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PACIFIC ISLANDS CONTINUING
CLINICAL EDUCATION PROGRAM
(PICCEP)
Final Report • December 2003
C E N T E R F O R H E A LT H W O R K F O R C E S T U D I E S
UNIVERSITY OF WASHINGTON
PACIFIC ISLANDS CONTINUING
CLINICAL EDUCATION PROGRAM
(PICCEP)
Final Report • December 2003
This report was written by Alice Porter, Susan M.
Skillman, Karin Johnson, Ronald Schneeweiss, and
L. Gary Hart, with significant contributions from
Matthew Thompson, Ruth Ballweg, Peter Milgrom,
and Heather Deacon. Catherine Veninga was the
cartographer. Alessandro Leveque designed the report.
The Pacific Islands Continuing Clinical Education
Program was funded by the U.S. Department of Health
and Human Services, Health Resources and Services
Administration (HRSA), Bureau of Health Professions
and Bureau of Primary Health Care. Many PICCEP
faculty and team members donated personal time and
resources to make this program successful. The PICCEP
team would like to acknowledge the tremendous
flexibility shown by the home departments and clinics
of PICCEP faculty, allowing these faculty to arrange time
away from their clinical and teaching responsibilities in
order to prepare and deliver PICCEP courses.
CENTER FOR HEALTH WORKFORCE STUDIES
DEPARTMENT OF FAMILY MEDICINE, BOX 354982
SCHOOL OF MEDICINE
UNIVERSIT Y OF WASHINGTON
SE AT T LE, WA 98195
The PICCEP team would like to acknowledge the
contributions of all who helped to make this program
successful, including the Ministers and Directors of
Health of the six U.S.-associated Pacific jurisdictions,
Julie Stellman-Moreno (HRSA), Nancy Knight (HRSA),
Lynette Araki (HRSA), Paul Nannis (HRSA), and David
Sundwall (American Clinical Laboratory Association).
The team would like to make special acknowledgment
of the support and guidance provided by the late John
Rodak, HRSA, who was PICCEP’s project officer during
the first years of the program. John was instrumental to
PICCEP’s ability to implement the program. The team is
deeply saddened by his recent death, and miss his
contributions.
The program could not have had such great success
without the eagerness and hard work of the clinicians in
the Pacific jurisdictions who participated in PICCEP’s
CCE programs.
PICCEP FINAL REPORT · DECEMBER 2003
3
Table of Contents
I
Overview 4
II
Building the Foundation 7
III
Continuing Clinical Education 11
IV
Clinical Reference Materials Supplementation 21
V
Other PICCEP Activity 23
VI
Sustainability 25
VII
Notes for Future Programs 27
PICCEP course, Pohnpei, FSM
Aloha
Hafa adai
Kalangan
Komol tata
Yokwe
—island greetings
OVERVIEW
4
Overview
Continuing medical education (CME) must be required for all levels of practitioners
and incorporated into each jurisdiction’s health care workforce training plan.
Institute of Medicine, 1998
When the Institute of Medicine recommended a new
course for U.S. involvement in the health workforce
needs of its affiliated jurisdictions of the Pacific Basin, the
federal government responded in part with the Pacific
Islands Continuing Clinical Education Program
(PICCEP). Financed by the U.S. Health Resources and
Services Administration (HRSA) and implemented by the
University of Washington Center for Health Workforce
Studies, PICCEP provided continuing clinical education
in a region that encompasses six jurisdictions, 104
inhabited islands, and nearly a half-million residents
dispersed across an expanse of the Pacific larger than the
continental United States.
The six jurisdictions—the U.S. flag territories of
American Samoa, the Commonwealth of the Northern
Mariana Islands (CNMI), and Guam, and the
independent countries, “freely associated with the United
States,” of the Federated States of Micronesia (FSM,
including Chuuk, Kosrae, Pohnpei and Yap), the
Republic of the Marshall Islands (RMI), and the
Republic of Palau—have both an economic and political
relationship with the United States. A trade partner since
the mid-19th century, the United States today serves as the
region’s primary funder of social and health services as
well as its United Nations-recognized “trust
administrator.” Acknowledging these strong connections,
the Institute of Medicine in 1998 examined health
services in the region and found a wealth of challenges:
deteriorating health system infrastructure, costly health
care provided in hospital and off-island settings, serious
health problems on some islands such as vitamin
deficiencies, low immunization rates, high rates of
substance abuse and infant mortality, and particularly,
“shortages of adequately trained health care personnel.”
Since the 1980s, the region also had a sad history of
visitors attempting to modernize and reform its health
services delivery system—efforts that were
characteristically short-term and unsustainable.
PICCEP responded to a specific recommendation of the
IOM report to provide postgraduate and continuing
medical education (CME) programs —short-term
training activities that are designed to maintain and
improve the skills of health care professionals. The
Institute found that such training in the Pacific region
was “provided in a rather haphazard fashion or not at
all.” It expressed particular concern for maintaining the
“clinical skills and knowledge” of graduates of the
Pacific Basin Medical Officers Training Program
(PBMOTP), a U.S.-financed regional training program
based in Pohnpei (FSM) that, during 1986-96 and at a
cost of nearly $15 million, graduated 70 students from a
rigorous five-year curriculum and two-year internship.
Particularly in Palau and the FSM, reported the IOM, the
PBMOTP graduates represent the “mainstay of the
physician workforce….But they will still need continued
education and training.”
This report recounts the activities that the PICCEP
organized to address this need. During the program’s
four-and-a-half years, the project team (see box, p 6)
facilitated or provided regional continuing clinical
education (CCE)1 in the course of nearly 30 site visits,
involving about 35 clinician-instructors and attracting as
many as 500 attendees per year (see box, p. 14). Each
course provided 16-20 hours of formal CCE and
additional time in consultations and ward rounds.
Altogether, the program provided more than 15,000
structured CCE contact hours and many more informal
1
CCE is the general term used by PICCEP to refer to continuing clinical education across
multiple health professions. Continuing Medical Education (CME) is used in this report only
when referring to continuing education specifically targeted at physicians.
Ebeye, Republic of the Marshall Islands
PICCEP FINAL REPORT · DECEMBER 2003
hours of contact. But before it could embark on this
work, the PICCEP team invested a year in studying the
5
region’s health care system and workforce and identifying
needs and resources.
