University of Vermont medical student Luke Neill, Class of 2016, is working with his long-time friend, Sam Meyer, on software that will do just that – give pharmacists and other healthcare providers a way to reach patients on a device they use all of the time – their cell phones. This low-cost idea could empower patients to take charge of their health, help to avoid additional problems or potentially life-threatening complications, and reduce the public health cost of medical non-compliance, which is estimated to total about $100 to $300 billion annually in the U.S. alone.

Although smartphone and computer applications for inputting personal medication information already exist, this software allows doctors and pharmacists to set up the messages and track compliance data. Meyer is working on the programming; Neill is developing the specific functions that will be useful for providers and patients. As a service that’s free to patients, this system is meant to reach populations that might not otherwise have access to such support.

“There’s a large problem in the U.S. with medication adherence,” Neill says. “We want to address that in a way that’s cost-effective.”

This month, the pair will have the chance to present their project at the Clinton Global Initiative University Conference at Washington University in St. Louis, Missouri, held April 5 to 7, 2013. Social activists, celebrities, political leaders, and experts in technology, business, and other fields – including former President Bill Clinton himself – come to this meeting to learn and support innovative ideas from students. Last year, more than 1,000 students from all 50 states were invited attend.

All invitees create a “Commitment to Action” that is specific and measureable, and geared to help on any scale – from the local to the global.

“Access to basic health information and instruction is one of the primary obstacles to improving healthcare globally,” Neill states in his Commitment to Action. “By leveraging the simplicity and ubiquity of text messages, I will be able to provide patients who lack the typical healthcare infrastructure with relevant and specific instruction and support.”

Neill’s and Meyer’s HIPAA-compliant software program allows patients to enroll at the pharmacy and then begin receiving text messages that help them understand their medications and implications for their health. The messages are not simply reminders, Neill says; they are designed to monitor behavior patterns and change habits as well.

“The best part is that we can contextualize the feedback and give it to them,” says Neill. Providers also benefit from aggregate data on compliance. Eventually, the goal is to make the software available in developing countries where access to other technology is limited, but cell phone use is widespread.

Neill set up a pilot to test the software with first-year students at the College of Medicine and help work out any bugs prior to the Clinton conference; next he plans to network with local pharmacists for a trial. All of these efforts come with a price tag – ultimately Neill and Meyer will be faced with applying for FDA approval, which can be a costly legal process.  Neill said he’s been in contact with some foundations and non-profits interested in helping support the cause.

The Clinton Global Initiative University could be beneficial on the financial front as well: More than $400,000 in seed funding is available to attendees. Neill’s commitment has also been selected for recognition prior to a panel discussion on Ensuring Medication Safety, as an exemplary approach to addressing a global public health challenge.

“It’ll be great to be at the conference and constantly surrounded by people with motivations I share,” Neill says. “Great ideas will come out of it.”

A Lake Placid, N.Y. native who attended UVM as an undergrad, Neill says he’s also hoping to build a connection between UVM and the Clinton Global Initiative University for future students. “I’m really grateful to the UVM College of Medicine,” Neill said. “I’m representing the College at the conference.”

Named for a long-time Dismas volunteer, the Ann Atherton Award is presented annually to dedicated volunteers who through their efforts, make a difference in the Dismas community.

“I have been a Dismas volunteer now for about five years now,” says Pantel. “Both my wife and I cook dinner at the house once a month. I have met many people from many different backgrounds over the course of my time at Dismas.”

Dismas Vermont, which has residences in Burlington, Winooski, Rutland and Hartford, seeks to serve former prisoners in their difficult transition from prison to the community, assuring harmony in their lives and greater public safety. The Burlington Dismas House was founded in 1986.

“It has been a great way to give back to my local community and also stay in touch with many diverse people from all over,” says Pantel. “The experience has truly kept me grounded during my time in medical school.”

Pantel will receive his medical degree from the UVM College of Medicine on Sunday, May19, 2013, following which he will be serving a residency in general surgery at the Lahey Clinic in Burlington, Mass.

Learn more about Dismas of Vermont.

“Some of the diseases you have a name for – we don’t have a name for back home,” she said. “I have to explain the effects.”

Kasim, who is originally from Somalia, shared her story and talked about medical interpretation with first-year medical students at the University of Vermont College of Medicine in their Professionalism, Communication and Reflection (PCR) course. PCR is part of the College of Medicine’s Vermont Integrated Curriculum.  Nine interpreters from the Burlington area met with students in February, discussing everything from translating in the labor and delivery room to the nuances of interpretation over the phone. Hailing from countries including Somalia, Burundi, Bhutan, Burma, Congo, and Iraq, the group also shared some of their own stories as refugees from conflict-ridden areas of the world.

This is the second year medical interpreters have visited the PCR course, said Lee Rosen, Ph.D., PCR course director and assistant professor of psychiatry. During the 33-week course student build connections with their peers and reflect on their experience in medical school. When the interpreters visit, he said he sees students think about medicine in ways that goes beyond what they’re learning in labs and lectures. The interpreters have often overcome great odds to be where they are, and bearing witness to their stories can be a meaningful reminder of the responsibility inherent in being a physician. Students write reflections about what they learned from the interpreters, he said, and have a discussion in their small groups.

Kasim came to the United States in 2004. Born in Somalia, her family moved to Tanzania to escape civil war when she was three years-old.  At 13, her family fled to a refugee camp in Kenya. She spent three years there before coming to Rochester, N.Y., with her husband. About two years later she relocated again to Vermont to meet her parents and several siblings, who were able to leave Kenya and settle in Burlington.

