Archive for the 'Residency Program in Social Medicine' Category

RPSM on Fox Business News (?!!?)

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A number of RPSM faculty and residents recently participated in a 6/21/2012 Fox Business News program about health care reform entitled: Is Obamacare a Good Law? During the program RPSM resident Dr. Manisha Sharma debated John C. Goodman. Here is the video:

Here is a brief description of the evening by Dr. Dan O’Connell:

RPSM on FOX (?!!?)

In an expected turn of events I was recruited by a bunch of Family Medicine residents to join them cheering Manisha Sharma PGY2 FP-Social Medicine, who was invited to debate the Affordable Care Act (Obamacare) deep inside the FOX BUSINESS NETWORK lair on “Stossel”.

Eight RPSM residents and a few other Docs for the 99% were in the studio audience supporting Manisha to “Occupy Fox” .

RPSMers in studio audience (and in fox-themed photo below): Hima Ekhanadam, Janel L’Oficial (and fiance Andrew), Rachelle Darout, Manisha Sharma, Sophia Lee, Roona Ray, Will DeWitt, Dan OConnell, and Shuchin Shukla.For those who don’t know, FOX BUSINESS NETWORK functions as a cross between a cable business channel and a minor league for Fox News Network, (which is by far the highest rated cable news channel, approximately twice that of MSNBC and the CNNs.  FBN has maybe 1/10th FNN’s ratings.

The episode  featured a surgeon who thought Obamacare would bring armageddon (or something like that) , 2 small business people who thought Obamacare would bring the collapse of the global economy (or something), John Stossels libertarian philosophy that if sick people have to pay cash for care instead of insurance companies or government,  we’ll save money because they’ll buy less health care, and a debate between economist John Goodman PhD, and Manisha Sharma MD on the merits of Obamacare.
Questioners from the audience during Q and A included Shuchin Shukla, Roona Ray, and Dan O’Connell.  Q and A respondants included the Libertarian host, the Right-Wing Think Tank Economist, the Conservative Small Business spokesperson against Manisha, who clearly knew her stuff (that’s 3-to-1, for those keeping score at home)
Posted by: Matt Anderson, MD

Cutting edge Social Medicine 2011: Resident Projects from the RPSM

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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, MD
Assessing 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, MPH
Implementing Group well child visits as part of a Patient Centered Medical Home at the Family Health Center
 
Traditionally 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, MD
The 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, MD
Making 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, MD
Retention 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, MSc
Meanings 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, MD
Perspectives 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, MD
The Use of Traditional Botanicals among Pregnant Women in Rwanda

 A survey of pregnant Rwandan women’s use of complementary medicine.

 

PHM activist Dr. Ravi Narayan @ Liberation Medicine Course

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On Friday, October 8, Dr. Ravi Narayan of the People’s Health Movement visited the Bronx to talk about his work; he spoke as part of the Liberation Medicine Course run by Dr. Lanny Smith. The talk took place in Dr. Smith’s apartment where some 30 students and health activists gathered to hear Dr. Narayan. Food was provided by Dr. Mario Chavero, a visiting psychiatrist from Rosario, Argentina.

Participants in the Liberation Medicine Course. Dr. Narayan in black Tshirt.

Dr. Narayan began by noting that this was his second trip to the Bronx. He had spoken to students at Albert Einstein College of Medicine in 2003 when he and his wife, Thelma, had presented at the GHEC conference in New York. He was here now as adviser to the Obama Administration’s Inter-Faith Initiative and also to consult with PAHO about community health. He seemed a bit bemused by the fact he had been invited to work on faith-based topics, but learned he had been chosen because of his work (see below) in getting several religious groups in India to work together.

Dr. Narayan told us he represents a collective of people still enthusiastic about the goal of Health for All.

Medical Training and Work in Refugee Camps

Dr. Narayan is a physician and graduated from medical school in Bangalore in 1971. After graduation and “quite by accident” he went to work in refugee camps along the border with Eastern Pakistan (now Bangladesh). As background, he told us that there were nine million refugees who walked across border into India because of a rampage by the Pakistani Army. Their sole crime was to participate in a democratic election. In this election the East Pakistanis (the majority in Pakistan) had voted for their own leader; in principle he was to become the Prime Minister. The West Pakistanis objected and sent the army to East Pakistan. The refugees walked across the border into western India where the government set up some thousand camps. A liberation struggle developed in East Pakistan which would eventually become the independent state of Bangladesh.  Seven to eight months after this exodus, the refugees returned home.

The experience of working in the camps caused a paradigm shift in his thinking. Were it not for this paradigm shift, he might have ended up on the east coast of the US, the goal of many well-educated Indian physicians. In fact, he noted with a wry smile, during this trip to the US he had been meeting with many of his old medical school classmates. Instead of coming to the US, however, he had been transformed by the “very human experience” of being a doctor working with a community. He had learned to listen, to see patients as participants in their own lives, to consider mental health, and to look at the social context of health. He had been exposed to a series of experiences – genocide, rape – which had been absent from the medical school curriculum. He was challenged to look at social, political, economic determinants that he learned very little about in medical school.

After working in the camps, he returned to the medical college and specialized in public health and preventive medicine. These were, he noted, the only specialties that would allow him to continue to work with people in the community as opposed to working in the hospital or outpatient clinic. He would later get a public health degree from the London School of Tropical Medicine and Hygiene and do further studies at the All-India Medical School (“India’s Johns Hopkins”).

Teaching Community Medicine

For 10 years he had taught in the St. John’s Medical School Department of Community Medicine trying to replicate for students his experience in the community of the camps. He found lots of support from young doctors who had been involved in natural disasters and been transformed by “the moving experience” of working with a community. His wife, Thelma, had this type of experience when she worked doing disaster relief. While he  described teaching this course as “10 years of great fun”, there were problems. The Department worked in five clusters of villages and they kept coming across problems, such as caste and gender, which were not medical. It was frustrating for the faculty not to be able to offer students “solutions” to these problems. Dr. Narayan cited a specific example. They used growth charts (called the “Road to Health”) to detect malnutrition in children. Over time it became clear that the children of dalits, the lowest case group, always had third degree malnutrition. “No matter what you did” it proved impossible to improve their nutritional status. The biomedical tools just did not work. They tried community-based interventions; he had attempted to organize unions. But this was a dangerous activity and he had been accused of being a Marxist. At the time, he said, he didn’t know what this meant, but he had read up on Marxism subsequently.

The faculty was frustrated and disturbed by the failure of biomedical solutions. They realized over time that medical schools always limited in their analysis to the biomedical part of problem and this led, inevitably, to a technical solution (usually a drug or vaccine).  Even when a social determinant was apparent, physicians kept it out of their thinking. After all, dealing with determinants was not taught in medical schools. They were also concerned that although they started each course with a definition of health, in the end the curriculum was entirely about ill-being. Finally, they were bothered by medicine’s orientation towards individual problems with no appreciation of collective responses.

Foundation of SOCHARA

In 1984 Dr. Narayan and three other members of the department left the medical school (“this symbolized our walking out of the biomedical model”) and established the Community Health Cell, SOCHARA. Other faculty would join them later. Rather than dealing with health problems, they wanted to work with people interested in wellbeing. They did not want to work with dispensaries, hospitals or drugs.  Rather, the wanted to work on health, wellbeing, and social determinants; they are not so concerned with medical problems.

Their focus shifted from doctors and nurses and they began to work with farmers, teachers, women, and street children. By 1990 SOCHARA was busy. It had grown by word of mouth and they were very happy doing this sort of work. They purposely avoided an academic institutional affiliation and they did not start any programs of their own. Rather they helped people to form their own networks.

