Author Archives: stfmguestblogger

Double Feature: A Spotlight on Global Health Education

Note from the Editor: The December blog contains two important submissions on global family medicine and the factors that contribute to inequities in the field including but not limited to funding, climate change, geopolitical events, and more. Thank you to Barry Bacon, MD, Martha Sommers, MD, Bhargavi Chkuri, MD, and Meredith Milligan, MD

Dream School: How One Patient Encounter Can Change the Direction of Your Life

One patient encounter can change the direction of your life.

Our team, Gambella Medical Team Connections in Western Ethiopia and Anchor Health for South Sudan in South Sudan, dreams of creating a medical school to change health outcomes for the region. This long-term strategy will build up the region’s workforce with physicians and other local-to-the-area healthcare workers familiar with the area’s needs.

The challenges we face include:

  • Lack of livable wages. Doctors in South Sudan are employed by the government and receive $12 per month.
  • Lack of funding and support. Donor countries who had been sponsoring healthcare support in South Sudan have retracted their financial support.
  • Lack of access to quality medical care. There are five hospitals in the Gambella region serving a million people. These hospitals have one functioning x-ray machine and one functioning operating room.
  • Lack of physicians. There are 120 physicians in South Sudan serving a population of 12 million, a ratio of 1:100,000. In 2013, there were nine midwives and eight OB/GYNs identified in all of South Sudan. As a result, one in seven women die from childbirth complications. We witnessed a child dying in his parents’ arms while waiting to be seen by a physician at the central hospital.
  • Lack of access to medicines, equipment, and tools required to provide quality care.
  • Lack of tools. Nursing schools in Gambella don’t even have a blood pressure cuff and must teach their students without one.
  • Outsourcing. Medical care is outsourced at a cost of $200 million per year to other countries.
  • Conflict. There are 400,000 refugees in the Gambella region. Facility transfers must transport patients during times of conflict.

Many members of our team fled South Sudan and Gambella due to the conflict and violence. After arriving in the United States, they received an education and they returned to the region, bringing colleagues and US recruits with them with the goal of transforming healthcare in South Sudan and the Gambella region of Ethiopia. Thanks to presentations at the 2019 and 2021 AAFP Global Health Summit, we were able to grow our team and support network. The connections built by our team, along with their local knowledge led to Marshall University’s Family Medicine Global Health Division joining the effort; and the sharing of widespread contacts that contribute to our progress.

We’ve been offered a hospital in Juba to create a multi-specialty healthcare center and a base for medical education. Our vision is to invite US-based instructors and specialty teams to provide care for patients while teaching medical students and South Sudanese physicians. Additionally, we must address the policy fiascos that prevent healthcare professionals from receiving sustainable, livable income. For over five years, we’ve worked on our dream of developing an international medical school with campuses, and teaching sites in remote hospital and clinical settings in South Sudan and Western Ethiopia. We have the support of both leaders in South Sudan, the Gamebella regional government, and are audacious enough to believe we will accomplish our dream.

Globally, the world is asking more of family medicine.  As teachers of family medicine, we are learning how to meet the needs in South Sudan and Gambella, and focusing on increasing opportunities to involve medical students, residents, and colleagues as we move forward.

Join us.

Barry Bacon, MD
250 S Main St
Colville, WA  99114
Anchor Health for South Sudan
Gambella Medical Team Connections

Martha Sommers, MD
Assistant Professor
Department of Family and Community Medicine
Marshall University



Margaret Chan. (June 26, 2013). The rising importance of family medicine. Paper presented at the 2013 World Congress of the World Organization of Family Doctors, Retrieved from

Modernizing Global Women’s Health Curricula: Inclusivity, Intersectionality, and Climate Change

by Bhargavi Chekuri, MD, University of Colorado School of Medicine, Aurora, CO, and Meredith Milligan, MD, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Gender inequality remains one of the most important drivers of disparities in health and well-being worldwide. To address these disparities, global women’s health research and curricula have been developed to better meet the unique health needs of women worldwide. While training programs often provide much needed focus on reproductive and obstetric care, infectious diseases, and cancer screening, significant blind spots remain.

First, gender continues to be categorized as binary in most of the research focused on global women’s health. As a result, teaching in this field fails to incorporate intersectionality, overlooking the physical and mental health needs of other sexual and gender minorities (SGMs). Additionally, teachers of global women’s health, and indeed medical educators more broadly, do not adequately integrate planetary health into their curricula. This is problematic because climate change is already worsening current global health disparities with well-documented gender-specific impacts, making it one of the most important, cross-cutting determinants of health in the 21st century. Research and teaching at the nexus of all three of these issues (global women’s health, health needs of other SGMs, and climate change) is even rarer, despite the fact that SGMs are particularly vulnerable due to compounding issues such as discrimination.

