Cambodia 2017

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Phnom Penh, Cambodia

Neurology Outreach Program Cambodia

I’ve had the extremely fortunate experience of traveling to Phnom Penh, Cambodia every summer for the past 3 years (2015-2017) to help build a postgraduate neurology residency training program at the University of Health Sciences in Cambodia. While there are currently no dedicated neurology residents in Cambodia, we have been working with neurosurgical, internal medicine, and psychiatry residents these past 3 summers with didactics, bedside teaching, and have given resources/tools to help with neurological care.

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Dr. Soma Sahai and Dr. Simon Liu, Teaching the neurological examination…without electricity… during one of the city’s rolling brownouts.

This year, we had the privilege of working with pediatric residents since we brought along pediatric neurologist to teach dedicated residents core didactics in pediatric neurology, incorporated Facebook as a learning platform, and conducted pre and post assessments to measure the impact of our program in the participant’s’ clinical knowledge and confidence.

We also had the honor of having the Director of Neurocritical Care at LAC+USC teach a brief introduction to Emergency Neurological Life Support. As the demand for enhanced neurocritical care increases with increased incidence of TBI (traumatic brain injury).

Lessons Learned:

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Dr. Brian Wong, teaching residents the lumbar puncture for pediatric patients.

Students here are hungry to learn. Despite the fact that they have to pay for residency training and find means of supporting themselves outside their training. They show up each day wanting to incorporate what they have learned/clarified into their clinical practices. The Facebook group has grown to more than 100 members and the SIGN Cambodia Page has grown to 300+ likes. The challenges over the next year will include the amount residents may retain, thus we wanted to incorporate regular contact via medium which is widely used by the residents there: Facebook.

The Future:

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My attending that I work with will most likely be returning next year with other neurologists to Cambodia to build on pediatric neurology, neurocritical care, vascular neurology, and EMG/EEG use in June 2018.

As for me, I am not so sure of what I’ll be doing “my last summer” of medical school. I am an open book when it comes to what specialty I’ll choose, so depending on what I gravitate toward may influence if I want to do research in that chosen field next summer. But then again, it’s really hard to say no to help make an impact in a place you call a second home.

Dear Cambodia:

Thank you USC Neurology for allowing me to be part of this team.

Thank you UHS Faculty and Staff for accommodating our needs to facilitate this program.

Thank you Residents for being hungry to learn and make an impact in your patients’ lives.

Thank you my cousins for allowing me to have a room in your home, and be just like another member of your household.

Thank you Cambodia, for being so resilient, so strong, and so resourceful despite the fact there is so little to work with on a day to day basis. I can’t imagine the tenacity it takes to thrive in Cambodia. There is much hope for today and the future.

 

Love always,

Heng

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I’m pretty sure I ate 3-4 pieces per day X 5 days per week X 6 weeks of Cambodia…so 90-120 pieces thus far. #Carbs #Carbodia #GrandUncleDurian

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#hengncambodia2015

HengNCambodia15s from Heng Nhoung on Vimeo.

15 Seconds:
1: Being a “patient” in a neuro video that we’ve given to medical students in Cambodia
2: Demonstrating neurological exam to about 50 medical residents in Cambodia over the course of 8 days of 4 hour lectures.
3. Typical heavy rain
4. A broken EEG machine
5. Stuck in traffic for 3 hours (before it got flooded)
6. Testing reflexes to physicians at pediatric mental clinic
7. Driving down the mountain Thansur Bokor Highland Resort
8. Haggling for fresh crabs in Kampot
9. Chilling in Kien Swai eating fresh fruits where I was almost married
10. Talented performers in Phare Circus in Battambang
11. Teaching neuroanatomy to physical therapists in Catholic charity clinic in Battambang
12. Meeting the Bishop based in Cambodia
13. Being treated medication by grandniece
14. A banana tree in my cousin’s garden
15. Chasing my grandnephew (not sure if his nanny knows what her shirt means)

Why I Was There

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One of my professors had been going to Cambodia for the last few years since her father lived there for his work. She decided that she wanted to do something health related seeing how there were 3 neurologists in the country as of 2012. I was blessed to have been able to go on this trip to help with logistics, interpretation, and technology usage. I was also blessed to have been able to stay with family for most of the trip and catch up with my cousins and their kids…and their grandkids.

