Incorporating Alternative Therapies Safely and Effectively Rimary Care Providers Are Increasingly in Integrating Alternative Medicine Into Alternative Therapies

Volume 10, Issue January/February 2004

s t re a Tmhe Migrant lHeai lthn New s eSource

Integrated Medicine: Incorporating Alternative Therapies Safely and Effectively rimary care providers are increasingly in integrating alternative medicine into alternative therapies. Larry Li will lead a aware of the fact that many patients, primary care. The presenters include Dona discussion on the practicalities of while not abandoning conventional Enriqueta, a Zapotecan midwife with over 45 incorporating integrative medicine in a medicine, are using alternative methods in years of experience using traditional migrant/community health center. The conjunction with standard medicine. While medicine. Dona Enriqueta will assist clinicians session will include cultural competency this is common practice, many patients do in understanding the health belief of simulation exercises, small group discussion not discuss complementary and alternative Oaxacan patients and link them to strategies and interactive case studies. medicine (CAM) use with their providers. they might employ in increasing their role in If you are interested in attending this Some of the reasons a patient may not self care. Amitava Dasgupta is a specialist in intensive session we ask that you complete disclosure the use of alternative therapy laboratory medicine who will lead a practical the enclosed card and mail it back to MCN. include that fact that many providers do not discussion of the use of common herbal Space is limited so send your registration in ask; a lack of provider knowledge of medicine and common drug-herb now! For more information about the overall alternative medicine; and patients’ perceived interactions. A summary of some of Dr. conference registration please refer to the negative reaction by the physician. Dasgupta’s key work is presented in this issue National Association of Community Health To provide the best quality care, health of Streamline. Deliana Garcia will present a Centers website, www.nachc.com or call literacy in patients must be matched with the review of current research on the use of them at (301) 347-0400. I cultural competency and knowledge of the provider. Open and nonjudgmental questioning of patients may help increase a provider’s knowledge of patient use of alternative therapies and lead to improved patient care, as clinicians, patients, and alternative providers can work together toward better health. Moreover, patients using alternative therapy, while also being monitored by their physician, will feel that they have been “listened to” in a safe environment. MCN is sponsoring an intensive session on Integrated Medicine at the 2004 National Farmworker Health Conference. This day-long session will provide participants with important skills, knowledge, and strategies to understand the role of alternative medicine for their patients. The session will be moderated by a practicing clinician with experience Review of Abnormal Laboratory Test Results and Toxic Effects Due to Use of Herbal Medicines Amitava Dasgupta, PhD Excerpted from Am J Clin Pathol 120(1):127-137, 2003.

erbal medicines are used widely in the United States Editor’s Note: The following article excerpts United States, and according to a from health food critical information from Dr. Dasgupta’s recent article in the American Journal of Clinical recent survey, the majority of people who stores without pre- Pathology on drug-herb interactions. We are use herbal medicines do not inform their scriptions. Ayurvedic privileged to have Dr. Dasgupta speak at the physicians about their use. Herbal medicines medicines are used upcoming 2004 National Farmworker Health can cause abnormal test results and confu- widely in India, and Conference at the day-long intensive on alter - sion in proper diagnosis. Herbal medicines some preparations are available native therapies Thursday April 29th in Key can alter test results by direct interference in the United States. Ginseng, St Biscayne, FL. If you are interested in learning with certain immunoassays. Drug-herb inter- John’s wort, ma huang, kava, ginkgo biloba, more from Dr. Dasgupta and our other distin - actions can result in unexpected concentra- Dan Shen, feverfew, garlic, ginger, saw pal- guished speakers, please fill out the enclosed tions of therapeutic drugs. metto, comfrey, pokeweed, hawthorn, dong card and mail it back to MCN. Herbal medicines, including Chinese quai, and cat’s claw are used by the general herbal products, are readily available in the population in the United States. Intended uses of common herbal medicines are given 1 Table 1 – Intended Uses of Common Herbal Medicines in Table 1. Gulla et al published a survey of 369 patient-escort pairs and reported that HERBAL MEDICINE INTENDED USE 174 patients (47.2%) used herbs. The most Tonic capable of invigorating users physically, mentally, common herbal product used was ginseng Ginseng and sexually; also used for dealing with stress; used in (20%) followed by