Double Feature: Global Family Medicine & The Case for Eliminating Global Health Rotations

Note from the Editor: This quarters publications contains two important submissions on global family medicine and it’s greater ramifications on the world at large. Thank you to William Ventres, MD, MA, Shailey Prasad, MD, MPH and Esther Johnston, MD, FAAFP, MPH as well as the Global Health Educators Collaborative.

Global Family Medicine
By William Ventres, MD, MA and Shailey Prasad, MD, MPH

Practicing global family medicine means more than working internationally. It means seeing the world from new perspectives, applying skills in solidarity with people in need, and learning from others.

Global family medicine embraces many themes, including educating the medical profession at home and abroad about the importance of family medicine as a foundational element of primary care, developing family medicine training programs in rural and urban settings to help ensure the provision of equitable medical care, and striving to ensure that family medicine is an essential part of health systems around the globe (Haq et al. 1995).


From a philosophical perspective, the concept of global family medicine means seeing the health of the world’s people in all its complexity from a point of view that includes, but is not limited by, the confines of the biomedical model (Ventres 2017). This concept prioritizes the needs of those people around the world who disproportionately suffer under the burdens of economic poverty and social marginalization due to political and economic structures that preferentially benefit the rich and powerful.


For physicians from the United States and other economically wealthy countries, global family medicine means looking beyond their training in increasingly fragmented professional cultures that neglect such basic tenets of primary care, community health, social accountability, and the equitable provision of universal health care. It means understanding how such basic principles like access, equity, and appropriateness are essential to improving health outcomes in medically underserved settings.


Global family medicine means doing the conceptual work of turning the world “upside down” from its conventional orientation, just as skilled physicians do when practicing patient- and people-centered clinical care, wherever they may be. The goal in each circumstance is to recognize differences in how people approach the structure and provision of medical care, to understand that many non-biological factors influence the presentation and amelioration of disease and illness, and to practice where need is greatest due to the effects of adverse social determinants of health. Global family medicine builds on the tenets of primary care (Starfield et.al 2005) by encouraging among its practitioners five attitudes (Ventres & Wilson 2015):


Awareness—Open one’s eyes and ears (and, within, one’s mind) to the historical, social, cultural, political, and economic contexts of the communities in which one lives and works.


Curiosity—Adopt a questioning approach—an anthropological gaze—to patient and community concerns. Exercise one’s senses, so often heightened in unfamiliar settings, to engage in honest, realistic, and inclusive assessments of how upstream causes affect disease and illness.


Humility—Engage with others, wary of the (often unconscious) influences of desires for power, yearnings for control, and the conceit that what we have, others in the world must want.


Meaning—Work with patients, families, and communities, not just for them: find worth in solidarity—in sharing—rather than simply in doing. Solidarity signifies recognizing, with others, the structural forces that contribute to poor health outcomes; it also signifies recognizing, with others, the structural barriers that negatively affect abilities to ameliorate those forces.


Intention—Learn through one’s work practicing and growing global family medicine. True learning implies welcoming a definitive change in some aspect of one’s own life.


Haq C, Ventres W, Hunt V, Mull D, Thompson R, Rivo M, Johnson P. Where there is no family doctor: The development of family medicine around the world. Academic Medicine. 1995;70(5):370-380.

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005;83(3):457-502.

Ventres W, Wilson C. Beyond ethical and curricular guidelines in global health: attitudinal development on international service-learning trips. BMC Medical Education. 2015;15(1):68.

Ventres WB. Global health and family medicine: a ‘UNIVERSAL’ mnemonic. Journal of the American Board of Family Medicine. 2017;30(1):104-108.


The Case for Eliminating Clinical Global Health Rotations
By Esther Johnston, MD;FAAFP;MPH

I was rounding one morning in the newborn nursery at a regional hospital in Tanzania, supervising 3rd and 4th year students from a nearby medical school, when a fellow educator grabbed my arm and pointed me to a bassinet in the corner. There was no movement, no respirations. I took a pulse – none.

Looking back at my year as a Global Health Service Partnership educator in Dar es Salaam, from 2014-2015, what strikes me about this moment was the sudden appearance in the midst of this code of several visiting undergraduate students from Europe, all wearing white coats.

Seemingly out of nowhere, these visiting students appeared in a flurry, running to look for supplies and stepping in front of my own Tanzanian medical students as they looked on in surprise.

There was no bag mask and no epinephrine easily accessible, and the code did not end well. I stepped outside with my own Tanzanian medical students to debrief together. And out of the corner of my eye, I saw the visiting student looking shell-shocked in a corner.