Gender-specific Impacts of Climate Change

Climate change harms human health by altering the quality and quantity of our air, water, food and weather. Increased temperatures and drought, poor air quality, more intense extreme weather events, and changing disease patterns all affect mortality and morbidity, resulting in injury, poor cardiovascular and respiratory outcomes, and worsening mental health worldwide. Globally, women and other SGMs face increased exposure to the consequences of climate change due to existing health disparities as well as differences in gender roles and responsibilities. When faced with these exposures, unequal resource distribution further limits the adaptive capacity and resilience of women and other SGMs. Women in low-income countries (LIC), for example, have disproportionate exposure to food insecurity because they are more likely to live in poverty and rely on subsistence farming to feed themselves and their families. When faced with lower crop yields, women are at higher risk for nutritional deficiencies, both because of increased reproductive demands (like menstruation and pregnancy), and because of underlying cultural norms that may prioritize feeding others. Similarly, gender-based social and cultural norms place responsibility for managing household water supply on women in LICs. As climate change strains freshwater resources globally, women spend more time and travel farther to locate, transport, and secure household water. Along the way, they can have increased exposure to heat, musculoskeletal injury, and face the threat of violence or abuse. Climate-related disasters like wildfires, storms, and flooding also have gendered health impacts. Women in low and middle-income countries are more likely to die from extreme weather or flooding events than their male counterparts because they are also more likely to be homebound, serving as caregivers, and unable to immediately escape climate-related disasters. Simultaneously, women have unequal access to disaster response services in the aftermath of such events, often losing access to essential sexual health and reproductive health services (SHRH) right when they need them the most.

SGMs are particularly socially vulnerable during disasters due to existing inequities as well as discriminatory disaster response policies. In the U.S., for example, LGBTQ+ people are more likely to live in poverty, experience unstable housing, and have chronic physical and mental health conditions, all leading to a higher risk of direct and indirect injury during extreme weather events. Additionally, disaster response policies in the U.S. do not explicitly prohibit discrimination based on sexual orientation or gender identity, or routinely recognize gender-diverse family structures, opening LGBTQ+ people to harm and separation when pursuing relief.

A Path Forward

Unfortunately, these are just a few of the many ways women and SGMs around the world are disproportionately impacted by the changing climate. Practitioners and teachers of global women’s health must be aware that current gaps in global health research limit our ability to fully understand and address gender-based health disparities worldwide. Integrating an intersectional and inclusive lens while defining, understanding, and teaching global women’s health is an important first step in addressing health disparities felt by women and other SGMs. Global women’s health practitioners must also use and teach a planetary health lens so they are better prepared to address contemporary health threats. Those leading community-based collaboration and bidirectional global women’s health partnerships must understand and teach concepts like gender-mainstreaming and climate action when developing projects aimed at improving women’s health. Lastly, global women’s health practitioners must understand and teach the importance of applying reproductive justice and human rights frameworks to climate action plans; this not only improves the adaptive capacity and resilience of women and other SGMs but also subsequently improves gender-based health disparities.


Sex refers to the biological characteristics that define humans such as female or male.

Gender refers to the socially constructed characteristics, norms, roles, and behaviors attributed to women, men, girls, boys, and non-binary people. Because gender is a social construct, ideas about gender vary across societies and time.

Gender equality refers to the equal rights, responsibilities, and opportunities of all genders.

LGBTQ+ is an acronym that collectively refers to individuals who are lesbian, gay, bisexual, transgender, or queer. The “Q” can also stand for questioning, referring to those who are still exploring their own sexuality and/or gender. The “+” represents those who are part of the community, but for whom LGBTQ does not accurately capture or reflect their identity.

Sexual and gender minorities (SGMs) refers more broadly to people whose biological sex, sexuality, gender identity and/or gender expression depart from majority norms. The term ‘sexual and gender minorities’ includes considerable diversity as well as a multiplicity of identities and behaviors, including, but not limited to, individuals who identify as LGBTQ+. The term ‘sexual and gender minorities’ is preferentially used in global health contexts because the term ‘LGBTQ+’ is derived from Western contexts which may not apply to many people in the world.

