Archive for May 10th, 2008

Social Medicine Rounds 2007

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Ernie DruckerJanuary 16: 4:30-6pm

Binswanger Auditorium

Ernie Drucker, PhD

“A Plague of Prisons –

The Epidemiology of Mass Incarceration”

America is now in the 30th year of a great epidemic – one of the most devastating in our nations history. It has already stolen more years of life from Americans than Yellow Fever or Cholera did in the 19th century or AIDS in the 20th. But unlike these afflictions, this epidemic is not caused by a deadly new virus or bacteria. It is self inflicted – the result of deliberate social policies. Hundreds of federal and state laws mandate it and the expenditure of a great fortune have financed it – more than $1 trillion in public funds over its 30-year course. This great American epidemic is mass incarceration – a plague of prisons.

Today there are millions of Americans behind bars – over 10 times the number we had 30 years ago – fueled by millions of arrests of the war on drugs, long mandatory prison sentences, and high rates of recidivism. The famous revolving door of the system puts 67% of re-entering prisoners back inside within 3 years of their release. Even a decade after drug use and crime declined sharply (reaching historic lows in 2005) the progression of epidemic incarceration is relentless – in 2006 there were over 1000 additional inmates put in prison each week, reaching 2,700,000 by Jan 1, 2007. Yet, despite its vast scale and profound effects on the lives of tens of millions of American families, this epidemic goes largely unrecognized. Indeed, for most Americans, massive imprisonment is not seen as a problem at all.

Mass incarceration in America disproportionately affects minorities. Only 1% of the country’s white adult male population is in the criminal justice system; but for blacks and Hispanics the figure is 13 %. In most big cities, 50% of all the African American males have been incarcerated in their lifetimes – in Washington DC the figure is over 85%. For the hundred years from the end of slavery to the 1970s, blacks were incarcerated at 3 – 4 times the rate of whites. Today that ratio is 12 to 1; for drug offenses it is 40 to 1 – despite evidence that blacks use illegal drugs at the same rate as whites

And this epidemic has another “hidden” face – an even larger population, none of whom are in prison, but who are powerfully affected – the “collateral damage” of mass incarceration. Tens of millions of children, wives, parents, siblings and other family members of those incarcerated over the course of the 30 year epidemic of incarceration. They are concentrated in the mostly urban minority communities targeted for mass arrests, and while innocent of any crime, they are also punished by the effects of incarceration, just as surely as if they were convicted. In this 30 year epidemic over 25 million American children have been directly exposed to parental incarceration. They are the “innocent” victims of the war on drugs – the children of the “feeder communities” where the epidemic of incarceration affects everyone – more damaging even then the drugs and other crimes that are the rationale for the arrests. In these communities incarceration has become the norm – spawning successive generations of prison orphans and gang members. Over 90% of all the extended black and Hispanic families in the US must by now have had a member incarcerated in the last 30 years.

This presentation will paint an epidemiological portrait of this great plague. The goal is to focus on the scale, structure, and effects of large-scale imprisonment – seen as a public health problem – with measures of disease, disability, and the loss of life that all epidemics bring with them – the closest thing we have to universal measure of human worth. I will also talk about some of the people and programs that are the “plague fighters” – individuals and organizations who are fighting mass imprisonment and beginning to turn the tide of this terrible epidemic.

Note: Mass Imprisonment was also discussed by Robin Steinberg of Bronx Defenders during Social Medicine Rounds of May 2, 2006

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February 6:

Residency Program in Social Medicine

3rd Floor Conference Room

4:30-6:00 PM

Megan Charlop, MPH and David Appel, MD,

Montefiore’s School Health Program:

A Unique Model of Primary Care

The Montefiore School Health Program is the largest school-based health program of its kind in the country, with more than 13,000 children registered in 13 schools in the Bronx – five elementary, one K-8, two middle and five high schools.

All Montefiore school-based health centers provide comprehensive primary care services. The program has a particular interest in improved asthma care. Mental health services focusing on depression, anxiety, bereavement, crisis intervention and family issues are available at each site.

The high school centers offer comprehensive adolescent health care including reproductive health care services that provide pregnancy testing and prenatal care; options counseling; family planning; screening, diagnosis and treatment of sexually transmitted diseases including HIV counseling and testing; and routine pap tests for sexually active girls. A mobile oral health program visits each elementary and middle school program, providing preventive care as well as minor reparative work.

