OHSU

Student Reflections from iCHEE

A Selection of iCHEE Reflections

Fall 2013 - iCHEE Reflection – Pharmacy Student

The Oregon State University College of Pharmacy requires students to take 2 credits of electives every year of the curriculum in order to satisfy graduation requirements. These electives generally focus on specialized areas of pharmacology such as poisons and toxins, narcotic abuse, geriatric pharmacology, etc. Lacking from the majority of these electives is a true interprofessional experience. Throughout my time as a Pharmacy student at Oregon State there were also mandatory interprofessional activities setup in collaboration with the other healthcare professional schools across the state, however, they failed to provide a cohesive, viable learning experience that could be utilized to further one’s understanding of working within a healthcare team towards a common goal.

iCHEE provided me with the most valuable interprofessional experience that I have had to date, and presented the experience in such a natural and fluid way that I finally welcomed the prospect of working with other healthcare professionals to achieve optimum patient care. There were no templates to follow, no barriers to restrict, and no limit to the amount of knowledge each interprofessional student involved could exchange with one another during this experience; we met with patient after patient in groups composed of a multitude of healthcare professional students and each got to contribute their unique skill set in evaluating and improving patient quality of life. Simply put, if you are a healthcare professional student longing to simulate working with other healthcare professionals dealing with a variety of patient populations in real time, then iCHEE is an extremely valuable experience.

Going into the iCHEE experience it was difficult for me to have positive expectations of an interprofessional experience due to the fact that previous organized attempts at similar situations were not structured well. In most cases of mandatory interprofessional experiences many situations fabricated by the academic organization were far-fetched and more often than not utilized some professions (MDs, and nurses) more than others, which left many students with a complex of uncertainty concerning interprofessional activities. Where these past activities failed, iCHEE succeeded as it provided an environment where medical students, nurses, dental students, and pharmacists could collaborate together on a much more equal level. The iCHEE experience met on 5 Saturdays of the term at various underprivileged locale and students were split into groups comprised of equal amounts of medical, pharmacy, nursing, and dental students. Each group would have approximately 6 to 8 patient interactions that were each unique in the problems that they presented. Patients presented with health concerns, exacerbated disease states, and medication problems and questions. The beauty of iCHEE was that the teams were formulated before patients were received, so there was no reviewing of patient problems prior and no segregation of team members whose skills may not have been pertinent to a particular evaluation. Due to this the team atmosphere was much more natural, and silos of each healthcare profession faded throughout the experience; we began to work cohesively and with each other instead of individually. 

Working as a cohesive unit allowed for more of a complete healthcare evaluation and better experience for most patients, as each member of the team started to focus on the overall health of the patients instead of only concerning themselves with patient problems that had to do with their professional expertise. All students involved gained valuable skills in terms of patient interaction and empathy. The patients seen were either migrant workers, or homeless thus thoughtful and patient connected interaction was very important. Many students left the course having avidly grown in terms of empathy and presenting healthcare information in a manner meaningful to patients. A respect for other healthcare professionals also blossomed, as members of each discipline began to realize the value and necessity other healthcare professionals provided when the goal was overall patient well being. Going through this elective I felt I was a tremendous advocate for my profession, because I was able to share my advanced knowledge of disease states and drug treatments in a multitude of areas such as diabetes, heart failure, hypertension, depression, anxiety, and psychosis. In reflection sessions after each Saturday meeting it was made apparent of how some of the other students gained a new respect for pharmacists and the integral role they play in patient care. Without iCHEE I may never have been able to impact the thoughts of other healthcare professional students in relation to pharmacy; the amount of reward and fulfillment I received was unparalleled. Another huge advantage of iCHEE in terms of knowledge and skill sharing was the disparity between the levels of healthcare professional students within the program. Medical, dental, and nursing students ranged from 1st year to 4th year and a mentoring effect was palpable throughout the experience. Only 3rd year pharmacy students were involved, however, we are well versed in physical examination technique and got to mentor young medical students on chest examinations, blood pressure readings, and eye examinations as well. 

iCHEE had a remarkable faculty team involved, with experts from medical, nursing, dental, and pharmacy represented. Patient to team interactions were not regularly intervened on by the faculty, however, when questions arose about recommendations to the patients, or if the patient was a particularly overt case then faculty assistance was readily available. The real value in having faculty there was reflecting on how patient meetings ensued, and if they had any clinical expertise to share on patient matters. Personally, I learned a lot from the pharmacy and nursing faculty that were present as my group had several difficult cases throughout the term; the pharmacy faculty gave me insight on medications that I was unaware of, and the nursing faculty had superb physical examination and patient evaluation technique. Having the opportunity to learn alongside experts in the healthcare field was an invaluable experience, and helped to strengthen relationships with faculty from the various OHSU professional schools. 

iCHEE is the definitive interprofessional education experience and is unequaled by any other interprofessional experience offered currently at OHSU. Being a part of this elective gave me the opportunity to work with other healthcare professionals as equals, and also subjected me to a patient population that I had never interacted with before. The skills, knowledge, and relationships that I formed throughout this program will continue to serve me in my future career endeavors.

Fall 2013 – iCHEE Reflections – MD Graduate/MPH Candidate

As opposed to most other students, I have the opportunity of learning about the iCHEE program as a senior student and working with the generous faculty members who founded it and volunteered their Saturday mornings facilitating student groups. Only towards the end of my medical school training have I begun to realize the importance of interdisciplinary effort as a team in order to provide efficient and comprehensive care to our patients and maximize their health outcomes. This concept is best demonstrated by the patient-centered medical home model that our healthcare system currently has been evolving towards, with the goals of allowing better access to health care, increasing satisfaction with care, and improving overall health.

As medical professionals navigate through the complex healthcare system we live in today and face the diverse populations with a variety of medical and social problems, we can no longer remain isolated within each of our own fields during our training period. The earlier we become familiar with other medical professions, the better we can identify, further develop and utilize each others’ talents and skills to fulfill the unmet healthcare needs of the communities that we serve. 

As a medical student, the majority of my training was focused on solidifying basic science and medical knowledge and management, as well as improvement of one-on-one interaction with the patients in front of me in the exam rooms. While it is obvious to me that other medical personnel, including the nurses, pharmacists, dentists, PAs, social workers, MAs, play a role in patient care, I have little knowledge of the type of training that these essential members of the team have gone through and most importantly, their goals and philosophies to patient care. This lack of knowledge will likely result in unutilized skill sets that can further contribute to better patient care.

The interaction of medical students with other professional members of the team was predominantly limited to fulfilling the care plans dictated by the attending and resident physicians. After that, we go about our busy day in the clinic or on the wards and promptly move onto managing the next patient on the list. This class allowed me to gain a glimpse of different perspectives by working with other professional students in the medical field, and approach our clients/patients as a team.

For instance, dental health has been an unfamiliar topic to me throughout my training. The world inside the oral cavity is something that is largely foreign to medical students and most physicians. During the interviews with our clients, it was apparent that dental health was a priority and the primary motivation for many of them to seek medical attention, particularly at Transition Project. I had the opportunity to observe the dental students taking oral health-related medical history, history of present illness, and performing simple physical exams. As a future physician interested in primary care, having basic knowledge of oral health, knowing how to identify alarming signs and symptoms and providing fundamental oral health education to my patients may serve as an important resource and preventive measures to those with difficulty accessing a dentist or dental hygienist for care.

Additionally, since this class was not aimed at providing direct and comprehensive medical services to clients, I have had the luxury of speaking to them and focus on learning about their life stories. While my clinical training instincts constantly pulled me towards assessing the healthcare needs of the clients as I subconsciously construct and prioritize a checklist of to-do’s in the back of my head, my teammates reminded me that a large part of our goals is to lend a good pair of ears, to listen and empathize with the stories they had to tell. Every Saturday morning, I was reminded one of the most basic but important skills to be a good provider, to be a good listener.

I highly urge the curriculum committee across the professional schools to take advantage of this existing unique class and integrate it into the current interdisciplinary curriculum training for the students of medicine, nursing, dentistry, pharmacy, social work, and physicians’ assistant program. From the perspective of a graduating senior, having a living and breathing patient sitting in front of me with real health problems and life concerns seeking for help provides me a learning experience that simply cannot be matched by any simulation cases or discussions of theoretical framework in a classroom setting. This is an excellent venue for professional students from different fields to meet and develop familiarity with each others’ professional goals and philosophies early on in their career to foster future collaborations and improve our currently inefficient and unreasonably costly U.S. healthcare system.

In reflecting upon my medical school training, I think this class would be a unique and invaluable part of medical school education, particularly early on and prior to starting of third year clerkships. It would have improved my communication skills with other members of the healthcare team and learn from them in addition to my attending and resident physicians as I went through each rotation by better understand how other members of the medical team see a particular medical encounter and the needs of our patients from their training and background.

I hope this class can expand much further if all students are required to enroll for at least one term. Not only do the students gain valuable experiences working with clients/patients, we will also be able to provide a stable service to the community members who otherwise feel too stigmatized or lack the language skills to seek any medical attention. This is a marginalized population in our community where the students can potentially make a significant difference with the limited amount of clinical training they have received while fostering inter-professional camaraderie.

