Our colleagues at MEDICC, Medical Education Cooperation with Cuba, have been very busy over the past several months and it seemed time for an update about their activities:
Nineteen US students graduate from ELAM (The Latin American School of Medicine)
This year is the 7th in which US students have graduated from ELAM; Dr. Cedric Edwards was the first US graduate in 2005. Readers who would like to know more about ELAM should consult Don Fitz’s article published in the March Monthly Review entitled The Latin American School of Medicine Today. This article goes over both the strengths and challenges of study in Cuba.
MEDICC support for US students studying at ELAM
The process of picking US students for scholarships is managed by IFCo/Pastors for Peace. MEDICC, through its MD Pipeline to Community Service program has been playing a key role in helping these students make their transition back to clinical practice in the US. This has involved financial assistance in the form of form of MNISI fellowships that allow students to prepare for and take their US licensing board examinations. The fellowships are vital to make sure that ELAM graduates get positions in US residency programs and do well in those positions. But MEDICC has also developed a mentorship program to give ELAM students practice working in US clinical settings.
If you would be interested in donating, $100 will defray the costs of US exam fees and prep courses; $250 will allow students to prepare for their US board exams with 1,000 online practice questions; and $750 will pay the full cost of one US Medical Licensing Exam.
Would you like to become a mentor?
MEDICC is looking for US health care professionals who would be willing to mentor ELAM students. I personally have mentored several and found them to be a bright and highly motivated group anxious to demonstrate their history and physical examination skills (in fluent Spanish). MEDICC’s Rachel True is responsible for the mentorship program and writes: ”As the cohort of US ELAM students continues to grow, so does our need for mentors all over the country. We are currently looking for more mentors in the following areas of the country: Atlanta, Washington, D.C., Texas, Southern states (AL, MS, LA), Chicago, Los Angeles, and the Midwest (MN, ND, MI). If you have any colleagues or friends who might be interested, please let them know about our program and put them in touch with me. If you would like me to provide you with a brief description of the program, I would be happy to do so.”
Achieving Universal Health Care: A New Issue of MEDICC/Review
MEDICC Review, the International Journal of Cuban Health and Medicine, published its most recent issue in July; the issue is entitled Achieving Universal Health Care and contains articles from Colombia, Brazil, Ecuador, Cuba, Vietnam, Ethiopia, and Nigeria. The full table of contents is given below. I was particularly interested in an update on medical schools who were seeking to be socially accountable (i.e. to train graduates who met the health needs of their countries, Roundtable: Revisiting Innovative Leaders in Medical Education) and a brief description of changes to the Ecuadorean health system (Sumak Kawsay: Ecuador Builds a New Health Paradigm). Following a new 2008 constitution health in Ecuador has been declared a right and discussion is underway about how build a care system built on sumak kawsay, a Quecha phrase translated as collective well-being. This idea has been related to the concept of sustainable development as well as the Brazilian formulation of collective health (the Brazilian form of social medicine).
Finally, some collective well-being captured on the streets of Havana
For those of you who don’t speak Spanish, these are the “rappers of the third age”, i.e. geriatric rappers. The lead singer informs us that she has” five children, 11 grandchildren, five great-grandchildren and nothing stops me from singing and dancing.”
What is the cutting edge in Social Medicine in 2011, at least in the Bronx?
The 18 social medicine projects completed by the 2011 graduates of Residency Program in Social Medicine offer one perspective. These projects cover a wide variety of topics; three were conducted internationally (Quito Ecuador; Andhra Pradesh, India; and Rwanda). Among the questions addressed were:
1) Are medical schools and residency programs accountable to the broader society?
2) Does the promotion of Zumba dance in the clinic improve the health of diabetics?
3) What are the barriers to reproductive health care among homeless adolescents living in shelters?
4) What is a social medicine doctor?
The abstracts published below represent work by residents in Social Pediatrics, Family Medicine, and Social Internal Medicine/Primary Care. The actual presentations were made during Social Medicine Rounds on May 24, May 31 and June 7, 2011.
Molly Broder, MD, Laura Polizzi, MD, MPH & Ravi Saksena, MDAssessing Sources and Knowledge of Reproductive Health in 14-21 year-olds in the Bronx
The objectives of this study are to obtain information about where teenagers receive their information about sexual health topics, to obtain information about the use of the internet/social networking, and to evaluate adolescent knowledge concerning reproductive health. Male and female adolescents between the ages of 14 and 21 were recruited from two urban clinics in the Bronx. They were asked to complete an anonymous survey which included basic demographic information, internet availability, a knowledge assessment, and questions assessing sources of information and their usefulness. Participants were also asked specifics about websites/social networking resources utilized. Responses to survey questions were tabulated in Excel and descriptive statistics were calculated.
One-hundred and eighty-nine adolescents were surveyed during their clinic visits. The median percent correct on knowledge questions was 64.7%. The most common sources were medical professionals (93%), mothers (85%), friends (86%) and the internet (83%). Information provided by medical professionals was seen as the most useful (92%) followed by mom (81%), boy/girlfriend (79%) and the internet (73%). The most common websites used were Google (74%), Yahoo (26%), and Wikipedia (26%). The top four search terms were sex, condoms, birth control, and HIV.
Elizabeth N. Alt, MD, MPHImplementing Group well child visits as part of a Patient Centered Medical Home at the Family Health CenterTraditionally well-child care occurs with individual providers, either family physicians or pediatricians. Studies suggest that group visits with patients in certain chronic disease management and prenatal care groups can improve overall health and well being, compared to individual visits.
To assess the potential of group visits in comparison to individual visits, a Centering Parenting Model of group well-child care was implemented at a Federally Qualified Health Center in an urban primary care setting designated as Patient-Centered Medical Home.
Study participants are parent-baby dyads and are established patients at the Family Health Center. Centering Parenting groups consisting of 5-10 pairs meet at predefined routine well-child visits to receive routine well baby care in a group setting.
