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Setup Instructions |
U.S. - Mexico
Border Centers of Excellence Consortium Forum Proceedings
Welcome and Meeting Overview Ana Maria López, MD, MPH, University of Arizona College of Medicine Dr. López is Associate Dean for Outreach and Multicultural Affairs and Associate Professor of Clinical Medicine and Pathology at the University of Arizona. She is the Medical Director of the Arizona Telemedicine Program. She received her AB in philosophy from Bryn Mawr College and earned her MD from Jefferson Medical College. After her residency and general internal medicine fellowship, Dr. López received her MPH at the University of Arizona, and within a year she also completed a fellowship in hematology/oncology. For 10 years, she was Medical Director of the Women’s Health Initiative at the University of Arizona. Since 1997 she has been Medical Director of the Telemedicine Program, where she helps improve access to health care for rural patients and her impact reaches far beyond the local hospital setting. She is an experienced researcher whose work has appeared in various peer-reviewed publications. These accomplishments and others have earned her the Local Legends Award and a spot on the list of the Best Doctors in America. After welcoming participants, Dr. López will provide an overview of this year’s forum and the three topics to be discussed: community service learning programs in the context of community health centers; cultural and linguistic competence and minority women’s health curriculum; and Promotoras as community teachers for health profession students. “Service, Learning, and Community: Necessary Elements for Effective Delivery of Human Needs” Robert D. Shumer, PhD, University of Minnesota School of Social Work Dr. Shumer is an expert and pioneer in the field of service learning. He is a member of the community faculty and a lecturer at the University of Minnesota, where he developed and was director of the National Service-Learning Clearinghouse, the largest source of information about service learning in the United States. Dr. Shumer received his BA from the University of California, Santa Barbara and his MA in educational psychology from California State University, Northridge. He earned his PhD in education from the University of California, Los Angeles. He has contributed much to the field of service learning through his research and publications. He has received many grants, contributed to more than 25 studies, and published more than 70 articles, monographs, book chapters, and books. He has taught and developed curriculum for every level of education from kindergarten to college, and he has worked with faculty from major universities across the country to develop service- and experiential-learning programs. He has been invited to speak and present at local, state, regional, national, and international conferences to share his extensive knowledge about experiential learning. Health occupations are located in the service sector. Health professionals provide education and specialized services to meet the needs of communities. How we conceptualize the organization and delivery of services is critical to the effectiveness of programs and the empowerment of individuals to ensure their needs are being met. Service learning and community engagement are two terms used today to describe the nature and context of connections between universities, schools, and communities that address the concerns of civil society. In this presentation, we discuss the reasons why service, learning, and community involvement are important components of effective delivery of health care in any community setting. “Community Service Learning Programs in the Context of Community Health Centers” Vickie Ybarra, RN, MPH, Yakima Valley Farm Workers Clinic Ms. Ybarra is Director of Planning and Development at Yakima Valley Farm Workers Clinic, a large community/migrant health center in central Washington State. She worked as Director of Community Health Services for eight years before recently being promoted to her current position. She has her undergraduate degree in nursing, and in 1996 completed her Master’s in Public Health at the University of Washington. Most of her work involves development, oversight and evaluation of support programs for Spanish-speaking pregnant women and families with young children. She is also active in her community with health care workforce development, particularly working to increase the number of local Hispanics entering nursing. Vickie is also active in statewide health policy development as a member of the Washington State Board of Health. She developed principles of community-campus collaboration used by her health center; pioneered a pipeline to higher education for Hispanic children through partnerships with K-12 schools, colleges, universities, and residency programs; and engaged in community-based participatory research partnerships that are addressing health disparities. Ms. Ybarra serves on the Yakima School Board and is a board member emeritus of Community-Campus Partnerships for Health. She was recently appointed chair of the Washington State Governor’s Task Force on Health Disparities. This presentation will provide information on the efforts of the Yakima Valley Farm Workers Clinic and its partners to expose middle school to college students to health careers. Ms. Ybarra will discuss the various components of the ConneX Program and the effect of budget cuts on Title VII programs. In a post-HCOP climate, however, opportunities have arisen for new partnerships, communication about concordance, planning for change, program evaluation, and leadership. Panel Discussion: “Community Service Learning in the Context of Community Health Centers” Representatives of Border States: Sandra Daley Dr. Daley is a Professor of Pediatrics and Assistant Dean of Diversity and Community Partnerships at the University of California, San Diego School of Medicine (UCSD). She received her medical degree from the same university. After completing her residency training, she spent 12 years of her professional career as a clinician medical director. She became the Executive Director of the Comprehensive Health Center, a community-oriented primary care clinic located in the predominantly Hispanic and African-American low-income neighborhood of southeast San Diego. Dr. Daley is of African origin and Hispanic cultural background. She is fluent in Spanish and English. Her professional and community activities involve the development of innovative models of health care delivery and programs to increase diversity in the workforce. She combines research and community service by developing, implementing, and evaluating a school-linked Health Service and Educational Models in a Community Outreach Partnership Center in the Mid City area of San Diego and a Center of Excellence in Partnership for Community Outreach, Research and Training (EXPORT). Dr. Daley has participated in the design and implementation of programs in partnership with agencies such as the San Diego Community College District; the County Department of Health and Human Services; the San Diego and Sweetwater School Districts; the San Diego Housing Department; Children's Hospital and Health Center; and Mid City for Youth. As the Director of Pediatrics at the Comprehensive Health Center, a community clinic in a predominantly Latino low-income community in San Diego, Dr. Daley designed a Core Clinical Pediatric four-week rotation at the Center. Dr. Daley describes how the 10 principles of good practice in combining service and learning were applied in the design of the clinical training experience. Adela Valdez Dr. Valdez is the Regional Assistant Dean at the Regional Academic Health Center, a regional campus in Harlingen, Texas, of the University of Texas Health Science Center at San Antonio. In 2000, she completed a one-year NYU/NHMA fellowship in Health Disparities with emphasis in cultural competence. She is a past member of the state government relations and diversity committees of the American Cancer Society (ACS). Dr. Valdez was named as Presiding Officer of the governor-appointed State Health Disparities Task Force (served 2001-2005). She is Chairperson of the Valley Baptist Medical Center (VBMC) CME Committee, and active member of the VBMC IRB committee. Dr. Valdez has lectured at state health disparities conferences on health disparities, and presented in academic medical centers on Folk Medicine and Mexican American belief systems. She was named the state’s representative to the Agency for Health Research and Quality national conference, which focused on best practices and review of the National Health Disparities Report (2004). Dr. Valdez’s past experiences include AHEC Center Director, a state indigent hospital administrator, and medical director. Dr. Valdez was the founding Interim Program Director of the VBMC Family Practice Program. Titled “Community Service Learning South