Fall 2013 – iCHEE Reflections – Dental Student

How do I describe five Saturdays of interprofessional interaction and work in two pages? Maybe it will help if I start from the beginning and slowly sum up my experience as I progress. 

iCHEE Day 1, at Medical Teams International: This was the first Saturday of the academic Fall term and even though I had decided to sign up for this course, I did not want to wake up! After somehow managing to get out of bed after a long first week of biochemistry and histology, I drove to Medical Teams International. I had never heard of this organization before. After some time waiting for everyone to show up, we began the tour of the facility. The space was divided into different countries that support and help had been sent to; places like New Orleans, Japan, Guatemala, Mexico, and Indonesia were displayed. It was beautifully made and was just like an exhibit at a museum, but it was very, very saddening. All over, there were drawings and short reflections by children, of what they had just experienced. Some of them drew their experience of a tsunami, and how they had seen their parents disappear before their eyes, while others spoke of being taken into a children's army in Uganda, where they were raped and abused. It was truly heartbreaking. There were some exhibits that I could not step into, and some reflections that I just couldn't read. I had tears in my eyes almost the entire time. Later on, we were given a tour of the rest of the building, where I saw the two dental vans that MTI has, as well as their storage space and their sorting and packaging space. It was really neat and wonderful to see that there are people who are ready to leave everything behind and help out those in need after a tragedy such as an earthquake or tsunami, and I went home that day truly believing that the world is not so bad after all; there are those who are true angels on this earth. 

Now I'll condense my iCHEE experience for the remaining five Saturdays: Our first day working as a team was a fun one, but also a very awkward one. None of us really knew what to do or what to say in order to make the conversation with the clients go smoothly and swiftly. We were hesitant to do anything, lest we might do it wrong. Thankfully the first client my group worked with was very friendly and opened up the conversation himself. That was a great way to start, and with all of our clients after that we felt much more at ease. I quickly realized that the work we were doing was really helpful and the clients truly appreciated it; plus, it was fun. Being a dental student, I was the one looking in the clients' mouths and I got to see some interesting things. For instance, I had never actually seen (except in pictures) a case of severe gingivitis and I was able to experience that during one of our days at VOZ. My days at VOZ also allowed me to practice Spanish, which was great since it had been a long time since I had spoken it. It was definitely a great experience but it was interesting to notice how much one can truly forget unless the language is put to use. Although I tried my best to communicate with the clients and to also interpret for the rest of my group, it was difficult because I am not familiar with any medical terms and so I had to be creative and use other words in order to explain a medical condition, concept, etc. 

One interesting thing that I think all of us in the group noted was the drastic difference in client type and needs between Transition Projects and VOZ. The people we saw at Transition Projects were a mix of men and women, mostly homeless, some trying to find work, others trying to battle their addictions with drugs, and one who was on the verge of committing suicide. In terms of their health, most of them had high blood pressure, and many of them didn't really want to have their health checked, they just wanted someone to talk to. The clients at VOZ, however, were all men, most of them had families, and of course they were all looking for work. Because of the manual work they did, they were all in pretty good shape and most of them didn't have high blood pressure. They weren't really looking for someone to talk to, but wanted a quick health check up so they could then get on with their day and find work. They seemed much more determined and focused, whereas the people at Transition Projects were trying to get their life in order. It was really interesting to see this great difference, and the challenge for us was to recognize the different needs in order to try and accommodate both groups of people and help them all as best as possible. 

This year OHSU has implemented an interprofessional course in the curricula of the school's programs. Medical, dental, nursing, and pharmacy students (there are some others as well) gather once a term to learn about interprofessional education and work. Unfortunately, since this is the first year of this program, there are some problems. One of these problems is that the example given to us students so far has been the hospital setting and how interprofessionalism can be implemented in that particular location. However, most of us will not be working in a hospital, particularly dentists, and therefore that example will not be useful to us. I think iCHEE has been much more relevant and useful experience that has taught us how to work together as a team. If it wasn't for the pharmacy students, there is absolutely no way us first and second years (dental or medical students) could have known so much about the medications that our clients were taking, and we could not have given them appropriate advice on how and when to take their medications and why they are so important. All of that was the work of the pharmacy students. Without the medical students, we could not have detected the signs of certain diseases and I am sure we would have missed critical information that we obtained from just observing the clients and talking to them. Most people don't really want to look into other people's mouths, and therefore without us dental students, we would not have really checked the oral health of the clients in order to advise them on how to best take care of it. We learned how to work with each other, talk to one another, and we learned about each other's professions, programs, and experiences. 

For instance, I learned how to do four quick eye tests, and learned that for each one I was really testing the function of multiple nerves. I would never have known that, had I not worked with a medical student who was willing to teach me. Another important lesson that I learned (again, from a medical student) is that I need to listen to the client, but also observe them and formulate my opinions based on what I see and feel, as well as what they tell me. For instance, one of our clients had very high blood pressure and when asked about shortness of breath and chest pain, he said that he didn't have any. However after a few quick tests and after looking at his wrists and ankles, we found that had been untruthful for some reason and actually had edema. 

All in all, I am glad I signed up for iCHEE. I made some great friends, learned about the different programs offered at OHSU and their respected curriculums, and I also learned valuable lessons. I learned that interprofessional work really is important, and that without the collaboration and experience of the different health care professionals, it would extremely difficult (if not impossible) to help those in need. After all, each of us has chosen to be a part of our programs for one main reason: to help others, and this course put us to work doing just that.

Fall 2013 – iCHEE Reflections – Medical Student

The man sitting in front of me couldn't keep still. He kept looking at the table, legs twitching, hands constantly moving, and the words poured out of him as fast as he could speak them. The story itself was full of tragedy, a life of drugs: heroin, meth, and cocaine, living on the streets, being forced to do many things as a child that had obviously scarred him for life, ending with a near suicide attempt - jumping off the Burnside Bridge. What made him come back down he couldn't really explain, just the need to fight to the end, the desire never to give up, to let something else win. He had lost everything, his wife, kids, job, his entire life and he knew it. Yet here he was, sitting in front of me trying to explain how badly he wanted to be done, and how hard of a fight it was too. I felt in awe of his ability to come in at all and completely underqualified to help him. I'm not sure what I was expecting from iCHEE, but I knew this wasn't it.

iCHEE began with a trip to Medical Teams International and their exhibit called 'Real. Life.' I must begin by explaining that I have traveled overseas working with various humanitarian aid organizations, building homes and teaching English in China, and once on vacation in Ensenada I had seen the cardboard cities of Mexico. While I knew I didn't know the state of most of the world, I felt like I had a handle on what poverty truly looked like. This exhibit was both a confirmation of what I already knew and a slap in the face of my western idealism. What stood out to me the most was the stories of the child armies in Africa, the wars and brutality that many deal with on a daily basis and consider to be normal. I have always had a soft spot for children, while I would do a lot to help adults, it is the children who break my heart. I often long to provide all of them with homes full of love and every good thing they need, a place for them to be safe and happy.

But we are in America, with it's own unique needs and problems. The place we started was downtown at Transition Projects, a place for the homeless to sit in out of the cold, use computers, do laundry and take showers. Quite a few of the people we saw were actually interested in a general health check, but more of them had a specific problem or concern they were worried about, and had no one else to talk to. One client we actually sent to the ED, but the rest we were able to manage there or send to the Richmond clinic. We were lucky to be holding these health care checks in the fall, so close to Mission of Mercy's dental care conference, and we referred many clients to that conference. I do not remember seeing a single client who was completely healthy, and with follow up so difficult, it may be that none of them ever get the care they need. Most of them didn't know about their high blood pressure or why they had shortness of breath. All of them had stories to tell, and many of those stories were like the man who was coming clean: full of failure, and hope.

That first day I sat and listened to him for a full 45 min, and at the end he just thanked us for being there, for being willing to listen. He came back the next week and was able to sit still, able to talk about his diabetes, eye problems and Grave's disease. By the time iCHEE was over I was feeling very confident that he would make it. He was in a church now, talking about a power to get him through, and feeling hopeful that his life would turn around. Once he left I sat there feeling stunned. After the years and years of education and exams that I had taken to make a difference in people's lives I had offered this man only one thing: someone to talk to. Out of all of the things I had to offer, that had actually seemed to be enough.

We were fortunate enough in this class to be able to also visit the VOZ day labor center for migrant workers. Here we worked with interpreters to ask which country in South America these men were from, and what had brought them to the states, how things were going, and what health concerns they were having. I had expected them to be much the same as the homeless population downtown, looking for someone to talk to because we were there and they had just thought of something that was bothering them. I was wrong. Here they actually understood that they needed to take care of themselves, what their symptoms might mean, and it was simply the lack of access to care that was keeping them from being much healthier. They were all hard workers, you could tell by how fit they were, and I believe that given even one chance, they would do very well in this country.

It was at VOZ (Portland Day Labor Center) that I was able to interact more with my classmates as well, we were short an interpreter one day and one of the dental students who spoke Spanish served as the interpreter for my group. It was fascinating to watch the things they knew how to do, and hear about their curriculums. I was surprised to learn that the pharmacy students learn many of the same things we do, and simply do not have the place to practice them. A lot of my colleagues learn in accelerated programs that take only a few years and do not have accompanying residency programs, which sounds very intense to me. I have really enjoyed working in teams and it's made me look forward to working with other specialties in the future.

This brings me to the problems currently facing medical education around the nation: interprofessionalism. We have concluded that we need to work together to bring the best health care to our patients, the problem lies in knowing who is best able to deliver care, and in learning how to work with other professions we know nothing about. I feel like this way, coming together while still in school to provide care for patients, is the the best way to do this. We were able to come to a much better understanding about the best way to provide care because we worked it out long before our profession biases had been set, while working towards a common goal. I highly recommend this course to anyone looking for a better understanding of other professions, of the challenges facing those with lack of access to care, and of other cultures living right alongside us. I have known for a very long time that I wanted to work with underserved populations, wanted to bring care to those who could not come to us. This elective served as an excellent confirmation, bringing me the chance to work where I would like to work, and it was just as exciting and challenging as I was hoping for. I may not have had the experiences I was expecting, but I had exactly the ones I needed.