But by 1990 they became increasingly aware of how decisions made in Delhi and elsewhere (he mentioned Washington) were affecting them. Malnutrition in Bangalore began to increase because millet was no long available cheaply on the local market; it was being exported. Development did not seem relevant to the people in the area, rather it benefitted other people who lived someplace else. The example of millet export showed how agricultural policy was relevant to malnutrition. They set out to study economics and social conditions.  SOCHARA by this time had an extensive network of alumni and contacts, so when they came across something they did not understand, they found a colleague who was an expert. Sometimes what they learned made sense and sometimes it didn’t. They often felt that the social sciences helped to understand what was going on, but didn’t provide tools to make things better.

In 1992 India accepted a World Bank’s Structural Adjustment Program and made significant cuts in social benefits. The result was to further polarize society. Bangalore, Dr. Narayan’s home, was now the most globalized city in the world. The expression “to be Bangalored” meant to have your job moved to India. Around his family home you could find all major multinationals within walking distance. But whereas 400 million Indians were now living in the globalized world (“I can eat McDonald’s or Kentucky Friend Chicken and wear Nike shoes”), 800 million Indians “don’t even get the basics.” There are two Indias now.

People’s Health Movement in India

By 1999 SOCHARA had come to feel the need for a countervailing power which could speak truth to power from the bottom up. This was the impetus for the formation of the People’s Health Movement in India. During its history SOCHARA had worked with 18 large networks and in 2000 they called them together in a meeting in Hydrabad. It was a diverse group which included Marxists, Gandhians, and Christians. Five representatives of each network assembled on April 7th 2000, divided themselves into working groups, and produced “five little books.” These book examined what globalization had done to health, to primary health care, and to basic needs. The content of the books was then converted into popular formats (cartoons, songs) and used to mobilize some 300 communities. In December 2000, some 2500 people packed into four trains and came to Calcutta for first national People’s Health Assembly; this launched the national PHM of India.

As an interesting side note, Dr. Narayan briefly discussed the armed resistance to British colonial rule. He noted that although we, as Americans, would be surely surprised to hear this, it was not Gandhi who had forced the English out. Rather the English left because large sections of the army had deserted (to join the armed resistance) and the country had become ungovernable. “As a result, we went from one group of Brahmins [i.e. the British], to another and the revolution was incomplete.” He sees this failure as the reason that 1/3 of India is currently under a Maoist insurgency and they (like many other progressives) are often accused of being Maoists.

Formation of an international People’s Health Movement

“Of course, internationally we were not alone.” Similar initiatives had been going on in a number of countries and in December 2000 a meeting was held in Savar, Bangladesh which founded the international PHM.  The resultant People’s Health Charter went beyond Alma Ata. He is in love with the charter: “2 pages of problems and 6 pages on how to fix it.”

Speaking of PHM, Dr. Narayan noted: “It’s a movement, you can’t pay to join it.” The work of the People’s Health Movement has evolved into four main activities: 1) the development of country circles which range from a few people who communicate by list serves to large national organizations with state and district level committees (India), 2) the publication of  Global Health Watch every five years, 3) holding of International Peoples Health Universities, 7-10 day training programs for activists from around the world, and 4) the organization of  the international  People’s Health Assembly every five years.

After 10 years of existence, he felt that PHM is now getting to be well known. Many articles have been published about PHM or by PHM members. Discussion of PHM now appears in textbooks of global health. PHM has been described as the “globalization of health solidarity from below” a description he feels is apt. He now devotes his energies to talking to students in public health and challenges them that: “If your professors aren’t teaching you about PHM, perhaps they are dinosaurs.”

Questions from the Students

“You make it sound easy, but surely there were difficulties.” Dr. Narayan noted that he had offered us just a ‘short story’ about their work, and that yes, it was a challenge and a struggle. They had been victims of political persecution. But he also noted that one of the largest challenges was to change what is inside of ourselves. They have a fellowship program (Community Health Learning Program) which is a six week experience of the movement. Two weeks are spent at SOCHARA and there are two additional two week placements elsewhere. This fellowship allows people to become familiar with their work. Their principles for selecting people are two. They only take people who are confused; “if you’re not confused, you don’t need us to teach you.” They also feel that you can’t be part of the solution unless you realize you are part of the problem. Fellows, for example, need to unlearn professional biases. “You need to see every person as a participant.” But he also stressed the importance of professionals sharing their knowledge (to demystify things) as well as accepting that other people had expertise that they did not. There needs to “eyeball to eyeball” communication, i.e. communication between equals.

“How did SOCARA succeed in getting diverse groups to work together?” Dr. Narayan addressed this question by pointing to some of the traps into which organizations fall. The first was elite capture which occurs when an elite group (perhaps the academics) takes over an organization and other groups are marginalized. There was ideological capture in which different groups competed to see who was the most left.  He feels it is important to ask: “Is this policy pro-people or pro-market?” Finally, there was individual capture in which a charismatic person takes over the organization.

“How did you get paid when you worked at SOCHARA?” First, they had to accept that they wouldn’t earn as much they would in other areas. Second, they don’t require people to be full time; there are many degrees of participation in SOCHARA. Salaried staff were actually quite few. When he was the PHM global coordinator, the movement only had four salaried people in the entire world.

Two other speakers followed Dr. Narayan. Samuel Mwenda Rukunga,  from PHM Kenya, discussed their work providing health care and advocacy in the context of religious health care institutions.  Manoj Kurian MD, Program Executive of  Health and Healing, World Council of Churchs discussed how religious faith informed his advocacy for health for all.

Interested readers may also want to look at our interview with Dr. Narayan published in 2005 in Social Medicine.

Posted by Matt Anderson

2010 RPSM Social Medicine Projects

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All graduating residents from the Residency Program in Social Medicine complete a social medicine project. This year’s graduates presented their  projects during Social Medicine Rounds on May 25,  June 1, and June 8, 2010.  What follows are the project abstracts:

Drs. Viraj Patel, Vanessa Pratomo, Rahul Wadke, Insung Min, Dana Schonberg and Humberto Jimenez

Adamma Mba-Jonas, MD
Exploring Concomitant Acceptance of Seasonal and H1N1 Influenza Vaccine

The purpose of this study was to explore patient willingness to accept influenza vaccinations during the 2009-2010 influenza season, which was unique due to the concomitant H1N1 pandemic.  It is well documented that many patients, particularly minorities and those of lower socioeconomic status, routinely do not receive seasonal influenza vaccine. This card study sought to investigate patient’s attitudes towards and uptake of the seasonal and H1N1 vaccines, and to determine whether patients acceptance of seasonal influenza vaccination was in some way altered this past season by concerns about H1N1.

Cameron Page, MD
Are Internal Medicine Doctors Serving Our Patients’ Reproductive Health Needs? A cross-sectional survey of the reproductive health needs and preferences of women in an urban Internal Medicine clinic.

Celia Quinn, MD, MPH
Breastfeeding Support in Pediatric Practices

The objective of this project was to identify specific breastfeeding challenges among the CHCC clinic population with the aim to improve educational materials and breastfeeding support in the outpatient setting.  A qualitative study utilizing focus groups and semi-structured interviews was designed to elicit thoughts about breastfeeding support in the hospital, at home, and in the clinic.  Analysis revealed that a key theme was interest in educational materials specific to situation and culture. Participants preferred materials explaining problems they had experienced (e.g., sore nipples). They expressed enthusiasm for scenes of cultural familiarity. Women described lack of support for breastfeeding in the hospital, at home, and in the community. Availability of formula in the hospital contributed to early supplementation. Additionally, lack of understanding among family members about the frequency of breastfeeding was identified as a barrier in the home. Participants also expressed a perceived disapproval with public breastfeeding as a barrier within the community.

