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An Innovative Way to Teach Hospital Leadership and Administration in Residency

by Andrea Heyn, MD, University of Arizona, Tucson.

As a family medicine resident, I have spent countless hours learning how to treat chronic medical conditions in the clinic, delivering and caring for newborn babies, and managing hospitalized patients. However, I have always wanted more experience in hospital leadership and administration, as I am fascinated by what goes on behind the scenes. I had the opportunity to participate in a leadership program offered by my residency, but it did not give me the firsthand exposure I envisioned, so I took the opportunity to design an elective that would give me experience to find out if this could be part of my career.

The elective was 2 weeks long, and consisted of two portions. I worked hands-on with Bethany Bruzzi, DO, one of the family medicine resident attendings, who was the hospital’s new chief medical officer. The first portion of the elective revolved around self-reflection and assessment. I received a 360 evaluation, completed by my supervisors, direct peers, those whom I supervise, and support staff such as the medical assistants and receptionists. This helped me identify my strengths and weaknesses with regards to effective communication and interpersonal relationships. Additionally, as part of this self-reflection process, I read several books and articles on personal development. One particular article, Connect, Then Lead, from the Harvard Business Review, helped me refine how I interacted with my co-residents as a senior resident, which was particularly helpful as someone who is a direct communicator.

The second portion of the elective involved my participation in various meetings and discussions. Each morning, we had daily hospital rounds with social workers, physicians, and nurses to discuss the discharge needs of patients. One specific example was of a patient who had been admitted for multiple weeks without a next of kin, awaiting a public fiduciary. We consequently spent hours working with the court liaison on streamlining the process of assigning a public fiduciary for future patients. We had phone meetings with the IT department advocating for physicians’ requests for changes and additions to the EMR system, with one particular meeting focused on revising discharge templates. We also met with representatives from various departments who were part of the Quality and Safety Council to discuss quarterly initiatives for the hospital.  This meeting was dynamic and progressive, with changes implemented as a direct result of feedback from staff and physicians. However, what I found most interesting was the budget discussion. I now appreciate the challenge of attempting to meet the needs of so many, from doctors requesting new ultrasounds, to the kitchen needing new stoves, while staying within the budgetary constraints. Finally, I got to sit in on the Executive Stewardship meeting and watched as the needs of the hospital were negotiated from a corporate level.

I am grateful for the opportunity to have worked alongside Dr Bruzzi. As a female physician, she is an inspiration to me as I prepare to graduate from residency and advance my career. Her promotion to CMO of this teaching hospital as a family physician speaks strongly to the dynamic role family physicians, particularly women, have in the medical arena.

This rotation has brought me to further appreciate the collaborative effort that is required to effect positive change in a multidimensional setting, where the needs of each player – patients, staff, nurses, residents, and attendings—vary tremendously. Furthermore, as I interview for jobs, prospective hires like to hear about my interest in future leadership positions, and discuss my goals and potential mentoring strategies.  I would encourage other residents to pursue leadership and administrative experiences via this direct approach. For those already in leadership roles, I ask you to create an opportunity for residents like myself to inspire and encourage us to become future leaders in family medicine.

The Importance of Refugee Care in Family Medicine

The Issue

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Jeffrey Walden, MD

Immigration as a whole, and refugees in particular, have been much in the news for the past several years. According to the United Nations High Commissioner for Refugees, as of 2018 about 68.5 million people worldwide have been forcibly displaced—more than at any other time in human history.1 Over a third of these people have crossed international borders while fleeing persecution and violence, and have therefore been labeled refugees.

While war and political upheaval have uprooted people for centuries, the plight of those fleeing persecution formally became codified into law with the 1951 Convention Relating to the Status of Refugees. Based on this definition, a refugee is someone who, “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.”2

The United States has historically resettled between 70,000 and 80,000 refugees per year, with a steep drop-off in the past several years due to changes instituted by the current presidential administration.3 With almost 30 million refugees worldwide, these numbers mean less than 0.3% of the world’s refugees are resettled in the United States in any given year. We as a nation can thereby exercise much discretion when selecting which refugees enter the United States. Indeed, the process to vet potential refugees involves security clearances by numerous federal agencies, including the Department of Homeland Security, and can take upwards of 18 to 36 months.