Fall 2013 - iCHEE Reflection - MD/MPH Candidate

I came to medical school after working at a local community health organization, where I provided over-the-phone clinic and resource referrals to low-income, uninsured community members; most were very sick or in pain, all were desperate to find a way to access health care. It was sometimes a frustrating and isolating experience, full of questions unanswerable in our brief phone encounter. Who were these community members? What was their story? Did they have a safe place to live? Would they be able to find or afford transportation to the clinic I suggested? 

The iCHEE course provided the beginning of an answer to these questions, and helped me formulate new questions to take with me as I move forward in my medical education and ultimately my career. I feel so fortunate to have been part of iCHEE during my first months in medical school, and experience often isolated from the community. 

Reflecting back, there were two components of iCHEE which I valued most: the opportunity to work directly with community members, and the chance to work closely in inter-professional teams with students from different disciplines but with shared social values. 

The first component, working person-to-person with vulnerable community members, was what I was most excited for going in to iCHEE. It was really wonderful and eye-opening to have the opportunity to just listen, without an agenda, to people who are so marginalized that they often are voiceless in our society. Both populations we worked with, homeless individuals and day laborers who were also likely undocumented immigrants, face hurdles to accomplish basic tasks in our society, let alone to access medical care. As we move towards health care reform, these are two populations most at risk for being left out. When we walk down the streets of our city, these are the people we, as a society, are most likely to avoid eye contact with. At iCHEE, we disrupted this socially constructed power hierarchy. While not always recognized by the traditional medical establishment, we operated within the framework that the clients are the experts in their lived experiences, their health, and their bodies. When listening to their stories, we were honoring these experiences and hopefully allowing them to access the therapeutic power of talk. However, we were also learning about their culture and their reality, and learning about the diversity of experiences and cultures possible within our city, a specific community, a subset within that community, and even from person to person. 

I learned some very concrete things about realities of being homeless in Portland: I learned that living on the streets in downtown is one of the hardest places to stay sober, with a seemingly constant offering of an addict's drug of choice; I learned that staying in a shelter is not a viable option if you can't bring the tools you need to work in with you; that taking any medications and especially diabetes medications or blood checks on a regular schedule is basically logistically impossible. I learned less concrete things from experiences clients shared with me: the fear in the eyes of a woman gearing up for her first winter on the streets, kicked out of her former living arrangements due to a relapse and on a 3 month waiting list for a new place; the sadness and resignation of a homeless dad separated from his daughter for over 20 years but still calling her his own; and the seemingly ceaseless optimism of the man with a laundry list of medical problems and no regular place to live who just kept smiling and saying things were looking up.   

The second component of iCHEE that I valued most, working with students from different professions, was something I did not go into iCHEE expecting to appreciate. However, working in the interprofessional teams was crucial to making the experience as wonderful as it was. On a practical level, I learned so much from my colleagues in the different schools. I had limited understanding of the education that pharmacists or dental students received, or of what their training allowed them to do. Working together with a shared goal of helping the person sitting in front of us allowed me to fully understand and appreciate what each member and each profession can bring to a medical encounter. It helped me see the crucial role of each profession in serving underserved communities and improving health equity. Without our pharmacy student, we would have been at a loss for what to say to the client who kept all of their pills together in an Altoids container, or how to talk to the client with alarmingly elevated blood pressure about maybe finding a way to fit the blood pressure medication she already had prescribed to her into her routine. Without the dental student, I wouldn't have known what to look for in a client's mouth when they complained of tooth pain, or had any understanding of what to suggest to the client with ill-fitting dentures. I have a huge appreciation now for my colleagues in these two fields, and an understanding of their role in health that is drastically different than my initial understanding. 

After participating in the University-wide "Inter-Professional Initiative," and participating in iCHEE, I strongly feel that a version of iCHEE should be a required course to replace the IPE lecture/discussion program. From iCHEE I learned in detail about the education and expertise of colleagues in different programs while developing a strong respect for their work. I feel extremely likely to collaborate with a dental or pharmacy colleague in the future. I believe the crucial component that gave iCHEE strength in inter-professional education, and the key distinction from the other lecture-based program, was having inter-professional students working together in a meaningful task towards a shared, genuine goal. I believe that it would be possible to develop a similar, modified university-wide curriculum that would be of great value to the students and the community while promoting inter-professional education. It would also be closely aligned with OHSU's mission to strive for excellence in community service, and to “lead and advocate for programs that improve health for all Oregonians, and extend OHSU’s education, research and healthcare missions through community service, partnerships and outreach.”

I leave the iCHEE course feeling inspired, frustrated, and grateful. While some of the resources available in our community, such as TPI's new facility, are wonderfully impressive and show a true commitment to serving the most vulnerable in our community, the very fact that services such as theirs are needed in our wealthy country is disappointing. I am grateful to the community members who shared their stories and experiences with me and my teammates, and to the faculty and staff who took their weekend time to help create this experience. I highly recommend this course to every OHSU student! 

Fall 2013 - iCHEE Reflection - MD/MPH Candidate 

I came to medical school after working at a local community health organization, where I provided over-the-phone clinic and resource referrals to low-income, uninsured community members; most were very sick or in pain, all were desperate to find a way to access health care. It was sometimes a frustrating and isolating experience, full of questions unanswerable in our brief phone encounter. Who were these community members? What was their story? Did they have a safe place to live? Would they be able to find or afford transportation to the clinic I suggested? 

The iCHEE course provided the beginning of an answer to these questions, and helped me formulate new questions to take with me as I move forward in my medical education and ultimately my career. I feel so fortunate to have been part of iCHEE during my first months in medical school, and experience often isolated from the community. 

Reflecting back, there were two components of iCHEE which I valued most: the opportunity to work directly with community members, and the chance to work closely in inter-professional teams with students from different disciplines but with shared social values. 

The first component, working person-to-person with vulnerable community members, was what I was most excited for going in to iCHEE. It was really wonderful and eye-opening to have the opportunity to just listen, without an agenda, to people who are so marginalized that they often are voiceless in our society. Both populations we worked with, homeless individuals and day laborers who were also likely undocumented immigrants, face hurdles to accomplish basic tasks in our society, let alone to access medical care. As we move towards health care reform, these are two populations most at risk for being left out. When we walk down the streets of our city, these are the people we, as a society, are most likely to avoid eye contact with. At iCHEE, we disrupted this socially constructed power hierarchy. While not always recognized by the traditional medical establishment, we operated within the framework that the clients are the experts in their lived experiences, their health, and their bodies. When listening to their stories, we were honoring these experiences and hopefully allowing them to access the therapeutic power of talk. However, we were also learning about their culture and their reality, and learning about the diversity of experiences and cultures possible within our city, a specific community, a subset within that community, and even from person to person. 

I learned some very concrete things about realities of being homeless in Portland: I learned that living on the streets in downtown is one of the hardest places to stay sober, with a seemingly constant offering of an addict's drug of choice; I learned that staying in a shelter is not a viable option if you can't bring the tools you need to work in with you; that taking any medications and especially diabetes medications or blood checks on a regular schedule is basically logistically impossible. I learned less concrete things from experiences clients shared with me: the fear in the eyes of a woman gearing up for her first winter on the streets, kicked out of her former living arrangements due to a relapse and on a 3 month waiting list for a new place; the sadness and resignation of a homeless dad separated from his daughter for over 20 years but still calling her his own; and the seemingly ceaseless optimism of the man with a laundry list of medical problems and no regular place to live who just kept smiling and saying things were looking up.   

The second component of iCHEE that I valued most, working with students from different professions, was something I did not go into iCHEE expecting to appreciate. However, working in the interprofessional teams was crucial to making the experience as wonderful as it was. On a practical level, I learned so much from my colleagues in the different schools. I had limited understanding of the education that pharmacists or dental students received, or of what their training allowed them to do. Working together with a shared goal of helping the person sitting in front of us allowed me to fully understand and appreciate what each member and each profession can bring to a medical encounter. It helped me see the crucial role of each profession in serving underserved communities and improving health equity. Without our pharmacy student, we would have been at a loss for what to say to the client who kept all of their pills together in an Altoids container, or how to talk to the client with alarmingly elevated blood pressure about maybe finding a way to fit the blood pressure medication she already had prescribed to her into her routine. Without the dental student, I wouldn't have known what to look for in a client's mouth when they complained of tooth pain, or had any understanding of what to suggest to the client with ill-fitting dentures. I have a huge appreciation now for my colleagues in these two fields, and an understanding of their role in health that is drastically different than my initial understanding. 

After participating in the University-wide "Inter-Professional Initiative," and participating in iCHEE, I strongly feel that a version of iCHEE should be a required course to replace the IPE lecture/discussion program. From iCHEE I learned in detail about the education and expertise of colleagues in different programs while developing a strong respect for their work. I feel extremely likely to collaborate with a dental or pharmacy colleague in the future. I believe the crucial component that gave iCHEE strength in inter-professional education, and the key distinction from the other lecture-based program, was having inter-professional students working together in a meaningful task towards a shared, genuine goal. I believe that it would be possible to develop a similar, modified university-wide curriculum that would be of great value to the students and the community while promoting inter-professional education. It would also be closely aligned with OHSU's mission to strive for excellence in community service, and to “lead and advocate for programs that improve health for all Oregonians, and extend OHSU’s education, research and healthcare missions through community service, partnerships and outreach.” 

