 Good afternoon. I want to welcome you out to today's session of the McLean Center 29th Annual Interdisciplinary Faculty Seminar Series. My name is Eric Whitaker and the topic for this year, as you all know, we've been to sessions as health disparities, local, national and global. This event, in addition to being sponsored by the McLean Center, is co-sponsored by the Urban Health Initiative, which I lead. The Global Health Initiative led by Dr. Fumio La Potti and the Robert Johnson Foundation Finding Answers Disparities Research for Change, led by Dr. Marshall Chan. I get to be Mark Siegler for just a moment and want to advise you at the conclusion of Dr. Greer's remarks. We have this microphone which is for recording that amplification. I get the pleasure of introducing a good friend, Dr. Pedro Jose Joe Greer, also known as Dr. Joe. His official title is Assistant Dean of Academic Affairs at Florida International University, where he's leading the effort to transform medical education with this relatively new medical school. At FIU, he's aiming to develop highly skilled, ethical, culturally competent physicians who are socially accountable to their communities. He can talk to U.S. President as he's counsel at the last three, as well as the homeless man in his clinic. So he has a very common touch. Dr. Joe's work on health care homelessness and poverty has earned him the MacArthur Fellows Award. And just a year ago, he was granted the Presidential Medal of Freedom by President Barack Obama, which as you know is America's highest civilian honor. I give you Dr. Greer, who is one of America's medicines crew changes. Thank you. Eric, thank you very much. I actually have, I'm wired here, as they say. I'm, first of all, I want to thank you all for the snow. I mean, I'm a Cuban Irish. That's my background, so you want minorities and disparities. The question is, has American medical education kept up with the needs of America's health? I think this would be probably the shortest lecture in the world and I could just turn around and say no. And that's the end of my talk. But actually, what I wanted to do today was to present to you the reason why we need to change the whole direction of medical education, equally as important because we are celebrating the 100th anniversary of the Fleckner Report or the Carnegie Report, which was in itself an inherently racist and sexist report. So the state of Florida's 50th in uninsured adults, 49th in uninsured children. Miami Dade County, which is the county of that houses the Miami Heat, the Marlins, and the Dolphins, has one of the highest uninsured rates in the country. In 2002, we had 26% of our population was uninsured, whereas in the rest of the United States it was only 18%. Infant mortality industrialized nations, we rank last. Life expectancy from birth of industrialized nations, we rank last. Where is it that we turn around and say what is our responsibility as medical educators to turn the system around to produce what we need? We have simply become a country, like myself. I did internal medicine, chief medical resident, hepatology, gastroenterology. I was trained in one organ. But I get paid 10 times more than the person that's trained to take care of the entire body, which makes no sense to me whatsoever. So what have we become? We become a nation that won't let you die, but allows you to go back out and suffer. We've been so concentrated on what we do and we base ourselves out of hospitals that were the real causes of disease. We're not addressing. We're addressing the consequences of these diseases. You want to go for it? Do whatever you need to do. So because of that, we continue to train the way we do. Medical schools in this country have become battleships and swimming pools were very difficult to change direction, but we add things on regardless of the suggestions from the double AMC, the Institute of Medicine going back six years when the Institute of Medicine recommended in one of their brief reports that social sciences and community based education be integrated into medical education for all four years of a student's education. Ethics, cultural competency, the ability to work in teams, things that our profession has had a problem with. Ethics. I'm in from South Florida. We rank number one in the country in Medicare fraud. We're good. We are. We bring those prices twice as high as anybody else and they make millions and that's because now there's no mortgage fraud. So that's the only thing that was left. So we maintain it that way. The ethics in the profession, I've been bouncing between academics and private practice. Let me tell you from where I come from in South Florida, there's some huge ethical issues that deal with whether it is the conflict of how they make the money, how they bill, how they take care of patients. In today's modern world, we teach our students that you're not allowed to abandon a patient. This has all been sort of played around with that you have different HMOs and different panels. But now we have an economic downfall. Patients lose their insurance because of their employment. Physicians where I come from refuse to see them unless they pay. That is not only an ethical and immoral issue, but I would even go as far as to say it has to be a legal issue and one that we need to address seriously within our profession and to educate our students not to do that. Why? Because it's just wrong and we need to be the examples that show the students how we do this. You want my code? 1428. You can break in anytime you want. It's also my home address. So anybody can figure it out. I mean, I'm like a real bad techie, folks, okay? It's called the keynote. And so as we try and educate our students, we're sitting there saying well what are we doing wrong? Where has it fallen? When it comes down to the table to sit down and develop what we're doing, I bring in a lot of money as a gastroenterologist and hepatologist. Okay. Okay, done. What do I touch? Okay. That was the no. That was the conclusion of my talk. Where are we? Okay. The consequences of the problem from Florida and the American perspective. These were the statistics I was giving you about the uninsured and okay, nobody touch anything else, all right? This is a ranking we were going through life expectancy. Oh yes, I almost forgot the Rick Scott thing. Capacity. That's something that we as medical educators and in the medical education can control. There's a huge capacity issue. If we are to treat the entire population of this country, we don't have the physicians to do it. We haven't developed the new medical schools that are needed from 1960 to 1980. We almost double the output of medical students or physicians. Then we stopped. Then we made everybody a specialist. So what ended up happening? Well, in the state of Florida in 2008, every other year, allopathic physicians have to be licensed yearly, osteopathic physicians. And these were the statistics that came out from the state of Florida. There's over 51,000 MDs in the state of Florida and almost 5,000 DOs. 77% are males, 78% are white non-Hispanic males. Only one third are between the ages of 25 and 45. 13 will greatly reduce or leave their practice of medicine in the next five years. 60% of all practicing OBs do not deliver children anymore. 