Historically, the United States has not discriminated a refugee’s case based on his or her ability to integrate. While this ensures granting the most vulnerable equal access to protection and resettlement, refugees may therefore arrive with chronic or serious health problems.4

The Importance to Family Medicine

Although all applicants for refugee status undergo health screening overseas by a trained panel physician, refugees may have had little prior care for any of their longstanding medical issues. Family physicians, whether in academic centers or private practice, therefore often encounter refugee patients after arrival in the United States. Learning to care for these—and by extension other—underserved patients serves an important part of the undergraduate and graduate medical education curriculum.

Refugees form a heterogeneous group, arising from areas of the world as disparate as East and Central Africa, the Middle East, Southeast Asia, Eastern Europe, and Central and South America. Despite these differences, they have some unifying factors—all refugees have faced persecution, by definition of their status. Many have been subjected to various diseases of poverty and nutritional deficiencies. All will face challenges when resettling in the United States with cultural issues and social determinants of health.

Culturally appropriate care—the type of care typically provided by family physicians—can help these patients better integrate into US society. Assisting refugees along their path toward self-sufficiency and citizenship requires developing strategic partnerships and community engagement. Fostering such relationships can potentially strengthen a clinic’s outreach in the community to address other social determinants of health for all clinic patients.

Involving Learners

Since 2014, the Cone Health Family Medicine Residency Program has sponsored a dedicated refugee and immigrant clinic within our larger family medicine clinic. Structured toward both learners and patients, the clinic serves as an intake evaluation to review the patients’ overseas paperwork, obtain medical and social histories (often the main difference between these patients and “regular” patients), screen for infectious disease, and identify any current needs or issues. The first 30 minutes of each clinic are dedicated to didactic teaching about a specific refugee topic, after which residents interview and examine the patient. The resident who sees that patient then becomes his or her primary care physician. All residents rotate through the clinic during their community medicine rotation:  2 weeks during their second year and 4 weeks during their third year.

Our clinic also serves as a rotational site for visiting third- and fourth-year medical students. This has provided students the opportunity to experience underserved care within a primary care and family medicine context. By working specifically with refugees, learners gain opportunities for advocacy, improvements in cultural humility and competence, and the ability to pursue global health work without needing to find the time or funds to travel.

Due to ongoing worldwide conflicts, issues of migration won’t be going away anytime soon. Exposing learners to such issues can broaden medical education while serving a community need. Beyond that, caring for refugees and learning how they have responded to persecution can teach clinicians valuable lessons about resilience in this time of perceived physician burnout.

Ways to Get Involved

  • Commit to seeing refugee patients in your clinic
  • Develop a refugee, migrant, or other underserved clinic within your program
  • Volunteer at an underserved clinic or health department
  • Conduct medical forensic evaluations for those seeking asylum
  • Complete N-648 certifications—a topic for a future blog post

Further Reading

References

  1. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. Figures at a Glance. https://www.unhcr.org/figures-at-a-glance.html. Accessed May 22, 2019.
  2. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. The 1951 Refugee Convention. http://www.unhcr.org/pages/49da0e466.html.
  3. Migration Policy Institute. S. Annual Refugee Resettlement Ceilings and Numbers of Refugees Admitted, 1980-Present. https://www.migrationpolicy.org/programs/data-hub/charts/us-annual-refugee-resettlement-ceilings-and-number-refugees-admitted-united. Accessed May 22, 2019.
  4. Hebrank K. Introduction to Refugees. In: Annamalai A, ed. Refugee Health Care: An Essential Medical Guide. New York: Springer Science; 2014:3-11. https://doi.org/10.1007/978-1-4939-0271-2_1

In Pursuit of Equity

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Cleveland Piggott, MD, MPH

“He died because he’s black!” screamed his mother, inconsolable in the intensive care unit as her unresponsive teenage son underwent formal neurologic examination. We had done all that we could. Mr M had experienced a cardiac arrest for unknown reasons at home, and his mom felt the emergency medical technicians treated her son differently, possibly even withholding care, because of his race. She already knew what the result of the neurologic testing would be, as did I, a second-year family medicine resident at the time. Now I’m an assistant professor, and I still remember the despair in that mother’s voice and the weight of her statement.