I leave the iCHEE course feeling inspired, frustrated, and grateful. While some of the resources available in our community, such as TPI's new facility, are wonderfully impressive and show a true commitment to serving the most vulnerable in our community, the very fact that services such as theirs are needed in our wealthy country is disappointing. I am grateful to the community members who shared their stories and experiences with me and my teammates, and to the faculty and staff who took their weekend time to help create this experience. I highly recommend this course to every OHSU student! Fall 2013 - iCHEE Reflection - MD/MPH Candidate

I came to medical school after working at a local community health organization, where I provided over-the-phone clinic and resource referrals to low-income, uninsured community members; most were very sick or in pain, all were desperate to find a way to access health care. It was sometimes a frustrating and isolating experience, full of questions unanswerable in our brief phone encounter. Who were these community members? What was their story? Did they have a safe place to live? Would they be able to find or afford transportation to the clinic I suggested?

The iCHEE course provided the beginning of an answer to these questions, and helped me formulate new questions to take with me as I move forward in my medical education and ultimately my career. I feel so fortunate to have been part of iCHEE during my first months in medical school, and experience often isolated from the community.

Reflecting back, there were two components of iCHEE which I valued most: the opportunity to work directly with community members, and the chance to work closely in inter-professional teams with students from different disciplines but with shared social values.

The first component, working person-to-person with vulnerable community members, was what I was most excited for going in to iCHEE. It was really wonderful and eye-opening to have the opportunity to just listen, without an agenda, to people who are so marginalized that they often are voiceless in our society. Both populations we worked with, homeless individuals and day laborers who were also likely undocumented immigrants, face hurdles to accomplish basic tasks in our society, let alone to access medical care. As we move towards health care reform, these are two populations most at risk for being left out. When we walk down the streets of our city, these are the people we, as a society, are most likely to avoid eye contact with. At iCHEE, we disrupted this socially constructed power hierarchy. While not always recognized by the traditional medical establishment, we operated within the framework that the clients are the experts in their lived experiences, their health, and their bodies. When listening to their stories, we were honoring these experiences and hopefully allowing them to access the therapeutic power of talk. However, we were also learning about their culture and their reality, and learning about the diversity of experiences and cultures possible within our city, a specific community, a subset within that community, and even from person to person.

I learned some very concrete things about realities of being homeless in Portland: I learned that living on the streets in downtown is one of the hardest places to stay sober, with a seemingly constant offering of an addict's drug of choice; I learned that staying in a shelter is not a viable option if you can't bring the tools you need to work in with you; that taking any medications and especially diabetes medications or blood checks on a regular schedule is basically logistically impossible. I learned less concrete things from experiences clients shared with me: the fear in the eyes of a woman gearing up for her first winter on the streets, kicked out of her former living arrangements due to a relapse and on a 3 month waiting list for a new place; the sadness and resignation of a homeless dad separated from his daughter for over 20 years but still calling her his own; and the seemingly ceaseless optimism of the man with a laundry list of medical problems and no regular place to live who just kept smiling and saying things were looking up.  

The second component of iCHEE that I valued most, working with students from different professions, was something I did not go into iCHEE expecting to appreciate. However, working in the interprofessional teams was crucial to making the experience as wonderful as it was. On a practical level, I learned so much from my colleagues in the different schools. I had limited understanding of the education that pharmacists or dental students received, or of what their training allowed them to do. Working together with a shared goal of helping the person sitting in front of us allowed me to fully understand and appreciate what each member and each profession can bring to a medical encounter. It helped me see the crucial role of each profession in serving underserved communities and improving health equity. Without our pharmacy student, we would have been at a loss for what to say to the client who kept all of their pills together in an Altoids container, or how to talk to the client with alarmingly elevated blood pressure about maybe finding a way to fit the blood pressure medication she already had prescribed to her into her routine. Without the dental student, I wouldn't have known what to look for in a client's mouth when they complained of tooth pain, or had any understanding of what to suggest to the client with ill-fitting dentures. I have a huge appreciation now for my colleagues in these two fields, and an understanding of their role in health that is drastically different than my initial understanding.

After participating in the University-wide "Inter-Professional Initiative," and participating in iCHEE, I strongly feel that a version of iCHEE should be a required course to replace the IPE lecture/discussion program. From iCHEE I learned in detail about the education and expertise of colleagues in different programs while developing a strong respect for their work. I feel extremely likely to collaborate with a dental or pharmacy colleague in the future. I believe the crucial component that gave iCHEE strength in inter-professional education, and the key distinction from the other lecture-based program, was having inter-professional students working together in a meaningful task towards a shared, genuine goal. I believe that it would be possible to develop a similar, modified university-wide curriculum that would be of great value to the students and the community while promoting inter-professional education. It would also be closely aligned with OHSU's mission to strive for excellence in community service, and to “lead and advocate for programs that improve health for all Oregonians, and extend OHSU’s education, research and healthcare missions through community service, partnerships and outreach.”

I leave the iCHEE course feeling inspired, frustrated, and grateful. While some of the resources available in our community, such as TPI's new facility, are wonderfully impressive and show a true commitment to serving the most vulnerable in our community, the very fact that services such as theirs are needed in our wealthy country is disappointing. I am grateful to the community members who shared their stories and experiences with me and my teammates, and to the faculty and staff who took their weekend time to help create this experience. I highly recommend this course to every OHSU student!

Spring 2013 – iCHEE Reflections – Medical Student

I came into this experience with expectations for something entirely different: I was expecting to work with immigrant and refugee populations, helping give health screenings with students from other health professions and connect people with the resources they needed in our community. Immigrants were replaced by the local homeless, health screening became conversations and connecting people with available resources turned into learning about what was not available. At the end of the class, I think I can say I have never been more pleased by unmet expectations (though I should say we did successfully work as an interdisciplinary team).


What this class turned out to be was a revelation. That is not to say I was unaware of the homeless population in Portland prior to this class, but that I knew it like I know the Eiffel Tower: I know it exists, where it is and what it looks like, but I have never been there, nor really experienced it. Working at Transitions Project, talking with person after person, hearing their stories, connecting with them and learning from them: that truly revealed this population to me, and I experienced it in a way that is not possible with lectures full of pictures and numbers.


I learned many surprising things in these interactions. First, that the homeless are not as homogeneous as I had thought. I was amazed by the varied and diverse backgrounds of the people I met. In that diversity though, a few patterns did emerge: the first was that most of the people fit into one of two subtypes.


The most common were what I would “long-term” homeless. These were people who for the most part suffered from serious mental illness, substance abuse problems or a combination thereof. Marginalized by society, unable to work and without family support, most had been homeless for years and many had experienced astonishing levels of deprivation and misery. Few saw potential for much change, some even seemed to accept their situation as fate. The other group were “recently homeless”, people who had up until fairly recently, been employed and housed. Most were still connected to the social structures of the community, and most of this group had support from family or friends. The bad economy was discouraging, but for the most part they were actively looking for work and felt confident they would likely be back on their feet eventually.


There were several patterns that cut across both groups, however. The most surprising being that a staggeringly high percentage of people were new arrivals to Portland, and not just from the surrounding suburban area, or even other parts of the state. People had come to Portland from as far afield as Florida, Illinois and Arkansas. Without exception, all these people said they came to Portland not by chance, but specifically because of the services available. Of particular note, one had even researched Bud Clark Commons / Transition Projects online before leaving Chicago, and shockingly, another had been given a bus ticket to Portland from Arkansas, paid for by the court, in lieu of jail time for the offense of camping without a permit.


I must say, on one hand, I am proud of Portland for having such good services that we are known across the nation. On the other, I am ashamed of these other cities for leaving us to shoulder the burden they would not, and for turning their own neighbors into what could be called internal refugees, displaced by the callous sentiment that the problem of homelessness can be “solved” by pushing it away.


Another pattern that emerged from both groups was that they know far more about the available services than we did. Even the recently homeless were already fairly aware of what was available, which I credit to the diligent work of Transition Projects, but this was especially true of the people who had been homeless for a long time: many had personal experience at a variety of the locations. Binder in hand, I flipped back and forth mostly for my own reference while I listened to someone’s experience about a resource.


This became a source of frustration, partly because there was a sense that we were not able to offer people any new resources, but mostly because time after time we discovered that resources were simply lacking in some needed area.


More than anything else, I keep coming back to one word in trying to describe iCHEE: Experience. I remember a sense of ambiguity when I asked students who had taken it previously to describe it for me. Now I am faced with a similar problem. It is hard to pin down exactly what made the class so valuable to me, other than a gestalt that it was more than the sum of its parts. I learned far more than I helped, and in fact often felt frustrated that I was not able to help at all, but that frustration was an integral part of the experience.


As it turned out, I did help, just not in the way I had expected. Simply listening to people tell their stories, empathizing with them and validating their experiences is valuable, even healing. As a medical student, we all learn this in our first year. It is the core of the doctor patient relationship, but the fast-paced, pathology oriented nature of our training and profession continually threatens to wring it out of us. The problems that ensue are not subtle: poor doctor patient relationships lead to inferior patient care, and the physician who does not find meaning or fulfillment in work is at risk for burnout.