14% said they will quit doing it in two years. And the average age of a male MDs in the in the state of Florida is 52 and women is 48. There's no way we can handle the capacity and the flow of patients that are going to be coming in. The number of patients of physicians in the state of Florida that are reducing taking Medicare and forget Medicaid. We are one of the worst states in the country in Medicaid reimbursement. We're at about 59%. So we even have a lawsuit going on right now by pediatric cardiologists against the state to be able to take care of these patients. All of these things are going to just be set on the back burner as our new legislative group got elected. I come from a very interesting state. Only in my state can we elect a senator who in Spanish will tell you why the Arizona immigration laws are too soft and why we should be an English only country in Spanish and he gets elected. Okay that is the state I come from. A state which is a majority minorities yet we're not represented anywhere near that in our profession. Less than 6% of physicians in the state of Florida are Hispanic. They're all in Miami. There's two in Orlando and about a little over 5% are African Americans. We're from the south where we have probably the largest population of minorities yet we are not represented in our schools and in the professions that we have. So what do we decide to do about it? Well first we have to address what are the hidden agendas in medical education today. Let's be very frank. The statistics show it. We don't have to say it's not there it is. Number one underrepresented minorities. Okay we're not very well represented especially the Cuban Irish group. It makes you cubish. That's one poor small Catholic island corrupt to another one. The less than 15% of students in American medical schools are from underrepresented minorities. Less than 7 and a half percent of medical faculties. The medical students and this is the breakdown 6.4 in the United States or African American Hispanics or 6.4 American Indians, Alaskan Hawaiian and other Pacific Islanders less than 1%. In the year 2000 the American Association of Medical Colleges had a goal of 3,000 underrepresented minorities. Eric said it perfectly. They got the numbers wrong. Their goal was by 3,000 to have 2,000 because in 2007 we didn't quite meet that number. The other hidden agenda in medical education, primary care. One of the young faculty members I just recently hired who happened to have graduated at number two in her class at Brown, Afro Caribbean woman who wanted to go into family medicine told me how she was called into her dean's office and sat down and told your number two in your class you're way too smart. Why do you want to go into family medicine? When you rotate in the hospitals and you're doing a primary care rotation the frustration of primary care doctors because of the inequities in pay distribution or even the ability to sit at the table and make decisions will discourage students from going into primary care. So we ourselves that do primary care which I have despecialized we're discouraging our own students from going into what is mostly needed in this country. We also need if we're going to properly do this is define exactly what is the role of a primary care doctor in American society today. To what extent do they go to when do they refer to when do they not refer and we need to train this and do this but we need to do it in a way that it's emphasized where it's not the neurosurgeon that's the only king or queen of the medical faculty but the primary care doctor that's doing the yeoman's work that's turning around that needs to have this emphasized because why did I go into hepatology? Well for a couple reasons because we as Cubans had twice the incidence of a paddle cellular carcinoma turned out to be hepatitis C and because the doctor Eugene Schiff because he was like the happiest doctor I ever met in my life so it must be livers and he also taught us that an alcoholic was anybody who drank more than a hepatologist. We have insufficient numbers of primary care, maldistribution of physician throughout the country, complete lack of representation from the underrepresented minorities in our communities and we as medical educators and as institutions are accountable for what we produce and put out in this country and the country then has the consequences of what we do. I can go through all the different things from the Leapy Institute out of Harvard, from the Macy Foundation, the Carnegie Institute, all the different meetings and organizations the New Horizons Conference which brought in all the medical schools, the ABIM Foundation Forum, the Institute of Medicine report on enhancing the behavior and social science content of medical curricula in the year 2004 that's been sitting on the cells for a while and Butler out of Baylor said in 91 academic medicine has entered a new and stormy season of accountability and social responsibility due to the public concerns about the overall health care system. When the reality is and this was said by one of the and I forgot his name he was the Minister of Health and Welfare in Canada, if you really want to reform the health outcomes of a country the health care system is nothing more than a bit player. It is the social determinants that is the social policies that are the public policies but we become the agents that see these issues and have to turn around and fight for the legislative appropriateness of what has passed. Obligations arrive implicitly from the generous public funding and other benefits medical schools receive. Schools primary obligation is to improve the nation's health. The obligation is carried out most directly by educating the next generation of physicians, biomedical scientists in a manner that instills appropriate professional attitudes, values and skills. There is no medical school in this country that is not heavily funded by the tax dollar and as such because we are we have an obligation to those that are paying for us to maintain these buildings and our educational system going and that obligation that responsibility is the health outcomes of this nation and we're not meeting them. We're not even getting close we're actually getting worse. All medical schools have the obligation to educate future physicians who are prepared to assess and to meet the health care needs of the public that was the Macy Foundation 2009. The head of the Macy Foundation who used to be one of these deans at the Harvard Medical School also made a very interesting quote when we met with him which he said American medical education has become a place where rich white kids go to become richer and statistic bear that out that the majority of medical students do come from affluent families. Having said that you know my kids have the benefit of private education of course my daughter chose public interest law so I could support her the rest of my life that's I thought that was really nice of her but we're there this obligation consists that all medical students retain their enthusiasm for medicine and commitment to societal mission. You guys got to keep the students pumped up and fired up you have to be enthusiastic the mission is too big it is the responsibility of life and the health outcomes of this country. It's not just the political battles we fight within our own institutions. I'm Catholic too so I know about all these politics but it's how we turn around and portray this to the students what can they do where can they go what difference can they make to improve the health of this nation. The educational experiences which we'll go through later providing a physician workforce drawn from all sectors of American society educate medical students who are prepared to choose careers as generalists and specialists in adequate numbers and distributed appropriately foster greater interprofessional teamwork. Why is that I don't know when I was an intern we used to round with