Women who choose to breastfeed weigh perceived benefits against the difficulties they face, often with little support. Improving support in the outpatient setting requires messages that acknowledge these challenges and help families to find ways to address them. Materials for breastfeeding promotion should exhibit cultural variety and address specific challenges. Development of educational materials targeting family members should be considered. Qualitative methods can serve to elicit additional information for quality improvement in breastfeeding educational materials.

Margo D. Simon, MD
“PGY-What?”  Towards an integrated residency program in family medicine and psychiatry

People living with mental illness have substantially higher rates of other illnesses, including chronic disease, substance abuse, and HIV/AIDS, as well as poorer health outcomes.  They are among the most marginalized not only within in society at large, but also within our healthcare system.  Obstacles to accessing care in an increasingly specialized and fragmented system are often insurmountable, especially for those with psychosocially disordered lives.  Because of the sociological overlap of these healthcare needs, integration of services benefits not only those with “triple diagnosis,” but also the many living under the complex conditions of urban poverty in the U.S.  Under these conditions where mental health, socioeconomic status, and health outcomes are intimately intertwined, a family practitioner-psychiatrist offers ease of access to multiple integrated levels of care and a uniquely trusted relationship, which are essential to maximize health outcomes and minimize health disparities.  Yet, too few combined residency programs exist to train physicians to address the complex needs of people living with co-morbid medical and mental illness, none of which are in major metropolitan areas.  Therefore, a 5-year training curriculum that independently fulfills the ACGME requirements for each family medicine and psychiatry residency program was developed in an urban, underserved, academic medical center setting.  This case study examined the feasibility, strengths and limitations of such a primary care-based integrated residency curriculum.

Humberto Jimenez, MD
Will existing recommendations to improve LGBT patient comfort be applicable in diverse health centers? Thoughts from the MSM population at Family Health Center–a needs assessment.

The objective of the project was to assess the level of LGBT patient comfort at Family Health Center and identify areas of improvement.  Since the recommendations published from the Gay and Lesbian Medial Association was extracted from work at Fenway, Mass., at an exclusively LGBT clinic, the applicability of such recommendations is questionable.  We sought to extract ideas from our patients about which of these strategies might work at FHC and asked them about other ways LGBT patient comfort could be improved. Patients were key informants identified by FHC providers.

Viraj Patel, MD
A Community Based Health Needs assessment of Bangladeshi Immigrants in the Bronx

South Asian immigrants, and particularly Bangladeshi immigrants in the Bronx is a rapidly growing community. The limited data that exists on this community show high rates of cardiovascular disease. However, little else is known about the health needs of this population. To address this lack of information and address the health and social concerns of this group through a social justice platform,  we formed a community-academic partnership (Westchester Square Partnership). Community Health Promoters have been recruited and trained to help administer a variety of programs. They have also conducted a community mapping project and a health needs assessment. The project continues to grow and more programs are being developed to address the needs of this community

Vanessa Pratomo, MD
Conceptualizing patient centered care in the context of social medicine

This was a qualitative study looking at how family medicine residents  conceptualize their practice of patient centered care, learned patient  centered care and view the relationship between patient centered care  and social medicine. This study consisted of interviews of nine RPSM  family medicine residents from the class of 2009.  In identifying  common themes, we hoped to identify areas for future study, better  understand how residents learn to be patient centered, and discover  possibilities for improving the psychosocial curriculum.

Rahul Wadke, MD
Psychosocial barriers to care in patients with diabetic foot ulcers.

Patients with diabetic foot ulcers have identifiable psychosocial barriers to care that delay initial presentation and impede treatment adherence. The study aims (using  qualitative analysis of patient narratives) to identify barriers to care from psychological, educational, social, disability-related, and financial sources and to explore the perceived role of health care providers in overcoming those barriers.

InSung Min, MD & Dana Schonberg, MD
Introducing Training in Correctional Health to Residents

This project aimed to expand correctional health training in medical education. A card study performed at a number of Montefiore clinics found that a significant portion of our patients and communities were involved with the criminal justice system. Involvement in the criminal justice system is associated with numerous complex medical and psychosocial issues yet traditional medical education fails to adequately train health professionals to work with this population.

In response, we conducted a literature review of existing training programs in correctional health. This was followed by the creation of a Marginalized Populations Elective during which residents rotate through the intake center of Riker’s Jail. The final part of the project took steps towards creating a standard national curriculum in correctional health to train health professionals to effectively treat those involved in the criminal justice system.

Mary Foote, MD
Medical Advocacy for Immigrant Detainees

For my project I performed medical reviews for clients being held in immigration detention facilities.  Clients were referred by a lawyer for a medical record review to address various issues pertaining to the medical care that clients had received while in detention.  Reviews were performed for various reasons including: 1) to help assess and improve care pertaining to a specific medical complaint. 2) to assess cases for potential medical parole. 3) to review cases to determine the causes of poor outcomes.  Upon review of the records, a summary was compiled with a focus on potential issues with medical management and included a summary of accepted standard of care for the given condition.  The client and lawyer were then able to use the summary as a tool to advocate for improved medical care within the immigration detention system.

Joy Hao, MD
Patient Characteristics Associated with Physician-Delivered Smoking Cessation Counseling in a South Bronx Community Clinic

This study seeks to determine patient-level characteristics associated with the receipt of smoking cessation counseling at CHCC, and to evaluate whether patients’ beliefs and attitudes regarding the importance and efficacy of smoking cessation counseling are associated with receipt of smoking cessation counseling.

Stephanie Lovinsky, MD
Managing Pediatric Asthma Medications: The Transition from ED to Clinic Care

Two projects developed from related concerns. Are our children receiving treatment for chronic symptoms of asthma in the face of an acute exacerbation in the ED?  And if so, how is that information reaching the primary care providers? I performed a retrospective chart review of patients evaluated in the pediatric ED for asthma and quantified controller medication prescriptions. I then designed an Asthma Health Passport to bridge the gap between providers in the ED and primary care clinics.

Victoria Mayer, MD
A Community-based partnership for residency education in obesity and nutrition

The obesity epidemic in the United States is disproportionately prevalent in indigent communities, where access to healthy food is problematic. For resident physicians to become effective in reducing this health disparity, they must develop culturally competent knowledge and skills to address obesity and nutrition.  We have developed a partnership between a community organization, the South Bronx Food Cooperative, and our primary care residency program with the goals of supporting a local effort to improve access to healthy food while fulfilling a need to train residents in nutrition and obesity.

Lysette Ramos, MD
Nonresident Fathers and Fatherhood: A Needs Assessment

Research has shown that a father’s involvement in a child’s life impacts every domain in their functioning, from birth through adolescence.  However, 24 million children in the United States (34 percent) do not live with their biological father.  In 2000, the Bronx was one of the five counties in the US with the highest percentage of single mother households (> 30%). This trend has been more pronounced for African American children, with 50% living in single mother homes in 2007. This study’s objective was to obtain data on the parenting experience of nonresident fathers by exploring their perceived roles, learning processes, challenges, and supports.

A qualitative study was undertaken using semi-structured interviews (n=5) with nonresident fathers recruited from CHCC and a focus group (n=11) with a community organization in the Bronx that serves nonresident fathers. Themes identified are presented to increase awareness of the unique challenges and perspectives of nonresident fatherhood in order to provide appropriate education, support, and anticipatory guidance.

