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Lessons From an Unlikely Land – Reflection From the Recent Trip to Cuba by STFM

The 1966 AMA Report of the Ad Hoc Committee on Education For Family Practice (aka “The Willard Report”) affirmed an AMA House of Delegates assertion “…that family practice is important for optimal health care…” while also expressing concerns over the adequacy of the future supply and preparation of the family practitioner. The report argued “that there is a need for a new kind of specialist in family medicine, educated to provide comprehensive personal health care…”  soon thereafter, in 1969, the 20th major specialty, “Family Practice,” was born to great promise and hope.

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Richard Streiffer MD    University of Alabama

 

Today, despite compelling and robust international evidence of the importance of a well-trained, accessible, and ample family physician workforce to the health of a population, we remain well short of that goal in the United States. I believe that many family physicians feel a sense of collective disappointment in this failing, and clearly many are dissatisfied with the narrowing scope and role of the family physician. Many are frustrated by the perception of the collective failure of family medicine to have a greater influence on the nation’s health  as envisioned at our discipline’s launch.  

Still, family physicians aspire to the role which Ian McWhinney clearly laid out his classic Textbook of Family Medicine, where he said that the comprehensive family physician:

  • sees every encounter as an opportunity for prevention
  • sees himself or herself as part of the community-wide network of supportive health care agencies
  • views his or her practice as a “population at risk”
  • visits patients in their homes and “should share the same habitat as their patients” 
  • is a manager of resources.

Elsewhere around the world, this model of the comprehensive, familiar, accessible, prevention- and community-oriented family physician is not only alive and well, but is fundamental to health systems, most of which have better outcomes than here. 

In January 2020, 25 STFM members spent a week in Havana, Cuba, where we visited one such system—the resource-frugal health care system that the Cubans have built is admired around the world for its achievements. A major motivation in visiting Cuba was to see a model where the family doctor is central and deeply inculcated into the very design of the system. 

During our week, we visited and had talks and conversations at numerous representative facilities in the greater Havana area, including a family doctor/nurse consultorio, a polyclinic, a maternity care specialty hospital, a maternity home, a diabetes specialty care center, Centro de Investigación y Desarrollo de Medicamentos (CIDEM – Cuba’s Center for Drug Research and Development), Escuela Nacional de Salud Pública  (ENSAP – the national school of public health), the Facultad Manuel Fajarod campus of the Universidad de Ciencias Médicas de la Habana (The University of Medical Sciences of Havana), and Escuela Latinoamericana de Medicina (ELAM- the Latin American School of Medicine). We also experienced the culture and values of this fascinating Caribbean land, one that at times seems stuck in the 1950s, yet whose people are happy, positive, appreciative of our presence, and have achieved so much not just in medicine, but in science, music, arts and the humanities. 

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To understand the health achievements in Cuba, it’s critical to appreciate that the “developing country” conditions—illnesses and disparities of access to care that characterized the country at the time of the Cuban Revolution in the middle of the 20th century—have been eliminated. Today, despite economic and political challenges, the overall health measures of the Cuban population are near to, and in some areas above that of the United States, and all achieved at a fraction of the per capita costs.  

How have they done this? First, health care is accessible and guaranteed for all, and prevention is first and foremost to their method. Public health and medicine, as well as attention to social determinants of health, are largely integrated compared to the United States, where the fields have largely pursued separate tracks in training and practice. In addition to these principles that guide them, the Cubans are able to articulate clear priorities that drive their resources, attention, and approach. For example, virtually every health professional we met talked about the importance of prevention and of the role of the family doctor, and how pregnant women and their babies followed, closely by the growing elderly population, are at the top of their priority list.  

