When Books Are the Best Medicine: Fostering Literacy in the ER

Sometimes the best thing an emergency room doctor can give a kid is a book. In a world where low-income children hear 30 million fewer words than more affluent peers, literacy’s the true life-saver. Sutures and IVs can do only so much to address the aftermath of poverty—violence, drugs and abuse—that accounts for so many ER visits.

Just ask Dr. Robin Foster, chief of pediatric emergency services at VCU Medical Center, who says she makes as much impact with social engagement as with medical intervention. Foster helped found in-hospital programs dedicated to child advocacy, youth violence prevention and literacy–all with the goal of reducing the need for emergency services by nipping issues before they reach crisis levels.

Read on to see how Foster and her colleagues promote early literacy and school readiness as a site of Reach Out and Read, a national program that integrates children’s books and parental advice into medical visits.

What attracted you to health care?

That was not always my intent. I actually thought I wanted to be a lawyer. So I started out as a government major at [College of] William & Mary. Then I went and worked in a law firm after my freshman year of college, for the summer, and it was a corporate law firm.

At that point in time, I decided that I probably needed a profession that was a little more straightforward in terms of knowing that you’re doing good. Corporate law seemed very complicated to me. People might argue something that they didn’t necessarily believe in.

So I came back and switched from being a government major to being a chemistry major at William & Mary and decided that maybe medicine would be a little bit less shades of gray about the difference between right and wrong.

Did the medical profession meet your expectations in that sense of knowing that you’re doing good?

I love my job. I love my job because at VCU—even though healthcare has changed a lot in terms of becoming much more of an industry–the bottom line at the end of the day is still, if you’re trying to do the right thing for a family, you get support not only from staff and colleagues, but from administration as well.

That’s why I’m still here. I ran away to Philadelphia to do a fellowship but came back, because I’ve always been able to pursue whatever community or advocacy project I was interested in and with the full support of my bosses, whether it be our child abuse program that we started or this literacy program or the violence prevention initiative.

Lots of these things don’t really represent revenue programs for the hospital. Instead, they end up being a cost to the hospital, or at least we have to find outside dollars for them, but I still always had the latitude to do that.

I think a lot of people think that in ER, you just kind of address whatever the acute complaint is, but we actually have this literacy program in our emergency department. That’s the first place it was, and it’s in all of our primary care clinics as well.

I think when people come into ERs, they’re in crisis, and lots of times, those crises aren’t all medical. There are social crises. By providing a lot more than just medical care, you actually not only fix the current issue, but maybe, for the long-term, prevent that kind of pattern behavior of recurrent visits.

Can you talk a little more about the crises that you see in the emergency room that aren’t always medical?

People will show up in our emergency department sometimes with very serious illnesses, but sometimes they’ll show up in the emergency department with a diaper rash or with some other complaint that’s not critical. That’s sort of a non-acute complaint.

But if you spend some time with our families, and you wonder why this mom came into the ER, and this child has had the same diaper rash for the last two weeks, and she’s got cream for it and everything–if you delve into, “What else is going in your life?” well, she just moved out of whoever her significant other’s home was. Now, they’re in a homeless shelter, and she doesn’t have her WIC [Women, Infants, Children program] to get formula for the baby.

If you spend some time with our families in the emergency department, you find out that the reason that they showed up in the ER may not be simply because of whatever the medical issue is going on with the child, but because there are a lot of other things going on that are chaotic in their homes that preclude them from normal sick visits to their pediatricians because of transportation issues or a lack of, actually, a primary care physician because they’ve lost Medicaid, or they have no insurance, or they’ve lost their job.

So I think it’s important to spend a lot of time talking not only to the parents with critically-ill children, but those who have non critically-ill children because a lot of times, there are other reasons that have really motivated them showing up to the ER setting than simply the diaper rash.

So after 25 years, I figured out: I sit down. I usually sit down lower in the room than the family. I usually sit on the ground, or I sit on the trash can. I ask them an open-ended question when they go in, and I’ll ask them what’s going on. What’s going on that you decided to come visit us today?