0
0
250
1,000
500
2,000 Miles
1,000 Miles
Commonwealth of the
Northern Mariana Islands
Republic of the
Guam
Marshall Islands
Republic of
Chuuk
Palau
Yap
Pohnpei
Kosrae
Federated States of
Micronesia
Equator
INDONESIA
PAPUA NEW GUINEA
American Samoa
AUSTRALIA
Cartography: Catherine Veninga
PICCEP Sites
6
OVERVIEW
THE PICCEP TEAM
L. Gary Hart, PhD, PICCEP director and core program
team member, Department of Family Medicine,
University of Washington
Craig Scott, PhD, PICCEP evaluation team member,
Department of Medical Education, University of
Washington.
Ronald Schneeweiss, MBChB, PICCEP medical director
and core program team member, Department of Family
Medicine, University of Washington
Sharon Dobie, MD, PICCEP core program team member,
Department of Family Medicine, University of
Washington.
Susan Skillman, MS, PICCEP deputy director and core
program team member, Department of Family Medicine,
University of Washington
Larry Mauksch, M.Ed, PICCEP behavioral health
curriculum team, Department of Family Medicine,
University of Washington.
Heather Deacon, PICCEP program coordinator and core
program team member, Department of Family Medicine,
University of Washington
Don Downing, RPh, PICCEP core program team member
and faculty, Department of Pharmacy, University of
Washington
Matthew Thompson, MBChB, MPH, PICCEP core
program team member and faculty, Department of
Family Medicine, University of Washington
Eric Larson, PhD, PICCEP core program team member,
Department of Family Medicine, University of
Washington
Karin Johnson, PhD, PICCEP core program team
member and research assistant, Department of Family
Medicine, University of Washington
Christine Riedy, PhD, PICCEP oral health program team
member, Department of Public Health Dentistry,
University of Washington
Peter Milgrom, DDS, PICCEP oral health program
director, Department of Public Health Dentistry,
University of Washington
Barbara Burns McGrath, RN, PhD, PICCEP core
program team member, Department of Psychosocial and
Community Health, University of Washington
Lawrence Wilson, MD, PICCEP core program team
member and faculty, Department of Psychiatry and
Behavioral Sciences, University of Washington
Beth Kirlin, PICCEP research assistant, Department of
Family Medicine, University of Washington
Kathleen Ellsbury, MD, PICCEP core program team
member and faculty, Department of Family Medicine,
University of Washington
Ruth Ballweg, PA-C, MPA, PICCEP core program team
member and faculty, MEDEX Northwest program,
University of Washington.
Daniel Hunt, MD, PICCEP core program team member,
Associate Dean of Academic Affairs, School of Medicine,
University of Washington
Philip Weinstein, PhD, PICCEP oral health program team
member and faculty, and behavioral health curriculum
team member, Department of Public Health Dentistry,
University of Washington
Adam Garcia, PICCEP research assistant, Department of
Family Medicine, University of Washington
Neal Palafox, MD, director of University of Hawaii
contract and PICCEP faculty, University of Hawaii John
A. Burns School of Medicine
Steve Gallon, PhD, PICCEP behavioral health curriculum
team member and PICCEP faculty, Northwest Addiction
Technology Transfer Center, Salem, Oregon
PICCEP FINAL REPORT · DECEMBER 2003
7
Building the Foundation
In Pacific Partnerships for Health:
Charting a New Course, the IOM
described a region with health
problems typical of both the
developing world (malnutrition,
cholera) and the developed world
(heart disease, cancer). In addition
to “incredible population growth”
since World War II (now tempered
by out-migration), the islands have
undergone a wrenching shift from
subsistence island economies based
on communal farming and fishing
to modern cash economies—a
transition that has caused radical
changes in the population’s culture,
family life, health practice, and
health status—as well as
dependence on foreign aid. More
than 40 federal agencies, along with
several international agencies, non-
profit organizations, and religiously
affiliated groups are involved in the
region, and by the late 1990s, the
U.S. Department of Health and
Human Services alone was
providing about $70 million a
year to the jurisdictions’ health
care systems, most of it invested
in the flag territories. Nonetheless,
in general the islands’ health status
compared unfavorably with that
of the mainland United States as
measured by such indicators as life
expectancy, infant mortality, oral
health, and prevalence of diseases
including diabetes, cancer,
tuberculosis, and nutrition-related
preventable diseases.
Responding to these needs, the
IOM reported, was a workforce
of some 3,100 physicians, nurses,
dental professionals, mid-level
practitioners, health assistants, and allied health workers.
This workforce reflects large numbers of expatriate
clinicians working on contracts, an inadequate ratio
of dentists and other dental clinicians to total population
through much of the region, a widespread nursing
shortage, and disproportionate investment (as much
as a fourth of some island health budgets) in off-island
patient referrals. Centralized hospitals—many of which
have deteriorating capital plants and shortages of
essential supplies—were the primary venue for health
services delivery. This was a legacy of the 1950s, when
the U.S. Navy set up field hospitals in each state, and a
rebuilding program conducted during the 1970s and
‘80s. All of these factors made as formidable challenge
of the IOM’s recommendation to improve “prevention
and primary care and…population-based public health
care in the region.”
With funding from the HRSA Bureau of Health
Professions and the Bureau of Primary Health Care,
PICCEP convened a study team in September 1999 to
begin developing a sustainable CCE program for health
professionals. The team compiled available written
materials on the region, contacted other programs
providing health-related services in the region, and made
at least one site visit to each of the jurisdictions,
Poster in Majuro Hospital, Republic of the Marshall Islands
8
including the four FSM states, during September 1999September 2000 as part of its initial needs assessment.
During this period, team members also attended meetings
of the regional medical, dental, and nursing associations
to discuss the region’s health workforce training needs.
They began to build collaborative relationships with
hospital administrators and staff, clinic and public health
providers, policy makers, and patients—a process
continued throughout PICCEP’s four years duration to
collect information about needs, resources, and current
training options.
The PICCEP team communicated insights from these
visits and solicited expertise from health system
representatives from the region at a meeting on Guam
during July 20-21, 2000. Participants included more than
30 representatives from clinical training institutions,
provider professional organizations, and other health
policy leaders from the region. Among the health
organizations identified as “sources of strength” in the
region were the Western Pacific Health Nets (telehealth
system), the Pacific Basin Medical Association, the Pacific
Islands Health Officers Association, the American Pacific
Nurse Leaders Council, and the Micronesia Medical
Council. Participants shared their experiences with local
CME and identified characteristics of successful
programs and barriers to success (see next column).2
BUILDING THE FOUNDATION
CHARACTERISTICS OF SUCCESSFUL
CCE PROGRAMS
• Positive incentives: financial (promotion), release
time/coverage to attend sessions, etc.