Intersectionality refers to a theoretical framework born out of the Black feminist movement which maintains that individual identities (such as race, class, gender, sexual orientation, immigration status, etc.) intersect to create experiences of inequality within society. Research using intersectionality methods is ideally built on a foundation of coalition-building with the aim of gaining a deep understanding of the diversity of lived experiences and the ways in which systems of oppression and privilege impact these varied experiences. Such research also maintains that emphasis on one identity over another fails to capture the true causes of disparity in the world.

Gender mainstreaming is defined by the UN as “the process of assessing the implications for women and men of any planned action, including legislation, policies, or programs, in all areas and at all levels. It is a strategy for making women’s as well as men’s concerns and experiences an integral dimension of the design, implementation, monitoring, and evaluation of policies and programs in all political, economic, and societal spheres so that women and men benefit equally, and inequality is not perpetuated. The ultimate goal is to achieve gender equality.”

Bhargavi Chekuri, MD, is Co-Director, Diploma in Climate Medicine, and Assistant Professor, Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO

Meredith Milligan, MD, is Family Physician and Leadership Preventive Medicine Resident, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Mistakes That Authors Make in Their Submissions to Family Medicine

By Sarina Schrager, MD, MS, Editor in Chief, Family Medicine, and the Family Medicine editorial team.

As the official journal of STFM, Family Medicine aims to publish papers that will advance the art and science of academic family medicine. The journal is interested in curriculum designed for medical students and residents, projects that impact resident and faculty work life, as well as policy papers that comment on issues related to the discipline. The journal is also interested in papers describing DEIA initiatives developed in departments, residencies, and medical schools. We publish research, narratives, and commentaries. The editorial team wants authors to be successful and has come up with the following list of common errors to avoid when submitting a manuscript.

Not following the author instructions. There is nothing that annoys an editor more than a paper that is formatted incorrectly, submitted in the wrong category, doesn’t meet the word count requirement, or when authors submit a paper that is outside the scope of Family Medicine. Please read and follow the author instructions before you submit a paper, available here Family Medicine Author Information (  

Submitting a paper that is outside of the scope of the journal. Reviewing the author instructions can help you understand the goals and aims of the journal. Family Medicine is focused on education in primary care and does not publish clinical articles. Some papers about quality improvement will be within the scope of the journal, if the project is done in a residency clinic or has an impact on learners, for example, but much QI that is focused on clinical improvement only is not in the scope of the journal. If you are unsure whether your paper is within the scope of the journal, please e-mail us at

Does not fill a gap in the literature. This may seem obvious, but the editors suggest doing a thorough literature search before you start your research project so that you can make sure that no one else has done the same study. If there are similar studies in the literature, think carefully about what your work adds. Is your study in a different population? Do you use different methods to measure the same outcome? Are you confirming the results of a previous small study? If you are just doing the same study that others have done, then we may not be interested in accepting the paper. We suggest that you be very clear in your paper what your study adds to the existing literature.

Lack of a cohesive narrative through your paper. For example, does the title of your paper describe what you did in your study, or what results you found?Does the methodology of your study answer the questions you propose in your objectives? Do your conclusions arise directly from your results?  Be careful about editorializing (i.e. making large generalizations from limited data or data from a limited sample). The editors frequently see a mismatch between the objectives of the study or research question, the data collected and the conclusions. We recommend that you think through these questions before you start writing. 

Lack of robust evaluation of your data. This mistake is by far the most common error that the editors see with original research submissions or brief reports.When you are starting to plan your study or your curricular change, it is important to think about how you are going to evaluate your intervention. The Kirkpatrick levels of evaluation (The Kirkpatrick Model ( provide a template to use when thinking about the outcomes of your study. The Kirkpatrick Model describes how learners or participants change after your intervention. 

  • Level 1 evaluation looks at the reaction to the intervention. Did the participants enjoy the educational activity?  Did they think it was relevant to their work?  Family Medicine does not publish papers with only Level 1 evaluations. 
  • Level 2 evaluation measures how much participants learned during the intervention.  Pre and post-tests immediately after a seminar are examples of level 2 evaluations.  Family Medicine will occasionally publish otherwise well-done studies that only use Level 2 evaluation, but most of the time these papers will be rejected.
  •  Level 3 evaluation is looking at whether the educational intervention changed the behaviors of participants. For example, after a seminar about lung cancer screening, you could measure how often residents ordered low dose lung CT scans.  
  • Level 4 evaluation measures results of outcomes.  This is the highest level of evaluation.  In the previous example, you would be looking to see if rates of lung cancer deaths decreased, or if rates of early diagnosis of lung cancer was affected. 

