[Rebecca Schmitt]

Question #2: What does a fee-for-service payment system reward? Describe one initiative of the 2010 ACA or 2015 MACRA legislation intended to transform payment models to increase value.
Per the “Prescription for the Future” book, fee-for-service systems create fragmented care. This system does not promote physicians and hospitals to work hand in hand together. It wrongly promotes clinicians to do unnecessary labs, imaging, procedures, etc. In addition, without specific performance data and objective benchmarks, it’s very challenging to improve quality.
The Oncology Care Model is a bundled-payment system that is a prime example of patient-focused care. Going through cancer treatment is exceedingly difficult for the patient and their family. So having 24/7 access to a clinician with realtime access to their patient record is wonderful. In addition, it’s important for the entire oncology team to be on the same page in regards to treatment being either 1) to cure the cancer or 2) be palliative.

[Rebecca Schmitt]

Question #1: When was the last time you were overwhelmed with too many options? How did you make the decision easier and overcome uncertainty?
I think I can make a fair statement that we all suffer from decision paralysis at the grocery store. I had a heck of a time when I did the “Whole 30” diet (or “lifestyle change”) where for 30 days straight, you completely eliminate: alcohol, added sugar, grains, legumes, dairy, carrageenan or sulfites and recreating baked goods/”treats”/junk food with approved ingredients. The purpose it to eliminate all things that can cause digestive concerns. Then very slowly reintroduce one thing at a time back into your diet and listen to your body on how it responds. My partner and I both did it together, so made it much easier. Going to the grocery was a constant struggle. (We quickly realized that added sugar is in a crazy amount of things!…it’s always important to check the <1% ingredients, because often it will be listed there, which many of us don’t even read). As an example, we had a very challenging time picking a salad dressing. All the ones we currently had in our fridge did not make the cut. When looking in the grocery store, there are TONSs of dressings available, however very few actually met the criteria. We picked a few of those, which we did not like, so ultimately ended up sticking to oil and vinegar nearly the entire month. Here in the USA, we are “blessed” (I question if that is truly a blessing…) to have so many options, which constantly leads us to decision paralysis

To comment on Abiodun’s answer, I had a difficult time with deciding on the institution to work for after graduating residency as well. He had some big factors at play I did not have (namely, no husband or kids). For me, the biggest factors boiled down to wanting a location closest to my parents, working for a faith-based medical system and to be at a smaller institution. After boiling it down to that, two were nearly tied. Ultimately, I ended up picking the one that was a little closer to family.

[Rebecca Schmitt]

Melchizedek, I am very interested to learn more about the Amedicare Foundation initiatives. I had discussed on the call last week my plans to implement Helping Babies Breathe (HBB) to low resource communities throughout the world. I’m planning on traveling to Costa Rica early next year to volunteer at a clinic and teach the course for their healthcare providers/midwives/traditional birth attendants. HBB teaches, in an interactive and hands-on method, the key principles to assist a baby to breathe on their own during the first “golden minute” of life. These basic principles can decrease infant mortality rate by up to 50% in these low resource communities.
One may assume that teaching this course will be very well accepted by the learners, however there are many factors at play in order to make sure it indeed is well accepted and is sustainable for the future. As you stated, communities may have lost trust in prior organizations, which will be a challenge we will be ready for.

[Rebecca Schmitt]

Question #1: What problem are you currently facing that appears to be a people problem but may actually be related to the situation they (or you) are in? My sister has been working as a 7th grade social studies teacher in New Orleans for the past 5 years, working in an at risk school. During the shut down, these children were expected to participate in online schooling. Almost the entire class had fallen significantly behind (as did the majority of children worldwide of course). She initially had got very frustrated on a daily basis due to kids not logging in to their virtual classroom and completing their homework. This initially could be conceived as a “lazy” or “not wanting to learn” mentality. But, after a while, it became very clear that the majority of the student body didn’t have reliable access to internet and/or they would be busy tending to other things in the home that had taken higher priority, such as helping take care of their siblings. She had to mold her teaching practices to fit these challenges in order for everyone to make the best of a terrible situation.

Question #2: Provide a ‘Miss Harris’ example from your own experience. How might they have benefited from consistently higher-quality, lower-cost, and more patient-focused care?
As a pediatrician working through this COVID pandemic, I have seen countless families fall through the cracks. This specifically has been affecting my patients that fall in the low SES. Our routine well child exams that we do (at 1, 2, 4, 6, 9, 12, 15, 24, 30 months and then yearly starting at 3 years old), are comprehensive including height, weight, vitals, vaccines, developmental milestones, school readiness, anticipatory guidance, mental health screenings, routine lab work. A lot of patients had missed these crucial well exams during the pandemic, which has caused a lot of challenges and setbacks. One of the largest of course, worldwide, is the decrease in vaccination rates as a whole.