We cannot remove that nature of the training which is necessary, but we can put back that which is lacking. iCHEE is a chance to connect with people without the pressure of time or diagnosis, to empathize with their plight without necessarily trying to fix it, to fully understand their situation, and to soak up some humanity. In this sense, and fitting with OHSU’s mission and goals, I would advocate for all students to take iCHEE, or something similar, as a required class. We would all be better for it.

On Suicide

On May 11th, roughly 100 feet to my left, a man fell to his death from Bud Clark commons. I don’t know exactly what happened, but the likely cause was suicide.
Two days later, a man jumped from the Vista Bridge.
A week before, on April 29th, a man jumped off of a downtown Portland hotel.
Three people jumping to their death in two weeks eventually brought this to the media’s attention. There were expressions of sadness and the police issued a routine press release to let people know that the Cascadia Behavioral Healthcare free walk-in clinic is open 7:00am to 10:30pm every day, and the crisis phone line is open 24/7. They also noted that two men had hanged themselves at their homes on the 12th. The media’s reaction of shock is understandable: all suicides are tragic and traumatic to those who are around them, but the public and dramatic nature of these events profoundly affected a great many people. The police’s reaction is also understandable: this is sadly all-too-routine for them. In Oregon there were 685 deaths from suicide in 2010 (17.9 per 100,000 people). That works out to a bit more than two per week for Portland proper, and more than one per day for the whole Portland metro area.


I understand these reactions, but they are frustrating. Nothing is being done to change the status quo. Publishing the hours of a free mental health clinic and a suicide hotline is better than nothing, but it is not enough.


Access to providers is certainly an issue, but stigma can be just as big a barrier to care. I was in Bud Clark commons ready to talk to people with mental health issues, did the person who jumped know we were there, or was he too ashamed to talk to anyone? Hopefully access will start to improve with the new healthcare changes, but fighting stigma will require a sea change in society’s view of mental health issues. This is a problem so big I don’t even know where to start.


Access to means is also a problem. I was told the windows at Bud Clark Commons are designed not to open far enough for a person to fit through, and that the individual had broken the window. This is a good measure, but what about the Vista Bridge? The iconic location is notorious for suicides, with more than one a year. Like the Golden Gate Bridge, where over 1,600 people have died from jumping, there is no safety netting. Barriers are opposed for both aesthetic reasons and a pessimistic belief that nothing will stop a person who has decided to end his or her life. However, safety barriers work, especially around alluring picturesque structures, by preventing attempts - people do not simply pick a different location - and by preventing fatal injury. Furthermore, 90% of people who survive a suicide attempt do not go on to complete a suicide**. As for the aesthetics, barriers have worked at the Empire State building, the Eiffel Tower, and others while preserving their beauty There is only so far one can go in prevention before a determined individual will overcome it, but there are other simple ways we can prevent easy access to the most fatal means: Simply changing from bulk packaging to smaller packages for certain medications has cut overdose deaths. Regulating pesticide sales in India could help cut deaths by farmers, where one third of suicides are by poisoning. Guns are one of the most lethal means of attempting suicide, but the approach here needs to avoid further stigmatizing the mentally ill with blanket bans: When a gun is present, the risk of a completed suicide does goes up, but observing proper gun safety with locks and separated ammo lowers it back down. Surrendering of weapons should be done as a last resort, with the knowledge that the mentally ill are far, far, more likely to be victims of violence than perpetrators.


The last thing I would like to reflect on is the ability to force treatment. Competency and capacity are what we have been discussing quite a bit in our class as it relates to consent for treatment. I understand that the pendulum has swung a long way from the bad old days of the sanitariums, where people simply disappeared from society, but in talking with psychiatrists, it seems that perhaps it has swung a bit too far in the other direction. Commitments are now often very difficult except in cases of imminent danger, and often things cannot move forward until the situation has spiraled completely out of control. How do you balance freedom of choice against coercion if someone is so ill that they cannot make a rational choice in their own self-interest? I understand the logic behind the thinking that as long as someone is not a danger to others or himself/herself, we should respect patient autonomy. However, I question if you really are providing someone autonomy if you let them decide while in the grip of an irrational illness. If diseases like schizophrenia were curable or easy to treat, I don’t think this would be an issue: we would simply treat people. But since it seems the best we can do is manage symptoms into some level of remission, with unpleasant side effects, we must respect what autonomy the person has, and just be ready to pick up the pieces.
I’d like to end on a few more statistics:  

  • Twice as many people die from suicide than from car crashes. 
  • More than twice as many people die from suicide than homicide.  
  • The suicide rate has been increasing since 2001, it is now the:  
  • 2nd leading cause of death for College students and people aged 25-34 
  • 3rd leading cause of death for those aged 10-24 
  • 4th leading cause of death for everyone aged 18-65 

In a tragic coincidence, Bud Clark, the former mayor and namesake of Bud Clark Commons, once witnessed a suicide from the Vista Bridge. He supports barriers. *Suicide statistics from Dr. Stewart Newman MD lecture on suicide 4/5/2013 **http://www.bridgerail.org/lives-can-be-saved/what-science-tells-us

Spring 2013 – iCHEE Reflections – Nursing Student

Interdisciplinary: Working with students from other schools on the hill was a great way to build relationships, learn about each others professional roles, and learn from the clinical knowledge of other students. It was invaluable to me, an undergraduate nursing student, to have a pharmacy student on the team. Beyond knowing what medications are used for and their side effects, she was able to address how side effects might interact with daily life, and on available discounts to obtain medications at the most cost-effective rate. I saw these aspects to be particularly important in the community setting, and she was able to answer several clients’ questions because of this. Our other team member is a practicing RN who is now graduating with a Masters degree. It was obvious that she evaluated clients and their circumstances is a very holistic way, and tried to address things like having a safe place to sleep at night as equally important to clinical symptoms or medications.  I feel fortunate that my team interacted extremely well with each other. Because we were considerate to each other, it was easy to keep our focus on the well-being of the client.


Community Health: When I signed up for iCHEE, I thought I was going to be working with people who had come to the United States from other countries, and who spoke other languages- who were of a different “culture” than me. Initially, I was disappointed that we would be working in downtown Portland with the homeless population, and not with immigrant groups. In the end, my eyes were opened to just what I had been hoping for, a “culture” that had been around me in Portland all along, and that I’d never otherwise taken the time to learn much about. As we were based at Transition Projects, the majority of our clients were homeless, most were also unemployed. Some had OHP or Medicaid, many were uninsured. At our first week of iCHEE, we were armed and ready with lists of primary care, naturopathic, and dental community health resources. It only took two clients, on that first day, for us to realize that this list of resources was not sufficient to meet this population’s needs. After discussing one client’s health concerns, we thought that Old Town Clinic was a place where he should try seeking medical care. He proceeded to tell us that he had been there, and they had told him it would be a month and a half wait to see a mental health practitioner who could prescribe his psych meds, which had been stolen from him and he needed now. Another client told us that OTC wasn’t taking new patients, so now he didn’t know where to seek care. There seemed to be several available resources, however, these clients were still expressing unmet medical needs. Community resources for mental health seemed to be hard to come by, and, although some dental services are available, they usually only provide basic services, so, if the client’s need is beyond that, there may not be resources available to them if they don’t (or even if they do!) have insurance. Through our iCHEE experience, we found that linking people to the resources they need, and then actually getting the care they need, can be quite challenging.


Education exchange: In my first week of iCHEE, I had to get over the fact that we weren’t a clinic setting and that we could only attempt to refer clients to resources where they could get the medical care they were seeking. What was soon pointed out to us was that, although we weren’t providing direct patient care, the conversations we were having, and the fact that we were actually listen to clients, could be a  therapeutic experience for them. Before talking with our student team, clients were told by our faculty that this was an educational experience for us, the students, and that we wanted to hear their story in addition to addressing their medical needs. This opened up the opportunity for us to hear a bit about the situations leading up to the client’s current circumstances. We heard about clients’ pasts of clinical depression and attempted suicide, former methamphetamine and alcohol abuse, domestic violence, and incarceration, we even heard about a career working for the circus. Several people had come to Portland within the last few months, to escape a bad situation, or because they had heard that Portland offered many services to those in need. Our iCHEE group discussed the trend of people coming here because of Portland’s reputation for availability of social services; it even seemed that a couple folks may have been “sent” here because wherever they had been before, no one wanted to deal with them and their “problems.” This is potentially an issue that could use more research.


However it was that they got here, it was interesting to note that not all clients were unhappy with their current situation (homeless, low-income). Some clients were actively taking steps to obtain housing or were looking for work. Some simply were looking for medical, dental, or eye care. One of our clients made the Dean’s List at PCC while he was living on the streets. One had personally trained his own service dog to recognize his (client’s) signs of depression and then to do silly things to cheer him up. One client had been off meth for four days. I learned that no two clients were the same, and that within this culture, there were differences- in circumstances and in motivations-that made each person unique. For example, some clients consciously avoided areas of town or individuals who did drugs or frequently engaged in criminal activity. Whereas I, as an “outsider,” may just see “homeless people,” some clients definitely thought of themselves differently than others and separated themselves from what was (previously) my stereotype.
Conclusion: My iCHEE experience opened my eyes to some of the prevalent issues in the homeless community. I am grateful to have had this opportunity to talk with clients about their lives, their circumstances, and their medical issues, in a supportive, educational environment.  Learning from the real stories of these clients was more valuable than anything I could have found in a textbook. Through personal interactions with people from a different culture than me, discussions of difficult issues, and by challenging my stereotypes, iCHEE has enriched my learning at OHSU and will enhance my future career as a nurse.

