Advertisement

Journal of Technology in Behavioral Science

, Volume 3, Issue 3, pp 206–220 | Cite as

Telehealth for Rural Diverse Populations: Cultural and Telebehavioral Competencies and Practical Approaches for Clinical Services

  • Donald M. Hilty
  • Gregory Evangelatos
  • G. Andrew Valasquez
  • Christine Le
  • Juan Sosa
Article

Abstract

Rural health care settings are challenged to provide timely and evidence-based care, particularly for culturally diverse patients with behavioral health disorders. Telepsychiatry and telebehavioral health improve access to care and leverage scarce resources like specialty expertise and language interpreters. This paper focuses on the three questions, particularly related to medical settings: (1) What are the components of culturally competency clinical care and what fundamental approaches help providers? (2) What fundamental approaches like the cultural formulation interview and the bio-psycho-socio-cultural model help providers achieve it? (3) How do we link outcomes with culturally competent and telepsychiatric competencies? Rural underserved patients need culturally competent care, which requires skills by all health care team members. Skill-focused training based on practical everyday practices, cases, and pedagogic methods can improve care and engage participants. Telepsychiatric care is similar to in-person care, either requires integrated cultural and telepsychiatric skills. Educational and administrative adjustments are needed to promote culturally competent care, particularly by telehealth. Rural populations need culturally competent care and teams with telepsychiatric skill sets increase access. More quantitative and qualitative research is suggested to improve the approach and better evaluate, administer, and finance services.

Keywords

Telepsychiatry Behavioral health Academic health centers Culture Competencies Models Approaches 

Notes

Acknowledgements

American Association of Directors of Psychiatry Residency Training, Coalition for Technology in Behavioral Science (CTIBS), Telebehavioral Behavioral Health Institute (TBHI), and UC Davis School of Medicine and Department of Psychiatry and Behavioral Sciences were acknowledged, including Drs. Francis Lu, Russell Lim, and Hendry Ton.