Jennifer Reckrey, MD
Surrogate Decision Making:  Residents’ Perspectives

There is a substantial literature about what it is like for health care proxies, families, and other surrogates to make health care decisions. Less is known, however, about what residents bring to the table.  What do residents experience as they try to help surrogates make decisions?  How do they learn to do this? What do they think their role in the process should be, and how do they decide when to give surrogates recommendations or advice?

To explore these questions, I conducted 45 minute semi-structured interviews with second and third year family medicine residents at Montefiore, Jamaica, and Beth Israel hospitals.  Interviews were transcribed, a coding scheme was developed, and these codes were applied to all interviews.  Preliminary analysis of the data suggests that residents receive little formal education about how to help surrogates make decisions despite the significant emotional burden of these interactions.  Residents adopt a broad range of roles when interacting with surrogates, including advice-giving.  Yet residents uniformly express concern that recommendations may negatively impact patient and surrogate autonomy.  This concern adds to the emotional burden of the interactions.

Miriam Shiferaw, MD
Global Health Training in Pediatric Residency: Interest, Needs and Barriers to Participation

I performed a cross-sectional survey of the pediatric residents at the Children’s Hospital at Montefiore to assess residents’ previous global health experiences, satisfaction level with their current global health training, interest in having increased exposure to global health education and also their perceived barriers to participating in an international global health elective.  The goal of this project is to use the needs assessment as a framework to inform the development of a global health curriculum for the pediatric residents over the next two years.

Marianna Borkovskaya Shimelfarb, MD & Guido Grasso-Knight, MD, MPH
Taking a Step Towards a Healthier Workplace

As part of our Departmental Social Medicine Project we drafted a survey to assess physical activity among Montefiore employees and also provider views on healthy lifestyle. We made the survey available online through “surveymonkey.com” and through notices in the Montefiore Bulletin. Our goal is to contribute to the broader efforts to improve the healthiness of our workplace for our staff and patients.

Melissa Berlin, MD & Lisa Lapman, MD
Zumba: The Effect of Dance on Quality of Life in Community Dwelling Seniors in the Bronx

Our project investigated the effects of dance on quality of life and vitality in seniors. At the RAIN Senior Center, we taught a 12 week Zumba class (a Salsa Dance Exercise class) and conducted pre and post-class surveys using the Vitality Plus Scale (VPS) and a modified version of the SF36. We also collected demographic data and followed attendance rates. Although our study design did not have enough power to achieve statistical significance, we did find a definite trend towards improvement in the VPS. We hope that this data can be utilized in a larger study to quantify the effects of Zumba on Vitality in Seniors in the Bronx.

RPSM @ the Unity Walk for Health Care Reform in Times Square

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hcrally01

Credit: Casperr of the Daily Kos

spaceballLast Saturday (8/29/2009) at least 3000 people (according to police estimates) gathered in Times Square for the Unity Walk in support of health care reform.   Montefiore Residency Program in Social Medicine resident, Cameron Page, and graduates Oni Blackstock, Karen Wang, Manel Silva, Bill Jordan, David Herszenson, Giliane Joseph, and Jonathan Arend all played a large role in organizing the event.  There were dozens of students from Einstein, Mt. Sinai, and other NY medical schools.

Here is a list of some of the news coverage of the event:

Dr. Herzenson wrote to us that: “This is a cause that is close to my heart, and unfortunately, there has been a lot of misinformation out there about the current proposals.  This site offers an insightful article on what reform means for those who already have insurance: (click here).   This site debunks a lot of the myths that have been spread: (click here).  Finally, if you want to get more involved, even just by writing an e-mail to your legislator or putting a sign in your window, go to http://www.healthcareforamericanow.org/ This is an umbrella organization that is out there fighting the fight.”

The RPSM participants are all involved with the National Physicians Alliance.  The webpage for their local (New York City) NPA group is http://npany.blogspot.com/ Their next meeting will be on Wed, Sept 9th at 7:30 pm, location: TBD

posted by Matt Anderson, MD

2009 Social Medicine Projects

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Below is a listing of the Social Medicine Projects (with their abstracts) for the 2009 graduating class of the Residency Program in Social Medicine at Montefiore Medical Center:

Eleanor Bathory, MD and Sharyn Miskovitz, MD: Perceptions about Exercise among Inner-City Adolescent Girls

Funded by a Community Access to Child Health (CATCH) grant, we conducted three focus groups at the South Bronx High School to determine the perceptions about exercise among inner-city adolescent girls.  We recruited female high school students to participate in one of three 60-minute focus groups of 10-11 students each.  Our objectives were to understand the perceptions of adolescent girls regarding their involvement in exercise, benefits of exercise, barriers to exercise, and factors that would motivate them to participate in an exercise program.   The adolescent girls who participated in the focus groups recognized important psychological benefits of exercise and offered critical information on barriers and motivating factors.  Based on these results we held three sample exercise classes (step aerobics, kickboxing, and double-dutch jump rope) and asked the participants to complete a survey after each class.  The participants enjoyed all of the exercise classes and were enthusiastic to participate in an after-school exercise program.

R. Max Dyksterhouse, MS, MD: Routine opt-out HIV testing in an urban community center

Undiagnosed HIV infection remains a significant public health problem.  To address this, the Centers for Disease Control and Prevention revised testing recommendations, calling for routine opt-out HIV screening among adults in health care settings. We examined acceptability of opt-out HIV testing in an urban community health center and factors associated with accepting testing.

Sadiqa Edmonds-Myles, MD: The Impact of Mass Incarceration on Children

The term “Mass Incarceration” has been used to describe extraordinarily high incarceration rates seen in working class communities of color. Despite an estimate of 1.5 to 2 million children affected by parental incarceration, little is known about how mass incarceration affects the health of children or the practice of primary care pediatrics. Previous studies have shown various psychosocial effects of parental incarceration, including PTSD, ADHD, depression, and attachment disorders; however very few have evaluated the breadth of patients in low income urban areas affected by this issue, or the effect of mass incarceration on the health care of children. I participated in two related studies to further evaluate these issues.

The first study was completed during Social Medicine Orientation, and involved a joint effort by Department of Family & Social Medicine residents and faculty to assess the prevalence of arrest and incarceration in patients attending primary care clinics in the Bronx.  A card study was completed during a 2.5 week period. 118 cards were completed; one third of which were with parents of pediatric patients.  18% of patients (or parents) currently had a family member in jail. 25% reported having been arrested, and 51% reported they or a family member had spent time in jail. On nearly all variables rates were higher for pediatric visits than for adult visits.  Clinicians participating in the study reported positive responses to discussing incarceration.

In order to further evaluate the impact of parental incarceration on the health and health care of children, I am currently working on a qualitative study to evaluate access to a medical home among children of previously incarcerated parents.  We have conducted a focus group with the staff of Hour Children, a non-profit organization which assists incarcerated mothers with transition and reunification with their children once released from jail or prison. We are also in the process of conducting in-depth interviews with previously incarcerated mothers to learn more about the effect of incarceration on the health and health care of their children.

James A. Fausto, Jr., MD: Home- and Office-based Buprenorphine Inductions:  a qualitative study exploring patients’ experiences with initiation of opioid addiction therapy

Context: Buprenorphine, a partial opioid agonist, is effective in treating opioid dependence in primary care settings.  Initiation of buprenorphine treatment (i.e., induction) is challenging because patients typically must be in opioid withdrawal.  Although inductions have traditionally occurred in medical settings, home-based inductions have recently emerged as a new treatment strategy.  No studies have examined patientsâ   experiences with buprenorphine inductions.
Objective: To explore patientsâ   experiences with buprenorphine induction.