Dr. David Appel was designated one of New York Magazine’s most “Influentials”of 2006. Dr. Appel has been one of the most visible faces and audible voices advocating for children’s access to quality, comprehensive primary care and mental health services in school-based settings. For more information on Dr. Appel, click here. For a brochure about the program, click here.Some articles describing the program are available at the following links:Burden of Asthma in Inner-city Elementary Schoolchildren: Do School-Based Health Centers Make a Difference? Arch Pediatr Adolesc Med. 2003;157:125-129. Impact of Asthma Intervention in Two Elementary School-Based Health Centers in the Bronx, New York City. Pediatric Pulmonology 40:487–493 (2005)

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February 27

4:30-6PM

Rounds in the Community:

Visit to the Ahmadiyya Community Center

Muslim Law and Culture

in the Doctor-Patient Relationship

Imam I.H. Kauser and Dr. Shaded Ahmad will discuss issues related to the medical treatment of Islamic patients. A Halal meal will be served by Imam Kauser’s congregation following the presentation. The Ahmadiyya Community Center is located at 3421 White Plains Road (between a gas station and law offices). This event is a chance to explore many questions related to our practices in the treatment of Muslim patients such as:

1. What is relevant culture/law/expectations regarding female/male dress/undress and touch during physical examinations?

2. What is relevant law during Ramadan and any other designated time in Islam regarding fasting, the taking of medications, water for people who may be frail and dehydrated, etc.

3. What is the advisable way for a physician to greet/say goodbye/wish good health, etc. to an Islamic patient?

4. Are there cultural and/or family issues we should be aware of related to recent immigrants from Bangladesh/West Africa of Muslim faith?

This Social Medicine Rounds was featured in an article in the New York Times
by Clyde Haberman published on March 6, 2007 entitled: “At Mosque, Doctors’ Ways Get an Update”:

“As the city’s population continues to change, pretty much everyone must come to grips sooner or later with new realities. Exceptions are
few. They most definitely do not include doctors.

“And that is why about 20 attending physicians and residents at Montefiore Medical Center found themselves in a small mosque in the
Bronx the other evening. With not a Muslim in the bunch, they were there for a quickie course on how Islamic law and customs can affect
patient-doctor relationships — from womb to tomb, with much of life’s messiness in between. […]”

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March 6: Global Health Month

Residency Program in Social Medicine

3rd Floor Conference Room

4:30-6:00 PM

Viewing of the Film “Salud!”

Produced and directed by Academy Award nominee Connie Field, the film tells the story of Cuba’s unique and highly effective health system and how it brings its community-oriented and preventive model to medically under-served nations in other parts of the world. The film also takes viewers inside the Latin American School of Medicine (ELAM) in Havana where 12,000 low income students from 27 countries-including about 100 from the USA-receive a free education in exchange for pledging to return to poor communities when they graduate. In this school, as in all other medical schools in Cuba, the goal of the curriculum is to produce doctors committed to public service. The film probes the motivations of the students attending ELAM and traces the opinions and competing agendas that mark the battle for better global health. For more information visit the Film’s website.

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March 20: Global Health Month

Residency Program

in Social Medicine,4:30-6PM

3rd Floor Conference Room

Darin Portnoy, MD, MPH

Medical Humanitarian Aid Organizations:

Present Crises and Future Challenges

Doctors without Borders (www.msf.org) is the world’s largest medical humanitarian aid organization, working in over 70 countries bringing direct medical assistance to populations in need. In more than 30 years of work this group has worked to alleviate suffering and to speak out often and strongly for those that have no voice.

Much has changed since the organization was founded, and humanitarian aid workers now routinely arrive to work in extremely complicated and politically charged environments. Hundreds of international organizations now undertake medical humanitarian work. And while this ought to translate into less need and diminished crisis around the world, this has not been the case.

Using the example of Doctors without Borders and the contexts where the organization is now active, Dr. Portnoy will explain the work of humanitarian aid organizations. In the presentation he will explain how an organization chooses where to work, how it works and how it decides when to leave a particular country. And he will discuss some of the world’s most neglected and underreported crisis and share his impressions of what organizations can expect to confront in coming years.

