Letters to the Editor

To the Editors of MEDICC Review: Of particular interest is the ed States for all but their first year of edu- University Polyclinic Medical cation. Their educational and clinical home The fall 2008 issue of MEDICC Review will be the community health center (simi- (Teaching for Health Equity: Changing Training Program (UPMTP) lar to a polyclinic), and they will spend time Paradigms of Medical Education) treats in Cuba, which moves the “back-rotating” to hospitals for limited pe- the rarely discussed topic of “teaching for principle site of medical riods and specialty exposure. The school health equity”. Within medical education, education out of the hospital has yet to have any graduates or any em- there is discussion of medical ethics, pro- and into the polyclinic ulators, so it is hard to speak definitively fessionalism, and, sometimes, services about how it will fare in the US medical to the underserved. The broad issue an outpatient base for medical education educational and practice environment, but of equity—health equity—receives little would greatly increase the capacity of any it does represent the boldest effort in the attention, either in the design of medi- institution or country. Secondly, the focus United States to depart from the traditional cal education programs or their con- of education in ambulatory facilities is far Flexnerian medical center-based model of tent. Medical education systems in most more congruent with the population’s ex- medical education and, like Cuba’s Univer- countries are wedded to traditional so- perience with health, the vast majority of sity Polyclinic Medical Training Program, it cial and economic structures that usually which does not occur in hospitals. None- promises to graduate physicians for whom are geared toward producing physicians theless, moving medical education out of health equity is an implicit mission. for that part of the citizenry that is eco- hospitals has proved a Sisyphean task nomically and socially advantaged. The that has stigmatized the education, val- Fitzhugh Mullan, MD predominance of private practice and mar- ues, and perceptions of many generations Murdock Head Professor of Medicine and ket-based economies in many countries fa- of physicians. One of the reasons for the Health Policy cilitates the movement of doctors through global crisis in primary care delivery is that The George Washington University medical school into practice among those physicians in many countries eschew am- Washington, DC with wealth and health insurance. In the bulatory work in favor of hospital-centric process, health equity is not well served. specialty careers that minimize the role of Poor populations have fewer physicians health prevention and maintenance, and To the Editors of MEDICC Review: (and other health professionals), less maximize expensive salvage strategies in services provided, poorer outcomes, and medicine. My compliments on the quality and content of greater morbidity and mortality. the fall 2008 MEDICC Review (Teaching for In the United States, some 20 new medi- Health Equity: Changing Paradigms of Medi- The historical and current efforts of the Cu- cal schools were opened in the 1960s and cal Education). It is noteworthy, and I’m sure ban medical education system to reverse 70s whose missions included community- not coincidental, that those innovative medi- these trends, both in Cuba and around the focused education. Their curricula fea- cal programs which embrace social account- world, are global exceptions. The recent ef- tured an emphasis on community medi- ability as a major premise in developing their forts to increase the output of medical edu- cine, greatly increased extramural and novel curricula are in countries that have a cation from Cuban schools for both domes- community-based rotations, an emphasis national health program or governments with tic and global practice are well-described on family medicine, and a faculty com- a strong commitment to improving health eq- in “Cuban Medical Education: Aiming for mitted to a new model of medicine. For uity. It is clear that all nations—developing or the Six-Star Doctor” by Ileana del Rosario the most part, these schools have mod- developed—need to use this approach in Morales Suárez, MD, MS, José A Fernán- est research bases and do not fare well in order successfully to address the healthcare dez Sacasas, MD, MS, and Francisco prestige-based national ranking systems. challenges of the 21st century. Durán García, MD (see MEDICC Review. Many of them, however, have remained 2008;10(4):5-9). Of particular interest is the constant to their mission and have pro- …those medical schools authors’ description of the University Poly- duced large numbers of primary care in the United States that clinic Medical Training Program (UPMTP) graduates who are essential to rural and in Cuba, which moves the principle site of regional health and wellbeing. are attempting to address medical education out of the hospital and the issues of health equity into the polyclinic. They report that 292 of In the American osteopathic school com- frequently are hampered by the country’s 498 polyclinics are now en- munity, a number of experiments in com- inadequate funding gaged in the UPMTP program. Seventy- munity-oriented medical education have five to eighty percent of all educational ex- taken place over the years. The most nota- periences for students in the program take ble one that has elements in common with It is unfortunate that, in spite of the efforts place in community primary care facilities. the Cuban UPMTP program is the Mesa, of some US medical schools to establish Only a quarter of students’ six-year experi- Arizona-based campus of the A.T. Still Uni- innovative and model curricula such as ence takes place in hospitals. versity School of Osteopathic Medicine in those described in MEDICC Review (e.g. Arizona (SOMA). This program, started in the University of New Mexico School of The benefits of this program are many, 2006, sends all of its students to one of 11 Medicine), the majority remain adherent to but two stand out. The successful use of community health centers around the Unit- the Flexnerian model of medical education.

