Report from Cape Town: Family Medicine in South Africa

David Power, MD, MPH

The following blog post was written by University of Minnesota Family Medicine and Community Health medical student education director David Power, MD, MPH. Power is on a single semester leave at the University of Cape Town School of Public Health and Family Medicine in South Africa. He is teaching medical students and residents, consulting on curriculum, and making connections for University of Minnesota students to study abroad in family medicine. 

Report from Cape Town, South Africa

Written by: David Power, MD, MPH

I am midway through my single semester sabbatical. It has been a full, busy, interesting, disconcerting, warm, but generally fun time so far. Cape Town has been very welcoming. I’ve been given my own small office. They stand on ceremony here more than in the United States; since I am a full professor, they call me “Prof Power.” My host Derek Hellenberg, MBChB, and clerkship director Nazlie Beckett, MBChB, have included me on site visits to the community health clinics where students are placed. In general, students here are given less responsibility in patient care than at our clinics in the United States.

Office at the University of Cape Town

Family Medicine and Public Health Integration

At the University of Cape Town, family medicine is a division in the School of Public Health and Family Medicine, which is quite interesting for me given my appointment as integration leader of public health and health policy in the University of Minnesota Medical School. 

The dean here at Cape Town has asked me to present to the school on the integration of family medicine and public health, which is causing me a little anxiety as I prepare! I’ll also be presenting to educators on the results of the multi-institutional study I was involved in that explored mental health and the impact of burnout on medical students. My intention with both of these presentations is to generate a healthy discussion so that the learning goes both ways.

Family Medicine Residency (or Registrarship)

Left to right: Derek Hellenberg, MBChB,
 Nazlie Beckett, MBChB, and David Power, MD, MPH

Family medicine residency (called a registrarship here) is a relatively new field in this area, first recognized in 2007. There is no residency clinic. Registrars get assigned to hospitals and community clinics on a rotating basis. One of the recruitment challenges is that after six years of medical school, everyone is required to complete two years of internship and one year of community service. Family medicine (and other specialties) are then required an additional four years after that. Hence, the majority of physicians who want to work in primary care do not pursue residency once they have completed their three years of service. 

The internship is designed to enable all physicians to be able to practice independently in a rural hospital—so at the end of it, they should be competent to administer anesthetics, perform cesarean sections, as well as manage acute and chronic diseases. It seems that many of those who do elect to sign up for family medicine residency are either interested in administrative training or in leaving the country, since Canada recognizes training here as equivalent to their own.

The long-term goal in South Africa is that family physicians will be the ones managing the health of entire regions, several with populations of more than a million. They will also manage the budget for that region and distribute funds to specialists and allied health providers—quite the tall order. 

I will be doing site visits to observe registrars in action and provide formative feedback using the Patient Centered Assessment Method (PCAM) tool. I will also encourage registrars to develop individual learning goals.

Cape Town Medical School

The Cape Town medical school is considered one of the premier schools in sub-Saharan Africa. It has taken the lead in promoting multiculturalism and presently 70% of students are female and less than 40% are white—quite the change from 20 years ago. 

Family medicine runs a required course over almost all six years of medical school, teaching students to speak medical Afrikaans and medical isiXhosa (Xhosa). Both of these languages are the primary languages of many Cape Town residents; a desire to provide patient-centered care in the patients' preferred languages is what drives this curriculum.

David Power, MD, MPH, University of Cape Town ID

I hadn’t realized how much of an icon Christiaan Barnard, MD, is in Cape Town. There is a museum here celebrating the first successful heart transplant, which he performed in 1967. Did you know that he started as a general practitioner and received his cardiac surgery training under Walt Lillihei, MD, PhD, during a two-year fellowship at the University of Minnesota?