the entire team social worker nurses pharmacist we don't do that anymore we sometimes call them in on consultation most of us get out of medical school without even knowing the real functions of our professional colleagues that help us out when we need their help why are we not integrating that into the medical education undergraduate and graduate medical education so we added on a new competency a c has six patient care medical knowledge interpersonal communication skills professionalism system based practice practice based learning and improvement and at our school we added social accountability as one of the major competencies we expect our students to graduate with and we grade them heavily on both professionalism and social accountability we're teaching them that this is not a game they chose to come into medical school this is the responsibility they have unprofessional behavior is unacceptable and reason for failure and the same with social accountability why because that's the role that we have been given and that's who we have to train our patients for our physicians for our social bishops to improve the quality of life of individuals households and community while educating men and women in medicine nancy canter at syracuse said i want to make this the case that civic engagement is not one more thing on the plate it is the plate it is the community it is the country it is everybody that lives within our borders that we are responsible for the reality is we should be responsible for the whole world as physicians but let's start off at home and work our way and get this done it's not like we don't have to clean house so what we did at the herbert worthine college of medicine was we decided to have five major thematic strands throughout the four years of medical education human biology disease illness and injury clinical medicine professional development and medicine society which is the strand i'm in charge of when we were first hired and putting together this medical school one of the things that i sat down with the dean was it's very difficult to hire faculty to become a member of a strand i actually remember the very first time i sat down with john rock the dean when we came in he said as opposed to strands they were calling them themes he hadn't quite explained this concept to me yet and he brings me in his office says we want you to be a theme director thinking what is it like mexican night italian night what's the theme and then we said then i went through this and this makes perfect sense because we divide our medical school not into four years but four periods with different time periods for the first second third and fourth we do organs based system of learning when we teach and we also have something else that we did was the department that we created to be able to fully do this medicine society and so i sat down with them and we developed the department of humanities health and society three divisions within this department which consists of medicine society which is the curricular arm community engagement and policy which is the community arm and family medicine we took family medicine from being a department and we made a division now somebody says if you're so hard so you're pushing so hard for primary care and generalists why would you take a department and make it a division very few places in this country does family medicine have a big chair at the table so what happened because of the hidden agenda they're pushed back their salaries are low and you have a problem students get their six weeks of family medicine family patricians are frustrated the students don't get the exposure they need so by making family medicine a division it now became a four-year clerkship so all students will have as their mentor because just for academics we are hiring one family or primary care doctor for every 10 students as mentors to educate these students we also have a thing called panther communities because we're the florida international university panthers so we have four panther communities we're now beginning to integrate them with the different classes we only had one and they are responsible for community and civic activities which they do as volunteers all that is integrated also into the communities where they will be working so the students are fully engaged fully immersed and trained and mentored by family practitioners now it also becomes important that as you hire your faculty you represent what you need two of our three chiefs in my department are social scientists they're not mds i have a virus martinis who we hired from hopkins who's an anthropologist and in public health and she's in charge of the curricular arm why is that because it's social sciences we're teaching not the family medicine part and lou bruster who just came back from europe as the marshal uh fellow for two months he was out there who trained under marmont in england who's our community engagement chief 50 percent of my faculty is women 67 percent or underrepresented minorities the interesting thing with all this this composition was not made by design but by application we sat there and these were the individuals that were interested in leading this with over half of them being ivy league graduates david brown who is the head of family medicine who's brilliant i was so glad he applied because i told david i did i need like one white jewish guy because i really don't have the diversity i need who's come in and he has been just phenomenal with family medicine turned it around but as far as recruiting under represented minorities you really need people that look like us or talk like us or have similar backgrounds to make somebody feel comfortable in an environment it also becomes vitally important as we try to develop more physicians for south florida because we're a public university as we're in the communities that kids from these neighborhoods who have probably never seen a college student or much less a graduate student actually see those that come from the same background that they do so showing them that wow this is all achievable this is not something we cannot do and as such then we can start getting to the goals that we have designed for ourselves the green family foundation you donate a lot of money you get your name big letters who gave us eight million dollars to start our department and do what we're doing which is supposed to be matched by the state but the state tells us they have no money this is our signature program in medicine society and it is the flagship of what we do at our medical school we're going to expose our medical nursing social work and other fi u students of social determinants of disease and health and provide services to medically underserved communities by harnessing fi u educational resources through our urban coalition medicine side this is the curricular arm of the four periods we start off with the ethical foundations and moral justifications of medicine we expect our students not to become ethicists but to become critical thinkers to be able to at least predict some of the ethical conflicts that come across and some of the moral issues that they come across on a daily basis apart from that we want to take it a step further which policy is unethical which policy has adverse effects on the outcome of a nation as a gastroenterologist the american college of gastroenterology three years ago because of the disparities in health care and because of a 25 higher rate of colorectal cancer in african-americans is that me uh and a 45 higher mortality rate set changed our screening protocols which were african-americans were to be