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Western medicine has a long tradition of humanitarian service in developing countries. But, over the past two decades, the manner in which medical services are provided to under-resourced nations has evolved. Rather than volunteering to deliver acute care through humanitarian missions, a new generation of global health physicians aims to become dispensable. Through new nonprofit and collaborative models, they are establishing ongoing relationships with medical professionals in host countries to actively promote capacity building, from construction of new facilities to medical education and training.
“Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting,” says HealthPartners hospitalist Brett R. Hendel-Paterson, MD, an assistant professor of medicine at the University of Minnesota who also practices in HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., and is co-director of the UM/CDC online global health course.
Sriram Shamasunder, MD, DTM&H, hospitalist, health sciences assistant clinical professor, and co-director of the University of California San Francisco (UCSF) Global Health-Hospital Medicine Fellowship, agrees. “Mission medicine has incredibly well-meaning and committed people, but to address the upstream problems that bring people to the hospital, there need to be systems-based solutions,” he says.
And that is where hospitalists come in.
Growing numbers of hospitalists are joining in global health efforts, as Marwa Shoeb, MD, MS, and Phuoc Le, MD, MPH, DTM&H, discovered when they surveyed SHM members about participation in global health activities. Drs. Shoeb and Le are assistant clinical professors in the division of hospital medicine at UCSF. The survey (J Hosp Med. 2013;8(13):162-163) revealed that 51% of 232 respondents had done global health work prior to becoming a hospitalist; another third continued global health work after they began their HM careers.
Many believe hospitalists are uniquely qualified for global health initiatives. HM’s emphasis on systems of care delivery and quality improvement can supply much-needed knowledge as under-resourced countries strive to increase access to health care, says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School in Boston and deputy chief medical officer of Partners in Health (PIH) in Haiti (www.pih.org).
“Being a hospitalist is incredibly complementary to doing global health work,” Dr. Morse says. PIH has maintained a presence in Haiti for more than two decades and just recently celebrated a milestone with the Haitian medical community: establishment of the country’s newest medical residency training at University Hospital in Mirebalais.
Embrace Challenges
In early December, a group of UCSF hospitalists visited another PIH site, a Haitian Ministry of Health hospital in Hinche, located in the central plateau region of the country. Robin Tittle, MD, and Varun Verma, MD, were nearing the end of their first three-month rotation in the country as clinical fellows in the two-year-old Global Health-Hospital Medicine Fellowship.
According to Dr. Tittle, working in a resource-challenged hospital such as the one in Hinche is an irreplaceable experience. She and Dr. Verma discovered new levels of meaning in the term “workaround.” For example, “we have really limited lab capacity,” Dr. Tittle says. “One interesting thing I learned is how much your lab depends on access to reliable electricity. A number of our machines have been ruined because of electrical power surges. There are only certain people in the lab who know how to run certain tests.”
Dr. Tittle has learned that “you can’t practice medicine [in Haiti] without addressing the system.” Exposure to QI methods during training have been useful, she says, as she and Dr. Verma designed a medical education seminar for their Haitian colleagues by identifying the top 10 diagnoses in the nursing discharge registry. Still, she admits that the effort was hampered by nonspecific diagnoses—again a result of their inability to run diagnostic tests.
The learning has been reciprocal, notes Dr. Jacquelin Pierre Auguste, one of the Haitian internists in Hinche.
“We share a lot of knowledge,” he says, enthusiastically.
One example Dr. Pierre shared was being able to bring the clinical fellows into the case of a young mother who had developed postpartum cardiomyopathy. For unknown reasons, the condition is 10-20 times as common in Haiti as in the U.S., according to Dr. Le, who is co-director of the UCSF Global Health-Hospital Medicine Fellowship program. “Our fellows are also learning much more about the management of late-stage disease in tuberculosis and HIV,” he adds.
Several hospitalists have witnessed misappropriation of resources in global health projects, which can occur during emergency situations, such as in post-earthquake Haiti. For benefits to be sustainable, it’s best not to “charge in,” but to carefully assess the needs of the host setting. Although needs assessment should be handled by the sponsoring organization, hospitalists can contribute to this effort so that well-intentioned relief efforts do not cause unintended consequences, Dr. Hendel-Paterson says.