• CCE requirement for re-licensure or certification
• Local determination of priorities
• Available resources for local coordination of the CCE
• Courses facilitated by the learners themselves,
relevant to their expertise, local conditions
and resources
• Courses built on those already in progress
• Culture of life-long learning
• Effective teaching methods
• Courses that are scheduled and structured
(e.g. weekly rounds)
• Lectures that involve both local and distant/
visiting consultants
• Support from administration
• Modular, to achieve a further qualification
BARRIERS TO SUCCESSFUL CCE PROGRAMS
• Lack of resources
• Lecture-only format
• Clinical responsibilities that interfere with attendance
• Distance too great to CCE venue
• No reward (no recognition of CCE participation in
promotion or career path)
• Confusion about what CCE actually is (e.g., a
morning report?)
PICCEP planning meeting participants, Guam, 2000
• Poor logistical support (timing, scheduling, publicity)
• Inadequate reference resources or library support
• Assumption that love of knowledge is sufficient
motivation for successful CCE
• Lack of local control
• Lack of coordination among visiting consultants
and programs
• Topics and methods that are irrelevant to
local situations
2
Thompson MJ, Skillman SM, Schneeweis R, Hart LG, Johnson K, and PICCEP study team.
The University of Washington Pacific Islands continuing education program (PICCEP):
Guam conference on continuing clinical education programs in the U.S.-associated
jurisdictions. Pacific Health Dialogue, 2002. 9:1, 119-122
PICCEP FINAL REPORT · DECEMBER 2003
A group of participants reviewed the status of
telecommunications resources in the region, concluding
that e-mail, phone, and fax were the most effective
current methods and that internet communication in
the region was still “complicated to use,” expensive,
and slow. By the conclusion of the meeting, participants
had agreed on a vision of integrated clinical and public
health CCE characterized by local involvement in design
and implementation, content relevant to local clinical
problems, and inclusion of all health care professions.
PICCEP’s third significant task during its first year was
an assessment of physicians’ CME needs. The PICCEP
surveyed all physicians in the region about their training,
experiences with CME and priorities for medical
education in their jurisdictions. It achieved response rates
ranging from 18% in CNMI to 85% in Kosrae (FSM).
Nearly two-thirds (64%) of the 143 physicians
responding had attended a CME event during the two
previous years, and 71% had access to local CME at
least once a week. But most of these events were of
short duration (1-2 hours)—suggesting that they were
regular local CME sessions rather than structured CME
conferences—and were of variable utility. The physicians
identified priority learning needs that included updates
on non-communicable diseases such as diabetes and
hypertension and communicable diseases such as
tuberculosis and HIV/AIDS. The survey also revealed the
importance of training in practice skills that are essential
in remote island environments, such as interpretation of
EKGs and X-rays and management of trauma and
obstetric complications. Specific skill-training requests
varied by jurisdiction.3
The PICCEP team compiled available statistics on the
health workforce of each jurisdiction, including the
numbers of clinicians (physicians, nurses, oral health
care providers, and allied health professionals), the state
of its CCE, medical reference and telecommunications
resources, and practice conditions. It considered these
data, the physicians’ survey, and insights from interviews
with providers from the region, along with
recommendations for CME collected from the Pacific
Basin Medical Association and Pacific Islands Health
Officers’ Association. By the end of the first year of
the project, the PICCEP team concluded that the r
egion’s health care providers were hampered by
provider shortages (especially nurses and allied health
professionals), inadequate financial resources for facilities
3
Thompson MJ, Skillman SM, Johnson K, Schneeweis R, Ellsbury K, Hart LG, and PICCEP study
team. Assessing physicians’ continuing medical education (CME) needs in the U.S.associated Pacific jurisdictions. Pacific Health Dialogue, 2002. 9:1, 11-16
9
and supplies, insufficient referral networks, low salaries
and generally inadequate professional incentives, and
limited resources for training. It identified the long-term
need for sustainable CCE, directed—largely or entirely—
by the jurisdictions themselves, preferably with incentives
(such as promotion and/or license renewal) linked to
participation. The PICCEP team translated these
findings into a set of guiding principles for the PICCEP
program (see box, below).
PICCEP GUIDING PRINCIPLES
PICCEP’s guiding principles are to develop and implement a
program that:
• addresses the stated and observed CCE needs of
the region’s health care providers,
• uses educational interventions that have a high
likelihood of increasing the clinical skills of providers
to improve the quality of care they deliver,
• helps create a sustainable CCE program that
coordinates and collaborates with CCE resources
of the Pacific region, is feasible within the resource
constraints of PICCEP and the jurisdictions, cultivates
local CCE norms, and fosters an ongoing regional
infrastructure for coordinating future CCE planning
and implementation, and
• emphasizes primary care physician CME, in
particular for graduates of the Pacific Basin Medical
Officers Training Program, but also strategically
addresses the CCE needs of other types of health
care providers.
10
PICCEP was prepared to organize and deliver CCE in the
Pacific region over the course of the next 3-5 years and to
coordinate the resources and logistics to support these
activities. It also made plans to develop the program with
substantial input from the region and to coordinate these
activities with other federal and international programs
delivering health system support in the Pacific, including
American Samoa
BUILDING THE FOUNDATION
professional organizations, education programs of the
University of Hawaii, the University of Guam, Fiji School
of Medicine, the University of Auckland, the National
Institutes of Health, the U.S. Centers for Disease Control
and Prevention, and with the health workforce-related
efforts of the federal Department of Health and Human
Services (Region IX) and the World Health Organization.
PICCEP FINAL REPORT · DECEMBER 2003
11
Continuing Clinical Education
PICCEP’s design for CCE incorporated the wisdom the
team members gathered from the needs assessment, their
own experiences with CCE, a review of literature, and
discussions with clinicians during site visits. The CCE
designed for clinicians had the following characteristics:
• Teams of at least two faculty for each jurisdiction for
2-3 days of CME activities for physicians. (Slightly
different models were employed in Guam and CNMI
to accommodate their health system structure).
• Teaching sessions coordinated with participants’
clinical responsibilities
• Problem-based and other interactive
learning methods
• Use of didactic presentations, cases, discussions,
and practical skills workshops
• Recognition of ad hoc educational needs
• Use of existing ward rounds for bedside
teaching sessions
• Use of local staff for lectures and case presentations,
where appropriate
• Emphasis on population-based medicine and public
health precepts, where appropriate
• Practical match of sessions with high-priority topics
identified by physicians in the needs assessment
“I think this is the first time that doctors
and nurses and other people get together.