echinacea (19%), ginkgo China for more than 5,000 years biloba (15%), and St John’s wort (14%).1 Herbal products do not fall under the cat- Siberian Ginseng Similar to ginseng egory of drugs as long as they are not mar- St. John’s Wort Treatment of mood disorders, particularly depression keted for the prevention of any diseases, and Mainly to sharpen mental focus in otherwise healthy FDA approval is not needed. Herbal products adults and also in people with dementia; improvement are classified as “dietary supplements” and Ginkgo biloba of blood flow in the brain and peripheral circulation; are marketed pursuant to the Dietary treatment of diabetes mellitus-related circulatory Supplement Health & Education act of 1994. disorders, impotence, and vertigo. Effect of Herbal Medicines on Kava Relief of anxiety and stress; sedative Clinical Laboratory Testing Valerian Treatment of insomnia Abnormal laboratory test results due to the Immune stimulant that helps increase resistance to use of herbal medicines can be classified in Echinacea colds, influenza, and other infections; wound healing 3 categories: Saw palmetto Treatment of benign prostatic hypertrophy 1. Abnormal test results due to direct interference of a component of the herbal Feverfew Relief from migraine headache and arthritis medicine with the assay To lower cholesterol levels and blood pressure; 2. Unexpected concentration of a therapeu- Garlic prevention of heart attack and stroke tic drug due to drug-herb interactions 3. Abnormal test results due to toxic effects Prevention of motion sickness, morning sickness, & Ginger of the herbal product nausea Treatment of urinary tract infection; decrease kidney Abnormal Drug Cranberry stone formation Concentrations Due to the Use of Herbal Medicine To heal wounds, burns, skin ulcers; also used as a Aloe laxative Several herbal medicines lower the seizure Senna Laxative threshold maintained by phenobarbital, To alleviate problems associated with menstruation and offsetting the beneficial anticonvulsant Dong quai menopause activity. Evening primrose oil contains gamolenic acid that lowers the seizure Immunostimulant with antiviral activity; also used by Cat’s claw people with AIDS; prevention of colds and influenza; threshold maintained by several anti- 16 treatment of chronic fatigue syndrome convulsants. Borage oil (starflower) also contains gamolenic acid. Shankhapushpi, an Hawthorn For heart failure, hypertension, and angina pectoris a y u rvedic medicine for epilepsy, has adversely Antiviral and antineoplastic; eating uncooked berry or affected the effectiveness of phenytoin. Pokeweed root may cause serious poisoning Wa rf a r i n is an anticoagulant with a narro w

2 MCN Streamline therapeutic range. The drug has potentially Table 3. Common Drug-Herb Interactions serious consequences if bleeding complications Interacting Herbal Product Comments develop or if a subtherapeutic level occurs, Drug thus failing to protect the patient fro m Ginseng may decrease effectiveness of Warfarin t h romboembolic events. Several herbs interact warfarin with warfarin. The herbs that may increase the Ginseng Toxic symptoms, eg, headache, risk of bleeding (potentiate effects of warf a r i n ) Phenelzine include angelica root, arnica flower, ansine, insomnia, and irritability Paroxetine bogbean, borage seed oil, capsicum, feverf e w, Lethargy, incoherence, nausea garlic, ginger, ginkgo, horse chestnut, licorice hydrochloride root, and willow bark. The herbs with D e c r eased AUC; peak and tro u g h documented interaction with warfarin include Digoxin concentration of digoxin; may re d u c e Dan Shen, ginseng, Siberian ginseng, Devil’s e ffectiveness of digoxin c l a w, and dong quai, among others.1 8 Lower cyclosporine concentration due to A 47-year-old man with a mechanical St. John’s Wort Cyclosporine i n c reased clearance may cause transplant heart valve took warfarin for 5 years and had an average international normalized ratio re j e c t i o n (INR) of 4. Within 2 weeks of using ginseng, Lower concentration, thus decreases Theophylline his INR dropped to 1.5, but 2 weeks after the efficacy of theophylline discontinuing ginseng use, it returned to 3.3. Lower concentration may cause Fortunately, no adverse effects occurred Indinavir during the 2 weeks with a subtherapeutic treatment failure in patients with HIV 19 INR. A subtherapeutic INR due to the intake Aspirin Bleeding; ginkgo can inhibit PAF of soy protein in the form of soy milk also has been reported in a 70-year-old man. INR Ginkgo biloba Warfarin Hemorrhage values returned to normal 2 weeks after Thiazide Hypertension discontinuation of soy milk.20 Conversely Dan Additive effects with CNS depressants, Shen caused inappropriately increased Kava Alprazolam anticoagulation (INR values ranging from alcohol 21,22 Increased effectiveness of warfarin; 5.5-8.4) in patients taking warfarin. Apart Garlic Warfarin from inhibition of platelet aggregation, Dan bleeding Shen also promotes fibrinolysis due to Increased effectiveness of warfarin; Ginger Warfarin antithrombin III-like activities. Dan Shen bleeding increases the concentration of warfarin