Hospitalists Unite
In the global health survey conducted in 2012, Drs. Shoeb and Le found that 46% of respondents were interested in collaborating with other hospitalists in order to increase their impact on health equity. In response to these and other observations about a need for mentorship, SHM established a Global Health and Human Rights Section, chaired by Drs. Shoeb and Le. They will be hosting a special global health forum at HM14 later this month in Las Vegas (www.hospitalmedicine2014.org).
The section goals are to:
- Provide a forum for like-minded hospitalists to share experiences and knowledge;
- Enhance the skill sets of hospitalists to apply their expertise in resource-poor settings; and
- Strengthen the capacity of local health systems through long-term collaborations and training in quality improvement.
Dr. Le, who has been affiliated with Partners in Health since his residency at Harvard Medical School, has spent time in sub-Saharan Africa as well as Haiti. He has been instrumental in advancing the HM global health agenda at UCSF and helped to organize the first national retreat on global health in HM last year. The program held its second annual retreat in February 2014.
Besides UCSF, two other global health fellowships are designed specifically for hospitalists: the University of Chicago Global Hospital Medicine Fellowship is headed by Evan Lyon, MD, an assistant professor of medicine in the section of hospital medicine in the UC Department of Medicine; the University of Florida College of Medicine’s Global Health-Hospitalist Fellowship program in Gainesville is headed by Vincent DeGennaro, Jr., MD, MPH, assistant professor in the division of hospital medicine.
In addition, hospitalist Deepak Asudani, MD, MPH, FHM, health sciences assistant clinical professor at the University of California San Diego, reports that his department is interested in organizing a global health fellowship program. A firm believer in the distinction between global health and international health, Dr. Asudani explains that the UCSD program will be geared to teach U.S.-trained physicians how to practice medicine in resource-limited countries. It will have a track for physicians from other countries to study hospital medicine here.
Sustainable Care
During their rotations in Haiti, Dr. Le says the UCSF clinical fellows’ mission is capacity building, meaning they usually do not deliver care as primary physicians but rather engage in what he calls “clinical accompaniment.” They assist with care delivery and teach clinical skills to Haitian trainees.
“We do not want to be a substitute for doctors who are there,” he says. “We want to support Haitian residents and give consultative advice on difficult cases. We do not want to go, provide care, and leave. We are moving toward long-term relationships that foster systemic change.”
Clinical fellows teach quality improvement methods, and then the local partners, whether in Liberia or Haiti, generate ideas for QI projects around their most pressing needs. The fellows then offer support in the development and implementation of those projects.
Congruent Practice
The global health program at the University of Minnesota, led by Patricia Walker, MD, DTM&H, has established a medical teaching collaboration with Selian Lutheran Hospital in Arusha, Tanzania. Its name, Tufundishane, is a Swahili word meaning “let us all teach one another” and points out one of the many benefits for hospitalists who pursue this type of work. They report that the work changes the way they practice when they resume clinical duties back home.
Dr. Verma, a UCSF clinical fellow, can attest to those changes. After a three-month stint at St. Thérèse Hospital in Hinche, Dr. Verma says he intended to challenge his residents on the teaching service to “think about every single test they’re ordering.” That resolve was just one consequence of working in a resource-challenged hospital environment.
Speaking from Hinche in December, Dr. Verma says that in the U.S., “you can order a complete blood count and electrolytes for your patients every day they’re in the hospital. But here, if I want to get a renal test on a patient, I have to find the lab manager and find out if we have the reagents for those tests. It makes me question whether I really need that test or whether I am ordering it to make myself feel better.”
Dr. Verma views the workaround challenges as a net positive.
“Many times, you can do a lot of good for patients with an incomplete picture,” he says. It’s a view shared by other hospitalists who incorporate global health work into their clinical duties back in the U.S.
Dr. Hendel-Paterson has a wealth of global health experience: He worked in India and Zimbabwe during medical school, conducted research in Uganda, volunteered in Haiti, and has taught a tropical medicine course in Thailand. He says hospitalists can benefit from knowledge about global health when treating their own patients. For example, seeing patients with malaria or dengue fever during volunteer or service work can help providers recognize, diagnose, and treat those diseases in returning U.S. travelers. It also can help hospitalists avoid causing iatrogenic disease, as in the case of disseminated strongyloidiasis, which can result when people who have lived in or visited endemic areas are treated with immunosuppressants like corticosteroids.