In taking a little time to connect afterwards, I learned that these visitors were associated with a major international volunteer organization known for offering short term global health rotations to students at various levels of training. They were dropped into a hospital in Tanzania, without proper supervision or mentorship, medical licenses or credentials, to participate in direct patient care. Over the coming weeks I met others placed through the same mechanism who, perceived to be licensed attending physicians in their white coats, were allowed to deliver babies or suture unsupervised.

This practice was harmful to the visiting students, witnessing confusing and traumatic events without guidance. It was harmful to medical and nursing students in Tanzania, whose faculty and clinical mentors felt obligated to help manage unsupervised visitors. It was harmful to the hosting hospital and the patients it served, who were misled about the qualifications of those providing their care. Practices such as these are deeply unethical. And sadly, the organization involved was just one of many sending trainees abroad to perform clinical work in this fashion.

The world has changed much since 2014. In health professions training schools around the United States, discussion occurs more often regarding the utility and application of the Working Group on Ethics Guidelines for Global Health Training (WEIGHT), which offers ethical principles and best practices for international training experiences. Greater attention is being paid to the need for antiracism and decolonization of global health. A pandemic has occurred, and in the process many academic institutions in the United States have pulled back their students and residents from rotations abroad.

And now, as we look towards a day when we will again be able to more fully engage in international partnership, we have a unique opportunity to pause and ask, is our practice of sending students and residents abroad for clinical global health rotations truly ethical, legal and responsible?

The Brocher Declaration has emerged in this year of pause. Developed by a coalition of stakeholders involved in short-term global health engagements, from faith-based organizations to academic institutions, the declaration challenges existing practices for short term global rotations, and asks us to commit to better.

This building movement should compel us to ask an essential question: why do we allow our learners to work clinically when on international rotations at all? Would we think it was acceptable for someone from another country to drop into our own clinics, without a license or credentialing, without the weeks of orientation and onboarding expected of our own residents and clinicians, demanding the supervision of often overworked clinical faculty in areas with severe health professional shortages, to evaluate, diagnose, and treat patients? If we wouldn’t find this appropriate in our own clinic, why do we facilitate our learners to do it abroad?

Arundhati Roy wrote that “[h]istorically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice…our avarice, our data banks and dead ideas…[o]r we can walk through lightly, with little luggage, ready to imagine another world.”

As borders open and flights resume, will we as educators seize on this moment to let go of outdated practices and unethical approaches, and find better ways to teach future family medicine physicians to engage in the global environment?

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Physician Coaching, An Evidence-based Tool for Resident Wellness

  • Tonya L. Caylor, MD, FAAFP
  • tlcaylor@mac.com
  • Clinical Associate Faculty, On-call Faculty for Alaska Family Medicine Residency
  • Joy in Family Medicine Coaching Services®

Physician coaching, a key tool for preventing and addressing burnout, is being incorporated into residency and fellowship training programs. Professional coaching has been around for decades for leaders in fortune 500 companies. It turns out, that it translates well to medicine and impacts burnout. In August of 2019, JAMA published an article telling of the benefits of physician coaching: it decreases emotional exhaustion and burnout out while increasing resilience and quality of life.1  Other studies show similar results. 2,4

For those unfamiliar with professional coaching, it’s good to start with a definition of what it is and isn’t. First, coaches are not mentors; mentors are those looked up to and emulated. Coaches are not advisors; advisors guide, direct and give advice.  Coaches are not therapists. Therapists diagnose and treat those with DSMV mental health conditions. Coaching officially defined as partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential. Foundational to coaching is that the client is seen as whole, capable, and resourceful. Most academic medicine coaches use a causal-coaching approach rooted in positive cognitive psychology.

After my own personal burnout period, I discovered coaching. I grew tremendously. I was so convinced that these principles and approaches were critical for everyone, including those I’m most dedicated to – resident physicians. I began my coaching journey in the Fall 2019, took courses, became certified, and started my business in 2020. I have had the privilege of coaching high-functioning residents that want to grow into their goals as well as some who are struggling in one area or another. The outcomes are the similar. They uncover limiting beliefs, learn tools to navigate life and career, decrease unnecessary suffering, improve their outlook, and move toward the future they envision. Physicians who are trained coaches have the unique advantage of understanding issues that augment relating to the client. It is worth pointing out, that residents need a safe space, so using non-evaluative physician coaches is crucial.  