The purpose of this project is to provide group well child care as an alternative to individual provider care with the hope of improving quality outcomes and parent satisfaction.
Cedric Edwards, MDThe Effectiveness of a Mobile Cervical Cancer Screening Program in Andhra Pradesh, India
Background: Cervical cancer is a completely preventable disease. Yet 470,000 new cases of cervical cancer are diagnosed each year and 300,000 women die annually worldwide. The overwhelming majority of these cervical cancer cases occur in the developing world. Pap smears are the main screening test for cervical cancer but many developing countries lack the infrastructure to perform pap smears. To address this need for cervical cancer screening in the developing world, the medical organization Prevention International: No Cervical Cancer (PINCC) developed a mobile service which screens for precancerous cervical cells using direct visual inspection of the cervix with acetic acid (VIA) and immediately removes suspected lesions in a single visit using either cryotherapy or LEEP. This study aims to evaluate the effectiveness of PINCC’s mobile cervical cancer screening program in Andhra Pradesh, India.
Methods: For 12 days in August and in December 2009, PINCC went to a different village each day in Andhra Pradesh, India. Mobile cervical screening using VIA was performed on non-pregnant, non-menstruating women between the ages of 23 and 75 who did not have signs of vaginitis. Pap smears were often performed for VIA-negative lesions, or if the squamocolumnar junction (SCJ) was not fully visualized because it extended into the cervical os. Biopsies were taken of VIA-positive lesions. Cryotherapy was performed if VIA-positive lesions covered less than 75% of the cervix and there was adequate visualization of the SCJ. Women with VIA-positive lesions covering >75% of the cervix received LEEP. PINCC referred all women suspected of having cervical cancer to the local hospital, based on the screening VIA results and biopsy. These women did not undergo cryotherapy or LEEP treatment.
Results: PINCC screened 623 women for cervical cancer during the 24 days that they were in Andhra Pradesh, India. Cervical samples from only 543 women were used in this study since there were missing data for 80 screened patients. Of the 543 women screened, 431 were VIA-negative and 112 were VIA positive. The VIA-negative group included 391 completely normal cervical screening after adequate visualization of the SCJ and 40 women who had to undergo pap smears for inadequate visualization of the SCJ. Precancerous cervical cells were found in 3 of 40 pap smears. Of the 112 participants with positive VIA lesions, 21% had cryotherapy, 27% had LEEP, and 45% were biopsied only without treatment due to either a non-functional cryotherapy or LEEP. Squamous cell carcinoma was found in 1.3% of the screened women. Of all the 112 VIA-positive lesions seen, biopsies found cancer or precancerous cells in 53 women, for a positive predictive value of 47%.
Conclusions: In 24 days, PINCC effectively screened 543 women with the low-cost method of VIA and immediately treated them with cryotherapy or LEEP. The PPV of VIA to detect precancerous cells was similar to other studies involving VIA. Further measures need to be taken to reduce the number of samples with missing data and to ensure operational equipment. A mobile “see and treat” model is a feasible method to address the high cervical cancer rates in the developing world.
Ross MacDonald, MD:Montefiore Transitions Clinic: Reaching the Recently Incarcerated
The Montefiore Transitions Clinic (TC) was established to provide access to primary care, mental health services and social services for recently incarcerated adults. In July, 2009, we established a TC for recently incarcerated adults through partnership with Bronx Parole Board and The Osborne Association, a local prisoner advocacy community based organization (CBO). Initially, referrals to TC were primarily from parole officers and the overall burden of chronic illness was low. Here we report on the impact of a community health worker (CHW) on patient recruitment and disease severity.
To evaluate the impact of the referral source on the disease prevalence seen at TC, we performed a retrospective chart review comparing patients seen before and after the CHW was hired. Data was available for the first 39 TC patients, of whom 38 were referred by the Parole Committee, and the 30 most recent TC patients, 29 of whom were referred by the CBO through the CHW. Our primary measure of interest is prevalence of chronic disease in TC patients, including HIV, hepatitis C, mental illness, opioid dependence and diabetes. Secondary measures include time from correctional facility release to first clinic visit and insurance status.
With the assistance of a CHW, the TC has reached a population of former inmates with a higher burden of chronic illness. Referrals from a CBO, coordinated by a community health worker, identified a population with a high prevalence of chronic diseases including HIV, hepatitis C, mental illness and opioid dependence. system of facilitated referrals, along with access to health centers where barriers to care are minimized, can help bridge gaps in care for the formerly incarcerated population.
Shwetha Iyer, MD:Improving Resident Counseling Competence: Implementing and Evaluating the Impact of a 5A’s skills-based obesity curriculum
Needs and Objectives: Although weight loss can lead to a reduction in diabetes and hypertension and improve health outcomes, only 42% of obese U.S. adults report that their physicians have counseled them about weight loss. Even when weight loss is advised, most physicians do not discuss specific weight loss strategies, indicating that the quality of counseling may be poor. To address this gap, we adapted, implemented, and conducted a pilot evaluation of a previously developed theory-based obesity counseling curriculum for residents using a 5A’s behavioral change model. In this model, residents are trained to assess obesity risk, agree on mutual goals, advise a weight-control program, assist in establishing appropriate intervention, and arrange for follow-up. The objective of our evaluation was to determine the feasibility and impact of a novel obesity counseling curriculum, which incorporates training and practice in obesity counseling skills, on residents’ self-assessed competency in obesity counseling.
Setting and Participants: Our target audience was 28 interns and residents in the Primary Care/Social Internal Medicine Residency Program at Montefiore Medical Center, Bronx, New York.
