July 17, 2009

From Argentina: Symposium exploring Family Medicine in the Americas

Recently I was asked to give a talk in Buenos Aires, Argentina at a symposium exploring the crisis in Family Medicine and Primary Care in the Americas. I was delighted to accept and was able to arrange for one of our first year medical students to join me. What an opportunity to reconnect with the physicians I had worked with during my sabbatical, and of course, to show off the best of Buenos Aires to Ani, the medical student who accompanied me!

The symposium was organized by Dr. Julio Ceitlin, a family physician who has worked all his life to promote primary care and founder of family medicine in many Latin American countries. The purpose of the symposium was to present our experiences/ frustrations with promoting, practicing and teaching primary care in our respective countries. I was asked to present on the Medical Home and on Chronic Disease Management, concepts that are unique to family medicine in the United States. Ani presented beautifully in her fluent Spanish on how the University of Minnesota teaches and promotes family medicine. In attendance were program directors, medical school faculty, residents and family physicians from the US, Argentina, Paraguay and Venezuela.

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Pita Presents her Lecture at the Symposium

I learned, as I often experienced during my sabbatical, that we are blessed in the United States. We have the Academy of Family Medicine that works tirelessly at the local, state and national level to promote our profession and the health of our nation. We have 400+ family medicine residencies, Departments of Family Medicine at most medical schools and ample employment opportunities for our graduating residents. Much of the presentations from our Latin American colleagues focused on the paucity of trained primary care physicians, how other specialties have little understanding of the principles and worth of family medicine and the lack of family physician academies or central organizing bodies. I was deeply impressed by their dedication and persistence in promoting the ideals of primary care (despite the forces against them) and a little embarrassed by my/our complaints about family medicine in the US.

Ani, Dr. Ceitlan and Dr. Cantale.JPG

Dr. Julio Ceitlin, founder of family medicine in South America; U of M MS-2 Anastasia Kolasa-Lenarz; Dr. Carlos Cantale, Family Medicine Physician who works with Dr. Ceitlin.

So often we become entangled and immersed in the complicated details of our day to day practice that we forget why we do what we do. Listening to our colleagues fighting for family medicine, I was reminded of the essentials of what we do - attend to the common medical, psychological and social needs of our patients through listening, testing and teaching of our patients, their families and the community.

Personally, I was tickled to be back in Buenos Aires. Despite being in the midst of winter (we went the end of May) the weather was just as warm and the vegetation just as green as in the Twin Cities. I ate way too many media lunas (small sweet croissants that way out shine our mega chocolate chip conference cookies), savored their gelato ice cream (had to do so for my children) and took Ani to our favorite restaurant. Ani and I were able to have tea and dinner with my favorite aunt, stroll through the artist markets and visit a few of the historic sites.

Where from here? At the symposium, we all agreed to organize an "Observatorio" a group dedicated to observe our specialty and report back to the others what we are seeing. We hope collectively to support each other and help promote our specialty in our respective countries. Today I received my first email from the Observatorio - stay tuned on what we discover and the work we hope to do.

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Dr. Carlos Cantale, Dr. Pita Adam, Dr. Julio Ceitlin

December 11, 2008

My many homes--Pita's Last Blog from Argentina

As I sit at the MSP airport, in the oh-so-familiar “E� terminal, eating my healthy D’Amico and Sons salad, watching CNN and listening for boarding calls for flight 9203 to Atlanta, I think of home. Home, because I am returning to Argentina to be with my family, and home, because I just spent a wonderful week at Smiley’s and my home town St. Paul.

At Smiley’s I was busy from minute one working with Nancy and Rossi, interviewing applicants in person (!), meeting with Tim, Joel and Deanne, participating in an all-clinic meeting, eating lunch with Jen, enjoying a lively discussion on global practice, meeting with the Fairview leadership regarding our plans for the teaching service at the U and trying to catch up with everyone I could. Despite the bitter cold outside, I felt the warmth, light, energy and security inside the doors of our clinic. The connection I feel for Smiley’s and all of us who strive to make it the best place to work, learn and care for people was stronger than when I left on my sabbatical.

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Pita's presentation on International and Argentinean Health Care at the Dec 4th Smiley's Event.

Home that week was not at my own house, which I visited for 30 minutes to pick up George’s yo-yo and Alex’s books, but with my friends the O’Sheas. It was home because I could plop down my suitcase (with its contents spread out all over the place), kick off my shoes and be embraced as the quirky individual that I am. Family dinners, family shopping at Target (where I saw 4 people I know!)and family walks with dog along the River Road.

I am going home--home to the tiny apartment with piles of Yu-Gi-Oh cards everywhere, Michael on the internet reading the New York Times and my boys trying hard to play together without arguing. Home to my father who spends a third of the year in Buenos Aires, and home to my favorite aunt and many cousins. I am going home, even though I am returning to a country I’ve temporarily adopted, to a language that isn’t fully my own and a people I am just starting to understand.

We at Smiley’s are building a medical home. It isn’t the structure (albeit beautiful), nor our location (next to the Greenway, the light rail and Lake street), the languages we speak (English, Somali, Spanish, Arabic, Oromo, Vietnamese …) but the people we are and our determination to connect with our patients and our colleagues that makes us a medical home.

I am extremely fortunate to have so many homes.

Editorial Note: Dr. Adam will be returning to Smiley's January 1st. Between now and then, she will continue to travel with family and interview applicants via webcam.

November 24, 2008

11.24.8

This last week I learned about medical education in Argentina. Not surprisingly, the system of higher education in Argentina is different from ours.

Essentially, anyone who has graduated from high school and completed and passed a one year preparatory “leveling out� year can enter medical school in the public universities. The largest public medical school is part of the very large Universidad de Buenos Aires which is free and open to anyone. No MCAT or grade criteria required. You just need to pass their one year course that is designed to make sure you have learned the basic pre-medical school material. If you don’t pass that year, you can take the year over. Their quality control is through attrition; only half of the medical students who matriculate graduate. The classes are so large, it is not unusual for 20 students to share a cadaver in anatomy class and faculty are unable to help any of those who are struggling. This open door policy in education is likely related to the long standing populist egalitarian ideal in Argentinean politics. It is however, a large drain on resources for the public universities (imagine teaching close to a thousand students medicine for 2 years who then leave) and I would assume impacts quality.

There are about 25 medical schools in Argentina (many of them private) and together these medical schools graduate about 6000 doctors a year. There are however, only 4000 residency spots in the country and so every year 2000 of these physicians cannot get further training. Many end up working in the interior of the country for miserable salaries of $1000 a month. The work is very difficult, call is every other night, and their resources are minimal despite having to handle very advanced stages of diseases. Other physicians without residency training are hired to work call shifts in Buenos Aires, also at very poor pay ($100 for 24 hours). So the government “saves� on health care costs through allowing excess physicians to be trained who never make it into residency.

I learned much of what I relate above from Dr. Marcela Barrios, a family physician who is the director of the family medicine department at the University of Maimonides and also director of the “Family Medicine Career� offered through their university. She is an amazingly dedicated family physician who despite many obstacles continues to fight for primary care in Argentina. I was able to spend several half days meeting with her, her faculty, the Dean and observing student faculty interaction.

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The Universidad de Maimonides is unique in its approach to teaching medicine. Most of their teaching is through Problem Based Learning (PBL) classes. I was a PBL tutor way back in my fellowship days and then also participated in PBL teaching when I volunteered with my husband in a medical school on the island of Pohnpei in Micronesia. So it was quite a treat for me to observe a PBL class while touring the University. The Universidad de Maimonides is also unique in that its curriculum is largely based on the principles of family medicine. Seventy percent of their medical school faculty are family physicians (!!) who in addition to teaching content typical of primary care (community health and assessment, principles of ambulatory care etc.) teach patient centered communication and professionalism. They unfortunately don’t graduate many family physicians because employment as a family physician is less inviting (lower pay, clinics and health care systems that don’t understand family medicine) but they feel strongly (and I agree) that their graduates will be better specialists with their strong primary care background.

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Dr. Adam gives a lecture on Pap Smears at Construir Salud

Dr. Barrio has also been collaborating with the Dean’s of other medical schools in writing the basic competencies physicians must have prior to graduation. The Ministry of Education finally signed off on the 30 page legal document listing the competencies but continues to insist that medical schools not have a cap on applicants (ie. All who want to should be able to study medicine). Dr. Barrios and the other Deans rightfully point out that they must be able to limit their medical school classes in order to evaluate the competencies they just wrote into law. To evaluate competencies, one requires expensive resources for OSCEs (they test chest tube placement with pig models – imagine needing hundreds of pigs to test hundreds of students!) and individual observation, not multiple choice tests.