For her family and for many others, the Vermont Refugee Resettlement Program (VRRP) helped ease the transition to a new culture. The program, which is a field office of the U.S. Committee for Refugees and Immigrants, supports refugees as they find housing and jobs, enroll children in schools, and acclimate to life in the U.S. The program also administers the interpretation service, coordinating interpreter trainings in medical and legal settings, in addition to other areas. The VRRP has interpreters on staff for more than 25 languages.

There are many nuances to the process of interpreting, especially in a doctor’s office or hospital where patients may not be familiar with the interaction. Professional interpreters know how to make sure both parties are heard and understood.

“All of the interpreters are trained to sit beside the patient,” Kasim told the group of medical students she met with. This facilitates eye contact between the physician and the patient, helping to empower the patient and make them feel in control.

Cultural differences also play into how the interpreter communicates. Aline Niyonzima, from Burundi, said HIV/AIDS came up in her group as a particularly difficult disease to discuss given the stigma attached to it in some countries.

“When they are here they don’t want people to know about [their diagnosis] and they don’t want the interpreter to know,” she said in a discussion with fellow interpreters. Negotiating this dilemma requires diplomacy and patience as the relationship between the physician, interpreter and patient develops.

In some cases, especially for chronic conditions, a doctor may call the same interpreter back for multiple visits. Treating mental health issues in particular often benefits from one interpreter staying with a patient over time, said Sita Luitel, an interpreter from Bhutan. This is in part because patients, too, come to trust an interpreter and develop a rapport.

Bijoux Bahati, an interpreter who came to the U.S. from the Democratic Republic of Congo eight years ago, talked to her group about her journey to the U.S. She arrived knowing no English, and recently started working as an on-call interpreter. For her, the work allows her to stay connected to fellow refugees, and her own language. In many ways she sees her role as “interpreting culture” while she’s facilitating a conversation between doctor and patient.

“It’s not just passing on the words,” she said. “It’s building community.”

The conversations with interpreters left an impression on first-year medical students.

“The biggest lesson that I took from this meeting was that remaining non-judgmental and keeping the lines of communication open with your patients is probably the most valuable skill of a clinician,” said Shane Greene ’16. “Although it helps to be aware of common practices within, for example, the Somali community, every patient is different and much can be learned by trying to determine the cultural context that helps them understand their symptoms.”

For Nick Monte ’16, the experience opened his eyes “to the realization that our interpreters serve an essential role that extends far beyond their translation skills.”

“[They] are fundamental in helping to bridge the cultural and social gaps that are vital to providing comprehensive care that meets all of our patients’ needs,” he said. “This experience is one that I will carry with me throughout my career, and one that I am certain will enhance my ability to care for my future patients.”

Wakefield, global ambassador and a co-founder of BeadforLife, talked about her organization’s mission to empower women in Uganda. Founded in 2004, the non-profit supports innovative programs that teach women entrepreneurial skills and prepare them to launch sustainable businesses. As a psychologist and public health administrator, Wakefield’s life interests span personal health and well-being to cultural and social change at the community and national level. She has lived and worked in India, Nepal, Mexico, Kenya, and Uganda.

Steinberg, chief senior trainer and consultant at the Infectious Diseases Institute at the Makerere University Medical School in Kampala, Uganda, spoke about challenges and rewards of teaching HIV care around the world. Steinberg began working on HIV/AIDS treatment in the early 1980s. In 1985, he founded a clinic for people living with HIV/AIDS, and in 1987 created a national conference to help his patients develop a support community. From 1995 to 2003, he directed the Beacon Center for Infectious Disease in Boulder, Col. At the Makerere University Medical School in Kampala, Uganda, he trains nurses and clinical officers to be primary caregivers to people living with HIV/AIDS.

The first three sessions in the Global Health Series were held at UVM in October and December of 2012, and January of 2013. Students, residents, faculty, and staff from the UVM College of Medicine, UVM College of Nursing and Health Sciences, and Fletcher Allen Health Care are invited to attend the sessions, which include refreshments.

For more information about the series, contact Audree Frey in the UVM College of Medicine Office of Medical Student Education.

Danbury Hospital contributed to this report.

BeadforLife
Makerere University Medical School

Nora Enright, a sophomore from Otter Valley Union High School in Brandon, Vt., clinched first place, which includes funding to travel to and compete in the National Brain Bee in Baltimore, Md., March 2 to 4, 2013. Champlain Valley Union High School senior Gabriel Peck Frame qualified for second place, and John Mlcuch, a senior from Mount Abraham Union High School in Bristol, came in third place. All of the Brain Bee participants received a certificate at the conclusion of the event.

In addition to Otter Valley, CVU and Mount Abraham, this year’s Brain Bee also included participants from Rice Memorial High School in Burlington; Vergennes Union High School; Stowe High School; Middlebury Union High School; and Burlington Technical Center. Many of these schools have Brain Science or Neuroscience clubs that helped students prepare for the Bee all year-long.

Brain Bee participants completed a half-hour written test in the College’s Medical Education Center, a half-hour practical test that included several “wet” specimens and took place in the Pathology Lab, as well as preliminary and final Oral Bee Rounds. For the first time in the event’s four-year history, all of the participants – versus two-thirds to three-quarters as in years past – qualified for the Oral Bee Rounds.

During the lunch break, Brain Bee attendees listened to a keynote presentation by Alexandra Potter, Ph.D., UVM assistant professor of psychiatry and psychology, titled “Adolescents, Impulsivity and Brain Function.” Following the Oral Bee Rounds, students heard a panel of UVM neuroscience undergraduate and graduate students discuss their educational and research experiences, as well as future plans.