Even if the experience does not give enough expertise to diagnose and treat, he says it can help providers realize that they should be asking for more testing or consultation in appropriate settings.
—Brett R. Hendel-Paterson, MD, assistant professor of medicine, University of Minnesota, hospitalist, HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., co-director, UM/CDC online global health course.
Expand Your Thinking
Global health hospitalists interviewed by The Hospitalist believe good medicine is not tied to any particular place. Many find that work in other countries enriches their own core competencies as physicians.
As partnerships between health systems in other countries and the U.S. continue to grow, leaders hope the exchange will bring improvements for all parties. Dr. Shamasunder points out that as the healthcare dollar becomes scarcer in the U.S., those who work abroad might have much to contribute to the systems they work.
For Dr. Shamasunder and his colleagues, global health is not just about making people’s lives better but is also about taking into consideration the social determinants of health. What becomes clear after doing this work, he says, is that resource-challenged environments are everywhere and that patients’ social histories are relevant no matter the locale.
“If you simply treat a patient who has anemia from lead exposure, and you have no mechanism to address the presence of that toxin in their substandard housing, that patient may end up with lead poisoning,” he says.
As Dr. Hendel-Paterson sums it up: “There is no such thing as healthcare over here and healthcare over there.” That’s why he and other global health hospitalists are convinced that “global is local.”
Gretchen Henkel is a freelance writer in southern California.
Western medicine has a long tradition of humanitarian service in developing countries. But, over the past two decades, the manner in which medical services are provided to under-resourced nations has evolved. Rather than volunteering to deliver acute care through humanitarian missions, a new generation of global health physicians aims to become dispensable. Through new nonprofit and collaborative models, they are establishing ongoing relationships with medical professionals in host countries to actively promote capacity building, from construction of new facilities to medical education and training.
“Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting,” says HealthPartners hospitalist Brett R. Hendel-Paterson, MD, an assistant professor of medicine at the University of Minnesota who also practices in HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., and is co-director of the UM/CDC online global health course.
Sriram Shamasunder, MD, DTM&H, hospitalist, health sciences assistant clinical professor, and co-director of the University of California San Francisco (UCSF) Global Health-Hospital Medicine Fellowship, agrees. “Mission medicine has incredibly well-meaning and committed people, but to address the upstream problems that bring people to the hospital, there need to be systems-based solutions,” he says.
And that is where hospitalists come in.
Growing numbers of hospitalists are joining in global health efforts, as Marwa Shoeb, MD, MS, and Phuoc Le, MD, MPH, DTM&H, discovered when they surveyed SHM members about participation in global health activities. Drs. Shoeb and Le are assistant clinical professors in the division of hospital medicine at UCSF. The survey (J Hosp Med. 2013;8(13):162-163) revealed that 51% of 232 respondents had done global health work prior to becoming a hospitalist; another third continued global health work after they began their HM careers.
Many believe hospitalists are uniquely qualified for global health initiatives. HM’s emphasis on systems of care delivery and quality improvement can supply much-needed knowledge as under-resourced countries strive to increase access to health care, says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School in Boston and deputy chief medical officer of Partners in Health (PIH) in Haiti (www.pih.org).
“Being a hospitalist is incredibly complementary to doing global health work,” Dr. Morse says. PIH has maintained a presence in Haiti for more than two decades and just recently celebrated a milestone with the Haitian medical community: establishment of the country’s newest medical residency training at University Hospital in Mirebalais.
Embrace Challenges
In early December, a group of UCSF hospitalists visited another PIH site, a Haitian Ministry of Health hospital in Hinche, located in the central plateau region of the country. Robin Tittle, MD, and Varun Verma, MD, were nearing the end of their first three-month rotation in the country as clinical fellows in the two-year-old Global Health-Hospital Medicine Fellowship.
According to Dr. Tittle, working in a resource-challenged hospital such as the one in Hinche is an irreplaceable experience. She and Dr. Verma discovered new levels of meaning in the term “workaround.” For example, “we have really limited lab capacity,” Dr. Tittle says. “One interesting thing I learned is how much your lab depends on access to reliable electricity. A number of our machines have been ruined because of electrical power surges. There are only certain people in the lab who know how to run certain tests.”
