before committing to a career path.
This week has been significant in terms of my learning journey, both professionally and personally. With these lessons and experiences in the E.R in mind, I look forward to educating more diabetic patients in the E.R. next week!
That’s all for this week, stay safe and curious out there!
Week 3: Communicating with Diabetes Patients
Welcome back to my Week 3 Senior Blog, everyone! This week, I was able to sync my circadian rhythm with my night shifts and experience the productivity that many healthcare workers experience at night!
Throughout this week, I continued to put my educational sessions in action and hold them with patients coming into the E.R. With my most recent patient, I learned to convey the material to them in a different way than I had originally planned while making my educational material. Understanding that many patients often have language barriers and may be unable to pick up a pen to fill out the comprehension questions, I decided to verbally read my comprehension questions, taking my time for each question. With each question, I used my hands to act out the questions, used my facial expressions to illustrate the tone of the question, and read each option out in a comprehensible manner. With this new method, I was able to have the patient fill out the comprehension questions in a way both of us could understand and communicate.
In addition to my E.R. shifts, I worked asynchronously on the survey to be given to patients as a follow-up to their visits to the E.R. Working in the E.R. has proven to be quite rewarding and inspiring, meeting multiple healthcare workers, from E.R. technicians to ICU physicians. With the advice given to me as an aspiring physician, I have began to look at life in a different way and understand the unique experiences of healthcare workers, such as facing the death of their first patient and their strong sense of clinical ethics.
This week has taught me the value of patience and connecting with patients despite having communication barriers. With this practice, I look forward in the coming weeks to working in the outpatient diabetes center to learn and implement teaching techniques that certified diabetes educators use.
That’s all for this week, keep calm and LEARN on!
Week 4: Attending the Outpatient Diabetes Clinic & Surveying Diabetes Patients
Week 4:
Hey all! Welcome to my Week 4 Senior Project Blog. This week, I was able to explore the diabetes outpatient clinic, sit in on appointments of certified diabetes educators and dieticians, and learn the techniques used when teaching diabetic patients.
During this week, I was able to receive many resources from the outpatient diabetes clinic including diabetes books, handouts, ideal meal containers, and overall general information. During appointments with diabetes educators and their patients, I was able to observe nurses using the Diabetes Self-Management Education (DSME) curriculum, a curriculum that is nationally used. Additionally, I was able to speak with the dietician to receive feedback on my meal planning handout that I give to diabetic patients in the E.R. With this new feedback and information in mind, I implemented the new learning techniques I learned at the diabetes outpatient clinic for patients in the E.R. Lastly, I continued to survey diabetes patients and conduct educational sessions.
In addition to my E.R. and clinic shifts, I worked asynchronously on my research paper. I started with the introduction and background information, using the information learned from my own research and the information provided by the outpatient diabetes clinic.
This week has allowed me to experience different jobs in healthcare in different perspectives, from medicine to dietetics in relation to diabetes education. Also, I learned the value of teamwork in healthcare, specifically in diabetes, it requires a multi-speciality team to help prevent further complications and manage the underlying condition.
Thank you for reading, and make sure to keep asking questions about the world around you!
Week 5: Learning about Sugar Sweeteners & Collecting Data
Welcome back to my blog everyone! This week, I was able to continue exploring the outpatient diabetes clinic, collect data from diabetes patients in the E.R, and work on my research paper.
During this week, I was able to explore sugar sweeteners and the multiple options that patients have access to. The different types include: Caloric, Low-Caloric, Non-Caloric.I was specifically able to learn about Monk Fruit, a common alternative to sugar in people’s meals and drinks. Monk fruit, containing high intensity sweetener mogroside, serves as a non caloric sweetener, is naturally derived and is proven to unaffect blood sugar. Lastly, I was able to learn about common misconceptions diabetic patients have about alternative sweeteners and their assumed health benefits.
In addition, in the Emergency Department, I was able to collect data using the comprehension questions I created from a few more diabetic patients. I was able to see patterns and variations between the patients’ answers, calculate their percentage of questions correct, and identify their baseline for their knowledge in diabetes management.
Lastly, I continued working asynchronously on my research paper. I am finishing up my methodology section and continuing my research for my background and introduction. After receiving more resources and being exposed to more topics at the outpatient diabetes clinic, I contextualize my data.