Increased effectiveness of warfarin; Feverfew Warfarin owing to a decrease in clearance.22 bleeding Licorice may offset the ability of Dong quai contains coumarin; dong spironolactones to reduce blood pressure. Dong quai Warfarin quai increases INR for warfarin, causes Licorice is used as an antiinflammatory herb bleeding and also as a remedy for gastric and peptic ulcers. Carbenoxolone, one of the components Increased effectiveness of warfarin of licorice, can elevate blood pressure and Dan Shen Warfarin owing to reduced elimination of cause hypokalemia. warfarin Soy Milk Warfarin Causes decline in INR Significantly Lower Concentrations of Drugs Increased metabolism of comfrey Due to Concurrent Use Comfrey Phenobarbital producing a lethal metabolite from of St. John’s Wort pyrrolizidine; severe hepatotoxic effects St. John’s wort is prepared from Hypricum, a May lower seizure threshold, requiring Borage oil Phenobarbital perennial aromatic shrub with bright yellow dosage increase flowers. Many chemicals have been isolated May lower seizure threshold, requiring Evening primrose oil Phenobarbital from St. John’s wort, including hypericin, dosage increase pseudohypericin, guercetin, isoquercitrin, Licorice Spironolactone May offset the effect of spironolactone rutin, amentoflavone, hyperforin, other flavonoids, and xanthones. Melatonin, a Lower phenytoin level and loss of Shankhapushpi Phenytoin human pineal gland hormone, is also found seizure control 27 in St. John’s wort. The mechanism of AUC, area under the curve; CNS, central nervous system; INR, international normalized ratio; PA F, platelet-activating factor. action of St. John’s wort is not well established.28 Several reports describe unexpected low concentrations of certain therapeutic the curve of the HIV-1 protease inhibitor Fugh-Berman34 and later Fugh-Berman drugs due to concurrent use of St John’s indinavir by a mean of 57% and decreased and Ernst35 have written reviews on interac- wort. Use of St. John’s wort resulted in a the extrapolated trough by 81%. A re d u c t i o n tions between herbs and drugs. The most decrease of trough serum digoxin concentra- in indinavir concentration of this magnitude common interactions between herbs and tions by 33% and peak digoxin concentra- could lead to treatment failure.32 A case drugs are summarized in Table 3. tion by 26%. report describes an interaction between St. St. John’s wort reduced the area under John’s wort and theophylline. continued on page 4

MCN Streamline 3 I Herbal Medicines continued from page 3 Unexpected Presence of a a n o rexi a, fatigue, nausea, and vomiting. The centuries. Twenty-six cases of germ a n - Drug in a Patient Who Never results of liver enzyme and other liver func- d e r -induced hepatotoxicity have been Used That Drug: Herbal tion tests were abnormally high (ALT, 1,611 reported in Europe. U/L; AST, 957 U/L; alkaline phosphatase, 265 Medicines Adulterated With Comfrey and Liver Damage. Western Medicines U/L; g-glutamyltransferase, 993 U/L; and b i l i rubin, 11.6 mg/dL [198 µmol/L]). Vi r a l The regular use of comfrey is a potential The adulteration of Chinese herbal pro d u c t s hepatitis, cytomegaloviru s , and Epstein-Barr health risk owing to the presence of with We s t e rn drugs is a serious problem. Of v i rus were ruled out. Liver biopsy showed pyrrolizidine alkaloids. These alkaloids have 2,069 samples of traditional Chinese medi- acute inflammation with neutrophil and lym- hepatotoxic effects in animals and humans cines obtained from 8 hospitals in Ta i w a n , phoplasmacytic infiltration, hepatic disarr a y, and also induce tumors in animals. 23.7% contained pharmaceuticals, most com- and necro s i s . 4 7 G o rdon et al[48] re p o rted a monly caffeine, acetaminophen, indomethacin, case in which hepatitis developed in a 60- Kelp and Abnormal Thyroid Profile. h y d ro c h l o r othiazide, and pre d n i s o l o n e . 3 6 y e a r -old woman owing to the use of chapar- Kelp (seaweed) tablets are available in health N o n s t e roidal antiinflammatory drugs and ral for 10 months. Despite aggressive thera- food stores and are used as a thyroid tonic, an benzodiazepines have been found in many p y, the condition of the patient deteriorated, a n t i - i n f l a m m a t o ry, and a metabolic tonic. Kelp Chinese medicines sold outside Asia. These and she re q u i red orthotopic liver transplanta- tablets are rich in vitamins and minerals but herbs include Miracle-Herb, tung shueh, and t i o n . 4 8 Other cases of toxic effects on the liver also contain a substantial amount of iodine. Cuifong To u k u w a n . 3 7 Heavy metal contamina- due to chaparral have been re p o rt e d . 4 9 T h e tion also was found in herbal products. 