Dr. Tittle has learned that “you can’t practice medicine [in Haiti] without addressing the system.” Exposure to QI methods during training have been useful, she says, as she and Dr. Verma designed a medical education seminar for their Haitian colleagues by identifying the top 10 diagnoses in the nursing discharge registry. Still, she admits that the effort was hampered by nonspecific diagnoses—again a result of their inability to run diagnostic tests.
The learning has been reciprocal, notes Dr. Jacquelin Pierre Auguste, one of the Haitian internists in Hinche.
“We share a lot of knowledge,” he says, enthusiastically.
One example Dr. Pierre shared was being able to bring the clinical fellows into the case of a young mother who had developed postpartum cardiomyopathy. For unknown reasons, the condition is 10-20 times as common in Haiti as in the U.S., according to Dr. Le, who is co-director of the UCSF Global Health-Hospital Medicine Fellowship program. “Our fellows are also learning much more about the management of late-stage disease in tuberculosis and HIV,” he adds.
Several hospitalists have witnessed misappropriation of resources in global health projects, which can occur during emergency situations, such as in post-earthquake Haiti. For benefits to be sustainable, it’s best not to “charge in,” but to carefully assess the needs of the host setting. Although needs assessment should be handled by the sponsoring organization, hospitalists can contribute to this effort so that well-intentioned relief efforts do not cause unintended consequences, Dr. Hendel-Paterson says.
Hospitalists Unite
In the global health survey conducted in 2012, Drs. Shoeb and Le found that 46% of respondents were interested in collaborating with other hospitalists in order to increase their impact on health equity. In response to these and other observations about a need for mentorship, SHM established a Global Health and Human Rights Section, chaired by Drs. Shoeb and Le. They will be hosting a special global health forum at HM14 later this month in Las Vegas (www.hospitalmedicine2014.org).
The section goals are to:
- Provide a forum for like-minded hospitalists to share experiences and knowledge;
- Enhance the skill sets of hospitalists to apply their expertise in resource-poor settings; and
- Strengthen the capacity of local health systems through long-term collaborations and training in quality improvement.
Dr. Le, who has been affiliated with Partners in Health since his residency at Harvard Medical School, has spent time in sub-Saharan Africa as well as Haiti. He has been instrumental in advancing the HM global health agenda at UCSF and helped to organize the first national retreat on global health in HM last year. The program held its second annual retreat in February 2014.
Besides UCSF, two other global health fellowships are designed specifically for hospitalists: the University of Chicago Global Hospital Medicine Fellowship is headed by Evan Lyon, MD, an assistant professor of medicine in the section of hospital medicine in the UC Department of Medicine; the University of Florida College of Medicine’s Global Health-Hospitalist Fellowship program in Gainesville is headed by Vincent DeGennaro, Jr., MD, MPH, assistant professor in the division of hospital medicine.
In addition, hospitalist Deepak Asudani, MD, MPH, FHM, health sciences assistant clinical professor at the University of California San Diego, reports that his department is interested in organizing a global health fellowship program. A firm believer in the distinction between global health and international health, Dr. Asudani explains that the UCSD program will be geared to teach U.S.-trained physicians how to practice medicine in resource-limited countries. It will have a track for physicians from other countries to study hospital medicine here.
Sustainable Care
During their rotations in Haiti, Dr. Le says the UCSF clinical fellows’ mission is capacity building, meaning they usually do not deliver care as primary physicians but rather engage in what he calls “clinical accompaniment.” They assist with care delivery and teach clinical skills to Haitian trainees.
“We do not want to be a substitute for doctors who are there,” he says. “We want to support Haitian residents and give consultative advice on difficult cases. We do not want to go, provide care, and leave. We are moving toward long-term relationships that foster systemic change.”
Clinical fellows teach quality improvement methods, and then the local partners, whether in Liberia or Haiti, generate ideas for QI projects around their most pressing needs. The fellows then offer support in the development and implementation of those projects.
Congruent Practice
The global health program at the University of Minnesota, led by Patricia Walker, MD, DTM&H, has established a medical teaching collaboration with Selian Lutheran Hospital in Arusha, Tanzania. Its name, Tufundishane, is a Swahili word meaning “let us all teach one another” and points out one of the many benefits for hospitalists who pursue this type of work. They report that the work changes the way they practice when they resume clinical duties back home.