screened at the age of 45 without any risk factors the rest of the population at the age of 50 unless you had risk factors the ethical dilemma that i present to the students is once we came out with this information we presented a digestive disease week at the american college of gastroenterology meetings we published it in our journals and that was it you discover something that's killing people at higher rates than it should isn't your obligation to go a little bit further than your own scientific community would have not been appropriate for gastroenterologists in mass or perhaps the whole medical profession in mass to turn around and say if the issue is that they're not being screened because coverage or capacity we have to stand up and make sure legislation is changed so that they are covered and the people are there that are trained to be able to do these type of procedures to prevent a disease that is killing a population which we have seen through colonoscopies and screening we've gone from number two as the number number two killer of cancer in this country to number three so yes it does work but still with the disparities in health care we've completely eliminated an entire population and in the south one that is at extremely high risk for being uninsured and that's african americans in the southeastern united states so yeah ethically we failed within my specialty because it's not good enough to make a discovery of your scientist it's only good enough when you take that discovery that can help people and save their lives and make sure it gets implemented those are the ethical questions we want them to go through not just patient physician interactions life and death things of that nature it's important that they understand all of these we can talk to them about double jeopardy we can talk to them about all the different thing in ethics but if people are dying when they shouldn't be there's an ethical and a moral issue involved especially since that's the profession we decided to be from there we go into the socio economic and cultural aspects of medicine we're in miami folks you name a culture we have it you name anything we have it and what the students need to understand that as we go uh speaking with them and they're talking to their patients about end-of-life issues and they start talking about procurement of organs for possible transplantation well there's certain cultures in miami that that's just one of the greatest taboos for example within the Haitian culture so that is not an issue you bring up to a family member that is dying or to family members of a patient that is dying in a culture that considers this taboo unless you've discussed with this at length the Hispanic culture we like to say Hispanics well let me tell you something there's a big difference between a Guatemalan and an Argentinian and there's a big difference between a Chilean and a Colombian a big difference between a Cuban and probably anything else we've been sort of isolated and there's many things we have in common we have language we don't have food in common different cultural aspects we have very different and it also depends on what generation you're in this country if you're second generation or third generation is very different than the recent immigrants these are day and night issues and unless you understand these cultural issues you're not going to get anywhere interprofessional approaches and i'll go into how we did that we actually have joint classes with nurses social worker and public health students we also have the law school involved and we're getting the hospitality school involved maybe we can teach how to be hospitable it will really improve in the history when the patient feels comfortable and they'll be able to tell you exactly what they feel and guess what you can make a better diagnosis and probably quicker the foundations of community and team partnerships and then from here we're in the second period which is generally in march is when we start communities culture and health is when these students are then assigned households in the poorest communities in day county and they're responsible for the health outcomes of these of these households until they graduate and then the families will graduate with the students because we expect not just the students out there teaching health issues or disease prevention issues but these families to teach our students what are the realities here this is not a clinic they're going into the households they're sitting there they're seeing the environment where patients live they're seeing the realities that they have every single day they're seeing the difficulties that it might be in getting their 70-year-old patient in a household that's cluttered with boxes and steps that walks around and has a the exposure to fractures and falls which they might not have realized if they weren't there the fact that there's a two-year-old and they're putting the medicines for the rest of the family on a table that sits tall and the exposure to that child they're looking into these neighborhoods they're looking at their diets because we have nutrition to which is not part of the actual teaching but they come in and do assessments of the households to try and teach them how to eat properly based upon their cultural preferences you could go into Miami and say just read the labels well our educational system is not that good in day county so if you went through the day county public school system chances are you're not going to read it that's number one number two the very impoverished and particularly the immigrant communities that we have in day county they buy things instead of buying a bottle of oil they'll come in with a cup and they'll fill the cup with oil there's no labels they can't afford a pack of cigarettes so they'll buy one or two they get a lot of products from Latin America and we also find out they get a lot of their medications and health advice from Latin America or the Caribbean because they can't afford to go to anything here we've come across diabetics that have had their medications but haven't seen a doctor in eight years nine years so we want to make sure that they're getting the best care possible as we try to assure all people in this country they continue through this here in the fourth period where they have electives and selectives in the they and part of the third period here they also have an official family medicine clerkship starting in day one they're assigned to different community clinics with different mentors that they go through here for every household visit we actually have a faculty member at the household visit which is either medicine nursing social work or public health and why do we do that they've just started and so while we're in there with the students we're guiding them along we meet with the students before we have the household visit we meet afterwards they have to put plans together they have to be able to tie these patients into the different systems they'll find out that their patient that's 62 years old although has Medicaid has never had screening tests that they needed they go through these lists they teach them how to eat how to take their medications at the level before they get to a clinic and be referred to where they need to go to and all of these components we do in the classroom both formal and we have community classrooms where we actually take the students and we'll give them a formal lecture in a community-based organization outside of the actual school of medicine the workshops that we put together the health science pipeline program which the students are