24 of FDA has warned the public about the dan- Chromium and Hypoglycemic Herbs: 254 Asian patented medicines obtained fro m gers of consuming chaparr a l . Abnormally Low Glucose Concentrations. herbal stores in California contained lead, 36 Athletes and body builders use chromium p roducts contained arsenic, and 35 pro d u c t s Mistletoe and Liver Damage. for improving performance. Chromium is contained merc u r y. Mistletoe is a parasitic evergreen plant that a trace metal that has an effect on the lives on trees such as oaks, elms, firs, pines, glucose-insulin system. Bunner and Abnormal Laboratory Test and apple. Mistletoe was used in folk medi- McGinnis59 described a case in which a 29- Results Due to Toxic Effects cine as a digestive aid, heart tonic, and year-old man was referred to the outpatient of Herbal Medicines sedative. Mistletoe berries are poisonous. In neuropsychiatry clinic because of his unusual Kava-Kava and Abnormal a 49-year-old woman with nausea, general behavior at work. The patient had been Liver Function Test Results. malaise, and dull abdominal pain, the results diagnosed with diabetes mellitus at the age of liver function tests suggested hepatitis of 20 years and was taking 9 U of NPH Kava is an herbal sedative with a purported (ALT, 123 U/L; lactate dehydrogenase, 395 insulin (Humulin N) per day. His blood glu- antianxiety or calming effect. Kava is pre- U/L; AST, 250 U/L). Liver biopsy also sug- cose concentrations ranged between 90 and pared from a South Pacific plant (Piper gested hepatitis. However, all serologic tests 120 mg/dL (5.0-6.7 mmol/L). During the mesthysticum). The main bioactive com- for hepatitis were negative. The patient had episode, he was agitated, and on admission pounds include yangonin, desmethoxyyan- drug-induced hepatitis probably due to to the hospital, his blood glucose concentra- gonin, 11-methoxyyangonin, kavain, and mistletoe.50 tion was 30 mg/dL (1.7 mmol/L). The dihydroxykavin. patient was taking 200 to 300 µg of chromi- Kava can have additive effects with central Germander and Elevated um 2 to 3 times per week for bodybuilding, n e rvous system depressants. A patient who Liver Enzyme Levels. and the hypoglycemic episode most likely was taking alprazolam (Xanax), cimetidine, G e r mander has been used as a re m e d y was linked to chromium use.59 Anderson60 and terazosin became lethargic and disorient- for weight loss and as a general tonic. reviewed the effect of chromium on the glu- ed after ingesting kava.4 3 Kava lactones can G e r mander tea is made from the aerial inhibit cytochrome P-450 activities and have a p a r ts of the plant and has been in use for continued on page 5 potential for interaction with drugs that are 4 4 metabolized by the liver. Heavy cnsumption Table 4. Potentially Toxic Herbs of kava has been associated with incre a s e d concentrations of y-glutamyltransferase. A Toxic Effect or Herb Intended Use (Should Anyone Use?) case in which severe hepatitis was associated System Affected with kava use. The patient eventually re c e i v e d Repairing of bone & muscle; prevention of 4 5 Comfrey Hepatotoxic a liver transplant. Because of the potential kidney stones for toxic effects on the liver, the FDA warn e d the public against the use of kava-kava.4 6 Ephedra Cardiovascular Herbal weight loss Chaparral and Abnormal Liver Chan Su Cardiovascular Tonic for heart Function Test Results. Borage H e p a t o t o x i c ; Source of essential fatty acids; rheumatoid C h a p a rral can be found in health food store s oil h e p a t o c a rc i n o g e n i c arthritis; hypertension as capsules and tablets and is used as an Calamus Carcinogenic Psychoactive, not promoted in the US antioxidant and an anticancer herbal pro d- Hepatotoxic; uct. Leaves, stems, and bark also are available Chaparra General cleansing tonic; blood thinner; nephrotoxic; in bulk for brewing tea. Chaparr a l - a s s o c i a t e d l arthritis remedy; weight loss product carcinogenic hepatitis has been re p o rted. A 45-year- o l d P s e u d o a l d o s t e ro n i s m Treatment of peptic ulcer; flavoring agent woman who took 160 mg/d of chaparral for Licorice 10 weeks sought care because of jaundice, (sodium and water) retention, hypertension, heart failure)

4 MCN Streamline I Herbal Medicines continued from page 4 cose-insulin system in subjects with hypo- 23-year-old man with a 5-day history of both herbs have been reported to aggravate glycemia, hyperglycemia, diabetes mellitus, severe, diffuse abdominal pain, vomiting, bleeding. Ginkgo biloba should be discontin- and hyperlipidemia. Ginseng, whose activity and diarrhea followed by constipation. The ued 3 days before surgery because it inhibits has been attributed to 2% to 3% ginseno- laboratory investigation showed elevated platelet aggregation, causing bleeding. Kava sides, has been associated with hypo- bilirubin and alanine transaminase concen- should be discontinued at least 24 hours glycemic properties. Fenugreek, ginger, net- trations, but the alkaline phosphatase activity before surgery because kava can increase the tle, sage, and devil’s claw also can affect glu- was normal. The urinary porphyrin screen sedative effect of anesthetics. Ma huang cose levels. Karela has been shown to was positive, indicating the possibility of (ephedra) should be discontinued 24 hours improve glucose tolerance.61 acute porphyria. Further investigation before surgery because ma huang increases showed elevated concentrations of zinc pro- the blood pressure and the heart rate. St. Licorice-induced hypokalemic myopathy toporphyrin (145 µmol/L; reference range, John’s wort should be discontinued 5 days Licorice-induced pseudoaldosteronism also has <70 µmol/L) and lead (77 µg/dL [3.7 before surgery. been re p o rt e d . 