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This session will help health educators understand the cultural factors that shape up the health behavior of the immigrant population. It will also help the health educators develop the strategies to reach the ethnic minorities and formulate appropriate policies and interventions.

kamrun

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This is a great article by Pauline Chen.

Rethinking the Way We Rank Medical Schools

By PAULINE W. CHEN, M.D.

http://www.nytimes.com/2010/06/17/health/17chen.html?ref=health

Published: June 17, 2010

“So doctor,” she said as I pulled my stethoscope out to listen to her heart, “where did you go to medical school?”

In a social context, I might have considered her question to be polite chatter, a filler during an awkward quiet moment. But on that particular afternoon her words felt more like a dart lobbed at what I had presumed to be a budding and promising patient-doctor relationship.

Trust from this patient, I remember thinking, is not going to depend on my bedside manner or clinical judgment but my medical school.

But even before I had placed my stethoscope bell against my patient’s chest, I realized that I, too, had been culpable of submitting doctors to the same line of questioning. Although I might have satisfied my curiosity more surreptitiously — searching on the Internet, scanning hospital directories, inconspicuously craning my neck to discern Latinized school names on diplomas — I was just as eager as my patient to learn about the medical schools my doctors had attended.

Once I had the information, I would do what my patient did that afternoon: I would mentally find its place within the medical school hierarchy in my mind. Like some existential fast forward button, the right answer to this question could raise the trust in any patient-doctor relationship to a whole new level without a second thought, because by virtue of having graduated from a “good” school, that doctor had the ability to address the most pressing needs of all of his or her patients.

The thought process was easy — good school, good doctor; bad school, bad doctor.

Maybe.

Shaped by magazine lists, friends’ and strangers’ confirmations and professional hearsay, the notion that a medical school’s quality can be ranked and then passed on directly to their graduates has become an integral part of American culture. But most of these popular rankings reflect a school’s highly specialized research funding and capabilities, not the general quality of its medical school graduates. Criteria like research funding and cutting edge investigations are of course significant, but they more accurately reflect the social needs of the previous century when medicine, backed by scientific investigation, was just starting to make a difference in the health care outcomes of patients.

Thanks to many of those advances, the population as a whole has successfully aged. But the drive to elucidate, for example, the molecular basis of high blood pressure has in turn become less urgent. Instead, other, more social, health care issues have reached critical points: the shortage of primary care physicians; the lack of accessible health care and providers in certain areas of the country; and the yawning disparity between racial and economic backgrounds of those who become doctors and those who are their patients.

Despite the changes in patient needs, many patients, and their doctors, continue to fall back on old rankings, assuming that institutions that succeeded in addressing the needs of the 20th century can still do so in the 21st. But according to a report published this week in The Annals of Internal Medicine, it is time to reexamine that assumption.

Researchers from the George Washington University School of Medicine looked at the more than 60,000 graduates of America’s 141 medical schools — both allopathic and osteopathic — from 1999 to 2001. Putting the issues of primary care shortage, underserved communities and workforce diversity under the banner of “social mission,” the researchers found that many of the schools that were traditionally ranked highly were also among those least focused and least successful in addressing the most pressing issues facing the country right now.

“The absolute irreducible mission of medical schools is the education and graduation of doctors to care for the country as a whole,” said Dr. Fitzhugh Mullan, lead author of the study and a professor of health policy and pediatrics at the university. “U.S. medical education has drifted over to this highly rarified and specialized focus that has resulted in some major shortfalls.”

The funding system has encouraged this drift toward specialization and hi-tech research. The investigators also found that institutions that received more federally funded grants, in the form of research grants from the National Institutes of Health, also tended to devote fewer efforts to a school’s social mission. Grant money and the security it affords individuals and institutions drive institutions to emphasize research, sometimes at the expense of other urgent but less lucrative endeavors.

The opportunity to learn from and be mentored by faculty members involved with the latest research can be stimulating for medical students, but the pressure to bring grant money into an institution can draw even the most enthusiastic educator away from students and back to the laboratory bench. “Research is not the same as medical education,” Dr. Mullan observed. “Research is important, but it can overwhelm.”

And when medical schools “are already heavily invested in a mission that is traditional and research oriented,” noted Dr. Mullan, broadening their focus can be slow and difficult, even if they are aware of the growing crises in primary care and the health care work force.

In recent years, some visionary medical educators have left older institutions in an effort to jump-start such changes in new medical schools. Most of these new schools, sometimes referred to as “millennial medical schools,” embrace missions that unabashedly attempt to address some of the ills of the current health care system. The A.T. Still University of Health Sciences School of Osteopathic Medicine in Mesa, Ariz., and the Herbert Wertheim College of Medicine at Florida International University in Miami, for example, “embed” students in underserved areas from as early as the first year of medical school. Other institutions, like the Hofstra-North Shore -LIJ School of Medicine, which is due to begin classes in August 2011, have made it a priority to educate students from diverse, nontraditional backgrounds.