Description: The curriculum was delivered 4 times over a 6 month period to groups of 5 to 10 residents during ambulatory medicine blocks. One week prior to curriculum participation, residents completed a previously validated survey with 9 items measuring self-assessed obesity counseling competence, based on the 5A’s model. Each question used a 4-point likert scale. The 3-hour 5A’s Obesity Curriculum included a 2-hour didactic and discussion session on the epidemiology of obesity, 5A’s obesity counseling framework and practical tools for its implementation. Case-based discussions of treatment modalities included behavior change, medication, and surgical options for weight loss. The final hour involved reviewing motivational interviewing (MI) and practicing with a standardized patient. Two months after participation, residents completed a post-intervention survey, and gave general feedback. Preliminary analyses compared median scores before and after curriculum participation using the Wilcoxin test.
Evaluation: To date, 16 residents have completed the curriculum and surveys, with another 10 scheduled to participate. Residents reported their counseling competence in: 1) assessing patients’ stage of change, 2) diet and 3) current level of physical activity; 4) agreeing on mutual goals for weight loss; 5) assisting patients in goal setting for weight loss; 6) responding to patients’ questions about behavior change; 7) offering medication and 8 ) surgical weight loss options; and 9) using MI techniques to change behavior. After the curriculum, there was a significant increase in the median scores from 2 to 3 (2=somewhat able to perform, 3=able to perform adequately) in residents’ report of assessing stage of change, assisting in goal setting, discussing treatment options and using MI techniques. There were no differences in the remaining domains. On qualitative questions, residents reported a high degree of satisfaction with the curriculum and requested additional skills practice sessions in MI.
Discussion: We developed and implemented a novel curriculum for residents to address strategies for weight loss using the 5A’s behavior change model, which incorporated obesity counseling skills practice. Preliminary pre and post curricular analyses showed improvements in several areas of residents’ obesity counseling competence. Implementing this three hour curriculum in a residency program was feasible. Post curricular questionnaires indicated that residents were satisfied with the curriculum, and were eager for additional sessions for continued practice and refinement of obesity counseling using MI skills. Further evaluation, with additional learners, and direct observation of counseling skills is needed to fully elucidate the impact of the curriculum in promoting effective obesity counseling skills.
Preetha Iyengar, MD:Effectiveness of a Brief Health Education Intervention to Address Chronic Malnutrition in Quito, Ecuador
Chronic malnutrition is associated with childhood mortality and affects up to a quarter of children in Ecuador. In southern Quito, lack of knowledge and poor diet diversification are contributing factors. Existing research has shown health education is a critical component in influencing behavioral changes and local collaborators, such as the Ecuadorian Ministry of Health and community physicians, have identified health education as an area that merits further investigation in their patient population. Hence, the objective of our study was to assess the effectiveness of a health education intervention given at a government-run clinic in Quito, Ecuador.
A 20-minute workshop and pictogram handouts were developed to provide education on the effects of protein malnutrition and highlight locally available protein sources. The workshop was offered daily over a 4-week period and the handout was distributed to a subset of patients after the workshop. Oral questionnaires were developed to assess protein nutrition knowledge, confidence in participant’s own knowledge, and protein intake pre- and post-workshop and at home visits three weeks later. A total of 98 participants completed pre- and post-workshop questionnaires and 57 completed home visit questionnaires. We found that knowledge and confidence increased after protein education workshops with retention at home visits. The utilization of pictogram handouts in educational sessions improved protein intake. These findings support continuing to work with Ecuadorian collaborators to further develop one-time, concise educational interventions to improve dietary behavior.
Anjani Reddy, MD: Exploring GME Social Accountability
[This presentation won the Daniel Leicht Social Medicine Award and the Chairman's Research Award.]
Purpose: Seen as a public good, graduate medical education (GME) was financed by Medicare 1965, expecting that this responsibility would continue “until the community bears the cost in some other way”. Over 40 years later, Medicare is still bearing the brunt of GME financing, spending $9.5 billion last year. Many have suggested that academic health centers have become dependent on such financing. We sought to better understand the perceived responsibility of GME institutions in addressing the needs of the nation, and the utility of and most likely methods to measure and compare the social impact of GME institutions.
Method: Eighteen informants were interviewed via semi-structured interviews done by phone and in-person. Key informants were chosen from salient national agencies/associations after developing a sampling matrix to ensure appropriate breadth of perspectives. Snowballing technique was employed, and informant interviews were continued until saturation of themes was achieved and confirmed via search for disconfirming data.
Results: Seventeen of eighteen informants noted that GME institutions have a responsibility to be socially accountable. Informants’ definitions of social accountability included: training of future physicians, addressing workforce shortages and providing service to the institution’s community. Multiple informants noted barriers to measuring social accountability, though many informants suggested possible tools for measurement of social accountability.
Conclusions: GME is largely seen as a public good, and multiple informants noted that recipients of GME funding should be responsible to their communities. However, time constraints, financial limitations, and curriculum overload limit GME institutions’ ability to be socially accountable. Financial incentives, accreditation requirements and maintenance of mission values can address GME institutions’ responsibility to medical education, workforce shortages and community service.
Irene Hwang, MD: Development of a Longitudinal Curriculum in Correctional Health at RPSM
Prison release rates in New York City correlate directly with poverty rates, and a disproportionate number of prisoners are returning to the Bronx. Recently released individuals attempting to reintegrate into the community are among the most marginalized of populations and have grave health outcomes. RPSM residents provide care for many of these patients who are directly or indirectly impacted by incarceration. The goal of this project was to develop a longitudinal training program in correctional health for family and internal medicine residents. Methods included reviewing existing correctional health training programs, interviews with medical and academic directors, rotations and site visits to correctional facilities and transitions clinics in San Francisco and New York City.
The proposal for a longitudinal correctional health curriculum is comprised of required clinical and didactic components: Transitions Clinic sessions at FHC and CHCC during elective blocks throughout residency as the foundation; health education workshops, targeted outreach and discharge planning at Rikers Island and VCBC; buprenorphine training and case-based discussions with a substance abuse specialist; and cross-track conferences to discuss syllabus readings. Residents interviewed unanimously support a longitudinal model of learning and this proposed curriculum provides an example of a rigorous training program to meet their educational needs.