very active in the community health centers educational programs and all the other community-based service organizations the household visits and then the service learning projects and the capstone which they percent in their fourth year which they have to present a project that they've put together to improve the health outcome of a household or an entire community it doesn't have to be huge it has to be innovative it has to be well thought out and as of right now the students have come forward and two of the students very interestingly have come forward and they've created a clinic in Little Haiti with the mass number of patients that we've received after the earthquake in Haiti and with no care that they have there because they were going to a community-based organization and they noticed this in particularly in the pediatric population they came forward to us to do that so that's what they're doing and we're working very closely with public health as a matter of fact they're letting us their facilities to be able to do this throughout the four years of undergraduate medical education students will address ethical and potential ethical issues social cultural and non biological issues and their clinical presentations in other words every single case that they have no matter what organ system they're rotating through reproductive digestive etc we will have as their presentations questions on ethics questions on social determinants questions on all the non-biologic causes how can affect it what can be done we have to have our students thinking in this wide manner to be able to truly address the problems and particularly of the underrepresented minorities and what they're suffering in the communities of day county when we put together the curriculum this was a job try and get the school of nursing the school of public health to change their curriculums to match yours try and get all these done especially as i found out that since we decided to be the non-union college of the university that worked out really easily with the union faculty from the other universities and getting all these things working together getting them to have approved by their respective accrediting agencies to be able to do this and of course nobody has money the reality is you could do this with very little money it's a matter of changing curriculum adjusting here and adjusting there and the truth is we share when we get it we're not a big revenue winner yet the programs that we're doing are purely educational but as a gastroenterologist and running the clinical gastroenterology at the university one of the deals i made was i get a percentage of those revenues for my department and my department's also going to be the ones that are going to be doing the primary care for the university eventually so there's we can be innovative money can be shared how do we teach we teach with faculty students and community all together and we try never to separate it the hardest thing we found out was as we hired a lot of our faculty getting them to understand the importance of what we're doing it to integrate it and just understand it as they go through what they're teaching the basic sciences are important i don't think they're as important as the basic scientists think they are i think the clinical scientists are more important sorry basic scientists i did study physics as an undergrad so i can tell you why an apple falls but uh if you're producing this type of physician it's important to put the emphasis where you need to train your doctors the ones that want to go into basic science research they need to be emphasized in that area our characteristic of engagement in the community is intentional impactful synergistic we align research learning and service to solve local state national problems and long-term and sustainable this is not episodic if we go into a neighborhood we're staying the idea is not to go in which is the tradition that we've had at least in south florida the university comes in does a study says it can do this and then leaves nobody responds to that study but if you respond to the community and you try and do as much as you can to be true community participatory research the results become huge lou bruster who's a the chief here put this together we identify community assets we identify service opportunities we create community participation vehicles we provide service and we value community trust it really comes down to being that simple the going into a community and earning the trust of that community we go into a community now the difference we're going in we set ourselves up two and a half years prior to bringing our students in there we develop the community advisory team well this is what we hope to do is educate our future physicians while providing service to communities learning opportunities to expose our students to the non-biological factors that influence health and disease and community engagement and learning from the community not just teaching a community this is how we do it i'm going to go a little quicker since i'm running out of time here these are our learning objectives this is what we hope to do to educate our students to form interprofessional intercultural collaborative partnerships to improve the health of patients households and communities integrate students into medically underserved communities to develop social accountability and increase social capital in these communities we explained to these students that they were a white coat they go into a community that has rarely seen a white coat they join that community board they've they're offering social capital they're making an important impact just by doing that whether they're students or physicians transform medical education to meet the needs of patients communities in society based on the acgme general competencies and adding to the other competencies social accountability which by the way the canadian medical schools have done for years and this is not done on south of their border but it surely is north of it and the last one is we expect our students to save the world and we tell them that at the beginning set your goals high tell them the importance of what they're doing because it is it is that important and you then give them the tools to go out and make the world better we coordinate this all those in households neighborhood health centers hospitals community centers as I had said earlier the household visits I already went through the organizations that we we build the the community advisory teams are phenomenal when we did our benchmark survey we sat down with them what are the questions you want to have which was very interesting because we had our staunch old basic scientists there that sat there and our research and IRRB's and I remember one meeting one of one of our most prominent faculty members a world-renowned scientist was shocked that we would suggest that as we were reviewing the data the community participatory with the community participatory research we would have the community at the table and I just remember him looking and saying well what do they take our data and I'm thinking what are they going to sell it for what are you going to do with data if you're in a community what are you going to do sit in the corner say you want some crack no I got data you want data what else you need I got it this is Miami it's not the season I got lobsters you want lobsters the truth is when you involve the community they turn around right away one of our community advisory team members who lost her job became one of our surveyors who stood up as we brought the president of the