If fighting the Ministry of Education were not enough, Dr. Barrio’s is also responsible for a 3 year “Carrera de Especialista en Medicina Familiar�, a 3 year course for physicians interested in advanced training in family medicine. This is not a residency but directed more to practicing non- residency trained physicians. Much of the medical care in the country outside of Buenos Aires is delivered by non- residency trained generalists through the public health system in provinces that are generally quite poor. The course is long distance, web-based with regularly scheduled class time and includes supervised practice and ongoing testing (including OSCE). The first year they worked jointly with one province, La Pampa, and enrolled the 70 generalists working at the time in their public hospitals. During the three year training, these physicians were required to complete a community project. One physician succeeded in decreasing HTN in his town through a community effort to consume a low salt diet (worked with the bakeries to remove salt from the bread) and increased areas to walk (worked with the police). Since this 3 year training in Family Medicine, La Pampa has seen a marked decline in teen pregnancies as well. I find these accomplishments so inspiring; education in primary care and community health making a difference in the health of the community. Unfortunately, only one other province in Argentina is willing to support this type of training of their generalist physicians. But Dr. Barrio and the Universidad de Maimonides are not ready to give up.
Argentineans are creative people who are used to having to fight for what they see as just and right. There are daily protests in the center of Buenos Aires and frequent strikes. The words “desafio� (challenge) and “te animas?� (do you dare?) are heard all the time in conversation. It reminds me how lucky we are in the United States to have an organized and functioning medical system that we can engage in to make change.

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Argintinean reaction to the US Election; Sprintime in Argentina

On another note: I will be back in Minneapolis the first week in December and am excited to see everyone! I will be talking a bit about my experiences in Argentina at the Smiley’s Global Docs: International Medicine and Electives event on December 4th.

November 14, 2008

11.14.08

As I have been blogging at the Smiley’s website about our sabbatical experience, my husband and I have also been blogging about the more touristy activities we have done and about how we as a family are adjusting. For this blog, I thought I would cut and paste from our family blog, so you can also learn about our wonderful 3 days visiting Patagonia several weeks ago. We started at Puerto Madryn, the gateway to the famed natural habitat for penguins and whales in Patagonia, Argentina. It was a great vacation for all, especially for the kids who didn’t need to look at one ruin and got within touching distance of a whale.

We travelled the 1300 Km (670 miles) on a “Cama Suite� Sleeper, a Double Decker bus where the chairs pull out fully and the foot rest lifts up to create a comfortable bed. These sleeper buses are a very common way to travel here, since the trips are much cheaper than flying and likely a little more reliable (Aerolineas Argentina is known for cancelling flights and never leaving on time because of their fleet of “10� planes). We saved about 400$ each by taking the bus, and since they drive during the night one doesn’t lose much time. So, backpacks and suitcase in hand, we rode the SubTe (metro) to the bus station in downtown Buenos Aires and then hopped on our 8:30pm bus. They fed us dinner and breakfast and played two movies. Our only complaint was the loud music videos that they played until 10:30 pm, making it difficult for Sam and Alex to fall asleep (children here don’t go to sleep much before 10pm – how they do that, I don’t know!). Otherwise, we all slept reasonably well and had a great time hanging out on this bus for 16 hours. Yes – 16, which was way better than the ride home which was on a less fancy bus, took 22 hours, had seats that did not make true beds, a toilet right next to us that exuded a continuous odor of urine and was labeled not to be used for “solids� (????). Needless to say, our ride back was not much fun but the children did amazingly well.

Bus home.JPG

In Patagonia, we spent a day touring Peninsula Valdez and another driving along the coast to Punta Tombo, the area with the largest penguin colony outside of Antarctica. Both days turned out to be fabulous, with the kids consistently rating their experiences greater than 8/10. We stayed in a hostel called El Retorno (poor boys got to hear their parents wax nostalgic about their backpacking days in Europe) where we were lucky to get our own room and bath for the 5 of us and were hosted by a wonderful couple.

So day 1 in Patagonia, we joined a tour of 10 others and travelled in a little micro bus all around the Peninsula Valdez. This is a wildlife reserve although there are still private sheep farmers there whose family’s estancias (ranches) had been there before the reserve was created. The highlights were the whale watching that we could see right from the coast – the whale we saw must have been 100 yards from the beach – followed by a whale watching boat ride. Turns out that for 9 months out of the year, the whales come to this protected bay (protected from the Orca, their main predator) where they mate and deliver their young before returning to the ocean further south. The bay is deep very close to the shore, so it is common for them to come very near the coast.

The whale viewing boat ride was spectacular. The kids loved the adventure of the yacht speeding out into the bay, hitting the waves with spray going in all directions. We spotted a whale pretty quickly, a medium sized whale that was literally fascinated by us. He/she/it made sure to study each and every one of the 40 of us on the boat – literally. The whale kept circling the boat, coming up frequently right next to the boat, in arms reach, its barnacle covered forehead and mouth glistening in the sun. Alex was so excited when sitting at the bow, the whale came up next to him and blew out of both blow holes, covering him in spray. He and my husband (Michael) could see the blow holes open and close in unison. I was busy further back on the boat trying to capture all this on “digital?� while trying to avoid spray, people, and falling on the slippery heaving deck. This one whale provided us a show for a good 30 minutes, after which, understandably he got bored and left. We then found a pair of whales, a mother and her calf that was about 4 yards long. That was a joy too, to see the two heads coming up together and the two tails hitting the water. Unfortunately, we were not able to get a photo of both.

Whale surfacing right by the boat.JPG Us getting splashed in boat.JPG

In the afternoon, we drove around the peninsula on a “safari� looking for native animals: mara (a large hare that we realize now was the hare that roams around the Buenos Aires zoo on its own), guanaco (small relatives to the llama), a small burrowing land owl, and nandu (emus) which are the South American version of the ostrich. We also stopped at a small penguin colony that was fine to see but didn’t compare in the least to the one we visited the following day. We also visited a sea elephant colony, where the males languished by the water with their 10 females around them, braying (sounded more like farting) every once in awhile and chasing of younger males who dared to lumber by.

Day 2, we visited Punto Tombo to see the massive penguin colony and on the way, take a dolphin boat ride. Again, the kids loved the speed boat ride just as much as the dolphins. It took a good 20 minutes to spot the first dolphin, since they were busy eating when we first set out, but once they finished their meal they surfaced to play. It also helped to locate another dolphin sighting boat so we could share the 8 dolphins surrounding both boats. They were soooo cute (!) according to all of us! They are called Toninas, are the smallest of dolphins and look a bit like Orcas – black and white. They love to play, chase speed boats, jump up next to them, then dive under and jump out on the other side. Several got in front of the other speed boat and swam at the same speed, constantly right in front of the boat, leaping in and out of the water. They can also reach speeds of 80 km/h and literally were able to come from behind in our wake and then pass us, no problem!

Tonina playing with boats.JPG

After a bagged lunch of ham and cheese sandwiches and a 2 ½ hour bus ride on a dusty and hot road, we reached Punta Tombo where the Penguin Colony is. Again – fabulous. We were literally surrounded by 1/2 million penguins (that is the official number that live there) as we walked on this small path through their habitat. Under every wooden bush, there was a nest dug into the dry dirt and a penguin roosting on its two eggs. Next to the nest, there was invariably another penguin, keeping guard. At times there were two penguins snuggling in the nest (and yes, Alex and Michael were privileged to watch two mating under their bush). Penguins were also on the march, crossing the path or walking on the path to wherever they were going. There was a definite “penguin road� that led from the small hills to the beach with dirty penguins wobbling down and clean, wet penguins returning to their nests. At the beach, we could see 20 – 30 penguins hanging out at the edge, some getting into the water and others bobbing on the waves for a nice swim. More inland, as far as you could see, were small rolling hills covered by burrows of nests, little heads poking out of the nests or little bodies standing as sentinels next to the nests. The sight was quite surreal, almost lunar with all the small craters. The picture we have doesn’t capture the panoramic feel of hills with their sentinels. And the penguins weren’t the only animals living there. Along a swatch of the beach, among the penguin nests, sheep and guanaco grazed. Most of the Patagonian landscape was a bit dull and brown (semi arid) but the penguin coast was just gorgeous.