Ari Kriegsman, MD & Allison Stark, MD, MBA: A resident-driven approach to systems-based practice education and innovation at a primary care medicine ambulatory teaching clinic
Description: During the academic year 2010 – 2011 we initiated an iterative educational process to engage residents in a dialogue about SBP. An anonymous web-based survey was sent to all 19 PGY2 and 3 residents asking them how they would handle four common clinical scenarios that occur when the resident is not in clinic or between patients’ clinic visits: (1) following up of critical lab values; (2) scheduling non-routine follow-up appointments; (3) handling urgent care situations when patients call from home; and (4) titrating medications. Each scenario was derived from our clinical experience and piloted with colleagues prior to survey distribution. Results were analyzed and a set of best practices was created. At a program-wide retreat attended by approximately 25 residents and faculty we moderated a two-hour discussion on the survey results, best practices and other SBP topics identified. A second anonymous survey was sent to the same 19 residents assessing the value of monthly SBP meetings.
Evaluation: Seventy-four percent (14/19) of residents responded to the initial survey, with up to 5 solutions given for each scenario. Responses varied by the skill level of the clinic staff member asked to assist with the task, the number of phone calls, emails, and hand-offs required, and the time needed for task completion. Given the heterogeneity of responses a set of best practices, emphasizing non-physician resources, was created and disseminated. Our second survey used a 5-point Likert scale (5=Quite Valuable, 1=No Value) to quantify the value of monthly SBP discussions. One hundred percent (14/14) of responders reported that sessions would be valuables or quite valuable. We then initiated monthly discussions (60-75 minutes) during ambulatory blocks (4-8 residents/month). To date we have held two sessions. Prior to each session we solicit SBP topics and distribute a resident derived agenda. Afterwards, we email key takeaway points and post updates on our program’s searchable website.
Bonnie Stahl, MD: Routine Gonorrhea and Chlamydia Screening for Women entering Methadone Mainteance Treatment: Is it worth it?
Background: Chlamydia and gonorrhea (GC) screening in specific populations, including substance users, is recommended. Entry into methadone maintenance treatment presents an opportunity to screen a high risk population, yet the prevalence of Chlamydia and GC infection in this population has not been well-defined. To address this gap, we began to routinely offer screening to women admitted to our Bronx methadone maintenance treatment program (MMTP).
Methods: A chart review of consecutively admitted adult female patients from June 1, 2010 is underway. Using a structured chart review instrument, we abstracted sociodemographics (age, race, income), substance type, injection use, trauma and incarceration history; HIV antibody status, syphilis titer, and urine GC and Chlamydia results.
Results: Forty-nine women were entered treatment between June and December 21, 2010. Eleven (22%) self-identified as Black, 32(65%) as Hispanic. Their mean age was 40 All had heroin dependence. Thirty-one (63%) reported cocaine use. Twenty-two (45%) had injected. Eleven (22%) had experienced domestic violence and 30(61%) had been incarcerated. Nine (18%) were HIV positive, and five (10%) had serologic evidence of syphilis infection. None of the 46 (94%) women tested for GC and Chlamydia were positive.
Conclusions: Although women entering MMTP are typically considered at high risk for sexually transmitted diseases, routine testing GC and Chlamydia testing did not identify any infections. The HIV and syphilis infection rates we found warrant routine screening, but the absence of GC and Chlamydia in this population does not thus far support routine screening with drug use as a sole risk factor.
Asiya S. Tschannerl, MD, MPH, MSc: What is a Social Medicine Doctor?
Purpose: It is clear that social conditions contribute to ill health. This was described as early as the 19th century by Rudolf Virchow, generally considered the founder of social medicine. Yet, medical training continues to center on the molecular basis of disease. In efforts to create a different model of physician training, the Residency Program in Social Medicine (RPSM) of Montefiore Hospital was founded in 1970 to train a cadre of socially-minded physicians dedicated to providing care for the underserved. The RPSM is a holistic curriculum that encompasses an understanding of social problems affecting the health of individuals and communities and strategies for addressing these issues, while training in community health centers. This study investigates what encompasses a social medicine physician today, and how their practice differs from other primary care doctors.
Methods: All current residents, faculty and alumni of the Residency Program were eligible to participate in the survey, which was emailed in March 2009. A survey monkey questionnaire was used, and emailed to current department members and an alumni list-serve. The complete survey had seven items that included status (resident, faculty, or alumni); specialty (Family Medicine, Internal Medicine, Pediatrics); questions about the role of social medicine in regards to their practice, how it differs from other primary care doctors, and questions regarding the RPSM curriculum. Demographic data describing the participants was tabulated, and comments were grouped into themes and investigated via textual and qualitative analysis.
Results: The survey was completed by 173 participants. Forty-seven percent were in the field of Family Medicine, 30% in Internal Medicine, and 24% in Pediatrics. Fifty-six percent were alumni, 26% were faculty, and 21% were current residents. There were three main themes that were common to most responses, which were that social medicine doctors 1) have a broad knowledge of the social determinants of health, 2) have the ability to translate this broad knowledge of health into a specific treatment plan, and 3) promote social justice. Within each theme were various sub-themes which provided a richer description of social medicine concepts and its practice contrasted with the practice other primary care physicians.
Conclusions: Social conditions are not separate from medical conditions, an integral concept of social medicine and RPSM. Although this study was limited in that not all potential subjects responded and responses varied greatly in length and description, the concepts of social medicine are clearly central to their practice of medicine. Social medicine is thought to be valuable and essential in the treatment of individuals and communities, and an opportunity for social change. This model of medicine was viewed as fundamentally different from the practice of other primary care physicians. Further research in the practice of social medicine on patient outcomes, and perspectives of patients treated by social medicine doctors could be helpful in substantiating our findings and expanding the number of social medicine residency programs nation-wide.
