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 CBHI@state.ma.us.

CANS Conference Call Information

Date: December 12, 2008

Time: 12:00 pm - 1:00 pm

Phone: 866-565-6580

Passcode: 9593452 (then press #)

CBHI
Children's Behavioral Health Initiative
www.mass.gov/masshealth/childbehavioralhealth
email us: CBHI@state.ma.us

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 CBHI@state.ma.us 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 MassCANS@umassmed.edu. 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 CBHI@state.ma.us.






CBHI
Children's Behavioral Health Initiative
www.mass.gov/masshealth/childbehavioralhealth
email us: CBHI@state.ma.us

Home

Home.

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.

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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".

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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.

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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.

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It's amazing how fast ten minutes goes.

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.

Day 3: Presenting in Cuba: A Digression on Medical Education

There is a maxim that I need to source one of these days: “all systems are perfectly designed to achieve the results that they actually achieve”. (Internet is $10/hour here in Cuba, so I may save the research until later). The conference is fabulous and oversubscribed (> 700 attendees), but the facility is not perfectly designed for such a number. So it is sometimes a little crowded; they didn’t make arrangements for such a number to tour hospitals and the medical school, and I was unable to get my name on the proper list to have that opportunity. Still, the atmosphere is electric. People from all over the world (I heard 22 countries, but I have no official word on who is here) are gathered to discuss the complexity of integrating social medicine (for want of a better word) into the lexicon of medical education. Each country faces challenges consistent with the way in which their health care system is designed. Cuba excels at this stuff: the Cuban schools are full of examples of students getting out there and helping folks throughout the island. Mexico, Philippines, Salvador, Argentina; all have curricula that enables medical trainees to engage communities in improving their own health. They are dealing with levels of poverty and access to resources at such low levels that we would find them unfathomable in the context of the United States. It is actually possible to measure some change in health outcomes as a result of the student’s activities in some cases. In many of the programs presented, they simply don’t have the time to gather much data. The is simply too much to do. (The picture is of Valerie getting ready for our presentation)
Our session is opening late, and will begin with a discussion of “Training of Trainers at the Higher Institute of Medical Sciences in Havana”, followed by three talks about the Cuban system: “The National Diploma Course in Medical Education”, “Public Health History Course for the History of Medicine Course” and Drug Abuse Prevention Strategy of the Medical Sciences University of Havana”. I am not sure how we fit into that context, but it will be interesting. I’ll post our presentation later, but I will try to capture the flavor of the three talks (in Spanish) that precede it.
We begin: “Project Majesterio” is PAHO project of the Union of Universities of Latin America to teach how to teach in collaboration with the School of Education. They noticed that the quality of teaching in medical school suffered because professors had not undergone training in how to teach. He pointed out that high school teachers had more training in how to teach than did the medical school faculty. Their project had three principles including a commitment to teaching humanism and social justice (if I caught the translation accurately). The training is rolled out throughout Latin America, with “sub-leaders” in various parts of South America. They are using internet and tele-training to make all of this happen. One of the sites for this work is in Ecuador; where they actually have separate tracks for treachers and what we would call educational scholars- folks who do evaluations of educational interventions. What is interesting to me is how our Faculty Development and Educational Scholars programs mirror this work. We also heard from Mexico, who emphasized their connection and the need for support from Cuba to make this curriculum happen in a real way. There they are trying to start a Masters program in Medical Education, to help them to establish a reputation in a country with a large number of other Universities that have focused primarily on research. In El Salvador, Nicaragua, Honduras and Panama have a collaborative approach to their faculty development, and again speak of the social problems of Central America in the mission of their organization. They ran their first course with the folks from Havana in 2002, and have had 24 graduates for far. They use a Virtual Platform that sounds a lot like our Virtual Learning Platform”, and have expanded out from El Salvador to the other 4 countries. Interesting, they have not spoken much abouthte specific curriculum: I wonder if they focus on the teaching of science or the teaching of communication skills, as we do in a lot of our work with the Clinical Faculty Development Center?
So adding it up, they have trained more than 500 faculty members throughout Latin America. (and 34 folks have traveled to Cuba for the same training), and now have a Center for Academic Development in Health, which has online courses. Impressive program, little data presented that show efficacy of the results.(they have a system in place, that collects a lot of information of people within Cuba, but less information is available in the other countries)
The first speaker was not present, but the second one went on. She described the development of a curriculum on the history of public health for the local medical school. They used this to help doctors develop a sense of their roles in an ongoing and proud tradition, both in European and Cuban medicine. The book that she developed sounds really interesting; I am often impressed by the ahistorical nature of our more science-based education.
After that we heard of about a drug prevention curriculum in the Cuban Medical school, that was developed because of concerns that the massive drug trade from South America to “El Norte”. Apparently, the problems with which they actually deal are addiction to cigarettes and rum (similar to what we were told many years ago), they screened, found more problems than they thought, and had reasonable success (self-report) in treating them. I was interested to hear that they have expert committees on drug abuse at all of the medical schools, when it sounded like they really done have much clinical experience in the problems.
Our talk was well received, and I got a certificate; that one gets framed. About 40 people in the audience- given that it is a nice day outside, we didn’t do so badly. (THe picture is of me presenting, and we heard nice things from a number of folks afterwards, so that was good)
After us, we heard from a fellow American about the barriers to care experienced by the African-American community in the United States, which was really more of an opinion piece than a curriculum. Following him was a great speaker from Brazil who involved high school students in a community based participatory research project. She billed it as a way to promote social cohesion, and she actually measured the elderly folks response to show that they felt more integrated after working with adolescents. Nice little study, but I wasn’t sure what it had to do with Medical Education.
So overall, the session was quite similar to a meeting in the United States. The striking difference was the lack of questions; I asked one (in Spanish), but noone else did. We were running close to 50 minutes behind schedule at the start, so perhaps people were reluctant to question so that we could get back on schedule. Also, two of the eight speakers weren’t present- not sure why. But the nature of the presentations was quite similar to other medical education meetings that I have attending; a strong emphasis on program description, and little data to show the effectiveness of the intervention. Our work in the Educational Scholars program in of critical importance. I think that I will close here, although there are more presentations coming. This post has grown long enough. More tomorrow, hopefully of more relevance to mental health services.

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