It used to be like the nurses go and train in
one workshop, but that’s because we never
get together. So I think this is a start for us.”
–course participant
Chuuk, FSM
The PICCEP team anticipated unique challenges
implementing CCE in the Pacific region. The teaching
settings often had limited facilities. Audiences included
both physicians with a wide range of medical training
(both PBMOTP and medical school graduates from
Fiji, the Philippines, Burma, Sri Lanka, Nepal, and
China as well as the United States and other developed
countries) and non-physician practitioners such as
nurses, health assistants, pharmacists, and dentists.
PICCEP welcomed this mix of clinicians in the
classroom as a device to help promote communication
among the health care team. Although the PICCEP
team made every effort to coordinate the teaching
sessions with local clinical responsibilities, occasional
disruptions occurred such as the closure of outpatient
facilities to release clinicians for the training. The team
saw these occurrences as evidence of the enthusiastic
support by clinicians for PICCEP’s CCE programs.
The box on the next page lists PICCEP faculty.
CCE
12
PICCEP FACULTY
NAME
TITLE
AFFILIATED INSTITUTION
DEPARTMENT
CITY
Marco Alberts, DMD, MPH
Director
University of WA,
Harborview Medical Center
Dental/OralSurgery Clinic
Seattle, WA
Sylvia Andres, MD
Administrator
Palau Ministry of Health
Behavioral Health Division
Koror, Palau
Wendy Atkinson, MD
Assistant Professor
University of WA
Obstetrics-Gynecology
Seattle, WA
Ruth Ballweg, PA-C, MPA
Director
University of WA
MEDEX
Seattle, WA
Kay Bauman, MD, MPH
University of HI
Family Medicine
Honolulu, HI
Dennis Butcher, MD
Clinical Instructor
University of WA
Medicine
Jackson, WY
Jack Carr, PhD, ABPP
Professor Emeritus
University of WA
Psychiatry and Behavioral Sciences
Seattle, WA
Roy Colven, MD
Associate Professor
University of WA
Medicine (Dermatology)
Seattle, WA
Don Downing, RPh.
Clinical Associate Professor
University of WA
Pharmacy
Seattle, WA
Kathleen Ellsbury, MD, MSPH Associate Professor
University of WA
Family Medicine
Seattle, WA
Manny Eusebio, MD, FAAP
Clinical Instructor
University of WA
Pediatrics
Seattle, WA
Tim Evans, MD, PhD
Assistant Professor,
Medical Director
University of WA
Medicine,MEDEX
Seattle, WA
Steve Gallon, PhD
Adjunct Associate Professor,
Director
Oregon Health Sciences University,
Northwest Frontier Addiction
Technology Transfer Center
Public Health and Preventive Medicine
Portland, OR
Salem, OR
Greg Gardner, MD
Associate Professor
University of WA
Rheumatology
Seattle, WA
Bruce Gilliland, MD
Professor
University of WA
Medicine and Laboratory Medicine
Seattle, WA
University of WA
MEDEX
Seattle, WA
Ellen Harder, PA-C
Claire Haycox, MD
Clinical Assistant Professor
University of WA,
Valley Dermatology
Dermatology
Sequim, WA
Robin Hornung, MD
Assistant Professor
University of WA
Pediatrics
Seattle, WA
Dan Hunt, MD
Professor and Associate Dean University of WA
Psychiatry and Behavioral Science,
Medicine
Seattle, WA
Mark Koday, DDS
Dental Director
Yakima Valley Farmworkers’ Clinic
Pediatric Dentistry
Toppenish, WA
Grace Landel, PA
Associate Director, Lecturer
University of WA
MEDEX
Seattle, WA
Barbara Burns-McGrath, PhD Research Assistant Professor University of WA
Psychosocial and Community Health
Seattle, WA
Peter Milgrom, DDS
Professor
University of WA
Dental Public Health Sciences
Seattle, WA
Colleen Murphy, MD
Obstetrician-Gynecologist
Private Practice
Obstetrics-Gynecology
Anchorage, AK
May Okihiro, MD
Pediatrician
Waianae Coast
Comprehensive Health Center
Neal Palafox, MD
Professor and Chair
University of HI
Family Medicine
Honolulu, HI
Bill Plummer, PA-C
Lecturer
University of WA
MEDEX
Seattle, WA
Fred Quarnstrom, DDS
Affiliate Assistant Professor
University of WA
Dental Public Health Sciences
Seattle, WA
Mike Richardson, MD
Professor
University of WA
Radiology
Seattle, WA
Ron Schneeweiss, MBChB
Professor
University of WA
Family Medicine
Seattle, WA
Eric Stern, MD
Professor
University of WA
Radiology and Medicine
Seattle, WA
Matthew Thompson, MBChB
Assistant Professor
University of WA
Family Medicine
Seattle, WA
Mark Tuccillo, MD
Clinical Instructor
University of WA
Family Medicine
Anchorage, AK
Philip Weinstein, PhD
Professor
University of WA
Dental Public Health Sciences
Seattle, WA
Larry Wilson, MD
Associate Professor
University of WA
Psychiatry and Behavioral Sciences
Seattle, WA
Waianae, HI
PICCEP FINAL REPORT · DECEMBER 2003
Over three years the program provided four broad types
of CCE; medical courses, behavioral health courses, oral
health programs, and health assistant programs. PICCEP
carried out the CCE through structured teaching sessions
and informal teaching by making hospital rounds with
physicians, consulting on problem cases, and visiting and
providing seminars for dental and public health clinic
staff. PICCEP faculty and staff also worked to build the
infrastructure for CCE in each jurisdiction and to
promote the importance of disease prevention and
primary care by meeting with local and regional health
officials, other key political figures, and community
members. Insights from these exchanges were
incorporated into PICCEP program plans.
To keep current on regional
health issues and to solicit input
on PICCEP programs, PICCEP
faculty participated in health
policy and planning forums
affecting the region. These
included:
• Pacific Island Health Officers
Association (PIHOA),
(annual meetings at various
locations throughout
the region)
• Pacific Basin Medical
Association (PBMA),
(annual meetings at various
locations throughout
the region)
• American Pacific Nursing
Leaders’ Council (APNLC),
Chuuk (FSM)— June 2002
PICCEP workshop, Chuuk, FSM
• Medical Officer, Nursing,
and Allied Health Sciences
Training Project (MONAHP), Port Moresby,
Papua New Guinea—August 2000
• DHHS Region IX—Public Health Institute,
San Francisco—May 2000
• HRSA “Primary Care in the Pacific” Conference,
Palau—February 2002
• Oral Health Summit (jointly sponsored by WHO,
South Pacific Commission, Fiji School of
Medicine)—December 2001
13
MEDICAL COURSES
During 2000-03, the PICCEP team held medical CCE
courses in Palau, FSM (in Yap, Pohnpei, Chuuk, and
Kosrae), the RMI (in Ebeye and Majuro), Guam, and
CNMI. The curriculum included topics in general
internal medicine, obstetrics and gynecology, emergency
medicine, pediatrics, and various specialized topics,
as well as mental health and oral health (see table, p 14).