Design:  This qualitative study used semistructured interviews of patients who underwent buprenorphine induction.  Interviews were digitally recorded and professionally transcribed.  A coding scheme was developed to capture key themes.  Each encounter was coded independently by two of three investigators; coded data were entered into NVivo 8® to retrieve thematically-related text.

Setting: A community health center in the Bronx, NY.

Participants:  Twenty patients who underwent buprenorphine inductions (10 office-based and 10 home-based inductions).

Results:  Narrative themes included: reasons for starting treatment, social supports, health care system engagement, addiction history, and induction experience.  Many patients appreciated the anonymity provided by primary care physicians treating their opioid addiction.  All patients would recommend buprenorphine treatment to others seeking opioid addiction treatment.  Despite a lack of consensus on preferred induction site, all patients valued the potential to customize the induction process to their needs and preferences.

Conclusions: Patients identified that customizing buprenorphine inductions to their needs was important.  Incorporating patient-centered strategies with buprenorphine induction appears to be an important for buprenorphine therapy in the primary care settings. These results can help guide buprenorphine treatment in primary care settings.

Uriel Felsen, MD, MPH: High rates of clinical factors associated with advanced liver disease in patients with chronic hepatitis C at an urban methadone maintenance program

Background: Chronic hepatitis C (CHC) is a significant cause of morbidity and mortality among injection drug users. While prior studies have demonstrated a high prevalence of CHC among participants of methadone maintenance programs (MMPs), little data exist regarding the clinical factors that impact CHC morbidity and mortality in this population. Mount Sinai Medical Center’s Narcotics Rehabilitation Center (NRC) served approximately 650 patients before closing in 2007. The center offered methadone maintenance, on-site primary care and psychiatric services, and institutional linkages to CHC specialty care. The goals of this study were to elucidate: 1) the CHC-specific healthcare practices at the NRC; 2) the presence of clinical factors associated with advanced liver disease in those with CHC; 3) the presence of co-morbidities complicating or precluding CHC treatment; and 4) the number of patients who accessed CHC specialty services and were treated.

Methods: A chart review of a random sample of active patients was conducted between December 2005 and January 2006. Laboratory data collected included hepatitis C virus (HCV) antibody, HCV viral load, hepatitis A virus (HAV) and hepatitis B virus (HBV) serologies, and HIV status.  The CHC-specific healthcare practices reviewed included screening for CHC and vaccinating for HAV and HBV. Clinical factors associated with advanced liver disease included co-infection with HIV or chronic HBV (defined by a positive HBV surface antigen), alcohol abuse/dependence, and duration of infection >/= 20 years. Psychiatric co-morbidity was defined by presence of an axis I diagnosis or a psychiatric medication. Medical co-morbidities complicating or precluding CHC treatment included: malignancy, autoimmune disease, advanced liver disease, renal disease, active alcohol abuse, and other uncontrolled medical conditions. Access of CHC services included being seen by a specialist, undergoing liver biopsy, or having a history of CHC treatment.

Results: 207 charts were reviewed. 98.1% had an HCV antibody test and 99.3% of those that were positive had a confirmatory viral load. Overall, 54.6% (n=113) of participants had CHC. Of those with CHC who were non-immune to HAV, 56.6% were vaccinated for HAV; and 3.1% of those non-immune to HBV were vaccinated for HBV. Of the patients with CHC: 15.0% had HIV, 1.8% had HBV, 41.6% had a history of alcohol abuse, and 70.8% were infected for >/= 20 years. 7.1% of those with CHC actively abused or were dependent on alcohol, 54.9% had a psychiatric co-morbidity, and 22.1% had a medical co-morbidity that impacts CHC treatment. 25.7% of those with CHC accessed specialty services and 12.4% received CHC treatment.

Conclusion: While screening for CHC was successfully integrated into routine care, patients at this MMT would have benefited from a comprehensive vaccination program. Over half of the patients at this MMP were infected with CHC and many of them had clinical factors associated with the development of advanced liver disease, making timely evaluation and treatment even more urgent in this population. Few patients were evaluated for CHC and even fewer received treatment. Targeting on-site psychiatric treatment for those with CHC and strengthening the institutional affiliations with CHC specialty services may have increased the number of patients being treated. As an urban, academically-affiliated MMP, the NRC may be representative of similar MMPs which are well situated to address the current CHC epidemic within their patient population.

Thinh Xuan Ho, MD: Conceptual Models Of Hypertension Among Vietnamese Patients In The Bronx

It is well known that better treatment of hypertension is associated with significant improvement in morbidity and mortality.  Lack of adherence to treatment has been postulated as an important reason for poor control of hypertension.  Among many underlying causes of low adherence to treatment for hypertension, studies identified misunderstanding about hypertension, perceived efficacy of anti-hypertensive regimen, beliefs concerning the necessity of regular medication and the experience of side-effects, as all serving to discriminate between compliers and non-compliers (13, 14).  All of these factors are highly culturally shaped (15).

Although there is no available data about control of hypertension among Vietnamese-Americans, few small studies revealed that the level of awareness of hypertension among this population was even lower than that of the general US population.  In order to enhance the level of control of hypertension among Vietnamese-Americans, we conducted a qualitative interview study which investigated personal perspectives of hypertension among Vietnamese-American patients with and without the disease.  The ultimate goal of this study was to elicit their understanding about hypertension including prevalence, etiology, symptomatology, possible complications, necessary treatment, as well as its impacts on life.

Sybil Hodgson, MD & Betsy Mathew, MD: Using PhotoVoice to build Self Identity among Preteens

Photovoice is a medium that traditionally uses photography to stimulate grassroots social action by having traditionally underrepresented members of a community take photographs of the environment from their point of view.  Internationally, this has been applied to bring forth the voices of refugees, women, or other marginalized populations.   There have been attempts to use photovoice with adolescents to help them become active in their communities and learn from their peers.

This program utilized photovoice to develop self identity among preteens through a five session photography-based curriculum emphasizing integrity, communication, self perception and relationships.  Each participant created individual portfolios of all of their photographs and narratives.  The curriculum will conclude with a gallery session inviting community members and family to view the photographs and narratives compiled by the participants.

Anne Hyson, MD: Evaluation of a directly administered antiretroviral therapy program for HIV-infected people within a community-based harm reduction program

Background and Significance: Ensuring adherence to highly active antiretroviral therapy (HAART) for the treatment of HIV infection is especially challenging among patients who are facing other medical and social challenges, such as active or prior addiction.  Studies have demonstrated that adherence is strengthened and outcomes are improved when directly-observed therapy (DOT) is provided for complicated medical regimens through social networks and community-based organizations.  Despite this evidence, DOT is not currently a standard of practice to improve adherence and outcomes for HIV therapy.  We set out to examine the effectiveness and feasibility of DOT amongst clients who are most at risk of failing HAART because of mental illness or an unstable social situation.  Within the drop-in center of a community-based harm reduction organization, we provided specialized DOT called DAART (directly administered antiretroviral therapy) to clients who had been unsuccessful at adhering to antiretroviral therapy on their own.  We hypothesized that compared to baseline, six months after enrollment into the DAART program, clients would have a decrease in HIV viral loads and an increase in CD4 counts.

Methods: The study population included HIV-infected individuals who enrolled in the Montefiore/CitiWide Health Services DAART Program from April 1, 2006 to December 31, 2008.  The DAART Program was housed in the larger Montefiore/CitiWide Health Services Program, a collaborative program between an academic medical center and a community-based harm reduction organization that provides comprehensive services to HIV-infected individuals in New York City.  The following data were extracted from program logs and medical records: date of enrollment into the DAART Program, socio-demographic information, dates and values of CD4 counts and HIV viral loads, and co-morbid illnesses.  We used simple frequencies to describe the clients and program outcomes, defined as change in CD4 count of at least 50 cells/mL, and one log change in viral load (copies/mL).