Texas Style!” this presentation introduces participants to the Rio Grande Valley service area and the Multidisciplinary Primary Care Project. Dr. Valdez also tells the story of Barry, a third-year medical student, and his positive experience teaching middle school children about nutrition and health. Dan Young Dr. Young is the founding Director of the Research Service Learning Program, supported within University College in the University of New Mexico. As a faculty member at UNM, he directed the Middle-Level Teacher Education Program. He received his BA in Anthropology/Linguistics, M.Ed. in Curriculum and Instruction, and PhD in Curriculum and Instruction, all from the University of Washington. He was a Peace Corps Volunteer in Sierra Leone specializing in Community Development, taught English in a Nigerian secondary school, and has traveled extensively in India, where he is involved in rural community development initiatives. The Research Service Learning Program (RSLP) at the University of New Mexico is in the process of creating a program Web site that will provide campus and community partners with a comprehensive set of servi ces. It will provide essential program-related information about RSLP courses, community partners, community-based initiatives, and program emphases. It will also provide partners with information and tools, and may offer Web hosting. The organization of the Web site is being conceived as a series of concentric circles in which immediate needs (e.g., making students aware of course offerings) are addressed first, followed by gradual expansion to include UNM and community partners, links to relevant resources, and so forth. The prospect of opening a Web site to organizations across the state and region is thoroughly consistent with the RSLP’s goal of serving the people of New Mexico and would be a logical next step in the Web site’s development. Jill Guernsey de Zapien Ms. de Zapien is the Associate Dean for Community Programs at the University of Arizona Mel and Enid Zuckerman College of Public Health. With an academic professional appointment, Ms. de Zapien has been involved in community-based public health interventions and research in Arizona and throughout the Southwest and Mexico for more than 20 years. As co-investigator of the Canyon Ranch Center for Prevention and Health Promotion, the Reach 2010 Project, the Binational TIES and PIMSA Projects, the Border Women’s Health Institute and the Center for Health Equality, Ms. de Zapien partners across the university to work directly with communities in the Southwest to develop strategies for prevention interventions and the elimination of health disparities. Jill is particularly proud of her collaborative work with the promotora movement throughout Arizona and her long-term commitment to community-based participatory research and action. Most recently, she is serving as Principal Investigator of a Community Campus Partnership grant to establish the Border Health Service Learning Institute. This presentation will discuss the creation of a Border Health Service Learning Institute that will engage public health students, faculty, and community partners in comprehensive community-based collaboration to eliminate health disparities at the U.S.-Mexico border. The University’s partners in this endeavor are the Arizona Department of Health Services Border Health Office, the Southeast Arizona Area Health Education Center and the Colegio de Sonora. A week-long course for 20 master’s-level students will be offered by the Institute in the summers of 2008 and 2009. In 2008, the Institute will be implemented in Douglas/Agua Prieta, and in 2009, it will be implemented in Ambos Nogales. The curriculum is being developed by four faculty members, a research specialist and community partners. The Institute will also include service learning activities associated with Martin Luther King Day in 2008 and 2009, and will correlate with specific activities designed with the partners. The Institute will include students, faculty, and community partners. Upon completion of the three-year project, continued collaboration with partner organizations will ensure sustainability of the work. “Tri-national Health Council’s Perspective on Service Learning and Women’s Health” Silvia Parra, Tohono O’odham Nation Ms. Parra has extensive experience in working within the tribal government system, most recently as the Chief Administrative Officer of the Chairwoman of the Tohono O'odham Nation. In this capacity, Ms. Parra provided oversight of tribal government operations and collaborated across departmental disciplines to improve services to community members. Responsibilities included direct supervision of tribal indirect and financial programs. Accomplishments included a 25% increase in the indirect cost reimbursement rate; reduction in audit findings within the single audit; and development of a uniform budget process. Ms. Parra has also served as the Executive Director of Health and Human Services of the Tohono O'odham Nation. As the Executive Director, Ms. Parra was successful in collaborating in the development and completion of the tribe's first “Community Health Assessment." The health assessment included "face-to-face" interviews with tribal members on the U.S. and Mexico sides of the border, which is where U.S. federally - recognized tribal members reside. Purpose: To describe cultural and logistical challenges in providing health care services to tribal members on both sides of the U.S.-Mexico border. Learning Objectives: To recognize access to health care issues faced by tribal members; to acknowledge how policy and practice negatively impact health care delivery; and to recognize and see the faces of those affected. Recommendation: Provide learning opportunities to tribal members on the use of contract health care and the cost of health care when not delivered directly by the Indian Health Service. Provide continuous education on the use of the tribe’s Health Transportation Services. Provide information on how to manage chronic diseases. “Cultural and Linguistic Competence and Minority Women’s Health Curriculum” Ana Nuñez, MD, Drexel University College of Medicine Dr. Núñez is an Associate Professor of Medicine and Director of the Center of Excellence in Women’s Health at the Drexel University College of Medicine. She is also Director of the Women’s Health Education Program at the College of Medicine. She received her MD training at Hahnemann University. She has additional fellowship training in medical education, health policy and health services research. Dr. Núñez is a nationally recognized medical educator in women’s health, primary care, cultural competency and health disparities. She has served on numerous expert panels on women’s health and cultural competency. She has been principal investigator on a number of DHHS- and NHLBI-funded, educationally focused, health services research studies. Dr. Núñez has presented nationally at conferences addressing women’s health, curricular reform, women and minorities in medicine, and cultural issues in health care delivery and practice. Her research interests are in girls’ and women’s health, minority women’s health, and culturally effective care. She has been an advocate on eliminating health disparities along gender and ethnic lines. She is a member of several professional societies, including the American College of Physicians, American Medical Association and National Academy of Women’s Health Educators. To achieve cross-cultural effectiveness, health professional education needs to augment and integrate specific elements and domains. Although these core skills are needed for the entire population, they are especially needed with minority women, who are more likely to have the burden of gender health disparities. Comprehensive girls’ and women’s health is defined as non-reproductive and reproductive health of the whole person appropriate to the context of her world. Beyond knowledge of food and habits, cross-cultural effectiveness includes skills such as a non-stereotyping attitude, an understanding of acculturation influence, a receptivity of a strengths-based approach to difference, an awareness of variance within a broader normative range, a fluidity and accuracy of interpretation of verbal and non-verbal behavior beyond one singular frame, an ability to effectively see one’s role within the dynamic, critical thinking about etiology of cultural variance and health outcomes, and the ability to generate a collaborative patient-health care professional team. Issues and resources of cultural and linguistic competence, as well as health priorities for minority women and educational strategies for integration, will be discussed. Panel Discussion: “Cultural and Linguistic Competence and Minority Women’s Health Curriculum” Representatives of Border States: Patricia Cantero Dr. Cantero is Director of Evaluation for Latino Health Access, a non-profit organization serving the Latino community in