Feyisara Akanki, MD & Scott Ikeda, MD, MPH:Staff perceptions of Patient Centered Medical Home implementation in two urban clinics
The Patient Centered Medical Home (PCMH) has received attention as a cost-effective way to address the myriad problems facing the US primary care system. As more practices become PCMH’s, staff must carry out this change, however their perceptions of the PCMH and the change process may not be congruent. We will compare staff opinions of the PCMH transformation at two primary care clinics in the Bronx, NY, using focus groups consisting of providers and support staff, and analyze recorded transcripts for themes. We anticipate the analysis will yield insight into perceptions of the PCMH and the capacities of the clinics to carry out their transformations that will be useful to other practices as they begin their own transformation processes.
Richard Gil, MD:Screening, brief intervention and referral to treatment (SBIRT) for opioid abuse in an urban hospitalized population: a pilot study
Numerous studies demonstrate the deleterious health outcomes associated with substance abuse and dependence. To intervene early in the course of substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been advocated by many.Few studies have examined the feasibility of or outcomes associated with conducting SBIRT in hospitalized patients. Although data regarding SBIRT for drug use has been sparse, with the rise in opioid use, abuse, and dependence, many advocate for SBIRT specifically for drug use. We sought to test the feasibility of conducting SBIRT for problematic opioid use targeting patients hospitalized on the medical wards of a large urban academic medical center.
We identified adult patients who were admitted floors of the medical wards and administered audio computer-assisted self-interviews assessing theirof problematic opioid use using the WHO ASSISTscreening tool.Patients were categorized as having no opioid use, or low, moderate, or high risk of problematic opioid use. Those who had moderate or high risk problematic opioid use received a brief computer-based intervention. We found that 42 (56.0%) reported no opioid use, 4 (5.3%) low risk, 26 (34.7%) moderate risk, and 3 (4.0%) high risk of problematic opioid use. Of the 29 patients with moderate or high risk, 19 (65.5%) were interested in referral to treatment and 27 (93.1%) reported that the brief computerized intervention was useful. We question whether our model of conducting SBIRT-with a dedicated person outside of the team delivering health care-is feasible. However, this urban inpatient population seems at significant risk thus more research is warranted on how to best use SBIRT to intervene on problematic opioid users in the inpatient setting.
Harini Kumar, MDMaking Exercise a Reality: Zumba Bronx
Zumba Bronx is a reproducible and sustainable form of dance exercise that is built on one of the strengths of an underserved community, the passion to dance. Dance aerobic exercise has been shown to improve participants’ s BMI. The 2010 ADA noted that a 5-10% decrease in weight translates into a decrease in HbA1c. The literature review indicated that successful programs for weight loss have consolidated exercise, diet, and behavior modification plans. In addition, studies have illustrated the utilization of pedometers as a useful tool to motivate diabetic patients to increase physical activity and maintain these efforts. The goal of this social medicine project is to promote physical activity for patients with diabetes at the Williamsbridge Family Practice. The study will utilize this culturally appropriate, and cost-effective form of dance exercise, Zumba, coupled with pedometers, and develop patient centered support that can be incorporated into the FHC and CHCC health centers in the future. The objective of this project is to provide diabetic patients with the tools to develop and maintain a healthy lifestyle.
Anna E. Jackson, MDRetention and Screening of Immigrant Patients in the South Bronx
The purpose of this study was to evaluate whether a dedicated immigrant health session within a larger primary care practice can achieve retention in and quality of health care for immigrants. This was a retrospective cohort study with medical record review of all new patients seen at the OPEN-IT clinic at CHCC from October 1, 2007 to September 30, 2009. The primary outcome was retention in care, defined as at least one follow-up visit within one year after the initial visit. Secondary outcomes included rates of age-appropriate cancer screenings and results of specific screening tests as recommended by the CDC for refugee populations, including Hepatitis B surface antigen, tuberculin skin test, complete blood count, and ova and parasites in stool. Results showed that 79% of patients were retained in care, with no detected difference in retention based on age, gender, length of time in US, or presence of chronic illness. Rates of mammography and cervical cancer screening were 82% and 79% respectively, but the rate of age-appropriate colorectal cancer screening was only 24%. We also found that over a quarter of patients screened had evidence of latent tuberculosis, anemia, and intestinal parasites, although our numbers were small. Our results support the need for clear recommendations regarding immigrant-specific screening. Further work needs to be done to improve rates of colorectal cancer screening within our model and to better understand which diseases need to be screened for in the immigrant population.
Justin Sanders, MD, MScMeanings in Methadone:Perceptions About Methadone Doses Among Individuals in Methadone Maintenance Treatment.
Medicines have meaning and these meanings affect both their efficacy and their perception of it. Perceptions about efficacy affect adherence to and retention in treatment. Observations by substance abuse clinicians suggest that patients in methadone maintenance treatment(MMT)hold perceptions about methadone and methadone doses that may not reflect current medical understanding about methadone, including about interactions and adverse effects. Literature about the experience of patients in MMT is sparse, and this study aims to understand the experience with and perceptions about methadone among patients in an urban methadone clinic. Individuals in substance abuse treatment are a marginalized population. It is anticipated that a better understanding of their experience in a particularly stigmatized realm of medical treatment will allow clinicians to better understand their needs, their response to treatments with potential for interaction to methadone, and thereby improve the adherence to and retention in methadone treatment.
April Wilson , MD & Lin-Fan Wang, MDPerspectives on reproductive healthcare access among homeless female adolescents living in family shelters in the Bronx
Homeless adolescents experience multiple barriers to contraceptive use and they have high rates of unintended pregnancy and poor birth outcomes. The goal is to conduct semi-structured interviews with homeless female adolescents ages 14-18 at family shelters in the Bronx and to have teen educational seminars at a homeless family shelter. Interviews include questions on demographic data and open-ended questions regarding beliefs about contraception, experiences with accessing reproductive healthcare, future plans, and specific barriers to accessing reproductive healthcare as an adolescent living in a family shelter. Teen seminars focus on pregnancy, sex, and STDs. The purpose of our study is to 1) describe the experience of unintended pregnancy, abortion, and contraceptive use; 2) identify barriers to reproductive healthcare access including contraception; and 3) describe preferences for reproductive healthcare access in homeless teens. This data will generate data for targeted changes in services.
