Student and faculty collaboration in a clinic for the medically underserved

BACKGROUND AND OBJECTIVES: Growing numbers of uninsured and underinsured individuals in the United States have resulted in increased needs for health care for medically underserved populations. Educational strategies are needed that provide opportunities for students to develop the attitudes, knowledge, and skills necessary for providing quality health care for underserved patients. METHODS: Medical students, residents, and faculty of the University of Wisconsin-Madison Medical School worked together to establish extracurricular opportunities for first- and second-year students to participate in medical clinics serving the poor and homeless. The process for the development and operation of a volunteer clinic is described. RESULTS: In the last 2 years, 163 medical students, 27 residents, and 21 faculty have provided care to more than 1,000 patients. Patients, students, residents, and faculty reported high satisfaction with the experience. CONCLUSIONS: Medical students, residents, and faculty working in collaboration can provide increased access to care for the medically underserved. Engaging in community-oriented primary health care early in their medical education provided positive learning opportunities for medical students, especially those interested in generalist careers.     

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study

BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.     

Professional classifications of American nurses, 1910 to 1935

The growing corporate dominance in U.S. medical care has been a major factor in the increasingly inequitable distribution of health care resources and the declining public health conditions in poor and minority urban communities. Alongside this trend has been a parallel phenomenon of economic disinvestment and political neglect in these same at-risk neighborhoods. This article analyzes these trends as related components of austerity, retrenchment, and capital consolidation policies that have characterized the U.S. political economy for several decades. Emphasized are the relationships among corporatization, capital consolidation, deindustrialization of the workforce, and medical indigence; the resulting economic stress placed upon community hospitals and other caregivers in poor and minority communities; and the marked discrepancy between conditions of development and underdevelopment in American cities. It is argued that the effects of these policies are pathogenic in nature: they place populations at risk for disease and social dysfunction, they reduce access to necessary preventive and curative services, and they weaken coping mechanisms. Community economic development, empowerment, and a direct challenge to the growing concentration of wealth and power in the corporate class are proposed as essential elements of public health policy.     

Teaching residents to care for culturally diverse populations

The authors discuss the growing need for primary care residents to learn how to care for patients of many cultural backgrounds. To effectively learn the needed skills, residents must incorporate insights from areas outside medicine. The authors focus on three such areas: cultural competency, public health, and community-oriented primary care. Regarding cultural competency, the authors make clear that on the one hand, physicians must be trained to be sensitive to cultural differences and patterns, but on the other, they cannot be expected to know the many cultures of their patients in depth. They discuss the Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care created by the Society of Teachers of Family Medicine. Regarding community-oriented primary care (COPC), a process introduced from Europe in 1982, the authors state that one of its key elements is to provide accessible care to diverse and often underserved populations. However, various factors have kept COPC, and the federally funded community health centers that address the concerns of COPC, from having the widespread effects they could have. Regarding public health, the authors review the various services and orientations of public health and show how these help foster care for diverse populations. The authors then briefly describe their own residency program and its work with diverse populations. They conclude by emphasizing the importance for residents of learning the principles and practices embodied in cultural competency, public health, and COPC in order to effectively communicate with their patients.     

-The clinical use of the cuffed oropharyngeal airway (COPA)-

BACKGROUND AND OBJECTIVES: Family physicians and other primary care providers play a pivotal role in preventing oral disease, especially among minority and underserved populations who have limited access to dental services and poorer oral health status. Oral diseases/conditions, such as caries, baby bottle tooth decay, gingivitis, periodontitis, oral pharyngeal malignancies, and orofacial trauma, are prevalent and costly, yet largely preventable. Given their role in promoting and protecting overall health and their historical role in serving minority and underserved families, family physicians occupy a unique position to assure equity, access, and improvement in oral health for all Americans.     

Comparison of the effects of levosimendan, pimobendan, and milrinone on canine left ventricular-arterial coupling and mechanical efficiency

The relationship between the primary service area (PSA) of an urban community health center (CHC) program and a federally defined "medically underserved area" (MUA) was assessed. Federal guidelines that most reliably predicted medical underservice were identified. The service area was statistically defined by census tract penetration rates. The MUA was defined by an index of medical underservice (IMU) according to federal parameters of physician supply, poverty level, percentage elderly persons, and infant mortality. An index score was calculated for the country, service area, and each census tract. Analysis by tract determined the most significant discriminating parameters. By excluding two tracts concentrated with managed-care physicians, the service area qualified as an MUA. Tracts that fulfilled MUA and service area criteria were highly associated (p < 0.0001). Only poverty level and infant mortality were useful discriminating parameters. Federal indicators of demand (elderly population) and supply (physicians) did not adequately address issues to access for the medically underserved in urban neighborhoods. Other parameters that might serve as proxies of care access and underserved are discussed.     