Penguin landscape.JPG Penguins hanging out by water.JPG

Generally, the penguins didn’t pay much attention to us. They would look at us, when we looked at them and would try to walk around us if we were in their way (the wardens made sure that people gave the penguins the right of way). Alex found an aggressive penguin that came chasing after him, pecking, when Alex got too close. A bit scary! One lady bent down to touch a penguin (forbidden and very upsetting to George) that pecked at her for every attempted touch. We were told that they do bite.

We learned that the penguins come to Punta Tombo every year to nest. They mate for life, find each other at the same nest year after year, where together they take turns roosting and then raising the chick. Every once in awhile, we could hear one of the penguins who was roosting honk loudly (they don’t need cell phones), calling its mate back to the nest so it could go to the ocean to swim and eat. Once the penguins are a few months old, the family takes to the ocean and rides one of the currents back up to the waters near Brazil, eating and growing along the way. They don’t go back onto land. They then turn around and take the current back to Punta Tombo to start the cycle all over again. Cool, no?

Three boys and penguin.JPG

That day ended with our bus ride back to Buenos Aires – the one that was not pleasant and almost a day long. We got back home about 7 pm the next evening, washed up, ate and crawled into bed. It was so worth it!

November 7, 2008

And now, a bit about the residency programs that I have been able to work with. Of several family medicine residency programs in Buenos Aires, I had the opportunity to work with two: CEMIC and Construir Salud. The program at CEMIC, founded in the 1980s, was the first official family medicine residency program in Argentina. Construir Salud is the Obra Social I mentioned in a previous blog which runs multiple family medicine residencies within its health care system.

Starting with CEMIC. Currently they recruit 2 residents a year for a total of 3 years and offer a 4th year chief residency position. The program director is aiming to increase to 6 residents a year since there is both interest in family medicine among students and employment opportunities in family medicine. In general, the structure of their overall curriculum is similar to ours, with similar content areas, rotations but different in that they don’t start continuity FM clinics until their second year. Their educational objectives are strikingly similar and include teaching residents self care and defining electives (need objectives, a project and must be within the resident’s curricular objectives). Their first year, they rotate through the inpatient setting with 2 months of OB, 3 of Peds and 4 of internal medicine (rotate with IM residents) and one of outpatient Family Medicine where I assume they observe family medicine faculty seeing patients. Starting their second year, they have 1 or more clinics in their Family Medicine Centers and also clinics in a pediatric center on a longitudinal basis. Then each month, they have about 4 half days a week that they devote to a subspecialty rotation. Their third year is very similar, except they have 3 half days a month in the rotation. And, just like us, they love to experience family medicine elsewhere, particularly Spain where family medicine is fairly well established with practice patterns more like ours.

Their curriculum differs strikingly from ours on the inpatient setting: they do not care for inpatient family medicine patients, or their OB patients. The objective of their IM inpatient rotation clearly states they need to understand when a patient needs admission and the basic care of an admitted patient (fluids, meds) but not the ongoing care of inpatients. Because there is no family medicine inpatient service, and no OB service (practicing family physicians don’t do OB here), they are freer to meet on their Tuesday academic day. In addition to the Tuesday lecture series, they have a weekly 90 minute get-together, facilitated by a psychiatrist, to discuss patient – physician encounters and communication. They also meet twice a month with a pediatrician to go over pediatric cases and attend regular classes that address research topics, EBM and other longitudinal topics. I have yet to learn about their call system, but know they have call duties on rotations and for their patients.

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CEMIC Main Hospital

Construir Salud residency is very different from CEMIC and most family medicine residencies here. Partially, because they are sponsored by an Obra Social, they were able to design the residency to fit their needs rather than follow the classic structure we use. They currently have positions for 3 residents a year who also train for 3 years. What is unique about their curriculum is that during their first year all they do is family medicine; the first 3 months they follow/shadow/work with the family medicine faculty in the clinic and then for the next 9 months, they see patients on their own. All their visits during that year are supervised. They intersperse their clinics with lectures and classes on the principles of family medicine. Tuesday afternoons they work with the psychologist who either presents a formal lecture or runs a team meeting regarding their difficult patients (sound familiar?). The psychologist can see patients with them in the clinic too, just like we do. The one Tuesday lecture I attended she gave an excellent lecture on giving directions to patients which included many tools we use (like agenda setting). It shouldn’t surprise me (but it does) how similar the communication tools are in our two countries. Despite cultural differences, we as humans are very similar in our basic needs and feelings. I will be talking to them in a few weeks about Motivational Interviewing and Action Plans which is becoming my contribution to family medicine here.

I also gave a talk on “Abnormal Paps� at CEMIC and will at Construir Salud (surprise!) and enjoyed it tremendously. Despite the fact that most practicing family physicians don’t do routine gyn care (the gynecologists have maintained that niche) the residents during residency do deliver full spectrum care and were interested in how we practice. I was very surprised to learn that most gynecologists here continue promoting the annual pap, often in adolescents, and perform colposcopy with each pap!! Enmeshed in the medical culture in Buenos Aires, the CEMIC residents weren’t concerned that unnecessary procedures were being done on patients, since the patients didn’t seem to mind and expected the colposcopy. I was reminded again, that as physicians we have to be so careful not to use the argument “we have always done it this way� to justify the status quo.

Back to Construir Salud. Because it is an Obra Social whose core physician staff are family physicians, the family physicians do routine gyn care (without colposcopy) and prenatal care, but don’t do inpatient medicine. After a year of family medicine, the second and third years start rotating with other specialties, focusing first on internal medicine, peds and OB and then on the subspecialties. Construir Salud has not lost a resident in their 12 years to another specialty, despite the specialty based medical culture in Buenos Aires (I saw a patient who went to ENT to have his ear wax removed!). All have graduated as family physicians with more than half working at Construir Salud and a third in the public sector. I believe their decision to flip their education around to emphasize family medicine in the first year was inspired because it works to undo the specialty medical culture here. Also, residents have the advantage of learning in an environment that has at its core, family medicine, where patients are required (and want to) see their primary family physician before seeing a specialist.

Since we too struggle with a specialty oriented health care system, should family medicine programs in the US similarly front load family medicine teaching into the first year rather than the third? When I first designed our Ambulatory Family Medicine rotation in the first year, my intent was to welcome our interns to family medicine, provide them with the opportunity to feel capable in our clinic, counter the continued specialty focus of our education and hopefully inculcate early the values and joys (I do think they are joys) of being a family physician. I think we need more concentrated learning in the clinic, since that is where family physicians work! As a specialty, right now, we are redesigning the way we teach our residents in the US. The Future of Family Medicine mandate to design innovative curricula initiated the Preparing the Personal Physician for Practice (P4) programs that are in the process of piloting new educational models with results expected after 2010. Curricular changes range from adding a 4th year with options for concentrated learning in specific fields to removing rotations and creating longitudinal learning with earlier and more frequent clinics in the family medicine center. So there is now, as the debate surrounding family medicine education becomes more heated, momentum for change. Stay tuned!

For those interested, I give you the link to a serious of thoughtful articles by family medicine leaders about the changes that need to occur in family medicine education: Green LA, Pugno P, Fetter G, Jones SM. Preparing the Personal Physician for Practice (P4): A national program testing innovations in family medicine residencies. J Am Board Fam Med 2007; 20: 329–31.[Free Full Text]. You can see descriptive summaries of the P4 pilots at: http://www.transformed.com/P4-participants.cfm


October 24, 2008

I am finally (just a little nervous ….) ready to start writing about my perceptions of chronic disease management here. I’m nervous because it has been a lot harder to determine what is being done here and how to interpret what I have seen than I anticipated. I also want to emphasize that despite meeting many physicians, I have only scratched the surface and so my views will be biased by the select doctors that I have worked with and by the paucity of information I have gleaned off the web.

First a quick review of what we know about the success of chronic disease management following the Wagner care model. I assume you have all been attending Dr. Harper’s Chronic Disease Lectures and know all about this model and it’s components (but I will attach a copy of it on this blog for all to see). There is evidence, from randomized controlled trials, that implementation of this model can change outcomes. The changes are not drastic and take a long time to implement, but in RCTs outcomes such as HgA1c levels (Piatt GA, Diabetes Care. 2006 Apr;29(4):811-7) in adults with diabetes and the number of asthma symptom days (Lozano P, Arch Pediatr Adolesc Med. 2004 Sep;158(9):875-83) improved more in the chronic care arm. Issues discovered along the way in implementing these models was higher cost of care (hiring of care coordinators and MD time), lack of time and venues for implementing and teaching staff and physicians, and reluctance among physicians to influence the practice of their colleagues. These are the same barriers we have experienced at Smiley’s and operate in the health care systems I have visited here as well.

