Foreign-born docs need extra training in TB
New training program aims to fill the gap
Say "foreign-born," and most people in TB care and research think of patients.
What they’re forgetting is that many of the providers who care for TB patients are foreign-born too, says Wafaa El-Sadr, MD, MPH, research director at the Charles P. Felton National Tuberculosis Center at Harlem Hospital in New York City, and head of the infectious disease division at the hospital.
Based on striking results of a survey of Harlem Hospital residents all of whom are foreign-born the TB center is preparing training materials targeted specifically to foreign-born providers, says Marita K. Murrman, EdD, director of education and training for the TB center.1
Surprisingly, the hospital survey found that while many foreign-born residents came to the United States. with a sound theoretical knowledge of TB, they brought little hands-on experience in applying that knowledge even though most came from parts of the world where TB is endemic.
As a result, many residents were found to be weak in their ability to diagnose and treat TB disease and infection. In addition, they often held beliefs about the efficacy of the BCG vaccination at odds with what is taught in the United States.
In other parts of the country, as well, TB experts say the Harlem Hospital survey findings ring true.
Survey findings ring true in other places, too
In Los Angeles County, for example, about half of all foreign-born TB patients (who make up 66% of the county’s TB caseload) get their care from private foreign-born doctors, whose language, ethnicity, or culture mirrors their own, says Brenda Ashkar, MSN, RN, nursing director for Los Angeles County TB control. Yet these foreign-born physicians often "have very little knowledge of TB treatment," says Ashkar. "And what knowledge they do have may not be in accord with [American Thoracic Society] recommendations."
In San Diego, it’s the same story, says Evelyn Lancaster, RN, MSN, TB program educator and consultant for the county. There, many foreign-born providers practicing in accordance with the World Health Organization-approved treatment strategy use sputum specimens and microscopy for diagnostic purposes but fail to take the next step, sending specimens off to be cultured. As a result, patients who aren’t smear-positive often are sent on their way, says Lancaster.
Then there are problems related to BCG. Foreign-born providers "tell kids who need their skin test to be admitted to school, Oh, no, you don’t need that you’ve had a BCG vaccination,’" says Ashkar.
When researchers at Harlem Hospital began their survey of medical staff, such discrepancies weren’t necessarily what they expected to find, says Murrman.
For one thing, the hospital’s foreign-schooled residents tend to be older than their American counterparts and often are seasoned by years already spent in practice.
For another, though it’s fashionable to denigrate the abilities of foreign-trained physicians, the facts belie that prejudice, says Murrman. For the past three years, for example, foreign-schooled residents have outperformed their American peers in the Internal Medicine In-Training Examination, a reliable predictor for subsequent performance on the rigorous certifying examination of the American Board of Internal Medicine.2
But mainly, surveyors assumed staff would already be familiar with TB, since most come from some of the countries where TB case rates are highest: in sub-Saharan Africa, predominantly Nigeria and Zaire; from Asia, mostly India and Pakistan; and certain countries in Latin America and the Caribbean.
"Given the rates of TB they’d been seeing [back home,] we assumed that experience would be transferable," says Murrman. Instead, many residents arrived in the United States having seen few TB cases outside those they’d witnessed in their personal lives.
Why? Because in their own countries, TB patients are often segregated in specialty TB clinics or sanatoria, Murrman says. Thus, the residents came equipped with a knowledge of TB from medical school but with little experience in applying that knowledge.
(Ironically, the survey did find residents who’d been at the hospital the longest did well in diagnosing and treating TB patients co-infected with HIV and TB reflecting the fact that the majority of patients they treat at Harlem Hospital are co-infected.)
An uneasy interpersonal rapport as well
The personal rapport between residents and patients was in some respects an uneasy one, too. "Our residents often come from the wealthiest and most powerful segments of their own society; yet here, they are called upon to treat the poorest segment of American society, and to do it in a sensitive and caring way," says Murrman.
Taken together, the survey findings highlighted a set of challenges. "The medical house staff here at Harlem are our front-line," says Murrman. "They’re the ones who see the most important group of patients the undiagnosed." Indeed, all across the United States, it is foreign-born providers who are the most likely to set up practices in poor communities, and to come into contact with many patients at risk for TB, studies show.2
The training program the TB center devised in response "isn’t particularly novel in terms of its components," says Murrman. "What’s new is the way we’ve targeted the program specifically to suit the needs of foreign-born providers."
The program should be ready in written form for others to use within six months or so, Murrman says. Some of the features that characterize the program now in use at the hospital include the following:
• TB Themes of the Month. "That’s the most important part of the program," says Murrman. Derived from survey findings, each monthly theme serves to "anchor" the remainder of a month’s worth of program activities.
• Grand Rounds talks. "Everyone vies for these meetings, and we felt lucky to be given three of them," says Murrman. "We save them for the most important themes." In December, for example, Edward Nardell, MD, MPH, TB controller of Massachusetts, gave a Grand Rounds talk on the subject of transmission.
• A TB journal club. Led by Garry Souffrant, MD, the hospital medical director, the club helps members learn how to critically review and interpret current literature, with a focus on TB literature, says Murrman.
• Weekly case studies. Murrman and El-Sadr work together to identify TB cases at the hospital that best illustrate the monthly theme.
• Weekly TB rounds, conducted by Souffrant.
• Lecture commitments from the division of pulmonary medicine.
Finally, the hospital incorporates what might be called, for lack of a better phrase, sensitivity training for its foreign-born residents. During their pulmonary rotations, all residents spend time working at the hospital’s TB clinic, where patients come for directly observed therapy (DOT) and directly observed preventive therapy (DOPT), says Murrman.
"Here, we try to improve their communication skills, by modeling behaviors we want them to emulate," says Murrman. Although these kinds of skills may not come easily to some, Frantz Medard, MD, the medical director of the New York state-funded Harlem Hospital DOT program, provides residents with a compelling role model, says Murrman.
The scion of a wealthy family in Haiti, Medard nearly died of multidrug-resistant TB before he was diagnosed and treated by El-Sadr. As a result, Medard "dedicated his life to helping other TB patients," says Murrman; his compassion and sensitivity have helped boost compliance rates for DOT and DOPT at the clinic to 96% to 97%, says Murrman, even though the only incentive given for DOPT is a subway token.
The Francis J. Curry National TB Center in San Francisco will incorporate some elements of the training program developed by Harlem Hospital into the strategic five-year plan it is currently developing for the training and education of U.S. physicians, says Elizabeth Stoller, MPH, Center director.
"Now, we’re trying to find out whether there’s something unique about this population of medical providers that necessitates a different sort of training," says Stoller.
As the San Francisco model center researchers listen to focus groups and talk to individual experts, one thing is clear, Stoller says: "The topic of foreign providers keeps coming up."
For more information on training materials for foreign-born providers that will soon be available from the Charles P. Felton National TB Center, contact: Marita K. Murrman, telephone: (212) 939-8240; fax: (212) 939-8259; or e-mail: [email protected].
References
1. Murrman MK, El-Sadr WM, Findley SE, et al. TB/related training and education of house staff: potential impact of country of origin. Am J Resp Crit Care Med 1997; 155:A567.
2. Waxman HS. Workforce reform, international medical graduates, and the in-training examination. Ann Intern Med 1997; 126:803-804.
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