References

  1. Accreditation Council for Graduate Medical Education (2007). Residency Review Committee, Guidelines for Psychiatric Residencies. Retrieved from www.acgme.org/acWebsite/downloads/RRC_progReq/400pr07012007.pdf.
  2. Accreditation Council on Graduate Medical Education (2013). Common program requirements. Retrieved from https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf.
  3. Adler, R. H. (2009). Engel’s biopsychosocial model is still relevant today. Journal of Psychosomatic Research, 67(6), 607–611.CrossRefPubMedGoogle Scholar
  4. Agency for Healthcare Research and Quality: National Healthcare Disparities Report, 2006. Rockville, MD, Agency for Healthcare Research and Quality, 2006. Retrieved from http://www.ahrq.gov/qual/nhdr06/nhdr06.htm.
  5. American Association for Family and Marital Therapy (2004). Core Competencies. Retrieved from: https://www.aamft.org/imis15/Documents/MFT_Core_Competencie.pdf.
  6. American Association for Family and Marital Therapy (2015). Code of Ethics. Retrieved from: http://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx.
  7. American Association of Directors of Psychiatry Residency Training (2017). Training Directors Curricula. Retrieved from http://www.aadprt.org/training-directors/curriculum.
  8. American Association of Medical Colleges, Core Medical Student Competencies (2015). Retrieved from https://www.aamc.org.
  9. American Counseling Association. (1992). Cross-cultural competencies and objectives. Retrieved from http://www.counseling.org/Publications/.
  10. American Psychiatric Association. (1969). Position statement on the delineation of transcultural psychiatry as a specialized field of study. American Journal of Psychiatry, 126, 453–455.CrossRefGoogle Scholar
  11. American Psychiatric Association Cultural Formulation Interview (2013). Patient Version. Website: http://www.dsm5.org/Pages/Feedback-Form.aspx, and Informant Version, at: http://www.multiculturalmentalhealth.ca/wp-content/uploads/2013/10/2013_DSM5_CFI_InformantVersion.pdf.
  12. American Psychiatric Association, Cultural Formulation Interview Supplementary Modules 2013. Website: http://www.multiculturalmentalhealth.ca/wp-content/uploads/2013/10/2013_CFI_supplementarymodules.pdf.
  13. American Psychological Association (2002). APA guidelines on multicultural education, training, research, practice and organizational change for psychologists. Retrieved from: http://www.apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx.
  14. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402.CrossRefGoogle Scholar
  15. American Psychological Association (2017). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. Retrieved from: http://www.apa.org/pi/oema/resources/policy/provider-guidelines.aspx.
  16. Americans with Disabilities Act 1990. Public law 101–336. (1990). Retrieved from http://library.clerk.house.gov/reference-files/PPL_101_336_AmericansWithDisabilities.pdf.
  17. Association of American Medical Colleges (2000). The AAMC Initiative for Cultural Competence in Medical Education. Retrieved from http://www.aamc.org/meded/tacct/culturalcomped.pdf.
  18. Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., et al. (2005). Cultural competency: a systematic review of health care provider educational interventions. Medical Care, 43(4), 356–373.CrossRefPubMedPubMedCentralGoogle Scholar
  19. Berger, J. T. (1998). Culture and ethnicity in clinical care. Archives of Internal Medicine, 158(19), 2085–2090.CrossRefPubMedGoogle Scholar
  20. Brooks, T. R. (1992). Pitfalls in communication with Hispanic and African-American patients: do translators help or harm? Journal of the National Medical Association, 84(11), 941–947.PubMedPubMedCentralGoogle Scholar
  21. Brown, M. T., Bussell, J. K. (2011). Medication adherence: WHO cares? Mayo Clinic Proceedings. 86(4), 304–314.Google Scholar
  22. Brua, C. (2008). Role-blurring and ethical grey zones associated with lay interpreters: Three case studies. Communication & Medicine, 5(1), 73-79.Google Scholar