Model.gif

Despite such obstacles, Smiley’s has been working hard to improve our diabetes care and have raised our rate of HgA1C’S below 7 from 48% to 57% and our grand slam rate to 12%. Some might think that 12% is still not very good, and it is not as good as the published data from some of the other clinics in Minneapolis, but it shows that our efforts are paying off. We should be proud. It also demonstrates the importance of measuring our outcomes since clinics and physicians tend to believe they are practicing better care than they truly are. When I first saw our clinic numbers, I didn’t believe them. Then I started making excuses. Now, when I get handed my panel’s HgA1c levels I am reminded that I still have work to do. That was frustrating at first but much less now that we have the systems in place to help my patients do better. I truly believe—even if there were no data to prove its value—that we practice better medicine when physicians agree to use decision tools, guidelines and protocols to determine management and when we collect data on how our patients are doing. Humility is a powerful force.

As expected, I have observed a large spectrum in the approach to the care of patients with chronic diseases in Buenos Aires. These approaches include: physicians in private practice working on their own to improve patient care through repeated education at clinic visits; hospital systems that have implemented registries; EMR; and workshops to educate both physicians and patients. They are all struggling with the same issues we have and still do. Adopting decision support tools such as protocols is very hard to do in a country where physician autonomy is paramount. Protocols and P4Ps don’t exist here. I attended an excellent academic seminar in an academic institution where the ACCORD and ADVANCE data were presented and recommendations made on HgA1c targets. However, I don’t think the plan of the seminar was to implement goals for all physicians to follow. Another important chronic disease management tool is physician performance feedback, through systematic review of panel data. In the same hospital, despite having data on physician outcome measures such as HgA1c, they have not started providing physicians feedback on their own performance yet. I sensed they are hesitant to provide that data to physicians. I remember being very nervous about Smiley’s decision to publish data on patient outcomes – now it is just part of our culture and is expected. In many private practice clinics here in Buenos Aires, where lab testing is done all over town and reports are not sent to the MD, it is nearly impossible to track HgA1c’s. Blood pressure tracking could be done. In more poor areas outside the city, patients cannot even measure glucose levels (they don’t have monitors) and it is hard for them to get HgA1c levels since they have to go to the hospital—where they often they run out of reagent. We have it easy! But I digress …

A third component of the chronic care model is teaching patients and families self management of their chronic illnesses. I have seen many physicians in different practice settings here struggle with improving the health of their patients through education at the clinic visit. They use the traditional approach of counseling and education about healthy behaviors that we all do; they just do more of it. As an observer, I get the luxury of seeing others do this work, while reflecting on how it relates to the care I give and it reminds me of how frustrating the traditional educational approach is. How many of us control our weight and our diets to the extent we expect our patients to?! In the US, we too struggle with this very difficult component of the model, teaching patients and families how to care for their chronic illness. I know that my default approach is to “educate� or tell my patients what to do even though I don’t believe it works. There is some evidence that Action Planning with patients is more effective. In one small study where Family Physicians were trained to use Action Planning to motivate their patients to change, they found that the technique was relatively easy to use and that 53% of patients described behavior changes consistent with their Action Plan (Handley, M. JABFM. 2006. 19:224-231). Yes, we have made big strides at Smiley’s in promoting self management and behavior change through our Diabetes group visits, Somali Diabetes groups and through referrals to Pat Graff, RN (DM Care Coordinator), Chrystian Pereira, PharmD and Dana Brandenburg, PsyD. I wonder, however, how effective we physicians are in promoting self management with our patients.

The physicians at one of the larger private hospital systems in town, the Hospital Italiano, have been successful in promoting self management through their patient education workshops. One cardiologist in particular, Dr. Carlos Galarza, has devoted much time and study in patient education. He published a study where he took 60 patients with HTN, who wanted to enroll in HTN patient education workshops and randomized them to either educational workshops using the traditional didactic approach (facts about HTN, dietary recommendations, bad outcomes caused by untreated HTN) or to a workshop that used a patient empowerment approach (patients identified what they wanted to know, reported their beliefs on HTN, practiced food label reading and exchanged ways of treating HTN that worked in their daily lives). HTN control did not change in the traditional educational group (remained at 45%) but improved to 70% in the more patient centered workshop despite no difference in number of medications patients were on (!). (Figar S. Am J Hypertens (2006) 19, 737–743). Their group has found these workshops so helpful, that they have created them for all sorts of chronic conditions, including fall prevention. Unfortunately, the vast majority of patients don’t take the time to come to workshops, so I shared with Dr. Galarza some of my thoughts about educating patients at the point of care through Action Planning. They have invited me to do a talk on Action Plans so that they might be able to start using these with their patients. It is one of my goals to make this technique a standard at Smiley’s as well.

Delivery System Designs and Clinical Information Systems, parts of chronic disease management that we have focused on intensely at Smiley’s, continue to be quite traditional here. In ambulatory clinics, the physician sees the patient alone, without nursing, and have the option to refer to nutrition and, on rare occasion, to health behavior counseling. In the public health system clinics, they have more teams that do include nursing and social work. I believe they also have nutritionists at the diabetes clinics there too. In one of the Obras Sociales – Constuir Salud – whose core physicians are family doctors, they too have implemented more team work in the ambulatory setting. In general though, there are few ancillary health care providers with whom physicians can partner to change the delivery system design. Rather than teams, they provide educational workshops run by the physicians themselves. As to EMR, it is becoming more prevalent with time but is still quite rare. One of the reasons the Hospital Italiano has been able to implement more components of the chronic disease model, is because they have a fully integrated EMR.

As I have said before, I truly value this opportunity to observe others caring for patients and to reflect on my/our own care. This weekend I will be attending a seminar (and speaking!) hosted by one of the premier family medicine residencies here on educating residents – totally looking forward to it!

Have a great Halloween and please someone take pictures of Dr. Ramer so I won’t miss the great event! We’ll find out if this US tradition has spread to the southern hemisphere.

October 17, 2008

10.14.8

The last few weeks I have focused on visiting clinics that serve the Obras Sociales, loosely translated as “social security here� and will try in this blog to describe a bit what they are, how they work and their intimate connection to the health of this nation.

The US census in 2004 determined that 85% of the U.S. population had health care coverage with 59.8% of the 85% covered by their employer or spouse’s employment. Only 9% were covered by privately purchased insurance with Medicare and Medicaid covering the rest of those insured. So, most people in the US rely on their jobs to provide health insurance in some way or other. As we all know this link between employment and health care coverage creates problems when workers change jobs, lose their jobs or heaven forbid, work for themselves. How it all works out for the patient is in some ways arbitrary, dependent on what health plans the employer offers the employee although generally the major health care plans in the US are more similar than dissimilar.

In Argentina, the work-health insurance connection is in some ways even more arbitrary because the patient’s health care is determined by his Obra Social. There are more than 300 of them and they are not all similar. Obras Sociales are organized through the unions and, as noted in a prior blog, provide health care coverage for about 40% of Argentineans. For example, the union for teachers negotiates a health care plan for the teachers or an Obra Social. If the teacher’s union is too small to create its own Obra Social, then the union can choose to buy into a private plan or into another Obra Social. A visit to the government’s “Health Care Service Supervision� website lists 300+ Obras Sociales, among them: OBRA SOCIAL DE FORD AGENTINA S.C.A, OBRA SOCIAL DE LOS MEDICOS DE LA CIUDAD DE BUENOS AIRES (of the doctors of Buenos Aires), OBRA SOCIAL DE RELOJEROS Y JOYEROS (of watch makers and jewelers), OBRA SOCIAL DE MINISTROS, SECRETARIOS Y SUBSECRETARIOS (of gov’t ministers, secretaries and subsecretaries) and so on. Those who are self-employed can buy into certain Obra Socials’ health plan or use the public health care system (which 40% of the population use).

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Pharmacy with Obras Sociales Contracted Plans Posted

The first Obra Social that I visited was Construir Salud which is sponsored by the union for construction workers and is responsible for 1 million members residing all over Argentina. The second is called PAMI and covers retired Argentineans who are not eligible for care under an Obra Social. The last was Luis Pasteur, a smaller Obra Social that has about 20,000 members and cares for executives from pharmaceutical companies.

Starting with Construir Salud. I was so excited to see that the core providers are family physicians, which differs from any other health care system that I have seen here so far. Each member has a family physician as their primary physician. Family Medicine as a specialty is less well known than in the US and the health care system (in Buenos Aires) tends to limit its scope of care to outpatient adult and peds, without gyn. Construir Salud is able to employ a large number of family physicians partly because it runs a family medicine residency and thus trains its future work force.

