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 Justin Altschuler and Dr. Harrison Alter

JMP student Justin Altschuler, left, with Dr. Harrison Alter, director of research at Highland Hospital Department of Emergency Medicine. (Cathy Cockrell photos)

Screening for diabetes in an emergency setting
At Highland Hospital in Oakland, a UC student tests the ER's capacity to address an epidemic

— Via a simple yet ambitious research project at Alameda County's Highland General Hospital, a University of California student is attempting to make inroads against one of the "big" diseases of the developed world, diabetes, and its epidemic proportions among the poor. Justin Altschuler, a future physician enrolled in the UC Berkeley-UC San Francisco Joint Medical Program (JMP), hopes to establish whether, in an imperfect world, the emergency room can serve as a place for effectively detecting undiagnosed cases of diabetes, which afflicts nearly 24 million people in the U.S. (about 7.8 percent).

CDC graph on prevalence of diabetes in U.S.
Estimated prevalence of diabetes (diagnosed and undiagnosed) in the U.S., among those 20 years or older, 2007
(Source: Centers for Disease Control and Prevention)

The ER, not the doctor's office, is where the poor and medically underinsured, increasingly, are getting their healthcare, notes Altschuler, 24. At Highland, in Oakland, and other public hospitals across the country, ER staff often treat medical crises that might have been preventable — from heart attacks in those who should have been on blood-pressure medication to gunshot wounds in youth.

With diabetes, lifestyle changes can prevent or delay the onset of the type that first presents in adulthood, and can help confirmed diabetics manage their symptoms. Yet some 5.7 million Americans with diabetes (the poor disproportionately) are unaware that they have a metabolic disorder that can lead to kidney damage, heart disease, nerve damage, even blindness or amputation, says the Centers for Disease Control and Prevention.

Altschuler — who will earn a UC Berkeley master's degree in health and medical sciences through the Joint Medical Program and a medical degree from UCSF — plans to enroll 500 patients at Highland's ER, employing a team of volunteers, mostly UC Berkeley undergraduates, to interview patients and arrange for the blood-sugar tests needed to establish a diabetes diagnosis. Participants in the FINDERS study (short for Finding Diabetes in the Emergency Setting) are recruited in eight-hour sampling blocks, during which "every patient in the emergency room is eligible for the study."

Undergraduate research:
Enrolling ER patients for diabetes screening

 Priya AsthanaCal senior Priya Asthana, one of close to a dozen FINDERS volunteers from UC Berkeley, learned about the study in her spring "Introduction to Epidemiology" course, where Altschuler was her graduate-student instructor.

His orientation for volunteers, she says, taught her the correct procedures for approaching and interviewing patients, but also helped her understand the purpose of the research — making her better able to explain it to those she approaches in the ER to seek their participation.

A pre-med student from a family of doctors, she's found it both eye-opening and fun to be involved in clinical research — particularly about a disease that feels close to home. "I'm Indian. Diabetes is really really high in South Asian populations," she explains.

During work shifts at Highland since April, Asthana has encountered ER patients who, like herself, "know that diabetes runs in their family. They're not insured, so they may not have had the opportunity to get tested before. They say 'sure, I'd like to find out, because I've been thinking I'm at risk.'"

Dr. Susan Ivey, a JMP associate professor and one of Altschuler's academic advisers, notes that the ER could offer a "unique opportunity" to deliver healthcare services that people aren't getting, provided that doesn't create backlogs. The FINDERS study at Highland seeks to address two pending questions, says Ivey: Will ER patients be receptive to extra screening? And can you successfully connect them to follow-up services?

It's already been shown, Ivey notes, that it can be effective to offer flu immunizations to elderly people who come to the ER for other reasons. "This is where Justin's research project inserts itself. If people are sitting around anyway," the thinking goes, "maybe we could be screening them." She calls Altschuler a "deep thinker with high ambitions. If anyone can pull this off," she says, "it will be Justin." The FINDERS study, she predicts, will result in "another piece of literature, before too long" on whether the ER can fill in gaps in the healthcare delivery system.

So far, about 200 of those approached at Highland's ER, roughly 60 percent, have agreed to answer the questionnaire and take a blood-sugar test. "Diabetes is so common in their communities, so people are concerned," says Altschuler. If a person's labs come back positive for diabetes, "we try and make sure they get the care they need," he adds. The study also looks at those who already know they have diabetes, to find out how well they are managing their condition.

This research dovetails perfectly with Highland's growing interest in the ways that social forces "interplay with the medical-care system through the ER," says Dr. Harrison Alter, director of research for the hospital's Department of Emergency Medicine and co-principal investigator on the study. By his calculation, "even if we were to come up with a fix" to the healthcare crisis in the next presidential administration, "we're probably 10 years away from settling into a system that works for people."

With 50 million medically uninsured Americans, and many more underinsured, "what are we going to do in the meantime?" Alter asks. "Emergency rooms are being left to clean up the mess. We want to figure out what's the best way to use the scarce resources of the ER. It's unknown what the ER is capable of, in terms of filling in gaps in the primary healthcare system." Altschuler, he says, has done "a masterful job of making his project comprehensible" to volunteer screeners "and making their role clear and unambiguous."

Like many of his fellow JMP students, Altschuler sees medicine as an avenue for addressing social injustice. (Other students are currently working to address, for example, Chagas' disease in Mexico; arsenic in drinking water in Bangladesh; and racial disparities, in the U.S., in prostate-cancer treatment.) "Everyone has some level of discomfort with inequality in the world," says Altschuler. "My way of dealing with that discomfort is to try and do something about it."