  23. California Department of Mental Health DMH Information Notice No: 02–03 (1997). Addendum for Implementation Plan for Phase II Consolidation of Medi-Cal Specialty Mental Health Services—Cultural Competence Plan Requirements; 2003, superseding (California) DMH Information Notice No: 97–14. Addendum for implementation plan for phase II consolidation of Medi-Cal specialty mental health services—cultural competence plan requirements; 1997. Retrieved from http://www.dmh.cahwnet.gov/DMHDocs/docs/notices02/02–03_Enclosure.pdf.
  24. Carlson, J. (2010). Breaking down language barriers. Hospital interpreters get credentialed with new certification programs. Modern Healthcare, 15;40(46), 32–34.Google Scholar
  25. Cerda, G. M., Hilty, D. M., Hales, R. E., & Nesbitt, T. S. (1999). Use of telemedicine with ethnic groups. Psychiatric Services, 50(10), 1364.CrossRefPubMedGoogle Scholar
  26. Chong, J., & Moreno, F. (2012). Feasibility and acceptability of clinic-based telepsychiatry for low-income Hispanic primary care patients. Telemedicine and e-Health, 18(4), 297–304.CrossRefPubMedGoogle Scholar
  27. Chung, R. C., & Bemak, F. (2002). The relationship of culture and empathy in cross-cultural counseling. Journal of Counseling & Development, 80(2), 154–159.CrossRefGoogle Scholar
  28. Civil Rights Act of 1964, Public Law 88-352 (1964).Retrieved from https://www.gpo.gov/fdsys/pkg/STATUTE-78/pdf/STATUTE-78-Pg241.pdf.
  29. Coalition for Technology in Behavioral in Behavioral Science (CTIBS) (2018). Retrieved from http://ctibs.org.
  30. Committee on the Accreditation of Canadian Medical Schools (2017). Retrieved from https://www.afmc.ca/accreditation/committee-accreditation-canadian-medical-schools-cacms/.
  31. Cross, T.L., Bazron, B.J., Dennis, K.W., et al. (1989). Towards a culturally competent system of care, volume 1. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. Retrieved from https://spu.edu/~/media/academics/school-of-education/Cultural%20Diversity/Towards%20a%20Culturally%20Competent%20System%20of%20Care%20Abridged.ashx.
  32. Elderkin-Thompson, V., Silver, R. C., & Waitzkin, H. (2001). When nurses double as interpreters: a study of Spanish-speaking patients in a US primary care setting. Social Sciences in Medicine, 52, 1343–1358.CrossRefGoogle Scholar
  33. Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136.CrossRefPubMedGoogle Scholar
  34. Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137(5), 535–544.CrossRefPubMedGoogle Scholar
  35. Flexner, A. (1910). Medical education in the United States and Canada: a report of the Carnegie Foundation of the advancement of teaching. Bulletin 4. Boston: Updyke.Google Scholar
  36. Frank, J. R. (2005) The CanMEDS 2005 Physician Competency Framework. Retrieved from http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf.
  37. Frank, J.R., Mungroo, R., Ahmad, Y., Wang, M., De Rossi, S., Horsley, T. (2010). Toward a definition of competency-based education in medicine: A systematic review of published definitions. Medical Teacher, 32(8), 631-637.  https://doi.org/10.3109/0142159X.2010.500898.
  38. Freeman, G. K., Rai, H., Walker, J. J., Howie, J. G. R., Heaney, D. J., & Maxwell, M. (2002). Non-English speakers consulting with the GP in their own language: a cross-sectional survey. The British Journal of General Practice, 52(474), 36–38.PubMedPubMedCentralGoogle Scholar
  39. Geller, J. M. (1999). Rural primary care providers’ perceptions of their roles in the provision of mental health services: voices from the plains. Journal of Rural Health, 15(3), 326–334.CrossRefPubMedGoogle Scholar
  40. Geller, J. M., & Muus, K. J. (2000). The role of rural primary care physicians in the provision of mental health services. Journal of the Washington Academy of Sciences, 86, 131–142.Google Scholar
  41. Ghaemi, S. N. (2006). Paradigms of psychiatry: eclecticism and its discontents. Current Opinion in Psychiatry, 19, 619–624.CrossRefPubMedGoogle Scholar
  42. Ghaemi, S. N. (2011). The biopsychosocial model in psychiatry: a critique. Existenz 2011. Spring, 6(1). http://www.bu.edu/paideia/existenz/volumes/Vol.6-1Ghaemi.html.