Dr. Portnoy is an Attending Physician, Montefiore Medical Group Family Health Center and President, Doctors Without Borders/Médecins Sans Frontières (MSF) USA. He has worked with Doctors without Borders/Medecins Sans Frontieres (MSF) for nearly 10 years and since 2004 he has been the President of the US section of MSF. He joined the organization in 1997 as a field doctor and later field coordinator for tuberculosis treatment and control programs in Uzbekistan. After an exploratory mission to Turkmenistan, in 1999, he ran cholera programs in El Salvador. He left for Georgia the following year, coordinating emergency health care for Chechen refugees. In 2003, he worked as a medical coordinator for sleeping sickness and primary health care programs in southern Sudan. And in 2004 he opened medical programs in the isolated northern part of Liberia. He was last in the field just over a year ago, in Nigeria, where he worked with a team to set up MSF’s emergency program to treat a measles outbreak.

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April 17

4:30-6PM

Moses II Conference Room

Walter Lear, MD

Pediatrician Activists

For information about Dr. Lear, please consult our posting: A Visit with Dr. Walter Lear.

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May 1: 4:30-6PM

RPSM 3rd Floor Conf. Room

“How We Get Better:

Family Medicine Residents and Practice Based Learning

and Improvement”

Convener: Victoria Gorski, MD
Presenters: Family medicine PGY-3s

This forum will feature presentations by the four resident/faculty/staff CQI teams of the Family Health Center and Williamsbridge Family Practice. Dr. Gorski will present a brief overview of CQI and its relationship to the ACGME competency “Practice Based Learning and Improvement”. Each team will present its work on behalf of improving tobacco cessation rates or improving parameters of diabetes care at the clinical sites. A discussion will follow on the implications of the teams’ work in fostering clinical quality improvement and resident learning/competency development.

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May 22, May 29th, June 5 4:30-6PM

RPSM 3rd Floor Conference Room

Social Medicine Project Presentations

Dr. Jamal Harris
Quality Improvement: HIV Testing of the Children
of Adult Patients in a HIV Treatment Program

During the summer of 2006, we conducted a quality improvement project to enhance family based care at Sinikithemba, the HIV/AIDS care program at McCord Hospital in Durban, South Africa. The project included revising the family care page with the introduction of an electronic version and a focus on the testing of children. To complete the project we conducted a retrospective chart review, staff interviews, focus groups, and staff trainings.

Dr. Manel Silva
Adolescence: At-Promise Group
Comprehensive health education as a primary prevention for HIV

Dr. Kathryn Scharbach
Development of a Pain Management Curriculum for Pediatric Residents

Inadequate treatment of pain has been a problem in children. Racial and ethnic minorities are at risk for problematic access to pain care and poor pain assessment, and often receive inferior treatment for their pain complaints. The goal of this project was to expand the “Pain Curriculum” for pediatric residents at CHAM. A survey was conducted among Pediatric Housestaff to assess: knowledge about and comfort with managing pain, perceived barriers to pain management, and preference for learning methods. Based on the results of this survey a morning lecture, two case conferences and an EBM session were created – these educational sessions were conducted in collaboration with the Pediatric Palliative Care Service and the Pediatric Pain Service. Finally, a post survey will be distributed to test the effectiveness of a pain management curriculum on improving knowledge & confidence.

Dr. Homer Venters
Bringing Primary Care to Legal Aid:
A Collaboration Between CHCC and the Bronx Defenders

Montefiore Comprehensive Health Care Clinic (CHCC) is located within one block of the Bronx Defenders, a legal aid agency that represents 12,000 criminal defense clients per year. For 2 1/2 years, we have collaborated in assessing the need for primary care services among Bronx Defenders clients. One medical resident has spent over 200 hours at Bronx Defenders helping clients with medical questions and reestablish prior medical care. For those who wish (approximately 1/3 of clients met), appointments were made at CHCC for medical care. This collaboration has joined the resources of two advocacy groups in the South Bronx with the goal of helping legal aid clients when their medical care is interrupted by arrest or other criminal justice system contact.