Orange County. She received her Doctor of Philosophy in Preventive Medicine from the University of Southern California (USC) and her Bachelor of Arts in Psychology from San Diego State University. Dr. Cantero has conducted research and published articles on Type 2 diabetes, breast cancer, and smoking cessation. She is the recipient of several honors and awards, including the National Cancer Institute Fellowship and the National Institutes of Health Minority Access to Research Careers grant. Dr. Cantero has also been a guest lecturer at USC on topics ranging from gender and minority health to basic theory and strategies for compliance. Medical schools include cultural competence components in their curriculums, and these could serve as examples for graduate programs that lack it entirely. If graduate students acquire any cultural competence, it is accidentally through research. It is essential for graduate students who conduct research primarily with Latino populations to also have a cultural competence curriculum. This would improve the research design, implementation, analysis, and interpretation of the findings, particularly in minority women’s health. The Por La Vida Cuidándome curriculum was created as a guide to conduct educational sessions on nutrition and cancer prevention among low-income Latinas. It has been a tool not only for Promotoras who conduct the sessions, but for medical and graduate students seeking to acquire cultural competence in minority women’s health. This discussion will focus on strategies for utilizing programs such as the Por La Vida Cuidándome curriculum to expose graduate students to culturally sensitive methods of designing and conducting minority women’s health research. Carmen Ferlan Ms. Ferlan is a Health Education Specialist at Mariposa Community Health Center. She was the U.S.-Mexico Border Health Commission (USMBHC) Outreach Coordinator for the Office of Border Health Arizona Delegation. She was responsible for working with the Arizona-Sonora Delegation to plan and support binational public health. Ms. Ferlan received her B.S. in Nutrition and a Master’s in Public Health from the Autonomous University of Nuevo León in Monterrey, Mexico, where she was the recipient of the "Academic Excellence" award from the School of Public Health. Ms. Ferlan also holds the MIS Master’s in Sciences Business Information Systems from the I.T.E.S.M. (Monterrey Institute of Technology and Higher Studies) in Monterrey, Mexico, where she was an Associate Professor for 21 years. During that time, she taught the use of different methodologies, including at-a-distance education via satellite, for the Humanities and Sciences Division. Ms. Ferlan was the Training Curricula Development Specialist at the Mariposa Community Health Center for four and a half years, during which time she developed several curricula for the Promotora position, such as: Lupus Awareness Project and educational curricula; Menopause; Salud para Mi (Overweight program); Salud Si III (nutrition and exercise), Healthy Heart (Corazon Saludable); HRSA; and Promotora Border Health Institute (Leadership Program). Ms. Ferlan served as Director of the Summer Computer Camp Program for children for four years at I.T.E.S.M. Ms. Ferlan was a founding Director of "The Wellness Program" at the I.T.E.S.M. She taught this program for four consecutive years and oversaw 30 campus sites throughout Mexico, being responsible for developing, implementing and evaluating health programs. Additional responsibilities included the development and implementation of an individual physical condition evaluation program, physical fitness activities, health education, health promotion, printed health materials, and management of the Program's Spanish language Web site. Ms. Ferlan received an Honorable Mention for Health Promotion and Education from the Mexican Health Foundation and Glaxo-SmithKline in 2001. She is a Martial Arts Instructor of Japanese-style "Goju Ryu.” Ms. Ferlan will discuss the development of a Promotora-based, culturally relevant lupus intervention program. This curriculum development process included a literature review; listening to lupus patients; an internal team development process; curriculum design; pre-testing of the pilot with staff and Promotoras; and continuous improvement and evaluation. Yolanda Gonzaga Ms. Gonzaga is director of Administrative Operations for the Office of Diversity and Multicultural Affairs at the Texas Tech University Health Sciences Center in Lubbock. Her responsibilities include overseeing all administrative functions of the office, management of scholarships and foundation funds, advising, and mentoring. She manages the outreach and enrichment programs, delivers diversity workforce leadership segments, and conducts presentations to community partners regarding diversity issues. For the past year she has focused her career on mentoring and serving underrepresented and disadvantaged students and is actively involved in the Closing the Gaps P-20 Coalition focusing on the educational pipeline. Prior to joining the Health Sciences Center, she served as clinical business administrator at University Medical Center and Gateways Counseling Center. Yolanda serves on the advisory council for the Covenant School of Nursing and is involved with several organizations within Texas Tech and the community. She holds a Bachelor of Science Degree in Business Administration and Health Organizational Management from Wayland Baptist University, and a Master’s Degree in Business Administration. Essential components in today’s workplace require an understanding of cultural and linguistic competency. The past decade bears witness to the increasing prevalence of health disparities in health care delivery. Individuals of limited English proficiency experience less than adequate access to health care, lower quality of care, and poorer health status, according to reports by the Institute of Medicine (IOM). Cultural and linguistic competency starts at the front desk, and to provide the best service (health care or professional services), providers must begin to recognize the importance of the diversity needs of their customers and staff. They must play a dual role by assessing and treating these individuals appropriately and in a manner that is sensitive to their learning styles, needs, and concerns. Susan Thom Loubet Ms. Loubet is co-founder of the New Mexico Women’s Agenda, where she served as Executive Director since 1989. She graduated with honors from Bryn Mawr College and received her Master’s Degree in Teaching from Yale University. Loubet has dedicated much of her efforts to improving the condition of women and children. She served as Executive Director of the New Mexico Commission on the Status of Women in 1994. In 1995 she helped plan and actualize the conference on Breast Cancer and Connection to the Environment. She has been very involved in public policy by serving on multiple committees and task forces, participating both as a member of committees and as a chair of committees. She dedicated three years, from 1994 to 1997, serving on the Development Task Force, and recently, in 2006, she was appointed to the Early Childhood Action Network by the lieutenant governor. She is published, and her voice is heard throughout New Mexico in a radio show called “Women’s Focus.” She has hosted this show since 1990. Her radio documentaries—titled “Women Going to Prison in New Mexico and What Happens When They Get Out” and “Voices of Domestic Violence”—have received national awards. As New Mexico considered changes and challenges to its health care system, several people involved in health care services delivery and health care advocacy were concerned that reforms to the system should bring a women-centered perspective that would focus on women’s unique life experiences and women’s DNA structure. A Women’s Health Advisory Council was established by Governor Richardson in March 2006 to explore the challenge of highlighting women’s health within the larger health system. This council has worked in conjunction with the community in general to develop background information on the status of women’s health in New Mexico, develop ways to make that information available to the public, and make recommendations about women’s health policy, including performance measures and outcomes specific to women’s health. There has been a particular effort to extend the definition of women’s health beyond reproductive health, with a focus on research on women’s health and women’s health in the context of community and health care delivery specific to women. “Promotoras as Community Teachers for Health Profession Students” Marylyn M. McEwen, PhD, The University of Arizona College of Nursing Dr. McEwen is an Associate Professor at the University of Arizona College of Nursing. After receiving her B.S. in Nursing at the University of Arizona, she began as a clinical nurse at the Kino Community Hospital. She served as head nurse at the