Wednesday, December 31, 2008

Mental Health and Disparities: There Just Isn't a Lot of Data

One of the things that I found striking in the Rosie D. decision was that the judge, who clearly saw the inadequacy of the current system for children's mental health care, did not find enough evidence to declare that the system discriminated against people of color.  Most of know that, given the disparities that we see in the allocation of resources to treat physical illness, there ought to be disparities in screening, diagnosis and treatment of mental illness as well.  When I went looking for the evidence, however, it was sparse.  Now part of that was just the lack of data;  I had trouble getting information on the prevalence of ADHD, depression and anxiety disorders in kids in Massachusetts.  Suicide rates we could follow, but rates of suicide attempts, depression, substance abuse- these were hard to find on a city or regional basis.  And breaking it all down by race and ethnicity- well, it just seemed that no one did the work.  
Earlier in the month, I had the opportunity to attend a meeting of the Health Disparities Council, now chaired by Byron Rushing and Susan Fargo of the General Court, and trying to develop a coherent set of recommendations for the Commonwealth on what steps the government should take to reduce and eliminate racial and ethnic disparities.  The Department recently released "A Profile of Health Among Massachusetts Adults, 2007: Results from the Behavioral Risk Factor Surveillance System",  downloadable as a .pdf and chock for of interesting data;  but still, there seems to be little  which relates to disparities in mental health treatment and outcome. It seems most interesting to look at this from the standpoint of what DID they measure:

Marker over Time Trend Gap vs. Af-Am Gap vs. Hispanic
Fair/poor health  Same Persists Persists
% insured Better Persists Persists
Disability Better Persists Persists
Smoking Better Closing Closing
Obesity Worse Persists Persists
Physical active Better Persists Persists
Cholesterol Same Closed N/A
Diabetes Worse Worse Worse
Screening Better Closed Closed

(Turns out to be hard to put a table on a blog, but you get the idea)  With the usual public health indicators, you can see that we made a bit of progress on cigarette smoking, access to care and screening, and have some work to do on diabetes and overweight.  But what about depression treatment?  What about ADHD?  How can we measure the disparities?

My notes from the session point out that there were a few indicators that suggest few disparities in mental health care:  
"Two bits relevant to mental health: Poor mental health no gap, re drinking whites worse."

We need some data on this if we are going to change it.  A thought for the future.  Got to go eat chile now.  Happy New Year!

Tuesday, December 30, 2008

View from the Cheap Seats: Attending a Transition Health Care Conversation

These meetings are happening everywhere.  Sunday, I moderated one of these. Today I participate. The meeting is at the home of one of our faculty, out in the woods. It was hard to find and I was late.  The following notes would have been "live-blogged", except I couldn't get an internet connection:
Democracy in action is a wonderful thing to watch. This is a big meeting, of folks who work in a wide array of the kinds of programs that are linked through the vast enterprise that is UMass Memorial Healthcare and UMass Medical School.  A number of high level leaders in the clinical and academic systems are present.  There are nurses and doctors, professors and clinicians, an exercise physiologist and educators (and a lawyer, friend of someone, I guess). I got here 35 minutes late, walking in the middle of the introductions, and taking a chair on the edge of the mob that spilled out of dining room into the hall.   I have already heard people talk about prevention and community and nurses and educating patients and parity and disparities; all of the issues on which we have pondered over the past decade. I am sitting next to a researcher who has won awards for his groundbreaking research, and who is concerned about how the health care system is about to split between the haves and the have-nots. (I might argue that it already has split)  His observation, that this is not going to be easy, resonated with everyone. We have done a lot to improve the practice of medicine over the years- the people around this table have testified to the things that they seen, but at the end of the introductions, it was clear that we still have a lot of work to do to bring our growing understanding of disease and the social factors that make disease happen into new systems of care.  
This was a very large group, with a lot of different agendas and many perspectives, working to find some way to make their voice heard in the transition process. 
Our moderator tried to pull key words out of the process: cost, quality, access, equity, coordination, prevention. After listening to all of us, she thought that cost is what bothers us the most; but that prevention is what we want.
Do I agree with that?  I guess so, although I heard a bit more about access and equity in the comments of my colleagues.  It was a bit hard to follow the argument- it kept whizzing back and forth. 
Key question: what drives up cost? After a bit of hemming and hawing, we finally realized that the cost of health care reflects by the way in which we are paid; fee for service will always drive the cost upwards. What is the incentive in such as positive feedback loop to put a lid on costs?  If nothing else, over the last 30 years, we have shown that we can build technology and then find a way to make money off of it. We have a hard time containing cost because we have a hard time estimating the marginal value of the next dollar.  Exactly how much bang are we going ot get for that buck?  One doesn't know, because we don't know how to put a value on health care.
Key question: what is value? Can we measure it? Some said yes, some said no. Some said that capitation is the way, some though that we needed to reward good behaviors.  Some said that the whole idea of pulling profit out of the system is simply wrong, that one cannot build a system predicated on profit that will care for the people on the margins.  Out of all this came a call to study the system: What works in systems as we build them in real-time? Can we set up a system that allows us to test systems in the practice?
Cost and value were the major things pulled out of the introduction by the moderator, interesting areas to focus our discussions.  But were these the issues that we wanted to discuss?
A deep breath: Reality check: What is doable in an incremental way?  Mr Obama is a pragmatist, one of group said.  We need to give him something to do on the day he takes office.
***Can we commit to a values construct:  All children under the age of 18 should have insurance by 2018.***
***How about the stimulus package: Can we fund the NIH at a 100% level?***
Everyone like this idea, but, as with all great ideas, it comes down to this: can all agree to it.  Not even close, it seems.
Then the discussion moved on: 2013 is when the medicare trust fund will run out of money. It will become a crisis. Some systems are starting to do this; Geisinger is doing this, and we are looking at that as well. Other thoughts crept into the discussion: prevention, at least in adults, doesn’t save money. Insurance won’t solve the problems of healthcare, even if it addresses the issue of payment. Poverty overrides many of the access issues. Can we afford universal coverage? I don’t know. And neither did the rest of the room.
Like ours, this was a free-wheeling conversation, ebbing and flowing. We moved onto systems: where do they find their primary care physician? And then, unlike our meeting, we had a break. Food, conversation, wine: good lubricants for a conversation.
After the break, we talked about population health: what can we do to encourage a healthy lifestyle? What can we do to make people want to stay healthy? Our culture is built on sitting, starting at a young age. What can we do to get young people engaged in the process? What can we do to make cigarettes go away? As people began peering off in the night, it was clear that this group was committed to change, and that they had not yet agreed on the appropriate strategy with which to put Humpty Dumpty back together again.
A friend of mine at the meeting last night wondered how effective these gatherings will be at moving the process of health care reform-  "another empty exercise, full of sound and fury, signifying ....?" was the phrase he used.  I don't believe that.  Change, in retrospect, is the inevitable product of circumstance, of economic pressures, of political forces that, it seems couldn't have gone any other way.  But we aren't part of change in retrospect.  These meetings (and you have read of two of them on this blog, with very different characters) are part of prospective change, which is an act of hope, and faith.  Hope springs from our experience on a small scale, where we have all been part of groups of people that have made something happen- a clinic in Webster,  a more efficient model of care for people living with AIDS, a hospital system rise from the ashes of the collision-merger of two health care cultures, a school for the lost youth of Providence.  We have all seen it work on a small scale;  we have all seen it fail, and we hope that we have the wisdom to scale success on a national scale.  Faith, well, that comes with the hope.  Faith is a core belief that this will be really hard, but this is doable and that we as a society are ready to take the leap.  Faith means the willing suspension of our disbelief that we have done this before, we have failed at this before, that those who failed were as smart or smarter than we are, and that we are doomed to failure.  Faith, in this context, is a belief that this process, inefficient and tedious as it is (newspaper said that there have been 8500 of these meetings around the country this week), is an essential part of the building that must go into making change happen in health care.  I stuck a copy of Rockwell's Freedom of Speech at the start of this post:  town meeting is boring, inefficient, contentious and long, but at it's core it is an act of hope and faith that we are an essential part of the process of our country.  What I find most encouraging about yesterday's meeting, and the one on Sunday is not the insight and expertise that we brought to the process.  I am excited by the fact that we all showed up.  We need to keep showing up to make this happen.

