TransCultural Medicine Alaskas Answer to Preparing for RuralRemote

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Trans-Cultural Medicine: Alaska’s Answer to Preparing for Rural/Remote Practice and Surviving the Wintertime Blues

Trans-Cultural Medicine: Alaska’s Answer to Preparing for Rural/Remote Practice and Surviving the Wintertime Blues STFM 43 rd Annual Spring Conference April 24 -28, 2010 Vancouver B. C. , Canada Barbara Doty M. D. , Ray Pastorino, Ph. D, JD, Gina Senko, Manager, Faculty Support Services

Goals For This Presentation §Explore how Alaska’s Residency Program developed curriculum designed specifically for

Goals For This Presentation §Explore how Alaska’s Residency Program developed curriculum designed specifically for bush Alaska practice §Gain understanding how a midyear 1 month seminar experience benefits resident morale §Identify specific components of Alaska’s Trans. Cultural Medicine curriculum designed to promote success in rural practice

The Setting l Alaska – population 698, 000 -Concentrated in Anchorage l Landmass- 21/2

The Setting l Alaska – population 698, 000 -Concentrated in Anchorage l Landmass- 21/2 times size Texas, 4 time Zones 1% Glaciers l Cultural diversity–Alaskan Native, Black, Military, Asian, Pacific Islanders, Hispanic, 96 languages spoken in the ASD. l Remote villages/towns -No road access, 5 th largest town <10, 000 l Subsistence lifestyles-Trade Economy l Challenging Arctic Environment- Darkness, Temp Extremes l Resource Economy: Petroleum, Fishing, Timber, Tourism, Mining

I HAD NO CLUE… Comments from the “Untrained” l “No one told me about

I HAD NO CLUE… Comments from the “Untrained” l “No one told me about colleagues’ personality disorders. ” l “I didn’t know I’d have to do consults at the PTA meetings. ” l “I did my training in “rural” Minnesota. Didn’t know “rural” until I got to Kotzebue. ” l “Why didn’t they tell me about life with a pager that won’t turn off!!” l “My husband loves it now, but you should have seen him the first three years!”

The Challenge: To Train Family Physicians who will THRIVE not just SURVIVE in Bush

The Challenge: To Train Family Physicians who will THRIVE not just SURVIVE in Bush Alaska Practice l How

History of Alaska as FP Training Site l 1993 to 1995 - Grass Roots

History of Alaska as FP Training Site l 1993 to 1995 - Grass Roots Development of Curriculum with Rural Alaska Physicians l 1995 to 1997 - Partnership Development Providence Hospital, U of Wash. , Yukon -Kuskoquim Health Corp. & Anchorage Neighborhood Health Center l 1997 - First Residency in Alaska Opens l 2000 - First Class of 8 Graduates Placed l 2006 - Class Expansion to 10 then 12 residents l 2010 - 81 Graduates, majority practice in AK

Alaska Family Medicine Residency l 50 th State to implement GME- Residency l Rural

Alaska Family Medicine Residency l 50 th State to implement GME- Residency l Rural Focus l Unopposed program in Tertiary Hospital l Collaboration with Alaska Native Medical Center l Dual accreditation DO and MD Residency l 12 residents per year

Curriculum Design for Alaskan Practice l Trans-Cultural Medicine 1 month Seminar Mid-Dec to Mid-Jan

Curriculum Design for Alaskan Practice l Trans-Cultural Medicine 1 month Seminar Mid-Dec to Mid-Jan l R 1 and R 3 Residents – No Call l Skills Development : Wilderness, Cultural, Behavioral, Integrative, Nutrition; l Talking Circles/Sweats led by Native Elders l l Frequent/Recurrent Rural Experiences R 1: ER 4 weeks l R 2: Bethel/Dillingham 6 weeks l R 3: Two 4 week Rural rotations in Alaska l

Trans-Cultural Medicine (TCM) l Health Care Delivery Systems – local, regional l Complimentary/Integrative Medicine