I performed pre- and post-course surveys with the Maslach Burnout Index and a linear quality of life scale for quality improvement to residents and recent graduates who went through my 6 session 1:1 coaching plus program. Eighty percent of those participating met burnout criteria at the beginning of the course, compared to only 40% who completed the program after the conclusion. Even the remaining 40% had significant improvement in emotional exhaustion, depersonalization, and personal accomplishment scores. 80% reported improved quality of life (none showed a decrease). All reported subjective positive feedback. Each 1:1 participant completed the course if they paid (with or without program support for time) and even if they didn’t pay (scholarship or program paid) but the program carved out time for them – one hour a week for 6 weeks. 

Coaching resident physicians is not only helpful for the individual, but the program as well. They have a different approach to their colleagues, staff, and attendings. An example – during a coaching session, a resident felt a particular attending was “against him.” We parsed out fact from thoughts. He was then open to giving the attending the benefit of the doubt. He had less rumination, less unnecessary suffering, and engaged with the attending in a healthier manner. Another program I had the honor of coaching, enrolled faculty and residents in a series of separate group sessions. They now share a common language and toolbox that improve the program’s culture. The program ran pre- and post- course surveys and are in the process of analyzing the data. 

Various methods to access coaching for residency and fellowship programs are being trialed, including one-on-one coaching, group coaching, and hybrid models, both with and without mini curricular topics, and some offer CME. Some institutions, such as Harvard4, explored basic coach training with their faculty to coach trainees outside their primary discipline. Others, such as Stanford, contract with an outside physician coach annually for their anesthesia fellows.  

Funding sources vary. In the Mass General study3, there were grants, and volunteer hours. In the Penn State study5 there was a designated FTE budget utilized. Various wellness funds, CME/book funds, HSA dollars, scholarships, and individual self-funding have all been used. New physician coaches often donate hours to get experience. (A list of coaches known to me with experience in academic coaching at various levels are listed in the table.)

I encourage all residency and fellowship programs to consider incorporating coaching into their wellness and remediation structure as the next step in supporting trainees and faculty, improving the culture of medicine, and preserving a healthy workforce that enjoy their chosen career.  

Table 1

Coaches/ProgramsLead CoachWebsiteEmailClient focus
Empowering Women PhysiciansSunny Smith, MD FAAFPempoweringwomenphysicians.comsunny@empoweringwomenphysicians.comClients: women physicians including all levels of academics
Joy in Family Medicine Coaching Services®*Tonya Caylor, MD FAAFPhttp://www.joyinfamilymedicine.comjoyinfamilymedicine@gmail.comClients: Family Medicine residents, faculty, and recent graduates
LadyDOxCorinna Muller, MD FACOOGhttp://www.ladydox.comdr_m@ladydox.comClients: women physicians including all levels of academics, not limited to DO’s
Pause and Presence CoachingJessie Mahoney, MDwww.jessiemahoneymd.comjessie@jessiemahoneymd.comClients: All including residents and fellows
The Institute for Physician WellnessKathy Stepien, MDhttp://www.instituteforphysicianwellness.comkathy@instituteforphysicianwellness.comClients: all physicians, including all level of academics
This Osteopathic Life Amelia Bueche, DOhttp://www.thisosteopathiclife.comthisosteopathiclife@gmail.comClients: all physicians, including all levels of academics, not limited to DO’s
*disclosure – the author has a financial relationship with the program that has an asterisk

References

  1. Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a Professional Coaching Intervention on the Well-being and Distress of Physicians: A Pilot Randomized Clinical Trial [published online ahead of print, 2019 Aug 5]. JAMA Intern Med. 2019;179(10):1406-1414. doi:10.1001/jamainternmed.2019.2425
  2. McGonagle AK, Schwab L, Yahanda N, et al. Coaching for primary care physician well-being: A randomized trial and follow-up analysis [published online ahead of print, 2020 Apr 16]. J Occup Health Psychol. 2020;10.1037/ocp0000180. doi:10.1037/ocp0000180
  3. Palamara, Kerri et al. “Promoting Success: A Professional Development Coaching Program for Interns in Medicine.” Journal of graduate medical education vol. 7,4 (2015): 630-7. doi:10.4300/JGME-D-14-00791.1
  4. Palamara K, Kauffman, C, et al. Professional Development Coaching for Residents: Results of a 3-Year Positive Psychology Coaching Intervention [published online ahead of print, 2018 Jul 23]. J Gen Intern Med. 2018;33(11):1842-1844. 
  5. Jed D. Gonzalo, Daniel R. Wolpaw, Karen L. Krok, Michael P. Pfeiffer & Jennifer S. McCall-Hosenfeld (2019) A Developmental Approach to Internal Medicine Residency Education: Lessons Learned from the Design and Implementation of a Novel Longitudinal Coaching Program, Medical Education Online, 24:1, DOI: 10.1080/10872981.2019.1591256