University Medical Center, joined the Pima Community College Faculty, and acted as research specialist before receiving her Master’s in Nursing from the University of Arizona. In 2003, she earned her PhD in Clinical Nursing from the University of Arizona and was promoted from lecturer to associate professor. She is a member of multiple health associations, including the American Nurses Association since 2003. Her research, which has been supported by grants from the National Institutes of Health and other agencies within the United States Department of Health and Human Services, has resulted in numerous publications. She has received many awards for her research, teaching, and work as a nurse. In 2006, she was honored with the Tucson Fabulous Fifty Nurse Award, and the American Public Health Association awarded her the Public Health Nursing Creative Achievement Award. The contribution of Promotoras to the health care delivery team has been well documented. The roles Promotoras assume in the context of health care organizations and community-based care are diverse and complex. The Promotora model is widely supported by national organizations such as the American Diabetes Association, the American Association of Diabetes Educators, and the U.S. Centers for Disease Control and Prevention. The evidence of Promotoras’ impact on the health of populations includes improved behavioral and physiologic outcomes for persons with diabetes, increased knowledge and health status for persons receiving interdisciplinary case management, improved cardiovascular disease risk profiles, improved prenatal care and birth outcomes, and improved access to health care. In contrast to their roles in health care delivery, the roles Promotoras assume as community teachers for health profession students has received limited attention. This presentation will focus on the roles and contributions of Promotoras to teaching health profession students. Exemplars are provided from an interdisciplinary rural health training program in which Promotoras were members of an interdisciplinary faculty team that prepared health profession students to deliver case management services to select populations and respond to community health needs. The role of the Promotora in contributing to students’ preparation for clinical practice, research, and service will be discussed and exemplars provided. “Promotoras as Community Teachers for Health Profession Students” Representatives of Border States: América Bracho Dr. Bracho is the Executive Director of Latino Health Access, a center for health promotion and disease prevention located in Santa Ana, California. This Center was created under her leadership to assist with the multiple health needs of Latinos in Orange County. Latino Health Access facilitates mechanisms of empowerment for the Latino community and uses participatory approaches to community health education. The programs train Community Health Workers as leaders of wellness and change. Dr. Bracho worked as a physician in her native Venezuela for several years, after which she came to the U.S. to obtain a Master’s Degree in Public Health at the University of Michigan. Her Public Health specialty is Health Education and Health Behavior. After completing her Master’s program, Dr. Bracho created and directed the AIDS project for Latino Family Services in Detroit, Michigan, for four years. The program integrated HIV education programs that addressed needs confronted by the community, including the need for jobs, parenting classes, women’s health services, drug treatment, and many others. She has been a trainer, presenter and consultant for numerous government and private agencies around the nation, including The Centers for Disease Control and Prevention, The National Council of La Raza, the University of Michigan, the University of California in Los Angeles, University of Maryland, Wayne State University, University of California in Riverside, John Hopkins University, University of California in San Diego, The U.S. – Mexico Border Association, the Texas Department of Health, the Joslin Diabetes Center, The National Conference of Lay Advisors, and The National Conference of Community Outreach Workers, among others. Jonah García Ms. García is a licensed independent Master’s-level Social Worker with more than 20 years’ experience in health, behavioral health and other social services programming. Ms. García has spent much of the last 10 years on “Systems of Care” development and program administration. Her broad work history and experience has led Jonah to concentrate efforts on serving individuals at the most vulnerable points in their lives, prenatal development and early childhood. Ms. García advocates that children are best served within the context of their family and environment, and promotes the value of family leadership in systems development. Ms. García has been the Program Director for the La Clinica De Familia Healthy Start Program in Las Cruces, New Mexico, since 1999. Since that time, she has integrated the Healthy Start Program with Adolescent Family Life, Bienestar (Health Education), Father/Father-Figure Involvement, and Early Head Start Programs to provide more comprehensive services to families. Ms. García will respond to the "Promotoras as Teachers" presentation from the perspective and socio-political experience of the Healthy Start Program's utilization of Promotoras. The Healthy Start Program is a component of La Clinica De Familia, which is located in Doña Ana County, New Mexico, on the U.S.-Mexico border. The program has been very successful in incorporating Promotoras into its philosophy and practice, teaching and learning with the communities through the particular skills brought and reproduced by each Promotora. Hence, the program has been able to operate in conjunction with community teams that, although centered on fostering a strong sense of community health action, differ in their concrete emphasis on the basis of their composition and Promotora leadership. The program couples this flexibility to community needs with its own requirements for standardizing case management through Promotora work. This, in turn, creates a creative tension for the ethos of Promotoras as teachers. The panelist will conclude by examining the implications and opportunities that this creative tension entails, especially in terms of the growth and complexity possibilities that bringing students into the equation could represent, both managerially and in terms of community service learning pedagogy. Emma Torres Ms. Torres is a co-founder and Executive Director for Campesinos Sin Fronteras (CSF), a grass-roots, non-profit, 501c3 community organization serving the U.S.-Mexico border communities of Yuma County, Arizona. She is presently serving a four-year presidential appointment to the U.S.-Mexico Border Health Commission. Torres is a nationally recognized Hispanic leader and a community health advocate at the forefront of low-income immigrants and the farmworker population’s needs. Torres is a Mexican immigrant who grew up working alongside her farmworker parents. As an adult, she put herself through school, and in May 2005 graduated with a Bachelor’s Degree in Social Work from Northern Arizona University. Torres has worked in social service and public health organizations for more than 20 years. She began her community work with the WIC Program, where she worked as a Community Nutrition Educator for six years. She worked for 10 years at the Valley Community Health Center, a 330 federally funded organization that she currently serves as a Board Member. Torres began addressing U.S.-Mexico border community health issues in 1999 through her employment with the Arizona Department of Health Services Office of Border Health. Torres has worked her way up from a low-income, low-literacy farmworker, young widow and mother of two to her present position as Executive Director for Campesinos Sin Fronteras. Ms. Torres’ most recent honorable recognition was when she became the 2005 recipient of the Ohtli Award presented by the Mexican Ministry of Foreign Affairs. The Ohtli Award recognizes individuals for their work, research and academic or cultural service that has contributed significantly to the furthering of U.S.-Mexico relations, and whose work contributes to the well-being of the community of people from Mexican origin living in the United States. Promotoras de Salud (Community Health Workers) have long been described as the bridge between the community and formalized clinical or social services. Promotoras are a source of health information and service referrals, as well as role models, support systems, community advocates, and a shoulder to cry on in times of need. On the U.S.