Courses in Guam and CNMI differed in approach, as
described below. Each CCE course engaged participants
for 16-20 credit hours. The faculty endeavored to
build rapport, conduct themselves in a culturally
sensitive manner, and conduct one-on-one instruction
whenever possible.
CCE
14
PICCEP GENERAL COURSE TOPICS BY JURISDICTION AND YEAR DELIVERED
FSM
Kosrae
2001 Emergency medicine
Rheumatology
Gynecology
Internal medicine
Obstetrics
Oral health
Pediatrics
Psychiatry/mental health
Preventive care
Osteopathy
Pre-hospital injury
management
Reducing medication errors
Patient consultations/
ward rounds
2002 Emergency medicine
Internal medicine
Obstetric topics
Oral health
Osteopathy
Pediatrics
Psychiatry/mental health
Preventive care/
provider-patient
communication
Radiology
Patient consultations/
ward rounds
2003 Emergency medicine
Dermatology
Hepatology
Orthopedics
Psychiatry/mental health
Preventive care/
provider-patient
communication
Radiology
Rheumatology
Patient consultations/
ward rounds
Chuuk
RMI
Pohnpei
Yap
X
Majuro
Ebeye
Republic
of Palau
X
American
Samoa*
CNMI
Guam
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
*The 2001 CCE course for American Samoa was cancelled due to the September 11 terrorist attack.
X
X
X
X
X
PICCEP FINAL REPORT · DECEMBER 2003
SAMPLE PICCEP MEDICAL COURSE TOPICS
Dermatology
• Skin infections
• Pediatric dermatology
• Biopsy workshop
Emergency medicine
• “All Stings Considered” update on marine injuries
• Advanced cardiac life support
• Ciguatera poisoning
• Diving medicine emergencies
• Wound management
General internal Medicine
• Asthma management
• Trends in diabetes management
• Update on management of hypertension
• Updates in stroke management
• Pneumonia
• Renal failure
Obstetric topics
• Update on STDs
• Diabetes in pregnancy
• Obstetric emergencies
Oral health
• Preventive oral health for non-dentists
Pediatrics
• Adolescent depression and suicide
• Newborn care
Psychiatry/mental health
• Depression and anxiety: medications and counseling
Radiology
• Reading X-rays: common errors
• Radiology of common fractures
Rheumatology
• Gout and crystal arthritis
• Osteoarthritis and diabetic musculoskeletal problems
• Joint aspiration workshop
15
Faculty from the University of Hawaii, with longstanding relationships throughout the region, were
part of the PICCEP team and participated in CCE in
American Samoa, Chuuk, Kosrae, Pohnpei, and the RMI.
In 2003, the University of Hawaii subcontracted to
conduct all of the PICCEP CME in American Samoa.
The courses were well-received by physicians, almost
all of whom attended in each jurisdiction, as well as
by clinical and public health nurses, certified nurse
midwives, health assistants, nursing assistants,
community health aides, and other staff. “A key
component of the success of the PICCEP program,”
the team wrote its funding agency in a report on the
program’s first year of CME activities, “has been
building the trust of the local physicians and health
system leaders.”
“Excellent. An intimidating course
made very user friendly.”
—course participant
Clinicians in Guam and the CNMI requested a somewhat
different approach to the CCE provided by PICCEP. For
Guam, where the Medical Association supports a more
developed CME program and physicians are required to
obtain CME credits annually as a condition of licensure,
PICCEP identified specialists in rheumatology and
hepatology for grand rounds presentations and
specialized consultations, which were provided in
2001 and 2003. CNMI was most interested in obtaining
Advanced Cardiac Life Support (ACLS) credentialing for
its providers, and in 2001, PICCEP contracted with
qualified Guam instructors to provide that course. In
2003, PICCEP arranged for a consultant in rheumatology
to provide CCE updates and consultation support to
CNMI, at the jurisdiction’s request.
PICCEP asked participants to evaluate all medical CCE
courses. The evaluation questionnaire included
satisfaction ratings on course organization and the match
of content with educational needs, the likelihood that the
course would improve clinical skills, and an opportunity
to provide comments on all aspects of the program.
Participants gave favorable reviews on all components,
as summarized in the chart on page 16.
CCE
16
EVALUATION OF PICCEP CCE COURSES (MEDICAL TOPICS): 2001-2003
4.4
Kosrae, FSM
4.9
4.7
Chuuk, FSM
4.7
4.7
4.7
Pohnpei, FSM
4.6
4.7
Jurisdiction
4.9
4.7
Yap, FSM
4.3
4.7
4.9
4.9
Majuro, RMI
4.8
Ebeye, RMI
4.6
4.9
4.4
Republic of Palau
4.2
4.8
American Samoa*
Very Poor (1)
2003
2002
2001
4.8
Poor (2)
Good (4)
Average (3)
Very Good (5)
Mean Course Rating (1-5)
CNMI and Guam received different types of CCE.
*The 2001 course in American Samoa was cancelled due to the Sept. 11 terrorist attacks. PICCEP partner U of HI provided CCE
to American Samoa in 2003 with a different evaluation protocol, but with same general results.
BEHAVIORAL HEALTH COURSES
PICCEP recognized that most physicians trained in the
resource-limited Pacific Islands had little exposure to
behavioral science concepts that had been only recently
introduced in medical schools in North America and
Europe. As is common in most of the developing world,
the region’s providers lacked training in patient-centered
care, effective and sensitive patient-provider
communication, shared decision-making about case
management, and ways to promote patients’ autonomy
so they engage in healthy behaviors and seek preventive
health services. Adding to this problem are issues of
cultural sensitivity in a region with a large share of
non-native physicians and other health care providers.
Training and awareness of behavioral concepts has
particular applicability to the Pacific region. High rates
of suicide, substance abuse, violence, and other conditions
with behavioral components indicate the burden of
behavior-related problems in many parts of the region,
as was confirmed during the PICCEP site visits and initial
“I liked the role-acting very well. It demonstrated
very clearly what we need to know.”