I’ve enjoyed spending time with Steve Reid, MBChB, MFamMed, PhD. Reid is a family physician and professor at the University of Cape Town. He runs the rural longitudinal clerkship and a multi-disciplinary course in health, the arts, and humanism. I will sit in on Steve’s humanism course when it starts in a few weeks and hope to write with him about the legacy of Christiaan Barnard, MD. Steve and an anthropologist colleague also run a Massive Open Online Course (MOOC) alongside the live course that anyone can join free. Visit https://www.futurelearn.com/courses/medicine-and-the-arts/ to sign up. Last year, more than 5,000 people worldwide participated.

Life in Cape Town

Lion's Head - Cape Town, South Africa

I can't say I'm missing the Minnesota winter! We're staying in a beautiful area. Our views each morning are of the harbor with Robben Island on one side and Lion’s Head—part of the dominating Table Mountain—on the other. 

Our kids have settled into the American International School of Cape Town quite well. The only minor headache is twice a week having to endure traffic jams as I drive 30 kilometers (18.6 miles) each way to pick them up from their sporting activities, which prevents them from taking the bus home. Minneapolis-St. Paul traffic has nothing on the gridlock that occurs here daily in the mornings and from about 3:00 pm to 7:00 pm.

I’ve maintained my University of Minnesota Medical School role from a distance, so I have regular Skype calls around 5:00 pm here, which is 9:00 am for you. Well, I better sign off now. I hope to share more learnings when I return. 

David Power, MD, MPH, with wife and children

Researchers Actively Communicate with Decision-makers

University of Minnesota family medicine faculty Susie Nanney, PhD, MS, and her research team are taking an active role in communicating research findings of the School Obesity-related Policy Evaluation (ScOPE) study to decision- or policy-makers, i.e., state agencies, advocacy groups, and lawmakers.

ScOPE is funded by the National Institute of Child Health and Human Development. The study primarily looks at school obesity-related policies to examine the impact on students.

Susie Nanney, PhD, MS, seated front, and team presenting
preliminary findings to decision-makers.

Most often research is published in academic journals and read by few non-academics. Yet, Nanney’s group has taken the unique approach of inviting decision-makers to hear and respond to the study’s preliminary work versus waiting to learn findings several years down the road. The results are communicated in an easy to understand way, specifically targeted to a lay audience of non-researchers.

Initial findings suggest:

1. It is important to monitor school weight-related policies and practices—for changes over time and with a health disparities lens.

2. The quality of school district wellness policies vary by region in the state of Minnesota.

3. Minnesota school and food activity policies are having a positive effect on student fruit, vegetable, and pop intake as well as physical behaviors and weight, especially among students in schools in low-income communities.

Nanney is the principal investigator of the ScOPE study. She is active in research and community initiatives promoting school wellness. Nanney earned her PhD in public health research and holds an MS in community nutrition. She is also a registered dietician.

Learn more about ScOPE at www.healthdisparities.umn.edu/research/scope.

Healthy Cooking for Healthy Communities

Johnna Nynas

Healthy Cooking for Healthy Communities is a series of free classes about healthy cooking, nutrition, and wellness designed to address the obesity epidemic at a local level. Classes were launched by University of Minnesota medical student Johnna Nynas as part of her Rural Physician Associate Program (RPAP) experience in Bemidji, Minnesota.

The program was well received by the community and garnered local media attention. Nynas hopes Healthy Cooking for Healthy Communities can serve as a model for those interested in implementing similar programming in their own communities.

What follows is a Q&A with Nynas about this innovative community project.

Q.  How did you get the idea for this community project?

A. My mentor, rural family physician Suzy Human, MD, and I share an interest in nutrition and healthy cooking. During my RPAP experience, we spent a great deal of time providing nutritional counseling to patients in clinic; however, words do not always translate into patient action. Using a group visit model, we created an extension of the clinic environment where patients could receive targeted nutritional information.