His mother may be right. The report Unequal Treatment showed us that health care disparities still exist among racial and ethnic groups even when you control for income, age, insurance, and severity of medical condition.1 Regardless of the facts of Mr M’s clinical course, his mother lost a son that day. Her trust and view of the health care system will never be the same. Our health care system often fails people that look like Mr M. It fails people that look like me.

Being new faculty and the only black, male member in our department of family medicine (DFM), which comprises more than 200 faculty, comes with its share of challenges and opportunities.

I love what I do. I’m so incredibly grateful that I found a job where they pay me to do what I love:  care for patients and teach the next generation of physicians. I find that to be a great privilege and honor. However, I pay close attention to what opportunities I take on, as I try to minimize the “minority tax” I have to pay.

The minority tax refers to the extra responsibilities placed on minority faculty in the name of diversity.2 This tax is extremely complex, and it is sometimes self-imposed by faculty due to a sense of responsibility they feel. For example, as a young faculty member in medical education, I know a day will come when I have to decide if I’ll be the one implementing curriculum or the one creating it. I worry that my ability to develop curriculum and essentially create change will be limited by my own obligation to make sure students of color see faculty that look like them. Nationally, only 4% of full-time faculty in academic medicine are black/African American, Hispanic/Latino, or Native American/Alaskan Native.3

Being an example for students of color is something I don’t take lightly. However, I have mixed emotions at times. I’m happy to stand with them in solidarity on issues that disproportionately affect them and people who look like them, but it can be emotionally exhausting at times—never more so than at last year’s White Coats for Black Lives Annual Die-In on the medical school campus.

During our demonstration, I felt a variety of emotions. Pride, as I lay on the ground with more than 50 medical students, residents, and other faculty as we reflected on dire outcomes inequity has in our society and the importance of health professionals using their power and their voice to advocate for change. Sad, that not a single one of my family medicine colleagues was out there with me. Tired, as I reflected on the long road ahead to achieve equity for all people. Determined to continue to advocate for equity, diversity, and inclusion (EDI) in medicine, starting with my own DFM.

Though family medicine boasts to be a specialty that advocates EDI, I was disappointed in the work happening in my own DFM. When I brought up some of my concerns with my department chair, to my surprise, he agreed. Additionally, he provided support and a stage to make improving EDI a priority in our department. I, along with some of my colleagues, formed a working group with that mission, and we called ourselves the “Justice League”.

Through the Justice League, we’re changing the culture of the DFM and have a lot of accomplishments and ongoing endeavors in less than a year of work, including the following:

  • Changing our mission, vision, and values statement to reflect our verbal commitment to EDI,
  • Providing monthly education sessions to DFM personnel on issues of EDI in medicine and how they can make change,
  • Reinvigorating a conversation among our researchers on how we incorporate EDI in all of our research,
  • Changing our website to make EDI more visible,
  • Collaborating with our clinical affairs team in changing their hiring practices,
  • Analyzing our health outcomes based on race and ethnicity at our largest clinic,
  • Conducting a climate survey to take a hard look at ourselves and areas of improvement,
  • Partnering with an outside consultant to do a training on racism in medicine,
  • Lastly, we’re in the process of creating a senior leadership position for EDI for our department and in negotiations for funding a team.

I’m incredibly proud of the work we’ve done and know we have so much more we can do both inside and outside of our department. More importantly, I look forward to seeing the impact this work and our future work will have on my colleagues, medical students, and our community.

Though I have little faith that we’ll get to equal treatment in this country, I am proud to be someone fighting to close the gap, one step at a time.

References

  1. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666-668.
  2. Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ. 2015;15(1):6. https://doi.org/10.1186/s12909-015-0290-9
  3. Association of American Medical Colleges Diversity Policy and Programs. Diversity in Medical Education: Facts and Figures. Washington, DC: AAMC; 2012.