An introduction to psychologists treating medically ill patients: Competent practice and seeking credentials in organized health care settings for routine or incidental practice.

Psychology has been recognized as a health care science and profession, and psychologists have been working clinically with medically ill patients and within organized health care settings and hospitals for decades. The potentially daunting environment of organized health care should be seen by psychology as an opportunity to further develop and expand its scope of practice. With knowledge of that environment's rules, regulations, ethics, bylaws, and traditions, the clinically competent psychologist who is first seeking to practice in hospitals should succeed alongside psychologists with busy practices who are already exclusively or occasionally within an organized health care setting or medical facility. This article reviews issues of competency, credentialing, privileges, bylaws, and practice expansion to guide psychologists toward a successful hospital practice with medically ill patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Third world medicine in first world cities: capital accumulation, uneven development and public health

This paper addresses issues of public health and access to care for the urban poor in the context of current U.S. urban, economic and industrial policy. The pathologies that threaten "inner city" neighborhoods are the result of decades of political neglect, economic exploitation and resource withdrawal, which themselves stem directly from public and corporate sector strategies to facilitate capital accumulation and consolidation. The resulting conditions of uneven development between wealthy and impoverished local sectors mirror similar relationships between First and Third World countries. These same patterns are reflected and reproduced in the health care "industry" itself, where growing corporate dominance has developed alongside a concomitant reduction in support for public sector and community-based care. These trends create and exacerbate conditions that place poor and minority populations at risk. Community development and political empowerment, as well as the overall corporate hegemony that increasingly characterizes the political economy of the U.S.A., are essential public health considerations that must be included in any meaningful health policy or health care reform proposals.     

School-based health care for urban minority junior high school students

OBJECTIVE: To describe the use of school-based health clinics by urban minority junior high school students. DESIGN: Review of demographic and utilization data collected by service providers during clinic visits. SETTINGS AND PARTICIPANTS: Health clinics in four junior high schools that enrolled predominantly Hispanic students who were residing in an economically disadvantaged, medically underserved New York (NY) school district. RESULTS: Of 5757 students who were enrolled in the schools, 5296 (92%) obtained parental consent to use the clinics, and 3723 (65%) used the clinics during the 1991-1992 academic year. Clinic users were 11 to 15 years old, 50% male and 50% female, 81% Hispanic and 14% black, and 29% sixth graders, 33% seventh graders, and 38% eighth graders. Clinic users made 16,340 clinic visits during the 1991-1992 academic year. Presenting complaints were mental health problems (32%), illness (14%), injury (12%), physical examination (5%), immunization (3%), follow-up (21%), and other (13%). Referral sources were clinic outreach (48%), self (44%), and school personnel (8%). Disposition of visits was on-site treatment (92%), referral to an affiliated hospital (5%), and referral elsewhere (3%). Compared with a nationwide group of high school-based clinics that served predominantly black adolescents, these clinics provided more mental health care (31% vs 21%), similar illness/injury care (32% vs 30%), and less preventive (10% vs 24%) and reproductive/contraceptive (7% vs 12%) care. CONCLUSIONS: Junior high school-based clinics can provide a wide range of primary and preventive health care services for large numbers of medically underserved youths. The provision of mental health services may fill a critical need among inner-city adolescents. Clinic outreach may be necessary to maximize utilization, especially among high-risk students.     

Community based study of treatment seeking among subjects with symptoms of sexually transmitted disease in rural Uganda

This paper presents a community based study of treatment seeking among people with symptoms of sexually transmitted diseases (STDs) in rural Uganda. The effects of asymptomatic infections and treatment seeking behavior on control of sexually transmitted disease were quantified. The study suggests that treating only individuals with STD symptoms results in only a small proportion of the infected population being reached. This situation leads to fewer people receiving effective health care. Thus, STD control programs in medically underserved populations must take into account the prevalence of asymptomatic infections and the health related practices of people with STDs symptoms to design strategies for reducing transmission of these diseases.     