Q. Can you describe a typical healthy cooking class?

A. Classes are facilitated by an interdisciplinary team of family physicians and local chefs and held in a community kitchen environment, like at Harmony Foods Co-op in Bemidji. Each class features demonstrations on how to prepare healthy meals using fresh, whole ingredients; unlike traditional nutrition classes, this allows patients to see how easy and delicious healthy cooking can be. Family physicians are available to answer patient questions about wellness and provide community education on everything from the health benefits of omega-3 fatty acids to postpartum weight loss. The nutritional education takes into consideration social issues, like picky eaters, busy schedules, cultural norms, budget concerns, and food availability.

Q. How were classes received by participants?

A. I believe the success of this program is best measured in participant comments. Here are some of my favorites: “loved the idea of incorporating vegetables in a delicious way;” “my family loved the recipes;” and “need more classes like this.” Pre- and post-class surveys were used to gather information on how well the classes improved participant knowledge of healthy ingredients and confidence in implementing changes at home.

Q. What makes this program innovative?

A. Its design. I researched barriers to office counseling cited by primary care providers and developed a program that would circumvent common pitfalls, like out-of-pocket patient costs, patient motivation to change behavior, provider knowledge of nutrition, and knowledge of cooking methods. The classes challenge common misconceptions that healthy cooking is expensive, tasteless, and time-consuming by showing how simple and delicious it can be to eat healthy. The most impressive aspect of this program comes down to health care costs. Physicians typically rely on referrals to nutritionists to help patients improve their diets; such visits are often not covered by insurance and may cost up to $300. These free classes provide two hours of cooking instruction from professional instructors; a delicious, healthy meal; education about nutrition concepts like portion sizes and reading food labels; and time to ask questions of health care providers.

Q. How did you finance Healthy Cooking for Healthy Communities?

A. Classes were free to participants, but cost $24 per person to operate. Funding came from Sanford Health in Bemidji and a David Mersy Student Externship Program grant from the Minnesota Academy of Family Physicians.

Q. What are the plans for continuing or growing this program?

A. The current RPAP student in Bemidji, Kelly Fellows, and rural family physician Suzy Human, MD, are continuing to bring these healthy cooking classes to the Bemidji community. My hope is that the work we have already done on this project will serve as a model for others interested in implementing similar programming. More formal research is needed to prove that this can be an effective way to help patients make meaningful, long-term behavior changes, but our experience has shown that patients are ready and excited to see this kind of innovative approach to medicine. Ultimately, I plan to continue my work on this project during residency and as a practicing physician. I would love to see this grow into a nonprofit that could distribute a formal curriculum, making it easier for hospitals and clinics to implement this in more communities.

For more information, e-mail me at nynas@umn.edu.

Safety of E-cigarettes Remains Unknown

There is no question that e-cigarettes have been sky-rocketing in popularity in the U.S.

Consider these stats:

• The CDC estimates that 6% of U.S. adults have smoked e-cigarettes, compared to 18% who smoke tobacco. 
• Forbes reported e-cigarette sales surpassed $1 billion in 2013.
• In 10 years, Wells Fargo estimates the e-cigarette industry will be as big as the tobacco industry.
  
  

What Are E-cigarettes?

Electronic cigarettes, or e-cigarettes for short, are battery-powered devices that emit doses of vaporized nicotine that are inhaled. 

Are E-cigarettes Safe? 

The safety of e-cigarettes is an unknown and will remain an unknown until the FDA starts regulating the content of e-cigarettes, says University of Minnesota Family Medicine and Community Health faculty Kola Okuyemi, MD, MPH. Without regulation, researching the full effects of e-cigarettes are difficult.

Okuyemi directs the University of Minnesota Program in Health Disparities Research and the Minnesota Center for Cancer Collaborations. He has devoted his career to improving the health of minorities and eliminating health disparities using pharmacological and culturally tailored behavioral interventions.

Okuyemi was interviewed for an article in the February 2014 edition of Minnesota Medicine about the safety of e-cigarettes. The article identifies some known pros and cons of e-cigarette use (see below), and Okuyemi encourages physicians to have an open, honest discussion with patients about the possible health risks and benefits. 