university and the dean to meet the surveyors so the surveyors could tell them what they were doing turned around and said now our school is a is a big university we're 45,000 students undergraduate and graduate so for the president of the university to be fully committed in this program is a huge huge issue it's from the top on down and I remember her sitting there saying I don't know why I got to go into a household with a stack of papers and sit for two hours asking questions until about the second or third week when I realized that everybody said yes to fruits and vegetables looked a lot better than everybody else so now I just eat fruits and vegetables now how long has she known this forever but unless somebody sees something they're not going to do it and she also talked about the household that she went into where the mother was kind enough to spend almost two hours with her in the survey while her 29 year old daughter died it was dying of cervical cancer in the back bedroom where then she realized the importance of primary care and visits to a physician for screening it's these stark realities that make it work one of our community advisory team members came to us as we're putting together the data and wanted to know if she could with her pastor at their church and their six thousand strong this information needs to be in the community and this information needs to be distributed by the leaders of the study which happened to be not just the medical school but the community advisory team they are equal in the leadership and the study here so when they percent that it has a much bigger impact than when Joe Greer goes into a community that I've been in there maybe 10 times in my life or 20 times whereas somebody lives there and they know the commitment that they have as we have a data coordinating center where we collected a population study and this is what we did for our first benchmark we went in we got the demographics be our health behaviors social capital access to health care social services chronic disease management now what you're going to be seeing here we went into four different communities and within this community is a very diverse population it's about 65 percent african-american about 25 percent Hispanic and about 10 percent combination of of anything we have in the city of miami gardens in opalaca this is famously known in day county as a triangle it's one of the most violent areas of day county and we chose the hardest hit area of day county because we're going to make an impact we have to make an impact in somewhere that counts security issues we're at hand and all that and we resolved all those things we actually go and work with the community and we have a police officer that goes around the neighborhoods when the students are there and we have a faculty member with the students when they're in the households we did a benchmark survey on 29,000 households in miami gardens 3000 in opalaca 14,000 in northwest unincorporated date and there's a small quadrant which is known as the jewish northeast quadrant which houses 3,800 holocaust survivors now the the the interesting thing of this the great majority of them are foreign born obviously that are there but the foreign and that's a typo there it's they have come recently from a foreign country all our holocaust survivors are foreign born and the majority are actually coming from land america and the soviet union so we have a large population with a whole nother language and other cultures involved the irony behind that is in the city of opalaca there's a place called bunch park bunch park is where african american world war two veterans were designated to live after the war so you have individuals that fought for the freedom of those that were being suppressed and brought back to this country in some of the most racist manners you can imagine right after world war two even if you look at the houses in bunch park they're flat roofed houses this is south florida this is the tropics you do not have a flat roofed house not with the rains and not with the heat it just doesn't work but this is where we put this population so the students are having families and get to interchange the stories and we bring them to give lectures to the students on two very interesting issues that will not be around very long but oral histories that the students have to understand that history does not change that much racism continues to exist there will be different other massacres and holocausts in the world and these are the type of things because of the profession they're going into and the leadership positions that they will be in they have to guard against and fight against and when they go into communities maybe they can help prevent a lot of these different things so what we're trying to teach the students is just to be really the best physicians possible not just the brightest but the best the best physicians that will turn around and make the outcomes of this country where we don't sit last in infant mortality but we sit first we have a great pride because we're number one in what we're doing not because we're number one in infant mortality as far as just that's concerned but in life expectancies in opportunities for all in making this country what it's supposed to be this is what america's supposed to be about apparently the other professions aren't picking up the the slack here so it's pretty much fallen on our shoulders and why is that because no matter what the social problem is it comes to our emergency room these have been some of the issues that we've had to deal with legal liability issues safety of team members interdisciplinary team management trying to coordinate three students from three different colleges faculty in a family when they can meet with everybody scheduled we've had to hire two people just for that after the first visit it becomes very easy because at that visit they all schedule their subsequent visits training for the team visits how do you train individuals to go into a household this is not a clinic visit this is somebody's home the students are asking well can i do a physical exam no you can not well why not because we generally don't do physical exams in the dining room and we don't do them on the couch what if they need their blood pressure check we'll ask them if they do you could do that if they're hypertensive or they have new medications and you can do that as you go along in your visits manage household and community expectations be honest with the communities let them know what we can offer and what can come back if we're honest it actually works faculty development and the last one i put on there which is bootcamp for faculty we're developing a three-day course on the importance of social sciences and social determinants and ethics and the teaching of medicine for all our new faculty that way they have a full understanding of what the flagship of the university is like and we're not isolated into our little silos of why it's so important to learn about all hepatocellular dysfunctions but the fact is that because of obesity in america today as hepatologists we predict down down alcoholics data hepatitis nash will be the number one cause of cirrhosis in this country the next five or ten years insulin resistance of the liver is the number one reason that you have the huge disparities and outcomes with hepatitis c in treatment with interferon and ribovirin we're in a white population you have a 54 sustained viral response in african-american populations less than 20 and hispanic populations less than 25 percent so yeah social determinants do count a lot because