Naysayers warn that this redirection of focus, whether in established medical schools or new ones, will decrease the selectivity of students and produce less competitive and less competent future physicians. But educators like Dr. Mullan counter that traditional selection criteria based on cognitive exams and premedical course grades do not necessarily translate into clinical ability.

“Doctors who have done very well on everything from kindergarten to residency training in terms of getting into prestige places are assumed to have sharp intellects,” Dr. Mullan said. “But none of that correlates in any scientific way with their performance as physicians.” The more relevant measure of high level competency, Dr. Mullan asserts, is the multiple certification evaluations that take place during medical school, training and licensure. “They have to pass these, otherwise they cannot practice.”

Moreover, Dr. Mullan noted, “If there’s not even a doctor near where you live who can offer services, then the quality a priori is bad.”

“The mission and function of all schools won’t be and shouldn’t be the same,” Dr. Mullan added. “But we all might think about how we could be a little more responsive to the ongoing needs of patients and of our country. If we continue to produce more doctors in the system we have now, we won’t be able to address the needs, the health outcomes and certainly the populations that are underserved, dying and suffering as a result of it.”

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Recent research into the biology of breast cancer is giving us hope with regard to treatment. Genetic subtypes of breast cancer are being identified. Now known are “luminal A” and “luminal B” hormone-receptor positive subtypes, subtypes characterized by low expression of hormone receptor-related genes include “HER2-enriched” and “basal-like”. More recently identified is one characterized by low expression of both luminal/hormone receptor-related and HER2-related gene clusters is the “claudin-low” subtype, of which there are more questions than answers. there is a fifth type, normal-like, which researchers are still questioning is it a real subtype or a technical artifact.

Knowing what her tumor reflects will aid a woman and her health provider select more targeted therapies in the future.

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This memo is intended for those who were registered with the old HEDIR.org page. IF YOU HAVE ALREADY REGISTERED AND JOINED THE HEDIR GROUP, YOU CAN IGNORE THIS MEMO.   We have imported your information into the new HEDIR.org site.  Theoretically (note the word), you should now be able to ‘log’ into the HEDIR.org site.  If you have forgotten your username, you can access via your email.  If you have forgotten your password, there is a mechanism for you to deal with that issue.

The new HEDIR.org site is part of the IDWellness Platform.  So, once you log in, you need to join the HEDIR Group.  You’ll see the blue icon on the right side of the screen.  If you are logged in you can click that and request membership into this group.  Once you are a member of the HEDIR group, you’ll be able to see people on the HEDIR Registry (the directory), as well as have access to a variety of other services (since as responding to blogs, uploading information, etc.)

On Sunday I’ll also go through the list of 150 people manually and ‘invite’ you to join the HEDIR group.

If you have any problems, feel free to contact me.  Also note that there is a ‘live operator’ available should you have any questions.

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Note:  The HEDIR Discussion and the HEDIR.org (HEDIR Registry) are DIFFERENT.  Obviously they’re related, but the HEDIR Registry is this site where the directory, blog, and other items will be located.  You need to register with the HEDIR Registry.  Click the ‘register‘ button to the right.

Continue

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Some of you have seen the following video that was created by a Great Britain community group to encourage the use of seat belts.  If you haven’t seen it, click  http://www.youtube.com/watch?v=h-8PBx7isoM and watch it.  Come back to this blog when you are through.

It’s a pretty good public service announcement.  I’m not sure what has been done to determine the impact, but it certainly follows into the path of health education where knowledge is just one (small) component of the health behavior component.  Working with one’s attitudes and emotions also plays an important point.

Let me share with you three issues that dealt with ‘the heart’:

• Some of you (if you’re around my age) remember back in the late 1970s and early 1980s…the American car companies of Ford, Chevrolet, and Chrysler were having major problems.  Besides shoddy work, they were being challenged by imports from Japan—Honda and Toyota.  Both Honda and Toyotas were less expensive than the American vehicles, and nobody could hold a candle to their reliability.  In the late 1970s Chrysler was having some serious problems and was asking the Federal Government for a $1.2 Billion dollar (a lot in the late 1970s) subsidized loan to get them stabilized.  I remember the discussion in Congress was pretty intense.  People were complaining that this was ‘corporate welfare’ and others from the other side  indicated that there were thousands of jobs at risk.  Congress and President Carter approved the loans in August, 1979.

One person in the Chrysler corporation was able to convince various groups in Congress to loan the money.  That person, Lee Iacocca was so impressive that he became the President of Chrysler.  In the early 1980s he ‘starred’ in the Chrysler ads as the spokesperson.  Mr. Iacocca was a congenial, friendly looking person. I remember most of his ads ended with him looking into the camera saying ‘Buy Chrysler…Buy American’.  He was obviously implying that by buying American you are supporting the thousands who work at Chrysler.

Chrysler’s stock took off;  sales were impressive in the early 1980s.  In fact, the $1.5 billion dollar loan that was due in 10 years was paid off in 3 years.  Lee Iacocca was the person who really oversaw a great turnabout for the company.  Yet, the ads didn’t talk about the fine craftsmanship;  the horsepower in the vehicles;  the prestige of driving a classy looking car.  It focused on the emotional aspect of ‘Buy American’. (Ironically, then, like now, most ‘American-made’ cars were actually made outside the United States–they are just ‘assembled’ here).