Trans-Cultural Medicine (TCM) l Health Care Delivery Systems – local, regional l Complimentary/Integrative Medicine l Rural Practice and Lifestyle- skills, issues l Community-based team practice l Cultural Competencies- general and specific l Ways of Knowing/Communicating

TCM Curricular Emphasis l Experiential Knowledge l Resident/Team Collaboration l Self-Directed Learning l Progressive

TCM Curricular Emphasis l Experiential Knowledge l Resident/Team Collaboration l Self-Directed Learning l Progressive Levels of Understanding l Vertical Mentoring-Senior Panels l Educators from Within the Community

TCM - Specific Goals l Develop Respect and Sensitivity for Differing Belief Systems and

TCM - Specific Goals l Develop Respect and Sensitivity for Differing Belief Systems and Cultures l Develop an Organized and Logical Approach to Complementary/Alternative Practices l Experience first-hand the Physician as a Partner in the Health of a Community (COPC) l Learn to Manage Progressive Levels of Cultural Complexity to Bridge Mistrust and Promote Understanding l Gain Understanding of Personal Issues when in a Rural Practice

TCM Daily Schedule TIME R 1 CLASS R 3 CLASS 8: 00 -9: 00

TCM Daily Schedule TIME R 1 CLASS R 3 CLASS 8: 00 -9: 00 am CLINIC Board Prep 9: 30 -10: 30 am LECTURE CLINIC 10: 45 -12: 00 pm LECTURE CLINIC 12: 00 -1: 30 pm Lunch/Admin 1: 30 -2: 00 pm 2: 00 -4: 00 pm Cultural Focus LECTURE

TCM Curricular Components-I l Health Care Delivery System – Rural, Alaska Native, Safety Net,

TCM Curricular Components-I l Health Care Delivery System – Rural, Alaska Native, Safety Net, Care of Underserved l Communication Techniques – Motivational Interviewing, Gender Age and Generation l Cultural Knowledge -Hmong, Pilipino, Alaska Native, Asian, Pacific Islander -Alaska Cultural-Medicine: Historical Overview -Talking Circle/Off-Site gatherings -Native Health Care Delivery System Overview -Use of Interpreters, Tribal Doctor/Pathfinder -Alaska Community Treasure Hunt

TCM Components-II l Rural Medicine – Veterinary medicine, dental emergencies, radio medicine, acute stabilization

TCM Components-II l Rural Medicine – Veterinary medicine, dental emergencies, radio medicine, acute stabilization and transport – Alaska Epidemiology, Care at Altitude, Hyperbaric care l Integrative Medicine – Mind/Body, Biofeedback, Naturopathy, Manual therapies, Herbal Medicine – Nutrition, Diet Types, Use of Supplements – Spirituality l Wilderness Medicine – Survival Techniques, Frostbite Prevention, Avalanche Safety l International Service and Humanitarian – Relief work, Care with Limited Resources, Locums Practice, Foreign Adoption

Bush Alaska Preparation l Village Health Aide Radio Traffic l Medicine at Altitude l

Bush Alaska Preparation l Village Health Aide Radio Traffic l Medicine at Altitude l Locums Job Opportunities l Nutrition/Use of Herbals l Native American Talking Circle l Motivational Interviewing l International/Disaster Relief l Behavioral Shadowing

The TCM Leadership Team l Interdisciplinary Team: Broad-based Skill Set Behaviorist, Logistics Coordinator, Clinician

The TCM Leadership Team l Interdisciplinary Team: Broad-based Skill Set Behaviorist, Logistics Coordinator, Clinician l Includes Active Resident Participation (vital to success) Program Pride l Flexible, Creative & Experimental Rapid Implementation of New Resources l Adaptive to Class-Specific Resident Needs Gender, Marital Status, Ethnicity l High Value placed on Relationship-Building

TCM Leadership Team Tasks l Timeline development - Calendar l Logistics l Speaker Database

TCM Leadership Team Tasks l Timeline development - Calendar l Logistics l Speaker Database l Nurturing Relationships l Ongoing Evaluation l Just-In-Time Modifications