Results: Thirty-four clients enrolled in the DAART Program.  The median age was 48 (range 28-60), and 26 (77%) were men.  Fourteen clients (41%) were hispanic, 13 (38%) were black, two (6%) were white, and five (15%) declined to answer.  The median CD4 count at baseline was 189 cells/mL (range 4-528), and the median viral load was 8866 copies/mL (range <75 to >500000).  Twenty-four clients (71%) were exposed to Hepatitis B, 20 (59%) were exposed to Hepatitis C, and of these, 16 (47%) had been exposed to both Hepatitis B and Hepatitis C.  Twelve clients were noted in the chart to be actively using drugs, and 12 were prescribed a psychiatric medicine other than a sleep aid.  Seventeen clients (50%) had more than one viral load within six months of beginning the study period.  Thirteen clients (76%) had a log decrease in their viral load, three clients (18%) had no change, and one client (6%) had a log increase in their viral load.  Nine (53%) achieved an undetectable viral load within the six month period after enrollment in the DAART Program.  Ten clients (59%) had a significant increase in their CD4 count, of at least 50 cells/mL.  One client (6%) had no change, and six (35%) had decreases in their CD4 counts after starting the program.

Conclusion: Despite a high drop-out rate, our data support the hypothesis that directly administered antiretroviral therapy can be an effective intervention to improve adherence and treatment outcomes among some clients with previous nonadherence to HIV therapy.  This evidence could be used to obtain funding for a larger intervention that is designed prospectively, which would enhance data collection and follow-up.

Christine A Lee, MD:Transgender Adolescents: Understanding Their Psychosocial Challenges and Barriers to Healthcare

Transgender (TG) individuals are those who identify with the gender opposite from their genetic and anatomical sex on psychological, sexual, and social levels. Little data exists regarding the health and psychosocial risks and needs of TG individuals, particularly adolescents. My objective was to determine the health and psychosocial challenges and barriers to healthcare access faced by TG adolescents living in New York City.  I obtained an Community Access to Child Health (CATCH) grant from The American Academy of Pediatrics to develop a medical home for TG adolescents in NYC.  Then I conducted a qualitative study, utilizing structured in-depth interviews. Adolescents were recruited from two community-based organizations providing services to the TG community. First, participants completed an anonymous self-administered survey to collect general information, and those interested consented to a 30-minute structured in-depth interview.  TG adolescents in this study cited multiple psychosocial challenges and systemic barriers to obtaining healthcare. This data provides new insight and builds upon the emerging body of research on TG adolescents. The findings were presented at two national conferences to inform and further educate health care providers.

Irina Linetskaya, MD: Montefiore Goes Green: Resident-Led Advocacy for Organizational Change: My recycling project

In January of 2007, Montefiore made an institutional commitment to adopt an environmentally sound waste management strategy aimed to reduce waste and institute recycling. A medical resident attained institutional buy-in from the hospital’s new CEO who committed financial support toward a recycling initiative. The “Montefiore Green Team,â   comprising leaders from departments such as engineering, facilities, and public relations, first piloted and evaluated a recycling initiative at CHCC, a satellite clinic in the South Bronx. Lessons learned there shaped the large-scale, Montefiore Medical Center based recycling program. Given the large projected volume of recycling, Montefiore secured lucrative contracts with local recycling contractors to install a free compactor (a savings of $300,000) and haul recycled paper, metal, glass, and oil free of charge, saving rather than costing Montefiore money to divert trash away from landfills.

One year after inception of an institution-wide program, Montefiore has recycled 36 tons of glass, metal, and plastics and 100,000 pounds of white paper. Montefiore’s cafeteria has eliminated the use of 5,000 Styrofoam trays per week, replacing them with recyclable products. Unexpectedly, rather costing money, recycling saves Montefiore over $1000 per week.

Grass-roots activism can catalyze institutional change, dramatically affecting institutional recycling practices. Although medical residents often feel powerless in a hierarchical medical system, they can represent a strong voice for innovation and change.

Sharissa Parker, MD: Perspectives on Culture, Food, Diet and Diabetes Among Jamaican Patients in the Bronx

Diabetes Mellitus is a common, costly condition associated with significant morbidity and mortality.  One of the main goals of treating patients with diabetes is to produce near-normal glucose levels to prevent the development of diabetic complications.  While pharmacological therapies are clearly effective, diabetes trials have repeatedly shown that adding nutrition and lifestyle approaches can be more effective in delaying the progression of the disease than drugs alone.  Diet is an important component of diabetes care, yet full cooperation of patients with dietary regimens can often prove difficult to achieve.  In minority ethnic groups, distinct cultural beliefs relating to diet, food and eating need to be understood and appreciated by the health professionals that provide care to these individuals.  Our goal was to explore significant questions about health behaviors in general and dietary management, as well as the unique beliefs of food and diet among Jamaicans with diabetes in the Bronx.

Using qualitative interview techniques, we investigated the cultural beliefs of food and eating among Jamaicans aged 18-75 with diabetes and their reactions to dietary advice given by their health care professional.  In recorded interviews of 10 participants, we found that all participants continued to eat at least one traditional food item after migrating to the United States.  All participants were told by their physician to change their diet, but only 20% of physicians were familiar with Jamaican cuisine.  Dietary advice was not specifically targeted to the foods participants consume.  In conclusion, this study is an important reminder to those providing care to Jamaicans, and all ethnic minorities, of the need to make dietary advice culturally sensitive.  Patients recognize the importance of healthy eating; they just need the principles of the advice translated into their own cultural food language.

Sharon Phillips Benattabou, MD and Arati Karnik, MD: Perceived Barriers to Contraception in an Underserved Population

More than half of the approximately 6 million yearly pregnancies in the US are unintended.  Lack of contraception use and unintended pregnancy are closely related, especially among young, poor women. Homeless women are both an at-risk population for unintended pregnancy and have a greater association of adverse outcomes in pregnancy, such as preterm labor and low birthweight infants.  Few studies have been done regarding contraceptive views among homeless women and ways in which to improve access. Contraception is key in this marginalized population which is at high risk both for unintended pregnancy and poor pregnancy outcomes.

Focus groups were conducted with women over the age of 18 at two family shelters located in the South Bronx in hopes of better understanding perceived barriers to contraception for homeless women in New York.  Data analysis used narrative theory to extrapolate common themes from transcribed group discussions.  Preliminary findings suggest that even sheltered populations with access to on-site clinics and health insurance find lack of patient education, expense, poor clinical rapport with doctors and side effects as some of the limiting factors to using contraception.  Continued efforts need to be made to reach this vulnerable population and improved access to reproductive healthcare.

Max E. Quintana, MD: Ay doctor me duele!  A typical Presentation of Depression in Latino Men.

It is a clinical chart review determining back pain as an initial complaint of depression in latino men between the ages of 20 and 60yo.