Rae Nishi, Ph.D., UVM professor of neurological sciences, director of the Neuroscience Graduate Program, and director of the Neuroscience, Behavior and Health (NBH) Initiative, and Mark Stefani, Ph.D., assistant professor of psychology at Middlebury College, developed the exam questions for the Brain Bee. Nishi and Eugene Delay, Ph.D., UVM associate professor of biology, served as judges of the Oral Bee Rounds. Additional Vermont Regional Brain Bee committee members include Lisa Bernardin, M.S., a traumatic brain injury survivor from Middlebury and Vermont Brain Bee coordinator; John Green, Ph.D., UVM associate professor of psychology; George Wellman, Ph.D., UVM associate professor of pharmacology and president, Vermont Chapter of the Society for Neuroscience; Sharon Leach, Ph.D., clinical neuropsychologist and licensed psychologist at the Stern Center for Language and Learning; and Hallie Davis-Penders, NBH Initiative assistant.

The 2013 Vermont Brain Bee was co-presented by the Vermont Chapter of the Society for Neuroscience and the Neuroscience, Behavior and Health Initiative at UVM. Learn more about the Vermont Brain Bee.

Diagnostic laboratories are primarily clinical and used for the diagnosis of disease, but can also function as data collection sites. Using laboratory techniques and technology helps ensure a more accurate diagnosis and treatment. According to Ackerman and Cooch, “Studies show that one microscope can significantly change diagnosis and treatment.” In one study of cases in Tanzania, out of about 4,500 patients treated for malaria, only 46.1 percent had malaria; the rest had other conditions, like bacterial sepsis, that had been misdiagnosed.

The two medical students, who are mentored by Majid Sadigh, M.D., director of Global Health at the UVM College of Medicine’s clinical teaching partner Danbury Hospital/Western Connecticut Health Network, learned that “simply bringing a microscope into an established clinic changed everything 180 degrees.” However, they also determined that there is a lack of supplies and training to gain the necessary skills to conduct lab tests using microscopes. Among their objectives is to distribute microscopes – several dozen of which they have received via College of Medicine Senior Associate Dean for Medical Education William Jeffries, Ph.D. – and others from the UVM/Fletcher Allen Department of Pathology, create a lab manual that is region-specific, and provide the new laboratory sites with funding.

With assistance from Sadigh, they have developed a relationship with physicians at Makerere University in Kampala, Uganda, via email communication, and have been invited to set up labs in strategic locations throughout that country.

Over the past several months, first- and second-year UVM medical students have participated in a series of basic microscopy and laboratory techniques sessions in conjunction with the project. First, Cooch and Ackerman led a basic microscopy session reviewing the parts of the microscope and trained their fellow students in tissue examination approaches. At a second session, Christine Griffin, M.S., senior lecturer in medical laboratory and radiation sciences in the UVM College of Nursing and Health Sciences, taught students how to make peripheral blood smears – something they do not get to do in medical school. The participating students returned a week later to learn how to interpret the slides they made on the microscopes. Mary Tang, M.D., associate professor of pathology, who trained Cooch in blood smear and diagnostic techniques, and Abiy Ambaye, M.D., associate professor of pathology, have assisted with this training effort.

“I came away so empowered with these techniques,” says Cooch, who has volunteered at clinics in Guatemala prior to and during medical school. Ackerman, who was a classical musician before learning laboratory techniques at Massachusetts General Hospital (MGH) in Boston prior to coming to UVM, agrees. “These simple laboratory techniques give us a world of information about our patients,” he says. “If you’re working overseas with limited resources, being able to do a blood smear on your own is invaluable.”

The next training session, which is tentatively planned for February 2013, will focus on how to perform fine needle aspirate (FNAs) – drawing out cells for examination under a microscope – and will be led by Ambaye. Students will learn this technique by either working with cadavers or using a simulated method that will allow them to practice the procedure and analyze the cells. Medical students and residents are eligible to apply for a microscope from TME and use the techniques they have learned to set up laboratories.

“UVM medical students and residents may be able to travel to labs around the world to share their technical skills and bring needed equipment and reagents, which will foster retention of the onsite technicians,” says Cooch.

In the meantime, Ackerman is working on gaining access to cytogenetics (fluorescence microscopes), and he and Cooch will be co-authoring (with Ackerman’s former MGH mentor, Dr. Aliyah Sohani) a chapter on essential laboratory skills for global health for a textbook being published by Wiley-Blackwell as part of their Essentials series. The lab manual, which is being worked on with pathology faculty, “will be heavy on photos and pictures, and simplified and translated so that everyone can understand it,” says Ackerman. UVM medical students, led by second-year medical student Elizabeth Landell, have also been assisting with conducting a literature review regarding setting up labs in resource-poor regions.

Cooch and Ackerman plan to travel to Haiti in March 2013 and then spend a month in Uganda during their fourth year of medical school. Any spare time they can find while in the middle of clinical rotations is spent soliciting more donations of lab materials and funding from outside institutions. In addition, the TME has a website, developed by first-year medical students Taylor Goller and Colette Oesterle, and Cooch and Ackerman have applied for a 503c tax ID number so that The Microscope Exchange is eligible to receive financial gifts to help propel the program – and its mission – forward.

They were all speakers for the second part of a Global Health Series presented by the College and Danbury Hospital. Students, faculty and staff from the College of Medicine, the College of Nursing and Health Sciences and Fletcher Allen Health Care attended the evening talk in the Sullivan Classroom. Additional presenters included John Curtis, editor of Yale Medicine, who showed a photo essay on a village in Uganda that is known as the birthplace of the AIDS epidemic; Maya Golts, a medical student from Kazan who talked about her experience in Uganda, and Mary Streeter, M.S., a clinical instructor of radiology at UVM who traveled to Uganda for the Imaging the World initiative.

Majid Sadigh, M.D., Director of Global Health at Danbury Hospital/Western Connecticut Health Network, discussed existing partnerships and programs in development, including a global health elective. In addition to an exchange program with Kazan State Medical University in Russia, students and residents have the opportunity to study at Makarere University School of Medicine in Kampala, Uganda. Opportunities in Vietnam, the Dominican Republic and Liberia are also in the works.  As a clinical affiliate of the College of Medicine, Danbury Hospital and its global health initiatives are providing new opportunities for students and residents. Sadigh argued that students are in a place to effect changes to how health care is delivered globally.