Content Development l Year round input of new ideas l Establishment and maintenance of

Content Development l Year round input of new ideas l Establishment and maintenance of an extended teaching network l Consideration of new ideas brought forth from faculty & residents l Consideration of learner feedback, course objectives, budgetary constraints and curricular balance before implementing new concepts l Continuous exploration for new community resources

Nurturing Relationships with Guest Faculty • Timely Feedback to Presenters • Acknowledgement of Contributions

Nurturing Relationships with Guest Faculty • Timely Feedback to Presenters • Acknowledgement of Contributions • Create Avenues for Ongoing Dialogue and Interaction • Maintain Relationships during Off Season • Lunch, Workshop Information and Service Exchange

Example of Methods: “The Talking Circle” Communication Circle Led by Native Elders Talking stick

Example of Methods: “The Talking Circle” Communication Circle Led by Native Elders Talking stick passed around the circle 1 -3 times Used to facilitate personal and professional growth Ground Rules: l No cross talk until the third round l No obligations to speak l Information shared within the circle is not discussed outside of the circle l Mutual respect and support

Curriculum PITFALLS l Management Concerns: Clinic Productivity, Continuity of Care, Budget Adequate staffing of

Curriculum PITFALLS l Management Concerns: Clinic Productivity, Continuity of Care, Budget Adequate staffing of inpatient service Resident Dis-Engagement in course: Burn-Out l Resistance to subject matter l Perception of Optional Participation by residents l Absenteeism due to vacation and poor personal accountability l “Soft” Material”: Non-Graded l

Lessons Learned l Accountability and Participation: Written Policy l Vacation during TCM: Specifically Defined

Lessons Learned l Accountability and Participation: Written Policy l Vacation during TCM: Specifically Defined l Course Management System: must be in place l Evaluation Process: Formalized, Multi-Faceted l Budget: appropriately distributed $1500 to $6000 l Class Size: Expansion from 8 to 12 residents changed dynamics l Cohesive Leadership Team: Required for success

Program Sustainability Document all Policies and Procedures l Keep Up-to-Date Database of Speakers and

Program Sustainability Document all Policies and Procedures l Keep Up-to-Date Database of Speakers and Contacts l Establish System for Introducing Speakers, Tying Together Presentations re: Purpose l Develop a routine for establishing dialogue with guest speakers: Luncheon, pre-meeting l Maintain environment of mutual respect and professionalism l Promote an atmosphere of tolerance and unbiased interface between speakers and learners l

Course Evaluation: How Have We Done? l Yearly TCM Feedback: Excellent! Program Centerpiece l

Course Evaluation: How Have We Done? l Yearly TCM Feedback: Excellent! Program Centerpiece l Resident Recruits attracted by unique curriculum l Statement by former Resident: “Having practiced in Barrow for several years before residency, I feel you are hitting what I needed years ago. ” l Feedback in the *Acosta Study Suggests Critical Components are Being Met for Rural Practice l Long-Term Curricular Review with Past Graduate Feedback planned 2010 at 10 year mark David Acosta, MD - Rural-Based Graduate Medical Education, A Workshop, San Antonio, Texas, February 2000

Leadership Team Observations l TCM Teaching Style: Faculty utilize a collaborative model with a

Leadership Team Observations l TCM Teaching Style: Faculty utilize a collaborative model with a shared vision-Not authoritative, more focused upon adult learning l Underlying emphasis: There is a Critical Role for Nurturing Relationships within a Community and Assimilating yourself into your Unique Practice Setting l In Talking Circles, Residents Have Their Humanity Validated by Elder Leaders who have been patients and are members of an Indigenous Culture

Application to Other Programs l All Practice Settings have unique characteristics l TCM Concepts

Application to Other Programs l All Practice Settings have unique characteristics l TCM Concepts are applicable beyond Rural and Remote Practice l Talking Circle and Cultural Elder teaching applicable to many cultural settings l Seminar setting with resident “breather” helpful for preventing burn-out and promoting resident retention and satisfaction