Professor of Clinical Medicine, Department of Medicine
Dr. Paccione's first experience in Global Health was between his 3rd and 4th years in medical school when he was the sole "physician" for 3 remote villages in Guatemala for a year. Since then he has tried to integrate global health practice and training into his educational career at Einstein. As Director of the Primary Care/Social Medicine Program and inpatient Firm leader at Montefiore from 1985-2007, he has initiated special clinics for immigrants in the South Bronx and victims of international Human Rights abuses; created global health rotations for residents in Latin America and Africa; and served on the Boards of Directors of Doctors of the World and Doctors for Global Health. Presently a Professor of Clinical Medicine at Einstein and a Board member of the Global Health Education Consortium, Dr. Paccione recently relinquished his postgraduate training roles at Montefiore to help develop the Global Health Center at Einstein, advise students, and create training opportunities for students and residents, linked with clinical and community service, in rural Uganda.
Educational Sponsored Einstein Projects
Dr. Paccione, Professor of Clinical Medicine at Einstein, Global Health Center Educational Alliance Director, and Board member of the Global Health Education Consortium. For the last 3 years now, Einstein has joined with Doctors for Global Health and Montefiore to help staff Kisoro District Hospital in rural Uganda with Medical senior residents and other DGH Volunteers. In addition, twice a year Dr.Paccione and 6 senior Einstein students work on the Medicine wards and in the community around Kisoro. Besides working in the hospital, DGH and Einstein have also joined with Kisoro in establishing a Village Health Worker )VHW) Program in 20 surrounding villages. The 40 VHWs have roles that include collecting data on various community problems, facilitating access to care, delivering basic primary care, teaching health, ensuring adherence to immunization and chronic disease medication (e.g. diabetes, hypertension, etc.), preventing disease, etc. Although the VHWs have been collecting data about nutrition, chronic disease, maternal mortality, water and hygiene, child health, etc., they have requested that Einstein students help them in research such as to analyze data, collaborate in expanding and assessing the impact of the Nutrition and the Cervical Cancer Screening programs co-established by DGH/Einstein students, and participate in HIV educational efforts in the communities. This has provided a perfect opportunity for our pre-clinical students to make a contribution to a very needy rural Ugandan community.
The Uganda Rotations of the Albert Einstein College of Medicine, 2013-14
In 2013-14, there will be 2 types of Uganda experiences offered, both of 2 months duration and both eligible for an Einstein GH Fellowship:
Option A combines both Clinical medicine in Kisoro District Hospital (with Jerry Paccione attending) and Community Health in the villages, has a prerequisite (Certificate-level) Global Health Course in June of MSIV, and can count as the Einstein Scholarly Project.
Option B is purely clinical - a mix of Medicine, Pediatrics and Obstetrics/Gynecology. The June GH course is not a prerequisite, and the rotation can NOT fulfill the SP.
Both options fulfill Einstein’s Ambulatory Requirement.
Below, both options are described.
** If students are interested a one-year Global Health Fellowship in Kisoro, discuss with Dr. Paccione.
The Uganda Rotation of the Albert Einstein College of Medicine, 2013-14
Option A: Clinical, Community, June GH Course Elective, Ambulatory Requirement and Scholarly Project Option
The district of Kisoro occupies the far Southwestern corner of Uganda, a few miles from both Rwanda to the South and the Congo to the West. It’s poor and remote, a beautifully rugged land of sharp hills, towering volcanoes, and serpentine lakes accessible only after hours of precipitous dirt roads. By rural measures, it’s overpopulated, which means the steep over-farmed soil can’t support the number of people who live on and draw sustenance from it, and a land where women commonly have 7-9 children, their only means of social security.
The Kisoro District Hospital is the public hospital in the district of 270,000, the hospital where people don’t pay. The other one, St. Francis, is in nearby Mutolere: it’s a Catholic, Dutch missionary hospital, nominally private, better equipped and charges for its services. Kisoro Hospital is very underfunded, especially for such a remote facility where more would have to be offered to attract health professionals e.g. doctors earn less than $4000 USD per year with little potential for a private practice to supplement income. In cities, the earning potential is at least twice that. The hospital is thus understaffed at every level: Two young physicians (the hospital is funded for 6) are responsible for over 150 beds comprising Medicine, Surgery, Pediatrics and Obstetrics/GYN Wards and bustling General Medicine and HIV clinics (with 150-200 patient visits/day. Likewise nursing is staffed at 60% capacity and the lab, with funding for 4, has 2.
It’s here in Kisoro that we can address serious need, and thus here that we work - Doctors for Global Health (an Eintein-affiliated, US-based NGO), faculty and residents from Montefiore’s Medicine and Primary Care/Social Medicine Programs, and Einstein students.
The 2 month AECOM senior Global Health fellowship in Uganda is offered twice a year – in the Fall and in the Spring – and incorporates of 2 types of health care experiences: an Einstein faculty-supervised (Jerry Paccione) “sub-intership” in Tropical Medicine for 3 weeks, and a 5 week immersion in Community Medicine in which students work as health educators and public health workers in the villages.
The Uganda experience is also be complemented by a very highly rated prerequisite: the Global Health Course at Montefiore with a focus on Africa and Uganda. The Course earns elective credit at Einstein and is co-sponsored by the Primary Care/Social Internal Medicine Programs at Montefiore. It comprises about 100 hours of class time, project workshops and interesting reading; takes place in the first month of the MS IV year, June; and will be taken with about 16 Montefiore PGY IIIs in Medicine who are also planning to work in Uganda the following year.