Spring 2013 – iCHEE Reflections – Pharmacy Student

Signing up for the Global Health iCHEE class, I expected to focus on world travel and how to provide assistance to areas devastated by natural disaster and poverty. The first day of class, we took a tour of the Medical Teams International Real Life exhibit and were able to tour the building where supplies are shipped out of. I was very excited to learn about the various areas assisted by Medical Teams International as I spent two weeks in a poverty stricken African village last summer. I went with a group of pharmacy students to Kenya to work at an HIV/AIDS clinic in a very small village near the Uganda border. It was a life changing experience and I have the desire to participate in another humanitarian trip sometime in the future. As I toured the exhibit, I found myself thinking about other areas of interest that may need assistance, areas that would not require the same extensive travel.
Two weeks later, we began our journey at Transition Projects, a homeless shelter in downtown Portland. We were told to expect many United States Veterans and drug addicts to come through needing assistance for health related concerns. The first gentleman we spoke with was exactly what I expected, a young male from rural Oregon addicted to methamphetamine. I was surprised to learn he had a stable job and enough money saved up in the bank to pay for a home if he chose to. He said he “didn’t like to feel trapped inside a box” and would rather sleep outside, which I expect is due to the effects of meth. He said he didn’t seek help for drug abuse because he did not want to be associated with the people loitering outside of the buildings, who he felt had far worse mental problems than he. We found this to be a consistent theme among those who met the qualifications for assistance at places like Central City Concern. Even if someone qualified for assistance, many did not want to walk up to the buildings providing the help they needed because they were frightened by the types of people located outside the buildings.


Over the next few weeks, we found there were many more people out on the streets who didn’t even qualify for assistance. They seemed to outnumber the amount of people who did qualify. We found that those who would appear to have the easiest time finding a job and home were not given any assistance because they did not have substance abuse problems or were not recently incarcerated. We found many homeless people to be “slipping through the cracks” when they would obviously be productive members of society if given the opportunity. We spoke with a retired nurse who had suffered domestic abuse problems, a student trying to apply for EMT school, a woman with a past career of helping elderly with their finances and a 60 year old man who had just spent his first week on the streets. These people face the overcrowded homeless shelters and tent shanties, getting scabies from the dirty blankets while trying to avoid confrontation with those that are in apparent need of psychiatric help.


I wish this was the extent of the problems that were brought to our attention in the very short time we spent at Transition Projects. An ambulance was needed for a 62 year old Navy Veteran who had experienced a heart attack that morning. After 20 years in the Navy, this man had to be convinced to talk to us because he was concerned about being a drain on society. I understand the military has taught him to toughen up and deal with problems on his own, but there is no reason a man who has spent 20 years protecting our country should feel like a drain on society, let alone spend a day in his life as homeless. I understand there are many Veterans who end up homeless because of unattended mental issues and this is a big concern already being addressed, but this man did not have any apparent mental illness and already received healthcare through the VA for his cardiovascular problems. I do not understand why this gentleman was not receiving assistance for housing or retirement after his 20 years of service. I believe there should be services in place at the VA that patients can be directed to receive these types of assistance. Most Veterans already receive healthcare at the VA and should not be forced to look elsewhere for other services, especially when they have so much pride and don’t want to look for more assistance as they feel they are a burden. I believe this is a problem that could be avoided if the governmental assistance programs for Veterans were not as compartmentalized as they are now.


The most disturbing story I heard was from a couple born and raised in Arkansas. This couple lost their home after the major employer in their rural town closed their business. The husband worked at this company for 8 years as many of the residents did. The city they lived in is not tolerant of the homeless and the couple was arrested after found camping in the forest. When brought to the judge he gave them an ultimatum, either face jail time or take a bus ticket provided by the court to Portland, OR. They were told by the judge in Arkansas that Portland had many resources available to the homeless and the couple was then shipped off, across the United States, to our humble city. Most of the people we spoke with over the last month had recently traveled to Portland from other states after learning about our extensive resources available to the homeless. Most of the people we talked to have only been in our town for two to six weeks. We spoke to people from all across the United States including Alaska, Colorado, California and Ohio. There is no wonder why our city is so clogged with homeless searching for help and why our native Oregonians are not receiving the help they need.


I began this elective expecting to find places outside of the United States that would need our assistance. I was hoping to find a poverty stricken place to travel to that would not require a 20 hour plane ride. I never expected to find our own city of Portland to be the poverty stricken location that would need so much assistance. I am now focusing my humanitarian skills on strengthening my local communities. This class has opened my eyes to the problems people are facing in my own backyard and has reinforced my skills needed to provide assistance to anyone I may come into contact with. I know how to look for and offer valuable resources to those in need, including housing, food, clothing and many different types of healthcare. I have learned valuable communication skills that will help me with my future career. These communication skills not only taught me how to empathize and listen to people needing assistance in my community, but how to collaborate and communicate with other healthcare professionals. I realize now most people going through rough times just need someone to talk to that understands their situation and is non-judgmental. This class was an extremely valuable learning experience and I will continue to apply the skills I have acquired in the last few weeks to help strengthen my community and help those in my own home town.

Spring 2013 – iCHEE Reflections – Nursing Student

I truly am grateful for the learning in this class. Between this course and the “Health & Illness in Context” elective with Central City Concern, I have a new understanding and a deeper appreciation for our citizens who are homeless and suffer from drug and alcohol substance abuse.  Initially, when I signed up for this class, I thought I was going to learn more about cultures other than my own. To me, this means getting to know people from other backgrounds or countries altogether.  I was so fixated on that, that when I heard we would be working with the homeless population, I was sort of dismayed.  I thought that what I needed to know about this subgroup of people I had already learned in my undergraduate nursing curriculum years ago. Now I desired to exchange information with people of different cultures, learn more about them, perhaps greet them in their own languages, or better understand their beliefs.


Well, to my enlightenment there was more involved than just learning about people from different cultures. Over the past three weeks, through the exchange of information and learning about the homeless population, I realized that theirs was definitely a culture different from my own. I learned about their personal stories, their struggles and concerns, and attitudes about their circumstances.  This opened my eyes to some of the root causes and consequences of social inequality. Though the majority of clients appeared to accept the circumstances of their homelessness, they also expressed strong motivation to improve their lives.  On the other hand, we also met clients who chose to live a “drifter’s life” meaning they traveled from city to city, and state to state living the homeless life they believed suited them.


I thought it interesting that not a single client expressed worry about food access when asked if that was a concern. My own bias was that if one were poor and living on the streets, food would be one of the most critical items needed day-in and day-out. According to some clients, Portland is one the better cities in which to live a street life.  A number of clients had recently moved to Portland from other states to receive better access to resources, and learned that accessing meals and food boxes was not a problem.  While exchanging information we provided clients with resources in the community.  However, we learned quickly that this population is extremely knowledgeable about what resources are available and what is inaccessible. Primary barriers were qualifications and navigating the “system.”


Another unique aspect was that we were at the same facility each week, performing health screens and education exchanges with the same population. Each week my team and I learned of a different hardship experienced by the group we met with that week. For instance, the first week, the primary concern of three out of four clients was obtaining affordable housing. The second week, all three clients mentioned their biggest concern was the lack of medical care from simple illnesses to extreme mental health problems. The third week, all three of our clients expressed difficulties in finding work. All of our clients were randomly invited to participate in the exchange of information on health and disease prevention, yet each week we learned of clients’ different needs that were beyond health and disease prevention.


In addition to health screenings we did a lot of therapeutic listening and acknowledging what seemed real to clients. Scenarios ranged from a relationship plagued by domestic violence, to a belief that tracking devices were implanted and controlled by radio and microwaves that caused radiating heat and pain in the arms and legs, to a client’s grief over witnessing the death of one of the residents at TPI last weekend.
I think this was where the frustration began for me. We took the time to ask clients how they were and if they needed anything. While I am grateful for the opportunity to acquire information, and to “be there” for some of the clients the past few weeks, I feel it was a temporary fix, which in the end would not benefit these clients. Granted there were some clients who did not care less about the health care system. However, the majority of these homeless clients needed medical care and mental health access. They needed long-term treatment plans. I feel helpless in a sense because even with the resources provided they would not be able to receive treatment because of the barriers in navigating the health care system. If they did qualify, it may be months or years before they could access necessary services. I felt I am not providing helpful information to these homeless people who were struggling just to survive.


Although we had a significant list of wonderful community resources to which we referred the clients, we were informed that stipulations prevented clients from accessing them. Clients must have a history of drug and/or alcohol addictions, currently use substances, and/or have criminal backgrounds that restrict them to be homelessness to qualify for medical care or housing access, or even to be on the waiting list.
I had a chance to interact with the homeless as people, not problems. Like anyone else, they deserve and want to be respected in life, and if we give them respect they will do the same. It was important to recognize that each person’s diverse experiences, values, and beliefs impact how he or she accesses services. Equally important, is recognizing that the cultural values of medical providers and service delivery systems have an effect on how services are delivered and accessed.  Knowing this will help health care professionals be more aware of the need to provide access to essential services to this particular population. Needless to say, this class increased my knowledge of the nature and extent of health disparities and health system gaps in my community.


Regarding working as a team with a variety of students from different disciplines, I thought it was a great set up. As team members, each of us provided information or teaching based on our backgrounds and on the client’s specific problems or concerns. We worked well together in that we had mutual respect for one another's “expertise” when we interacted with each other and with the clients. We exchanged information in such a way that clients had a very clear understanding that we did not provide diagnoses, medications, or treatment. In all honestly, I thought our clients would be disappointed, but instead they responded favorably to that approach.  
I thought the weekly note, taking turns to do the write-up, was helpful. It made the reflection more meaningful and in a sense, it challenged me to further develop and apply an ethic of social responsibility in that I had developed awareness and improved my attitudes and perceptions towards this underserved population. I was glad to be shown a culture I knew existed but never took the time to appreciate and understand the hardships and needs of the disadvantaged in our community.