-Mexico border, where there is a shortage of health providers and low-income communities face barriers to accessing care, Promotoras help to fill a critical gap in health service provision. As teachers for health professionals, Promotoras offer insights in two specific areas: (1) Culturally appropriate patient care Culturally appropriate care means creating an environment where patients feel respected and at ease, and where they are able to interact comfortably with clinical staff, ask questions, and understand instructions or advice from clinicians. As community members themselves and with experience as patient advocates, Promotoras provide expertise on cultural skills and patient needs. (2) Patient/community perspectives on health care quality and access to services Many systems beyond medical networks affect people’s health and health care. Family issues, employment, education, housing, and access to support services all have an impact on health status, access to care, and patient compliance. Promotoras interact with patients on a more personal level than health personnel are able to, giving them the “big picture” of health care issues in the community. Promotoras can help health providers understand the many factors affecting patients, therefore increasing the appropriateness of the medical care that providers offer. “Building Successful Strategies for the Future” Martha Medrano, MD, MPH, The University of Texas Health Science Center at San Antonio Dr. Martha A. Medrano was born and raised in El Paso, Texas, one of eight children. She obtained her undergraduate degree in 1977 from the University of Texas at El Paso, where she graduated with high honors. Dr Medrano attended the University of Texas Health Science Center at San Antonio (UTHSCSA) Medical School, graduating in 1981. She entered Pediatric Internship at UTHSCSA in 1981 and completed a General Psychiatry Residency and Child Psychiatry Fellowship at UTHSCSA in 1985. Since 1986, Dr Medrano has served on the faculty of the Department of Psychiatry, Division of Child Psychiatry and Alcohol and Drug Addiction. Dr Medrano describes herself as a community psychiatrist spending most of her career involved in community programs and activities. Because of her interest in health promotion and prevention, she returned to school and obtained a Master’s in Public Health in 1996 from the University of Texas Health Science Center in Houston, while continuing full-time faculty status. Dr. Medrano is the Director of the Medical Hispanic Center of Excellence at the University of Texas Health Science Center at San Antonio. She is also the South Central Regional Director for Redes En Acción, a multi-site grant funded by the National Cancer Institute to target cancer awareness, training, and research within Hispanic communities. She also serves on the Minority Women Panel of Experts for the National Office on Women's Health and the National Advisory Board for the National Hispanic Medical Association, and is the UTHSCSA representative to the National Association of Hispanic Serving Health Profession Schools. Her research area of interest is the effect of childhood trauma on women drug addicts. She recently served as guest editor for a special issue of women, drugs, and trauma. Dr Medrano has an interest in teaching medical students, and other health professions students, about differences in cultural health beliefs. She has assisted in the development of cultural competence teaching materials, case vignettes and case simulation. Dr. Medrano has partnered with the UTHSCSA Department of Family and Community Medicine to create a Medical Spanish course for second-year medical students and a Spanish-Speaking-Only patient rotation for senior students. Arizona State Meeting Summary Facilitator: Ana Maria Lopez, MD, University of Arizona Recorder: Andrew Stuck, Program Coordinator, University of Arizona 1. How can cultural and linguistic competence curricula encompass not only those experiences that take place within schools but the entire scope of formative experiences within and outside of schools? We need to start the learning process earlier by exposing students to our diverse communities and patient populations; e.g. field work courses for pre-med students, such as the FACES Internship (undergraduate course that allows students to explore cultural aspects of the health care system while shadowing health professionals in local hospitals -- www.diversity.medicine.arizona.edu), the Conversantes class (course that prepares undergraduates in medical interpretation techniques and terminology while serving as volunteer Spanish interpreters in local clinics), and guided tours of communities and agencies working in the U.S. - Mexico border region and American Indian reservations. However, in order to do this, health professions schools need to develop strong partnerships with undergraduate institutions and communities. We need to expose our undergraduate and graduate students to more health professional role models who come from culturally diverse backgrounds. We also need to develop more Service Learning (SL) opportunities and link them together (year-after-year whenever possible). For example, the Commitment to Underserved People Program (CUP- http://pcrm.medicine.arizona.edu/CUP/cup.html) –a medical student directed SL program that provides early clinical experience in the context of community service to rural and underserved populations in Arizona. Student leaders in CUP design, organize, and manage clinical and health education programs starting in their first year of medical school and continuing throughout their four years of medical school. Medical students earn points for participating in CUP and are recognize by the dean at graduation. 2. How can community service learning curricula facilitate the formation of thought of our students, not only at the level of the individual person but also at the level of the group’s culture and society? We need to change the institutional culture of our health professions schools. We also need to change the perception of society in how it views health professions schools; if society expects medical schools to value cultural diversity, it can guide schools on this path. We need to reform the process of admission at our health professions schools to take into account cultural and linguistic activities/proficiency in the decision making process. We need to create an institutional culture that values these experiences, e.g. reforms admissions, tenure process of giving credit to professors for mentoring students in these types of experiences and for working with the community. After all, the University of Arizona is a “land-grant” institution that embraces a threefold mission of excellence in teaching, research and public service. 3. How can Promotoras as community teachers of health professions students facilitate learning/teaching and formation of groups seen taking place reciprocally? Promotoras can fill the gap between the textbook and reality. They can introduce students into the community: teach them about its history, its resources, its values, its strengths and weaknesses. Promotoras can facilitate students’ entry into the community and also prepare the community for the students (what is expected from the community and how community members can participate in the teaching/learning process). However, Promotoras also should be remunerated appropriately for their work. Action Steps that evolve from the meeting: - Identify more service learning opportunities/sites and develop mutually beneficial partnerships with these individuals/agencies. - Improve process of connecting students with service learning sites (we will explore the possibility of developing a service learning opportunities database and connecting it to our website). - Explore linkages, and possibly share databases, with the Volunteer Center of Southern Arizona (http://volunteersoaz.org) and other organizations from around the state that promote/facilitate volunteer experiences for students. - Increase interdisciplinary learning opportunities for students in the health professions, such as Nuestra Comunidad, Nuestra Salud (www.pharmacy.arizona.edu/outreach/ncns). Include Promotoras as community guides, cultural brokers and teachers of these students. - Increase awareness of tri-national issues among COE Consortium members and federal and government officials. California State Meeting Summary Facilitators: Kathy Flores MD, University of California at San Francisco-Fresno, and Sandra Daley, MD, University of California at San Diego Note Taker: Adriana Padilla, M.D. University of California, San Francisco School of Medicine Fresno Medical Education Program 1. How can cultural and linguistic competence curricula encompass not only those experiences that take place within schools but the entire scope of formative experiences within and outside of schools?
2. How can community service learning curricula facilitate the formation of thought of our students, not only at the level of the individual person but also at the level of the group’s culture and society?
3. How can Promotoras/es as community teachers of health professions students facilitate learning/teaching and formation of groups seen taking place reciprocally?