Dr. Verma, a UCSF clinical fellow, can attest to those changes. After a three-month stint at St. Thérèse Hospital in Hinche, Dr. Verma says he intended to challenge his residents on the teaching service to “think about every single test they’re ordering.” That resolve was just one consequence of working in a resource-challenged hospital environment.
Speaking from Hinche in December, Dr. Verma says that in the U.S., “you can order a complete blood count and electrolytes for your patients every day they’re in the hospital. But here, if I want to get a renal test on a patient, I have to find the lab manager and find out if we have the reagents for those tests. It makes me question whether I really need that test or whether I am ordering it to make myself feel better.”
Dr. Verma views the workaround challenges as a net positive.
“Many times, you can do a lot of good for patients with an incomplete picture,” he says. It’s a view shared by other hospitalists who incorporate global health work into their clinical duties back in the U.S.
Dr. Hendel-Paterson has a wealth of global health experience: He worked in India and Zimbabwe during medical school, conducted research in Uganda, volunteered in Haiti, and has taught a tropical medicine course in Thailand. He says hospitalists can benefit from knowledge about global health when treating their own patients. For example, seeing patients with malaria or dengue fever during volunteer or service work can help providers recognize, diagnose, and treat those diseases in returning U.S. travelers. It also can help hospitalists avoid causing iatrogenic disease, as in the case of disseminated strongyloidiasis, which can result when people who have lived in or visited endemic areas are treated with immunosuppressants like corticosteroids.
Even if the experience does not give enough expertise to diagnose and treat, he says it can help providers realize that they should be asking for more testing or consultation in appropriate settings.
—Brett R. Hendel-Paterson, MD, assistant professor of medicine, University of Minnesota, hospitalist, HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., co-director, UM/CDC online global health course.
Expand Your Thinking
Global health hospitalists interviewed by The Hospitalist believe good medicine is not tied to any particular place. Many find that work in other countries enriches their own core competencies as physicians.
As partnerships between health systems in other countries and the U.S. continue to grow, leaders hope the exchange will bring improvements for all parties. Dr. Shamasunder points out that as the healthcare dollar becomes scarcer in the U.S., those who work abroad might have much to contribute to the systems they work.
For Dr. Shamasunder and his colleagues, global health is not just about making people’s lives better but is also about taking into consideration the social determinants of health. What becomes clear after doing this work, he says, is that resource-challenged environments are everywhere and that patients’ social histories are relevant no matter the locale.
“If you simply treat a patient who has anemia from lead exposure, and you have no mechanism to address the presence of that toxin in their substandard housing, that patient may end up with lead poisoning,” he says.
As Dr. Hendel-Paterson sums it up: “There is no such thing as healthcare over here and healthcare over there.” That’s why he and other global health hospitalists are convinced that “global is local.”
Gretchen Henkel is a freelance writer in southern California.
Western medicine has a long tradition of humanitarian service in developing countries. But, over the past two decades, the manner in which medical services are provided to under-resourced nations has evolved. Rather than volunteering to deliver acute care through humanitarian missions, a new generation of global health physicians aims to become dispensable. Through new nonprofit and collaborative models, they are establishing ongoing relationships with medical professionals in host countries to actively promote capacity building, from construction of new facilities to medical education and training.
“Global health work needs to be collaborative and bilateral, not just an export of our Western medical model to a low-resource setting,” says HealthPartners hospitalist Brett R. Hendel-Paterson, MD, an assistant professor of medicine at the University of Minnesota who also practices in HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., and is co-director of the UM/CDC online global health course.
Sriram Shamasunder, MD, DTM&H, hospitalist, health sciences assistant clinical professor, and co-director of the University of California San Francisco (UCSF) Global Health-Hospital Medicine Fellowship, agrees. “Mission medicine has incredibly well-meaning and committed people, but to address the upstream problems that bring people to the hospital, there need to be systems-based solutions,” he says.
And that is where hospitalists come in.
Growing numbers of hospitalists are joining in global health efforts, as Marwa Shoeb, MD, MS, and Phuoc Le, MD, MPH, DTM&H, discovered when they surveyed SHM members about participation in global health activities. Drs. Shoeb and Le are assistant clinical professors in the division of hospital medicine at UCSF. The survey (J Hosp Med. 2013;8(13):162-163) revealed that 51% of 232 respondents had done global health work prior to becoming a hospitalist; another third continued global health work after they began their HM careers.