6 4 Licorice contains glycyrrh i z i c µmol/L]). The patient was taking an herb acid, which inhibits the enzyme 11-B-hydro x- purchased in India. After discontinuation of Toxic Effects of Herbal y s t e r oid dehydrogenase. There f o r e, concentra- the herbal medicine, his blood concentra- Medicines tions of cortisol may increase. Renin activity tions of lead and zinc protoporphyrin were Toxic effects of herbal medicines range from and aldosterone concentrations in serum reduced significantly.65 allergic reaction to cardiovascular, hepatic, usually decrease. renal, neurologic, and dermatologic toxic Herbal Medicine and Surgery effects. Although ginseng is considered safe, Lead Poisoning Due to Herbs: The American Society of Anesthesiologists the toxicity of ginseng has been reported in Abnormal Laboratory Test Results suggested that patients should discontinue the literature. See Table 4 for common toxic Unexpected lead poisoning may occur their herbal medicines at least 2 weeks reactions to herbal medicine. owing to the use of herbal medicines con- before surgery. Ang-Lee at al67 recommend- Please contact MCN for a full list of references taminated with lead.38 Anderson et al65 ed that garlic and ginseng should be discon- for this article, [email protected] or reported a case of lead poisoning in a tinued at least 7 days before surgery because 530-345-4806 What’s Happening with HepTalk? Kath Anderson magine three people in a small room. One a d d ressed and minimized. s u p p o rte d re s e a rch in Rochester. In the is a clinician, one is a sick child, and the H e p Talk will use Standardized Patient H e p Talk model, actors would exhibit sensitivity other is the mother of the child. The clinician Training to help clinicians understand the bar- a r ound issues relevant to migrant workers, as has examined the child and diagnosed flu, but riers to conversation (such as the clinician’s in the example above, such as lack of sanita- knows that several cases of Hepatitis A have feeling of helplessness, and the client’s feeling tion, povert y, shame, foreignness, and pre j u - recently been seen at the clinic. She wants to that she will be stigmatized if she reveals too dice, in addition to emotionally charged topics have a discussion with the mother about the much about her situation), and to re i n f o rc e which are manifest in the general population. risks she and her child are facing, but she skills that repair conversational bre a k d o w n s . These include discussions of sexual practices looks at the woman and reads tiredness in her A standardized patient (SP) is an actor trained and iv drug use, both potential risk factors for face, anxiety and withdrawal in her posture . to play the part of a patient and to give feed- hepatitis and barriers to successful conversa- The discussion halts when the mother looks back to the clinician following the clinical tions. Following the standardized patient away and a vision flashes through the clini- e n c o u n t e r. “ At least 94 medical schools in e n c o u n t e r, the standardized patient and the c i a n ’s mind of where she is living—in a car for the U.S. and Canada currently employ SP’s in clinician would address those skills necessary n o w, with no access to running, much less their teaching programs, and 26 U.S. medical for negotiating awkward moments. w a r m, water. She had begun to tell the moth- schools cooperate in re s o u rce-sharing, stan- The first step in developing this model will er that she must wash her hands every time d a rd-setting, and other issues relevant to be two workshop sessions at the 2004 after she changes her child’s diaper, but implementing effective SP pro g r a m s . ” 1 National Farmworker Health Conference in instead she trails off and changes the subject. A recent study at the University of Key Biscayne, FL April 29-May 1. The first One major goal of HepTalk, the new R o c h e s t e r ’s Family Medicine Depart m e n t conference session will deliver concrete med- re s e a rch collaboration between MCN and showed that standardized patient training is ical details on testing and treating hepatitis Community Health Education Concepts also effective in helping practicing clinicians in mobile populations. In the second session (CHEC), is to pinpoint that exact moment in assess their interviewing skills, especially clinicians will access their own experiences conversations about hepatitis risk and pre v e n - re g a rding emotionally charged topics sur- dealing with emotionally charged issues, and tion when communication breaks down. It rounding HIV such as iv drug use and sexual they will receive training in how to address aims to help clinicians negotiate the silence so p r a c t i c e s . 