Effects of the growth of managed care on academic medical centers and graduate medical education

The author offers insights into how the proliferation of competitive health care financing and service delivery systems based on managed care affects the financial support available to academic medical centers (AMCs), especially to their programs in graduate medical education (GME). The paper is based largely on case studies of AMCs conducted by the author in the summer of 1994 in the health care markets of San Diego, California, Minneapolis-St. Paul, Minnesota, and Washington, D.C., complemented by a review of the literature. In sum, the investigator found consensus among all parties that in the current market, managed care plans neither are willing nor feel able to pay much, if any, premium for the services of AMCs, particularly when established, respected alternatives exist, as they typically do for most services in major urban markets. Relatively few short-term adverse effects on AMCs were found from the growth of competitive systems, but AMCs are nevertheless very concerned that managed care will put them at a disadvantage. They are thus seeking ways to position themselves for the future. The AMCs are concerned that at some point, the cost reductions they are making will hinder the fulfillment of their unique traditional mission, since they believe that the costs of their GME programs can be reduced only so far without harming residents' training. Many managed care plans, however, question the AMC mission, taking issue particularly with the training AMCs provide and its relevance to current needs for primary and ambulatory care. The investigators also found considerable support for pooled funding for GME among diverse parties, but no consensus on how this funding should be structured, who should receive it, or what it should support. Potential conflicts were also identified between national, state, and market objectives for provider supply and specialty distribution because these objectives can embody different criteria for assessing the handling and locations of specialists' training. In addition, the findings indicate that it could be unwise to consider AMC policy independent of workforce objectives; doing so could create conflicts about the kinds of physicians who should be trained. The author concludes with a list of approaches to future research that may be constructive.     

Public health crises of cities in developing countries

During the decade and a half after Alma Ata hundreds of projects were started in developing countries to implement the principles of PHC and start community based health care programs in the rural areas of developing countries. Until the past five years urban health was not seen as a special health problem. Population pressure in the rural areas has created shortages of land, food and employment opportunities. These forces have generated major population movements to the urban centres. The population movements have encouraged unprecedented expansion of urban centres. This sudden concentration of large populations in small geographical areas has resulted in the urban health crises of the developing world. The poor who live in the slum areas have no access to adequate health services, they experience frequent epidemics of communicable diseases like cholera, they live within a heavily polluted environment, and their children have very poor health because they are not immunized and are malnourished. The paper agrees with approaches which have been championed by development agencies to address the urban health crises. These approaches propose the reorientation of urban health systems to include adoption of PHC for urban health programs, intersectoral collaboration and extra budgetary support. The paper argues for further strengthening of the reorientation approach by adjusting the development planning model. It is proposed that the urban plan be integrated into the national development plan so that emerging urban health crises can receive special attention in resource allocation.     

Rural telepsychiatry

Telepsychiatry is the use of telecommunications technology to connect patients and health care providers, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities. Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for clinics and hospitals in remote areas of areas underserved by psychiatrists and other mental health care specialists. In the United States, eastern Oregon's RodeoNet telepsychiatry program and the telemedicine program of the Kansas University Medical Center, which has a psychiatric component, are excellent models. Telepsychiatric applications can be cost-effective, but careful evaluation is needed.     

Surgery in South Africa

The practice of surgery in South Africa ranges from full-time service in state-funded and academic hospitals serving a largely indigent population to a private sector for medically insured patients. Surgical training occurs at eight medical schools, and specialist registration is obtained after 4 to 5 years with either a university-conferred degree or a fellowship from the College of Surgeons of South Africa. The wide spectrum of First- to Third-World diseases and the high incidence of trauma provide comprehensive experience for practical training. Surgical standards are uniformly high, matching and sometimes pioneering the very best of Western medicine. The health care system is undergoing radical change to correct the imbalances of the apartheid era. Academic institutions are under pressure, and with incipient major financial cutbacks, there is concern that the proud record of service, teaching, and research excellence may be compromised. To facilitate the mission of broadening health care services, diploma training in surgery for rural practitioners is being developed. Outreach programs and closer liaisons with surgical societies in sub-Saharan African countries have also been initiated.     

Establishing outreach health services for homeless persons: an emerging role for nurse managers

Nurse-managed clinics can be an effective strategy for addressing the health care needs of homeless and indigent populations. The role of the nurse manager in the establishment of a clinic involves community leadership--specifically, it involves addressing strategic planning, financial and manpower issues. The collaborative relationship of nurse managers, educators, and the community laid the groundwork for accessible and affordable health care for the homeless and indigent of one northwest Georgia community. Specific tools and strategies are presented.     