“The soul and the energy of an institution are in the hands of the medical students,” he said.

While in Kazan for a clinical elective, Fabricius learned that interacting with Russian patients required different skills than the U.S., and in some cases carried different expectations. “It gave me an awareness of the social and cultural aspects of health care,” he said.

Golts, who visited Uganda in 2011, experienced first-hand the health disparities that exist between regions of the world, but said it’s important to focus on how small actions can add up to larger change. “You just continue on this work…you can make it better,” she said.

The same attitude prevails for students and medical professionals involved with Imaging the World, an initiative that brings ultrasound machines and training to areas of Uganda and potentially other countries in the future. The focus is on improving maternal/fetal health and creating a sustainable model for training the workforce.  

“It’s very exciting to be part of this new model for global health,” Goldberg said.

Co-organized by Barbara Frankowski, M.D., professor of pediatrics, and Charlotte Reback, M.D., assistant professor of family medicine and director of the College of Medicine’s Generations course, the event provides an opportunity for second-year medical students to learn about adolescence from adolescents. Vermont Integrated Curriculum Coordinator Aaron Hurwitz works with VUMC teachers to ensure the event’s success.

Delivered by teams of two, the seventh-graders’ presentations focused on a wide variety of adolescent-related topics, such as concussions, acne, and suicide. Middle-schoolers and medical students alike benefit from this learning experience, which is an eagerly anticipated highlight of the seven-week course covering a wide range of topics from reproduction to death.

Following the presentations in Carpenter, the middle school students broke up into small groups and joined medical students for an hour-long discussion in the Medical Education Center.

Fall 2012 lecture dates, topics and speakers include:

• September 11, “Creating Order Out of Chaos: New Research on Treating Atrial Fibrillation” by Peter Spector, M.D., Professor of Medicine and Director of Cardiac Electrophysiology

• September 18, “Getting to the Point: Childhood Immunizations” by William Raszka, M.D., Professor of Pediatrics and Chief, Pediatric Infectious Diseases

• September 25, “Handle with Care: Managing Traumatic Burn Injuries” by Margaret Tandoh, M.D., Assistant Professor of Surgery and Trauma Surgeon

• October 2, “Saving Your Skin: How Mohs Surgery Treats Skin Cancer” by Glenn Goldman, M.D., Professor of Medicine and Dermatologist

• October 9, SPECIAL PANEL PRESENTATION: “Gut Instincts: Food, Facts and Fiction in Irritable Bowel Disease” featuring Jean Harvey-Berino, Ph.D., Professor and Chair of Nutrition and Food Sciences and Associate Professor of Medicine; Gary Mawe, Ph.D., Professor of Neurological Sciences; and Peter Moses, M.D., Professor of Medicine and Gastroenterologist

Free parking is available onsite. Registration and additional information are available at 802-847-2886 or Community Medical School.

Organized by the UVM Center for Clinical and Translational Science (CCTS), the Vermont Center for Emerging Technologies and RHT Partners, the forum was an interdisciplinary gathering of students, academics and representatives from the local Vermont venture capital community. Participants had an opportunity to meet Syed and engage in open dialogue with him on such diverse topics as: a new model for funding academic initiatives; cultural issues surrounding Islamic finance; sovereign wealth as an enabler of expanding Western medical education to the Middle East; and opportunities for Vermont to share its intellectual capital with sister states of comparable size in the Gulf.

Syed, who received his B.A. degree from the University of California, Berkeley, and M.B.A. degree from Columbia University, has held senior venture roles in RSM Equico and Partheo. His organization – RHT – was established in 2006 by a senior team of western-trained investment professionals with the support of leading UAE investors. A corporate finance and private equity investment firm, RHT sources, evaluates and manages post-acquisition direct investment on a deal-by-deal basis for, and on behalf of, a group of prominent investors looking to make direct equity investments into knowledge-based industries. RHT seeks to create longstanding relationships between prominent institutions and spin-off companies and its group of prominent Emirati investors, from whom it has raised around $150 million in recent capital commitments. Some focus areas include: medical and business education, clinical and translational science, health IT, and health economics. More information on recent investments can be found on the RHT website.

Directed by Richard Galbraith, M.D., Ph.D., professor of medicine, the UVM CCTS is an innovative multidisciplinary program focused on clinical and translational science (CTS) – the body of knowledge that spans basic biology, clinical medicine and health policy that allows scientists to develop new approaches and systems to improve human health. Studies in CTS help translate knowledge from the cellular and molecular level into interventions for individuals and populations. The UVM CCTS provides an opportunity for young professionals to be trained in clinical and translational research and links them to a fellowship that allows them to actively perform such research in conjunction with a mentor, with the goal of helping produce the next generation of well-trained, independently-funded clinical and translational researchers.

Near the end of the clerkship year, the College of Medicine's Office of Student Medical Education surveys the class using the CourseEval system to rate their perception of their many clerkship experiences. Based on these evaluations, the top program is recognized with the "Best Clerkship of the Year Award." This year, two programs at St. Mary's Medical Center, the Department of Obstetrics & Gynecology and the Department of Surgery, shared the award.

At a presentation in West Palm Beach earlier this summer, UVM Associate Professor of Obstetrics, Gynecology & Reproductive Sciences Elise Everett, M.D., presented award plaques to obstetrician John Caravello, M.D., and surgeon Robert Borrego, M.D.

