Trans-Cultural Medicine:
Alaska’s Answer to Preparing
for Rural/Remote Practice and
Surviving the Wintertime Blues
STFM 43rd Annual Spring Conference
April 24-28, 2010
Vancouver B.C., Canada
Barbara Doty M.D., Ray Pastorino, PhD, JD,
Gina Senko, Manager, Faculty Support Services
Goals For This Presentation
Explore how Alaska’s Residency Program developed
curriculum designed specifically for bush Alaska
practice
Gain understanding how a midyear 1 month seminar
experience benefits resident morale
Identify specific components of Alaska’s TransCultural Medicine curriculum designed to promote
success in rural practice
The Setting
Alaska – population 698,000-Concentrated in Anchorage
 Landmass- 21/2 times size Texas, 4 time Zones 1% Glaciers
 Cultural diversity–Alaskan Native, Black, Military, Asian, Pacific

Islanders, Hispanic, 96 languages spoken in the ASD.

Remote villages/towns -No road access, 5th largest town <10,000
 Subsistence lifestyles-Trade Economy
 Challenging Arctic Environment- Darkness, Temp Extremes
 Resource Economy: Petroleum, Fishing, Timber, Tourism, Mining
I HAD NO CLUE…
Comments from the “Untrained”
“No one told me about colleagues’ personality
disorders.”
 “I didn’t know I’d have to do consults at the
PTA meetings.”
 “I did my training in “rural” Minnesota. Didn’t
know “rural” until I got to Kotzebue.”
 “Why didn’t they tell me about life with a pager
that won’t turn off!!”
 “My husband loves it now, but you should have
seen him the first three years!”

The Challenge:
To Train Family Physicians
who will THRIVE not just SURVIVE
in Bush Alaska Practice
 How
History of Alaska as FP Training Site

1993 to 1995 - Grass Roots Development of
Curriculum with Rural Alaska Physicians

1995 to 1997 - Partnership Development
Providence Hospital, U of Wash., Yukon
-Kuskoquim Health Corp. & Anchorage
Neighborhood Health Center

1997 - First Residency in Alaska Opens

2000 - First Class of 8 Graduates Placed

2006 - Class Expansion to 10 then 12 residents

2010 - 81 Graduates, majority practice in AK
Alaska Family Medicine
Residency
 50th
State to implement GME- Residency
 Rural Focus
 Unopposed program in Tertiary Hospital
 Collaboration with Alaska Native Medical
Center
 Dual accreditation DO and MD Residency
 12 residents per year
Curriculum Design for Alaskan
Practice
 Trans-Cultural




Medicine
1 month Seminar Mid-Dec to Mid-Jan
R1 and R3 Residents – No Call
Skills Development : Wilderness, Cultural, Behavioral,
Integrative, Nutrition;
Talking Circles/Sweats led by Native Elders
 Frequent/Recurrent



Rural Experiences
R1: ER 4 weeks
R2: Bethel/Dillingham 6 weeks
R3: Two 4 week Rural rotations in Alaska
Trans-Cultural Medicine (TCM)
Health Care Delivery Systems – local, regional
 Complimentary/Integrative Medicine
 Rural Practice and Lifestyle- skills, issues
 Community-based team practice
 Cultural Competencies- general and specific
 Ways of Knowing/Communicating

TCM Curricular Emphasis

Experiential Knowledge
 Resident/Team Collaboration
 Self-Directed Learning
 Progressive Levels of Understanding
 Vertical Mentoring-Senior Panels
 Educators from Within the Community
TCM - Specific Goals

Develop Respect and Sensitivity for Differing Belief Systems
and Cultures

Develop an Organized and Logical Approach to
Complementary/Alternative Practices

Experience first-hand the Physician as a Partner in the
Health of a Community (COPC)

Learn to Manage Progressive Levels of Cultural Complexity
to Bridge Mistrust and Promote Understanding

Gain Understanding of Personal Issues when in a Rural
Practice
TCM Daily Schedule
TIME
R1 CLASS
R3 CLASS
8:00-9:00am
CLINIC
Board Prep
9:30-10:30am
LECTURE
CLINIC
10:45-12:00pm
LECTURE
CLINIC
12:00-1:30pm Lunch/Admin Lunch/Admin
1:30-2:00pm
2:00-4:00pm
Cultural Focus Cultural Focus
LECTURE
LECTURE
TCM Curricular Components-I

Health Care Delivery System
– Rural, Alaska Native, Safety Net, Care of Underserved

Communication Techniques
– Motivational Interviewing, Gender Age and Generation

Cultural Knowledge
-Hmong, Pilipino, Alaska Native, Asian, Pacific Islander
-Alaska Cultural-Medicine: Historical Overview
-Talking Circle/Off-Site gatherings
-Native Health Care Delivery System Overview
-Use of Interpreters, Tribal Doctor/Pathfinder
-Alaska Community Treasure Hunt
TCM Components-II