• I also recall my years teaching at Youngstown State from 1979 to 1989.  I typically taught 2-3 sections of first aid/cpr each year.  As somewhat of an ice-breaker, I typically asked why people signed up for the class.  Some indicated it was a major requirements;  some indicated an interest in helping people.  The ones who were really motivated were those who indicated that they have had a loved one who just had a heart attack or they just had a baby and wanted to learn this to possibly save their lives.  That’s a powerful motivator and those people tended to do very well.

• I also remember taking driver education while a sophomore in high school.  The first day we were shown a series of movies promoting safe driving that had pictures of decapitated drivers, blood (enhanced by an artist) all over the highway, and pictures of people who went through the windshield.  I think the intent was to encourage us to become safe drivers.  Not sure if it worked, but I still remember those films.

• A good friend of mine is an exercise physiologist who works in cardiac rehabilitation.  He constantly talks about the motivation that people have to change lifestyle AFTER they’ve had a heart attack.  I guess one could say that the emotion of having a heart attack wills a person to make difficult decisions and changes.  Quite literally, the heart attack ‘captured’ their heart, in getting them to change their behavior.  It’s unfortunate that people have to get to that stage for them to make changes.

As health educators we do a pretty good job at providing updated information, reasons why, or precautions against.  I’m not sure how effective we are at using that approach.  Yet, when we can ‘capture’ the heart of the person (i.e., student, client, patient) we may have a much better chance of helping  people help themselves.

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Once completed, all subscribers will have an opportunity to be listed in the Member Directory (and they will be able to update their own files); receive HEDIR list messages; and (and this is big) be able to post to the HEDIR Blog.

Currently we are requiring all new HEDIR subscribers to go through this new system. Starting around August 1 we’ll start opening it up to all subscribers (currently about 1,800). I’m creating a series of tutorials to help walk you through this process.

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In the past several days, President Obama and HHS Secretary Sebelius have been ramping up their efforts to generate a groundswell of support for reform of the American dysfunctional non-health care system. Top Republicans have declared there will be no government health care system. Given that the World Health Organization’s most recent rating of health care provided by nations rates health care services in the good ol’ USA as 37th among the 191 nations and worst among those with the largest economies, while health care provided in France is rated as best, maybe we should look to Western Europe for ways to improve the health care provided in our country.
Supporters of government involvement in health care point to the fact that the US government is already assuring health care for the aged, those with low incomes, veterans and government employees, including members of Congress. The federal and state governments of the US already pay for more than 44% of health care costs in our country. Also, they note that thecost of health care in the US is above 17% of GDP, while it is 11% of the GDP of France. According to an article in The Dallas Morning News of May 18, 2009, the average cost of health care for an individual in the US in 2006 was $6,714, while for the individual in France it was $3,450. While anybody living in France for more than three months is covered by the national health insurance program, it is estimated that approximately 45 million citizens of our country have no health insurance.
The French health care system is not perfect; people of lower middle income complain that they cannot afford supplemental health insurance available to those who can afford it. As a result, many have to pay more for their medical care costs than the rich and the poor, with the latter having their supplemental health insurance paid by the French government. France is struggling to cover rising health care costs within its national budget, but its problem is considerably smaller and more manageable than the health care costs problems facing both the government and private citizens in our country.
Germany has per capita health care costs similar to those of France. The average cost per person in Germany in 2005 was $3,628, which was just over half the cost in the US, and German health care costs were 10.7% of GDP, as compared with over 16% in the US in that year. The World Health Organization rated the German health care system as 25th or 191 national systems, or 12 positions ahead of the US “system”.
Of course, there are reasons to suggest we look to the Far East for a model for health care reform. Japan enjoys the lowest per capita health care costs, which are less than half of those in the US at US$2,908 in 2005, or 8.2% of GDP, which is almost half of 16% of GDP in the US in that year. Japan enjoys the highest life expectancy of any major nation in the world.
While top Republican leaders say government cannot run a health care system a well as private sector businesses, we have decades of evidence that governments in other countries are running their health care systems more effectively than the combined governments and private sector businesses management pattern in our country. American private sector businesses failed badly in recent years in managing the real estate market, banking, hedge fund investments, automobile manufacturing and marketing, high tech corporations, utilities distribution and insurance businesses. Why should we buy the old saw that private industry can manage health care better than governments?

Related websites:

http://republicanleader.house.gov/News/DocumentSingle.aspx?DocumentID=131326

http://www.allhealthcare.com/news/articles/3480-is-french-health-system-a-model-for-us

http://www.healthcarefinancenews.com/news/republican-senate-leader-obama-essential-healthcare-reform

http://www.photius.com/rankings/healthranks.html

http://www.photius.com/rankings/healthy_life_table2.html

http://www.photius.com/rankings/who_world_health_ranks.html

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