Some of the comments submitted by medical students during the rating process were read aloud at the award ceremony. Students praised the OB/GYN staff for pushing them to work outside their "comfort zones," and for allowing direct student participation in various kinds of deliveries of babies. Surgical clerkship participants cited the ample amount of one-on-one teaching time given by surgeons, and the good balance struck by the program between time in the operating room and time making rounds in the St. Mary's wards.

The award, which becomes effective September 1, 2012, provides James with support to pursue a mentored educational innovation project, as well as engaging in other developmental activities. As a Macy Faculty Scholar, James will develop an innovative, longitudinal curriculum in patient safety and quality incorporating elements of inter-professional education and simulation. The project will help develop an infrastructure to support efforts of health care quality improvement at the College of Medicine, College of Nursing and Health Sciences, and Fletcher Allen Health Care.

Launched in December 2010, the Macy Faculty Scholars program aims to accelerate needed reforms in health professions education to accommodate the dramatic changes occurring in medical practice and health care delivery. Under the program, the Foundation selects up to five faculty leaders annually. Scholars must be nominated by the dean of their institutions. Each school may nominate only one candidate each year, and is expected to provide a senior faculty member to mentor the scholar. Tania Bertsch, M.D., associate dean for clinical education, will serve as the senior faculty mentor on the project. James also received support from the department of surgery in his application for the Faculty Scholar award.

Through the Macy Faculty Scholars program the Macy Foundation supports educational change in each scholar’s institution and develops a national network for the scholars, who receive career advice from a national advisory committee and participate in an annual meeting for the program.

James, who was recently named clinical director of the Clinical Simulation Laboratory, is the co-recipient of a 2011 Frymoyer Scholarship and has served as director of the Surgery Clerkship and both the Surgery Senior Major and Surgery Scholarly Programs.

“The students also created an honor wall at their school where people could honor someone they knew who had passed away from or survived cancer,” says Sarah Keblin, interim team leader and director of annual giving for the UVM College of Medicine.

Shelburne Community School middle school basketball coaches, including Anthony Spagnolo, Andrew Riegler, and Alan Mihan supported the teams in making this happen. In addition to the activities that took place during the Shelburne Community School middle school basketball games, about 50 students attended one of the Play 4Kay (formerly Pink Zone) basketball games, which are part of UVM’s Rally for Cancer initiative.

The survey tracked clinical hours of primary care practitioners – including physicians, advanced registered nurse practitioners, certified nurse midwives, and certified physician assistants – at 224 primary care practice sites.

Among the findings was evidence of pressure on the supply of primary care providers; an increasing number of primary care practices had limited or closed their practice to new patients during the period.

Compared to 2009 figures, Southern Vermont experienced the greatest decline in full-time primary care providers, the Champlain Valley saw a lesser decline, and the Northeastern region of the state actually saw a slight improvement. The report applied national benchmarks to the Vermont population to determine how many primary care practitioners were required for what was deemed an “adequate supply.” In relation to these benchmarks, Vermont showed “a persistent shortage of more than 50 general internal medicine physicians.”

“With the state’s aging population and primary care workforce, as well as heightened competition for primary care practitioners from other states, Vermont’s ability to maintain and increase the supply of primary care providers for adults will remain a challenge,” says Denis Barton, M.A., M.B.A., director of the Office of Primary Care and AHEC Program at UVM.

According to the Association of American Medical College’s 2011 State Physician Workforce Data Book, “in 2010, there were 79.4 primary care physicians active in patient care per 100,000 population in the United States, ranging from a low of 58.4 in Utah to a high of 111.5 in Vermont.” Charles MacLean, M.D., interim associate dean for primary care, is aware that compared to other regions of the country, Vermont has better access to primary care.

“Primary care is the backbone of the health care system, but is only as strong as its ability to coordinate with a robust specialty care system,” he explains. “The Vermont Blueprint for Health approach to improving the health of Vermont’s citizens relies on a well-trained and available primary care workforce.”

“More than 40 percent of Vermont’s primary care physicians either attended medical school at UVM or completed a primary care residency at the UVM/Fletcher Allen Health Care," adds MacLean. "By continuing to train the primary care providers for the future, we help make an impact,” he says.

Several AHEC activities are expected to help offset these shortages, including the state-funded, AHEC-administered, Vermont Educational Loan Repayment Program for Primary Care Practitioners, which helps with recruiting primary care physicians to the state, as well as ongoing efforts to promote the health care field, which is projected to be the largest industry in Vermont in the next 10 to 15 years. Last December, the Vermont AHEC office distributed the 2011 edition of its Health Careers: More Than a Job directory to middle and high school guidance counselors, school nurses and health teachers, as part of its ongoing efforts to ensure the state has an adequately staffed health care workforce.

To link to the 2011 Vermont Primary Care Workforce Snapshot, visit: www.uvm.edu/medicine/ahec/. For information on the Health Careers directory, go to: www.vthealthcareers.org.

About Vermont AHEC
Established in 1996 by the Office of Primary Care at the UVM College of Medicine, AHEC is a dynamic, academic community partnership linking the UVM College of Medicine and Vermont’s communities in all fourteen counties. In collaboration with many partners, VT AHEC improves access to quality health care through its focus on workforce development. Activities include: support for pipeline programs in health careers awareness and exploration for Vermont youth; support for and engagement of UVM health professions students and residents at Fletcher Allen Health Care; and support to help recruit and retain a high-quality healthcare workforce in Vermont. In addition, AHEC brings educational and quality improvement programming to Vermont’s primary care practitioners and supports community health education. The Vermont AHEC Program is funded through multiple grants and contracts, including: Federal HRSA Title VII, State of Vermont, Vermont Department of Health, UVM College of Medicine, Fletcher Allen Health Care, Vermont’s 13 community hospitals, and private foundations. The statewide infrastructure of AHEC consists of a program office at UVM and three regional centers which are 501(c)(3), non-profit organizations. Vermont AHEC offices include Northeastern Vermont AHEC in St. Johnsbury, Vt.; Champlain Valley AHEC in St. Albans, Vt.; Southern Vermont AHEC in Springfield, Vt.; and the UVM AHEC Program Office in Burlington, Vt.