[Rebecca Schmitt]

I have the same frustrations with my office as Christina does in terms of communication when patients call. When I first joined my practice (originally there were 4 of us MDs, now just 3), we were very spoiled in the sense that when patients called the clinic, they would immediately get connected with our pediatric triage nurse, who would then relay the message on to us providers if needed. We have had the same two triage nurses for several years, so they know our patients and their families well and are very knowledgable about peds. However, since just before COVID started, we have a new system that ALL patients who call in go to a central line and then will get transferred as needed to the respective departments. Families have been very frustrated to say the least with this system. There is high turnover in the call center and often there is very long wait times.

[Rebecca Schmitt]

Hello everyone. My name is Rebecca Schmitt

1. I work as a general pediatrician in Manitowoc, WI, in both the outpatient and inpatient setting (primarily the nursery). I took the Helping Babies Breathe course last summer and had the privilege of teaching the HBB course, along with the Essential Care for Every Baby and Small Babies courses this Summer alongside Dr. Comninellis. I have a special interest in neonatal medicine and have a strong desire to implement HBB courses internationally.
2. I am taking this course in order to have a stronger foundation and better understanding of leadership and management in the medical setting in general. Unfortunately, medical school and residency did not focus on these topics, so I believe it is critical to have this foundation going on forward in the international medical missions I am planning on being a part of in the future.
3. I am currently in the early stages of creating a search engine/database connecting globally-minded healthcare professionals with international medical mission trips. In order to successfully create this platform, it is important to work closely with international medicine organizations, a few of which I already have planned for the coming year.

I’m greatly looking forward to the course and excited to meet you all.

[Rebecca Schmitt]

QUESTION 1: As the article stated, in order for there to be success in global education and partnership, there needs to be alignment with local needs, avoidance of persistent dependency and development of trust. The international collaboration must be seen by the locals as something that is worth spending time and effort on and something that will ultimately lead to better health and wellness of the local people. ( Need for “Buy in”). There needs to be realistic and attainable goals and objectives that are mutually agreed upon by both parties. There needs to be a focus on working as a team and having everyone know their role and take “ownership” of that role. In doing so, this will facilitate autonomy and purpose for all team members. Anticipate and prepare for the challenges that will come and brainstorm as a team ways to overcome these challenges.

QUESTION 2: Compassion is a habit of exemplary clinical teaching translatable to education in LMIC settings. One of my pediatric hematology/oncology attendings that I trained with is such an angelic, compassionate and warmhearted soul. I vividly remember the moment when we had to break the news to a mother and father that their 5 year old daughter was diagnosed with acute lymphoblastic leukemia. This was the first time I was part of this conversation of breaking bad news. Despite this being one of the hardest things I have ever had to be part of, my attending had this incredible way of shedding this beam of hope and security onto the family. I hope to be able to emulate that feeling of hope and security to my patients and their families during my career.

Jeanne, I like the way you think about clinical ideas of residents as being in “3 buckets”.
Chering, thanks for sharing that touching story of your patient. It is indeed very important to treat your patients as a PERSON, not just a body. In doing so, there will be so much more added information you will gain, which likely will be pertinent to their overall condition.

[Rebecca Schmitt]

QUESTION 1:
That article was very sobering to say the least and should be a huge wake up call to many.
Sadly, a lot of physicians go into the field of medicine with altruistic intentions, however the deeper one gets into practice (starting as early as the premed and medical school years), it is easy to get jaded and lose sight of those altruistic intentions. There needs to be a “reset button” and physician’s need to take more accountability and serve as a role model and leader for the entire medical community at large.
Continuing medical education, as a mandatory part of our work in the field, needs to be as relevant as possible to our everyday practice. This will keep physicians updated on current medical practice, new research, guidelines, etc, which leads to better patient outcomes.In addition, there needs to be a standard protocol for treatment and management of common diseases in order to standardize medical care and assure each patient is getting the most appropriate care. “The right care, right place and right time.” Providers need to also be mindful of the distrust many patients have of the medical community. Recognition, acknowledgment and desire for change needs to be at the forefront in order to attempt to gain that trust back, which will take time.
As stated by many of you, the “brain drain” is a real problem, and one that needs to be seriously addressed. I like Alice’s idea of creating a contractual requirement of “X” amount of years that would be dedicated to serving the marginalized communities of that individual’s home country before they are able to seek work elsewhere that may be more desirable for various reasons.