What I Learned

UHS Residents Final Group Picture

There is enormous potential for the country to improve its health care. Currently, many people go to Singapore or Thailand for specialty care and hopefully as medical training and technology access improves in Cambodia, there won’t be a need to spend thousands of dollars to travel. There is a growing middle class which is good for the country, but that also means more cars and more congestion. Hopefully, something could be done to curb the import of second hand cars, and also improve public transportation. And finally, as I’m still processing this trip for myself, I have to consider what my role will be in the future. I am in a very privileged position having the opportunity to complete my education in the United States, with access to great health care and an abundance of medical tech. I need to realize that many Cambodians will not have the same access to technology, training, and mediations. And for me to really meet people where they’re at, I want to help produce practical solutions with the resources they have.

What Drives Me

The possibility of a healthier world, where people of all economic backgrounds can get humane and effective healthcare. That every person has the opportunity to recover and heal from illness to be who they were made to be. To clean up after the wars that have ended too many innocent lives. To simply pay it forward to the doctors that saved my parents life at the Thai Refugee Camps outside Cambodia.

40 Years: Past, Present, and Future

April 17 Commemoration

Left: Parents Wedding Photo May 1974 (the only photo remaining from before the Khmer Rouge) Center: The march out of Phnom Penh, concentration camps, and my family in a Thai Refugee Camp in the mid 1980s Right: My father helping my nephew put on his shoe

The Past

This day 40 years ago, my father (22) and my mother(16) who was 6 months pregnant with my older brother was forced to evacuate Phnom Penh and march for days to work in concentration camps for nearly 4 years. My attempts to formally interview my parents about their accounts have not been quite successful because of time constraints and discomfort rehashing painful moments. While I have tried videotaping my parents comment on documentaries like “The Missing Picture” to help share their version of events, their stories come out at really random times when I’m with them. These are some of the things I’ve learned:

  • One of my uncles died because he was a surgeon (anyone found to be educated, even wearing glasses, was executed)
  • My paternal grandmother passed away from what sounds like stroke (sudden unilateral weakness, aphasia, confusion)
  • My older brother Chang-Leng died at 10 months
  • They survived despite all the near death experiences of drowning in leech infested waters, crossfire while trying to escape to Thailand, and attempted executions for being “upperclass” or looking Vietnamese

This TED Talk is also an amazing account of a family’s experience and escape of the Khmer Rouge
https://embed-ssl.ted.com/talks/sophal_ear_escaping_the_khmer_rouge.html

The Present

Today, I mourn the loss of those who perished during that time and am grateful for the opportunities that my parents had been given living in this country.  I am touched by the stories of resiliency in our community and am happy to see that families are being reunited in Cambodia as well.

But I understand there are still many challenges the Cambodian refugee population and their families face. These are current stats on health and education in Cambodian American Community:

Educational Attainment

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Going to UC Berkeley, I was aware that Asian Americans would be well represented. But I didn’t think I would struggle to find other Cambodian Americans. (35% have a high school diploma). This PBS Documentary highlights the challenges Cambodian Americans face when culturally speaking, parents have never really been involved in their children’s education, and don’t speak the same language at home. Even though I may have graduated from high school and college, I understand that I had enormous support from high school teachers, and mentors in college, and that I had to fight this self-deprecating lie that I wasn’t “smart enough.”

Chronic Health Conditions

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My parents and many other Cambodian refugees struggle with limited English speaking ability, anxiety, and PTSD. And while Obamacare has re-enabled people like my parents to get Medi-Cal and access to a primary care doctor, there are barriers because of declining reimbursement rates, and a lack of coordinated care for those who struggle coping with mental illness and the capacity of maintaining good health.

The Future

Given these challenges, I’ve been inspired and motivated to help address these issues in the aging Cambodian refugee community, and other refugee communities that are suffering as we speak.

High School Mentoring

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I’ve been blessed to have been given the chance to mentor Cambodian American high school students through the Khmer Alumni Association. This experience has been valuable for me because it’s given me the chance to elaborate on my story and mistakes so future generations don’t have to make the same mistakes I did in college.

My Interest in Health Services Research

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San Francisco’s On Lok Senior Health Services

The problems I want to help solve: can we give effective treatment to patients and better coordinate primary care not only that they are gateways to specialty care, but also other allied health professions such as nutrition, pharmacy, psychology, therapies? My hope is that we build on something like the Patient Centered Medical Home that can adequately coordinate care for very complex issues in patients to minimize ER visits and unnecessary suffering.

For Holocaust survivors, there are incidences of delayed onset PTSD and I wonder what that means for our aging baby boomer Cambodian refugee population as they reach retirement and senior life. And if something like OnLok could exist in the aging Cambodian population, it would alleviate the impending burden and conflict that aging parents and adult children have. Will aging Cambodian Americans live with their children? Or will there children want their parents to live in Nursing Home facilities? Will those nursing homes provide the culturally competent care that will allow people to age with dignity?