Monday, December 29, 2008

Interesting Stuff from the New England Journal: Teens, Anxiety and Treatment

Last week's New England Journal should be of interest to all of us trying to build evidence-based systems of care for children with mental health issues; a new study showed that anxiety disorder in teens can be treated relatively effectively by both pharmacological and non-pharmacological means. (abstract is here- they charge for the whole article) It was a straightforward study:  488 kids between 7 and 17 (interesting choice of ages) got randomized to placebo, cognitive-behavioral therapy (CBT), sertraline, or CBT + sertraline treatment for 12 weeks.  CBT worked, sertraline worked and the combination did better than either individually.  Oh, and the folks on CB with placebo had fewer side effects.  Big study, lots of statistical power, should do us a lot of good in improving the quality of care for kids with anxiety disorders of various kinds.  To my mind, this says:  send them for 3 months of CBT first, then think about medication.  Or start the medication with the CBT- you will get more bang for the buck.
Except,  I have no way of knowing if the therapist that my patient finds, through the insurance or the agency or the friend that they are seeing, is actually doing  CBT.   In my neck of the woods, when I refer to an agency, they evaluate the child and assign them to a provider.  None of my patients can tell me what kind of therapy they are receiving and I only sometimes get feedback from the mental health agency about the nature of the treatment that they are using.  So I don't know what or if they are getting therapy.  Operationalizing this exciting bit of evidence may be harder than it looks.

Sunday, December 28, 2008

Live from Pawtucket: A Transition Discussion

12 citizens in a room, talking health care:  how does that influence the flow of change?  Our group was certainly not representative of America.  For one thing, we were mostly all invested in the development of a single payer system, and acutely aware of the economic forces that are working against the change that we all need.  For another, we all thought that there were major systemic reforms that need to be put in place to complement the change in the way in which we think about health care.  A few great quotes:
"The Obama folks haven’t thought this through- a soft sell for a needed revolution. This stuff is pap for the common people."
"Why aren't employers out in front of this stuff?  This is costing them so much..."
"We need to build systems which actually provide health care, rather than focusing on who should get insurance."
""Health care for profit" is just doesn't work"
"We need to get away from talking about health insurance and talk instead about health care."
"We shouldn’t be apologetic to spend more money to help people do better."
Like Paul Krugman, our group seemed to feel that the real danger in this current move to reform is that the action will not be bold enough.  I'll try to get more notes up soon, but the commentary is too fast and too passionate.  We really need this change.  (The Obama folks suggested a 6o minute discussion, and we are at 90 minutes with no sign of stopping.)
So, here's my first draft of the report back to the Obama folks.  Not live, but close to it:

Health Care Community Discussion
Group Submission
28 December 2008, 3 PM
Home of David Keller and Julie Meyers
Pawtucket RI 02860
General Questions:
􀂃 How many people attended your health care community discussion? Thirteen. We had a mixture of physicians (3 pediatricians, an internist and a family practitioner), a nurse, a speech pathologist, an attorney, an architect, 2 small businesspeople (one profit and one non-profit), a poet and a teacher.
􀂃 Please summarize compelling personal stories from attendees about the need for health care reform in our country and provide their contact information.
Central point of the stories was that the current healthcare system is too complex, and that we need to develop a system that is built around the needs of the patient and family.
PA: Spoke of an elderly couple who could not coordinate their care
because of the separate systems of care for veterans and non-veterans.
CM: Spoke of the need for coverage for the immigrants seen at the hospital where he volunteers.
SD: Spoke of her struggle to get coverage for testing ordered by her physician and not covered when her health insurance was changed by her employer.
JM: Spoke of the needless complexity of the system, which would be poorly comprehended by anyone without a medical degree.
Summary of Responses from Discussion Questions:
􀂃 What does the group perceive as the biggest problem in the health system?
1) Value received for money spent: “The biggest problem is the amount of money that we spend on health care. As an employer, each year we got a shocking increase in the cost of health care. Nothing can be done until the cost per person is reduced.”
2) Cost of pharmaceuticals: This was seen by many are a major area that needs to be addressed. Pharma is really influencing decisions of physicians in order to maximize profits. All of the physicians in the room can recall talks designed to promote the idea that a disease was prevalent, needed to be treated and required urgent treatment. Direct to consumer advertising puts doctors on the spot by asking people to “Ask your doctor about this or that?” Most of the new drugs that are developed are “Me too” drugs, that are not as needed in many circumstances. Detailing gets doctors to forget about generic drugs. Federal regulations need to: Ban direct marketing to consumers. Include efficacy in the FDA approval and test drugs against existing ones. Create a registry of all clinical trials through the FDA. Make it illegal to “datamine” physician prescribing habits.
3) Lack of systems thinking: The solo practitioner does not allow for adequate monitoring of patient safety or use of evidence based approaches; we need to encourage the creation of systems that are family friendly, the work effectively, and that use a primary care model to focus families on appropriate levels of services and help them coordinate care. In retrospective, this seems to be the “medical home concept” long championed by the AAP and recently endorsed by the AAFP and SGIM. In addition, we need to find a “no fault” way of dealing with medical mistakes besides the malpractice system as currently structured. Currently 25% of our healthcare budget is administrative, which is terribly wasteful.
4) Inter- and intra-systems communication: Compatible electronic medical records are part of the solution, but also need to be incentives for the various parts of the system to talk with each other. Within systems, various parts (doctors, nurses, allied health folks) need to talk to each other. Lack of communication between doctors and hospitals and PTs and schools is even more complicated because of the privacy laws. The difficulties that families have are extraordinary, especially for those with special needs. This business of dumping it all onto the school and the parents is unconscionable. How to help the underserved? The system is just too complicated; if you are not a medical person, it is really hard to navigate the system.
5) Access to care remains a problem for many people: Medicaid (Rite-Care) frequently cuts people off for no apparent reason and many poor folks don’t have the energy or resources to fight back. In Rim, poor people have rouble getting specialty care; some hospitals set up obstacles for care. Care for poor people is just not adequate, and they can’t fight their way through the system, because of a lot of little obstacles. In Rhode Island, access to health services is also in danger for low income residents by the pending Medicaid waiver, which we think should not be permitted to go through.
6) Training and workforce issues: Medical education system needs a lot of fixing: Primary care is denigrated as a field, especially family medicine and the provision of mental health services. How can we make the curriculum match the needs of the community? Mental health and primary care are the most important parts of the system, and yet get the least attention in the curriculum.
􀂃 How do attendees choose a doctor or hospital? Where do attendees get information in making that decision? How should public policy promote quality health care providers? One participant choose her doctor through her health plan (Fallon) and was very happy with that choice. Others used word of mouth. Concern was raised regarding the “lone wolf” solo practitiotioner- efforts should be made within the Federal government to encourage doctors to practice according to guidelines and in concordance with “best practice”. Government should play a larger role in workforce management- coordinate decisions with medical schools, including loan forgiveness, incentives to go into the areas of medicine that we need such as psychiatry and primary care. Currently, the salary structure drives the market in the wrong direction. If there are no guidelines, then the public is vulnerable. Information systems that hype “lack of lawsuit” as a criterion for quality are not useful. In RI, primary care doctors get paid even less than in other states, driving down supply. There just aren’t any Primary Care doctors in RI. Medicaid waiver will drive us further down the tube.
􀂃 Have attendees or their family members experienced difficulty paying medical bills? How can policy makers address this problem? One member of the group is currently fighting with a health plan over covered labwork- it was approved by her original healthplan, but when she changed plans in mid-treatment, suddenly it was not covered.
􀂃 In addition to employer-based coverage, would the group like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare? Employer purchased insurance is a major source of the problem. Employers in Canada and Denmark don’t have these sorts of problems. Doctors are pushed around by the industry. We can’t just shut it down, but we need to work out a way to make it change and to get employers out of the health care market. People in the room really wanted a single payer system, most thought that we needed to get their incrementally..
􀂃 Did attendees know how much they or their employer pays for health insurance? What should employer’s role be in a reformed health care system? Single payer is the only way to get a handle on the cost of medical care. The beauty of the European doctors and dentists are that they have a guaranteed income, and are not driven to crazy practice styles by the economic demands of the practice. We should have done it 70 years ago. Doesn’t think that employer has no role in paying for health care. Most people don’t know how much is actually costs. People don’t look at they paychecks.
􀂃 Were attendees familiar with the types of preventive services Americans should receive? Had attendees gotten the recommended prevention? If not, how can public policy help? HMO gets her a primary care doctor. EMR helps them to track the needs for screening and preventive care. There were many other comments in support of protable, usable electronic medical records.
􀂃 How can public policy promote healthier lifestyles?
Some of this will take a culture change: we will need a massive campaign promoting “slow medicine” in the same way that we are promoting “slow food”. We need to focus on preventive things that are outside of the hospital. In Europe, they are much more aggressive about restricting exposure t

General Comments:
Some folks were concerned by the lack of detail in the Obama health plan: “Did I misread this, or is there not a lot of information about children with disabilities?”
“I am not sure that this is a major priority for the administration.”
We directed people to read the website for more information (
Others were concerned that the change was not bold enough: “Why are employers not clamoring to change this?”. “The Obama folks haven’t thought this through- a soft sell for a needed revolution. This stuff is pap for the common people.”
Other countries have done this better: “We should look at Taiwan- how do they cover everyone in a for profit model?” This requires that we look at ourselves and at society in a different way. “It needs to be part of a societal campaign.” We cannot forget the poor among us “ How can we care for ourselves if we don’t care for the immigrants, legal and otherwise, in our midst?
All wanted the Health Care Transition/Reform Team to know that they need to involve us in the change, and that they need to include incentives for us to change. This has to be a win-win for all of us.
Final thoughts: “We shouldn’t be apologetic to spend more money to help people do better.” In regards hospital care, the nurse-patient ratio is a problem. At least part of the nursing shortage is caused by working conditions: people don’t want to work in the hospitals because of the quality of the workforce.” Finally, don’t forget quality: Many of the folks in solo practice have marginal qualifications and would benefit from the support of a group.
That captures a lot of it.  I actually audiotaped the session and will try to get it transcribed. Transcription is posted on the Obama-Biden website

A Digression to Help with the Transition: A Tea Party for Health Care Reform

Among the many problems facing President-elect Obama is the need to change the way in which we provide and pay for health care in America.  So, a while ago, a call went out, asking Americans to gather in groups large and small to kick around some ideas about how to do this, and give feedback to the folks currently working on plan that they want to unveil.  Kind of a Health Care Caucus.  We made ours a tea-party, and, at 3 PM today we will gather and discuss the questions posed by the incoming Administration.  My brother pointed out that it is unlikely that Mr. Obama will actually hear what we have to say, but, as I said to him back then, it is nice to be asked.  The questions, by the way, are a bit rigged;  no hints of single-payor in this mix:
1. Briefly, from your own experience, what do you perceive is the biggest problem in the health system?
2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?
3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy makers can do to address this problem?
4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?
5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?
6. Below are examples of the types of preventive services Americans should receive. Have you gotten the prevention you should have? If not, how can public policy help?
7. How can public policy promote healthier lifestyles?
Still, it a start.  We will be live-blogging our event- stay tuned for further developments.  Feel free to add you own thoughts as comments to this post.

Mental health care for children isn't the only thing that we need to change around here.