  43. Gifford, V., Niles, B., Rivkin, I., Koverola, C., & Polaha, J. (2012). Continuing education training focused on the development of behavioral telehealth competencies in behavioral healthcare providers. Rural Remote Health, 12(2108), 1–15 Retrieved from file:///Users/user/Downloads/article_print_2108.pdf.Google Scholar
  44. Hilty, D. M. (2016). Advancing science, clinical care and education: shall we update Engel’s biopsychosocial model to a bio-psycho-socio-cultural model? Psychology and Cognitive Sciences - Open Journal, 1(1), e1–e5.  https://doi.org/10.17140/pcsoj-1-e001.CrossRefGoogle Scholar
  45. Hilty, D. M., Marks, S. L., Urness, D., Yellowlees, P. M., & Nesbitt, T. S. (2004). Clinical and educational applications of telepsychiatry: a review. The Canadian Journal of Psychiatry, 49(1), 12–23.CrossRefPubMedGoogle Scholar
  46. Hilty, D. M., Nesbitt, T. S., Kuenneth, C. A., Cruz, G. M., & Hales, R. E. (2007). Rural versus suburban primary care needs, utilization, and satisfaction with telepsychiatric consultation. Journal of Rural Health, 23(2), 163–165.CrossRefPubMedGoogle Scholar
  47. Hilty, D. M., Ferrer, D., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: a 2013 review. Telemedicine Journal and E-Health, 19(6), 444–454.CrossRefPubMedPubMedCentralGoogle Scholar
  48. Hilty, D. M., Ton, H., Lu, F., & Yager, J. (2014). Revising Engel’s biopsychosocial model to the biopsychosocialcultural model? Suggestions and implications. Keystone: Workshop, American Directors of Medical Student Education in Psychiatry.Google Scholar
  49. Hilty, D. M., Lim, R. F., Nasatir-Hilty, S. E., Koike, A. K., Ton, H., & Nesbitt, T. S. (2015a). Planning for telepsychiatric consultation: a needs assessment for cultural and language services at rural sites in California. Journal of Rural Mental Health, 39(3–4), 153–161  https://doi.org/10.1037/rmh0000035.CrossRefGoogle Scholar
  50. Hilty, D. M., Crawford, A., Teshima, J., Chan, S., Sunderji, N., Yellowlees, P. M.,. .. Li, S. (2015b). A framework for telepsychiatric training and e-health: competency-based education, evaluation and implications. International Review of Psychiatry, 27(6), 569–592. doi: https://doi.org/10.3109/09540261.2015.1091292.CrossRefPubMedGoogle Scholar
  51. Hilty, D. M., Ton, H., St. George, C., & Lim, R. (2015c). The ‘how to’ on training medical students on culture and diversity: interviewing tips, brief cultural formulation, biopsychosociocultural treatment planning, and psych OSCE options. Workshop presented at the meeting of the Association of Directors of medical student education in psychiatry, Stowe, VT.Google Scholar
  52. Hilty, D. M., Yellowlees, P. M., Parish, M. B., & Chan, S. (2015d). Telepsychiatry: effective, evidence-based and at a tipping point in healthcare delivery. Psychiatric Clinics of North America, 38(3), 559–592.  https://doi.org/10.1016/j.psc.2015.05.006.CrossRefPubMedGoogle Scholar
  53. Hilty D.M., Maheu, M., Doarn, C., Ommen, S., Nesbitt T.S. (2016a). A framework for telemedicine trainineg and E-health: competency-based education, Evaluation and Implications . Short Course presented at the meeting of the American Telemedicine Association, Minneapolis.Google Scholar
  54. Hilty, D. M., Shoemaker, E., Chan, S., O’Neill, P., Snowdy, C., Torous, J., DeJong, S. (2016b). A framework for telepsychiatric, social media and other technologies: competency-based education, evaluation and implications. Education Workshop Session presented at the meeting of the American Association of Directors of Psychiatry Residency Training, Austin, TX.Google Scholar
  55. Hilty, D. M., Maheu, M., Drude, K., Hertlein, K., Long, R., Luoma, T., & Ford, D. (2017a). Telebehavioral health, telemental health, e-therapy and e-health competencies: the need for an interdisciplinary framework. Journal of Technology in Behavioral Science, 2, 171–189.  https://doi.org/10.1007/s41347-017-0036-0.CrossRefGoogle Scholar
  56. Hilty, D. M., Zalpuri, I., Stubbe, D., Snowdy, C., Shoemaker, E. Z., Myint, M., Liu, H. (2017b). Social media/networking as part of e-behavioral health and psychiatric education: competencies, teaching methods, and implications. Journal of Technology in Behavioral Science, in press.Google Scholar