Rural Medicine
– Veterinary medicine, dental emergencies, radio medicine,
acute stabilization and transport
– Alaska Epidemiology, Care at Altitude, Hyperbaric care

Integrative Medicine
– Mind/Body, Biofeedback, Naturopathy, Manual
therapies, Herbal Medicine
– Nutrition, Diet Types, Use of Supplements
– Spirituality

Wilderness Medicine
– Survival Techniques, Frostbite Prevention, Avalanche
Safety

International Service and Humanitarian
– Relief work, Care with Limited Resources, Locums
Practice, Foreign Adoption
Bush Alaska Preparation

Village Health Aide Radio Traffic
 Medicine at Altitude
 Locums Job Opportunities
 Nutrition/Use of Herbals
 Native American Talking Circle
 Motivational Interviewing
 International/Disaster Relief
 Behavioral Shadowing
The TCM Leadership Team

Interdisciplinary Team: Broad-based Skill Set
Behaviorist, Logistics Coordinator, Clinician

Includes Active Resident Participation (vital
to success) Program Pride

Flexible, Creative & Experimental
Rapid Implementation of New Resources

Adaptive to Class-Specific Resident Needs
Gender, Marital Status, Ethnicity

High Value placed on Relationship-Building
TCM Leadership Team Tasks

Timeline development - Calendar
 Logistics
 Speaker Database
 Nurturing Relationships
 Ongoing Evaluation
 Just-In-Time Modifications
Content Development

Year round input of new ideas
 Establishment and maintenance of an extended
teaching network
 Consideration of new ideas brought forth from
faculty & residents
 Consideration of learner feedback, course
objectives, budgetary constraints and curricular
balance before implementing new concepts
 Continuous exploration for new community
resources
Nurturing Relationships with
Guest Faculty
•
Timely Feedback to Presenters
•
Acknowledgement of Contributions
•
Create Avenues for Ongoing Dialogue
and Interaction
•
Maintain Relationships during Off Season
•
Lunch, Workshop Information and Service
Exchange
Example of Methods:
“The Talking Circle”
Communication Circle Led by Native Elders
Talking stick passed around the circle 1-3 times
Used to facilitate personal and professional
growth
Ground Rules:
 No cross talk until the third round
 No obligations to speak
 Information shared within the circle is not
discussed outside of the circle
 Mutual respect and support
Curriculum PITFALLS

Management Concerns:
Clinic Productivity, Continuity of Care, Budget
Adequate staffing of inpatient service





Resident Dis-Engagement in course: Burn-Out
Resistance to subject matter
Perception of Optional Participation by residents
Absenteeism due to vacation and poor personal
accountability
“Soft” Material”: Non-Graded
Lessons Learned

Accountability and Participation: Written Policy
 Vacation during TCM: Specifically Defined
 Course Management System: must be in place
 Evaluation Process: Formalized, Multi-Faceted
 Budget: appropriately distributed $1500 to $6000
 Class Size: Expansion from 8 to 12 residents changed
dynamics

Cohesive Leadership Team: Required for success
Program Sustainability

Document all Policies and Procedures
 Keep Up-to-Date Database of Speakers and
Contacts
 Establish System for Introducing Speakers,
Tying Together Presentations re: Purpose
 Develop a routine for establishing dialogue with
guest speakers: Luncheon, pre-meeting
 Maintain environment of mutual respect and
professionalism
 Promote an atmosphere of tolerance and
unbiased interface between speakers and learners
Course Evaluation: How Have We
Done?

Yearly TCM Feedback: Excellent! Program
Centerpiece

Resident Recruits attracted by unique curriculum

Statement by former Resident: “Having practiced in
Barrow for several years before residency, I feel you
are hitting what I needed years ago.”

Feedback in the *Acosta Study Suggests Critical
Components are Being Met for Rural Practice

Long-Term Curricular Review with Past Graduate
Feedback planned 2010 at 10 year mark
David Acosta, MD - Rural-Based Graduate Medical Education, A Workshop, San Antonio, Texas, February 2000
Leadership Team Observations

TCM Teaching Style: Faculty utilize a
collaborative model with a shared vision-Not
authoritative, more focused upon adult learning

Underlying emphasis: There is a Critical Role for
Nurturing Relationships within a Community and
Assimilating yourself into your Unique Practice
Setting

In Talking Circles, Residents Have Their
Humanity Validated by Elder Leaders who have
been patients and are members of an Indigenous
Culture
Application to Other Programs

All Practice Settings have unique characteristics

TCM Concepts are applicable beyond Rural and
Remote Practice

Talking Circle and Cultural Elder teaching
applicable to many cultural settings

Seminar setting with resident “breather” helpful for
preventing burn-out and promoting resident
retention and satisfaction
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