The following is an outline of the 2 month experience in Uganda:
- The Wards: the first 3 weeks
- Four-six students work on the male and female wards of Kisoro District Hospital with Montefiore residents and Jerry Paccione, attending.
Students work up and follow daily all patients admitted to their ward, an average of 2-3 admissions per day per student. An “admission” takes about 30-40 minutes, write-up included. There are usually no “old records” save for occasional scattered papers carried by the patients themselves, the histories often sparse, labs absent.
Accurate diagnosis depends on epidemiologic probability, history and physical, and astute clinical judgment that incorporates the time course and severity of symptoms, sensitivity to the cultural expressions of stress, and judicious and often step-wise use of empiric therapy.
The lab facilities are basic, and often 1-2 days delayed or unavailable (e.g. nothing over the weekend or after 5:00PM). Tests include ESR, CBC, AFB and malaria smears, basic microscopy, HIV and CD4, sporadic EKG (when it’s working), chest X-ray (when there’s film) and ultrasound (when there’s electricity). We bring glucometers and U/A strips.
Two Montefiore PGY IIIs work with students on the wards. The resident and Jerry Paccione (JP) supervise as resident/attending team. They round with each student individually every day and hold Teaching Rounds, with all students, on 4-6 of the most interesting patients from 2:00-4:30PM. During rounds, History, Physical Exam and Clinical Reasoning are emphasized.
The work week during the first 3 clinical weeks is about 60-65 hours, with a mix of both inpatient wards and clinic.
Weekends: Saturday and Sunday are 8-hour workdays (from 9-5PM) for those on-call. On the first weekend, all come in and round for 3 hours on their “off-day”, but otherwise when not on-call, weekend days are off.
All students work with translators, one-on-one, during their time on the wards, in the clinic, and later in the community.
There’s invariably a great spirit of collaboration and pulling together, which makes the time on the wards exciting and fun.
Clinical medicine is a language and a culture we’re all familiar with, and thus a good way to ease into Uganda. By stripping away the accoutrements of modern medicine and the familiarity of culture, the principle educational goal of the first 3 weeks’ ward experience is to experience “doctoring” - all the more tangible in context of another culture - and to develop, grow comfortable with and trust your own clinical skills. Like the experience, the “education” is self-generated, internally motivated, fueled by the very real possibility of making a difference in people lives.
B. Community Medicine: the next 5 weeks
During the second month, we capitalize on the powerful introduction to Ugandan culture you received though your patients and families to delve more deeply into Ugandan culture, to witness firsthand the social determinants of health, and to grapple with diagnosing health problems at the community level.
The Community Medicine Project offers a rich personal experience as an educator and public health worker in Ugandan villages, and the opportunity to make an educational contribution in an area where it’s needed most.
Students will spend 4 of the 5 CM weeks working in one village each, with Village Health Workers (VHWs) and interpreters. Here they will:
a) Deliver, with their VHWs, weekly Community Talks on topics prepared during the June GH Course that are relevant to their village;
b) Perform Surveys door-to-door, also prepared in June. Students will gain skills in the methodology of survey development, data collection and data analysis to answer Community Health questions in the developing world;
c) Screen for disease and educate families about health.
Mentoring: the project will be closely mentored, starting in June at Einstein by Dr. Paccione and the June GH faculty.
In Kisoro, there will be 2-3 mentor/supervisors from Kisoro Hospital. Two to three times a week regular “wrap-up” or “project discussion” sessions will be scheduled from 5:00-6:00PM during which students will work with on-site mentors.
Timetable for project completion:
In the U.S.: During the June GH Course Month, students will meet with Dr. Paccione frequently, and pair up to work on their Community Talks and Survey project. (N.B.The survey analysis will be the subject of the final (4th) Community talk in the villages).
Week 1: VHW Training sessions with students as co-trainers; introduction to community.
Week 2: Home visits, Community Talks, Surveys, screening [3 night village-homestay]
Week 3: Home visits, Community Talks, Surveys, screening….
Week 4: Home visits, Community Talks, Surveys, screening….
Week 5: Data analysis, report writing and presentation to Village and Kisoro Hospital
A written report will be completed and oral project presentations to both the Village and the Kisoro Hospital staff are made during the last week of the rotation.
N.B. Students can elect to make their community project in Uganda the basis of their required Scholarly Project (SP).
Option B: Clinical 8 weeks: Medicine 4 weeks, Peds 2 weeks, Ob-Gyn 2 weeks
(no June GH Course Elective, no SP Option), fulfills Ambulatory Medicine requirement.
Option B is a purely clinical experience in Kisoro District Hospital.
Students will work on the IM wards for 4 weeks with Montefiore faculty (faculty-fellows in the Global Health and Clinical Skills Faculty Development Program) and Medicine residents (see description in Option A) and then spend 2 weeks in Pediatrics and 2 weeks in Obstetrics-gynecology under the supervision of Kisoro physicians. There will be a weekly ambulatory experience in a community Health Center, as well as a continuity clinic experience throughout the entire 8 week experience.
The June Course will not be required. The SP can NOT be earned through Option B.
A GH Fellowship paper based on the epidemiology and records of the student’s clinical experience, will be required.
N.G. Both Uganda experiences incorporate considerable ambulatory medicine and fulfill the Ambulatory requirement at Einstein.