Many believe hospitalists are uniquely qualified for global health initiatives. HM’s emphasis on systems of care delivery and quality improvement can supply much-needed knowledge as under-resourced countries strive to increase access to health care, says Michelle Morse, MD, MPH, an instructor in medicine at Harvard Medical School in Boston and deputy chief medical officer of Partners in Health (PIH) in Haiti (www.pih.org).
“Being a hospitalist is incredibly complementary to doing global health work,” Dr. Morse says. PIH has maintained a presence in Haiti for more than two decades and just recently celebrated a milestone with the Haitian medical community: establishment of the country’s newest medical residency training at University Hospital in Mirebalais.
Embrace Challenges
In early December, a group of UCSF hospitalists visited another PIH site, a Haitian Ministry of Health hospital in Hinche, located in the central plateau region of the country. Robin Tittle, MD, and Varun Verma, MD, were nearing the end of their first three-month rotation in the country as clinical fellows in the two-year-old Global Health-Hospital Medicine Fellowship.
According to Dr. Tittle, working in a resource-challenged hospital such as the one in Hinche is an irreplaceable experience. She and Dr. Verma discovered new levels of meaning in the term “workaround.” For example, “we have really limited lab capacity,” Dr. Tittle says. “One interesting thing I learned is how much your lab depends on access to reliable electricity. A number of our machines have been ruined because of electrical power surges. There are only certain people in the lab who know how to run certain tests.”
Dr. Tittle has learned that “you can’t practice medicine [in Haiti] without addressing the system.” Exposure to QI methods during training have been useful, she says, as she and Dr. Verma designed a medical education seminar for their Haitian colleagues by identifying the top 10 diagnoses in the nursing discharge registry. Still, she admits that the effort was hampered by nonspecific diagnoses—again a result of their inability to run diagnostic tests.
The learning has been reciprocal, notes Dr. Jacquelin Pierre Auguste, one of the Haitian internists in Hinche.
“We share a lot of knowledge,” he says, enthusiastically.
One example Dr. Pierre shared was being able to bring the clinical fellows into the case of a young mother who had developed postpartum cardiomyopathy. For unknown reasons, the condition is 10-20 times as common in Haiti as in the U.S., according to Dr. Le, who is co-director of the UCSF Global Health-Hospital Medicine Fellowship program. “Our fellows are also learning much more about the management of late-stage disease in tuberculosis and HIV,” he adds.
Several hospitalists have witnessed misappropriation of resources in global health projects, which can occur during emergency situations, such as in post-earthquake Haiti. For benefits to be sustainable, it’s best not to “charge in,” but to carefully assess the needs of the host setting. Although needs assessment should be handled by the sponsoring organization, hospitalists can contribute to this effort so that well-intentioned relief efforts do not cause unintended consequences, Dr. Hendel-Paterson says.
Hospitalists Unite
In the global health survey conducted in 2012, Drs. Shoeb and Le found that 46% of respondents were interested in collaborating with other hospitalists in order to increase their impact on health equity. In response to these and other observations about a need for mentorship, SHM established a Global Health and Human Rights Section, chaired by Drs. Shoeb and Le. They will be hosting a special global health forum at HM14 later this month in Las Vegas (www.hospitalmedicine2014.org).
The section goals are to:
- Provide a forum for like-minded hospitalists to share experiences and knowledge;
- Enhance the skill sets of hospitalists to apply their expertise in resource-poor settings; and
- Strengthen the capacity of local health systems through long-term collaborations and training in quality improvement.
Dr. Le, who has been affiliated with Partners in Health since his residency at Harvard Medical School, has spent time in sub-Saharan Africa as well as Haiti. He has been instrumental in advancing the HM global health agenda at UCSF and helped to organize the first national retreat on global health in HM last year. The program held its second annual retreat in February 2014.
Besides UCSF, two other global health fellowships are designed specifically for hospitalists: the University of Chicago Global Hospital Medicine Fellowship is headed by Evan Lyon, MD, an assistant professor of medicine in the section of hospital medicine in the UC Department of Medicine; the University of Florida College of Medicine’s Global Health-Hospitalist Fellowship program in Gainesville is headed by Vincent DeGennaro, Jr., MD, MPH, assistant professor in the division of hospital medicine.