It was a bright and bustling morning in Trivandrum, the capital of India’s southwesternmost state, Kerala. A third-year resident in family medicine, I had come here to work with the staff of an Indian nonprofit devoted to advancing palliative care services across India. Seema was a young, newly qualified junior doctor who had only recently joined the organization. We were traveling with five others — our driver, two nurses and two nursing trainees — into the mountains east of Trivandrum for the day.

“We don’t really speak about the weather like you do,” Seema gently chided. “In the West you spend lots of time talking about the weather.” As I silently ceded her point, she consoled me: “I think you have more variety to your weather. Here it is only hot, very hot, or cold and rainy. Most people carry an umbrella because it’s useful in any of those cases.”

I counted the passing umbrellas as our van carried us into the foothills on our way to Palode, a village where we would hold a small outpatient clinic before making home visits. After the clinic session, Seema looked tired. I asked what she was thinking.

“Sometimes I feel frustrated that we can’t do more for our patients,” she said. “Doesn’t this frustrate you?”
Of course, I thought. It frustrates all of us.

A bit tentatively, I asked, “Have you heard, Seema, about the idea of bearing witness?” She shook her head.

“It’s the idea that just being present with someone can be healing,” I went on. “In the Bronx, where I work, lots of our patients suffer from sicknesses and social ills that we can’t do much about. Sometimes, just being there is doing something; sometimes it’s the best we can offer.” Perhaps this notion was merely a salve for my feelings of helplessness. Still, I hoped that it was true. Seema’s answer was silence — whether thoughtful or skeptical, I couldn’t tell.

After lunch, we were joined by a beautiful ten-year-old girl named Paadini. A member of her school’s health club, she aspired to be a doctor and sometimes accompanied the palliative-care team on home visits.

As we drove deeper into the mountains, Paadini sang quietly to herself, and Seema told me about the patient we were going to see. Diagnosed at forty-eight with breast cancer, she’d had a left radical mastectomy and multiple rounds of chemotherapy and radiation therapy. The treatment had been unsuccessful, likely because of her late diagnosis — common in a country where most people don’t have access to primary care or the money to pay for it.

The woman’s alcoholic husband had left her years before, but had returned home a month or so back, Seema said. “He had nowhere else to go, and she could not, as his wife, turn him away.” He’d recently been found lying dead in the road. The woman’s son worked nearby, but was rarely home; a few months back, her daughter had fled with a boy. The patient, bed-bound and fed twice daily by a seventeen-year-old neighbor, was essentially alone.

The road’s jagged asphalt gave way to red dust. We passed government-owned bamboo and acacia farms, abandoned bus shelters and a painted cement statue of Shiva — the giver and taker of life — with his blue skin, dreadlocks, and trident. Crossing over a fast-flowing river, we reached the patient’s small village and stopped to buy biscuits and bananas to bring the patient.

We parked the van and descended into a shallow valley of rice paddies and palms. Led by Paadini in her pink dress, we walked single-file through the lush, green landscape to the sound of a gently trickling stream and goats bleating in the distance. Around us, white cranes swooped into placid ponds filled with blooming lotus flowers.
As we scrambled up a steep rise to a small, dark, mud-brick home, an eager puppy on a chain barked piercingly, announcing our arrival.

Our patient lay in the open front porch, naked except for a stained white sari blouse and the bright pink blankets that covered her. Eyes closed, she moaned quietly, grimacing between shallow, rasping breaths. Her head, covered with short wisps of hair, lay awkwardly on the pillow. Her cheekbones jutted over sunken cheeks, her lips were dry and cracked, her exposed arms were wasted. On a bench a package of steroids, unused since the team’s visit a week back, sat next to a tin of watery rice porridge — her unfinished breakfast.

Responding to our greeting, she seemed confused. She’d tried to bathe that morning, she said, but had fallen in the pool — an event that had actually taken place two weeks before. She complained of being in pain, and she looked it. When she rolled over, I saw bits of dry feces caked to her thigh. She seemed very close to death.

Hoping to relieve her pain and breathlessness, I asked Seema, “Can we give her morphine?”

“No,” Seema answered. “None of her family are here. If we give her morphine and then something happens, her family will say that she was fine when they last saw her and blame us for making her worse. Our hands are tied.” I suppressed a flash of anger. There must be something we can do.

We crushed the steroid pills into the rice milk, and the nurse spooned it into her mouth. We tried and failed to take her blood pressure; her weak, thready pulse told us that it was very low.

As a team member called the woman’s son on a mobile phone, we sat on a mat next to the woman’s bed. Looking around, she locked her eyes onto mine, then reached for my hand.

I clasped her hand in mine, and we sat for several minutes, looking at each other. As I had many times in my brief medical career, I moved past my own discomfort by acting as I thought a good doctor would. And though I wouldn’t generally use these words, I think that I prayed for her. I also wondered how she understood this strange situation, and wondered who was comforting who more.

“She doesn’t know us, but she knows that we’re here to help her, ” Seema said.

An idea occurred to me. Turning, I caught Paadini’s eye. “She’s very sick, Paadini,” I said gently. “Maybe it would make her feel better if you could sing her a song.” But Paadini shrank back shyly.

The son arrived, doe-eyed and bewildered. Seema explained that his mother was very close to death; that she needed to be cleaned and to have someone stay with her. The son promised to take care of these things.
Bending down, I took the woman’s hand again and smiled. Then Seema did the same.
Our earlier conversation came back to me. Our presence may be the best thing we have to offer.
We left and walked back through the forest.