—course participant
needs assessment. Other conditions common to the Pacific
Islands—hypertension, diabetes, and obesity—have
behavioral components that require patient compliance to
medical regimens. Many physicians were frustrated by
their lack of training and tools to deal with patient mental
health and psychiatric problems.
PICCEP worked collaboratively with other faculty from
the University of Washington Department of Family
Medicine, the Northwest Frontier Addiction Technology
Transfer Center, and faculty from the University of Hawaii
School of Medicine to develop a behavioral health
PICCEP FINAL REPORT · DECEMBER 2003
17
EVALUATION OF PICCEP CME COURSES (BEHAVIORAL HEALTH TOPICS): 2002-2003
4.7
4.8
Kosrae, FSM
4.8
Chuuk, FSM
4.3
4.8
4.9
Jurisdiction
Pohnpei, FSM
4.6
4.7
Yap, FSM
4.7
Majuro, RMI
4.9
Ebeye, RMI
4.9
4.7
4.8
Republic of Palau
Very poor (1)
Poor (2)
2003
Average (3)
Very good (5)
Good (5)
Mean Course Rating (1-5)
2002
CNMI and Guam received different types of CCE.
PICCEP partner U of HI provided CCE to American Samoa with different evaluation protocol, with same general results.
curriculum that focused on provider-patient
communication. The interactive instruction and small
groups workshops led participants through techniques
for recognizing and prioritizing problem behaviors with
patients, identification of where patients fall on the “stages
of change” continuum, and techniques to help patients to
change problem behaviors. In addition, the curriculum
addressed mental health and psychiatric topics of
particular importance to primary care providers, including
diagnosis and management of acute psychosis, recognition
and management of depression and anxiety and panic
disorders, and substance abuse and dependence. The
program consisted of a total of 12 hours (four hours in
2002 and eight hours in 2003) of on-site workshops in
all PICCEP sites except Guam and CNMI (where PICCEP
provided specific CCE courses requested by those
jurisdictions).
Participants evaluated all of the behavioral health courses,
which were consistently well-attended and received (see
box above).
SAMPLE PICCEP BEHAVIORAL HEALTH
COURSE TOPICS
• Alcohol problems:
screening and brief interventions
• Enhancing patient motivation:
Managing chronic
health and substance abuse problems
• Enhancing motivation with diabetes patients (exercise)
• Smoking cessation
“Much-needed training and guidance.
This will definitely facilitate my clinical life.”
—course participant
• Definitions:
Substance abuse and dependence
• Alcohol and tobacco problems:
and managing patients
Assessing, intervening
CCE
18
ORAL HEALTH PROGRAMS
In part because some of their faculty had
worked previously in the Pacific Islands, the
PICCEP team knew at the outset of the
PICCEP that early childhood dental disease
was highly prevalent in the region. It affects
more than 90% of the children, a rate more
than double that of the mainland United
States. A survey conducted on Kosrae by a
local dentist in 2002 found only 1 of 123 firstgrade children to be free of dental decay. The
IOM report, a review of research literature,
and PICCEP site visits identified a general
shortage of dentists and dental health workers
in many parts of the region.
But poor oral health has been evident even in
areas with highly developed health systems
PICCEP oral health demonstration, Chuuk, FSM
and large health workforces. The problem is
closely linked to changes in lifestyle that have
occurred with the shift to cash economies, and by
promote awareness of the problem and encourage
extension, to a diet rich in such “cariogenic” foods
basic preventive behaviors, the team looked not only
as soft drinks and sugary cereals and snacks. Bottleto non-dental providers such as physicians, nurses, and
feeding behaviors, particularly using sugar-containing
community health workers but also to such “auxiliary”
substances, have further contributed to an outbreak
providers as directors of Head Start and of public health
of caries in young children. When children contract
and maternal and child health programs. PICCEP dental
the infection—often from their mothers and before
faculty from the University of Washington School of
their first birthdays—it spreads rapidly to deciduous
Dentistry developed a series of CCE lectures and
and then permanent teeth, causing pain, dysfunction,
workshops on dental health issues—combining didactic
and demand for expensive (and often inaccessible)
and hands-on methods—that was presented in
dental health services.
conjunction with the CME provided by the project’s
medical team. The program focused on interventions
To address the problem, PICCEP developed an oral
for pregnant women and very young children.
health CCE component to train providers in caries
prevention strategies that can be performed in the usual
The PICCEP team assembled a packet of oral health
scope of work of primary care providers. The education
information and protocols to be distributed in the Pacific
and training engaged both dental and medical providers
jurisdictions. The PICCEP oral health team emphasized
in achieving a common goal of recognizing oral health
the integration of preventive oral health strategies into
as an integral part of general health, and dental care as
primary medical care, shared preventive techniques such
an important component of primary health care. To
as the application of fluoride varnishes, and provided
instruction in diagnosis of dental disease, identification
of referral and treatment options, and consultation with
dental providers, physicians, and others working with
children. In response to requests, PICCEP provided
translations of University of Washington published
“Very practical information/application
materials (including the “Lift the Lip” flip chart), in
which are simple but can take care of a very
Marshallese and Kosraen.
serious and prevalent problem with children.
Thank you very much for sharing with us.”
—course participant
The program has raised the region’s awareness of the
integration of oral health strategies into primary care,
and some of the jurisdictions have continued the work.
Palau, for example, developed a model oral health
program that includes an oral health nurse who works
with MCH providers. The RMI has initiated new oral
PICCEP FINAL REPORT · DECEMBER 2003
19
HEALTH ASSISTANT PROGRAMS
“Eye-opening remarks on practical things
that can be done with very low financing;
very practical–maybe we
need to implement urgently.”
—course participant
health surveillance methods for young children. PICCEP
also identified regional individuals who could be involved
in providing oral health CCE to encourage regional
sustainability, and it helped revitalize the Pacific Basin
Dental Association as an active subgroup under the
PIHOA. PICCEP oral health faculty helped several
jurisdictions prepare successful grants to CDC for oral
health programs in the region. Several dentists from the
region have attended the University of Washington
Dental School Summer Institute.
The PICCEP oral health program faculty participated
in many regional planning and policy forums, including
the Oral Health Summit held by the South Pacific
Commission, WHO, and a meeting with the dental
program leadership of the Fiji School of Medicine (where
many of the region’s dentists are trained) in early 2001.
The program stressed the importance of integrating
oral health into the larger system of primary care and
involving medical personnel in anticipatory guidance
and preventive services.