2 The study determined that physi- those issues. that dialogue about hepatitis risk and pre v e n- cians can recognize problematic conversations 1. “The Virtual Standardized Patient: Simulated tion occurs. If the discussion occurs and if cli- when they are present in videotapes or stan- Patient-Practitioner Dialogue for Patient Interview nician and patient can engage with one d a rdized patient encounters, and can learn Training” Robert C. Hubal, M.S., Ph.D., Paul N. another on these sensitive issues, the discus- skills to address these “awkward moments” Kizakevich, M.S., P.E., Curry I. Guinn, Ph.D., Kevin D. sion in and of itself will have a pro d u c t i v e such as re t u rning after digressions, re p h r a s i n g Merino, B.E.D., Suzanne L. West, Ph.D. Research Triangle Institute,3040 Cornwallis Rd., Research e ffect on the patient’s behavior. Paolo Fre i r e ’s and clarifying and refocusing on the patient. Triangle Park, NC 27709 [email protected] “ d i a l o g i c i t y,” the dialogue itself, is the out- The HepTalk team will develop standard i z e d 2. “Improving Physicians’ HIV Risk-assessment Skill come (Fre i re, 1970).. The prevention plan that patient training for primary care clinicians Using Announced and Unannounced Standardized is “co-authored” by the patient will be most working with the mobile poor. The training Patients” Ronald Epstein et al, J Gen Internal Med likely to be adopted and risks will be will be based on the Robert Wood Johnson- 2001;16: 176-180. MCN Streamline 5 Recruitment and Retention of Clinicians in Migrant Health: Tools and Assistance Candace Kugel, CNM, CFNP

inding and keeping good clinicians rate In response to the critical need to both ment approach to a health center’s recruit- high on the priority lists of most find and hire new providers and retain those ment and retention policy, MCN developed Migrant and Community Health Centers. that are currently in practice, MCN has the Recruitment and Retention Effectiveness Where the “business” of an organization is moved more aggressively into the arena. We Review (RRER), similar in format to the famil- providing excellent patient care, quality clini- have initiated and refined a number of our iar Primary Care Effectiveness Review (PCER). cians are obviously crucial to the success of efforts, which are designed to directly The primary purpose of the RRER is to assess the health center. Many administrators know impact on the problems we hear from those health center readiness to recruit and retain the aggravation of coping with the unex- in the field high quality clinical staff and to identify pected departure of a clinician. Clinical staff We have surveyed clinicians through our areas requiring improvement. The RRER has vacancies can not only affect health center membership, at workshops and at site visits, different aspects, which can be selected earnings, but other providers are stressed by a process that has resulted in some consis- depending on need. an increased patient load, continuity of care tent findings and recommendations. Our A 15-item Health Center Self-Assessment is interrupted, and organizational morale next step has been to take this information was developed, to be used by health center drops. directly to the health centers, in the form of leaders in order to arrive at a score reflecting Human Resources departments are not tools and expertise that can help them to their level of preparation for responding to the only ones who are seeking help with plan and prepare for their current and future clinical recruitment and retention needs in these issues. Clinicians who are motivated to recruitment and retention needs for clinical their setting. Results of this brief survey can work with the underserved also regularly staff. indicate whether the health center may need express their frustrations regarding finding For an in-depth evaluation and improve- technical assistance in this area. work that meets their needs professionally and personally. The following are MCN resources that foster the recruitment and retention of clinicians in Health centers serving large numbers of migrant health. migrant patients face some unique chal- lenges in building a clinical staff that pos- New Provider Practicum in Migrant Health The New Provider Practicum in Migrant Health is a program that provides for a four- sesses the specialized skills needed to work month working and learning experience in a migrant health center for new health care with a mobile multicultural population. professionals. The purpose of the program is to increase the sensitivity and Clinicians in these settings also face unusual understanding of migrant health care issues for the New Providers as they consider demands, such as professional isolation, the careers working with underserved populations. complexity of services needed to provide basic health care, and drastic seasonal Job Bank changes in work load. New providers often The Migrant Health Job Bank is an excellent place to list job vacancies or post resumes. find that their training programs did not The Job Bank lists migrant health employment opportunities, including outreach/health adequately prepare them for what can seem educators, physicians, nurses, advanced practice nurses, dentists, physician assistants, like overwhelming needs. More seasoned cli- and others. Go to