I thought about how much suffering the woman had endured. I hoped that our presence had meant something to her. Quietly, I wished that her pain would go, that her breathlessness would cease, that she would die peacefully and soon.
Up ahead I could hear Paadini, leading us out of the green valley with a song. VM

Epilogue: The following week, I learned that the woman had died within an hour of our visit.

“Our institution is in company with three other medical schools -- UCLA, Johns Hopkins, and the University of Michigan -- along with established NGOs such as Project Smile and Project Hope, that are currently participating in this mission,” Freeman explains. “As our first step in this affiliation, I spent a week working with Brett Larson, a pre-medical student, in Guatemala, performing volunteer medical work in collaboration with Navy medical staff.”

The Continuing Promise deployments involve U.S. Navy amphibious ships that bring health care and other relief services. The mission aims to foster goodwill and demonstrate U.S. commitment and support to the region. “I was impressed with the professionalism and the humanism of the USA and its representatives on board the USS Iwo Jima,” says Freeman. “It was amazing to see the coordinated effort between the different branches, the variety of NGOs, and the myriad of activities occurring simultaneously including medical, dental, preventative medicine, veterinarian, engineering, education, and diplomacy. I'll especially remember the commanding officer, Navy Capt. Thomas N. Negus, greeting us every morning as we went out with a sincere handshake and positive word.”

The medical work was challenging, says Freeman, but seemed to make a real impact. “Taking care of the Guatemalans, especially the indigenous people in the jungle clinic who had no real access to health care, reminds us of why we practice as physicians,” he says.

Freeman hopes to continue to participate in more Continuing Promise and future collaborative engagements with the Department of the Navy. “I'd like add some of my expertise in emergency medicine to help further the humanitarian effort. Since the Johns Hopkins team has disaster medicine pretty well covered, I've talked with the Navy about establishing an EMS education curriculum, to help developing nations build their pre-hospital medicine infrastructure.” Rural emergency medicine services have a long history of research and development in Vermont, Freeman notes, including transportation, technology, and telemedicine. “I offered to bring our Vermont EMS experts to work with PREV-MED (the military's preventative medicine team) and local hospital emergency departments throughout the SOUTHCOM region for education about pre-hospital emergency care.”

Through the affiliation with Continuing Promise, UVM now has a formal mechanism for placing students in a well-supervised, international volunteer medical environment that makes real humanitarian impact. “This program will help our students gain an international health care perspective,” says Freeman. “Many of our students today are interested in international medicine opportunities as part of their medical school experience.”

Future Continuing Promise missions will involve one- to two-week commitments in Latin American and Caribbean nations including Haiti, Costa Rica, Guatemala, Panama and Columbia, during the late spring and summer timeframes. Freeman notes that in particular licensed M.D.'s and P.A.'s interested in providing primary care are needed.

Second-year medical student Amanda Schwartz leads the medical student interest group of about two dozen students who regularly head out to local elementary schools to run SmileDoc sessions. These groups visit the same classrooms several times in a semester, with one of a number of educative modules that have been developed by the group over the years. “We’ll work through modules about heart function, the five senses, the lungs,” she says. “And since we go back to the same class several times, we get to know the kids better and I think they really look forward to our coming.” After their fall semester at St. Francis Xavier, this year’s SmileDocs group was presented with a “thank you” book of letters from all the children in the classroom.

For nearly as long as medical students have been running their program, Janet Schwarz, senior laboratory technician at UVM’s Microscopy Imaging Center, and Professor of Pathology Douglas Taatjes, Ph.D., have spearheaded Project Micro. Launched originally as an effort of the Microscopy Society of America, the Vermont Project Micro is now a national model of successful community interaction that uses microscopy to foster scientific interest in young people, reaching schools in every corner of Vermont with hands-on microscopy sessions presented by Schwarz, her colleagues, and interested graduate students. Schwarz and Taatjes have even published on the effort, presenting an overview of their work this past summer in the journal Microscopy and Microanalysis. As of this year, the Vermont Project Micro has reached more than 5000 schoolchildren through the state.

Vermont’s Area Health Education Centers (AHEC) focus on high school students who are beginning to ask the question “what will I be when I grow up?” Many students have an interest in science, but only a vague notion of what a health care career can be like. AHEC’s MedQuest HealthCareers Exploration Program is designed to give these students exposure to health care career opportunities that they would otherwise not encounter. Each of the three regional AHEC offices around Vermont run intensive, week-long MedQuest programs, where a group of about 30 high school students immerse themselves in the world of health care. At UVM/Fletcher Allen this summer, two MedQuest groups lived on campus for a week while they shadowed health care professionals at three hospitals and an elder care facility, conducted research in the College’s laboratories, and learned about health challenges facing all Vermonters. UVM medical students serve as conselors all week.

More than 300 Vermont high school students have explored health care careers through MedQuest over the past eight years. Gwen Fitz-Gerald was one of those kids, and today she is a second-year medical student at the College. She credits MedQuest with inspiring her to choose a career in health care. “MedQuest convinced me that medicine was the direction I wanted to take,” Gwen says. “My counselors — all medical students at UVM — were particularly inspirational.” This summer, Gwen honored her MedQuest experience by serving as a counselor.
 
In addition to longstanding programs, the College also serves as an educational resource for science teachers and their students around the state. This past year, the College’s simulation laboratory was visited by students from PILOT, the Program to Inspire Leadership, Opportunity, and Thought, a youth leadership program for high school juniors in Chittenden County. And, for the second year in a row, students from Vergennes Middle School became teachers on campus, taking part in a module on adolescent development with second-year medical students as a part of the College’s “Generations” course.