Jason Beste, MDThe Use of Traditional Botanicals among Pregnant Women in Rwanda
A survey of pregnant Rwandan women’s use of complementary medicine.
I requested a year off from school to go to Haiti and work with the Cuban doctors after completing my 2nd semester of 3rd year at ELAM (the Latin American School of Medicine). I am one of 120 American citizens studying medicine in Cuba free of charge, with plans to practice medicine upon graduation in underserved communities of the United States and around the world.
When I arrived, I found several international ELAM graduates (http://elamedicosinternacionalistas.wordpress.com), including 7 United States graduates (http://www.michaelmoore.com/words/mike-friends-blog/cuban-trained-us-docs-complete-haiti-mission), and a number of Haitian medical students working alongside the Cuban doctors. We were stationed at a field hospital set up by the Henry Reeve Brigade of Cuban doctors on January 28th in a small central park of Croix des Bouquet, just outside Puerto Prince. Together we served displaced earthquake victims and patients suffering from inadequate health care services.
In the first six months the hospital was established, we addressed the needs of more than 70,312 patients; 53,588 at the hospital and 16,723 in the field. We performed a total of 2,506 operations on-site, with 786 major surgeries; including emergency caesarean sections, ectopic pregnancies, thyroidectomy, hernias, hydroceles, hysterectomies of uterine fibroids, orthopedic surgeries and more. We assisted 116 natural births. We diagnosed 3,533 patients with our on-site laboratory and diagnostics center. We saw 3,192 patients for x-rays and ultrasounds. We treated 8,778 patients with physical therapy, and we hospitalized 2,053 patients on-site (Information provided by the Henry Reeve Brigade of Croix des Bouquet Statistical Report, June 2010).
When you stepped out of the hospitals and into the streets the only question that came to mind had to be, “where is the aid?” It was obvious, even six months after the earthquake that little progress had been made, with little to no evidence of monetary support. Hundreds of thousands of people were still living displaced in make-shift tent cities. The city still resembled a disaster zone with buildings teetering above cracked foundations, while corpses remain beneath the rubble. The doctors seemed to be the only relief effort making a difference.
The Cuban doctors were accomplishing more than what the international community was willing to recognize. Croix des Bouquet was just one of several field hospitals established by the Henry Reeve Brigade to serve communities in and around Puerto Prince free of charge. CNN even had to apologize after interviewing one of the Cuban doctors and crediting him as Spaniard. Fortunately, Cuban doctors aren’t looking for recognition; they are out to save lives and continue to do so all over the world.
The Henry Reeve Brigade has since moved on to other emergencies, like the fires plaguing Russia. Other Cuban doctors have replaced them to continue serving the Haitian community free of charge. Brazil and Cuba have signed a trilateral accord with the Haitian Health Minister to establish three hospitals staffed by Cuban doctors located in communities surrounding Puerto Prince where health services are limited to non-existent. Cuba has been dedicated to sending doctors to Haiti for 11 years. Amidst the unfortunate circumstances of the earthquake, they continue to fulfill their commitment to the Haitian community by sending doctors. With the success of the students working alongside the doctors, they now have plans to send more students in the years to come.
Note: Article written by Joanna Mae Souers. Photograph titled, “Joanna Mae Souers on Wound Care” was taken by Cuban photographer, Juvenal Balán. The other photographs were taken by Joanna Mae Souers.
We invite medical students to apply for the second annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 10, 2011 through February 4, 2011. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can also be arranged. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).
For more information, we invite you to view the short video about this year’s course, available at:
If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.
Sincerely,
Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)
January 6th, 2010 will mark the beginning of the Albert Einstein College of Medicine student-run Social Medicine Course. This course is a unique opportunity for the Einstein students to cover “essentials of medical practice not taught in medical school.” This year’s list of speakers amply illustrates the connections between clinical practice and social activism.
The opening speaker will be Dr. Joia Mukerjee of Partners in Health who will discuss “Social Forces in Medicine.” This event will take place at 5:30 PM at the Riklis Auditorium and will be followed by a reception. Subsequent sessions will take place each Wednesday (with one exception) at the 5th floor Forchheimer Auditorium at 5;30PM. Dinner is provided. All events in this series will be listed at the top of our blog roll.
At last year’s course several local readers of the Social Medicine Portal dropped by. Please feel free to come, but write to Ms. Karp (see below) so that we can inform security.
The list of speakers and topics is as follows:
Jan 13 ∙ History of Social Medicine ∙ Matt Anderson, MD, MS.
Jan 20 ∙ LGBT Health and Community Organizing ∙ John-Paul Sanchez, MD, MPH
Jan 27 ∙ Race and Health in the Bronx ∙ Robert Fullilove, EdD
Feb 3 ∙ Harm Reduction in the Bronx: Dealing with the Hepatitis Epidemic among IV Drug Users ∙ Donald Davis
Feb 10 ∙ Motivational Interviewing and Nutrition in the Bronx ∙Yasmin Mossavar-Rahmani, PhD, RD, CDN
Feb 17 ∙ The Impact of Hep B on Pregnancy in the Asian American Community∙Tomoaki Kato, MD; Maya Gambarin-Gelwin, MD
Feb 24 ∙ Abortion Care in NYC∙Marji Gold, MD
Mar 3 ∙ Native American Health ∙ Donna Perry, MD *Price Center Auditorium
Mar 10 ∙ Separate and Unequal: Medical Apartheid ∙ Neil Calman, MD and Nisha Agarwal, JD
Mar 16* ∙ Liberation Medicine ∙Lanny Smith, MD, MPH, DTM&H *Tuesday at 7:15pm*
Mar 17 ∙ Reentry: Old Fears, New Hopes ∙Meekaelle Joseph
Mar 24 ∙ Street Medicine ∙ Jim Withers, MD
Apr 7 ∙ The History and Practice of Community Psychiatry ∙Thomas Betzler, MD
Apr 14 ∙ Nyaya Health: A Case Study in Developing a Healthcare NGO∙ Ryan Schwarz and Bijay Acharya, MD
Apr 21 ∙ Refugee and Asylee care: Human Rights for Torture Survivors ∙ Nicole Sirotin, MD
Apr 28 ∙ Ayurvedic Medicine ∙Bhaswati Bhattacharya, MD, PhD
May 5 ∙ The War on Women: Criminalization of Reproduction in the United States ∙Robert Roose, MD
For any questions or kosher meal requests, please contact Jessica Karp at jkarp@einstein.yu.edu.