Teaching hospital costs: implications for academic missions in a competitive market

CONTEXT: As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions. OBJECTIVE: To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME). DESIGN: Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds). SETTING AND PARTICIPANTS: A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals. MAJOR OUTCOME MEASURES: Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case. RESULTS: In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity. CONCLUSIONS: The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.     

Molecular follow-up of patients with promyelocytic leukaemia treated with all-trans retinoic acid

Historically, University teaching hospitals have been the primary providers of health care to the indigent population. With the advent of managed health-care plans, the university hospitals have seen a rapid decline in their obstetrical patient populations. This decrease is reflected in the numbers of deliveries and gynecological surgeries. From 1990 to 1995, these changes resulted in a significant decline in deliveries at our hospital, the Lyndon B. Johnson General Hospital. To reverse this ominous trend, we instituted a variety of changes resulting in a more patient-centered system and found an improvement in the numbers of obstetrical patients. In the following report, we describe these changes and the subsequent outcome.     

Telehealth: A clinical application model for rural consultation.

This article describes how a child psychologist in a rural community provides the necessary comprehensive consultation and clinical services using a video telephone and the services of Kentucky Telecare. The authors present a clinical consultation model of health care for underserved populations where professional consultation with a team of professionals may benefit service providers in rural communities. The article examines an innovative model of telehealth care delivery through a university-based telehealth system to an underserved regional school system. A number of applications within a broad spectrum of services using telehealth technology are offered. Finally, shifts in administrative paradigms, clinical models, and information technology prevention services through telehealth are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Telestroke" : the application of telemedicine for stroke

BACKGROUND: Time is of the essence for effective intervention in acute ischemic stroke. Efforts including stroke teams that are "on call" around-the-clock are emerging to reduce the time from emergency room arrival to evaluation and treatment. SUMMARY OF COMMENT: Based on the results of the NINDS rt-PA Stroke Trial, which demonstrated both clinical effectiveness in reducing neurological deficits and disability and cost savings to health care systems, many community hospitals and managed-care organizations are exploring methods to enhance and expedite acute stroke care in their local communities. Only a small fraction of acute stroke victims is currently treated with thrombolytics (<1.5% nationally), and few benefit from the expertise and experience of the stroke teams. It is essential to develop new paradigms to improve acute stroke care in all settings, rural and urban. Rapid linkages to expert stroke care can help the underserved areas. Telemedicine for stroke, "Telestroke, " uses state-of-the-art video telecommunications that may be a potential solution and may maximize the number of patients given effective acute stroke treatment across the country and across the world. Telestroke could facilitate remote cerebrovascular specialty consults from virtually any location within minutes of attempted contact, adding greater expertise to the care of any individual patient. This model also has the potential to enhance patient entry into clinical trials. Telestroke would enhance stroke education through the use of Internet-based interactives for health-care professionals and patients. Education would be facilitated through the creation of telecommunication-linked classes providing interactive information on stroke care and prevention to places where they are otherwise not available. Health-care professionals will gain experience and expertise through the interaction with a remote expert--telementoring. Telestroke provides an excellent medium for data collection and an unprecedented opportunity for quality assurance. Monitoring of an entire tele-interaction can offer real-time assessments, which can then be analyzed in-depth at a later date for unique insights into health-care delivery. Prehospital use of telemedicine for stroke is already being piloted, linking patients in the ambulance to the emergency department. Legal and economic parameters must be established for telemedicine in the areas of reimbursement, liability, malpractice insurance, licensing, and credentialing. Issues of protection of privacy and confidentiality, informed consent, product liability, and industry standards must be addressed to facilitate the use of this new and potentially useful technology. CONCLUSIONS: Computer-based technology can now be used to integrate electronic medical information, clinical assessment tools, neuroradiology, laboratory data, and clinical pathways to bring state-of-the-art expert stroke care to underserved areas.     

Maternal smoking and age. Effect on birthweight and risk for small-for-gestational age births

Health care reform proposals may affect public hospitals in a number of ways. To insure that such proposals benefit the underserved communities within which public hospitals operate, reform initiatives should be evaluated against 10 criteria that emphasize prevention and primary care, community health education, cost control, tort reform, and community values.