Potential Pros of E-cigarette Use

• E-cigarettes are less toxic than tobacco cigarettes.
• Studies show switching to e-cigarettes may reduce use of tobacco.
• E-cigarettes are cheaper and cleaner.

Potential Cons of E-cigarette Use

• E-cigarette users often use both electronic and tobacco cigarettes. Some evidence suggests use of both makes you less likely to quit tobacco.
• E-cigarettes contain known carcinogens and potentially other harmful ingredients whose effects on health have not been adequately studied.
• Nicotine remains addictive.
• Nicotine is a potential poison.

Read the Minnesota Medicine article on e-cigarettes. 

NIH Ranks UMN Family Medicine Third

Faculty Susie Nanney, PhD, MS, (pictured
right, with staff Sherri Fong, MPH) at an
event promoting an NIH-funded school
breakfast study.

The Blue Ridge Institute for Medical Research recently released ranking tables of National Institutes of Health (NIH) funding to U.S. medical schools in 2013.

The University of Minnesota Department of Family Medicine and Community Health consistently ranks among the top NIH-funded family medicine departments. This year, we ranked third in the nation, with more than $5 million in funding.

Four department faculty also ranked in the top 30 for principal investigators:

• Sharon Allen, MD, PhD
• Jerica Berge, PhD, MPH
• Susie Nanney, PhD, MS
• Kola Okuyemi, MD, MPH
  

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ABOUT UMN FAMILY MEDICINE RESEARCH

Research is an integral component of the University of Minnesota Department of Family Medicine and Community Health mission. We are committed to evaluating important practice innovations in family medicine and primary care.

Unlike other clinical science departments, we do not maintain a specific disease-related research focus. Instead, we embrace translational research that explores health care delivery in a primary care setting, the roles and activities of primary care providers, and the engagement of community members in advancing clinical science and addressing health disparities in the communities we serve. 

 

Research foci include:

• Behavioral and mental health
• Childhood and adolescent obesity
• Chronic diseases
• Health disparities
• Human sexuality
• Medical education
• Practice-based research
• Sports medicine
• Women's health

Interview with Jon Hallberg, MD: Macro-medicine with MPR

Jon Hallberg, MD

Jon Hallberg, MD, is an associate professor at the University of Minnesota Department of Family Medicine and Community Health and a regular medical analyst with Minnesota Public Radio (MPR). He recently celebrated his tenth anniversary with MPR’s “All Things Considered.”

What follows is a Q&A with Hallberg reflecting on his time with MPR.

Q. How long have you been serving as a medical analyst with MPR? 

 

A. Just over ten years. My first appearance was on September 30, 2003.

Q. Do you remember your first topic?

 

A. Yes, it was on direct-to-consumer pharmaceutical advertising. I just
returned from testifying before the FDA in Washington, DC, on the topic.

Q. To-date, you have done more than 350 spots. That’s a lot of minutes on air. Any memorable moments or experiences?

 

A. I remember a lot about the people I’ve worked with—much more than the topics themselves. I remember the first host I worked with, David Molpus. He left after a year, so it was quite an experience to work with a number of potential hosts as they were auditioning for the position.

Q. What’s it like working with MPR's Tom Crann?

 

A. Tom’s terrific! He has given me a lot of great advice. He once told me that I should never worry about what I could have said; listeners only hear what was actually said. He’s also a great storyteller. He always breaks the ice and gets me relaxed before we record.

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Jon has done an amazing job for us. I always say that my conversations with him are one of the highlights of my week. I hear from listeners all the time who agree and love hearing Jon talk about medical topics. He has a rare quality—being able to make complex topics approachable in a smart, listenable way. –Tom Crann

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Q. How do you prepare for tapings? Do you know the topics ahead of time?

