Global Health: It’s Not About Becoming Worldly, It’s About Becoming Better Doctors

Heidi Chumley, MD

Heidi Chumley, MD

As we continue to evolve how we prepare medical students to join the US physician workforce, we should continue to create global health experiences that will impact how we approach clinical practice—whether that be when managing a diverse patient population or when addressing the global health issues that are now on our doorstep.

When I was in medical school, we often saw the term international health in the context of faraway villages where issues like access to clean water, sanitation, and basic understanding of the spread of disease were at the heart of figuring out how to improve a community’s well-being.

As medical students, we viewed short-term medical mission trips as our way of getting a glimpse of the world outside our environment and gaining exposure to not just tropical diseases that we would never see at home, but also to the ways that healthcare providers in these settings coped in order to care for their patients.

Things changed somewhere along the way, and what we used to call international health became global health, the term much more indicative of a connected world where diseases–and physicians–crossed borders. A decade ago it was SARS and later the avian flu. Recently we had our first cases of Ebola in Dallas and New York City. Global health, it seems, has come home.

In the journal Family Medicine, Dr John Frey III of the University of Wisconsin writes that global health experiences can be “a treatment for [US] medical myopia,” referring to a seeming inability for the US clinical and educational systems to learn from other cultures and systems. “At its best,” he writes, “global health offers a perspective based on humility rather than arrogance and on an openness and generosity of thought that changes thinking and practice in all directions.”

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Intimate Partner Violence: An Educational Priority

By Katherine Bakke, BA, Halley P. Crissman, BSc, MPH, Vijay Singh, MD, MPH, MS, and Arno K. Kumagai, MD, University of Michigan

Given their primary responsibility for the health and safety of their patients, physicians are the natural candidates to champion efforts to end intimate partner violence (IPV).1 According to the Centers for Disease Control and Prevention, nearly one in three women and one in four men report lifetime physical assault by an intimate partner, and IPV represents a leading cause of morbidity and mortality of women in this country.2 Medical education stands to play a key role in this area; however, with recent changes in the Liaison Committee on Medical Education (LCME) standards, the next generation of physicians may be even less likely to initiate conversations about IPV with their patients.

The LCME, which accredits all US and Canadian medical schools based on compliance with specific educational standards, recently announced reformatted standards that will come into effect after July 2015.3 Although perhaps not intended, the changes include a small but significant omission. In contrast to previous versions,4 the 2015 standards dropped violence and abuse as an example of a societal problem that should be covered in medical school curricula.5 While this omission may seem trivial, it is potentially of great consequence, for the risk of not educating medical students how to screen for, and assist survivors of, interpersonal violence threatens to perpetuate IPV as a significant, and more importantly preventable, cause of injury and death among women.

Merely because the LCME has failed to explicitly require education on IPV does not mean that medical schools will ignore the subject. Nonetheless, in an educational environment dominated by outcomes-based assessments—by checklists of competencies, milestones, and standards—omitting interpersonal violence on such lists has the ultimate effect of devaluing its educational and clinical importance and lowering the priority conferred on it by institutions that are anxious to maintain accreditation. Moreover, with recent US Preventive Services Taskforce guidelines recommending IPV screening and brief counseling of reproductive-age women,6 and Affordable Care Act coverage of such preventive services,7 our female patients and insurance providers will increasingly demand our physician workforce to be educated about this topic.

Educating medical students about IPV is challenging. Culturally, we do not want to talk about IPV—the conversation asks us to confront nearly every contentious topic from intimacy and privacy, gender and sexual orientation, as well as race, socioeconomic class, gun control, and self-defense laws.

But to remain silent is to remain complicit, and we should challenge ourselves to do better.

Physicians are in a unique position to ask about IPV for two simple reasons. First, it is our job to ask sometimes uncomfortable, personal questions in order to inform diagnosis and management plans, and second, we do so in an environment of confidentiality protected by law. There are few spaces for survivors of IPV to talk so freely and openly; the doctor’s office is one of them. When it comes to IPV, our patients need us to be courageous and “end the silence.”1

Courage and commitment to address IPV is necessary—on personal, professional, and institutional levels. Medical education is no exception.

The current situation demands nothing less than a call to action by all those who are interested in health, safety, and equity: addressing interpersonal violence must be an educational, societal, and medical priority and should be an essential component of the education of all health professionals.

Such a call to action might involve an insistence by students, faculty, and administrators that IPV should be as important in the education of physicians as the physical exam, that such teaching and learning of IPV should meaningfully incorporate the voices of survivors and their families, that accrediting bodies, such as the LCME, overcome a near-exclusive emphasis on the “medical” (read, “pathophysiological”) causes of disease while lumping major social and historical factors leading to suffering, disabilities, and preventable deaths in our patients into a general, optional category of “societal issues.”

Educating the nation’s medical students on how to ask patients about IPV is an essential act of justice, for it will prepare them to act in the world with compassion and fairness for all patients and their families.

 

References

  1. Leonard Harrison S. Ending the silence. In: Eggers S, ed. Family Medicine Blog. Leawood: Society of Teachers of Family Medicine, 2014.
  2. Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization—National Intimate Partner and Sexual Violence Survey, United States, 2011. Morb Mortal Wkly Rep 2014;63:1-18. Surveillance Summaries.
  3. Liaison Committee on Medical Education. Reformatted 2015-2016 Standards approved by the LCME. 2014. http://www.lcme.org/2015-reformat-project.htm.
  4. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. Washington, DC: Association of American Medical Colleges, June 2013.
  5. Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. Washington, DC: Liaison Committee on Medical Education, 2014.
  6. Moyer VA, Force USPST. Screening for intimate partner violence and abuse of elderly and vulnerable adults: US Preventive Services Task Force recommendation statement. [Summary for patients in Ann Intern Med 2013 Mar 19;158(6):I-28. PMID: 23338797]. Ann Intern Med 2013;158:478-86.
  7. Health policy brief: Preventive services without cost sharing. Health Aff 2010 Dec 28. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_37.pdf.