QUESTION 2:
One of the communities of interest that I work with on a regular basis is the Hmong population, who are a group of people originally from China and Southeast Asia. We could better serve this community by partnering with Hmong community members and have them serve as CHWs. Educating our medical community members on Hmong culture, including their traditions/beliefs/practices/etc, would help with building rapport and strengthen the relationship and trust they have with the medical community.

[Rebecca Schmitt]

ANSWER 1:
Avoiding conflict in general is the biggest feat…and admittedly, this is a very daunting task and it is hard to even know where to begin with how to avoid conflict. As the article illustrated, infectious disease plays a significant role in CE-associated morbidity and mortality (up to 95%, which I was surprised how high that number was). So when looking at it from a public health perspective, there needs to be focus on improving the overall health and safety of the high risk communities. This can be done by improving vaccination rates, prioritizing WASH, and having appropriate disaster plans, which emphasize the importance of accessibility to food, water, medications, shelter, etc.

Alice brings up a great point regarding emphasis on education at the primary and secondary school level.
I like Jonathon’s statement about supporting a weapons buy-back program. Earlier in this course there was the example of the ”Guns for Cows” program in Albania in the early/mid 2000s. Initiatives such as this would serve as a great incentive to reduce armed violence and promote peace amongst people.

ANSWER 2:
In my opinion, disaster prevention is minimized when compared to disaster response for a few reasons. First off, it is all too common for people to have a mindset that by not addressing and preparing for a harmful future event, you in turn (consciously or subconsciously) deny it’s existence. In addition, media coverage plays a significant role. News stories tend to spread like wildfire when the actual disaster itself occurs and there needs to be an immediate response effort. However, once the immediate disaster response ceases, media coverage fades away, and few people/organizations/governments actually learn from what had happened and plan accordingly to prevent future occurrences.
As an example of this, Shirene brings up a good point about the lack of PPE at both the time of H1N1 and again the same lack of PPE during the current COVID pandemic.

Jonathan, I like your comparison of primary care with disaster prevention and subspecialty (eg. stent placement) with disaster response. As a pediatrician myself, it is vital that we keep our patient population healthy in order for them to avoid needing subspecialty care down the line.

[Rebecca Schmitt]

QUESTION 1:
The actions healthcare providers can take to decrease cross-cultural barriers are
1) Respect for differences across cultures
2) Become more aware of one’s own implicit bias (lectures, questionnaires, etc)
3) Learning the language of the people (or at minimum a handful of basic phrases that will help build a sense of rapport)
4) Having the patience and understanding that goes with the extra time and effort it takes to work with those with language barriers
5) Actively engage in learning more about other cultures
6) Understand and acknowledge the history behind the distrust other cultures have had in regards to modernized medicine and healthcare at large (Examples: reading “The spirit catches you and you fall down” and “The Immortal Life of Henrietta Lacks”)
It would be very beneficial to do formal training, for not only healthcare providers, but to everyone in the institution that will be having contact and interaction with those of other cultures.

I agree with Chering that compassion does not need a shared language.
Shirene brings up a good point in that throughout medical training, emphasis has been on asking patients about their culture and religious beliefs, however this is often lost in practice. We need to be more cognizant of this and incorporate it in our interactions with those of other cultures/backgrounds.

QUESTION 2:
Short-term healthcare trips can be more effective by emphasizing that the importance of the trip should be on bettering the community served and creating sustainability. Teaming up with the local healthcare providers is vital in creating this sustainability.
After the trip is over, there should be regular check in times with the local healthcare team to see what other resources or support may be necessary to assure continued services. Debriefing at the end of the trip, and even a few times throughout the trip, is beneficial, particularly to address the culture shock that many may be experiencing.
Shirene brings up a good point that sufficient pre-trip preparations and training should be utilized in order to maximize the services when actually in the local community.