I look forward to seeing more patients next week and conducting my follow-up survey over the phone with patients. Thank you for reading, and see you next time!
Week 6: Conducting Post-Surveys and Observing Diabetes Education Teaching Styles
Hey hey hey! Welcome to Week 6, more than halfway to the finish line. This week I was able to divide both my time in the Emergency Department, working on my research paper, and observing Inpatient Diabetes Education at the Main Hospital.
Earlier in the week, I started off with my shift in the Emergency Department, collecting data from patients seen previously last week, with the collaboration of Dr. Srinivas. After receiving the data from comprehension questions, I proceeded to obtain phone numbers of the patients seen over a month ago in the E.D. from my external advisor. Over the phone, I was able to conduct post-surveys, gauging patients’ understanding acquired after diabetes educational sessions.
With these phone calls, I encountered multiple challenges, with having to call back multiple times. There was also an added obstacle of language barriers. I had to kindly request family members translate every question and options I asked patients.
Later on in the week, I accompanied the Inpatient Diabetes Educator from the Outpatient Diabetes Clinic, observing patients that were brought into diabetes related complications.
A patient in particular inspired me. She was a female patient in her 70s, with a medical history of having an A1C level between 8 and 9 (diabetes range), reducing her A1C level to 6 (prediabetes range) over the course of two years. This was a result of her discipline with effective application of eating balanced meals and consistent exercise, such as taking walks around her neighborhood after each meal. Additionally, I was able to observe the teaching style of the diabetes educator and classify it as a Q&A interactive teaching style. The educator asked deeper and more personal medical questions after getting to know the patient and their concerns. With my observations and information collected at the clinic and main hospital, I was able to write my “In-patient Diabetes Education” section of my research paper.
Lastly, I was able to witness an up-close demonstration of the application of the lancet and glucose meter device. A lancet, a cutting instrument that makes small incisions, is used with a glucose meter, which measures the blood sugar levels from the blood obtained by the lancet. I even tried and practiced on myself!
Next week, I look forward to continuing to contact patients over the phone for my follow-up surveys. Thank you for reading, and make sure to keep your blood sugars in check!
Post 8: Conducting More Post-Surveys and Compiling Data
Welcome to Week 7, almost to the end of senior projects. This week I was able to survey more patients in the E.R., work on my research paper, and call more patients for follow up surveys.
Earlier in the week, I started off with my day shift in the E.R, holding more educational sessions and having patients fill out comprehension questions. With my observations of my educational sessions, I was able to cater my educational sessions to family members of patients and patients themselves, identifying that family members of patients play a huge role in reducing A1C levels and blood sugars in diabetic patients.
After collecting data from a few patients, I was able to transfer my data from the spreadsheet created, to start recording the data in bar graphs and in a presentable format for my upcoming research paper to be presented. Lastly, I was able to add some edits to my In-Patient Diabetes Education section of my research paper as well as continue working on my research on background information for diabetes education.
Next week, I look forward to continuing to survey more patients and reach a sample size that I am satisfied with to present later on.
Thank you for staying with me, and make sure to keep calm and check blood sugar levels on!
Week 8: Writing My Research Paper & Calling Patients for Post Surveys
Welcome to Week 8, in the last stretch. This week I was able to work on my research paper and call the last few patients for post surveys.
For the next few weeks, I realize that I need to work harder and finish reading all my sources and finish conducting my research. One book, I am reading, “Standards of Care in Diabetes-2023” has been taking up a lot of time, being around 200 pages, in which I am using some of the information in my research paper.
With collecting my data, I was able to add onto my bar graph and combine all my data into an end product. I was overjoyed to see that my project has been successful with many patients’ knowledge of diabetes education increasing by 10 - 20% after conducting my diabetes educational sessions with them.
Next week, I look forward to wrapping up my research paper and preparing for my practice presentations to present my findings to you all, the audience!
Thank you for reading my blogs, and see you soon!
Week 9: Working on my Research Paper & Reflecting on My Project’s Challenges
Welcome to Week 9! This week I was able to further interact with patients, work on the “Results and Discussion” section of my research paper, and start preparing to work on my research poster.
