Border Health

Border Health Rotation

Faculty Chair:

Danielle Fitzsimmons-Pattison, MD

Lead Contacts:

1. Danielle Fitzsimmons-Pattison MD
2. Clark Alves, MD

Associate Contacts:
Laura Parajon, MD (UNM)
Art Kaufman, MD (UNM)

Required Experiences:

1. 1. Asylum seeker shelters (Dona Ana and Luna Counties)
   2. Department of Health activities
   3. Community experiences
   4. Memorial Medical Center 

Weekly Schedule:

Based on 4 week schedule

	Mon	Tues	Wed	Thurs	Fri	Sat
AM	Community Experience	FP Clinic	Community Experience	FP Clinic	Journal Activity	Community Experience
PM	Journal Activity	Admin	Didactics	Admin	Self Study	Self Study
Eve	call	call	call	call	call	call

Weekly Schedule: based on 3 week schedule

	Mon	Tues	Wed	Thurs	Fri	Sat
AM	Community Experience	Community Experience	Community Experience	Journal Activity	Journal Activity	Community Experience
PM	Journal Activity	Self Study	Didactics	Self Study	Self Study	Self Study
Eve	call	call	call	call	call	call

Weekly schedules may be adjusted to meet the needs of individual residents or residency programs. * Call is asylum clinic call varies on number of seekers and shelters.

RRC Requirements:
No specific requirements

Rotation Description
The United States-Mexico border region is a unique area with its own specific health care challenges that are different from both the interior of the United States and the interior of Mexico. Health inequities related to poverty, immigration status, access to healthy foods, and access to health care among other social factors, are stark. Although there are unique issues on each side of the border, families and communities stretch across it in a number of different ways. In that fluidity, we see different populations of asylum seekers, migrants, and other immigrants who come to the region to seek safety or better opportunities.

This rotation focuses on understanding the factors that affect the health of people in this area both those living in the region and in transit. The rotation introduces some history of the border region, the processes by which refugees and asylum seekers come to the US, specific health issues and programs aimed at addressing them, and how to work together with local communities to improve conditions that may lead to poor health for border region residents and visitors.  It provides an opportunity to interact with community and focus on appropriate intervention. In addition, it offers an opportunity to help the training institution collaborate with community partners and public agencies while mobilizing to respond to local and national crises, as well as with the day-to-day health care needs in the border region.

Expectations:
Residents:
Residents are expected to arrive to rotational experiences and clinics on time and dress and act in a professional manner. They are expected to contact the organizer prior to the first day of rotation to set up an initial meeting on the first day of the rotation.  It is expected that residents will be respectful of all preceptors, community members and spaces.  Residents will contact preceptors or community members they are working in any case they are unable to attend an experience.  The residents will be expected to be proactive in seeking out areas of interest.

The resident will be expected to maintain a journal of their experience, complete all assignments, and report back to program directors and home institutions their findings and recommendations.

 Faculty:
The preceptors and community educators will be expected to be respectful to residents and help them develop an understanding of the complexity of care for border populations. Based on resident’s level of training they should be available either in person or via telephone to precept cases seen in outreach clinics.

Call:
Residents will be on call for the asylum seeker clinic.

Outcome statements:
1. By the end of the first week, the resident will be able to evaluate how the unique history and current dynamics of the border region influence border residents’ health through a discussion of this topic in reflection journal assignment #1.

2. By the end of the rotation, the resident will be able to analyze the ethics of doing health care in the border region, including the effects of bias and “volunteerism” on the practice of health care through a discussion of these topics in reflection journal assignments #2 and #3.

3. By the end of the rotation, the resident will be able to evaluate the needs of different border populations due to experiences of arrival, historical contexts, and other relevant social processes through a discussion of these topics in reflection journal assignments #4, #5, and #6.

4. By the end of the rotation, the resident will be able to create recommendations for their home institution to better address the health and social needs of border residents and immigrants in their home communities through a plan developed in activity #7 and the final activity.

Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.  Residents are expected to:

Competencies
Cares for acutely ill or injured patients in urgent and emergent situations and in all settings

Cares for patients with chronic conditions

Partners with the patient, family, and community to improve health through disease prevention and health promotion.

Objectives

• By the end of the rotation the resident will be expected to apply concepts of cultural humility through respectful interactions with vulnerable populations and when working with community and care teams.
• Through the rotation the resident will develop an understanding of how living in Colonias or other under resourced areas of the border affects chronic disease management such as Diabetes and will tailor counseling and drug management to help patients and families.
• At completion of rotation the resident will exhibit an understanding of caring for people in transit through identification of appropriate short term management strategies for minor ailments that could affect their travel while recognizing risks of overtreatment and retraumatization without clear follow up.

Medical Knowledge
Goal

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.  Residents are expected to:

Competencies

1 Demonstrates medical knowledge of sufficient breadth and depth to practice family medicine

2 Applies critical thinking skills in patient care

Objectives

By the end of the rotation the resident will demonstrate understanding of cultural aspects of health perceptions in both the community as a whole through participation in asylum seeker shelter clinics and assigned readings.