Social Medicine, our open-access, online academic journal has just published its latest issue. Here is a brief summary of the articles all of which are available for free at www.socialmedicine.info and www.medicinasocial.info (in Spanish).
Children in post-Civil War Nepal singing revoutionary songs
Special Theme: Social Medicine & War
For this special theme issue on Social Medicine & War, Dr. Vic Sidel served as guest editor. His lead editorial (co-authored with Dr. Barry Levy) examines the diversion of resources to war and the preparation for war.
Quoting from their introduction to the three original research articles about war, Drs. Sidel and Levy write: ”Dr. Andrea Angulo Menasse, a researcher from Mexico City’s Autonomous University, documents the very personal story of how the violence of the Spanish Civil War affected one family. In her case study the trauma suffered by Spanish Republicans is traced through three generations and crosses the Atlantic Ocean as the family moves is exiled in Mexico. Dr. Sachin Ghimire from the Centre of Social Medicine and Community Health of the Jawaharlal Nehru University reports on his fieldwork in Rolpa, Nepal, the district from which the Nepal Civil War (also called the People’s War) originated in 1996. Based on 80 interviews, he documents the difficulties faced by health care workers as they negotiated the sometimes deadly task of remaining in communities where control alternated between Nepalese Special Forces and the Maoist rebels. Finally, Colombian researcher, Carlos Iván Pacheco Sánchez, from the University of Rosario in Bogota, brings an epidemiologist’s tools to examine the impact of the ongoing armed conflict in the border Department of Nariño. His discussion is informed by the current debate over health care in Colombia where a recent Constitutional Court decision has found that the current health care system violates the right to health.”
Closing the Gap: Where are we one year later
In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.
The Peckham Experiment
We are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The Pioneer Health Center was designed around the idea of studying (and fostering) what makes people healthy, rather than what makes them sick. Imagine that!
Please visit the journal and explore the breadth, depth and scope of social medicine past and present. Along with some suggestions for the future.
…Take a year out of med school between my third and fourth years?
…Delay residency for a year after graduation?
…Leave my practice as a physician or my retirement for a time?
In Estancia, El Salvador, a clinic in a remote, rural community needs you. To trek up mudslicked hillsides in the dusk to find a pregnant women who can´t move her limbs or a man in a hammock with a toothache run out-of-control. To think about and act upon the lack of latrines and the rampant childhood malnutrition. To face the health effects of rising food prices and strip mining projects, and to be called to speak out…
Come, work with Doctors for Global Health www.dghonline.org, a volunteer-run organization of health providers, teachers, psychologists, artists, and anyone with a mind for health, that seeks to foster a vision of Liberation Medicine through accompanying grass roots projects in Latin America and Uganda.
It is an amazing education in being a community physician, in public health, and the need for activism on the policy level. You will be challenged in your medical knowledge, but mostly in your personal sources of energy, motivation, courage, and strength. You will changed by people living in poverty who work for liberation.
For more info on this amazing international health opportunity, please visit the website for Doctors for Global Health, www.dghonline.org. If you want to talk about volunteering in Estancia or about what it’s like to break from the traditional course of medical education, feel free to contact us.
November 30th 2008, commenced the 4-day conference, “Medical Education for the 21st Century: Teaching for Health Equity,” at the National Hotel of Cuba. The conference brought together health professionals, educators, administrators and researchers from around the world to exchange the latest in socially “accountable” health education.
The opening night included an inaugural address by Dr. Roberto Gonzalez, the Vice Minister of Public Health in Cuba, and a lecture by Dr. Charles Boelen, an international consultant on health care and ex-coordinator of the World Health Organization’s (WHO) Program for Human Resources.
The turnout was impressive with 230 presenters from 29 different countries including Cuba, the Philippines, the United States, Canada, Belgium, Honduras, Chile, Ethiopia, Columbia, Iran, Egypt, Ecuador, Argentina, South Africa, Mexico, Brazil, Spain, Great Britain, Greece, Germany, Ecuador, Belgium, Switzerland, Puerto Rico, Hungary, Tanzania, Australia, Pakistan, and New Zealand.
I was amazed that 54 of the 230 presenters came from the United States, representing a plethora of institutions including the American Association of Medical Colleges (AAMC), UCSF-UC Berkley, Albert Einstein College of Medicine, Boston University, The Jay Weiss Center for Social Medicine and Health Equity of the Leonard Miller School of Medicine, George Washington University, the University of Wisconsin, and the list goes on.
As representative students of the Latin American School of Medicine (ELAM), we were very pleased to be invited as guests of the non-profit organization, MEDICC (Medical Education Cooperation with Cuba). MEDICC, one of the many sponsors, has worked closely with Cuba over the years to bring awareness to the international community the highly qualified human resources they have developed to meet the needs of the Cuban people and others around the world.
It was a wonderful opportunity for students to meet and share their experience with health care educators from around the world. Educators were mostly impressed with the student’s humanistic ideals and their well-established set stride ahead of the curve on Social Health Care.