Every April 17, I write and reflect on where I’ve come from because I believe it is vital to know your history to know yourself.

“He who controls the past controls the future. He who controls the present controls the past.”― George Orwell, 1984
“Now Testify.” -Rage Against the Machine

“I didn’t request a new doctor, why am I being forced to change doctors?”

An unexpected letter

After being able to see her primary care doctor in 2014 for the first time in 5 years, it was over. A letter from her provider simply stated that my mother will be seeing a new primary care doctor beginning February 2015. That was it.

My mother looked to me to try and fix this problem, but there wasn’t anything I could do to keep her primary care doctor. What was even more frustrating was the fact the letter was in Khmer that was too formal/poorly written for my mother to really understand (many Cambodians are actually illiterate because schooling was interrupted (interrupted as in there were bombs being dropped) throughout the Cambodian Civil War in the 1960s).

It seemed as if there was really no point in her being eligible for health coverage since the doctor that knows her can’t really afford to keep her as a patient anymore. Medi-Cal, California’s Medicaid for lower income patients was not given approval to renew the rates given by the Affordable Care Act in 2014. This means more new patients for doctors, but at 2012 reimbursement rates. The map below compares Medicaid Rates where CA rates will be cut by more than 50%. A doctor will earn about 41% from a Medicaid patient compared to a Medicare patient.

So what is there to do at this point, given her position and the doctor’s position? 

  1. Gather medical records and schedules for upcoming routine check ups based on any chronic conditions
  2. Find the right primary care physician
  3. Be Prepared on Your First Visit

The Importance of Having Primary Care:

From my experiences, witnessing a lack of access to a dedicated primary care physician means not having someone interpret your test results, your medications, and your overall story and what it means for you in the long term. It’s like trying to navigate open seas without a compass. And the seas get rougher as we age with chronic conditions. For more research on impact of primary care

Learning with what we got

After researching physicians and considering some, my mother is now with another primary care provider and ready to continue her strides toward better health.

Health in the Park Event | August 30, 2014 | Long Beach, CA

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Today I had the privilege of helping out at a community health event by doing stroke outreach and awareness in Cambodia Town, Long Beach.

Number of people outreached: 40- 50 with 90% being Cambodian/Khmer speaking.

Thoughts:

Attendees were attracted to winning raffles which allowed all tables to give information for stamps that would qualify a raffle a ticket. Some were so focused on obtaining the needed “stamp” that they did not show any interest in listening to what I had to say. What concerned me most about this was that these attendees likely don’t have the best access to healthcare, and likely don’t know what their blood pressure/glucose levels are…so they’re more at risk from having the stroke I’m trying to warn them about. It was frustrating because I knew this information could only help them. But at the same time, in their eyes, am I really helping them with their needs at the moment?

One of the things I constantly see when doing community events is that, while healthcare professionals may come in with “A” and hope that “they” understand “A,” community members have “B, C, and D” concerns that aren’t really dealt with in the healthcare field. In an ideal world, it would be dealt with in the primary care setting.

But when reimbursement rates for Medi-Cal and Medicare patients are at all time lows, and patients can only be seen for 15 minutes. There’s only so much doctors can do.

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Next Time:
I’ll focus more on signs of stroke, but also include key prevention factors such as blood pressure and glucose. I’ll be in contact with primary care docs who serve community members.

But how do I bring awareness into the day to day decisions community members make about their lifestyle? Telling them to eat healthy and exercise is a serious broken record because it sounds like it to me already.

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So What?

In my pursuit of a career in healthcare to understand and help the aging Cambodian refugee population, this is a question that I dread, but must answer for myself.

‘So What?’

‘Why does this matter?’

  1. Cambodians Americans have poor health status (RAND Corporation)
  2. There is a lack of physicians/healthcare providers that speak the language (UCSF)
  3. Cambodian Americans are aggregated into the large Asian categories which distort the realities of diverse ethnic groups (Journal of Immigrant and Minority Health)
  4. Second and third generation Cambodian Americans are losing the ability to speak Khmer (Wayne Wright, my Kindergarten teacher!!)
  5. Expectations aging parents differ greatly than they do in the United States. (New York Times)
  6. PTSD Symptoms present as people age. (Boston Globe)
  7. As decedents of survivors come to adulthood, it’s up to us to address how to carry on our family’s legacy.