Perhaps most fundamental to their success has been the foundation provided by the network of the neighborhood-based family doctor-nurse consultorio dyads. Each family doctor/nurse pair lives in a neighborhood where they care for a defined population that they can describe in some detail at the drop of a hat. They use population health methods to conduct risk stratification for their patients, and track their patients with simple, low-tech techniques like daily logs, family (paper) charts, manual screening registries, and home visits. The family doctors are in turn supported through a team of health professionals that includes an epidemiologist based out of the larger hub called the polyclinic. These polyclinics are served by general and specialty hospitals, and a series of subspecialized clinical and research institutes. Throughout the system, the role and importance of the family doctor for implementation and follow-up of any plan is reinforced. 

One of the other more remarkable institutions we visited is ELAM—the Latin American Medical School in Havana—where some 100 US citizens are studying medicine along with thousands of other young people mostly from developing countries from around the world. The Americans do so at no cost to themselves, with only the expectation that they return to their home and serve as physicians in communities with a need. We were privileged to meet with a group of these US students over dinner and learn how unique and special they are. Mostly underrepresented in medicine students, largely from economically disadvantaged backgrounds, 100% fluent in Spanish, predominantly women, disproportionately interested in family medicine careers, and well trained in public health, community involvement in health care, and low-tech, patient-centered care, they are admirably committed to the principles of population health and returning to practice in an underserved community of the United States.  

Most fascinating, this diverse group of Americans is studying in Cuba by choice. Few of them even considered or applied to US medical schools, opting purposefully for the Cuban model out of conviction of its superiority for their future service in communities of need. By training side by side with Cuban medical students and living and working in this system, these Americans are experiencing firsthand the value of the family physician-nurse team’s knowledge of their patients and the neighborhood influences; of the role of the community assessment and home visits; of the potential of prevention and lifestyle change; of how to judiciously use precious resources and a low-tech approach; and of systematic data collection to inform population-oriented priorities.

The burning question for me throughout the trip was “Are there lessons here that we might apply back home?”  Mind you, there’s no delusion here, though at times we were admiring, and perhaps a bit euphoric and somewhat envious. We all knew that this was Cuba—that quirky little embargoed island just off the coast of Florida. Our size, political, and cultural differences from Cuba are significant, so that adoption of a system like theirs is neither realistic nor advisable for the United States. Yet, there are lessons to learn from the principles upon which their successes are based, the most important one being the value of the family doctor to a health system and its ability to improve population health. 

Suggested Reading 

Bhardwaj N, Skinner D. Primary Care in Cuba: considerations for the US. J Health Care Poor Underserved. 2019;30(2):456-467.   https://doi.org/10.1353/hpu.2019.0041

Campion EW, Morrissey S. A Different Model—medical care in Cuba.” N Engl J Med. 2013;368(4):297-299.() https://doi.org/10.1056/NEJMp1215226

Gorry C. Your primary care doctor may have an MD from Cuba: Experiences from the Latin American Medical School.” MEDICC rev. 2018;20(2):11-16.

Gorry C. Cuba’s family doctor-and-nurse teams: a day in the life.” MEDICC Rev 2017;19(1):6-9.

Keck C, Reed GA. The curious case of Cuba.” Am JPubHealth. 2012;102.8:e13-e22.

Ladden M, Mende S. Field Notes: c. Robert Wood Johnson Culture of Health Blog. https://www.rwjf.org/en/blog/2015/01/field_notes_whatcu.html. Posted January 29.  Accessed February 27, 2020.

Dwamena A. Why African-American Doctors Are Choosing To Study Medicine In Cuba.  The New Yorker. https://www.newyorker.com/science/elements/why-african-american-doctors-are-choosing-to-study-medicine-in-cuba. Published June 6, 2018. Accessed February 27, 2020.

Frist B. A Look Inside Cuba’s Family Clinics. Forbes.https://www.forbes.com/sites/billfrist/2015/10/07/a-look-inside-cubas-family-clinics/. Published October 7, 2015. Accessed February 27, 2020.

Hamblin J. How Cubans Live as Long as Americans at a Tenth of the Cost. The Atlantic. https://www.theatlantic.com/health/archive/2016/11/cuba-health/508859/. Published November 29, 2016. Accessed February 27, 2020.

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