Their main clinic in Buenos Aires employs 31 family docs, 2 pediatricians and 6 OB/gyn. It was extremely busy, with family physicians seeing patients every 15 minutes for full spectrum care, including prenatal care. Their patients were socioeconomically more disadvantaged compared to private practice since (as would be expected) the majority of patients were construction workers, their families or other self employed laborers. Their no show rate is 30 – 40% with most not showing for the 8:00 am early appointments. Would you believe I came all this way to experience a worse no show rate than ours? The medical problems I saw were also more similar to ours, with much more obesity, diabetes and hypertension than in the private practice.

At Construir Salud they work hard on managing their members’ health. Just like an HMO, Construir Salud is responsible for the health of their patients/workers. It is in their best interest to maintain their patients’ health. They run a health maintenance and disease prevention program called “Programas Sanos� (Healthy Programs) which most recently focused on obesity and hypertension. Through physician conferences, they keep MDs up to date and discuss ways to improve care in those areas. For patients, they have ongoing educational workshops and mini lectures given by the G1s in the waiting room (hmmm…). They also track all their prenatal and pediatric patients through age 6 and will call patients who have not kept appointments to determine how to get them in. They do not have an EMR (very rare here) but still manage a registry of their diabetics (monitor frequency of HgA1c and other measures that I was not able to get a close look at) and other outcomes such as preterm deliveries, cervical cancer and colon cancer. The chart also includes a preprinted flowsheet for diabetes, obesity and hypertension that the MDs use regularly and helps support their decision making. They do not have care coordinators, but as in private practice here, the physicians use frequent patient visits to manage these chronic illnesses step by step. Unfortunately, long term follow up is limited by patients changing jobs (lose their coverage with Construir Salud) and/or they have trouble keeping their appointments due to work. Sound familiar?

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Reception area at Construir Salud

Construir Salud is able to do more disease management than other ambulatory clinics I have seen because they have nurses! Here in Argentina, after visiting clinic after clinic without nurses, seeing a clinic that works well with nurses reminds you of how important a role they play. They don’t room patients other than for the prenatal patients and pediatric patients who they do vitals on, vaccines and routine care similar to what our CMAs do. To keep their nurses engaged, they rotate them through different roles and jobs, so they become true primary care nurses.
One more tidbit before talking about PAMI is this – Construir Salud uses family charts. I have heard of these but have never seen them. In the front of the chart is the family genogram, followed by a section for each family member starting with the adults. No more having to duplicate family histories in 6 places and remembering of family names. Such a chart would decrease Nancy Krell’s work by 50%! Nicole Chaisson at Smileys has advocated many times for electronic linkage between family member’s charts; we can only hope that a future version of Allscript does this.

Now about PAMI. This is the Obra Social that is available for retired persons who don’t have an Obra Social or pension that they can turn to for care. All providers, hospitals and pharmacies contract with PAMI to provide care to its members. The physicians are paid through capitation and so the system requires that everyone have a primary care physician. Physicians then work out of a clinic (PAMI doesn’t have clinics) where they see their PAMI patients. Physicians are also expected to make home visits on patients who cannot make it in to clinic and coordinate care between the hospital and specialists. Patients are restricted to care at contracted hospitals and pharmacies. For convenience sake, many PAMI patients alternate their care between the public hospital and their PAMI primary clinic since the contracted hospitals are not always conveniently located. I’ve included a picture of a pharmacy which has printed all around it all the plans that have contracted with that pharmacy – both the private and the Obra Sociales. We think it is hard to negotiate our plans. Plans here are much more restrictive.

Luis Pasteur is the last Obra Social clinic that I visited. The clinic was located in an upscale neighborhood, was beautifully designed (almost as nice as Smiley’s) with large patient care rooms (unlike Construir Salud whose patient rooms were too small for me to sit and observe comfortably) that included computers and an EMR (!). Their health plan also offers 30% discount to Laura’s Spa, discounts on vacation packages and tours, in addition to their weight loss program (nutrition counseling and support group) and their nicotine quit program (counseling, group therapy and discount on meds). I’ve included a picture of one of their patient care rooms, and of Dr. Cantale who works at many of the clinics I have described and has been a wonderful guide and teacher.

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Dr. Cantale at Luis Pasteur Clinic

So, one can see how one’s profession – pharmaceutical executive or construction worker – impacts the health care plan that one is eligible for and supported by one’s union. Unions are a very strong political force in Argentina and continue to be a large driving force in the health of the nation. And because there are so many unions, there are so many health care plans for the government to organize and monitor- a monumental task that was not well done until recently. The PAMI website highlights how in the last 10 years they have been able to rid themselves of the deep corruption embedded in its prior administration. Nevertheless, despite the complexity and the patients’ need to navigate this complexity, all citizens have health care available to them, which we in the US do not.

October 6, 2008

Well last week we took our “spring break� in Peru. It was a fabulous trip for the adults and “OK� for the kids. A bit more on the “OK� bit later.

We started by flying into Cuzco (the capital of the Incan Empire) where we stayed for all of 30 minutes before getting a ride into a small village 40 minutes away called Pisaq. Pisaq is one of the many villages in the Sacred Valley, the large expanse of valley and Andean mountains where the Inca once centered their government. Pisaq is at a lower altitude than Cuzco which, as the highest ancient Incan city, is at 11,207 ft. A good friend of ours recommended we spend a few days at an altitude lower than Cuzco’s to get used to the low oxygen tension. And great advice that was, since we could feel the lack of oxygen when hiking in the ruins even in Pisaq.

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Historic Plaza in Cuzco

For fun, before landing in Cuzco, all of us checked our pulses and then compared them once landed. All our pulses climbed between 10 – 15 beats and even climbing a set of stairs in the airport made us breathe heavily.
Pisaq was a wonderful village to start in, a pueblo that is both authentic (primarily adobe houses with people dressed in traditional robes carrying everything in bright colorful bags on their backs while conducting their everyday business) while offering typical tourist attractions (beautiful ruins at the tips of the mountains, a vibrant market and a hotel with hot water and TV). My middle child was a bit taken aback by the condition of some of the adobe houses we passed and was worried that “we were staying in a mud hut� near Machu Picchu. No, the adults are too accustomed to the comforts of home to travel that rustically!

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Market in Pisaq; Mother and Child in Pisaq; Farmers Market in Pisaq

Once acclimated, we returned to Cuzco for a few days. We truly enjoyed the historic center of Cuzco. The historic Plaza de Armas is very picturesque, surrounded by great Spanish colonial buildings and several cathedrals and churches, and it had all the amenities of a big city (better restaurants, museums, lots of stores and plenty of internet!). There we met Mariela and her mother who joined us for the rest of the trip. Three years ago, we hosted Mariela in our home for a year while she worked as an exchange teacher in the Spanish Immersion School our children attended at that time. We absolutely loved having her live with us and were just tickled to be able to see her again and get to know her family. Her mother “took care of us� by finding us the authentic restaurants and making sure we were not overcharged for our meals. Of note, Mariela was the only one of the 7 of us who got altitude sickness (headache, dizziness and nausea and vomiting) which shows how unpredictable that condition can be!

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The Asado Family; Perfect Incan Windows; Spanish Architecture Superimposed on Incan Architecture

During our week in the Sacred Valley, we visited many Inca (or better said Quechua – Inca actually refers to the successive 12 rulers of the civilization) ruins but of course the most impressive was Machu Picchu. The Incan empire that built the city of Machu Picchu had spread all over South America even into Chile and Argentina and had reached an incredible height in agriculture (200+ types of potatoes and 20+ types of corn!) and architecture. They were able to sculpt and move 100 ton granite rocks into interlocking blocks that lay together so perfectly that no spaces existed between the rocks and in such perfect symmetry that one could look through one window and see through all the others. All this without metal tools. Their construction was exact enough to place windows and sundials in perfect alignment for determining the exact time of the solstice, so they knew when to plant and when to harvest. Most of their work was destroyed by the Spaniards. As has happened so many times in world history, the Spaniards conquered the Quechua and superimposed their catholic religion and culture upon the native culture creating a blend that was evident in the paintings, cathedrals, food and language all around us. While still on Machu Picchu, Michael and I were gifted some free babysitting by Mariela and her mother who took the children back to the hotel after the tour, allowing us to hike a small part of the Inca trail and truly commune with the spiritual qualities of the mountain.