Saturday, December 27, 2008

From (and to) the CBHI: An End of Year Message

This was in my inbox from last week, and seemed worthy of comment:
Thanks so much ...
November 30, 2008 was such an amazing milestone for the Children's Behavioral Health Initiative. Its the date the Court established for the implementation of the Child and Adolescent Needs and Strengths (CANS) and the date for us to complete planning for CBHI data collection. Well, we did it! And we accomplished it with your help. Together, we met November 30th with many great achievements: Primary Care Behavioral Health Screening, two versions of the CANS, nearly 7,000 clinicians trained and over 6,000 certified, an IT system barreling toward implementation , new billing codes and nearly everything that we planned to do by this date. So, to those who attended seemingly endless meetings, drove to meetings at Hoagland-Pincus in Shrewsbury , fed your kids and then raced-off to a Family Forum, tirelessly worked off-hours responding to RFIs , RFRs and RFPs or patiently sat through the "technical difficulties" of a CBHI conference call ... we say thanks! Thank you for helping us reach this milestone and, equally important, thanks for your continued commitment to building a strength-based, family-focused system of care for very deserving kids and their families.

Happy Holidays,
The CBHI Staff
Pretty impressive year, isn't it?  We really on the way to changing the way in which we think about mental health care in Massachusetts.   And yet:
  • To the child with mental illness, it is still hard to understand that, despite your illness, you are still a child who wants to learn and have friends and do well and be good  and play in the snow, like every other child in the Commonwealth.
  • To the parent of the child with mental illness, it is still hard to find a mental health therapist who fits your schedule, takes your insurance and gets along with you and your child.
  • To the primary care doctor caring for a child with mental illness, it is still hard to know how to stay in touch with and contribute to the ever growing team of professionals working with the family
  • To the mental health therapist seeing the child, it is still hard to keep up with the paperwork required by most of the third party payers to provide evidence-based treatments for the children entering our increasingly integrated system.
  • To the teacher working with a child in treatment, it is still hard to know when education ends and mental health treatment begins.
So, as we move past solstice and into the next year, we should all applaud the CBHI for leading us through this tangled web, and we should applaud ourselves for the work and change that we have brought to the system.  Then we need to get back to work.  The new system's bones are falling into place, but we still all have a lot of meat to put on them.

Friday, December 26, 2008

I'm back: With a note on the recent issue of Pediatrics

Bread is done, abstracts are graded, and I have a backlog of things to blog about. Here's one that is relevant to the folks putting together their CSA's:
Pediatrics, the official journal of the American Academy of Pediatrics recently published an article in it’s electronic edition that would be of interest to you all. It comes out of Boston University, and, since it was published in the electronic edition, can be accessed here Titled "You Get What You Get": Unexpected Findings About Low-Income Parents'”, the authors write about their analysis of a series of audiotaped interviews collected over a 5 year period in which low-income parents were asked to reflect on their life experience. The authors were surprised to find that parents had strongly held opinions regarding their interactions with community-based organizations. To quote the authors, they found that:
(1) "engaging with services sometimes meant subjecting oneself to requirements perceived as unnecessary and, in the extreme, having to adopt the value systems of others;
(2) accepting services was sometimes perceived as a loss of control over one’s surroundings, which, in turn, was associated with feelings of sadness, helplessness, or stress;
(3) individuals staffing community agencies were sometimes seen as judgmental or intrusive, and when many services were accessed concurrently, information
sometimes became overbearing or a source of additional stress; and
(4) some services or advice received as part of such services were perceived as unhelpful because they were too generic or formulaic.”

As one who works in the community, this feels about right. Conflicting world views, judgement, loss of control and poor quality services are complaints that I here from all of my patients who need to confront the system, whether it is an insurance company or a school system. The difference is that many of those with money are able to do something to increase their control over the situation. So what does this imbalance of power mean to those of us trying to work with underserved populations?
1) Listen. A lot. When you think that you have heard enough, listen some more. We need to really understand where our patients/client are coming from in order to know what services they need and to offset their feeling of being shuffled through a system that is not grounded in their reality.
2) Stay in touch. When you send someone off to another agency, you asking them to take a leap of faith. Be there to help them through the sense of loss of control.
3) Lend them your strength. Empowerment is sometimes a cliché, yet the value of knowing that someone has your back is immeasurable.
4) Bend when possible. One size of service will not fit all, and you need to adapt to the person in front of you in order to help them.

We all knew this already, but this is a nice piece of qualitative research that suggests why being patient/client centered is so important.

Thursday, December 25, 2008

Bread Recipe

There has been a clamor for the recipe for the Swedish rye bread that has kept me out of the blogosphere for the last few weeks, so I thought I would devote at least one post to that:

Swedish Rye 
(makes 1 full size or 4 small loaves of bread)

First make the sponge:

Scald 1 cup of milk (whole is best, but skimmed works for those of you counting cholesterol)
Pour it onto a mixture:
  • 1 tablespoon butter (can substitute margarine)
  • 1/4 cup honey
  • 1.5 tsp fennel
  • 1.5 tsp instant coffee
  • 1/4 tsp salt (can omit, if you want)
While the mixture is cooling, add 1 packet of yeast to 1/4 cup of lukewarm water, and let it bubble. Add it to the scalded milk mixture after that mixture has cooled to lukewarm.
Then add:
  • 3 tablespoon sugar
  • 1.5 tsp orange peel
  • 1/4 tsp ground cloves
  • 1 cup of rye flour
  • 1 cup of whole wheat flour
  • 1/4 cup white flour.
Stir with a wooden spoon for 100 stirs and then leave the sponge to rise for 1-2 hours.

Then make the loaf:
Add 2 cups of white flour to the sponge, gradually kneading until firm and consistent.  Usually takes about 10 minutes for the whole loaf, and another 5 minutes if you choose to break it into small loaves.  Once your loaves are ready, let them rise in a warm place for an hour or two.

Preheat oven to 350 degrees.
Bake 50 minutes for full-sized loaf, 35 minutes for small size loaf.
Cool on rack, and then:
Devour with honey or peanut butter (also makes a mean grilled cheese sandwich).  Both the making and the eating of this bread will improve your mental health.  Sunny Solstice, Happy Hannukah, Merry Christmas, Kwazy Kwaanza and a tip top Tet to all!

Tuesday, December 23, 2008

Christmastime at the Blog: Rosie D at the turning of the year

Been a while since I posted, which doesn't mean that there is nothing going on the in the world of children's mental health reform in Massachusetts.  It mostly means that I have been baking bread, a nice Swedish rye that my nieces call "limpa", but isn't quite.  What it is, is delicious, and a little time consuming, and I've make close to 100 loaves in the last week.  Now if it can just get the gifts wrapped tonight.....
I'm sitting on some interesting stuff, too, that would be worth a bit of commentary:
CMS Update
The State Plan Amendment for Intensive Care Coordination has been officially approved by the Centers for Medicare and Medicaid Services (CMS). We continue to have helpful and productive conversations with CMS about the six remaining Remedy services.