the job bank on MCN’s website www.migrantclinician.org for nicians, on the other hand, are vulnerable to exciting career opportunities. burnout as their idealism fades. Orientation Materials Migrant Clinicians Network has long rec- MCN has both the materials and the expertise to provide an in-depth orientation to ognized the importance of clinician recruit- migrant health. ment and retention issues and has attempt- R&R Instruments and On-site TA ed to assist both health centers and clini- The Health Center Recruitment and Retention Effectiveness Review (RRER) cians in their efforts to develop stable, quali- instrument is designed to support on-going recruitment and retention of qualified clinical ty programs. Many of our programs have staff at health centers. See inside for more details about this important tool. been geared toward helping to augment the skills of clinicians through continuing educa- Continuing Education tion sessions, Spanish language training, and MCN is committed to providing high quality continuing education to health care development of practice tools and models providers serving migrants. MCN´s comprehensive clinical education program helps to for working with farmworkers. We have also develop excellence in practice, clinical leadership, and the dissemination of best models provided opportunities for clinicians to and practices. become involved in research, to improve Peer Networking their access to clinical information, to net- MCN serves as a source of peer networking and support. Peer networking provides not work with each other and to become effec- only psychological and professional support, but also allows for an exchange of tive advocates and national leaders. information on best practices, unique solutions to problems, and sources for other The creation of the Presidential Initiative resources. to double the number of access points with- Professional Development in the Migrant and Community Health MCN’s menu of services is designed to support and promote excellence in practice Center safety net, will require an additional among clinicians who serve mobile underserved populations. We offer a range of 15,000 clinicians. This estimate does not opportunities to accommodate a diversity of needs. MCN services provide support to take into account the current 20 to 30 per- clinicians from recruitment through all stages of their career. cent annual turn over within the system.

6 MCN Streamline The larger RRER tool contains guidelines for health centers in the development, Health Center Self-Assessment improvement or modification of a recruit- Directions: The following brief questionnaire serves as a quick self-assessment for health ment and retention plan. It is designed to be center leadership to determine readiness for effective recruitment and retention of clinical used in the context of a technical assistance staff. Answer the questions and score each response according to the number of points in site visit. MCN clinical staff piloted this parentheses. process with two migrant health centers in 2003. Prior to the on site visit, a preliminary 1 Is recruitment and retention of high quality clinical staff a health center priority? telephone meeting with the CEO provided I Yes (10) I No (0) background information about the health 2 Is regular attention given to retention and recruitment of all key positions in the center’s staffing and perceived needs. During health center? the one-day visit, the two reviewers met I Yes (10) I No (0) with key leaders, including CEO, Medical Director, and HR Director, and conducted 3 Does the center have a written recruitment and retention plan? one-on-one interviews with as many clini- I Yes (10) I No (0) cians as were available. A written report was provided after the visit, which included a 4 Is the plan reviewed annually by the board of directors? I I summary of the center’s current status, Yes (10) No (0) strengths, and recommended actions for 5 Does your center track the turnover rate of clinical staff? improvement of their recruitment and reten- I Yes (10) I No (0) tion efforts. Both were provided with resource materials as needed, such as an ori- 6 Are compensation comparability surveys conducted periodically to determine the entation checklist, clinician effectiveness going rates for comparable positions nationally and in the local area? review form, staff satisfaction survey, and I Yes (10) I No (0) sample credentialing and privileging policy. 7 Does your health center’s compensation schedule enable it to retain qualified clinical Following the pilot of this review process, staff? the tools have been revised and are ready I Yes (10) I No (0) for distribution. Health centers are encour- aged to do the brief self-assessment and to 8 Does the center address issues of succession of top clinical/management staff? contact MCN for technical assistance if I Yes (10) I No (0) needed. Clinical and education staff is available to provide various levels of technical 9 Does the health centers’ business plan address the cost of retention and recruitment assistance for recruitment and retention ini- of clinical staff? tiatives, as well as clinician orientation and I Yes (10) I No (0) development. 