Most of the U.S. students chose the Latin American School of Medicine not only as their first choice, but they chose it as their only choice for the program’s social, humanistic and altruistic ideals embedded in its history and carried out in its curriculum.
As a student of the Latin American School of Medicine, I am proud to represent Cuba’s thought provoking, innovative ways of approaching health education in the 21st Century. It was amazing to see so many people come together to share their ideas and show an interest in our experience. I hope that people will be further inspired to mark their experience with positive thinking and practical change.
Joanna Mae Souers
Escuela LatinoAmericana de Medicina
Carretera Panamericana
KM 3,5
Santa Fe, Playa
Ciudad de la Habana, CUBA
CP 19108
jsouers@gmail.com <mailto:jsouers@gmail.com>
There were a fair number of US citizens at the conference and we are fortunate that US Pediatrician David Keller (of UMass Medical School) has posted a day-by-day description of the conference (along with a few pictures) on his blog Rosie D and Me. He notes: “The conference is fabulous and oversubscribed (> 700 attendees), but the facility is not perfectly designed for such a number. So it is sometimes a little crowded; they didn’t make arrangements for such a number to tour hospitals and the medical school, and I was unable to get my name on the proper list to have that opportunity. Still, the atmosphere is electric. People from all over the world (I heard 22 countries, but I have no official word on who is here) are gathered to discuss the complexity of integrating social medicine (for want of a better word) into the lexicon of medical education. Each country faces challenges consistent with the way in which their health care system is designed.”
Another participant in the conference, my colleague Sherenne Simon, has posted photos of Cuba and the conference on Picasa.
One of the benefits of having US attendees in Havana was that they go to meet with the US students studying at the Latin American School of Medicine (see our posting Studying Medicine in Cuba: The Experience of Two US Students). Figuring out how to support these students in their transition back to the United States is a challenge. Medical education in Cuba is quite different from the US. However, as a group, the ELAM (Escuela Latinoamericana de Medicina) students seem highly motivated (who else would spend six years living as scholarship student in Cuba?), speak Spanish, and have a commitment to work in under-served areas on their return to the US. In some ways, they are ideal residency candidates for a US health care system that struggles to provide clinicians to many underserved communities.
One of the ELAM students provided us with a link to letters that student Ramon Alejandro Bernal has been sending back to his hometown Seattle. These are available at the website of Western Washington PNHP. ELAM has its own publication, Panorama: Cuba y Salud available at www.panorama.sld.cu. Articles have abstracts in English.
Any readers that might be interested in helping the US ELAM students out, can contact me. Their main interest is in finding clinical placements in the US during their summer breaks.
Finally, the keynote address was given by Dr. Charles Boelen, of the WHO’s Human Resources for Health Department: Entitled “Social Accountability: Medical Education’s Boldest Challenge” Dr. Boelen notes: “Until recently, the prevailing assumption was that community orientation and posting, along with problem-based learning, were adequate for medical schools to serve social needs. But now, this notion of social accountability has emerged, meriting attention worldwide, even within traditional medical circles. This concept urges medical schools to go beyond pedagogical innovations and search for optimal integration of their graduates into health systems.” This paper was published in the most recent edition of MEDICC Review which has several excellent articles on international experience in Teaching for Health Equity.
[Correction: The day of action on 11/7/1008 has been canceled. See the comment section for another upcoming Rock Dove event.]
The Rock Dove Collective, a “radical community health exchange” is organizing a day of action on 11/7/2008 to find free and low cost health clinics in New York City. The development of a comprehensive list of such clinics – available on the web – would be a great resource.
The NYC Department of Health has free clinics available for STD screening and treatment, dental care, as well as for the treatment of tuberculosis. [In our opinion the City's chest clinics provide the best TB care in New York.] Unfortunately the link to the list of all DOH clinics is down. Calling 311 might be a good place to start to see if a clinic is available for a specific problem.
There are at least three student run free clinics in the city. The Institute for Urban Family Health runs two. The ECHO clinic in the Bronx was the first medical student free clinic, set up by students at AECOM. The New York City Free Clinic in Manhattan is a project of NYU medical students In addtition, students at SUNY/Downstate have organized the Brooklyn Free Clinic.
New York City also has an extensive network of Community Health Centers which provide low cost care to people without insurance.
Free clinics are not the solution to our healthcare problems, indeed they are a symptom of the problem. And yet they also point to what might be the ethos of a national health system devoted not to profit, but to health. I would be happy for interested readers to post additional resources.
What follows is the Rock Dove announcement:
Rock Dove Day of Action!!
Health Clinics for Community Healing
Friday November 7th
10:30am – 4:00pm
Your friendly neighborhood Rock Dove Collective is calling our second Day of Action! On Friday, November 7th, volunteers will fan out across the city, visiting free and low cost health clinics and gathering information about their services from both the staff and the clients who are there receiving services. Our goal is to use this information to create comprehensive profiles of health clinics in NYC, as part of our ongoing effort to make free and low cost health services accessible to those in need.
We will meet up in downtown Manhattan at 10:30am, at a location TBA. Over breakfast and icebreakers, volunteers will receive their travel plans for the day as well as a quick training on how to gather information when visiting a clinic. Volunteers will go out in pairs and hit up 1-2 clinics before we all meet up at 4pm to decompress, share information, eat, drink, and be merry!
How to Contribute:
-Volunteer! Bring your friends! Join us as we hoof it through NYC in search of comprehensive information about free and low cost health services. If you plan on volunteering, RSVP to Freya at freyapowell@gmail.com.
-Donate! If you can’t join us the day of, please donate food and/or cash so that we can feed our volunteers breakfast and snacks, and help them
January 6th, 2010 will mark the beginning of the Albert Einstein College of Medicine student-run Social Medicine Course. This course is a unique opportunity for the Einstein students to cover “essentials of medical practice not taught in medical school.” This year’s list of speakers amply illustrates the connections between clinical practice and social activism.
In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.
We are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The 