The whole plan depends on Medicaid being able to cover ICC as well as the other intensive home based services, and that requires Federal approval.  It's great that we have approval for the care coordination, but without the other services, then the wraparound will only be partial.  Congratulation to the folks at the CBHI for getting this done, and we can only hope that they can get the rest together soon.

Perhap I'll post the recipe for my Swedish rye bread on Christmas.  Until then, hope that the holidays are treating you well.

Thursday, December 18, 2008

Biederman Responds to Charges of Pharma's Influence

Original post, December 7th, 2008:  So, a week later, Dr. Biederman sent out his response to the charges that his Center at MGH has been tainted by Johnson & Johnson's money as it may the world safe for respiridol.  Check out his comments in the Globe here.  Apparently, he was not available for comment when the story broke, but has written a letter to the Globe, in which he points out that he was always transparent about the source of his funding, given that he named to the Center the Johnson and Johnson Center.  I find myself wishing that the Globe had simply published the letter, rather then simply reporting on it.  Would have been more interesting.
Update, December 18th, 2008:  Dr. Biederman has a letter in today's Wall St. Journal, saying that essentially that the appearance of corruption is in the eye of the beholder. He accuses the Journal of poor journalism.  I applaud the Journal for actually printing the letter.

Update 27 Dec 2008: Check out Marcia Angell's excellent article in the New York Review of Books on the same subject. This one just won't go away.

Wednesday, December 17, 2008

More on the Cuba Trip

Not a mental health post, but for those who haven't heard enough about my recent foray to Cuba should check out Fitzhugh Mullan's post on the Health Affairs blog here.  I have some thoughts for some mental health blog posting, but I have been baking a lot late in the night (holiday bread);  more thought to follow.

Saturday, December 13, 2008

Blogging One Year On: What Have I Learned So Far.

I noticed that week that it has been one year since my initial foray into blogosphere.  I started the blog in part as a way to chronicle my Physician Advocacy Fellowship, in part to share information that I was acquiring in dribs and drabs about the implementation of the Rosie D. case and the progress of children's mental health reform in Massachusetts and in part to get me to put words on a page in an environment a bit less harsh than that of the academic literature.  So, here we are, 186 posts later (about one every other day) with a regular audience of 10-20 hits daily, mostly within Massachusetts and surrounding states, and blog that has kept me in touch with the movement for Children's Mental Health reform in Massachusetts through the improbable rise of Barack Obama.  What have I learned:
1)  Blogging is an effective way to share information within a small group of dedicated activists.  The blog has been used by hundreds of people seeking information, and is read in the State House as well as in the Berkshires.
2)  Blogging can be an effective way of sharing information with folks behind the firewalls.  I'm a doctor, with no special connections to the organs of power.  I can meet with the folks who make decisions, but it often involves driving to Boston and parking.   Blogging is more efficient.
3)  Interest in blogs grows as they become more useful.  My links are numerous, and I try to comment on what is going on the world.
4)  Blogging in realtime is helpful to folks who can't make the meeting.
I've probably learned more things, but they haven't made the cut.  Going to sleep now.  Please make sure that you keep on reading.

Friday, December 12, 2008

Psychopharmacology and the Evidence: Meeting our New Child Psychiatrist in Chief

UPDATE: The CBHI Provider Conference Call on CANS scheduled for Friday, December 12, 2008, from 12:00 p.m. to 1:00 p.m. has been postponed to January 9, 2009 from 12:00 p.m. to 1:00 p.m.

Much weather in New England today-  the road on which I travel was flooded today, sloowing traffic to a crawl and making me late to Pediatrics Grand Rounds.  Unfortunate, really, as I wanted to hear this one badly.  At UMass, Jean Frazier MD was recently appointed to be the Vice-Chair of Psychiatry and Chief of Child Psychiatry at UMass Medical School.  Her introduction to our Department (Pediatrics, please note) is a talk on the current state of the evidence in the use of atypical antipsychotics in children.  She is a careful researcher, who had one pretty straightforward message for all of us;  while there are a lot of small studies of the use of various atypical antipsychotics in the treatment of bipolar disorder, PDD/autism and early onset schizophrenia, the sample size in general has been small, the outcome measures are limited and that there is not a lot of evidence that the newer agents are really much better than the older medications.  We really need to be doing more studies to understand these medications.  
Her major interest is in the children who are, in the child psychiatry world, the sickest of the sick.  She seemed to be most excited about the TEOSS study,  a study of comparing the use of two of the new drugs(Risperidone and Olanzapine) against one of the first generation of antipsychotics (Molindone) in the treatment of psychosis in children, that was not funded through pharmaceutical funding.  They looked at medication impact, medication side effects and tolerance of long term treatment using a multi-arm randomized controlled trial.  They managed to enroll 119 patients, the largest non-pharma study of these really sick children.  They had lots of weight gain, particularly with olanzipine (Zyprexa), some akanthisa (restless leg syndrome) and elevation in prolaction. The medications are fairly similar treatment outcomes in all three agents .  (molindone: 50%; olanzapine: 34%; risperidone: 46%)   Her main conclusion with that none of these medications were the silver bullet and that these children are very sick, and that careful evaluation of side effects is at least as important as treating the symptoms.   This is the quality of research is really encouraging to see;  she seems a careful prescriber who is acutely aware of how our understanding of psychopharmocology needs to evolve over the next few years.

For clinical practice, she pointed out that, for most of us, we will never see a child with early-onset schizophrenia, and that, in the use of the second-generation antipsychotics for bipolar disorder, it is not clear that high doses of the medication are better.  She is concerned that we are creating a bit of public health problem, as weight gain and even metabolic syndrome, can happen within the treatment.  She urged us to monitor lipids, glucose and hemoglobin A1C, and really push the use of exercise.

One thing I did notice in her compilation of data:  the pharmaceutical industry does not do head to head comparisons of new medications with the older medications-  they will only fund comparisons with a placebo arm.  What is wrong with this, you may ask?  It makes it harder to do detailed comparisons of the relative advantages and disadvantages of the newer and the older (read generic and less costly) medications.  It seems to me, after listening to Dr. Frazier, that one thing that we could do in the government to lessen the "pro-pharma" bias of studies is to create regulations within the FDA that require such studies as a condition of approval.  Probably not as easy as it sounds, but worth pursuing.

It will be nice to have a researcher of this caliber in our midst.