At the end of the state meeting summarize it would be helpful to include either recommendations or action steps that evolved from these meetings. Please forward these summaries to me by Friday October 12th. Summary and Recommendations:
Action Steps: The University of California is expanding class size by 10% in its Schools of Medicine. The students enrolled in the classes during this expansion will be selected for their interest in working with underserved populations and will participate in the Program in Medical Education (PRIME). PRIME Curriculum and courses designed to teach and train these students may inform the curriculum at each of the schools. The University of California, Davis School of Medicine PRIME program will focus on rural population medicine; University of California, Irvine PRIME currently includes promotoras in the design and implementation of curriculum for students in their Latino Culture program [however since this is not an integral part of the medical school budget process, the extent of involvement of promotoras is limited by the funding constraints of external grants and contracts); University of California, San Diego School of Medicine PRIME will focus on populations at risk for health disparities; University of California, San Francisco PRIME will focus on urban underserved populations; and, University of California, Los Angeles will focus on leadership and advocacy. The PRIME programs pose a unique opportunity to evaluate and track the type of curriculum and activities developed to teach; the extent to which these programs incorporate service learning and cultural and linguistic competence curricula and any of the recommendations from this consortium and other experts in the field; and the extent of the integration of PRIME curriculum, activities and teaching into the medical school. New Mexico State Meeting Summary Facilitator: Dan Young, PhD, University of New Mexico Recorder: Pamela DeVoe, MA, University of New Mexico Guiding questions:
One of the main considerations for cultural competence is the inclusion of all populations, especially minority and women, in teaching of clinical skills and research. NIH is so research focused that it doesn’t want to talk about service, in terms of access to healthcare, cultural competence in medical care, or the extent of diversity issues in medicine. For instance, the National Institute of Arthritis and Musculoskeletal and Skin Diseases discovered that it had no minority data, so there is a new focus now to do research on minority populations, including translational research. NIH created a fund of money that translates research into community service. It is important to look at different populations, and regional population differences. Health disparities—introduced as national issue--Every NIH Institute has its own focus on health disparities. Understanding differences in cultures precedes collaboration. So, the question is how to get people involved in professional training programs, applied research, etc., and in collaboration across disciplines. Common themes of this group today are:
For today’s discussion---How can people in New Mexico work together toward common goals? Specifically, what are best ways to direct and prepare students toward an interest in health care, especially from the high school age and older? Education & Training—Cultural & Linguistic Competence Curricula, Community Service Learning What are some new ways to help minority students to be more successful---- institutions are not set up for minority students—and any changes implemented will have to be an interdisciplinary effort. Some women want to be nurses, but there is lack of support and information available to minority students. Counselors need to give information at high schools, colleges; they need to be motivational. Lack of information blunts motivation. For example, there was an education summit in Las Cruces for high school dropouts, 100 kids attended and were asked why students drop out—they say when they transition from middle school to high school, they have no support from teachers and counselors—so they turn to peers for information but can’t get the information and guidance they need, so they give up and leave school. We need to search for the common good, and to accomplish this research in education and learning is needed. The public education environment is passive, boring, etc., and colleges are same—not motivational to students. How do we create culture change for the necessary motivation? What about training for specific jobs? Education which is focused on generalized learning has theoretical value, to promote academics; but then loses the practical focus, the application—so this is not a good fit. At two-year schools, such as branch campuses and community colleges, the focus is more applied, what we do is transformation; accomplished by using community service learning. Our students are mainly adult learners and connected to the community—so service learning experiences are more meaningful because they take place in the students’ own community. To develop valuable service learning experiences, ask community members what they need. For example, “If you could have one person for 4 months working with you, how would you use them?” It would be a valuable experience for graduate students to come to Gallup (UNM Branch Campus) for real applied experience that is community based, especially in Indian health and community health. Especially considering, how common it is for graduate students to not know about research until they are ready for dissertation. Applied practice could be a valuable experience for them as well, especially when integrated with research processes. Service learning, however, is more the exception than rule. We need to find ways to make it the rule, not just add service learning projects but integrate these experiences into the regular curriculum. To do this we need to put service learning into faculty portfolio requirements, because most teachers will teach as they are paid to teach, or as they are evaluated. So the question is, “how do we move toward this common purpose?” Can we work with kids at younger ages to get them involved in service learning, etc., and any community- based learning, so they come to college already knowing what it is about? Are communities willing to invest in a common agenda? Access—Promotoras as Community Teachers of Health Professions Students People confuse delivery of health care with paying for health care, assuming that paying equates with quality access. Questions remain, such as, in what ways does payment for services actually increase access to services, what challenges remain for patients? What does access to health care look like to men? What are the particular health issues for men? Pregnancy initiatives are focused on girls/women, but where are the boys/men? HIV also—where is the focus on men? Another point about access is language. In the border area, students need to speak Spanish; for university students, if they cannot become bilingual, they will have problems understanding fully what patients are saying. Institutional change. The ability and willingness for institutions to change is another issue. For example, the Promotora movement----it might be beneficial to change institutional views to give college credit for Promotoras’ training. Mentoring. NIH reports that seven of every 10 Latino students in the physical sciences are girls. When recruiting for scholarship programs, these social patterns need to be addressed. This is also true in engineering, technology, biomedical engineering, etc. We need to be mindful of keeping girls interested, and academically prepared and at the same time find ways to engage boys academically and hold their interest in school. Not only is recruiting necessary, but mentoring is also important. Immigrants need mentors in U.S., we know education is important, but we don’t know the system. For example, one school offers help for students. There is a parents and students program to visit universities, paid for by scholarship. Most often these are pre-college scholar programs; mother-daughter, father-son. Kids become motivated to attend college through these visits. Parents and teachers are as important in recruiting students. Opportunities for students exist, but there has to be preparation. When scientists complete letters of reference for students for NIH summer programs, they need to be detailed. So teachers need to be taught how to write good letters, using specific examples. Teachers have to be aware of the field, so students can get counseled. Teacher letters, notes are important because they can use community-based practitioners for references. Communities need to be concerned with the quality of the service learning experiences they provide for students. So there needs to be long term relationships between schools and community based organizations. The World Health Organization program has 20 years of different projects. We should have a state strategy that goes over several years, includes different disciplines, this will also have the benefit of stopping the “free volunteer labor” issue that comes up in service learning projects. Choice is very important in learning. It creates engagement for students, and when engaged, they have a higher level of commitment. What is needed for long-term planning? Start with high-functioning kids to build long-term commitment and credibility at community sites. Establish and then maintain relationships in the community, these sites will work with students year after year for the benefit of both students and community members. Goals, ideas for future directions Based on this discussion, what are we willing to do? What is people’s commitment? Changing school systems? Any project will take commitment. I contacted Medicaid office to pilot a Promotora model for case management, but also found that regulations and liabilities must be dealt with first. Universities are not the entities to change things. Communities can change things, for instance the project of increasing members from diverse communities in the health professions. An example is the fairly new UNM BA/MD program—an idea which came from New Mexico communities—and is an affirmation that we need more minorities in medical school. We also offer Lottery scholarships, for 