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.

Fierce Women and New Stars

For a long time I thought I was lucky to have fierce women who walked beside me & now I see the real luck was that these fierce women stayed there until I learned how to be fierce myself. —Brian Andreas, Creator of Story People and Flying Edna

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Andrea Anderson MD
The GW School of Medicine and Health Sciences

These words hang on the wall of my office and were the inspiration of my remarks when I accepted the 2019 Advocate Award for my work in encouraging resident advocacy. As I reflect on my career thus far as an academic physician, it is clear that actively seeking opportunities and receiving excellent mentorship have been driving forces. It is not a secret that mentorship is important in any career path. It is crucial for us as Black and Brown medical educators.

I grew up as the daughter of an inner city public school teacher. Even now, some 20 years later, my mother’s influence is still evident when former students happily greet her around town and proudly show off their accomplishments. After high school, I was accepted into the combined BA/MD program at Brown University. Even at a large progressive school like Brown, I could count on one hand the numbers of Black and Brown faces who stood before our medical school class as faculty or deans. My school was not unique. Nationwide, the numbers of Underrepresented in Medicine (URM) Faculty in US medical schools remains well below 10% and has not kept pace with the increasing diversity among the student body or the society as a whole. One of those faces who significantly impacted me was Alicia Monroe MD, current provost of Baylor College of Medicine. She was one of the plenary session speakers at the last STFM Annual Spring Conference in Toronto. When she was our dean of Minority Students at Brown, my friends and I would go to her office to receive support, guidance, mentorship, or frankly just to see a face that looked like ours. Recently I was heartened to hear that among the reasons she was encouraged by her then department chair to pursue promotion early in her academic career was because of all the female junior faculty and women who looked up to her. I was definitely one of them. My experiences as a student leader at Brown solidified my passion for advocacy and imprinted me with the notion of my responsibility to speak for those who have no voice.  I was awarded the National Health Service Corps Scholarship and committed myself to a career in family medicine.

After Brown I trained at Harbor-UCLA and completed an academic medicine fellowship and chief resident year. I continued to raise my voice as an advocate for marginalized and immigrant populations. In Southern California I became the president of our Resident Union and collaborated with local labor unions to help fight cuts to the community health center safety net.  I began to see how I could combine my passion for social justice with my love of teaching and medical education. Rooted among hardworking new and first generation mainly Spanish speaking immigrants, I became firmly bilingual. One of my patients even called me an honorary Latina. This work became not just something I loved to do, rather, it was something I had to do.  After completing my fellowship, I came to Washington, DC to serve my 2-year NHSC service commitment.

Those original 2 years morphed into 15 years as I stayed far past my service commitment serving a largely immigrant population at a 25,000 patient FQHC in DC. I sought out leadership roles such as medical director, director of student and resident education, and director of family medicine. As core faculty for our teaching health center/GME residency, I was introduced to STFM and attended my first conference in 2015.  I applied for and was selected for the Quality Mentoring Program and the Emerging Leaders Fellowship. In DC I continue to be active in professionalism and assessment as the appointed chair of the DC Board of Medicine and as an item writer and reviewer for the NBME. As a local advocate I have had the privilege to testify on a variety of topics affecting marginized populations before audiences as diverse as the AAFP, the Association of Clinicians for the Underserved, DC government, and the Senate HELP Committee. I taught health literacy, advocacy, and health policy to the students who rotated at our center and to the residents in our THCGME residency. I am excited to continue my interests in advocacy and professionalism as a recent appointee to the Board of Trustees of the Family Medicine Education Consortium and to the Board of Directors of the American Board of Family Medicine.  During my time at Unity, I taught scores of students from the GW School of Medicine and Health Science, a DC target school without an FM presence. I served as a kind of de facto community family medicine clerkship director as FM experiences were few and far between for the students.  My work as an adjunct was recognized—I advocated for increased roles for community medicine faculty role and was accepted into the Master teacher Leadership Development Program at GW, named to medical school committees, chosen to direct the senior capstone course, and promoted to clinical associate professor. These professional opportunities were the result of hard work and dedication along with the influences of key mentors along the way. Recognizing the voids in my past student experiences motivated me to think of creative ways to combine my passion and interests with my career goals. My life was busy and full as I juggled my work with my roles as a mother of two young children, a wife, and a daughter.

Although I felt respected from my adjunct teaching position, I began to feel that I could have a bigger impact at a university level as a full-time faculty member. Years of student and faculty advocacy for FM at GW caught momentum and I was asked to join the leadership of a small new Division of Family Medicine. This switch necessitated that I get firmly on a full-time academic track. But on the other hand, I loved my FQHC patients, families who I had cared for for generations. I struggled with how to advocate for them, full of angst as I announced my decision to leave. Several cards and letters of gratitude poured in from my patients and friends.  However, one from a teenage patient I have cared for since she was in kindergarten left a permanent mark on my heart.  In her adolescent script she said:

Don’t worry about me, Dr Anderson, I will achieve my dreams. I appreciate you so much.  But I know it is time for you to move on, time to make new stars. Many students will appreciate your hard work so they can light up their dreams as well.”

So this year at commencement, I will walk in my academic regalia, this time with the other full-time faculty. When I hear those bagpipes I am again reminded how proud I am to be an African American woman in academic medicine. In the spirit of those who have mentored me along the way, I march proudly and cheer for my students. As URM faculty, our presence says that we are still here and you can be here too. We are contributing, shaping the scholarly discourse of primary care, medicine, and public health for years to come. I nod to everyone, but especially to all those grandmothers and parents and aunties and uncles of color who have sacrificed, sweated, and prayed so that their loved ones could achieve their dreams. That nod that says I see you, and I am standing up here for you. I think of my own grandmother, a proud, smart, and beautiful woman who missed out on her college and career dreams, so eventually I could realize mine. I think of my former immigrant patients and how it is my responsibility to speak up for them. I think of the theme song played as I accepted my STFM Advocate Award, “Girl on Fire” by Alicia Keys.  STFM is a place where we are reminded that as family medicine educators, we are all on fire to create, as my teen patient and Brian Andreas would agree, Fierce New Stars. Let’s keep our torches burning brightly to do just that.

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.