Michael Reid, MD: Approaches to TB screening and diagnosis in people with HIV in resource limited settings

TB is the main cause of morbidity and mortality in people living with HIV/AIDS worldwide.  Early diagnosis and treatment is essential to addressing the dual epidemic of TB and HIV.  This study involved reviewing the diagnostic tools currently available to diagnose TB among people with HIV/AIDS

Leigh A. Rieper, DO: Implementing a Sustainable Program: Reach Out and Read at Williamsbridge Family Practice

Reach Out and Read trains doctors and nurses to advise parents about the importance of reading aloud and to give books to children at pediatric check-ups from six months to five years of age.  Reach Out and Read initiated in September 2007 at Williamsbridge Family Practice.  In the first year, over 500 books were distributed during 85.7% of well visits.  In order to maintain a sustainable program participation of all providers is needed.  Some of the barriers to having 100% participation of providers include time allowance, lack of interest and small pediatric panels.

Amit J Shah, MD: Investigation of Interest Towards Yoga and Meditation in an Inner City Population

Meditation and Yoga are two techniques for wellness that have shown efficacy in multiple medical and psychiatric conditions, such as depression, anxiety, hypertension, fibromyalgia, and lower back pain. The degree of interest towards this complementary modalities in an inner city setting is in question. In this survey study, patients from a general medicine clinic in the South Bronx are interviewed and asked multiple choice and open ended response questions for the purposes of assessing who would be interested in yoga and meditation, as well as factors that may influence this interest. If people show interest, then it may be justifiable to allocate resources towards offering and studying their benefits in this population

Lauren Shapiro, MD: Transition Clinic

The transition clinic is an open-access clinic that will provide health care to previously incarcerated persons upon their release from prison.  Recent studies have shown that the adjusted risk of death upon the initial two week period following release was 12.7 times that of other state residents, and 3.5 times greater over a two year period.  The leading causes of death were drug overdose, cardiovascular, homicide, and suicide. The challenges of release involve substantial health risks, in addition to the difficulty of finding a doctor to continue their 30 day supply of medicine they leave prison with.  The proposed clinic seeks to mitigate the role that absent or unstable medical care may play.

Our transition clinic is modeled after the only other transition program at the University of California, San Francisco and seeks to address the health and social needs of recently released prisoners.  We aim to provide four primary functions; acute stabilization and medication renewal, ongoing primary care to those with chronic medical conditions, training for residents, and research opportunities.   Through partnership with the Osborne Society, Department of Corrections, parole officers, and a community health worker we plan to open our doors July 11th 2009.

Michele Trela Bowdy, MD: The TRRIP Program: Teens Reducing the Risk of Infections & Pregnancy

The nature of the project was to create & implement a teen peer education program covering the topics of STDs, HIV/AIDS, & pregnancy prevention.  Research shows that these programs have great effect on teens’ HIV/AIDS-related knowledge, attitudes/beliefs about risky behaviors, ability to fight negative peer pressure, and time spent helping other youth avoid unprotected sex. The idea stemmed from a similar project that I did as an AmeriCorps*VISTA, while working at a Migrant Health Clinic. I enjoyed the experience I had with the teens then & wanted to do more work in the area of adolescent health.  Being that we practice in the Bronx, where we see many teen pregnancies & STDs, I thought it was a much needed program.

The curriculum is meant to promote healthy, responsible choices for teens by giving them information about health topics that will affect them. Through increased knowledge and skill-building sessions, teens will be better prepared to protect themselves against infections and pregnancy.  The Program encourages teens to discuss their health concerns with their parents and doctors. We encourage parents to use every chance to discuss health issues with their children. We also encourage parents to help their child learn to access health services provided by physicians and clinics in our community.

posted by Matt Anderson, MD

Addressing HIV & genocide in Rwanda: Work of Dr. Kathryn Anastos & Jon Wallen

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we-actx_logo1-300x243On Tuesday, March 10th Dr. Kathryn Anastos and Jon Wallen came to Social Medicine Rounds to discuss their work in Rwanda.   Dr. Anastos’  story illustrates one answer to the question: “What does a social medicine doctor do?”

Dr. Anastos is an Internist who  graduated from the Residency Program in Social Medicine in 1983.  She is currently a Professor at Albert Einstein College of Medicine in the Department of Medicine as well the Department of Epidemiology and Population Health.  She is known for her pioneering work in the study of HIV in women as principal investigator of the  Women’s Interagency HIV Study (WIHS).  Jonathan Wallen is a New York photographer who specializes in architectural and landmark photography.  Since 2003 they have become increasingly involved in work in Africa, some of which they shared last Tuesday.

Mr. Wallen filled the walls of the third floor conference room with pictures from the Tubeho (“To live again”) Project.  Tubeho documents the stories of female victims of the Rwandan genocide and consists of a series of photographs with accompanying stories (see an example at this link).  These were disturbing stories.  The pictures that accompanied them showed both women in the full bloom of life as well as others whose spirits and bodies seemed broken.  Showings of the exhibition have been used to raise funds for the genocide victims as well as to bring attention to the links between gender-based violence and the spread of HIV.

Dr. Anastos framed her work in the context of  Community Oriented Primary Care (COPC).  She shared her initial skepticism, developed from her work in the Bronx, in COPC as a model of care.  Rwanda, however, had changed her point of view.

The couple’s involvement in Rwanda began in 2003.  Dr. Anastos had been contacted by Les Veuves (the Widows) a group of genocide survivors, many of whom were infected with HIV.  They were incensed that they did not have access to treatment while their victimizers – on trial for genocide – were receiving HIV medicines.  Dr. Anastos had worked as an administrator at the Montefiore Medical Group and felt she knew about  building an efficient, comprehensive, high quality primary care practice for a chronic disease.  As she put it, her credibility was as an HIV expert, but her skill was as a manager.   With assistance from the Stephen Lewis Foundation she helped found We-ACTx (Women’s Equity in Access to Care and Treatment) in mid-2004. The goal was to create an HIV treatment program, but this implied first setting up HIV counselling and testing.

One of the lessons of this experience was to ” first, provide the services people ask for, not just those professionals think they need”. This, she felt, was the essence of COPC.  And what people wanted was wanted medical care (to prevent dying and promote health), HIV testing, medical care for their children, food, income, and – a top priority –  education for their children. The local women rejected the idea of going out “into the bush” to provide care.  They wanted it done through existing infrastructure and using local nurses and clinics.  By knitting together multiple small grants an HIV testing program was implemented in September of 2005 and has by now performed over 50,000 tests.  In January of 2006 anti-retroviral care was introduced and there are currently 2,400 people on ART, essentially “everyone who needs it, gets it”.  The program is implemented in coordination with 24 community partners and is staffed by 2 physicians, and 12 nurses.  She feels that the necessary skills to run the program exist locally (“if we left now, the program would continue”) but that the local staff continues to need salary support.

For a beautiful look at the WE-ACTx progam in action, you can see pictures in the linked slideshow.

Because of the focus on meeting people’s expressed needs, several “off mission” programs had been created.  “Just because I think it is not health service related, doesn’t mean we don’t have to find a way to provide it.”  These off mission programs included the provision of food supplements, creation of income generating activities (originally doll making, now bag making, see Ineza), community based education, and a program to help with school fees.More recent activities are a cohort study (requested by the community) and programs to address cervical cancer.  Cervical cancer, an essentially preventable disease is the number one cancer killer in Rwanda.

In considering the successes of their work (and of the COPC model) Dr. Anastos pointed to the strong sense of community in Rwanda.  “There is no cult of the individual. It is always my family, my community, my country.”

posted by Matt Anderson, MD

A Right to Health, Neighborhood Health Centers in Profile (A Classic Film)

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A friend recently brought to our attention the film, A Right to Health, Neighborhood Health Centers in Profile, made by the Office of Health Affairs of the Office of Economic Opportunity (OEO) apparently in the early to mid-1970’s. This 33 minute film highlights the work of diverse Community Health Centers in the US, beginning with Montefiore’s Martin Luther King Health Center in the South Bronx.