In addition, hospitalist Deepak Asudani, MD, MPH, FHM, health sciences assistant clinical professor at the University of California San Diego, reports that his department is interested in organizing a global health fellowship program. A firm believer in the distinction between global health and international health, Dr. Asudani explains that the UCSD program will be geared to teach U.S.-trained physicians how to practice medicine in resource-limited countries. It will have a track for physicians from other countries to study hospital medicine here.
Sustainable Care
During their rotations in Haiti, Dr. Le says the UCSF clinical fellows’ mission is capacity building, meaning they usually do not deliver care as primary physicians but rather engage in what he calls “clinical accompaniment.” They assist with care delivery and teach clinical skills to Haitian trainees.
“We do not want to be a substitute for doctors who are there,” he says. “We want to support Haitian residents and give consultative advice on difficult cases. We do not want to go, provide care, and leave. We are moving toward long-term relationships that foster systemic change.”
Clinical fellows teach quality improvement methods, and then the local partners, whether in Liberia or Haiti, generate ideas for QI projects around their most pressing needs. The fellows then offer support in the development and implementation of those projects.
Congruent Practice
The global health program at the University of Minnesota, led by Patricia Walker, MD, DTM&H, has established a medical teaching collaboration with Selian Lutheran Hospital in Arusha, Tanzania. Its name, Tufundishane, is a Swahili word meaning “let us all teach one another” and points out one of the many benefits for hospitalists who pursue this type of work. They report that the work changes the way they practice when they resume clinical duties back home.
Dr. Verma, a UCSF clinical fellow, can attest to those changes. After a three-month stint at St. Thérèse Hospital in Hinche, Dr. Verma says he intended to challenge his residents on the teaching service to “think about every single test they’re ordering.” That resolve was just one consequence of working in a resource-challenged hospital environment.
Speaking from Hinche in December, Dr. Verma says that in the U.S., “you can order a complete blood count and electrolytes for your patients every day they’re in the hospital. But here, if I want to get a renal test on a patient, I have to find the lab manager and find out if we have the reagents for those tests. It makes me question whether I really need that test or whether I am ordering it to make myself feel better.”
Dr. Verma views the workaround challenges as a net positive.
“Many times, you can do a lot of good for patients with an incomplete picture,” he says. It’s a view shared by other hospitalists who incorporate global health work into their clinical duties back in the U.S.
Dr. Hendel-Paterson has a wealth of global health experience: He worked in India and Zimbabwe during medical school, conducted research in Uganda, volunteered in Haiti, and has taught a tropical medicine course in Thailand. He says hospitalists can benefit from knowledge about global health when treating their own patients. For example, seeing patients with malaria or dengue fever during volunteer or service work can help providers recognize, diagnose, and treat those diseases in returning U.S. travelers. It also can help hospitalists avoid causing iatrogenic disease, as in the case of disseminated strongyloidiasis, which can result when people who have lived in or visited endemic areas are treated with immunosuppressants like corticosteroids.
Even if the experience does not give enough expertise to diagnose and treat, he says it can help providers realize that they should be asking for more testing or consultation in appropriate settings.
—Brett R. Hendel-Paterson, MD, assistant professor of medicine, University of Minnesota, hospitalist, HealthPartners’ Travel and Tropical Medicine Center in St. Paul, Minn., co-director, UM/CDC online global health course.
Expand Your Thinking
Global health hospitalists interviewed by The Hospitalist believe good medicine is not tied to any particular place. Many find that work in other countries enriches their own core competencies as physicians.
As partnerships between health systems in other countries and the U.S. continue to grow, leaders hope the exchange will bring improvements for all parties. Dr. Shamasunder points out that as the healthcare dollar becomes scarcer in the U.S., those who work abroad might have much to contribute to the systems they work.
For Dr. Shamasunder and his colleagues, global health is not just about making people’s lives better but is also about taking into consideration the social determinants of health. What becomes clear after doing this work, he says, is that resource-challenged environments are everywhere and that patients’ social histories are relevant no matter the locale.
“If you simply treat a patient who has anemia from lead exposure, and you have no mechanism to address the presence of that toxin in their substandard housing, that patient may end up with lead poisoning,” he says.
As Dr. Hendel-Paterson sums it up: “There is no such thing as healthcare over here and healthcare over there.” That’s why he and other global health hospitalists are convinced that “global is local.”
Gretchen Henkel is a freelance writer in southern California.