Machu Picchu 1.JPG


We also spent a few days in Lima (too few), where we stayed with Mariela and were treated to her mother’s delicious Pollo con Mani (chicken in peanut sauce). Unfortunately we didn’t get to see all we wanted to see (or what some of the residents at Smileys might have recommended!) but were impressed by the museum that depicted the terrorist times of the Shining Path, the wonderful asado (barbecue) hosted by her sister and the fountain and lights park that the children totally enjoyed. We heard much about the struggles the Peruvian people have been through and how crime continues quite rampant but is improving. There were police and security everywhere and one can now “rent� an escort by a policeman when going to the bank to withdraw money.

Rock shaped like mountains with family.JPG

So for Michael and I, the trip was a wonderful visit into the past and present of a people very different from ours. It proved yet again how much more enjoyable a trip is when you get to travel with good friends who are from the area and it gave us a chance to get to know Mariela’s family after sharing ours with her. The children enjoyed the ruins (at first and then they became “boring�), the hotels (especially the one with a ping pong table and Jacuzzi) and the train we took, but were definitely sustained by the internet cafes that we tried to visit every day and the TV that some of the hotels had. If they had their electronic dose for the day, they were much more willing to climb the ruins and walk the city streets. When I think back to the many trips I made with my family as a child, driving around Madrid or to the Pyrenees, I mostly remember the car rides, the endless landscapes and the cool Paradors (old castles or convents converted into hotels) we stayed in. We didn’t have internet, so we read. I don’t remember much more, so I wonder what about our trips the children will remember when older.

September 29, 2008

Food and Lifestyle

This blog is a week behind, written before we took our “spring break� last week to Peru. Warning, next week’s blog, after I have gone through the 300 or so photos of Peru, will be our “vacation slides�!
Oh, so on to food and lifestyle …

As everyone knows, obesity is increasing in prevalence in the U.S. and elsewhere in the world. When I was in Buenos Aires 12 years ago, I was struck by how thin the women were (culture of beauty is strong and the city has always had a high prevalence of anorexia nervosa) and now, the people look (to me) like we did 10 – 15 years ago.

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Culture of Beauty

Walking around the streets, riding the buses and metro, I would guess that the majority of people have near normal or mildly elevated BMIs. Actual epidemiologic data has shown that 25% of Argentineans have BMIs over 30 (30% in the US) and 35% between 25 and 29 (35% in US). Marked obesity is rare (5% in the US). Both Michael and I were surprised by this data, since the data seems to point to a very similar prevalence; I would guess however, that within these ranges, the Argentineans are on the lower end compared to the US. I have yet to see a person over 300 pounds and I have included a photo of a random street to “prove� it.

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A Random Street in Buenos Aires

Management of obesity is now increasingly discussed in the medical profession here. At one of the larger hospital/academic centers, they are offering classes on pharmacotherapy of obesity and bariatric surgery is now fully reimbursed by the government. Nutrition referrals are covered as well, so it is very common for people to be seeing a nutritionist on an ongoing or intermittent basis. That little piece – government supported nutritional education would be fabulous in the U.S.!!

I don’t know what underlies the more normal weight distributions here, but as you might expect, I have some guesses! Most of the patients I meet talk about “cuidarse� or “taking care of oneself�. That culture is strong here. Everyone knows that they need to exercise and eat well and it seems that people focus on “cuidandose� regularly. There also appears to be a higher baseline amount of movement. I met 2 elderly sisters who walk everywhere – that is there only mode of transportation and they do well. The one was very fit, the older one of 88 years was obese but probably with a BMI of 30. Most men that came in for physicals are involved in sports – usually soccer or volleyball – that they try to do at least once a week. Many frequent the gyms. The culture is to move. With that higher baseline of movement, it seems to me that there is less resistance to increasing it. The patients all seem in agreement that they need to move more and are eager to do so. In other words, the Argentinean’s I have met fluctuate between contemplation, action and maintenance, whereas in the U.S. we have many who are often in the precontemplative phase. They also can and must rely on public transportation more – buses are regularly full and at times we were not even able to get on to the SubTe it was so packed. Whether these cultural differences translate into more physical activity, I am not sure, but I believe it does.

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Many, Many Gyms

The diet is not much better than ours although meat is the core nutrient, followed by carbohydrates. Our diet is centered on carbohydrates and then meats. Vegetables are known to be healthy but many eat few vegetables here. One of the MDs told me that most Argentineans overcook vegetables so they don’t taste good, they export their best produce and they are relatively expensive. Practicing physicians live on salaries more akin to American residents, so imagine what the average wage here is. An empanada costs about 80 c (and is yummy!) and with three, you have a meal for 2.40$. A bushel of broccoli runs the same and just doesn’t seem as filling. Portion sizes in restaurants are often as large as ours, but it is rare to find an all you can eat buffet, so gross overeating is likely less common.

Sam and Choripan.JPG

A little aside: about 6 months ago, my husband and I went to a Harvard sponsored nutrition and cooking conference that was taught in conjunction with the CIA – Culinary Institute of America, the premier cooking school in our country. Yes it was fabulous, but what it emphasized is that many of us don’t know how to cook food that is healthy, filling, good for you and quick. And I agree. When we started to use the principles they taught us at the conference at home, both my husband and I lost weight (without trying) and the food tasted just as good as what we were used to. It has actually been very hard for us to duplicate that diet here in Argentina because it is harder for us to find the vegetables, legumes and nuts. The CEO of HealthPartners went to this conference (she paid for it herself!) and has since changed the training of the dieticians in their system to reflect the principles learned. In the US we need more nutrition centers where you learn how to cook healthily through workshops and practice, not just dieticians who tell you how to do it. That isn’t as effective. Wouldn’t that be fun!

Back to the medical: with the improved lifestyle habits, the cholesterol’s that I have seen are closer to normal. The highest I saw in the last 2 weeks was an LDL of 180. Many are around 150 or less. In the US, I had patients with levels up to 190 and 200! In addition, my patients who have lost a fair amount of weight and improved their diet in the U.S. have also had improvement of their cholesterol.

So again, looking at another population’s health has reminded me that healthy lifestyles can work as long as we support such habits through culture, education and our health care systems. Unfortunately, our health care system and nation don’t support good nutrition and exercise. Until then, we at Smileys will keep working on our own systems to support healthy choices, such as the pre-visit and post-visit check ins with patients that the diabetes CQI group is working on. Go team!


September 19, 2008

9.19.8 A Team of One

As you all know, I am interested in practice teams both at the point of care and for complex patients. At Smiley’s we have worked hard to create and support our teams. Our teams are an integral part of our work on chronic disease management, standardization of care and care of the complex patients. Here, in Argentina, I have seen very little team work. It seems to me that there is no perceived need for team work and several realities stand in the way of working as teams. For one, it is very rare for physicians in Argentina only to work for one clinic. Many work full time to make ends meet, but at several different clinics. The reason: to make sure that if one clinic closes due to poor economic times (which are extremely frequent) they still have income from the others. The founder of the private practice clinic I have been visiting, Dr. Ceitlin, tried very hard but unsuccessfully to hire full time physicians to his practice. So, for physicians working for many different clinics and systems, it must be hard for them to organize within each clinic to work as a team. And secondly, as discussed below, there are no other health care professionals to team up with!

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Evita's Masoleum


So each physician in the private practice I have been observing creates his or her own system of care. One of the physicians, Dr. Cantales, has created his own mini EMR on his cell phone using an excel spread sheet. It includes a picture of the patient and the important diagnosis and meds. He is the only MD at the private clinic that I have met who does this. He has thought of using forms for visits but finds they thicken the records so much and don’t actually improve his care and I would suspect (did not ask him and if he reads this blog he will correct me I hope!) that he would have to maintain his library of forms himself. When he works in his other clinics, some for the Obras Sociales (clinic that work as part of a union’s health plan) he has somewhat different systems set up because the requirements for these plans are different.

In addition, nursing, pharmacists and other providers are rare in the private practice setting because there are no nurses, PAs, NPs and technicians to hire. I was quoted that there are 0.2 nurses to one MD in Argentina. The nurses are paid so poorly, that no one wants to enter nursing and those that do typically work in hospitals. I also don’t see the private practice clinic expressing a great need. The MD does much of the nursing care and what he/she doesn’t do, is done elsewhere. Vaccines are given at the vaccine clinics. Labs are drawn at the lab across the street. Any more urgent concern is referred to the hospital or emergency room, such as stitches etc. And when we asked two 80+ year old sisters how they manage having to go here and there for their care, they said they did just fine! They walk to where they need to go and expect no less.