Here is the YouTube feed of the movie:

The film is also available in a better quality download (in 2 parts) from the Prelinger Collection.

We have also posted Out in the Rural, a film about one of the first two OEO community health centers, the Tufts-Delta Health Center of North Bolivar County, Mississippi.  See our media page for a link to this film and the following link for an introduction to Out in the Rural.

A Right to Health is made in the overly somber, paternalistic style of old public service announcements.  Nonetheless, the voice and feeling of the communities manages to emerge. Dr. Roger O. Egeberg, then Dean of USC School of Medicne, introduces the movie stating that it “describes new ways of providing health care for the poor.”  But this is a bit deceptive.  The film describes ways of organizing health care services – community care, comprehensive care, team care, the use of community health workers – that suggest a broader vision of clinical care than just “poor care.”  In fact, the title “A Right to Health” expresses a universal ideal that we have yet to achieve in the US.

Posted by Matt Anderson, MD

David Kindig: Health Care Reform is more than medical services

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Dr. David Kindig

Dr. David Kindig

On Tuesday January 20, 2009 Dr. David Kindig offered the second annual Harold Wise lecture as part of our Social Medicine Rounds series. The Wise lecture is organized the Residency Program in Social Medicine Alumni Committee.  His talk was entitled:  To: President Obama, From: Harold Wise, MD, RPSM Founder, Re: Beyond Health Care Reform. Dr. Kindig has kindly given us permission to post his presentation which can be downloaded here.  It should not be reproduced without his consent.

Dr. Kindig began with some memories of Harold Wise, a Canadian physician born in Hamilton Ontario in 1937.  After receiving his MD degree at the University of Toronto in 1961, Dr. Wise completed an Internal Medicine internship at the Kaiser Permanente Foundation Hospital.  In 1964 he moved to Bronx and completed his Medicine residency at Montefiore.  He then served as Director of Ambulatory Services and Home Care at Morrisania City Hospital, a New York City hospital affiliated at the time with Montefiore.  In 1969 he became the director of the Dr. Martin Luther King Jr. Health Center, one of the first OEO (Office of Economic Opportunity) Community Health Centers in the US.  Faced with the problem of finding well-trained clinicians interested in working in underserved areas, Dr. Wise created the Residency Program in Social Medicine.  He passed away in 1998.

Dr. Kindig then discussed his own path to the Bronx.  As a pediatrics resident at the University of Chicago he had been told that spending a month working at a community health center was “not a legitimate PGY-2 activity.”  He was becoming increasingly politically active at the time and became interested in pursuing other paths in medicine.  He met up with Harold Wise who convinced him to come to the Bronx and develop a “Social Pediatrics” residency program.  Dr. Kindig moved from Chicago to the Bronx both creating the residency program and becoming its first graduate in 1971.   He went on to have a distinguished career in academics and government service.  He is currently Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin-Madison, School of Medicine. He also serves as Senior Advisor to the Wisconsin Public Health and Health Policy Institute.

His talk focused on the need to move beyond simply reforming health care in the United States.  Insuring all Americans and providing them with health care are two necessary and important steps for the new  Administration in Washington. But they are not enough.  True health reform would require addressing the multiple social determinants of health.  He discussed how the book Why Are Some People Healthy and Others Not? The Determinants of Health of Populations had been an epiphany for him.  He had come to see that curative medical services were of limited value in addressing social disparities and that spending more on such services might actually reduce the overall health of the population.  He briefly reviewed some of the recent evolution of thinking on population health and spoke about his own work in conceptualizing reimbursement systems that would pay for population health. His concepts are outlined in his book Purchasing Population Health (available on Google Books) and in a 2006 JAMA article A pay-for-population health performance system.

Currently, Dr. Kindig is active in the Robert Wood Johnson Health & Society Scholars Program and the Population Health Initiative at the University of Wisconsin.  At the Population Health Institute he leads an initiative to make  Wisconsin the healthiest state and he shared some of that work with us.  The project produces an annual report card on Wisconsin health. The 2007 report card noted that while health in Wisconsin was improving it was not improving as fast as other states.  The state was graded B- overall for health and D for addressing health disparities.  The program is moving beyond merely grading the state to better understanding the determinants of health and then to suggesting specific evidence-based  actions to address each one. The work of the program seemed embued with a very political sense of making health statistics understandable to the people who could actually influence public policy.

It is impossible to comment on the talk without mentioning the spirit of optimism generated by the inauguration earlier in the day of Barack Obama.   Rounds took place at the Cherkasky auditorium where some five hours earlier hospital employees had watched President Obama sworn in.  It in words of Montefiore President Steven Safyer it was a moment of Jungian synchronicity.

posted by Matt Anderson, MD

Family Centered Maternity Care

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images3Our colleague, Dr. Rebecca Williams, has set up a website exploring Family Centered Maternity Care (FCMC).  Family Centered Maternity Care, as she explains it, is a philosophical approach to prenatal care and delivery providing care to the pregnant woman in the context of her family. FCMC is prenatal care that considers, includes, and fosters the development of families. Historically, practitioners have also promoted natural childbirth.” While the site is primarily towards the teaching and clinical needs of our Family Practice residents, Dr. Williams updates it on a regular basis, making it a valuable resource.

The movement for Family Centered Maternity Care is several decades old.  Interested readers may want to consult Celeste R. Phillips‘ book  Family-Centered Maternity Care some of which can be read on Google Books. Phillips, a pioneer in the field, defines FCMC as “a way of providing care for women and their families that integrates pregnancy, childbirth, postpartum, and infant care into the continuum of the family life cycle as normal, healthy life events.”  She developed the following 10 principles for FCMC:

Principle No.1: Childbirth is seen as wellness, not illness. Care is directed to maintaining labor, birth, postpartum, and newborn care as a normal life event involving dynamic emotional, social and physical change.

Principle No. 2: Prenatal care is personalized according to the individual psychosocial, educational, physical, spiritual and cultural needs of each woman and her family.

Principle No. 3: A comprehensive program of perinatal education prepares families for active participation throughoutthe evolving process of preconception, pregnancy, childbirth and parenting.

Principle No. 4: The hospital team helps the family make informed choices for their care during pregnancy, labor, birth, postpartum and newborn care, and strives to provide them with the experience they desire.

Principle No. 5: The father and/or other supportive persons of the mother’s choice are actively involved in the educational process, labor, birth, postpartum and newborn care.

Principle No. 6: Whenever the mother wishes, family and friends are encouraged to be present during the entire hospital stay including labor and birth.

Principle No. 7: Each woman’s labor and birth care are provided in the same location unless a Cesarean birth is necessary. When possible, postpartum and newborn care are also given in the same location and by the same caregivers.

Principle No. 8: Mothers are encouraged to keep their babies in their rooms at all times. Nursing care focuses on teaching and role modeling while providing safe, quality care for the mother and baby together.

Principle No. 9: When Mother-Baby care is implemented, the same person cares for the mother and baby couplet as a single-family unit, integrating the whole family into the care.

Principle No. 10: Parents have access to their high-risk newborns at all times and are included in the care of their infants to the extent possible given the newborn’s condition.

Dr. Phillips currently runs a healthcare consulting company, Phillips + Fenwick, which assists hospitals in implemented FCMC programs.  The company website – www.panf.com – has some resources on FCMC, such as a short reading list.  Of particular interest, is her 1999 article Family-Centered Maternity Care: Past, Present, Future which discusses the history and current of FCMC. Readers may also wish to consult the WHO’s document on Care in normal birth, although this document is now 12 years old.

posted by: Matt Anderson, MD





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