10 Does the organization perform clinician satisfaction surveys? For more information call 512-327-2017 I Yes (10) I No (0) or e-mail [email protected] 11 Does the center follow a formal orientation schedule for new providers? INTERNET-BASED I Yes (10) I No (0) RECRUITMENT RESOURCES 12 Is there clinical staff representation at the senior management and board levels? Rural Recruitment & Retention at I Yes (10) I No (0) www.3rnet.org is a national job bank for rural health care providers. It is free to list an 13 Is there clinical staff representation at the Board of Directors meetings? opening. I Yes (10) I No (0) The Migrant Clinicians Network operates a 14 Is there clinical staff representation on the quality management committee? job bank at www.migrantclinician.org. It is I Yes (10) I No (0) free to list openings and users can access individual clinicians who have listed their 15 Are there regular (at least monthly) meetings of your clinical staff? availability. I Yes (10) I No (0) The American College of Nurse-Midwives TOTAL SCORE: ______(ACNM) sponsors an internet-based job If you scored 90-110: Congratulations—your health center is a model! bank at www.midwifejobs.com, for which they charge $250 for a 4-week listing. If you scored 60-85: The RRER Health Center Evaluation tool will provide you with The National Rural Health Association guidance for refining your recruitment and retention plans. (NRHA) operates an online job bank If you scored less than 60: Call for technical assistance! for administrative positions only at www.nrharural.org. Practitioners operates an internet-based job See www.aafp.org/careers for a similar Online services aimed at recruiting doctors bank at www.aanpcareerlink.com. The database for family physicians. and nurses to rural locations are located American Academy of Physician Assistants Don’t forget the National Health Service at www.smalltownmdjobs.com and uses the same database, as do other profes- Corps. If you are eligible for placement of www.smalltownrnjobs.com. They charge sional organizations, which can be found at their loan repayment or scholarship $100 for a 60-day listing. www.healthecareers.com. Fees apply for candidates, you will be listed on their The American Academy of Nurse employers posting listings. website at www.nhsc.bhpr.hrsa.gov.

MCN Streamline 7 Non Profit Org. U.S. Postage P A I D Migrant Clinicians Network PERMIT NO. 2625 P.O. Box 164285 • Austin, TX 78716 Austin, TX

MCN Seeks 2003 Unsung Hero Nominations calendar In 1990, the Migrant Clinicians Network established its Annual Unsung Hero Award as a way 2004 National Farmworker to honor one of the unrecognized clinicians in the field of migrant health. The Award winner Health Conference will receive an expense paid trip to the 2004 Annual Migrant Health Conference in Key April 29-May 1, 2004 Biscayne, FL, where he or she will honored. Nominees for the Unsung Hero Award are distinguished by their demonstrated dedi- Miami, FL cation to migrant health, participation in a variety of areas in migrant health care deliv- National Association of Community ery, innovation in service delivery and prevention strategies, clinical leadership, and Health Centers lack of previous recognition for their contributions to migrant health. 301-347-0400 To nominate your Hero, please submit the clinician’s name, address, telephone number, www.nachc.com and a short paragraph describing why you believe the nominee is a Hero to: 27th Annual Rural Health [email protected] or mail it to Jillian Hopewell, Migrant Clinicians Network, 1309 Orchard Way, Chico, CA 95928, (530) 345-4806 voice and fax. Nominations should be Conference received by MCN no later than March 21st, 2004. May 26-29, 2004 Sheraton Harbour Island Hotel N E W S B R I E F S San Diego, CA National Rural Health Association New Web Resource for TB and HIV (816) 756-3140 The CDC has developed a new website “updated guidelines for the use of rifamycins for the tre a t- http://www.nrharural.org ment of tuberculosis among HIV-infected patients taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. The link is h t t p : / / w w w / c d c / g o v / n c h s t p / t b / T B _ H I V _ D ru g s / T O C . h t m. Fourth National Conference on Quality Health Care for La Voz del Campesino: Culturally Diverse Radio KDNA Northwest Communities Education Center Populations The recent 2004 Western Stream Forum featured the work of Radio KDNA, a minority public radio station in rural Washington state developed in response to the cultural and inform a t i o n a l September 28-October 1, 2004 isolation of Hispanic/Latino and other disadvantaged communities. Radio KDNA produces Washington, DC quality radio programming to help such communities overcome barriers of literacy, language, 718-270-7727 discrimination, poverty, and illness. KDNA aims to empower these communities to more fully www.DiversityRx.org/ccconf participate in our multiethnic society. For more information about this resource go to their website at http://www.kdna.org.

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