Practice-Based Learning and Improvement
Goal

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.  Residents are expected to develop skills and habits to be able to:

Competencies

• Locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems
• Participate in the education of patients, families, students, residents and other health professionals, as documented by evaluations of a resident’s teaching abilities by faculty and/or learners

Objectives

• Upon completion of the rotation the resident will be demonstrate use of reliable resource such as CDC website, Uptodate or Dynamed by investigating possible infectious risks of individuals seen based on their travel journeys.
• The resident will be expected to identify an area of interest to further explore in depth within the areas of care of immigrants, advocacy, ethics of cross cultural care or other appropriate subtopic.

Systems-Based Practice
Goal

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.  Residents are expected to:

Competencies

• Advocate for quality patient care and optimal patient care systems
• Work in interprofessional teams to enhance patient safety and improve patient care quality

Objectives:

• by the end of the rotation the resident will identify a policy that affects those in the region to present to a local political leader.
• At completion of rotation the resident will be able to identify the various legal status of  those arriving and currently living in the US and how this affects access to care through financial barriers, stigmatization, and mobility of individuals.

Professionalism
Goal

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.  Residents are expected to demonstrate:

Competencies

• Compassion, integrity, and respect for others
• Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

Objectives

• Through reflective journaling through the rotation the resident will Identify patterns of discrimination and begin to self evaluate own biases.
• Describe legal definitions of refugees, asylum seekers and other migrant statuses.

Interpersonal and Communication Skills
Goal

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.  Residents are expected to:

Competencies

• Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
• Work effectively as a member of leader of a health care team or other professional group

Objectives

• The resident will be expected to identify an area within the shelters or to contribute to after learning about the processes involved in mobilization of community response.
• The resident will through the rotation be expected to use appropriate translation services as well be able to convey findings and plan in a patient friendly manner

Teaching Methods
Teaching occurs through direct observation, community involvement,  direct reading and didactic presentation both  for and by the residents. Residents will also use reflective journaling as well as identifying an area of interest and presentation.

Assessment Methods (Residents)
Assessment is through direct observation, if pertinent direct chart review.  presentation evaluation review of reflective journaling.

Assessment Methods (Program Evaluation)
Rotation evaluation is by resident and preceptor written evaluation forms.

Level of Supervision
Residents are supervised by residency faculty and community preceptors through direct observation and review of written reports.

Educational Resources
Readings:

• Healthy border 2020 : US -Mexico Border Health Commision “Healthy Border 2020: A Prevention and Health Promotion Initiative” 2015 Handout
• National Rural Health Association Policy Brief: Addressing the Health Care Needs in the U.S.-Mexico Border Region
• “The State of the Border Report: A Comprehensive Analysis of the US-Mexico Border” May 2013

Ethics:

• How not to save the World: Why U.S. students who go to poor countries to ‘do good’ often do the opposite – The Washington Post 3/29/16,
• Melby el al. “Beyond Medical “Missions” to Impact-Driven Short-Term Experiences in Global Health (STEGHs): Ethical Principles to Optimize Community Benefit and Learner Experience” Academic Medicine
• Crump and Sugarman. “Ethical Considerations for Short-term Experiences by Trainees in Global Health”JAMA. 2008 September 24; 300(12): 1456–1458 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164760/pdf/nihms-318143.pdf

Resources: 

• State border heath sites
  1. New Mexico Department of Health: Office of Border Health https://nmhealth.org/about/asd/ohe/obh/
  2. Texas Department of State Health Services Office of Border Health web site https://www.dshs.texas.gov/borderhealth/
  3. Arizona Department of Health Services Office of Border Health website https://www.azdhs.gov/director/border-health/index.php
  4. California Department of Public Health The Office of Binational Border Health https://www.cdph.ca.gov/Programs/CID/OBBH/Pages/OBBHhome.aspx
  5. San Diego County Health and Human Services Agency Border Health Program Web site https://www.sandiegocounty.gov/hhsa/programs/phs/border_health_program/index.html
  6. Howard CA, Andrade SJ, Byrd T. The Ethical Dimensions of Cultural Competence in Border Health Care Settings.Fam Community Health. 2001 Jan;23(4):36-49. PubMed PMID: 11401622.
• National Rural Health Policy brief “ Addressing the health care needs of the US-Mexico Border Region 2010.
• https://www.ruralhealthweb.org/programs/border-health-initiative
• https://www.hudexchange.info/cdbg-colonias/colonias-history/
• https://www.who.int/hrh/documents/community_health_workers.pdf
• https://cimmcw.org/wp-content/uploads/NM_Bulletin-on-Best-Practices-in-Working-with-Immigrant-Families.pdf
• https://www.cdc.gov/immigrantrefugeehealth/index.html
• https://www.mass.gov/lists/refugee-health-assessment-a-guide-for-health-care-clinicians
• https://data.unicef.org/topic/child-health/immunization/
• https://www.pewresearch.org/fact-tank/2019/04/10/whats-happening-at-the-u-s-mexico-border-in-6-charts/
• https://www.who.int/tb/country/data/profiles/en/
• https://humaneborders.org/
• https://www.pbs.org/newshour/nation/what-happens-when-migrants-die-in-the-arizona-desert
• https://www.nytimes.com/2018/12/18/opinion/migrants-border-death.html