 

A. We always record Tuesday mornings in the studio. Ideally, we pick a topic the previous week, usually by Friday. That gives me plenty of time to mull it over and think about how I might approach it. However, we often choose a topic Monday afternoon or evening, and I’m scrambling a bit to think about how to frame it. Tuesday mornings, Tom and I call each other to talk through potential questions. As I’m driving to the station, Tom’s typing questions up and running them by the producers.

Q. What has been your greatest take away from your involvement with “All Things Considered?”

 

A. I love practicing medicine. In the clinic, I consider that “micro-medicine,” that is, one-on-one care. With my MPR work, I consider that “macro-medicine,” working with up to 36,000 people at a time. It’s an enormous responsibility for all kinds of reasons. I put a lot of pressure on myself to get it right—knowing how many of my colleagues are potentially listening.

Q. How long do you plan to continue serving as a medical analyst for MPR?

 

A. Good question! I consider it an honor to be able to work with what is, arguably, the best public radio network in the country. I suspect I’ll keep doing it until I’m asked to stop or Tom Crann moves away.

Q. When should we tune in to hear you?

 

A. My spot usually airs Tuesday afternoons, between 3:00 pm and 6:30 pm. (Read Hallberg's feature archive on MPR's website.)

MDH/UMN to Study the Integration of Primary Care Delivery and Public Health Services

Photo: Kevin A. Peterson, MD, MPH,
center, performing clinical research.
Credit: Richard Anderson

The Minnesota Department of Health (MDH) and University of Minnesota (UMN) received nearly $450,000 in grant funding to study how the integration of primary care delivery and public health services will benefit community health. The study will specifically look at the impact of this integration on health outcomes related to immunizations, tobacco use, obesity, and physical activity.

The three-year study, led by MDH and the University of Minnesota Department of Family Medicine and Community Health, will collect data from Minnesota, Wisconsin, Colorado and Washington. It will be the first study to quantify the degree and effectiveness of public health and primary care integration in these states.

“Minnesota and other states are facing increasing costs and suffering related to chronic diseases. It is clear that we cannot afford to just try and treat our way out of this problem,” said Minnesota Commissioner of Health Ed Ehlinger, MD, MSPH. “Prevention is the answer, and that is why we’re very excited to partner with the University and explore the question of how doctors and public health officials can better join forces to promote health.”

Minnesota researchers will examine organization, finance, and delivery of public health services, along with the impact on community health.

Study aims include:

• Examine variation in the degree of primary care and public health integration
• Identify factors that may contribute to or impede integration
• Assess whether areas of increased integration have better health outcomes

“Primary care and public health share a similar goal of health improvement and are uniquely positioned to play critical roles in addressing the complex health problems which exist in Minnesota and nationally,” said Macaran Baird, MD, MS, UMN Family Medicine and Community Health department head. “This collaboration provides an exciting opportunity to enhance our work together to achieve improved health outcomes for our citizens.”

MDH and the University of Minnesota received 1 of 11 new research awards totaling $2.7 million. The awards, facilitated by the National Network of Public Health Institutes (NNPHI) with guidance from the National Coordinating Center for Public Health Services and Systems Research (NCC), are funded by the Robert Wood Johnson Foundation.

“In this era of health reform, it is imperative that we not forget that public health holds a key to improving the population’s health, a major tenant of the Affordable Care Act,” said Douglas Scutchfield, MD, co-principal investigator of the NCC. “These grants will help us use research to further the efforts to develop public health’s capacity to perform in this changing health care environment.”

In Minnesota, this project will be managed by Beth Gyllstrom, PhD, MPH (MDH Office of Performance Management) and Kevin A. Peterson, MD, MPH (UMN Department of Family Medicine and Community Health director of research). Practice-based research networks representing public health and primary care in Colorado, Washington, and Wisconsin are also participating in the project. 

This Is Primary Care

The following editorial was written by University of Minnesota Family Medicine and Community Health faculty Shailey Prasad, MD, MPH. It appeared in our fall 2013 newsletter, the Family Medicine Connection, and was originally shared on the Primary Care Progress blog. 