In the public outpatient clinics where they serve a more needy population, I was told there are functioning teams that include a social worker and nursing. Also in the public hospitals there are teams within the specialties, more often composed of physician teams that address the more complex patients. Nevertheless, one cardiologist was telling me that when he sees his patients, he has no one to do the EKG, blood draws, the blood pressure or any other testing. He does it all. Physicians are paid quite poorly compared to the U.S. and so employing them to do both nursing, technical and physician work is not expensive. In the next few weeks I hope to observe a DM clinic in the public hospital and see how their teams function and see if they have any tricks we can adopt.
I have yet to see how a private hospital functions and so don’t want to generalize (which I have been doing!) too much more on teams.

One last point regarding teams has to do with clinic phone calls. All the physicians give out their cell phone numbers to their patients so that they are on call 24/7 for their patients. No triage nurse, no answering system. Dr. Cantales finds that answering the calls directly decreases the anxiety of his patients without increasing the work. They tend to call less, because they have access and don’t want to disturb him. If they call while he is with another patient, he answers it. The calls seem to take at most 2 minutes and he averages between 0 to 20+ calls a day, mostly during daylight hours. I by no means am advocating a change in how we manage our phone calls (easy for me to do from afar), but do think in the spirit of the Smileyota Way it is important to ask a few times “why� we manage patient calls as we do.

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Community Athletic Center Educational Poster

I miss the teams at Smileys and at times, find my little team of one quite lonely. So we make a point, when the kids are out of school to do fun things as a family. This next week though, I hope to start Skyping with faculty at Smileys and am looking forward to reconnecting!

September 12, 2008

9.12.8

This week I spent more time shadowing family physicians in private practice, visited one of the 4 or 5 family medicine residency programs in Buenos Aires and a public hospital. The public hospital system is legislated to be available for anyone, anytime for full care.

I will include just a few comments about the residency here, since I was not able to find out much about their curriculum. Look for more details on the residency program in future blogs. Tuesday is their “academic day� with the afternoon devoted to lectures (hmmm…). I was the show and tell that day and spent an hour answering questions about how family medicine cares for patients in the U.S. Seems like our system is more similar to primary care in Spain than Argentina because many would comment “that is how it is in Barcelona!� after I would explain how we cared for patients in the clinic. I was also there for one of the lectures given by a prior graduate of theirs who is working on his own EMR. I felt like I was in a time capsule listening to him talk about what it would be like not to have illegible paper charts, to quickly see prior visits and to be able to run simple demographics and diagnosis patterns on your patient panel. I also felt at home (!!) during the very lively discussion that followed among faculty and residents in the care of an obese patient with DJD of the hip. Their faculty talk as much as we do! Of all the places I have visited, I felt most energized by the residency program which confirms to me that I am doing the work that I love.

On to the public health system. . .
I visited a very large (spans two full blocks) public hospital (Hospital Ramon Mejia) that was impressive in the scope and complexity of its care and its aspiration for quality of care despite its limited access to technology. The physicians there were wonderful--eager to answer all my questions. Their outpatient area essentially consisted of a very long corridor with exam rooms (they have 142) that open onto the corridor. Each exam room is assigned a different specialty (some specialties have a cluster of rooms) and is where the MD sits and sees one patient at a time. They do their best to have scheduled appointments with the same physician longitudinally. To keep the hospital as more tier II care, they have created 7 multispecialty clinics in different neighborhoods that are designed to feed the hospital but still many get their primary care at the hospital.

Hospital corridor with outpatient rooms.JPG

Unlike in the U.S., their government legislates health care more than we do (surprise!). The public hospitals are the “buffer� zone, the means by which all can get care for free. During times of economic crises (most recently in 2000-2001) their volume of care skyrockets and they have to adapt. During such times they essentially became one huge walk in – urgent care hospital. There is no follow up; treatment has to be completed that day. Unlike in the U.S. where there is limited legislation on care that is deemed essential, Argentina has a PMO – Programa Medico Obligatorio. I was told that all providers, private and public, must comply with the rules of the “Compulsory Health Plan�. For example, all TB, HIV, DM, chemotherapy and seizure medications are free. Also most medications to treat chronic diseases have to be discounted – often up to 80%. Diabetics get guaranteed 400 strips a year and can get more if authorized by a physician. Bariatric surgery is now a free procedure. Prenatal care and postnatal care for the infant is free.

The disease spectrum and complexity of care is similar to ours with patients on 10 – 15 medicines a day. Smoking is much more common. Nevertheless, the annual health care expenditure is about 8% of the GDP, unlike the 15% or so it is in the U.S. They save money on technology (the ICU monitors are 20 years old), equipment (syringes, tubing etc. are washed and sterilized and reused until non functional), building maintenance (the hospital has not been renovated much in 125 years it has functioned) and in administration. Yet, despite much poorer conditions, they are monitoring their care and patient and employee satisfaction. Argentineans are used to working under poor economic conditions and thus by necessity are a creative and adaptive people.

Private Practice exam room.JPG Public Hospital exam room.JPG
Comparison of private and public exam rooms

I am finding, as I visit these many different systems of health care, that chronic disease management is in its infancy here compared to the U.S. Delivery system design is limited by the lack of teams: I was told there are 0.2 nurses for each MD in this country and MDs typically work in so many clinics that there is less incentive to collaborate (see next week’s blog for details). Clinical Information systems are still primarily paper based, with EMRs just starting, so feedback and monitoring of outcomes is more difficult. Decision Support is less commonly used since MDs tend to work in parallel, with each physician choosing the guideline or standards she/he wants to use and there is limited communication between consultants and primary care physicians. Family Education and Self Management Support is done through the physician and frequent clinic appointments.

Medical Records - outpt.JPG Public Hospital main waiting area.JPG
Outpatient Medical Records and the Central Waiting Room of the Public Hospital

I am still just starting to explore and discover how Argentineans care for their patients and so do not believe in any way that what I have seen all there is to see, nor that my impressions and conclusions won’t change. What I am rediscovering every day is that reflection and an being outsider looking in allows me to reconsider and reassess what I believe we as a clinic and as a nation need to be focusing on as we try to improve the care we give.

September 5, 2008

9.5.8 Back to Work and School

Our vacationing is over and the sabbatical has begun. I’ve started making contact with Family Physicians here in Buenos Aires, my children are now attending school full time and my husband is immersing himself in “castellano� (Spanish).

First, let me update you on the school experience for our children. Overall, our children have done a marvelous job adjusting; to a full day (8 am – 5pm), to new kids (they have friends already and have play dates planned!), to new classes (the youngest hasn’t learned cursive yet but teachers here don’t print), to using a fountain pen (and getting ink all over their uniforms!!), to a different method of child crowd control (more yelling) and of course, being taught in Spanish for half the day (which hasn’t seemed a problem for any of them, even the youngest whose Spanish knowledge is minimal). Of course they do complain and are eager to point out what is “stupid� but they truly like their teachers and are eager to be in the school talent show, participate in the chess tournament and exchange emails with their new found friends.

taking Subte to school in am.JPG After school Fredo break.JPG

Now onto a bit about medical care in Argentina. Their health care system is subdivided into 3 parts: the private sector (which serves only 8% of the population), the public sector that is entirely free (serves about 40%) and the Obras Sociales (loosely translated as social security) that serves members of the unions. Almost half of the Argentinean population belongs to trade unions (total greater than 350!) and each trade union is responsible for negotiating and subsidizing health care coverage for their members. Thus there are many, many different health plans functioning with some providing excellent and others poor coverage. The issue is that there is no strong oversight of these plans, despite multiple attempts to do so. So it is not unusual that those covered by an Obra Social also use the public system at times. Those who use the public hospitals and clinics essentially get their care for free. I plan to visit one of the public hospitals in the next few weeks to see what that care is like. Those who are lucky enough to be able to afford private health care insurance, have access to medical care very similar to ours.