Dr. Sean Misciagna
My Diabetes Visit Summary: A quality improvement effort
arising from an innovative approach to diabetes as
described by the Chronic Care Model

Historically, medicine has been designed to care for acute needs, and has been poorly equipped to deal with the chronic illness that many of our patients face. Diabetes is an example of this. In order to achieve quality care and improved outcomes, the Chronic Care Model was developed. My Diabetes Visit Summary is an example of a quality improvement effort that supports this model.

Drs. Melissa Tesher and Sarah Siegel
Use of a pocket guide to improve resident knowledge about,
and comfort with, breastfeeding support

Breastfeeding rates are generally lower in poor, urban communities. We evaluated knowledge about, and confidence with, breastfeeding guidance amongst residence physicians serving such a community. We then sought to improve residents’ confidence and knowledge by creating a pocket-sized breastfeeding guide, and evaluated the usefulness of this educational tool.

Dr. Misha Kogan
Spirituality in Family Decision Making in End of Life Care

Purpose: To understand the role of spirituality and spiritual values in family decision making at the end of life. Methods: Researchers observed 24 family meetings between house staff and families of patients who are unable or unwilling to make decisions. Semi-structured interviews were conducted immediately after initial meetings and at set time points including post-death follow-up. Using standard qualitative methods, we examined spiritual themes and functions emerging in family meetings and follow up interviews.

Drs. Carlos Victorica and Angela Vidal
Parenting behaviors of Bronx adolescents,
and the influence of a high school based parenting class intervention on parenting stress

Parenting behaviors and stress in the adolescent parent population can account for significant risk of morbidity to neonates, and has resulted in lower amounts of infant bonding and cognitive scoring. Our original project had hoped to assess the intervention of a physician assisted parenting program at Martha Nielson High School. Unfortunately, after several setbacks, the project was re-directed as a program in “responsible sexuality” at Marble Hill High School for International Studies. The new goals were to qualitatively assess some of the attitudes and beliefs of these adolescents with regards to STD’s, HIV, pregnancy and their management by physicians.

Drs. Ana Matos and Denise Reyes
Voluntary Counseling and Testing
and the HIV Partner Notification Project in Guatemala

The Guatemalan Health Law mandates a system for notification of partners of HIV-positive patients. This project followed in the footsteps of former resident Dr. Amy Miglani and was under the guidance of Dr. Matt Anderson. It included the feasibility of beginning a partner notification system in Guatemala and the pilot of a pre- and post-voluntary counseling and testing questionnaire to assess risk factors, effectiveness, and risk behavior change in patients presenting for HIV testing.

Dr. William B Jordan
HIV Prevention in a Community Mental Health Setting

HIV prevalence is high in the south Bronx and higher among those with chronic mental illness. Past HIV prevention classes for

community-dwelling populations with chronic mental illness demonstrated persistent effects on knowledge and behavior. No programs of this kind exist in the Bronx. This project attempted to demonstrate the feasibility of an HIV prevention workshop for people with chronic mental illness in the south Bronx. Retention rates were improved with incentives. Recruiting new students was challenging. Survey results trended towards improvement in knowledge and self-efficacy, but the sample size was too small for formal analysis.

Elizabeth Natal, MD
Patient-Physician Perceptions regarding Breastfeeding Counseling at Montefiore’s Family Medicine Community Health Centers

A study looking at what both physicians and patients believe is being done with regards to breastfeeding counseling at the clinics. An important focus of the study was to identify the key periods when patients were making decisions regarding infant feeding practices and the associated influencing factors. Another focus was to identify areas where we can mainstream efforts to continue current successful practices, as well as make overall improvements in less approached areas. The study is a quantitative retrospective study and data was collected through one time patient and physician surveys.

Aaron Fox, MD
Perceptions of health and housing
in an unstably housed HIV infected population

HIV-infected individuals, particularly those with unstable housing situations, have difficulty maintaining adequate access to health care. 14 semi-structured interviews were conducted with HIV-infected residents of single room occupancy (SRO) hotels in New York City. The interviews established detailed timelines related to housing status and health care following HIV diagnosis. For most individuals, diagnosis of HIV was followed by a period of chaos, which often included loss of housing, escalating drug use, and worsening self-care behaviors. Competing priorities negatively affected health care. The need for housing resulted in frequent moves, which disrupted continuity of medical care, and food insecurity impeded adherence with medications. Ultimately, when considering health care for HIV-infected marginalized populations, housing must be addressed as a vital component.