Members of the PICCEP team who had worked in
developing countries knew that much of the health
services provided in the remote locations of the Pacific
jurisdictions do not occur in the central hospitals but
in more remote clinics and dispensaries staffed by nonphysicians. In many locations, these staff are health
assistants or health aides who have had minimal clinical
training. Some Pacific states have adopted the health
assistant or health aide model, in which villages or
remote communities select lay members to receive basic
clinical protocol training to handle emergencies, provide
basic preventive and prenatal care, and treat common
infections. This often occurs under radio or telephone
supervision by centrally located physicians or other
clinicians. The Alaska Health Aide Program, which
began in the 1950s, is one example of the successful
application of the health assistant model. The University
of Washington physician assistant training program
(MEDEX Northwest) has a strong relationship with the
Alaska program, including the training of more than 30
health aides as physician assistants.
Drawing from its Alaska experience, MEDEX developed
and implemented a health worker program in FSM
during the 1970s. Health worker programs are in place
in Yap, Chuuk, and the RMI, operating with varying
resource, infrastructure, and training needs.
As part of the program needs assessment, MEDEX
staff during 2002 visited the RMI and FSM (Chuuk
and Yap) to assess continuing education for the health
assistants. They found, to different degrees, a poorly
maintained primary care system, one further undermined
by factionalism and nepotism. The over-riding problems
appeared to be deteriorating
infrastructure, the lack of even
radio communication in many
areas, and a dearth of resources to
transport both clinicians and supplies
to remote islands.
PICCEP sought new resources to
mobilize MEDEX to create and
implement CCE and additional
training for health assistants in the
region, a proposal that generated
strong interest in several jurisdictions.
It called for application of a “train
the trainer” model, through which
MEDEX staff would train physicians
in Chuuk, considered the most
challenging and needy environment
PICCEP course, Ebeye, RMI
20
in the region. The physicians would become familiar
with the health worker system, engage in curriculum
development, and deliver month-long CCE to health
assistants. These activities could be duplicated and
delivered in other jurisdictions over time.
To prepare for this effort, PICCEP in 2002 brought
health assistant program educators from Chuuk to
Alaska to observe training and operations of the Alaska
Pohnpei, FSM
CCE
Health Aide program, which trains lay community
members to provide, under physician direction, basic
health services in remote sites. But 2003 was to be the
final year of the PICCEP program because HRSA
decided to have a new competitive cycle to award CCE
funds for the Pacific jurisdictions. The health assistant
“train the trainer” program requests were not funded
by HRSA or others.
PICCEP FINAL REPORT · DECEMBER 2003
21
Clinical Reference Materials
Supplementation
During its initial site visits and needs assessment, the
PICCEP team discovered that the region’s health care
providers lacked up-to-date clinical reference materials.
Existing resources were dated and in poor condition.
Most facilities lacked libraries or librarians and had
limited, slow, and expensive internet access, making
use computerized medical databases impractical.
PICCEP concluded that ready access to medical reference
materials could greatly assist providers practicing in
isolated settings. But such book donation programs often
fail in the face of challenges including materials failing to
reach their intended audience, placed where few potential
Dear Professor,
It is great help for us through your effort
we got PICCEP. The books are very useful,
and all main reference books are placed
within reach of all medical & other
providers at the hospital nurses’ station,
which is opened and manned 24/7!…
Thanking you again,
—from a health official of a recipient jurisdiction
users know about them, and simply going missing.
PICCEP resolved to design its program to ensure the
long-term access and usefulness of the references.
PICCEP modeled this effort roughly on the World
Health Organization’s Blue Trunk Program in Africa.
During 2000-01, the program’s budget included $40,000
for a “reference materials supplementation program”
that targeted the region’s hospitals, where most
physicians are based. PICCEP sought to involve
each hospital in the selection of suitable materials, so a
clinician-staff team developed a “catalog” of core and
specialized references that would suit the needs of a
variety of health professionals in different clinical
settings. It identified a key contact at each hospital who
communicated the reference material preferences of their
clinical colleagues. The team categorized the resources
by topic, asked the hospitals to rank the priority of each
item in the catalog, and invited them to request resources
in addition to those listed.
Not surprisingly, the requests from the jurisdictions far
exceeded the project budget. PICCEP staff analyzed each
hospital’s choices and prioritized core items and materials
most relevant to its resources and community. PICCEP
Pohnpei, FSM
22
CLINICAL REFERENCE MATERIALS SUPPLEMENTATION
provided medical reference resources (books, CD-ROMs,
journals, posters, etc.) to hospitals in Palau, the four
states of the FSM, the RMI (Majuro and Ebeye),
American Samoa, Guam, and the CNMI (Saipan
and Rota). It purchased most selections through the
University Bookstore, which offered a discount as
well as free shipping. The American Academy of Family
Physicians International Fund, which channels donations
of medical reference resources to needy hospitals around
the world, contributed additional materials.4
Pohnpei, FSM
Johnson KE, Skillman SM, Ellsbury KE, Thompson MJ, and Hart, LG. Updating
hospital reference resources in the U.S.-associated Pacific Basin: Efforts of the
Pacific Islands Continuing Clinical Education Program (PICCEP). WWAMI Center for
Health Workforce Studies Working Paper #81. 2003 (September).
4
PICCEP FINAL REPORT · DECEMBER 2003
23
Other PICCEP Activity
ASSESSMENT OF CONTINUING EDUCATION
NEEDS OF NURSES IN THE PACIFIC BASIN
More than 100 nurses from all six jurisdictions attended
a meeting of the American Pacific Nurse Leaders Council
in Chuuk during June 18-22, 2001. PICCEP faculty took
this opportunity to interview key informants about the
continuing nursing education (CNE) needs in the region.
Nursing shortages afflict the entire region. In the
CNMI, for example, the shortage is so acute that
retirees have been called back to keep the jurisdiction’s
hospital open. The nurses expressed the need for CNE
that addresses patient communication and decisionmaking and organization skills—especially for those who
have been promoted to positions that require leadership
skills for which they have had no training. They also
mentioned the need for training in HIV/AIDS (which
is just making its way to the region), chronic disease
management, infection control, pediatric care, Vitamin
A deficiency and other nutritional issues, and CPR
training and recertification. The nurses mentioned the
need for CNE in helping patients manage substance
abuse and domestic violence issues. All of the PICCEP’s
core and behavioral health CCE courses included nurses
among the participants.
