Our Man in Havana: Conference Day 1

We met today in the Hotel’s Teatro Parisienne, which hosts a cabaret show in the evening. This morning, it filled up with international medical educators, sitting at cabaret tables for the opening plenary sessions. The room is bit musty, but that sense is overwhelmed by the sense of anticipation. The opening speaker is Fitzhugh Mullen, the only name that I recognized on the agenda, and I have high hopes that he will speak in English, facilitating my understanding. Fitz’s talk was entitled “Doctors and Flat Screens: The Poblem of Global Brain Balance.” Physician immigration is a problem that mirrors our experience with mental health workers in Massachusetts He felt that this problem, underlined in yesterdays talk, required active interventions on our part. Three things drive physician workforce equity: Location (rural ⇒ urban), migration (North trumps South) and specialization (Procedures trumps generalist). These are ongoing threats, inboard into our system of values, and need ongoing support, rather than episodic programs to counter it. This became really clear during the HIV epidemic, when programs to get antiretroviral medications failed because there no one there to give out the medications. 25% of trainees in the US are IMGs, mostly from poor countries. He showed that it is likely that the drain will continue or increase, unless the Northern countries should train toward self self-sufficiency, and consider making political and financial commitments to make this happen.
So how does this relate to mental health? Read “mental health workers seeing MassHealth” for “the South” and you have the same issues. Mental health workers migrate from public to private practice, from rural to urban practices and increasing specialization, often omitting children. Policy measures to fix this are also similar, so far mostly good intentions that don’t override the economic imperatives. As one of the questioners pointed out, the US medical education system is perfectly designed to develop the workforce to staff our procedure-driven, subspecialty heavy medical workforce. In mental health, the system drives people to private practice in wealthy areas in an efficient manner. I was looking for the answer to this problem in Fitz’s talk- I didn’t hear it.
We then moved into a panel discussion on how to get there. Traditional Medical Schools need to become Socially Accountable Medical School. How do you get the health needs to match the market needs? What is the incentive for folks to do this? A few schools have gotten onboard. The have picked a number of schools in Australia, Canada, Venezuela, South Africa and the Philippines as exemplary in this regard. We started hearing from Flinders, who addressed the issue by creating rural sites and indigenous communities in Australia for medical education. He thought that the training site was key- you practice in places like the place you grew up in. We then heard from the Phillipines, a major source of doctors and nurses for the North countries. Their approach is to integrate the students into the problems of the community in which they work. The also based their curriculum on the community needs assessment, and recruit specifically from the lower classes, encouraging them to stay in their community. In Canada, a new school was started in a part of the country that had few doctors. They based their curriculum on research showing things likely to result in a graduate remaining in rural practice are rural upbringing, positive experiences in rural setting and targeted training in residency training. They recruit locals, often aborignal and Francophone communities, and use a distributed community based education through all 4 years, These approaches on may have something to offer us