Wednesday, December 10, 2008

From the CBHI: An Updated timeline

Community Service Agency (CSA) Request for Response (RFR)
Updated Timeline-12/9/08
The deadline for the CSA RFR has been extended to allow those providers – who submitted a letter of intent to bid – additional time to assess their interest in submitting a proposal and to incorporate into their bid the Division of Healthcare Finance and Policy’s final rate determination for Intensive Care Coordination (ICC) and Caregiver Peer to Peer Support Services. The Massachusetts Behavioral Health Partnership (MBHP), in collaboration with the four MassHealth-contracted managed care organizations (MCOs) – Boston Medical Center HealthNet Plan, Fallon Community Health Plan, Neighborhood Health Plan1, and Network Health – announces the following updated CSA RFR procurement timeline:

Milestone Original Date Revised Date
RFR due 1/06/09 1/26/09

announced 2/10/09 3/6/09

period 2/11/09  3/6/09
– 6/29/09   – 6/29/09

Implementation 6/30/09 No change

We are also announcing that $3.2 million have been identified to assist with ramp-up needs of each CSA, including costs associated with loss of productivity for staff persons who are in attendance at required, state-sponsored trainings. Disbursement of these funds will depend on the start-up needs for each CSA, which may vary.

Tuesday, December 9, 2008

Another chance to talk to the CBHI: CANS Application - Fri, Dec 12th

UPDATE:  The CBHI Provider Conference Call on CANS scheduled for Friday, December 12, 2008, from 12:00 p.m. to 1:00 p.m. has been postponed to January 9, 2009 from 12:00 p.m. to 1:00 p.m. 

The Executive Office of Health and Human Services (EOHHS) invites behavioral health providers and other interested parties to join a statewide conference call on the Massachusetts CANS tool on Friday, December 12, 2008, from 12:00 p.m. to 1:00 p.m. Registration is not necessary.
During this call, Jack Simons, Assistant Director of the Children's Behavioral Health Initiative and other Commonwealth staff will:
  • discuss instructions for using the CANS Application upon release in late December 
  • review unanswered questions from the previous 12/5 conference call 
  • answer your current CANS questions* 
*In addition to asking questions "live" during the conference call, participants can forward questions in advance to

CANS Conference Call Information
Date: December 12, 2008
Time: 12:00 pm - 1:00 pm
Phone: 866-565-6580
Passcode: 9593452 (then press #)
Children's Behavioral Health Initiative
email us:

Friday, December 5, 2008

From the CBHI: ODDS and ENDS

Release Timeline for the Web-Based CANS Application
Please note the following important information on the release timeline for the CANS application.
Development and testing is progressing for the web-based CANS application that will be accessible through the Virtual Gateway (VG). The CANS application will now be rolled-out in two stages, with the first release to occur by the end of December 2008 and the second release to occur in spring 2009. Please note that providers who are required to use CANS are also required to utilize the web-based system when it becomes available. Providers who have registered with the VG for the CANS application will receive an e-mail when the system is operational.
The first release, which will allow providers to develop familiarity with the system, will ask providers to document certain demographic information and to answer the questions that determine whether a child has a Serious Emotional Disturbance (SED). For providers who have used the paper CANS form, the information requested will mirror the SED questions found in the first three pages. The second release will add the questions from the CANS evaluation tool.

Provider Conference Call: CANS Update - Fri, Dec 5th
The Executive Office of Health and Human Services (EOHHS) invites behavioral health providers and other interested parties to join a statewide conference call on the Massachusetts CANS tool on Friday, December 5, 2008, from 12:00 p.m. to 1:00 p.m. Registration is not necessary.
During this call, Jack Simons, Assistant Director of the Children's Behavioral Health Initiative, Carol Gyurina, Director of Analyst and Contracting, MassHealth Behavioral Health and other Commonwealth staff will:
  • discuss CANS implementation including the use of the "Paper CANS" during the period prior to the release of the Web-based system 
  • review unanswered questions from the previous 11/21 conference call 
  • answer your current CANS questions 
Next CANS Conference Call Information
Date: December 5, 2008
Time: 12:00 pm - 1:00 pm
Phone: 866-565-6580
Passcode: 9593452 (then press #)

Help Wanted
Have you used the MA CANS tool? If so, we'd like to hear from you. Please send us an e-mail at and share your experience, thoughts and opinions (good and bad) with us. We want to hear from you.

Staff Not Taken CANS Training?
If you are a provider or a clinician who hasn't attended CANS training, please call the Massachusetts CANS Training Center at (508) 856-1016 or e-mail at Hurry ... over 5,486 of your colleagues have done so already!

Question of the Week:
What address do I use to send you a completed Paper CANS?
Answer: No, please don't send it to us. All information recorded in the form titled "Identification of Children with Serious Emotional Disturbance (SED)" and in the CANS must be retained as part of the medical record.

Got a question? Send it to us at

Children's Behavioral Health Initiative
email us:

Thursday, December 4, 2008


I'll write more later, but I am currently in Philadelphia after leaving Havana this morning.  Two images:  a family immigrating, the school-aged child enthusiastic,  the father taciturn and the mother weeping quietly as she leaves that most beautiful island, green and verdant and decaying.
The Everglades as we land; the house-lawns are green and the Everglades are a desert, with canals siphoning the water to Miami.
I'm home.  Got to board now.
I've been back for a few days, and opened my paper today- the NY Times magazine has a brilliant cover story that summarizes my thoughts about Cuba pretty well here.  I think that I will refer you to that.   He really captures the terrible beauty of a revolution that achieved so much at an unbearable cost:  "Cuba catches my heart and then makes me count the cost of that enchantment".
Another addendum:  The New York Times is on a serious Havana kick-  check out Roger Cohen's column here.  I hereby volunteer to bring Ilse to Havana, so that we will always have Paris.  And I feel the same way about New York.

Our Presentation in Cuba

I couldn't post this when we were down there, as the bandwidth was not sufficient to load the 13 pictures.   Valerie Zolezzie-Wyndham and I presented this talk to an audience of about 50, and got positive feedback from several folks, including one Pediatrician from Cuba.  My work on the Medical-Legal Partnerships has been very exciting, and you can read more about it here.
Thank you. Medical-legal partnerships are collaborative programs that have been established in more than 100 hospitals and clinics throughout the United States since the founding of the first program at Boston Medical Center in 1993. They provide direct advocacy services to families who lack access to social systems that can offset the social factors that affect health. Many of these Partnerships also serve as sites for community-engaged education, allowing health care students in a variety of professional education programs the opportunity to 
understand the impact of poverty on the health of children and families, and the potential for health professionals to intervene on behalf of children. After I briefly outline the model and common structures of these programs, my colleague will highlight the ways in which 3 of these Partnerships have integrated undergraduate and graduate medical education training into the structure of their Partnerships, to the benefit of the programs, the patients and the students.