I’ve worked here for 20-some years. So we actually know a lot of the families. I know people really don’t think that there’s continuity of care [in the ER]. But in our patient population, between those children that have complex medical issues and those families that don’t have other resources, I would say I probably know at least 50% of the families that show up in our emergency department.

Wow.

So if you are respectful of them and offer other resources, and they know that, I think that ends up being a huge win for that child, because you’re going to prevent other more significant things that may be medical or may be otherwise, social and medical.

We just tried to spend a lot of time identifying kind of what do our families need to be more successful. So it became very clear that most of these kids don’t have books in their homes and that would be a great thing to offer families.

I think that a lot of our parents weren’t very successful in school and were very frustrated by the school system. Being able to educate them about the importance of literacy and how it will affect their children’s success in school changes the whole dynamic sometimes.

So for an example, we start giving books out when kids are about six months of age. That’s what the Reach Out and Read [hospital literacy program] model is. Our model actually gives books to children of all ages, but in terms of the Reach Out and Read model, I’ll go in and hand a book to a young mom for her baby. The baby will grab the book and put it in its mouth because that’s the way they explore their world. Right?

Then the mom will go, “Oh, you’re bad,” and she’ll smack the book or smack the child and say, “Don’t chew on that book.”

I’m like, “No, that’s great. Your baby is brilliant if they’re chewing on it because that’s how they explore their world. If you keep working with them with these books until they get into kindergarten, by the time they get into kindergarten, they’re going to be the smartest kid in their class.”

The mom will sort of look at me like, “I don’t really buy that.”

I’ll say, “Because if you show up at kindergarten, and you’ve never seen a book before, you’re already going to be behind. If you start out behind, you stay behind. But if you go, and your child is already totally comfortable with the book and how to turn the pages and how to recognize words, then they’re going to start out at the head of their class, and they’re going to stay at the head of their class because they’ve already got that advantage.”

“So all you have to do is let them chew on the book now, turn the pages and start reading to them, and eventually they’re going to get it before they ever start kindergarten. Then you’re not going to have to worry about anything because they’re going to be supporting you. They’re going to be so successful. They’ll be some kind of professional. It’s going to be great.”

Then the next time you go back in the room, that mom is reading to that baby, because I think they realize, “Okay, I wasn’t very successful in school, and it was very frustrating, and I started out behind and never had a chance to catch up.” So I think they realize that maybe that’s why, maybe because nobody was reading to me.

So I think giving them that opportunity for their child to be successful then increases their investment in that child, in terms of all things, in terms of seeking appropriate health care, providing a safe environment for the baby. One of the studies in Reach Out and Read shows that the program doesn’t only improve receptive and expressive vocabulary in kids. It improves those families’ compliance with their well-child checks.

Your site’s a bit unique among Reach Out and Read sites because you don’t conduct regularly scheduled well-child visits.

Right. We give books out to everybody that shows up here. The Reach Out and Read books are for six months to five years of age, but we still provide counseling in terms of the importance of literacy. A lot of our nurses are very invested. In fact, I’ve raced one of our nurses, Bonnie, who’s been here for 30-some years, into the room to see who can get the book to the child first.

So a lot of staff is very invested in talking to families about the importance of reading to their kids out loud. We have volunteers in the emergency department. We have a lot of undergraduate students either from VCU, some from the University of Richmond. So they’ll model behavior about how to read to kids.

A lot of times, their parents don’t know exactly how to read to their kids or feel uncomfortable doing so, and the kid may be two or three years old and running circles around them. They get frustrated with that.

We try to provide parallel readers to kind of show them if the two-year-old is running around, it’s okay. You can still point out pictures and words, and they don’t have to sit next to you, and they don’t have to be still the whole time for them to still benefit from that.