8 semesters, UNM also starts undergraduates with a “bridge” scholarship. These scholarships are a mixed blessing because students must come right after high school and may not be ready yet for college, or ready to make major career decisions. It might be preferable to grant students credit for what they know when they start university. Some deserving minority students don’t even get into college. These kids want service and community learning. If they take some work before college, the learning has more meaning for them. Our challenge is engaging them intellectually and socially. We’ll have to look at what goals are good for New Mexico long and short term? The pipeline into health professions needs attention, ways to ensure that students come to the university with preparation in math and science. What do we need and what can we bring to accomplish that? Although there are lots of needs in New Mexico, there is also lots of talent. Our problem is to connect the talent with the need---kids in school equal talent, especially when they get to college. How do we get the appropriate education for students and how do we help them thrive in college? People can collaborate on ways to get there. I know what I want to get out of this meeting, but I am not sure what I can contribute, because the population I work with is different. When I am not sure of what my place is, then I am not sure what I can contribute to the discussion. I can offer interesting experience with native communities. As someone who has done service learning for a long time, I can help to offer sites, etc. Another way to look at this is that relationships are reciprocal, so if you know what you need, this also leads to what you each can contribute. At state meetings, we should try to move toward more practical applications of what we’ve learned at the forum from Monday. What’s real, what are we trying to work on? How do these connections at the forum help the process? What mechanisms are now in place to help us move forward? Whatever we come up with, what is in place to help the process along? Supervision for Community Service Learning We would like students to be working with community groups. A barrier is that in schools of social work, we need someone with a master’s of social work to supervise graduate students. Every grant puts in for master’s-level social workers to work in community however this requires professional support in the community. A practical thing might be to identify—if you have a social work student—what could they do at agencies. From the perspective of Women’s Health Clinic in Santa Fe—as a clinic, we would like to see much more resource involvement. This involves identifying the need students and clients have, so schools can contact the clinic for these learning experiences. Social workers at that site would find health resources for clients, do patient counseling and advocacy, and do follow up. Is supervision an issue for others? Who monitors students in the community? An MSW needs an MSW to supervise, but other fields do not necessarily need the same credential to supervise. Not every agency has an MSW on staff. It is a matter of credentialing tasks, not individuals. At our school, when it is a practicum and clinical we do need an MSW to supervise, but otherwise when it is part of a class, we don’t need an MSW. Recruitment of students into Healthcare Training At Sunland Park, we would like to see Promotoras give presentations to school groups, and use a father, mother program where students and parents come to the university, and gather information on health careers. This exchange could happen once a week or once a month. We could start with high school, and add middle and elementary when there is funding. Students would be delighted to get this information—in a summer camp, autumn camp, etc. format. It has to be year round to gather students together. Also, make sure information about resources is available to all students, especially different parts of the state. Information needs to encompass opportunities in all health careers. We’re not reaching rural areas—students are not informed in middle and high school. Young people involved in sports are more involved, more in the know. In Anthony and Sunland Park, New Mexico, kids with higher grades get the information from counselors and teachers. As an average student, without a push from siblings, I would never have gone forward. We need information about financial aid; students are reluctant to ask for help, so if we can push it on students, they need that extra help. The UNM recruiting group is moving to other areas of the state with information. Recruitment of New Mexico students into health care, and retention of students in health care programs can be supported through community service opportunities. We could have Promotoras talk with students and have community members talk with students, and that way community members also gain confidence. This would give students information on what community health needs are, and how some different health providers address those needs. As Hispanic people, it is easier when Promotoras interpret medical services to clients. We have gone to schools to talk about social work. NMSU also has career fairs. Use of community colleges would help students get academics up to speed, then they could transfer to a four-year school. But students who start at community colleges usually don’t transfer to universities. This is only viable if there is a university presence in the community college to keep that connection. Improvements to better prepare students for health careers We are acknowledging we have multiple needs, but we have to prioritize. Before the workshop (this afternoon), we have to take some time to decide what are our community needs, then school needs, then state needs. Kids don’t know how to read—we teach theory without experience, but improving our dismal academic performance depends on applied experiences. Intel comes to town with a need for certain training, puts in some funding, and whole schools turn around academic offerings. We have lots of needs in New Mexico, but we could link needs with service learning activities to address these. How can we work together? When we send someone to community sites, what is it we want them to accomplish? What do we want to happen? At NMSU, had a needs assessment asking students what they see as community issues, etc. There are many ways getting at service learning, but we can also pay attention to student views. Universities in Mexico require a year of social service at poor clinics. Medical students also need to do this— it helps the community and the students learn from the people. We could use community clinics for these sites. We can have social work students go into communities to work with poor people in Anthony, Sunland Park and Chaparral, New Mexico. We would need transportation and bilingual individuals with desire to work in a community of underserved people. Students need to be able to speak with clients, and commit to a year or more to follow through. If you make requirements, this will happen. Recommendations
Texas State Meeting Summary Facilitator: Cliff Littlefield, Pharm D, University of Texas at Austin, College of Pharmacy Recorder: Larry Morningstar, DrPH, University of Texas Health Science Center at San Antonio, Department of Family and Community Medicine Three questions were to be discussed during state meeting:
These questions require the Texas group to explore new dimensions of human interactions and the concept of vulnerability that drive and bring us together. We need to get to the roots and causes, and get beyond the superficial differences that make us up. The following themes emerged and correspondence of participants around these themes is listed. This touches on cultural and linguistic issues within schools, and how uninformed our concepts are within and outside of schools of education. As institutions, we are getting more comfortable with cultural differences within different communities. In the community, we do not talk about our own individual differences, and it is reflected in us as health care providers. Current Cultural Competence (CC) models move across proficiency. Pharmacy has had heated debates with terms, for example, the definitions that are utilized for levels of CC proficiency. There has been a redefining and articulating of CC. It may be broader issues. For example, are we seeing a change in academic versus in society? Demographic changes are undergoing dramatic shifts and changes in population. We have the tendency to group with people that look like us and think like us. But a new shell is emerging that exposes us to our differences. What is important about those differences? The “construct” is where we may get in trouble. A society that is not familiar or similar to the emerging minority groups and the society’s responses to these groups is an ongoing issue. The solution to these perceived differences may be the partnerships that can be created to navigate these differences. We need to see our patients as people first. There are three complimentary terms—awareness, cultural confidence (after provider-patient interaction occurs well) and effectiveness—with all three being another aspect of a CC continuum. Linguistic and cultural awareness go beyond semantics differences. For example, in the clinical setting, we need to include and test CC of physicians. Sometimes, CC has to include the language of patients who are not primary English speaking. Cultural sensitivity is forgotten and impacts more than the language (Spanish) itself. Those cultural values will make the differences. The doctor has to connect with the patient’s culture. For example, an El Salvadoran patient may say his problem is “lungs were pricked: “Pulmones estan picado.” This regional difference in the same language of Spanish requires a cultural translation. The patient was describing symptoms of TB. Being able to speak and translate the language does not assure cultural competence. Enhancing the interaction between the provider and their patients is key. We need to be empathetic. Culture differences may not be as important as connection between the individuals. Barriers can be overcome because you as a doctor care about the patient. Obstacles to care may include using the wrong