[Rebecca Schmitt]

QUESTION 1: The actions that are most important to improve global nutrition are education of people and governments. This education needs to focus on teaching what foods promote health and what foods lead to disease (both food-borne disease and non-communicable disease, such as obesity, diabetes and heart disease). As emphasized in this week’s course work, the connection between health, general education/literacy and economics all work in harmony. In order for one to succeed, the other two must be strong players as well. Appropriate safety and preparation of food needs to be stressed as well. Proper washing and handling of food will decrease chances of developing food-borne illnesses. Boiling and cooking of food is imperative to avoid these diseases. In areas with lack of access to clean water, this is even more crucial. Creating incentives for both people and governments to push towards healthy, whole foods and away from highly processed.energy-dense foods will be a key driving force in improving global nutrition.
I agree with Shirene that as healthcare providers, we play a critical role in the education of our patients and families about healthy food choices to improve nutrition.

QUESTION 2:
In my opinion, the greatest obstacle to progress in global health is poverty, particularly extreme poverty. As mentioned above, the interconnectedness of 1) Health, 2) General education/literacy and 3) economics all work in cohesion. Poverty stricken areas of the world are hit the hardest. In order to achieve the Sustainable Development Goals, there must be drastic public health initiatives to create solutions to these issues. We must also view healthcare as a BASIC HUMAN RIGHT. The World Health Organization Constitution envisages “….the highest attainable standard of health as a fundamental right of every human being.” There ought to be a focus on prioritizing the needs of those most at need and allocate resources accordingly.
I agree with Ann Miriam that making healthcare affordable for all will decrease the gap between the haves and the have nots

[Rebecca Schmitt]

QUESTION 1:
The actions that need to be taken in order to increase availability of basic newborn resuscitation are appropriate implementation and delivery of evidence-based programs like Helping Babies Breathe to low-resource communities. It was shocking to me when learning that there is a nearly 50% decrease in neonatal mortality when implementing just the basic neonatal resuscitation 101: warming, stimulating, drying, suctioning, PPV. Experts are needed to set the groundwork, but there needs to be focus on educating and empowering community healthcare workers to learn HBB and hopefully go on to be teachers themselves and continue to spread this knowledge to other healthcare workers. Doing refresher courses, on a 6-12 month basis at minimum, will be needed for sustainability.
As Jonathon brought up, community buy-in needs to be at the forefront, otherwise efforts will fall by the wayside. As a few of you have already agreed, Jeanne has an excellent idea about cell phones. This would be a great tool, at the hands of most around the world, to help facilitate learning for all parties.

QUESTION 2:
WASH and nutrition go hand-in-hand in that both are a necessity to promote the physical and mental health and well being of our children. Lack of access to clean water and appropriate sanitation measures, as outlined throughout the course, puts people at huge risk of enteric diseases, diarrhea, respiratory illness, etc.
Shirene brings up a good point regarding breastfeeding. It is vital to teach mothers, and communities at large, about the benefits of breastfeeding, including but not limited to: nutrition, supporting healthy immune systems, promoting mother-baby bonding, decreasing chances of developing asthma, obesity, respiratory infections, SIDS, etc. Promoting breastfeeding, as the VERT FIRST means of nutrition from the moment of birth, sets the stage for healthy growth and development of that child.

[Rebecca Schmitt]

QUESTION 1: There are several factors that play into how conflict directly impacts the health of pregnant women, and the entire population of women at large. In my opinion, the most direct impacts are 1) decreased access to healthcare services and 2) increased risk of diseases secondary to poor shelter in close quarters, poor access to clean water and food and poor sanitation. These factors significantly increase morbidity and mortality of women. As the article states, financial constraints, safety/security and geographical restrictions all play into this. In addition, sexual violence and rape, which increase dramatically in conflict-ridden areas, lead to poor health outcomes. Although largely speaking armed conflict worsens the health of pregnant women, I found it interesting that the article states there are higher odds of skilled assistance at birth in the conflict areas of Northern Uganda, likely due to the interventions and humanitarian assistance and international aid.

QUESTION 2: For far too long, “Maternal health” has been unfairly confined to mostly the antepartum, peripartum and postpartum period. There needs to be a dramatic shift in order to better address all maternal health care issues. Chronic and non-communicable diseases are becoming more of a leading cause of morbidity and mortality, so it is crucial we shift this paradigm. In order to do so, we need to start focusing on preventative medicine. Using a patient-based model rather than disease-based model will significantly improve long term outcomes. For example, focusing on healthy diet, exercise and lifestyle modifications will pay huge dividends in the prevention of chronic disease such as diabetes and heart disease.