Centro Privado de Medicina Familiar.JPG

My mentor here is Dr. Julio Ceitlin, the founder of Family Medicine in Argentina and a good friend of our Chair, Dr. Macaran Baird. In addition to creating a residency program in Family Medicine, the Ibero-American Confederation of Family Medicine, he also started his own clinic (Centro Privado de Medicina Familiar) whose core physicians are family physicians. This clinic is typical of private practices in Argentina, which are run very differently from ours. Dr. Ceitlin’s practice continues with paper charts which looked surprisingly thin! Documentation doesn’t have to support billing, so the notes are 5 lines long. Patients are scheduled every 20 minutes and are seen in the one room or “consultorio� of each physician. The MD rooms the patient him/herself, and essentially does the entire visit in the consultorio without the assistance of a CMA (weighs patient, takes blood pressure if indicated etc.) Their lab is across the street and only open in the mornings. To order a lab test, the MD writes a Rx for the lab, the patient schedules a time for labs and then returns in a few days with the results that were mailed to the patient’s home. Together the MD and patient review the labs, which are returned to the patient. No copy is put in the chart; results are noted by the MD in the brief note. X-ray, other testing and referrals are done the same way. For medications, the patient takes the prescription to the pharmacy (like we used to do!) and then is given a little card (along with the medications) that has the name of the medication. The patients keep this card in their wallets so they can always show the MD which med they need for refills.

What struck me as I observed the first clinic was the simplicity of the system for the provider. The MD has time to deal with the chief complaint and maybe one more complaint, sends the patient for testing and schedules the follow up visit to discuss the tests and take the next step. One step at a time. I don’t know how effective this is with regards to outcomes, how often patients come back for follow up but I would say in the clinic I observed, 40% of the visits were follow up on labs and discussion of what to do next. I was told that most of the testing and referral sites are close by and so patients don’t have to travel far to get the testing, so it is not much of an inconvenience for the patient. It is also the expectation of the patient that they be referred for testing.

List of providers.JPG

What also struck me was how this system of care supports connection between the patient and the provider. While the provider is rooming the patient, taking vitals and weighing the patient, there is much time for chit chat and check in. I heard a lot of stories of stress, family dynamics and woe, in addition to the typical medical history. And you could truly sense the appreciation of the patients and their loyalty to their primary care MD. Patient expectations seemed to be less in “accomplishments� of the visit but being heard and a plan discussed.
I plan to continue to observe more clinics with different providers, to visit the residency affiliated with this private clinic, visit the public hospitals and also clinics that are run through the Obra Sociales. As I understand more in depth health care delivery here I will be able to better understand how they do or don’t manage chronic diseases. All that is still to come.

I am grateful for this opportunity to observe our colleagues’ work healing and caring for patients just like ours.

August 29, 2008

Settling in to our new home in Buenos Aires

8.28.8

This week we have been “settling in� and it has not been terribly fun.

The value of family and connections: This is the second time we have been to Buenos Aires in the last year and so had our “personal taxi� pick us up at the airport. Having been here before and having family in town has made our settling in here so much simpler. My aunt found the apartment (which is a gem) in a nice part of town and she was the one who visited the schools for us ahead of time. She made sure our internet was connected, our cleaning service was set and pointed us towards the grocery stores.

Shopping: What has been most frustrating for us has been finding and buying more specialized items. We have literally walked for hours in the last 3 days, clocking between 11,303 to 18,870 steps on my children’s pedometers, looking for a pillow for me, school uniforms and shoes for our children and some simple house hold items. Most of the stores here are small one item stores except for a few huge department stores that we have yet to locate. You find stores you need by asking passerby’s and kiosk owners where to buy “X� – can’t just search the internet. In the US, I lament the loss of the “mom and pop� stores but right now I could certainly use a Target!!

Cabildo main street by apartment.JPG


Transportation: Living without a car has been convenient and safe since we don’t need to park and don’t have to navigate one of the most dangerous cities in the world to drive in (second to Rome we were told by a taxi driver), but after only 3 days of walking many hours a day, I do miss my car! Cars are also good for carrying your packages … didn’t think about how my arms would feel after a day of shopping without an “auto.� Cars are also great for longer distances. I have spent several hours studying the map, the metro stations, the bus lines and the trains to determine how I am going to get around this city of 3 million jam-packed within an area of 80 square miles. My head hurts trying to keep it all straight!

Pita at her apartment entrance.JPG


Home Away from Home: The kids have been putting up with our days very well – they have had to walk along with us to buy their uniforms, books and shoes and then return home to a charming adult apartment that has very little to entertain them (we couldn’t pack all their toys). Even TV gets old in a few hours, especially in Spanish. “I’m bored!!� is what we hear a lot. The food isn’t the same and even when you order familiar foods, they don’t taste like you expect them to. Just salting our meals to taste is difficult since the salt is much finer and spreads differently. The one for sure item that never fails us is ice cream—better yet, gelato! My memories of arriving in Madrid at the age of 12 are related to food. The first breakfast I had, straight off the plane, was a fried egg, smothered in olive oil – “ugh!� was my reaction that day. I was much happier with the Kentucky Fried Chicken we found for lunch!

kids in front of school.JPG


Community: A highlight for the kids was visiting their school. They were very nervous going there and are now much more relaxed. We were soooo warmly received. We were ushered into a room and within minutes one of the cafeteria employees had brought us croissants (“media lunas� – our kids favorites), coca cola and coffee. The children they met were excited to meet them, show them around and then invite them into their classrooms. In addition to their Argentine classmates, they will have class mates from Nigeria, Venezuela, and Puerto Rico to just name a few. The school reminded me so much of the schools I attended in both Zurich and Madrid, international schools where I had friends from South Africa, Andorra, England and even Florida! Our children have commented several times about differences between the United States and Argentina. Like how “stupid� (my children are not terribly articulate) some of the customs here are, such as kissing hello. What better way to learn about cultures of the world than attending an international school?

George's Welcome breakfast.JPG Alex trying on his uniform.JPG Sam with classmates at his welcome party.JPG

Next week: school starts and so does my work. Stay tuned!

August 22, 2008

8.21.8 Hello from Santiago, Chile

Hello from Santiago, Chile where it is a cold 60°! Rather than travel directly to Buenos Aires, where we plan to live for the next 4 months, we chose to spend a week in Santiago, Chile with my cousin and her family. She and I spent time together growing up in Europe - she in Germany and I in Switzerland. I still vividly remember spending a week together in a winter ski camp in the Alps when I was about 8. Sam, my youngest, is 8 and I can’t imagine putting him on a plane alone and expecting him to land safely at a camp way up in the mountains!

Sleeping Masks on the Plane.JPG

In less than a week, we will arrive in Buenos Aires and will work on settling in. My children will start school, will need uniforms and I will prepare to learn about chronic disease management in Argentina, and to teach how we use chronic care. I have never “moved� to a different country as an adult before, only as a child. It is my turn now to create a household in a foreign land that feels like home but embraces the new. I certainly have renewed respect for our residents who have come from faraway places and manage the many complexities of life and work in the US.

When one thinks of Sabbatical, one thinks first of rest and then of time away – away from the usual routine and its restraints. So far, we have had little rest. I continue to feel post call after a nighttime flight with poor sleep, followed by a day of skiing in the Andes and then a full day sightseeing in the city.

Pita and Family Skiing.JPG

With regards to being away from the usual routine, it struck both my husband and I that it is much harder to separate today, in our global and fully wired world, than when we traveled 15 years ago. To stay connected then, our day revolved around finding the Herald Tribune in the Kiosks, finding the international phone center, hording airmail paper and stamps to send home a letter and figuring out which bank to use to exchange our traveler’s checks. Since we have arrived, we have read the NY Times online, Skyped with the grandparents, emailed family regularly, and are living off our credit card and the cash we get out of the many ATMs. It doesn’t feel like we are removed at all. I like it like that. I like being able to be away yet still be a part of our family and friend’s lives at home. On the other hand, it takes a conscious effort to cast away the routines we are accustomed to in order to experience a country as it truly is.

Chileans are both warm and friendly. My youngest Sam has had his hair fluffed many times, people are always smiling and eager to talk to us and answer our questions. We have been able to order dinner meals off the lunch menu and the man leading the outdoor chess reunions was willing to play with my middle son because none of the men there was interested in playing with a kid. In the afternoons, the parks and plazas are filled with people just hanging out. In the buses, the people talk to each other and to the bus driver, rather than sitting quietly minding their own business. On the other hand, we have been told not to wear jewelry, to carry our bags close to us and were the lucky recipients of a mad taxi ride through the crowded streets of Santiago at break neck speeds for twice the normal fee. I don’t know if there is an inverse relationship between the amount of law and order and the sense of a greater community; if there is I am not sure that increased order is worth the loss of community. It’s been a real joy observing and being a part of this culture.

Today we were witness to public health in action. It was the “Dia del Corazon� or “Day of the Heart� and there were tents in the plazas where people could get their cholesterol and blood pressure checked. There was quite a line of people waiting. I don’t know what the options were for those who tested high, but I assume they were directed to see a physician!

Heart fair in Santiago.JPG