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ACP Global Perspectives: Caribbean
Kenneth Connell, MBBS, DM (UWI), PhD (KCL), FACP
Interim Governor, ACP Caribbean Chapter
Faculty of Medical Sciences, Cave Hill Campus, The University of the West Indies, Barbados
The Caribbean is a region that consists of the Caribbean Sea, its islands (some surrounded by the Caribbean Sea and some bordering both the Caribbean Sea and the North Atlantic Ocean), and the surrounding coasts.*
The Caribbean is ACP’s newest Chapter, established July 1, 2016. This Chapter is made up of countries throughout the Caribbean, including Anguilla, Antigua and Barbuda, Bahamas, Barbados, Bermuda, Cayman Islands, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, St. Vincent and Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos, Virgin Islands (British), and Virgin Islands (US).
* Source - Wikipedia
What inspired you to become a physician?
I decided from the age of 6 years old that I wanted to become a physician. I was of course unsure as to what being a doctor even entailed, but was determined that, like my pediatrician, I was going to make people better by giving them "magic liquids or creams." Twelve years later, and armed with a maturing scientific mind, I entered medical school even more determined to fully understand how that "magic" worked.
What do you enjoy about being an internist?
Internal Medicine rocks! There is no other specialty that I would feel comfortable in; it satisfies my key areas for job satisfaction. First, the scientific nature of the discipline allows me the opportunity to continue to ask questions and search for answers. The discipline of true enquiry was kindled during my IM residency and continued, in a more structured way, during my PhD training at King's College London. Second, IM was an easy portal into an academic career with all the attributes of teaching, research, and patient care. I enjoy the infinite limits of the IM knowledge capsule and my journey towards mastery!
What is the role of the internist in Barbados and throughout the Caribbean? What are the education and training requirements needed to practice Internal Medicine or one of the subspecialties of Internal Medicine?
There are 2 training pathways for IM in the region, and both allow for specialist registration with the various independent medical councils.
- University of West Indies (UWI)—On completion of the MBBS primary medical degree of 5 years, medical graduates are preregistered for 1 year as a House Officer. This year involves rotations in 4 clinical specialties, including IM, for 3 months each. After internship, doctors are fully registered and may apply for the UWI Doctor of Medicine program in IM. This is a 4-year program and, on completion, graduates are eligible to register as a specialist in IM.
- Other—On completion of medical school, MBBS, or MD degrees, students sit for the traditional USMLE exams and compete as International Medical Graduates (IMGs) for residency positions in the United States. Approximately a third of internists are trained via this stream and most complete subspecialty training before returning to the region. The retention rate for most territories is more than 75%.
Internal Medicine specialists in the region function largely as hospitalists. Most may also carry a significantly smaller private primary care service commitment. In primary care, IM specialists function primarily on a referral basis in directing the care of complex medical cases.
What are some of the most significant challenges that physicians throughout the Caribbean face? What are your thoughts on the best way to meet those challenges?
Most of the challenges faced by Caribbean internists are not unique to the region. There is a broad spectrum of resource availability throughout the region from state-of-the-art practices to severely resource-limited hospitals. The standard of care is therefore the minimal best practice based on availability of resources.
The region also faces the rising problem surrounding the payment of health care. In most territories, internists practice in a dichotomy between fully private and public care. Access to care in the public sector is rapidly being restricted by the alarming costs of health care to governments and the absence of national insurance schemes.
What can other countries learn from your health care system?
The diversity of practices and the availability of resources offer a unique opportunity for the Caribbean region to utilize safe, best practices with available resources and skills. This has become especially evident during the period of austerity measures necessary post 2010, with the global economic recession.
The clinical spectrum of cases seen in the Caribbean region offers a unique opportunity for clinical management leadership and excellence. Some examples of these areas include:
- Arthropod-borne diseases—Dengue, Zika, and Chikungunya viruses
- Glaucoma—Drug-resistant glaucoma investigation and management (Barbados Eye Study)
- Non-communicable disease management—Health systems strengthening (CDC/PAHO Global Standardized Hypertension Treatment - Barbados Pilot Project)
Are enough young physicians in the Caribbean choosing to be internists? What makes them choose (or not choose) to practice Internal Medicine?
Aligned with Internal Medicine recruitment and global attrition, the region is experiencing the challenges of reduced applications for residency positions in General Internal Medicine. With approximately 60% of IM training occurring outside of the region, there is also the additional problem of migration of nationals, post training, to the United States. This is likely to have significant health care delivery implications for the future with changing demographics of medical school applicants; many potential applicants are now choosing career paths allowing for a better work–life balance.
What advice would you give to someone who is thinking about going into Internal Medicine?
Practitioners of Internal Medicine require a strong commitment to excellence in scholarship, leadership, and patient care. My advice to any young doctor considering a career in medicine is to be focused at the very start, charting a path to be a leader in patient care. This requires dedication to continued professional education and an inner inquisition to question the way we do things so that we may do them better! I am an obsessive planner and have embraced the reality of my strengths and weaknesses. I choose to spend more energy focusing on my strengths in an effort to capitalize on building a better doctor and person. I encourage and coach my students and residents to develop all domains of their professional and personal spheres.