if we can control these things a we could probably prevent the spread of disease and b we can prevent the the progression of the disease by having a sustained viral response to the virus and hepatitis c is the number one killer of hiv patients or it wasn't a recent study i read on the east coast of the united states this is the very first time we had all the students come together to make their presentations divided in four this is dr mark rozenberg he is the president of fiu he is not only present at these conferences with the students and listens in which was a big hassle too because as the students are presenting cases our attorney was going crazy with the HIPAA regulations i said you know he's a latin-american expert i don't think he really understands all the disease entities we're talking about but that's how engaged he is there's our faculty members and our students and that's our first class that we have and so the real question is what now what do we do it's about medical education we have to relook at admissions criteria the metrics that we use to admit students if m cats correlate wonderfully with us lme part one and we're thinking about getting rid of part one why the hell do we need the m cuts just a question just sort of curious what are the other criterias we're looking for to develop good physicians what type of medical school should be doing what we're doing and which are the ones that should be doing pure basic sciences and research or should there be a combination our general our graduate medical education that has to change too we are one of the hospitals in miami we work with an offer profit office their hospital for our family medicine residency i said that's wrong this is to be an outpatient residency it's primary care they do need to rotate through hospitals but these programs need to be based where we're going to be training our physician when i got done training at jackson memorial hospital which was the busiest public hospital in the country and i was done with my internal medicine in chief residency i could take care of you only if you were dying if you had a cold i had to look it up you know if your respiratory rate was less than your pulse you were a wimp you're not at the er okay so that's what happens when we're trained in these environments and you see these things exciting it's fun you're involved in it but it only takes care of the problem at the end it doesn't prevent the illness service to our nations as physicians you know what i'd love to see i'd love to see required for all medical school graduates after one year of training one to two years of service and under under uh served areas this area this is a ghost for everybody not just loan payback this is every physician the more under served area you go to the more points you get that way when you apply for your residency that goes along with your board scores and your letters of recommendation what a novel idea not only that what do you increase if we what how many medical school how many students do we graduate a year five thousand something of that nature four thousand so you already you've just increased your workforce in capacity by doing that number one you might get people actually interested in saving the world at that level and they stay and the other thing is if you have medical students already doing this and you have 18 to 20,000 medical students out there working in communities you have an extra four to 10,000 if they do two years in community serving this we're dealing with the capacity issue we're dealing with the disparities in health care and we're training physicians a better understand this country and represent us as we should NIH and medical school rankings and one of the quotes that i had there about the amount of funding that goes into a medical school and that and medical schools rank themselves by NIH funding then we have to get some really smart analyst to develop some sort of methodology that can actually measure the the contribution of medical school has to its community since the community is paying for it anyways and use that as one of the criterias for NIH funding boy will that change direction of education so just think if we can apply these different things the difference will make and the reality is it's not that huge of a change that we need to do the factors are all here in all the medical school it's a matter of and i say from the president to the deans to the chairs to the chiefs to all the faculty members to push this agenda and do it because if not you guys the health outcomes are just embarrassing and we're going to be sitting here lecturing on these things and martin's never going to finish his studies because the disparities will never end so my job is to get you out of a job okay so that way there are no disparities but that in conclusion is what we're doing with the new medical school we have in south florida some of the things we'd like to see in this country and i'd like to thank you all very much for inviting me here it's been quite an honor yes sir one of the two of the key metrics you had mentioned from the beginning and throughout is uh people going in primary care so providing the sort of care that that uh the americans need when they're not deathly ill and the second was being willing to serve in communities that are relatively medically underserved to what extent obviously this is a very unique medical school uh maybe not unique but not not not the median uh to what extent do you think you're going to achieve that by recruiting people who are already bent in that direction and kind of giving them a place where they can they can they can follow that track versus taking normal everyday average medical students and encouraging them to go into primary care that might have been here gone into gastroenterology that's assuming that your normal medical student doesn't have that interest i think that we need to do is instill that interest because you could still and i'm not saying we don't need gastroenterologist we need them we need ophthalmologist we need all the specialty cares because who you're going to refer these patients to but you can't have your gastroenterologist that will only take funded patients and not take medicaid or ryan white or unfunded you need your ophthalmologist that's willing to take care of the kids in these neighborhoods you need the pulmonologist that is taking care of all the asthma pediatric pulmonologist in the neighborhood that is being taken care of and if we distribute in essence the wealth as i would say if everybody did their little part we could resolve a lot of these issues but we got to get students back interested in primary care that means changing how we pay they should be paid a lot more than they are i mean i get paid for the amount of procedures i do there's nobody that buys a car because this is a company that makes the most of them so we're not being measured on how we perform just how often we perform so we need to change that too and that's a whole lot of matters that's a whole nother discussion a whole nother lecture but we do need to go in those directions because if not we're not going to stop rolling downhill it's wonderful that we can transplant a liver it's a lot more wonderful if we didn't have to so set your goals in those directions will the disease continue to happen yes imagine the amount of money we'll save if we cut liver transplantations by 50 percent and that money could be used for other areas of medicine and transplant surgeons could sleep a little more they'd be so much more pleasant but i mean it's yes it's skewed towards that type of student our numbers