Cardiac Screenings in a Faith-Based Setting: Interview with Nishaki Mehta, MD

In this interview, we learn more about Faith-Based Initiatives for Health (FBI4health), which conducts cardiac screenings for patients in a church setting. Founded and led by Dr. Nishaki Mehta, a team of physicians, nurse practitioners, nurses, pharmacists, and student volunteers work together to raise health awareness and help church communities gain access to healthcare in Charlottesville, Virginia.

Tell us a little about your medical background.

I came here from Mumbai in 2007 as an international exchange student (a program founded by Drs. Avinash and Nilima Patwardhan) and completed a post-doctoral fellowship with Drs. Katherine Luzuriaga and Mohan Somasundaran. After that, I completed my internship at the University of Massachusetts, residency at George Washington University, and cardiology fellowship at The Ohio State University. Following that, I did my electrophysiology fellowship at Brigham and Women’s Hospital, Harvard Medical School. I graduated last year, and started my faculty position (joint appointment in medicine and biomedical engineering) here at the University of Virginia (UVA) Health System last November.  

What is FBI4health, and why did you decide to create it?

As a child, my parents (Manisha and Kiran Mehta) encouraged me to participate in the medical ambulance health drives run by my grandfather (Rasiklal Mehta) to provide care in tribal areas in India. In a non-physician family, this was my first-hand experience with healthcare in communities. My folks always said to help people around you first. When I came on staff at UVA, I noticed few minority patients on the inpatient list. This was surprising to me, because although 18-20% of the population of Charlottesville is African American, the hospital census did not reflect that. This made me wonder whether these patients were either not falling sick or if they were just not showing up to seek care. In learning more about Charlottesville, I found it has a very rich history, including that it was the home of Thomas Jefferson. However, there still exists a huge divide, and given concerns for prior trials like the Tuskegee study, there remains mistrust in the minority population to seek help. As a consequence, when they do seek care, they often have advanced disease, which leads to poor outcomes. Sadly, it is a self-fulfilling prophecy. 

Around this time last November, I went to the American Heart Association’s (AHA) Scientific Sessions, where I attended a presentation of a close friend Dr. Khadijah Breathett, who specializes in heart failure and has devoted her career to racial disparities. Her research presented at AHA 2017 illustrated the disparity in healthcare that I was seeing clinically in my own patients. One of the session panelists asked what could be done to bridge this divide, which got me thinking: why not talk with patients about cardiovascular awareness in a safe and unthreatened environment when they were surrounded by family and friends, preferably at a comfortable or familiar location such as a church or barbershop? I decided to ask for help from my division chief, Dr. Brian Annex, and Dr. Sula Mazimba (heart failure cardiologist), who later became my partner in this project. I personally felt more comfortable going to a church, and because I was brand-new to the area, Dr. Mazimba was able to help identify some predominantly minority churches to approach. 

What were the next steps?

For the first phase of the project, Dr. Annex connected me with Dr. Kevin Thomas, an electrophysiologist who was working in a similar field in North Carolina. Based on the counsel I received, I initially thought of whether I should catalogue outcomes to demonstrate progress. I decided to leave that to my feedback from the initial encounters. My first step was to introduce myself to the 3 churches we identified, tell them our purpose, and let them know I would come back every 3 months on a Sunday after the church sermon to conduct screenings for cardiac health. Some of the churchgoers asked me “Are you planning to conduct research on us?” When I repeatedly got that question, I decided that we would catalogue the progress, but leave the records with the church unless they elected for us to track progress later. It was more important to engender confidence in the community, which was concerned about being misused for research. Since many of these churches do potlucks after the church sermon, the pastors suggested that it might be an ideal time to come when people are relaxed, to see if people were interested in learning a little more about cardiac health and get a basic evaluation.

To foster more collaboration, I asked the pastors to elect a church liaison, preferably a high school or college student interested in a career in healthcare, who could directly communicate with me about any concerns that the church members might have in-between my 3-month visits. This was partly inspired by the efforts of Dr. Quinn Capers to promote science interest at a high school level in order to encourage minority students to consider careers in healthcare. This point person would be familiar with the congregation they see on a weekly basis during church. At my very first talk, I provided an overview of the AHA’s “Life’s Simple 7” checklist, discussing how to stay healthy and when to seek care, in combination with some preventive cardiology pearls that I share with my patients in the EP clinic. I was lucky to work with Drs. Subha Raman and Martha Gulati in clinic as a general cardiology fellow — I had picked up a lot of preventive cardiology lessons. 

As I talked with the people at the church, I found that some of them didn’t have insurance. My focus was to provide a more sustainable model than a one-time screening effort. I made some local enquiries. UVA offers a clinic that can help Medicaid patients (University Medical Associates, or UMA), and a lot of them met that criteria, but didn’t know how to get started. In addition, there were some people who did not meet the Medicaid criteria because they were making a little more than that, but their employers did not offer insurance. Charlottesville has a free clinic that can help some of these people, and Dr. Mohan Nadkarni asked me if I could run cardiology clinics. Therefore, we made an arrangement so that after my sessions at the church on Sundays, I would conduct a cardiology session the following Monday for patients at the free clinic; this would allow care for patients who needed urgent attention from the Sunday screening to get preliminary labs and get started on medications. 