Can you describe the role of the Caribbean Cardiac Society (CCS)? What are its missions and goals?
The mission of the Caribbean Cardiac Society is “To improve the health of the Caribbean people through the advancement of cardiovascular knowledge and practice.” To this end, the Society has successfully grown as the largest regional medical professional group with membership in the region. Membership comprises of nurses, doctors, surgeons, and technologists, and it holds its annual scientific summer meeting in different member states.
You are currently the Interim Governor of the ACP Caribbean Chapter, ACP’s newest international Chapter, established July 1, 2016. Describe your involvement in establishing the ACP Chapter in the Caribbean.
The development of the ACP Caribbean Chapter has been a 2-year journey. It started as a vision whilst attending the ACP Internal Medicine meeting in 2014. At that time I had a strong belief that the region should not only contribute to the scientific and administrative development of the College, but also develop within the region as a standard-setting organization for IM. A group of about 15 clinicians from across the region then quickly formed to discuss the establishment of the chapter. Despite being a multi-country chapter, the existing structures in the region, such as the University of the West Indies (UWI), will make it easier for the continuation of close network of professionals. Many of us meet at least twice annually at the various regional meetings and have received our undergraduate training in the region at UWI.
It truly has been a group effort in both aggressive recruitment and developing the supporting documents for submission to the College for consideration. We received the news of the final ratification by the ACP Board of Regents in November 2015, and the drive to development has intensified!
What motivated you to take on a leadership role in establishing the Chapter?
It was an honor to be nominated by my peers as the first interim Governor of the Chapter from July 1, 2016. As a relatively young physician, I have found myself being nominated to lead several projects and committees both within and outside the walls of the university. As full-time Deputy Dean at the UWI Faculty of Medical Sciences Cave Hill campus in Barbados, more than half of my work week is spent in administration and leadership. I saw the opportunity for leadership within the Chapter as a tangible effort to bring our Caribbean internists closer together using some of my strengths.
The Caribbean Chapter comprises most of the countries in the Caribbean Community (CARICOM). Can you explain the role of CARICOM in the Caribbean?
CARICOM is a group of 25 countries: 15 Member States and 5 Associate Members. It is home to approximately 16 million citizens, 60% of who are under the age of 30, and from the main ethnic groups of indigenous peoples, Africans, Indians, Europeans, Chinese, and Portuguese. The community is multilingual, with English as the major language complemented by French and Dutch and variations of these, as well as African and Indian expressions.
Why do you think it is important to have an ACP Chapter in the Caribbean?
I believe that the importance of the Chapter will fall under the following key mandates:
- Setting the standard for best practice of Internal Medicine in the region
- Being an advocate for patient-centered care
- Providing a professional home for career development for its members
- Enhancing the profile of Internal Medicine in the region
- Fostering a platform to engage in research opportunities
- Acting as an advisory body to the health agencies of member states for health system strengthening
What do you hope to accomplish through this Chapter?
The new chapter will have a number of short- and long-term objectives. Some of these are listed below:
- Increase membership (Members, Fellows, and Physician Affiliates) to the 200-member mark by January 2017
- Host the first Internal Medicine Caribbean Chapter meeting in the Spring of 2018
- Increase the profile of the College within the many medical schools and universities in the chapter countries
- Consolidate chapter governance with the creation and development of committees—Awards, Membership, and Finance—to manage day-to-day chapter affairs
Why is it important for physicians in the Caribbean to belong to professional organizations like ACP?
All professionals, including medical professionals, require a professional home to encourage and rejuvenate their professional growth. This goes beyond the usual CME activities to involve socializing and sharing ideas about common health problems affecting the region. The ACP Caribbean chapter will aim to provide such a home.
Please share a memorable ACP international experience.
Every year, since my years as a resident, the annual ACP Internal Medicine meeting recharges me! It allows me to return to practice armed with new knowledge and skills that will affect the patients I care for, the students I teach, and the policy I support.
The 2015 Internal Medicine meeting was particularly special for me as I received the 2015 International Fellowship Exchange Program (IFEP) award at the International reception. I was awarded this fellowship and completed 6 weeks at the Coordinated Care Institute in Greenville, South Carolina, with Dr. Brent Egan. The fellowship allowed me to examine health systems strengthening in CVD risk management using highly structured performance metrics for health care providers. This work involved the use of electronic medical records and sophisticated databases to "package" information to be fed back to clinicians on their performance compared with clinic, state, and national levels. To have received the honor at the 2015 ACP International reception was especially gratifying as it signaled a greater recognition by the College and my peers.
I look forward to an exciting future with the College, as a Fellow and Interim Governor, in the growth of ACP’s newest Chapter!