MEDICC Review, Winter 2009, Vol 11, No 1 5 Letters to the Editor

The consequence of this is the perpetua- of social accountability in order to train sues on a community level throughout tion of fragmented, costly, specialty-driven physicians to become active players in the their careers. health care in what is effectively an illness development of healthier, more equitable treatment industry rather than a healthcare societies. ...the service-learning system. Moreover, those medical schools model is one method that in the United States that are attempting I would suggest that the service-learning can be used to address to address the issues of health equity model is one method that can be used to frequently are hampered by inadequate address social accountability in the medi- social accountability in the funding which, given the current economic cal school curriculum. “Service-learning” medical school curriculum crisis, likely will make it even more difficult is defined as a structured learning expe- to expand current programs or to develop rience that integrates community service I would assert that an institution that is able new ones. with preparation and reflection. Students to commit the faculty, staff, and financial engaged in service-learning provide com- resources to integrate service-learning into Richard Quint, MD, MPH munity service in response to community- its curriculum is well on its way to meet- Berkeley, California, USA identified concerns and learn about the ing the three standards that Dr Boelen dis- Clinical Professor (Emeritus) context in which service is provided, the cusses in his article. Social accountability University of California, San Francisco connection between their service and their in medical education will continue to be an academic coursework, and their roles as important issue as health systems across citizens and professionals.1 the world evolve, and medical schools To the Editor: must find creative ways to engage their Through the service-learning model, students in this evolution. I read with great interest the article “Social students can learn the tools of com- Accountability: Medical Education’s Bold- munity health needs assessment and Ayanna V. Buckner, MD, MPH est Challenge” by Charles Boelen in the fall health promotion and also become more Assistant Professor 2008 edition of MEDICC Review (Teaching acutely aware of the social determinants Morehouse School of Medicine for Health Equity: Changing Paradigms of of health. In medical education, service- Atlanta, Georgia Medical Education). Dr Boelen provided learning opportunities are designed with 1. Seifer SD. Service-learning: Community-campus an excellent viewpoint on the necessity of the intention that students will continue partnerships for health professions education. medical schools to meet the requirements to use these skills to address health is- Academic Medicine. 1998;73(3):273-7.

Peer Reviewers 2008

All original scientific articles appearing in MEDICC Review are subject to double-masked international peer review. MEDICC Review is indebted to the following colleagues for their collaboration as peer reviewers in 2008:

Armando Acosta, MD, PhD, Cuba Albert Kuperman, PhD, United States Roberto Aguila, MD, Cuba Silvia Teresa Linares, MD, United States Sonia Aguila, MD, PhD, Cuba Imar Mansilla, PhD, Puerto Rico Miguel A. Alvarez, PhD, Cuba Alvaro Margolis, MD, MS, Uruguay Juan A. Ayala, PhD, Spain Joan Martí, MD, PhD, Spain José Barajas, MD. PhD, Spain Silvia Martínez, MD, PhD, Cuba Rubén Bembibre, MD, PhD, Cuba André-Jacques Neusy, MD, DTM&H, Belgium Romel Calero, MS, Cuba F. Javier Nieto, MD, MHS, PhD, United States Vivian Céspedes, MS, Cuba Thomas Novotny, MD, MPH, United States Richard Cooper, MD, United States Damodar Peña, MD, Cuba Ernesto de la Torre, MD, PhD, Cuba Jesús Pérez, MD, PhD, Cuba Oscar Díaz, MD, Cuba Juan Prohías, PhD, MD, Cuba Alberto Domenech, MD, Argentina Patricia Rodney, PhD, MPH, RN, United States José Egido, MD, Spain Nancy Sánchez, MS, Cuba María Espino, MS, Cuba Carlos M. Santos, MD, PhD, Cuba María de los Angeles Fernández, MD, Spain Gustavo Sierra, MD, PhD, Cuba Edelberto Fuentes, MD, PhD, Cuba Luis Vélez, MD, MPH, PhD, United States Luis Guevara, MD, Cuba Silvia Venero, MD, MS, Cuba María Victoria Guzmán, MS, Cuba Sharon Hull, MD, United States We would also like to thank Silvio Soler Cárdenas, MS, Raúl Isea, PhD, Venezuela for his invaluable review of statistical data in articles Guillermo Jiménez, MD, Dominican Republic submitted to MEDICC Review for publication during C. William Keck, MD, MPH, FACPM, United States 2008.

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