and applications increase every year we get over 4,500 applications and this is for 40 slots next year it's going to be 80 and i really believe that most people the overwhelming majority of those that go into medicine are truly altruistic because you're going to be going through a hell number of years without a social life you better have a commitment that you want to do something with that and i think that we can orient that there's no there's not there's never going to be a poor doctor in america there'll be a doctor that's poorer than some of the other doctors but we're all in the top five percent of american income that's pretty damn good so we just have to instill these and also in the admissions criteria we have to make sure we get the right students just because of the brightest student doesn't mean they're going to do the best for our society and if our society is paying for their education there's an obligation involved now if they decided to become pure basic scientists that make these wonderful discoveries let's go for it and continue that i'm not saying get rid of that i'm saying just change the orientation so that we could start producing the the majority of our doctors to go in this direction yes ma'am um thanks so much for this very interesting talk and from the perspective of academic medicine i think that we've got a lot of folks in the room who are interested in working on these ideas around innovation but i'd like to uh flip this a little bit and to talk a little bit about population health and specifically how you've been able to integrate the curriculum that you've developed into initiatives that may have developed through miami date county's department of public health and what what those relationships are like well we have a wonderful relationship with the department of public health as a matter of fact their new building is being built right next to the medical school on our campus so the department of public health will become part of our medical sciences complex so with their health initiatives and what they teach our students actually one of the things we're trying to do is get our students certified in public health for those that don't want to master's because the amount of public health we put in there but it's that the importance of their initiatives that the students have to understand so they get the better picture on how to take care of overall populations that's an essential part of the curriculum that's not an add-on that that's one of the bars that keeps it steady and that's how we do that and we forged these relationships before we sat down seriously and it was a fun year because we sat down with competencies who do we need to get involved who do we need to track down and this and that and it's nice to sit at a table when there's no money involved because everybody talks you know well it's true when there's money involved everybody talks about the money but when you talk about a creative idea forget the money and then say collectively we'll work on this together it's amazing how people will sit at the table you know it was sort of interesting because the anger that we got from the nursing school at the beginning you guys always treat us so badly we're trying not to we're trying to be treat everybody as equals and we apologize and this one but their dean just came around unbelievably to the point of adding new faculty members and changing their curriculum and making sure they stayed accredited as they did in public health now public health was very interesting because public health likes to do large populations but their epidemiologists like to do households so you had two different schools saying well why do we have to go to the households we'll survey the whole community and the other one saying no we want to go into the households so it was very interesting discussions that we went through with public health too and it's also the old barriers of academia we're tradition we're tradition based so you got to break down some of the traditions to form new ones not get rid of all of them but mold it it's a it's a new millennium it's a new time to do stuff and it's time for us to turn around as medical professionals and say this is what we need to do anybody else yes hey um so it's wondering how do you assess if the students are adequately meeting the professionalism and social accountability criteria and what types of interventions do you do for students who aren't meeting those criteria that's a very good point professional the professionalism is done by every faculty member in every class okay it is we have a strand that teaches us throughout the four years but they are measured by that by each single faculty member of which when their grades come out that's come out at the end of the period so no faculty member's name is there so the students know they have to be on their best that was a question also that we can change perhaps behavior but do we change values that's where you have to measure values when you do your admissions criteria when you do have a student that is having a problem with right away we intervene we sit down we counsel the student offer them recommendations and the next step is incomplete grade suspension or failure we take this very very seriously with our students and when they are told that from day one that this is being measured for the social accountability that's measured in their service learning projects and as well as their caps known what did you see and what are you doing about it are you just telling me that no i just referred them to a primary care doctor or one student that we had that was just a a wise ass at the beginning when one of the families had come down from new jersey been employed by a canning company for 12 years they opened up a canning company meldley florida which is right outside miami still in day county within six months they closed the plant down fired him the family's left unemployed unemployed now for two years with no insurance multiple medical problems the only ones employed right now in the family was the 18-year-old who was in finishing up high school and another one had a part-time job the two youngest kids had Medicaid the parents had nothing as a matter of fact the parents saved their money to go back to their home country which is the Dominican Republic for medical care and come back which is not the best way to do medical care this student's suggestion was they should move out of florida we thought that was neither funny nor appropriate so what happened with that student after he made a couple of those comments was very simple he was given an incomplete and was given a project that he had to work in one of the inner city schools and start a class on on reading because i was his interest he was an english major well the kid has actually turned around apologized that he thought he was funny thought he was making these comments and what we see with a lot of these things is that the students that i see today are twice as smart as i am but they're half as mature so the maturity levels out there they don't have the life experiences they walk around with you know cell phones they talk to mom and dad every single day you know they very few of them had to work their way through to get somewhere they're very bright but these are life lessons that need to be taught so they need to know because we know we suspect that they will have the right values so we orient their behaviors to be in the right direction they're going to be physicians they have to be team members and they have to be team leaders and they have to be leader for society and so that's how we intervene