Rupali Kotwal-Doshi , MD
An Intimate Partner Violence Educational Program For Medical Residents

Primary care physicians frequently report feeling unprepared and uncomfortable with intimate partner violence (IPV), leading to low rates of screening and detection. To improve screening rates and comfort levels with IPV, a longitudinal, three-level educational intervention for internal medicine residents about IPV screening and management was developed and implemented. Data from the baseline questionnaire about knowledge, attitudes, and behavior about IPV will be presented, as well as follow-up data from the PGY-3 residents who participated in the first session. Overall, we detected low rates of screening and low levels of comfort with management of IPV among the study participants.

Catherine DeGood, DO
Abortion in Primary Care

A Needs Assessment Survey of Female Patients. A descriptive survey to assess the acceptability and desirability of early abortion provision at a residency-based family medicine office.

Carolyn Chu, MD
Social Medicine In Practice

Development of complementary audiovisual materials for “Social Medicine”, a new online journal devoted to the promotion of social medicine. (www.socialmedicine.info).

Dr. David Herszenson
Health care proxies in the outpatient setting:
Needs assessment and intervention

As our population ages and our ability to prolong life increases, it has become more and more important that those who treat adults in a primary care setting have discussions about advance directives. The health care proxy, the agent who makes decisions on behalf of the patient who is otherwise unable, is considered by many to be the most important component of one’s advance directives. This project includes an assessment and intervention at one of Montefiore’s outpatient clinics in regards to discussion and completion of the health care proxy.

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June 19, 4:30-6PM

Binswanger Auditorium

BCHN: Bronx Community Health Network

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July 3

RPSM goes to the Movies:

SiCKO

Clearview

Bronxville Cinema

Web sites related to the film:

Michael Moore’s official website for the movie is located at MichaelMoore.com

Physicians for a National Health Program created a website devoted to SiCKO which is available at www.sickocure.org.

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Amy Goodman hosted “An Hour with Michael Moore on ‘SiCKO,’ his Trip to Cuba with 9/11 Rescue Workers, the Removal of Private Healthcare Companies & the Healthcare Policies of the 2008 Democratic Candidates” on Democracy Now: www.democracynow.org.

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July 17:

Judy Sheridan-Gonzalez, RN (NYSNA)

Peter Barland, MD (PNHP)

SiCKO:
A discussion forum

3rd floor, RPSM

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August 7:

Dr. Penny Grant,

Methamphetamine labs: effects on children

Binswanger Auditorium

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September 4:

Lois Uttley, MPP,

Medicine and Morality:

The Impact of Faith-based Health Restrictions

on Patients’ Rights and Access Care

Binswanger Auditorium

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September 18, 4:30-6PM:

Linda Landesman, MSW, DrPH

Steven Safyer, MD

The Berger Commission Report:

What has been its Real Impact?

Binswanger Auditorium

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October 2, 2007

4:30-6PM

Camara Jones, MD

The Impact of Racism on the Health of Our Nation

Binswanger Auditorium

Camara Phyllis Jones, MD, MPH, PhD is Research Director on Social Determinants of Health in the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

Dr. Jones is a family physician and epidemiologist whose work focuses on the impacts of racism on the health and well-being of the nation. As a methodologist, she has developed new methods for comparing full distributions of data (rather than means or proportions) in order to investigate population-level risk factors and propose population-level interventions. As a social epidemiologist, her work on “race”-associated differences in health outcomes goes beyond documenting those differences to vigorously investigating the structural causes of the differences. As a teacher, her allegories on “race” and racism illuminate topics that are otherwise difficult for many Americans to understand or discuss. She hopes through her work to initiate a national conversation on racism that will eventually lead to a National Campaign Against Racism.