language or cultural terms. Perhaps the patients are very poor and many obstacles exist, and they are unable to tell you how poor they are. And you as a provider may not understand the issue and experience of poverty. We need to think about cultural humility. Accept that you do not know or understand about poverty and other issues such as gender, geography, age, history, immigration status, education, social economic status. Admit what you really do not know and build the relationship with your patient from there. Humanism is the culture of being human. There is a time constraint placed upon doctors as to how much time they spend with patients. When you have to translate into a different language and from a different culture, it becomes may problematic and a struggle to do in 20 minutes when a doctor has only a set amount of time. In the culture of medicine, the physician may not feel that they have the time to be empathic. Over time you will pick up knew knowledge about your patients as people. Try to learn something new from your patients that you do not know before with each interaction. Cultural Competence may be assuming we are mainstream as physicians and may not be thinking like our patients. Why is it that a line is drawn as to what is mainstream? We are a not a melting pot. The patient do have a culture and they bring it to the table as we do as physicians. This discussion for some participants grew beyond the paradigm of CC. When you strip it all away, isn’t it what one chooses to understand? What is the psychosocial context of health? How do people communicate and work within these variances? What can I get my hands on? Behaviors are emulated and modeled. We define ills from a lot of different sectors and there are system influences. We need to communicate, teach and practice effective techniques of providing care taking all these issues into consideration. One participant always start the CC seminar by asking the question: What is your culture? And ask student to define it for themselves. I think of culture as a salad—some are tomatoes, some are carrots, but we all are members of a this community salad. As providers we focus on patient-centered care but to be better providers, we need to understand ourselves and our culture first to understand how this interaction impact on the care we provide for our patients. Isn’t it a reasonable expectation to make health professions students more sensitive to cultures? We can attempt to determine the impact that learning has post training 1 year to 2 to 10 years. Should we be concerned with the decay associated with learning over time and does this learning decay as the providers enter into the real health professions workforce? One way to measure sustainability may be initially a pre-test of knowledge and then post-test again at year two after the completion of training. The outcomes that will demonstrate the degree of sustainability of CC training may be that the providers are working in community health centers or underserved areas UTHSCSA medical students self-select to rotate in Harlingen, Texas, an underserved community and already have an open attitude about CC and therefore learn more about the culture of the community and patients. The Lower Rio Grande Valley students were re-acculturated to the Hispanic culture on the US Mexico Border after spending their first two years in San Antonio. Our evaluation touched upon what they have learned to apply CC in the clinical setting which re-enforced what they learned in their first two years in medical school. What is the role of humanism, poverty and what the medical students may see from private practice? About 76% of physicians said they are successful when they feel they have communicated well with their patients. Being bilingual is seen as highly desirable by practicing physicians. Seeing CC in action in the practice setting, what is the longevity and longitudinal effect of the CC pedagogy if the previous medical student enters private practice? What effect does it have to come if some of medical student in a clinical rotation group comes from a Rio Grande Valley public school versus a prep school background? Have they learned to respect the local community? How do they interact with each other? Is there campus life for minority medical student when formal or distinct subgroup form? Realistically, what do you tell them as faculty members when you observe these in subgroups form? On campus, what do you do to foster community within the campus? What is the individual makeup of the first-year medical students, and how do we bring a group of total strangers together and engage with other people outside their subgroup? It is important that faculty model to students not judging their peers by perceived economic class and label all their peers as the same. The point is the diversity of your medical school class depends on admission criteria of the institution and barriers or access in creating a diverse student body within the institution. CC is not a hat that we can change when it is convenient. We need to know that is in use all the time and informs and molds our behavior. It is demonstrating respect and trust with our colleagues, students and patients. We need to demonstrate CC in a qualitative way in all aspects of our institutions. Here is a story of a white Anglo male. He is introduced to urban life and is terrified. He comes from a place where, as it developed, his world view is very small and his maturity is narrow. This creates anxiety. There is pulling and holding during the first two years, a sense of where can I go next. From interacting with him, how would we examine health outcomes and their impact with a sense of community and providers? Given the right stimulation, this can transforms this individual and all of us. The medical student participant was trying to understand the discussion while not having attended a lot of meetings with physicians. He observed how everyone was focused and struggling with how CC is defined. If we as faculty were struggling with CC terms and concepts he imagined it would really hard to teach this as an institution to students. Students feel pressured to understand basic medical student concepts, especially pathology because a test is coming. Students are limited by time. By shadowing physicians, Hispanic students in medical school observed CC in action. He has been involved with MAPA (the Mexican-American Physicians Association). The students are allowed to evaluate our courses. He commented in his course evaluation that a clinical skills lecturers describe the typical San Antonio Mexican is obese, etc., introducing personal biases and stereotypes into their teaching of culture. It might be important to go back and tell these educators that not all Hispanics are the same. Good role modeling is to teach empathic behaviors and not prejudice. Dr. Ana Nunez in her presentation today mentioned that within the system of health professions, we can take care of patients in a CC manner, but what can the provider do to change a culturally incompetent system? How do we model or CC to the larger system? How I can be a more effective health professional by attempting to impact the system? In the health system environment—on self-reflection—we are not perfect. If you care enough to see these barriers and make an effort to go over them, that is where you as the provider can connect with the patient and vice versa. We need to screen individuals in the system for cultural incompetence. Overt examples of personal bias and poor model of CC behavior should be addressed quickly. What is the adult learning principal to communicate change in practice over time? A 4th-year medical elective places students into the undeserved community, maybe at a CHC. This is a moment of opportunity. Some programs have seen changes in attitudes and behaviors, an impact on residency selection, and infusion of values into residency practices. These are social determinants of health and cultural awareness. It is may be more effective in a field such as biochemistry to infuse CC with case vignettes. Cultural anthropology and other disciplines may be needed in teaching CC in the curriculum. These are skills that an anthropologist, for example, might have in introducing the topic from a different disciplines perspective. Where do medical students start their learning about community lay workers? The medical students need an environment that allows for learning and they need permission to ask questions about preconceived concepts, such as Promotoras and asking questions like “where do they come from?” It is important to differentiate behavioral aspects, for example, thinking versus doing. For example, how would a provider touch a Hispanic patient in a culturally appropriate manner? In Hispanic culture, touching on arm may be acceptable but in majority culture it may be perceived as be sexual harassment. Also, coldness exhibited by a White doctor may be offensive to some patients from other cultures in whose native countries that behavior may not be appropriate. However, one cannot assume and in fact White doctors will understand that better than some Hispanic doctors. Dr. Littlefield asked how the information learned at this Forum can be used in members’ work. There is a statewide Area Health Education Center (AHEC) network. Each AHEC program does things differently, but they all work around major themes in approaching certain issues. Steve Shelton offered to disseminate what he learned about CSL in the eastern part of the state. Pam Danner offered to share with the west and on the border AHEC network. The AHEC program requested to add each group member to its statewide distribution list. Within the Consortium support, there is budget money to host a statewide meeting, but instead, the group will explore piggyback it to another planned meeting, possibly AHEC. Consortium members will be planning during the year and will continue to communicate about this option. The AHEC program has been involved with outreach work through Promotores. The AHEC network is about to complete the train-the-trainer application focusing advising kids to enter health careers. Using students to promote health careers is an additional idea for a new CSL project. Selective Recommendations:
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