The American Academy of Pediatrics “recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly, on the health and functioning of children.” Housing, utilities, food, employment, income, health care, to name a few , are of paramount concerns to families. Unmet basic needs can profoundly affect the stability of a family and the health of a child.

-   With insufficient money for food, a child who is already failing academically goes to school hungry.
-   A landlord’s failure to fix leaky pipes and eliminate vermin can have dire effects on the health of children.
-   Children who live under threat of deportation lay awake at night, anxious that a parent or caregiver will be sent away to their home country leaving them alone.

In the United States, there is a complex “safety net” to buffer families and in particular young children against the impact of the social determinants of health, regrettably the safety net is often difficult for those most in need to access. The social programs that make up the “safety net “ have complicated and intimidating rules which impede access and can interrupt the continuity of services.  Negative social determinants that can be remedied with legal advocacy often manifest themselves in a scheduled appointment or sick visit. The problem is that providers are not trained to identify a solution. So, can we teach medical students, residents and other health care workers that:
- Housing codes, when enforced, ensure safe conditions for children’s growth and development
- Utility protections can prevent power shutoff, allowing light and heat for families during the winter
- Maintaining health insurance in the context of ongoing documentation requirements is challenging for low income families and can interrupt care. 

Medical-legal partnerships allow physicians and lawyers together, to address the social factors that affect child health by ensuring a coordinated advocacy plan that tackles legal and medical issues likely to affect child health outcomes Medical-legal partnerships typically include three programmatic components: 
1) provider training on how to identify legal issues and how they affect health, 
2) legal advice and counsel for patients and families in need, and 
3) systemic advocacy to improve child health.

Today, we are focusing on the use of Medical-Legal Partnerships as vehicles for training in medical education. In 2007, medical-legal partnerships around the county conducted over 950 training sessions by both medical and legal staff. These trainings reached approximately 17,000 people. The majority of trainings conducted were for frontline health care staff, and the primary audience was medical faculty, residents, social workers and case managers. The trainings extended to staff in pediatrics, family medicine, internal medicine and other clinical settings.

The training process is central to the development of the partnership. Physicians need to learn how they can identify legal problems that can affect child health during their medical assessment. Attorneys need to learn how physicians approach clinical problems and what sorts of things they are likely to learn about their patients. Attorneys and physicians involved in medical legal partnerships often work together to create curriculum and to lead trainings that teach health care workers about the social determinants of health. Models of training vary, depending on the nature of the partnership and local educational resources. My partner will highlight the models of training used in three partnerships in New England: the Medical-Legal Partnership for Children of Rhode Island, a partnership of Hasbro  Children’s Hospital and Rhode Island Legal Services in Providence, RI; Family Advocates of Central Massachusetts, a partnership of UMass Medical  School and Legal Assistance Corporation of Central Massachusetts in Worcester  MA, and the Medical-Legal Partnership/Boston a partnership housed at Boston Medical Center in MA. We hope that by examining these collaborative teaching experiences other educators will develop an interest in developing similar inter- disciplinary educational programs that attack the negative social determinants of health.

The Rhode Island Medical Legal Partnership for Children is a collaboration among five medical and legal partners. The Partnership offers a joint course in Poverty, Health and Law, which brings together medical students at Warren Alpert Medical School at  Brown University and law students at Roger Williams University School of Law in a joint seminar program. The training is focused on three areas: professionalism, interdisciplinary skills, and the social determinants of health. The students examine several case studies, including the relationship between childhood asthma and safe and affordable housing, child development and lead paint and the domestic violence and family function as issues that demonstrate the need for a multidisciplinary approach.

A recent publication examined the self-reflections written by students for the course, and found evidence that course participation led to positive understanding of the values of diverse professional viewpoints and a positive understanding of their own role in the profession. “By taking away professional labels, one is able to focus solely on the client herself, her problems, and her concerns.” one student wrote, “Once this is achieved, then the labels of the professional can come back into play.” This kind of insight can only occur in the context of cross-disciplinary discussion. Some challenges in the logistics of the course were also noted. Medical school and law school calendars don’t match, the medical school is 30 miles distant from the law school and the styles of learning are quite different. With appropriate effort, however, collaborative teaching can open an interdisciplinary discussion about the social determinants of health.

Family Advocates of Central Massachusetts is a partnership of the Legal Assistance Corporation of Central Massachusetts and several primary care practices affiliated with the University of Massachusetts Medical School. For the last five years, it has been one of the sites used by students from the Medical School and Graduate School of Nursing on their Community Clerkship, a two to three week block rotation lets students learn about social issues affecting patients from different perspectives. In our rotation, the students shadow doctors in our partner practices, and participate in court proceedings involving families served by the M-L partnership. They also investigate a public health problem within our catchment area, and document the problem on a “public Health grid”. Finally, the students journal reflectively, and prepare posters to share their reflections with the other groups.

Feedback on FACM’s participation in the Clerkship has been overwhelmingly positive. As one student said ““I am gaining more background and insight into the where these kids come from … I have never had first hand experience in this type of context … Every court case I sit through or patient I shadow has real, immediate needs and their lives do not stop while I reflect on what it may mean to walk in their shoes. …These days have empowered me to make a difference moving forward but have also overwhelmed me as I face the vastness of our responsibility to patients...” This insight, achieved early in the first year, may help this student and others like him or her achieve much going forward into their clinical work.

The Boston Medical-Legal Partnership for Children is the founding program in our Network, and is well integrated with the Boston Combined Residency Program, which brings together Boston Medical Center, a “city hospital model program”, and Children’s Hospital Boston, a national leader in pediatric research and training. The Partnership runs several programs within the Residency: a poverty simulation during resident orientation to raise awareness of the social factors influencing patient health, a two-week block of didactic, observational and clinical activities in the primary care track that provides foundation for future work, and pre-clinic and noon conferences for all residents working in a primary care clinic at BMC. Beginning in spring 2009, MLPC will partner with physicians in internal medicine to pilot a four-week course for all primary care interns, moving out of pediatrics into the other specialty areas.

At each of our programs, medical students have become involved in ongoing research, assessing our educational modules and assuring the quality of what we have done. One project, involving the development of a brief screening tool to identify those most likely to need services, was extremely successful, and was published in a peer-reviewed journal. Others have been presented at national and regional meetings. These projects all demonstrate a depth of commitment that should be cultivated in the learners who will be the next generation of leadership within community health.