We’ve tried to emulate, to the letter, the whole model of Reach Out and Read in the emergency department. Like I said, unfortunately, even though we’ve gotten a lot more resources in healthcare with the new healthcare system, a lot of people still use the ED for a lot of primary care-related issues.

A lot of our families that come into the ED are really higher-risk than those who attend primary care offices. It’s a population that has even more to gain by being exposed to [Reach out and Read] than the traditional primary care setting.

Talk about the staff investment in talking to parents about books. Is that something that just emerges through seeing you and some of the nurses? It just sort of catches? Or do you do proactive training and development?

There is training. There’s a little video, and I’m a trainer for Reach Out and Read. I do it every year for the new residents.

I think it’s infectious. I think Reach Out and Read doesn’t only make that family happy and the child happy. It makes you, the provider, happier, because we do a lot of very invasive things to kids in the ED, IVs and suturing, lots of procedures that the child is not always thrilled [about]. So it’s nice to be able to kind of wear the other hat as an ED provider, to not only fix whatever’s broken, but to actually go in then and provide them with this bright, new, shiny, developmentally appropriate, culturally appropriate book that makes the whole family beam.

It’s infectious. People start doing it because they see us doing it, and then it becomes very habit-forming because it feels good. It feels like you’re doing the right thing because you realize that you’re making a big difference in this kid’s life.

There are lots of studies about Reach Out and Read that objectively look at the true science of it. But I have an anecdotal story about Reach Out and Read and how much it affects families. I tutor kids at George Mason Elementary School through my church, but I have one kid a year. So one year, I’m assigned this little boy who’s a first-grader named Chauncey. In October, I go and pick him up out of his classroom, and his teacher said, “Chauncey doesn’t know how to read at all. He needs work on sounding out consonants and vowels and word recognition.”

So I take him to the library, and I said, “Chauncey, how many books do you have at your house?” He said, “I have one book.” I said, “Well, what book is that?” He goes, “It’s ‘Where the Wild Things Are,’” and I’m thinking, we give a lot of those away because the Scholastic catalog has it at a very discounted price, and it’s a great book for little boys.

He said, “I named my dog Max after the little boy in the book.” I said, “That’s great. Chauncey, where did you get that book from?”

He goes, “From my doctor at MCV.”

I said, “That’s where I work.”

What are the chances that the one kid that I’m tutoring in the city this year, the only book that he owns in his house is from the Reach Out and Read program here?

So every week after that, I bring Chauncey a book. Chauncey was one of four boys in his family. He was the oldest and his mom was very young. At the end of the year, his mom comes to an ice cream social that the elementary school had at the end of the year to wrap up.

She said, “Are you the person that’s been bringing Chauncey all these books?”

Because–not just because of my hour with him; they had a lot of other programs that were helping him with reading–he could read anything by the end of that year. He would sound out a word if he didn’t know it. He’s reading these really long primers. He’s great. He’s totally caught up.

I said, “Yes, ma’am, because there’s a literacy program at VCU.” She said, “Well, I just want to tell you, Chauncey makes us all read.” She goes, “We used to put Gameboys in the car whenever we were going somewhere, but Chauncey insists that it’s books now. All of his brothers are reading.”

She said, “To be honest with you, I never used to read, and I read now, too.” What that told me is that not only did that affect change in that single child, but it basically affected change amongst his entire family, in terms of what value they place on literacy now and how that will affect her job opportunities or what she pursues in life, much less all of his brothers.

That anecdotal story, to me, was worth far more than all the great objective studies that have come out of Boston Medical Center and other academic sites that have Reach Out and Read. I like the objective studies. It’s great. It’s really important when you look for nonprofit funding. But why my staff and I are excited about the program and why we have sustained it through thick and thin since 1997, regardless of what federal funding is available, is because it makes a difference, a huge difference.

Medical care is a great thing, and it does a lot for these kids, but the kind of change [reading brings] in their lives is just immeasurable. It makes you excited about doing what you do.

Question: Other than the ER room, where else in the community would you love to see this kind of support for early literacy?