Ann Miriam brings up a good point in that often national healthcare facilities are affected by internal politics that do not reach the most needy and that corporate groups focus primarily on their own profits. I also agree with her in regards to advocacy being at the religious and local community leader level.
Jonathan brings up an excellent point regarding postpartum depression. It plays a huge role in maternal morbidity, and unfortunately mortality. We must include mental health in our education and address it just like it were (and is) any other disease. Mental health diseases continue to be highly stigmatized and remains a silent killer worldwide. Creating a platform that allows for normalization of these discussions regarding postpartum depression and mental health at large is crucial.

[Rebecca Schmitt]

QUESTION 1: In my perspective, the largest remaining barriers against worldwide HIV control are 1) STIGMA and 2) LATE DIAGNOSIS. This is particularly relevant for individuals who are infected due to sexual behavior and injection drug use. As the article had outlined, infection control by means of MTCT and blood transfusions are most attainable and realistic since there are prevention methods currently available, very effective and modes of transmission are within a medical setting. However, control over transmission via sexual behavior and injection drug use are challenging for multiple reasons, including being highly stigmatized and that the disease may not be recognized until the patient is far along in their course, when infection and malignancy arise. Focus on ART therapy, PreP, consistent condom use, needle and syringe programs and VMMC need to become more available and easily accessible to control the HIV epidemic.

QUESTION 2: Given that 90% of children infected with HIV are from MTCT, the focus on reversing this status of pediatric lags behind adults need to be continued targeting of reduction in MTCT. The fact that one in five women are either not being tested for HIV or are not started on ART during pregnancy shows that there is still much work to be done. If the diagnosis and treatment are not done early, infant and child mortality increases exponentially compared to adults. Point-of-care testing coupled with birth testing will significantly improve time to treatment initiation and reduce early morbidity and mortality. As outlined in the article, it is particularly important for the pediatric population to not only have the diagnosis and treatment of HIV made early, but also to have a comprehensive package of interventions including nutrition, psychosocial support, child development and social protection in order to thrive.

I agree with Alice in that one of the likely contributing factors of men having lags in HIV control are due to the fact that men tend to concentrate more on their jobs and are less interested than women in their health and other’s health.
I strongly agree with Jeanne in that adolescents are notoriously difficult to manage (not only for HIV, but multiple medical problems) due to their sense of invincibility, not appropriately getting screened and not taking medications as prescribed in order to keep their medical problems appropriately managed
Sirene brings up a sobering point in that if healthcare officials also have stigmatization of HIV, there will be less money they may put into research and treatment of HIV.

[Rebecca Schmitt]

QUESTION 1 ANSWER: People living in poverty are more likely to suffer from TB for a multitude of reasons, including but not limited to poor living conditions, lack of proper education and resources, poor general health and limited access to appropriate health care. As outlined in the article, these issues compound on each other and trigger a downward spiral. People get trapped in the cycle of living in poverty which increases chances of getting ill which therefore increases chances of living in more poverty. Acquiring other illnesses that disproportionately affect those who live in poverty, such as HIV, will also greatly increase one’s chances of developing complications of TB. In order to control the disease, joint efforts must be made to address all these risk factors. This is a huge feat that will need the appropriate policies and programs in place. Unfortunately, the political corruption in so many developing countries (and developed countries for that matter…) have greatly hindered the ability to reign in and control this horrific disease. As is quite evident, there are astronomic differences in terms of morbidity and mortality of the disease depending on which socioeconomic group you fall into in society.
I agree with Chering in that migration to the cities for work also significantly increases risk factors that play into TB transmission and that this migration also puts people at higher risk of alcoholism, smoking and promiscuity. In addition, Jeanne brings up a good point that impoverished communities have higher rates of MDR TB due to poor compliance.

QUESTION 2 ANSWER: In my opinion, the two interventions that would be most effective against NTDs are:
1) Educating political leaders and organizations about global NTDs, with a particular emphasis on the NTDs that affect their own people. With this education and understanding, the hopes are that that they will utilize this information to create the policies necessary and to funnel the appropriate funds needed to combat these NTDs.
2) Working closely with communities to create standardized policies for the diagnosis, treatment and prevention/control of NTDs that are tailored to that given community. As Chering stated, the community itself should be the big drivers in creation of these policies, with expert input. This gives the community the autonomy they want and deserve and will help assure sustainability over time. I loved the example she gave about her own NGO that noted the trends of hepatitis B patients coming from a particular region, and then taking the step of speaking with the CMO of that region, which brought forth the surveillance necessary. That is such an inspiring story and one that should be emulated

[Author]

Posts