Translation Difficulties
The week started off with interacting with patients. A certain patient I last spoke with had a communication barrier, as he was a dominant Spanish speaker. With this patient interaction, I learned to be independent and used the translating service that nurses used to communicate with patients who spoke different languages. Even with this translating service, I faced multiple difficulties. While both the patient and I experienced some frustration in the communication barrier, I managed to stay calm in this situation and understand that patients may not all react in the same ways to the information I was communicating with them. While I was able to have the translator translate each survey question and answer into Spanish, the patient expressed his frustration in the confusion over the purpose of my survey. After continuously explaining the purpose of my project and requesting his patience, he hesitantly agreed to answer my survey questions. When I started to educate him with the help of the translator, he fell asleep during my educational session, causing me to be unable to conduct the rest of my project procedure.
What I learned
With this experience, I learned that it was my responsibility, as someone who grew up learning multiple languages, to make my educational handouts more accessible to everyone. This way if I encountered any difficulties in my educational session with patients, the information I wanted to convey would be accessible through the handouts. This prompted me to translate all my educational handouts to several different languages commonly spoken in the Bay Area: Mandarin, Hindi, Spanish, and Tagalog.
This experience is something I will always remember and will be a motivating factor for me to learn as many languages as I can in the future. I wish to use these languages in the hospital setting, to further connect with patients and help make them comfortable to express any concerns they have.
Concerns
I was slightly worried over my small sample size. A few patients I surveyed initially, did not respond to the follow up survey I tried conducting over the phone. Due to this, my sample size was smaller than initially speculated in the beginning of my project. With this in mind, I am hoping to steer my project in the direction of a case study and continue emphasizing the correlation between diabetes education and literacy rates. After all, quality over quantity!
Thank you for reading my blogs, and stay tuned for my last blog next week!
Week 10: Wrapping up my Research Paper and Reflection on Medicine as a Career Path
Hi everyone! Welcome to my final blog.
This is so bittersweet, and I’m so sad to see the end of this senior project. The life lessons I’ve learned in the past 10 weeks have further solidified my drive to pursue medicine as a career path. Whether it be almost sleeping through my night shifts, having difficulty in speaking to patients in different languages, learning an introduction on how to read ECGs, or discussing important questions with doctors on how to cope with death and suffering of patients (something I’m worried about in the future), I’ve learned more about what it truly takes to become a doctor. This job requires a large amount of confidence, mental strength, vast amount of knowledge, critical thinking, and constant empathy for patients.
Working in the E.R. is intense, as everywhere you turn there will be children crying, different codes being cast across the intercom speaker to indicate medical emergencies, patients constantly being in pain, and family members in panic. But, for E.R. doctors, it is quite rewarding to be able to send a patient home either having solved or alleviating their medical issue, instead of admitting them to the hospital for further care.
In terms of my project, in all honesty, I am slightly behind. I was slightly worried about collecting my data, and in the end have ended up with 9 patients as my sample size. In a span of 2 months, I was truly expecting to at least reach 15 patients, but due to multiple factors my expected sample size was not reached. This is due to patients who have psychiatric illnesses who are not in a mental state to answer my survey questions, patients who have different language barriers, or patients who are unwilling to take part in my project.
Overall, I added a few more topics to my research paper such as a case study on the 77-year-old woman I met at the inpatient center, due to her remarkable decrease in A1C levels from the diabetes to prediabetes range. Additionally, I will be writing about diabetes education policies and the American Diabetes Association's standards for diabetes education across the US. While my project cannot project a direct cause and effect relationship between diabetes education and health literacy rates, I hope that this project furthers the movement to integrate preventive care in dominantly curative environments, such as in the E.R. I hope my project takes a step in this movement to hire mandatory diabetes educators in the E.R, or mandate E.R. nurses and doctors to be trained in diabetes education and hold 5 minute educational sessions. After all, it only takes 5 minutes to make a change! These patients improved their accuracy levels on comprehension questions from 10 - 20%. If these patients were able to improve their literacy rates by this much in a matter of 1-2 months, think about how much change we could create with an established diabetes education program at E.Rs!
Thank you for following along on my journey, and hopefully in a few years, you can also call me “Doc”!
Live, laugh, love, medicine!