To you Valerie, I want to thank you for this educational opportunity, and I so appreciate the work you do for the health of vulnerable populations. It takes a special kind of person, and I’m very glad and honor to know you through this class. Best wishes and take excellent care. :-)

 

Spring 2013 – iCHEE Reflections – Nursing Student

The folks we met at Transitions Projects told us many different stories about living with homelessness and unstable housing, but their stories shared a common theme of trauma and the struggle to survive the aftermath. One man experienced horrific trauma as a young child and ran away from home at age 6, living life as a train-hopper for the next fifty years. One woman had suffered a severe back injury and had recently lost her disability benefits because her caseworker believed that she was abusing her pain medications. This woman had never been homeless before, but now she and her fiancé were looking for free or subsidized housing—no small feat for a couple wanting to live together. Another woman had raised three successful, highly educated children, but refused to contact them for help because of her shame surrounding her alcoholism. Another woman had lupus and its myriad of neurological problems, which her doctors rarely understood. And another woman had just left her home and boyfriend because he had spent his share of the rent money on drugs, and she didn’t want to be a part of that.
A few were high or intoxicated at the time we saw them, and many others reported struggling with addiction. Some of them wanted help to recover, but did not like going to the rehab centers or the AA/NA meetings because that simply put them in contact with the very kind of people they didn’t want to identify with. One man spoke of the pain and betrayal he felt when he saw men from his AA group drinking on the streets after they had said at meetings that they’d been sober for ten years. He was clearly desperate for support and friendship, but if he couldn’t find it with other men attempting recovery, then where could he go?


Many of our clients had hypertension, diabetes, and heart disease. All of the clients we saw were health conscious and had good reasons for not wanting to sleep in shelters: bed bugs, scabies, contagious coughs. Many of them carried their medications with them, knew what they were for, and claimed to take them religiously. Some even had their own primary care and mental health providers that they saw regularly. And yet somehow that was not enough. Somehow they ended up at our door, wanting to know if their cough was really worth paying to see a doctor, wanting to know if they should get their teeth pulled and where, or if there might be any options for affordable crowns or dentures.


Dental health in particular was a great source of stress for nearly all of our clients. Although there are volunteer and non-profit “dental vans” and low-cost clinics that offer cleanings and tooth extractions around the city, these people had already had many teeth pulled and were struggling to eat whatever food was available at the shelters. Our expert dental professors were able to perform some wonderful on-the-spot assessments, but even they could not produce a truly affordable source for root canals, crowns, or dentures to help our clients save what teeth they had left. Even more so than in other areas of healthcare, it was as if we were drawing a line in the sand and saying, No, you cannot cross to our side; you cannot keep your teeth unless you have the money to pay. I felt guilty and sick whenever we got to that point in the dental conversation, and I could only imagine what it felt like to be the person so desperate to save a tooth.


A few clients presented with acute occupational injuries, and another with unstable angina and all the classic signs and symptoms of myocardial infarction. He was a veteran, but the students that saw him had to convince him that he wouldn’t be abusing the system by calling an ambulance for a heart attack. These were grateful and gracious people who often wanted to help others more than they wanted to help themselves.
And then one Saturday, as my group and I were finishing up a client conversation, a visitor to Transitions Projects broke a window upstairs and jumped six stories to his death. He lay there on the city sidewalk below our window for hours, only partially covered, while the police waited for the medical examiner. Some members of our class were shocked by the act of suicide, or heartbroken that we had been so close by and hadn’t known that this man needed help. I have a lot of experience with mental illness, and my thought at the time was simply that there are people all around us, all the time, who are thinking about killing themselves. It is sad, but it is a truth that must be accepted and openly acknowledged if we are to move forward as a society in the area of mental healthcare.


Our clients were so open with us about their struggles. That was the most beautiful thing about it all. Perhaps they didn’t feel that they had much to lose by sharing their struggles, especially with students, or perhaps they had shed some self-consciousness after many years of having to ask for help. Whatever the reason, most of our clients seemed to appreciate the opportunity to tell their story to someone who cared to listen and learn. When I started this class, I didn’t have many expectations at all. It has certainly been a pleasant change from my clinical hours in the hospital, where I care for patients who are wealthy and secure by comparison but do everything in their power to hide their emotions from me. As a student nurse, my instructors tell me every day to find out my patient’s stories. Caring for the whole person is the cornerstone of nursing. If you’re terrified that you will die a painful death from cancer like your grandmother did, we want to know that. If your house has a steep flight of stairs to the front door, we want to know that too. But when I dive into these topics with my clients at the hospital, I usually get only brief, polite answers. With our clients at Transitions Projects, all we had to say was, “Please have a seat,” and “Tell me about yourself,” and the stories came pouring out.


I feel privileged to have been in this class and had the opportunity to hear from some of the most discriminated-against members of our society. I was raised in a church that served meals at homeless shelters, and I have traveled in large cities all over Europe and America, but it has been a pleasure to put some stories behind the faces that I pass on the street and the people who walk through the trains asking for change. It is a different thing all together to sit down with someone in a quiet, neutral, indoor space, with no tables between us and no business to hurry off to. Although we were there under the pretense of healthcare, because we took the time to listen to anything and everything, it felt like we were sitting together as equals and peers.

Spring 2013 – iCHEE Reflections – Nursing Student

Expectations Going into the Class

I was interested in participating in the iCHEE program because I wanted to learn from colleagues and community members. I am also very interested in global health and thought that the class would provide me with the opportunity to explore the many cultures that are very much present in the Portland area, without leaving the country. I was also interested in learning more about local resources in our community since we often refer clients and patients to these resources in our clinical setting. I wanted to have a more community-based experience with individuals that actually use and need these resources, so it would be more than a name or phone number on a document. In addition to wanting to learn more about other cultures, I was very interested in working with fellow OHSU students that I rarely have the opportunity to collaborate with. We learn so much about the “health care team” and working together to deliver the best possible care to those we serve; yet we rarely get the opportunity to work with fellow OHSU students from other disciplines.

 

Group Dynamic and Experience

Working with my team was a wonderful experience. At first, I was hesitant about a group of 4 people speaking with one client, but it became more comfortable as the weeks passed by. It took us a while to adopt a natural flow to our meetings with the clients, but it seemed to work out well in the end. The first few sessions were particularly interesting because we were getting to know our teammates at the same time as the client. We also didn’t have much of a plan and didn’t know what to expect, but we ended up finding comfortable collaborative roles and had very meaningful and interesting conversations amongst ourselves and with the clients.
Structure, Interventions iCHEE


Other than working in teams and learning about other cultures, I wasn’t exactly sure what the role of an iCHEE student was in the community. As we approached the first Saturday, this role began to feel clearer. I found it interesting that we were there to chat and hear their story but also served as health care professionals that were able to do basic assessments and take blood pressure. I wondered how this dynamic would materialize in this setting. I definitely understand the benefit of having a focused and comfortable conversation with the client, but the clients often wondered what they were “supposed to do” or what exactly we were there for. I found the binder very helpful and informative, but I did feel a little uncomfortable jotting down names and numbers of clinics and organizations that I had never heard of or called to verify information. I know that it wasn’t part of our role to do verify or research in this setting, but I learned a lot about the resources from the actual clients (which was wonderful) and was informed about some misconceptions about certain places. For example, several clients told us that central city concern only accepts clients with drug abuse issues or Veterans, which posed a barrier to care for several of the clients we spoke with. It became clear after several sessions that we were there to hear their stories, share part of ours as appropriate and offer resources – whether it be clinics, eye exams/Casey Eye referrals, blood pressure readings or dental referrals. As we discussed in post conference several times, this experience while fascinating and rewarding was frustrating at times. It was difficult to speak with a client that needed a primary care provider and didn’t have one, and it was hard to send them off with the number to a county clinic knowing that I’d never see them again or they may not make it to the clinic for whatever reason. What was even more disappointing was speaking with clients that could clearly benefit from having resources that we could not provide – such as mental health. I wish that they could have a regular provider or someone following their health and well being regularly. It was hard knowing that meeting with us was such a small part of their health care trajectory and life experience, especially once unmet needs were identified.

 

Clients we saw/Stories we heard

We met a lot of very interesting clients over the term. The very first day, we met clients with a history of substance abuse, a woman who was a victim of domestic abuse, a homeless couple attending school full time and trying to find jobs and housing and a man who had recently lost his job and was traveling looking for work. This group gave us insight into the varied and complex issues this population faces in their daily lives. I thought that food security and untreated health issues would be more prevalent. What we found was housing, untreated mental health conditions and unemployment were the most common barriers these folks were faced with. I learned so much about where each of these clients came from, some milestones in their lives and how they got where they are now. Many of these individuals had traveled to Portland from other states because they had heard about the social services offered in Portland. Most of the clients we spoke with knew more about resources in Old Town than we did and were familiar with where they could go for showers, food, laundry, and a dry place to sleep. We did speak to a few clients that were new to the area and we were able to offer some resources that they had yet to hear about. I was surprised at how interconnected these individuals were with those in their community. Having the iCHEE sessions at Transitions Projects was really unique in that way. We were able to see a variety of different clients in one setting that were all there for different reasons. Transitions seemed like a very effective and helpful “home base” for a lot of these folks, and a place they felt welcome and comfortable.