Several of Dr. Jone’s papers can be downloaded here:

Levels of Racism: A Theoretic Framework and a Gardener’s Tale

“Race,” Racism, and the Practice of Epidemiology

Confronting Institutionalized Racism

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October 9, 5-6PM:

Nassim Assefi, MD

Why I left Medical Academia and
Global Health to Write Novels”

Binswanger Auditorium

Nassim Assefi (www.nassimassefi.com) is a writer and doctor specializing in women’s health and global medicine. She is the author of Aria (Harcourt, May 2007, and 5 foreign presses), an epistolary novel that explores the trajectory of maternal grief for an oncologist after the death of her only child. She has published a piece in This Side of Doctoring, an anthology of true stories by women in medicine (Sage Press, 2003). She is currently at work on her second novel, Say I Am You, set in post-conflict Afghanistan, where she was a humanitarian aid worker rebuilding health infrastructure for two years and an underground salsa teacher. She currently volunteers in the Women’s Clinic at Harborview, the county hospital affiliated with the University of Washington School of Medicine, where she was once full-time faculty and director of the abortion clinic. Nassim has now left a beloved post in academic medicine and the frontlines of international women’s health (where family planning really does save lives) to write fiction full-time. Come hear why she believes her social justice work is more effectively delivered as a writer and speaker, and why her only aspirations for medicine are now as a volunteer doc.

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October 16, 4:30-6PM:

Robert Ruben, MD

History of deaf culture

and treatment of hearing-impaired populations

Binswanger Auditorium

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November 13, 4:30-6PM:

Dr. Phuong

Health Impacts of Agent Orange

in South Vietnam

Binswanger Auditorium

To learn more about the campaign to clean up Agent Orange in Vietnam, visit the website of the Vietnam Agent Orange Relief & Responsibility Campaign. For learn about Dr. Phuong, click here.

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November 20

4:30-6PM:

Intern Orientation Project Presentation

Binswanger Auditorium

The 2007 Orientation explored the impact of violence on our clinical practices. This was done through indepth discussions of three actual cases. One involved issues of mass incarceration, the second domestic violence and the third concerned a political refugee, Victor Toro (shown above with Dr. Lanny Smith).

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December 11:

New York City Research and Improvement Networking Group (NYC RING) Convocation

Nurses’ Residence, Jacobi Medical Center

School of Social Medicine Genogram

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School of Social Medicine Genogram and Next Generation Medical Education

When Merle Cunningham MD came to visit the School of Osteopathic Medicine in Arizona (SOMA) the other day, the topic got around to the merger of two fine family lines. Merle has been active in Community Health Centers, NACHC, the National Health Service Corps, and health care access in NYC. He has been instrumental working through NACHC and Gary Cloud to help make SOMA a reality.

Forrest Lang MD was the second family line. He took his Social Medicine training to NHSC, Appalachia, East Tennesee State, and the Appalachian Preceptorship. I have the honor of being his adopted mentee. He brought me to TN and helped me to develop the ETSU Rural Fellowship, the Minifellowship, the Rural High School Career Fair, and the initial work toward the Mountain City rural site. One of the Rural Minifellows, faculty that were developing rural programs, was Tom McWilliams DO. His rural program for the Minifellowship was the revision of the Kirksville family practice preceptorship. Much “Social Medicine” type collaboration was involved in the Rural Minifellowship.

Tom McWilliams moved on to develop the first osteopathic school in Arizona at AZCOM and then the new ATSU SOMA, working back with the Kirksville folks. The preferential admissions process used was borrowed from my work which was borrowed from the various interactions with the Rural Minifellows. Tom hired me, Forrest Lang’s mentee, to come to Arizona to help develop this new school. Tom also shares NHSC background and helped recruit Barb Doty who helped found the Alaska FP training program that has top rates of underserved graduates in CHC And Native Consortia practice locations (about 43%). The Minifellowship, like the School of Social Medicine, helped keep ideals and ideas alive to translate them into action.

The School of Osteopathic Medicine of Arizona works with CHCs to funnel in applicants familiar with work with the underserved. SOMA admits medical students with a top priority on service orientation. The top priority is a match to the mission of returning them to CHC locations as long term primary care physicians. After one year at Mesa AZ, the medical students depart Mesa for sites from Hawaii to Brooklyn. The first class will begin in Brooklyn at Sunset Park in a few months. One of the faculty hired here at the same time was a lab tech at Sunset Park, Noel Carrasco, MD. who later did research, U Autonoma De Guadalajara, Neonatology, and Complementary and Alternative work with Andrew Weil.

Just wanted you to know that some epidemics are worth spreading and the School of Social Medicine is one of the best vectors.

When the new medical students arrive at Sunset Park, might just be worth “completing” their training where it began.

Robert C. Bowman, M.D.
rcbowman@atsu.edu




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