PHARMACY NEEDS ASSESSMENT
PICCEP faculty studied pharmacy needs during site
visits to the RMI (Majuro) and FSM (Pohnpei and
Chuuk) during July 2001. They found a general need
for better integration of pharmacy and medical services,
for timely reference texts, for refill protocols, and for
pharmacy computers with prescription-dispensing
software. In addition, pharmacists were needed at
hospitals in Pohnpei and Chuuk. The contribution
of volunteer pharmacists under AusAid, who spent two
years on site, has greatly improved pharmacy services
on Palau and Majuro.
VIDEO TELECONFERENCE TEST
The PICCEP team tested the utility of video
teleconference technology (VTC) to communicate
CME lectures to broader audiences. A test, conducted
in September 2002 at a Pacific Basin Medical Association
meeting in Kosrae, was not successful because it was
complicated by intermittently poor audio quality and
interference. Similar problems with videoconferencing
efforts were observed throughout the region over the
course of the PICCEP program. The PICCEP team
concluded that the best use of VTC would be as a
“store and forward” approach for presentations,
augmented by live long-distance telephone connections,
until the telecommunications infrastructure becomes
more reliable.
LABORATORY AND RADIOLOGY
PICCEP course, Majuro, RMI
During its needs assessment and CCE delivery, the
PICCEP team had numerous opportunities to observe lab
and radiology resources in the jurisdictions. They found
that these resources ranged from nearly non-existent in
some areas to reasonably adequate in others. In nearly
all the program sites, laboratory and radiology staff need
CCE in their fields, and in some cases, retraining as well.
This situation undermines the success of CCE, because
without reliable laboratory and radiology services,
clinicians cannot effectively practice their skills. Despite
its view that this was a major impediment to effective
health care delivery in the region, PICCEP was unable to
secure funding (sought from several potential sponsors)
to support additional laboratory and radiology CCE.
24
OTHER PICCEP ACTIVITY
STUDENT PROJECTS
During the four-years of PICCEP, the program provided
opportunities for several University of Washington
student research projects. Among these efforts was the
work of two University of Washington medical students,
who spent a summer quarter in Kosrae during the
summer of 2002, and another two who spent a quarter
in RMI in 2003 to assess knowledge and cultural beliefs
Chuuk, FSM
surrounding prevention and treatment of Type 2
diabetes and to assess prevalence of diabetic peripheral
neuropathy. The findings of this research are expected
to inform culturally appropriate CCE planning.
The students presented their study results at the
Carmel Western Research Forum, and one received
an honorable mention.
PICCEP FINAL REPORT · DECEMBER 2003
25
Sustainability
As PICCEP identified during its initial needs assessment,
for CCE to be effective in improving the clinical skills of
health providers, it must be ongoing. A sustainable model
of CCE, especially in areas with very limited resources
and where the health care systems are closely tied to
political systems, must recognize several key insights
developed in the course of PICCEP’s tenure:
1. Local incentives, such as connection to licensure,
must be in place to encourage participation in CCE.
2. Local health leaders—the “higher-ups” such as
politically appointed health officers and other health
policy makers—must recognize and endorse the
value of CCE for clinicians who are often
overworked and underpaid.
3. Once local clinicians and health leaders accept the
value of CCE, affordable models are needed that
can be locally maintained and replicated. These
models would reflect the success factors identified
at the Guam meeting.
Chuuk, FSM
4. New resources from the U.S. government,
combined with rational priority-setting among
the region’s health policy makers, will be needed
to address diminishing health budgets in the Pacific.
During its fourth year of operation in 2002-03, PICCEP
faced a 50% budget reduction, after which funding
ended altogether. The University of Washington’s
PICCEP partner, the University of Hawaii, has since
been awarded a four-year HRSA contract to deliver
CCE to the U.S.-associated Pacific jurisdictions. In
keeping with the PICCEP team’s original and continuing
views that the CCE for the Pacific jurisdictions should
be controlled from the Pacific region, the University of
Washington supported Hawaii’s application, and faculty
from the PICCEP team serveo n the new program’s
advisory committee.
26
National Day Parade, Kosrae, FSM
SUSTAINABILITY
PICCEP FINAL REPORT · DECEMBER 2003
27
Notes for Future Programs
The hope of any CCE program imported to the U.S.associated Pacific region should be to present models
of CCE that each jurisdiction can replicate—at least in
part. This region likely will be plagued by a shortage of
CCE resources for years to come. But nonetheless, CCE
programs designed with significant input and direction
from the health professionals of each site are more
likely to be sustained than those imposed without such
input. A CCE program should recognize the expertise
and skills of professionals in the region by inviting
them to plan and teach courses, thereby modeling
local resources that may be tapped in the future.
CCE programs designed around the priorities of each
jurisdiction are also more likely to attract participants
than those based on priorities set an ocean away.
Information technology can overcome the barriers
of expense and time required to bring faculty and
consultants to the islands. But access to the internet
and video conferencing are still expensive, and many
of the Pacific jurisdictions lack adequate
telecommunications infrastructure to support use of
these resources in a practical way. The challenge of
using telecommunications effectively for teaching is
especially formidable in regions, such as the Pacific,
where health professionals come from many different
cultures and speak different languages. Any CCE
program that mobilizes information technology should
include evaluation components to assess the success
with which various approaches overcome these
Kosrae, FSM
challenges. But, while telecommunications can
contribute to CCE in the region, it cannot substitute for
the learning that takes place informally on-site through
faculty participation in hospital rounds, discussing
patient issues during lunch, and first-hand experience
with different cultures.
A FINAL THOUGHT
PICCEP’s CCE program consistently built on face-toface interaction between its program faculty (primarily
from resource-rich institutions) and the health
professionals at the health care institutions of the Pacific
jurisdictions (which have much more limited resources).
Both parties benefited from the program. Faculty from
the University of Washington and other institutions who
led the PICCEP courses honed their professional skills
and brought back lessons that will be incorporated into
teaching curricula and clinical practice. Many of the
PICCEP team’s personal and professional relationships
with the islands’ health professionals and general
populations have continued long past the course
contact. In several instances, island physicians have
contacted PICCEP faculty to consult on difficult cases.
Future CCE programs in the region should recognize the
power of in-person communication and how it can
amplify learning experiences, and they should encourage
as many face-to-face instruction opportunities in their
programs as resources allow.
PACIFIC ISLANDS CONTINUING CLINICAL EDUCATION PROGRAM (PICCEP)
UNIVERSITY OF WASHINGTON
CENTER FOR HEALTH WORKFORCE STUDIES
BOX 354982
SEATTLE, WA 98195
http://www.fammed.washington.edu/CHWS/