  57. Hiratsuka, V., Delafield, R., Starks, H., Ambrose, A. J., & Mau, M. M. (2013). Patient and provider perspectives on using telemedicine for chronic disease management among native Hawaiian and Alaska native people. International Journal of Circumpolar Health, 72(1), 21401.  https://doi.org/10.3402/ijch.v72i0.21401.CrossRefGoogle Scholar
  58. Jaini, P. A., & Lee, J. S. (2015). A review of 21st century utility of a biopsychosocial model in United States medical school education. Journal of Lifestyle Medicine, 5(2), 49–59.  https://doi.org/10.15280/jlm.2015.5.2.49.CrossRefPubMedPubMedCentralGoogle Scholar
  59. Kim, G., Aguado Loi, C. X., Chiriboga, D. A., Jang, Y., Parmelee, P., & Allen, R. S. (2010). Limited English proficiency as a barrier to mental health service use: a study of Latino and Asian immigrants with psychiatric disorders. Journal of Psychiatric Research, 45(1), 104–110.CrossRefPubMedGoogle Scholar
  60. Lewis-Fernández, R., Aggarwal, N. K., Bäärnhielm, S., Rohlof, H., Kirmayer, L.J., Weiss, M.G., … & Lu, F. (2014). Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry, 77(2), 130-154.Google Scholar
  61. Liaison Committee on Medical Education Competencies Revision 2015. At: https://www.lcme.org/publications/2015-16-functions-and-structure-with-appendix.pdf.
  62. Lim, R., Luo, J., Suo, S., & Hales, R. (2008). Diversity initiatives in academic psychiatry: applying cultural competence. Academic Psychiatry, 32(4), 283–290.CrossRefPubMedGoogle Scholar
  63. Loue, S., Wilson-Delfosse, A., & Limbach, K. (2014). Identifying gaps in the cultural competence/sensitivity components of an undergraduate medical school curriculum: a needs assessment. Journal of Immigrant and Minority Health, 17(5), 1412–1419.  https://doi.org/10.1007/s10903-014-0102-z.CrossRefGoogle Scholar
  64. Maheu, M., Drude, K., Hertlein, K., Lipschutz, R., Wall, K., Long, R., ... & Hilty, D. M. (2018). An interdisciplinary framework for telebehavioral health competencies. Journal of Technology in Behavioral Science. https://link.springer.com/content/pdf/10.1007%2Fs41347-018-0046-6.pdf.
  65. Marcin, J. P., Nesbitt, T. S., Struve, S., Traugott, C., & Dimand, R. J. (2004). Financial benefits of a pediatric intensive care unit-based telemedicine program to a rural adult intensive care unit: impact of keeping acutely ill and injured children in their local community. Telemedicine Journal and e-Health, 10(Supplement 2), 1–5.CrossRefGoogle Scholar
  66. McLaren, N. (1998). A critical review of the biopsychosocial model. Australian and New Zealand. Journal of Psychiatry, 32:86–92.Google Scholar
  67. Moreno, F. A., Chong, J., Dumbauld, J., Humke, M., & Byreddy, S. (2012). Use of standard webcam and internet equipment for telepsychiatry treatment of depression among underserved Hispanics. Psychiatric Services, 63(12), 1213–1217.CrossRefPubMedGoogle Scholar
  68. Mucic, D. (2010). Transcultural telepsychiatry and its impact on patient satisfaction. Journal of Telemedicine and Telecare, 16(5), 237–242.CrossRefPubMedGoogle Scholar
  69. National Association of Social Workers (2001). Standards for cultural competence in social work practice. Retrieved from http://www.socialworkers.org/sections/credentials/cultural_comp.asp.
  70. New York State Office of Mental Health (1997). Cultural and linguistic competency standards. New York, Office of Mental Health. Retrieved from http://www.ct.gov/dmhas/LIB/dmhas/OMA/guidelines.pdf.
  71. Nieves, J. E., & Stack, K. M. (2007). Hispanics and telepsychiatry. Psychiatric Services, 58(6), 877–888.CrossRefPubMedGoogle Scholar
  72. Office of the Surgeon General Center for Mental Health Services and National Institute of Mental Health (2001). Mental health: culture, race, and ethnicity: a supplement to mental health: a report of the surgeon general. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44242/.
  73. Perez-Stable, E. J. (2007). Language access and Latino health care disparities. Medical Care, 45, 1009-1011.Google Scholar
  74. Pöchhacker, F. (2000). Language barriers in Vienna hospitals. Ethnicity and Health, 5(2), 113–119.CrossRefPubMedGoogle Scholar