 

Surprised me

We spoke with several clients who complained of radiowave communication through implanted devices of some sort. I honestly had never heard of anything like this, other than a list of possible symptoms for various mental illnesses. I was quite surprised to hear of similar complaints in two very different clients. One gentleman had been a truck driver for many years and felt that he had the power to control his physiology through special adaptations of his organs. He was a fascinating client to speak with and clearly had very thorough explanations of each and every one of his explanations for symptoms and rationales behind lifestyle choices. The other client we spoke with that mentioned an implanted tracking devices and radio active burns was an older gentleman who had been in prison for 7 years, and was convinced that he was implanted with a device during his sentence or at the time of release so that he could be tracked at all times. He too described physical symptoms that resulted from the implanted device. I felt that the first man had more mental health symptoms than the other gentlemen, who didn’t strike me as a mental health client at all – he completely denied any drug or alcohol use. I found this an interesting observation and a telling example of the mental health needs of this population. It also sparked my interest and made me curious if there was a common belief among this population or perhaps a different population that these types of devices exist and are present in this population. One man brought in a print out from a website that affirmed his suspicions.


I was caught very off guard by the suicide that occurred while we were in the building. Obviously, there was no way of preparing or preventing this death, but being so close was almost surreal. It certainly drew attention to the vast number of individuals requiring mental health treatment that may not be getting the help that they need. It was fortunate that several clients who were present during this tragedy were able to discuss their feelings with us.

Spring 2013 – iCHEE Reflections –Nursing Student

To echo the sentiments of the reflection you read in class I feel the same way.  I was very disappointed after the first class when I heard we were not going to be working at a location with immigrants and or refugees.    What I realized was that the population we served out of Transitions Project was exactly that of refugees and immigrants.   Except I felt I was able to truly serve, listen, and help them because there was no language barrier.  The common language made communication much easier and often more effective, although sometimes not.   Many of the clients were new to the city, wide eyed, and culturally cross eyed new to the culture of the homeless in Old Town.  Many of the clients had had fled situations and or persons that were harmful to them and looked to Portland as a refuge of their own.  They arrived having their own ideas of what they thought Portland would look and feel like.  The Burnside Bridge and Old Town seems to be the current Ellis Island of the West Coast. "Give me your tired, your poor / Your huddled masses yearning to breathe free / The wretched refuse of your teeming shore / Send these, the homeless, tempest-tost to me / I lift my lamp beside the golden door!" Emma Lazarus from the Statue of Liberty. They come knowing they will be served and taken care of.


What I appreciated from these individuals was their eagerness to help students and share their stories. They asked us frequently "what else do you want to know, how can I help you learn about homelessness? Granted I don't know how many individuals declined Peter's invitation to talk with us, but I was surprised with the amount of information they were willing to share with us. They opened themselves up and were very vulnerable as we were enthusiastic to help find them resources and give them hope. They openly cried in front of us while discussing deep, intimate, often painful experiences and memories. I did my best to acknowledge how uncomfortable this made me, I only found napkins to help dry their tears. (Perhaps next time we can bring Kleenex for clients?). I was uncomfortable because I knew I could not change their situation, only they have the power to do that.  My job was to listen, learn, and share the limited knowledge of resources for them in the Portland area. The clients often said that they were proud of us "young people" getting an education and wanting to help others.  I never would have thought a homeless African American man from the South would tell me that he was proud of me for working and going to school during this experience! But he did, and he made me smile and continued to tell us to go after our dreams! I still smile when I think of that particular client.  I felt that were we able to help these clients feel that they were also being of service to us.


I learned many lessons during these few Saturdays.  I saw how a dog could help keep a homeless man from committing suicide.  I saw that particular client melt into laughter as the "service dog" rolled around itching his back. This dog gave him a sense of purpose and joy in his life. I will say that I am glad they service dog law is written as it is, with us not being able to question people of the "validity" of their dog in this case.  I know I have judged people harshly with dogs that wear the service dog jacket that obviously have not been professionally trained to be one.  After the interaction with Smokey the dog I will check my judgment next time. We will never know the full story by only looking at appearances. This was another lesson I learned, you cannot judge a homeless person by appearances. We were privileged to speak with individuals of all shapes, sizes, colors, and smells.


I view homelessness differently now is with removal of judgment and replacing it with compassion. By taking this class along with HIC my eyes have been opened up to the spectrum of homeless, addiction, abuse, and crime. The social determinants of health were very much reinforced by what I have experienced and observed. No one becomes homeless and addicted to substances without previous life experiences and exposures that have led them down dim paths. I have really seen how childhood experiences, especially repeated trauma of any sort have extreme negative impacts on children's development and outcomes later in life.  It is: who raised you, where you grew physically grew up, who you played with, what you watched on TV or didn't watch, if you were read to, if you went to school, who was your teacher, did you get early intervention services, were you hungry when you went to school, did anyone hug you as a child, did someone help you with your homework, did you have grass to play on, did someone brush you off when you fell or push you down again, were you encouraged to follow your dreams, were you told you were loved or good enough, told you weren't good enough, had someone who believed in you, had dental care, had your immunizations, had shoes and clothes to wear, had neighbors who looked out for you or neighbors who shot at you.  All of these situations are calls for compassion and service of others.  As a nurse it is my duty to help assess these circumstances and do what is in my power to intervene, even if is just listening or offering a kleenex.


Thank you for the opportunity to confront my prejudices, preconceived notions, and the uncomfortable silence when we didn't know what to say or how to help.  I feel I have grown from this experience and will take this with me for my career.  We are taught active listening skills in nursing school, however we often don't have the unlimited time to practice them like we did through this experience, so thank you.

Spring 2013 – iCHEE Reflections –combined weekly reflection

What did you learn about the person and their culture?

Today we spoke with two clients who were migratory in pattern and one who had just spent six years in jail. The migratory clients came to Portland to knowing that it has good services for the homeless.  
One client struggled with being labeled delusional because of her experiences in interior Alaska.  She stated that she had witnessed some severe injustices committed against the native populations and was arrested for participating in a protest.  Her story is extreme, however the evidence that she is labeled and discriminated against because people think she has a mental illness that she is not controlling is damaging to her. As we have heard in previous classes, being labeled as delusional on the streets is a very negative label.


One client who is a registered sex offender echoed what I have previously heard about severe discrimination against sex offenders. The homeless and prison culture had prejudices against sex offenders, they are the "lowest of the low" in the prison system culture. Our client was verbally harassed for six years in prison, severely depleting her self-worth.

 

What hardships have they encountered in the US?

The clients all had some form of criminal record.  This presented them with obstacles in finding housing, employment, and social networks.  Finances are always a hardship, affording a phone and being able to be reached for follow ups on jobs, housing, appointments are always a struggle.  With no formal form of income all clients struggled to obtain basic health care.   One female client is a registered sex offender, this poses extreme hardship for her to find affordable housing that will accept her.  All stated that the US court system was very difficult for them to navigate, they felt discriminated against and unfairly punished.  

 

Did you clarify any misinformation about the US health system?

I believe the three clients all felt that they understood the health system, however they all stated frustrations and barriers to receiving care.  They shook their heads in disbelief at how hard it is to get "good" affordable care. 

 

How did you function as a team and what could you do to improve it?

I felt our team did a nice job of taking turns asking questions and really listening to our clients.  I think they felt safe to open up demonstrated by two of them crying and thanking us for listening and validating their feelings. It was nice to have Kevin join us this week, as he added a different male perspective to our group.

I think we could prep one another with how to ask more open ended questions.  I personally struggled with how personal to get with clients in the first and only meeting.  


How deep do your probe when you cannot predict the response? Do we risk making them feel vulnerable for the sake of our learning?

Our only "tools" were out counseling skills of validation and listening to help them through the difficult conversations.
 

Were there difficulties dealing with any issues, e.g. hygiene, women's health, sexual problems?

One client expressed that she needed her annual exam and wanted resources where she could have it completed.  The three took tooth brushes but declined soap and shampoo when offered.
The client who was a registered sexual offender seemed to have a history of sexual abuse herself.  She made vague comments about the things that she had to do and that were done to her as a young run away on the streets of Portland.  She did not elaborate on this only to express her frustrations with having her daughter taken away from her and spending 6 years in prison.

 

Were there any traditional health practices discussed?

One client stated that she was more interested in taking herbs or natural remedies for her blood pressure instead of pharmaceuticals.  She was happy to hear that she could receive acupuncture at the Central City Concern clinic and felt that may help her chronic pain issues more than narcotics.

 

Were there any barriers to communication?

All three clients spoke English well and seemed to have a high intelligence level demonstrated by word choice, critical thinking, and conversations skills.  They all spoke well and took notes on our suggestions.  They admitted to struggling with depression, however no obvious mental illnesses were noted.

 

What could be handled better and what went smoothly?

I wish we would have had more time to talk about the tragedy that happened on Saturday.  I had a hard time getting the image of the man's body on the street out of my head.  Like Valerie I struggled with the "what if" questions all weekend and wondered how the staff members and other clients were dealing with what they saw and felt.


As we discussed in the debriefing I appreciated Peter approaching clients and helping them understand what we were there for.  I hope we can continue to remain busy and listen to more client's stories.  If only for the short time we speak to them continue to help them feel heard, valued, and validated.


I am really enjoying this class, more than I anticipated! I love how much I am learning about homelessness in Portland from the brave clients who share with us.