I wished I could offer him more, knowing that his life was already filled with poverty and disease, and his next meal was anything but planned. He was four, but had the height and weight of a two year old. His failure to thrive had rendered his naturally curly black hair a tinted shade of red. His naked feet were covered in blisters in the absence of shoes and his ribs were protruding through his skin as if desperate to escape. The earthquake had left his mother a widow who struggled to care for him and his siblings in the remnants of their home town. The same earthquake that had shattered the buildings and what remained of the economic structure in Port-au-Prince and its surrounding provinces on January 12, 2010, had also shattered whatever hope he had left. The boy lived in what used to be a beautiful city, Leogane, now only known worldwide as the epicenter of the Haitian earthquake. I watched as he ate the piece of chocolate, careful to leave no crumbs, as if it were the last piece he’d ever see. I traveled to Port au Prince two months after the earthquake that registered 7.0 on the Richter scale, and its more than 50 aftershocks that shook the small Caribbean country. This was my second trip to the island of Hispaniola, having been here three years earlier with a group from the Department of Surgery. The journey transformed my view of healthcare and humanity, and further confirmed my belief that we as humanitarians can never do enough. Once the richest colony in the New World, Haiti now ranks as the poorest country in the Western Hemisphere. Fourteen of every 100 children die before the age of two, and the majority of children under five are malnourished. The inhospitable conditions, inadequate health care, and lack of proper nutrition cultivated disease in Haiti unlike anything I had ever seen. More remarkable and memorable, however, were the children I met during my stay. Seeing them made it obvious that disease and malnutrition had extended its grasp to even the smallest and most vulnerable. Were it not for the meals provided by various relief groups and militaries, a large portion of the children would surely have perished. As it was, an estimated 230,000 people had died, 300,000 had been injured and over a million had been left homeless. The majority of the children were excited to see visitors. Others were sad and lonely, longing to be comforted, but timid to ask for the privilege.

My time in Haiti was divided among multiple hospitals and locations throughout Port-au-Prince and the surrounding provinces on an as-needed basis. I arrived with my team at Quisqueya Christian School, which was originally constructed for foreign missionary and diplomats’ children, and now was converted into a command center for medical disaster relief. Following the earthquake, the school closed due to dwindling numbers of students, high numbers of teachers returning to the U.S., and a large portion of the children of foreign professionals who’d left the country with their families. Struggling to stay in part to help, the school’s remaining teachers reached out to various groups and organizations and offered their facilities as a base camp. Before they knew it, teams from all over the world were setting up camp in their backyard, including the United States military. With an intact structural foundation, and an even stronger emotional and spiritual foundation, the teachers of Quisqueya used their knowledge of Port-au-Prince and the surrounding areas to disperse the various organizations and groups in their backyard to locations with the most need. So the Vermont Federation of Nurses and Health Care Professionals team I arrived with were able to reach out and help as many as we could in the small amount of time we spent in the country.

With three years of medical school under my belt, and a little over a year away from graduation, I was pretty sure I would be able to handle any crush injury or infected wound that came my way. And for the most part, minus the experience and medical confidence to handle some situations, I was right. Additionally, I lucked out and was fortunate to have an amazing team to work with. Medically, we performed some amazing acts: removing rebar from a photographer’s leg, setting fractures, treating tropical infectious diseases, and even aiding a young woman who was hemorrhaging following a spontaneous abortion. What I was not ready for was the emotional diarrhea that would follow. I consider myself a fairly emotionally stable person, but spending over a week caring for elderly who are dying in front of you and mothers whose babies are limp and lifeless because they are getting no nutrition has an undeniable effect. I have trained for marathons, I’ve trained for medical school, but I’d never trained for the images and sights I witnessed in Port-au-Prince in March. It was not the gruesome images, but the widow with one-month-old twins who had lost her husband when their roof fell on him, or the grown men sleeping in the streets begging for a job, that will follow me forever. Nowadays, as I sit in the well lit, air conditioned medical library studying for my medical boards, the images make me realize that there are people out there right now who may die tomorrow because no one is there to help them.

Port-au-Prince may be thousands of miles away from Burlington, and the 5.5 rumbling last June that passes for an earthquake in this region may have been barely noticeable to most, but yet there are still those here who hang on the edge of healthcare. I have learned during my upbringing in Vermont and from the education and experiences I’ve had in school that, no matter how far you travel from home, problems still exist on your own doorstep. I have had the opportunities to see and experience all aspects of the healthcare system, and how it affects those it encompasses, but I have yet to understand how it misses so many. During my clinical years of school I had the opportunity to work in various offices throughout the state, and I’ve learned that neglect, poverty, malnutrition, and subsequent disease still exist even here in Vermont. It seems to me that the question we as physicians (and those of us soon to be physicians) have to ask ourselves is: How can this happen? How can we learn to prevent it, and how can we make it easier for those who seek to help themselves?

In the ever-powerful, industrialized United States, situations such as the starving children I witnessed in Haiti are not as common, but still present. Adults and children in developing countries are often faced daily with starvation, HIV, poverty and death. Countless children must fend for themselves, orphaned or left for dead by their parents. My goal as a future physician is to assist in caring for these children and find ways of preventing their conditions. Having grown up in small rural towns in Vermont, the aim of my medical career is toward underserved regions. My everyday experiences, connection, and enthusiasm for the younger population push me to follow this path. Reflecting on what I have done, seen, and hope to do as a physician I realize I want to use the knowledge and tools I have acquired at medical school and working in various underserved regions in Vermont to understand how it is that so many in Haiti are living below the poverty line, and why it is they can barely care for themselves, let alone their offspring. I would like to be able to apply what I have learned in rural Vermont on a global scale to understand why certain populations are at risk. Most importantly, I want to understand how we as physicians, or future physicians, can best utilize our resources and knowledge to follow the time-honored tenet of medical ethics: salus aegroti suprema lex — always, no matter what the cost, act in the best interest of the patient.