The screenings have been effective thus far. Many people were asymptomatic but had high blood pressure, some in the 190s-200s, so they needed to get started on treatment. When I would see them on Sunday, I would route them to UMA to see if they qualified for Medicaid, and meanwhile, I set up a free clinic appointment the following evening to ensure they didn’t slip through the cracks. The free clinic did a great job facilitating their Medicaid enlistment as well to have UVA take over their care. This chain of communication facilitated getting these people to enter the healthcare system. 

We identified 3 churches in the beginning, and would make sure to dedicate 1-2 hours of face time with the parishioners, one weekend day every 3 months. In one screening with my team, I can see about 10-12 patients. It’s similar to a condensed regular clinic, except that I don’t have paperwork issues to deal with!  

A few weeks into screening, I sent out a call to see if there were volunteers interested. Medical students, house staff, high school students, nurses, and pharmacists all responded to join this effort. My clinical practice nurse, Courtney Smart, came up with the term FBI4health. 

How many volunteers are involved with FBI4health? 

We have about 20 volunteers from Charlottesville, mostly from UVA, who contribute their time depending on their schedule. On average, I have about 3-5 volunteers participate each time, and with the church liaison present, that gives me enough manpower to conduct a session. 

What screenings are offered? 

During phase 1 (the first 3 months), I introduced BMI and blood pressure screening, and made sure the people we met with had a follow-up plan. My goal was to provide education but not necessarily intervention if they already had a physician; therefore, I would give them written goal cards showing what we discussed about incorporating healthy eating and exercise, and reaching an ideal blood pressure. 

We are now in our fourth (last) phase of screening for this calendar year. With our pharmacists now on board, we are able to offer blood glucose screening, provide pill boxes, as well as offer smoking cessation resources.  

Can you tell us a little about what you have found as a result of the screenings?

African Americans have a lower incidence of arrhythmias such as atrial fibrillation; however, what I have found is more instances of PVCs, high blood pressure, and uncontrolled early cardiomyopathy. In particular, I initially see a lot of cardiomyopathy caused by high blood pressure, obesity, and diabetes. The PVCs manifest from the cardiomyopathy, so the goal is to potentially reverse the cardiomyopathy to prevent a defibrillator implant down the road. It’s important to note that in order to establish trust with the community, all patient information is locked up and left at the church. The information does not come back to me unless people want me to track their performance.

What are your future goals with FBI4health?

I’d like to spread the word and potentially create smaller communities. My goal is to expand beyond these 3 churches. I’d also like to identify cardiology fellows who are interested in taking ownership of an individual church. Therefore, the goal for early next year is simply to reach out to more churches and create a systematic chain of command to make sure that there are physician contacts available. 

Why is it important to offer these screenings? What feedback have you received from patients?

It has been rewarding. The people we screen often come back to tell me how their other family members are doing — whether they’ve lost weight, started exercising, or lowered their blood pressure. In some cases, people have a church friend accompany them to the screening, and I’ve noticed that this really helps people stay on track as they are now accountable to someone dear to them. The other day, one of the church liaisons sent me a testimonial video on how initial screenings for hypertension have led to many downstream new-onset diagnoses that are now controlled. It was a very touching moment, and I still play that video at the end of a tough day. I have been warmly delighted to see how the community here in Charlottesville is coming together. The slogan “Stronger than Hate” absolutely rings true during these sessions.

Doing community service once a month (1-2 hour/weekend) is easy for me, because I’m doing what I’ve been trained to do. I just spoke with one of my team members who had struggled to find a babysitter for her 3-year-old to attend these sessions; I asked her to bring her daughter along (if she was comfortable), and shared how my initial impressions were founded as a child owing to my parents’ vision. So we might have a toddler provide some child laughter therapy at the next session. FBI4health has seamlessly incorporated into my daily life, without having to take a week or a month off or make trips abroad. It’s really not a lot of time that I’m expending now — there was more effort up front, but now it is running as a well-oiled system. However, I periodically remind myself to make sure I don’t overcommit and underdeliver.

Is there anything else you’d like to add?

Earlier this year, a clinical trial was published that demonstrated a similar effort with blood pressure screening, but in a barbershop setting. The study showed that health promotion by barbers resulted in blood pressure reduction.1 Therefore, I think this is a movement that will keep gaining traction. Going to an area where people are comfortable has helped increase value and impact, versus having a health fair where patients come to us. Another study illustrated reduction in hypertension in a similar church-based setting.² 

We recently came up on our first anniversary after starting the program on November 1st, 2017. This has been a genuine learning experience along the way, and a very dynamic process. It’s heartwarming to see how pharmacists, nurses, nurse practitioners, and young MDs have joined the initiative. I really hope people can take charge of similar healthcare team-led efforts in communities.

For more information, please contact Dr. Mehta on Twitter at: @Nishaki1

References

1. Victor RG, Lynch K, Li N, et al. A cluster-randomized trial of blood-pressure reduction in black barbershops. N Engl J Med. 2018;378;1291-1301. 
2. Schoenthaler AM, Lancaster KJ, Chaplin W, Butler M, Forsyth J, Ogedegbe G. Cluster Randomized Clinical Trial of FAITH (Faith-Based Approaches in the Treatment of Hypertension) in Blacks. Circ Cardiovasc Qual Outcomes. 2018;11(10):e004691.