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Shailey Prasad, MD, MPH

Inspired by a campaign that identified the work of public health, faculty Shailey Prasad MD, MPH, hopes the work of primary care will one day be identifiable in our communities, outside clinic walls.  

By Shailey Prasad, MD, MPH 

I recently saw a sticker on a bus shelter. It was an arrow about 10 inches long and 6 inches wide. It seemed to be pointing to the bus map. “This Is Public Health,” it said. The sticker, part of a larger campaign, gave me pause. Sure, a bus stop is public health because it’s a marker of mass transportation; it symbolizes improved access and decreased pollution from individual cars. Looking around, I saw a lot of places that would be appropriate for that sticker.

Later, I had the opportunity to talk with a few students who had participated in the campaign. They were thrilled with the neat places they had labeled, such as a bike path, a farmers market, and a park. And they were particularly happy that the exercise had led them to a clearer understanding of public health—that it is pervasive and promotes healthy choices.

Labeling Primary Care

Given a sticker that reads, “This Is Primary Care,” I wonder where I would put it. How would I define primary care? For a long time, primary care doctors were derisively called “just generalists.” Our discipline was the fallback for medical students who couldn’t get into another specialty. We were also the least understood discipline since we address such a wide range of health issues.

I’ve read essays from pre-medical students who wanted to go into medicine in order to understand and serve the human condition. Idealism is a strong component of the drive to go into medicine. And then, as we’ve all heard someone say before, “medical school beats it out of them.” One way or another, career choices are skewed away from primary care during medical school.

Primary care has a marketing problem. We need “This Is Primary Care” labels to stick in diverse places around our towns.

Primary care has the unique ability to keep one foot in clinical medicine and one in public health. But we lean toward the clinical side and need to explore the wide world of public health. Restrictive payment models combined with the enormity of public health work and our lack of familiarity with it have kept us in the clinical realm. We need to counterbalance the pull and top heaviness of “sickness care” with a move to public-health-focused “wellness care.” It would be more productive and complete the holistic approach that most of us crave.  

Merging Primary Care and Public Health

 

I’m not alone in my thinking. The Institute of Medicine has challenged our field to better integrate primary care and public health in the context of improving population health. Merging the here-and-now of clinical medicine with the long-term horizon of public health brings with it challenges and opportunities. But it is in this particular niche area that we can thrive. Keeping individuals in mind, aiming for community-wide impact, and shaping the future of larger swathes of society should be the goals of the primary care physician of the future.

Merging public health and primary care would close the loop on issues identified in clinics with input from homes and communities. It would put into context environmental factors that worsen a child’s asthma and would link community groups who would then be partners in developing means to address those factors. Well-child visits would include college preparation activities. Activities that start with the immediacy of a clinical encounter would lead to activities that make a broader community impact. For example, a clinical encounter dealing with domestic abuse would lead to building or strengthening shelters for battered women. It would add out-of-clinic population management activities to our current in-clinic encounters, such as creating walking groups for people with peripheral vascular disease.

Besides improving population health, I believe this approach would help address physician burnout. Could a move to a more holistic approach to care and wellness decrease the existential angst of dealing with emotionally draining clinical scenarios one at a time?

Moving from the Clinic to the Community 

 

The Affordable Care Act calls for more preventive services and requires not-for-profit hospitals to develop community assessment and create community assistance funds, bringing opportunities to change our current care delivery models. We need to embrace these opportunities to move out of traditional clinical settings, go into the communities that we serve, and understand and function in the manner that communities want. The newer models of care, such as patient-centered medical homes and accountable care organizations, provide us with a rubric for population management. Moving out of traditional settings and into the community will empower us to better use our skills.

And as we do this, migrating from the current restrictions within the four walls of the clinic to the communities that we work in, we will be able to place labels all over our communities that read, “This Is Primary Care.”