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.