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
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
Comments from the “Untrained”
“No one told me about colleagues’ personality
 “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
 50th
State to implement GME- Residency
 Rural Focus
 Unopposed program in Tertiary Hospital
 Collaboration with Alaska Native Medical
 Dual accreditation DO and MD Residency
 12 residents per year
Curriculum Design for Alaskan
 Trans-Cultural
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
TCM Daily Schedule
Board Prep
12:00-1:30pm Lunch/Admin Lunch/Admin
Cultural Focus Cultural Focus
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
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
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
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
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
“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
Cohesive Leadership Team: Required for success
Program Sustainability
Document all Policies and Procedures
 Keep Up-to-Date Database of Speakers and
 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
 Promote an atmosphere of tolerance and
unbiased interface between speakers and learners
Course Evaluation: How Have We
Yearly TCM Feedback: Excellent! Program
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
In Talking Circles, Residents Have Their
Humanity Validated by Elder Leaders who have
been patients and are members of an Indigenous
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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