At our programs, and at many of the programs throughout the United States, participation in Medical-Legal partnerships by clinical faculty has led to the integration of heath equity into the clinical teaching of our institutions. The Partnerships serve as a model for presenting diverse views of the complex problems associated with living in poverty. As more Partnerships develop, we expect that participation in a medical-legal partnership will enable medical faculty to address the social determinants of health while addressing the critical needs of low income families throughout the United States.   Thank you for your attention.
It's amazing how fast ten minutes goes.

Wednesday, December 3, 2008

Day 4: Workforce Issues: You Think We Have Problems?

So, I am sitting in a room today- no presentation pending, no real obligations other than paper and grant reviews, and a day of listening ahead of me. The interpreters were not in yet, so I am actually translating this in real time. Sorry for any misunderstandings. The opening speaker is the head of PAHO, speaking on the need for community-based education for primary care in Latin America. PAHO has a set of pillars that look, on face, a lot like those of the AAP. But the topics are difficult (the translators were not in at the start of the talk). I think that they translated as Primary Care for All, Protection of the Public Health, and Promotion of Social Justice. She had a very nicely done graphic to demonstrate the maldistribution of doctors (South America doesn’t do so badly compared to Africa) and the maldistribution of nurses (in which South America does badly). Only Cuba, Puerto Rico and Ecuador have more nurses than doctors- that represents a problem for the delivery of modern health care. She also highlights the ratio of doctors “in the Capital” (which in the Latin American context means urban) and the in rural areas. Finally, they spoke of the North “brain drain”: 1/3 Haitian and Jamaican doctors, 1/6 Dominican and 1/10 from the rest of Latin America (except Cuba) immigrate to the English speaking world. This is a horrible loss of resources for the Latin world. Similarly nurses also head North, for better wages. US imports nurses from the Phillipines and Latin America in really large numbers.
She then spoke of the role of Latin American medical education in this process. She spoke of the many medical schools in Latin American. PAHO issued a Call to Action in 2006 outlining an approach to the problem: Collaboration for the Health. It has components that address maldistribution, competency, quality, migration and regional planning, and she feels should form the basis of movement forward. The key is to her is one of planning: manpower management and curriculum should be driven by government planning.
What is interesting to me is the lack of interest in this and many other presentations at this meeting in the impact of market imperatives and the desires (rather than the needs) of the people being served. The underlying assumption is that we experts can effectively engineer social markets and institution, engaging the public in the process in a way that leaves the experts effectively in charge. That assumption is not widely shared in the United States, even within the government. We tend to distrust government’s ability to effectively organize anything, a tendency that has become really entrenched in the last 25 years. Both sides of this argument use the same examples to “prove” their arguments. The Canadian health care system is spoken of with reverence by the “government is your friend” school of thought. The same system is a symbol of what is wrong with socialized medicine that deprives patients of their right to an MRI by the other. Ditto Cuba. A centrally planned system is able to push Primary Health Care to some extent. But market forces drive those same doctors to specialize and immigrate to where they can make more money. Aside from locking the gates, no one has any great ideas on how to fix that.
This section is actually running on time. The opening talk is from Joel Lamphear, who spoke in the opening session, about his new program in Northern Ontario, at a new medical school devoted to primary care in the North (coolness: opening slide was in English, French, and Ogicree (First Nations language)). Cavieat: the medical school is only 3 years old. Concept: Distributed Community Engaged Learning: Uses a variety of community partners as “nodes on a grid” with important contributions to make to their education. It is an immersion experience in the context in which they are likely to practice. Their clinical rotation is 8 months long, and combines the medical specialties in small communities. The challenge is meeting LCME requirements; how do you establish common educational objectives and evaluation standards in those multiple settings? They have put lots of energy into this: they have extensive documentation of experiences, OSCEs, tests (standardized and otherwise), and a research and reflection exercise. The data shows that they are actually teaching in an effective manner. Interesting experiment in medical education- I hope to hear more about it in the future.
The next talk was from South Africa and was not about primary health care training. South Africa, it turns out, has a 10% prevalence of alcohol abuse or dependence, and no facilities for treatment (sound familiar). He looked at how GPs deal with this problem: do they do Brief Interventions? Why not? He surveyed 50 solo practicing GPs, seeing on average 21 patietns per do, most with no training in alcohol. Most do not screen for alcohol use, and many don’t even make the connection between physical complaints (liver disease) and alcohol consumption. Most of them don’t screen because they don’t think that it is their job to do so, and that they don’t know what to do with the information that they have obtained.
The next talk was about chronic disease management, which has moved from a single disease focus model, moving to an integrated model of chronic disease management (that looks suspiciously like primary health care) based on an employer based model. Examples: Dow Chemical has improved diabetes/hypertension/cholesterol risk. A company in South Africa was able to intervene effectively in HIV/AIDS in South Africa. The presentation was glaringly different in its lack of reference to primary health care, and its emphasis on the economic impact of disease on the company (rather than on the patient). The language of this conference is quite different than that of the standard medical meeting in the United States. Is healthcare a right, or is it a commodity? The US point of view is minority view.
After the most vigorous debate that I have yet seen at the meetings (the last presentation clearly struck a nerve in the minds of many), we resumed with this potpourri of talks. The University of South Carolina is teaching its Medical Students to the use hand carried ultrasound in their clinical assessments. He says that the cost is currently $20,000/ machine, and the goal is to get the cost down to $5K, at which point ultrasound will become the stethoscope of the 21st century. They use it in teaching anatomy, studying heart physiology, pathogy and physical examination courses in the preclinical years. It has also been incorporated into the bedside rounds of the internal medicine rotation, and has been incorporated into all of clinical rotations. They are also using ultrasound in to teach ultrasound-guided procedures. And they moved it into Global Medicine, taking it to Haiti and using it in diagnosis and treatment at Hospital Albert Scheitzer. Nice application of technology to the third world and beyond.
Leaving technology, we went to Tanzania, where we heard the case for the social science in Medicine. Anyone who looks at the distribution of disease burden worldwide knows that morbidity and mortality are related to the social system in which you work. Malaria and tuberculosis in Tanzania are a consequence of social isolation and poor sanitation. I really couldn’t follow his logic very well, and the way in which he sorted his slides made it very hard to follow. While I found this difficult, the Cuban medical students gave him a standing ovation.
So I thought that this would be a session on workforce issues- in fact, it was a session about—well, a bit of everything. There were more presentations, but I could not really connect them in a thematic fashion. This mélange highlighted one of the key issues in discussing health at a global level is getting us to talk about what each of us means when we are talking about the workforce- the distribution (PAHO and Ontario), the nature of training (Ultrasound, Alcoholism and Social Sciences) or economic forces (corporate support). One must approach these things will an open mind and sometimes interesting connections will be made.

FEEDJIT Live Traffic Map