  75. Rost, K., Williams, C., Wherry, J., & Smith Jr., G. R. (1995). The process and outcomes of care for major depression in rural family practice settings. The Journal of Rural Health, 11(2), 114–121.CrossRefPubMedGoogle Scholar
  76. Rost, K., Zhang, M., Fortney, J., Smith, J., & Smith, G. R. Jr. (1998). Rural-urban differences in depression treatment and suicidality. Medical Care, 36(7), 1098–1107.Google Scholar
  77. Royal College of Physicians and Surgeons, CanMEDS Framework (2005). Retrieved from http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework/.
  78. Saha, S., Komaromy, M., Koepsell, T. D., & Bindman, A. B. (1999). Patient-physician racial concordance and the perceived quality and use of health care. Archives of Internal Medicine, 159(9), 997–1004.CrossRefPubMedGoogle Scholar
  79. Shore, J. H., & Manson, S. M. (2005). A developmental model for rural telepsychiatry. Psychiatric Services, 56(8), 976–980.CrossRefPubMedGoogle Scholar
  80. Shore, J. H., Savin, D. M., Novins, D., & Manson, S. M. (2006). Cultural aspects of telepsychiatry. Journal of Telemedicine and Telecare, 12(3), 116–121.CrossRefPubMedGoogle Scholar
  81. Telebehavioral Behavioral Health Institute (TBHI) (2017). TBHI Professional Training Certification Programs. Retrieved from https://telehealth.org/certified/andtelehealth.org/courses/.
  82. Ton, H., Koike, A., Hales, R. E., Johnson, J. A., & Hilty, D. M. (2005). A qualitative needs assessment for development of a cultural consultation service. Transcultural Psychiatry, 42(3), 491–504.  https://doi.org/10.1177/1363461505055629.CrossRefPubMedGoogle Scholar
  83. United States Center for Mental Health Services. (2000). Cultural competence standards in managed care mental health services: four underserved/underrepresented racial/ethnic groups (publication no. SMA00–3457). Washington, DC: Substance Abuse and Mental Health Services Administration.Google Scholar
  84. United States Department of Agriculture (2015). What is rural? Retrieved from http://ric.nal.usda.gov/what-is-rural/.
  85. United States Department of Health and Human Services (2001). Mental Health: culture, race, and ethnicity. A supplement to mental health: a report of the surgeon general. Rockville, MD, DHHS. Retrieved from http://www.ct.gov/dmhas/lib/dmhas/publications/mhethnicity.pdf.
  86. Waldstein, S. R., Neumann, S. A., Drossman, D. A., & Novack, D. H. (2001). Teaching psychosomatic (biopsychosocial) medicine in United States medical schools: survey findings. Psychosomatic Medicine, 63(3), 335–343.CrossRefPubMedGoogle Scholar
  87. Weiner, M. F., Rossetti, H. C., & Harrah, K. (2011). Videoconference diagnosis and management of Choctaw Indian dementia patients. Alzheimer's & Dementia, 7(6), 562–566.CrossRefGoogle Scholar
  88. Ye, J., Shim, R., Lukaszewski, T., Yun, K., Kim, S. H., & Rust, G. (2012). Telepsychiatry services for Korean immigrants. Telemedicine and e-Health, 18(10), 797–802.CrossRefPubMedGoogle Scholar
  89. Yellowlees, P., Marks, S., Hilty, D., & Shore, J. H. (2008). Using e-health to enable culturally appropriate mental healthcare in rural areas. Telemedicine and e-Health, 14(5), 486–492.  https://doi.org/10.1089/tmj.2007.0070.CrossRefPubMedGoogle Scholar
  90. Yellowlees, P. M., Odor, A., Iosif, A. M., Parish, M. B., Nafiz, N., Patrice, K., et al. (2013). Transcultural psychiatry made simple—asynchronous telepsychiatry as an approach to providing culturally relevant care. Telemedicine and e-Health, 19(4), 1–6.CrossRefGoogle Scholar
  91. Yeung, A., Chang, D., Gresham, R. L., Nierenberg, A. A., & Fava, M. (2004). Illness beliefs of depressed Chinese American patients in primary care. The Journal of Nervous and Mental Disease, 192(4), 324–327.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Donald M. Hilty
    • 1
    • 2
  • Gregory Evangelatos
    • 3
  • G. Andrew Valasquez
    • 4
  • Christine Le
    • 3
  • Juan Sosa
    • 3
  1. 1.Mental Health, Northern California Veterans Administration Health Care SystemSacramentoUSA
  2. 2.Department of Psychiatry and Behavioral SciencesUC DavisDavisUSA
  3. 3.Psychiatry and Addiction MedicineKaweah Delta Medical CenterVisaliaUSA
  4. 4.Medical StudentAmerican University of Antigua College of MedicineNew YorkUSA

Personalised recommendations