Obviously, these higher levels of evaluation are harder to measure. Family Medicine prioritizes papers that use Level 3 or 4 evaluations.

Special consideration for narrative submissions. The editors of Family Medicine believe that stories about family medicine education and the clinical experiences of faculty and learners are vitally important to enhance the discipline.  As such, we seek narrative submissions, both poetry and essays. The biggest mistake that we see in narrative submissions is Telling not Showing. What do we mean by that?  Telling the reader that a patient was scared is much less effective than describing the nervous movements of her hands, for example.Describing how you feel with a sentence like, “I was happy”  is much less compelling than describing a characteristic, “like my face hurt from smiling so much” or “my heart felt light”. Here is more information that can help you when you are writing narratives. (Show, Don’t Tell: The Simple Guide for Writers (

Again, the editors of Family Medicine want to hear about your work. To paraphrase Leo Tolstoy, strong papers are all alike, but weak papers are each weak in their own specific way. We hope that this blog post helps authors consistently submit strong papers in the future.

Exploring Burnout and Resiliency Using the Photovoice Experience


Understanding physician burnout is an area of intense research. Commonly cited studies by Mayo Clinic and Medscape indicate levels of physician-reported burnout continue to rise.  Traditional ways of measuring burnout include questionnaires and surveys.  While these are popular and validated ways to assess burnout, they do not allow providers to self-define burnout and use scripted words that limit individual expression.  The movement to discuss burnout and its causes is welcome. However, perhaps more important is the shift that has occurred in the conversation from problem to solution.  Increasingly, the focus has been on the study of resiliency and how systematic changes can impact burnout rates.  

This exercise uses photography as a way for individuals to connect with and express what burnout and resilience mean to them.  Individuals will have the opportunity to self-express and process the experience of burnout or distress with others. Participation in the group experience will allow for perspective-taking and recognizing commonalities with peers. The shared experience gives participants the opportunity to be exposed to new strategies for resilience building by learning from their peers. Additionally, the outcome from the collective experience can lay the groundwork for systematic change.   

Photovoice is a qualitative method generally used in community-based participatory research.  It is action-oriented and meant to give a voice to people that are considered disempowered.  The aim of this research method is to evoke dialogue and create movement on social issues.  In this curriculum, the residents are empowered to use photography to create a shared experience which can lead to bolstering personal resilience and promotion of systematic change.   


After participating in the experience residents will … 

  1. Use photography to express their personal views on burnout and how to combat burnout 
  2. Enhance personal resiliency skills as a result of the shared experience  
  3. Create a collective dialogue that can be used to influence systemic change 

Photovoice Assignment Participants Guide

Take two photographs*, one to answer each of the following questions. 

  • What is burnout? 
  • How do I prevent or overcome burnout? 

With each image, write a brief statement describing why you chose the image. 

*photographs should be taken personally by the participant, not images found on the internet  

Instructions regarding photographs: 

Do not take photographs that: 

  • Include people who can be identified (you can see their faces clearly) 
  • Include people’s body parts in a dehumanizing way 
  • Are sexually explicit 
  • Include protected health information

You are allowed to edit photos, but don’t spend a lot of time on this. The purpose of the exercise is not the photographs themselves, but the experience of reflection. 

Take a photo that you are comfortable sharing with your group.  

The photos will be part of a group discussion. 

Photovoice Assignment Facilitator’s Guide 

(for virtual learning experience) 

Pre-Group Session:  

  1. Send out the assignment 1-2 weeks before the planned group session. 
  2. Give instructions for participants to email the photos and their descriptions to you several days before the group session. 
  3. Prior to the session, create a virtual visual display of the images and captions.
    1. Consider creating a PowerPoint or Google Slide presentation. 
    2. Place one picture on a slide and the caption on the following slide.
    3. The pictures and captions should be grouped with burnout images together and resiliency images together.
  4. Send out a link to an online meeting platform.
  5. Depending on the number of participants, 1-2 hours will be needed. 
  6. The recommended group size for online learning is no greater than 10 people

During the Session: 

  1. Create a safe space and discuss possible trigger warnings with the option for individuals to take a break if needed. 
  2. Share the presentation with participants
    1. The presentation, because it is full of images, will likely be too large to mail.  Consider posting it as an online secure link (Example – Google slide file that has access through invitation only)
      1. Give the participants dedicated time to review the images and captions:
      2. 20 minutes is a good estimate but more time may be needed depending on the number of participants. 
  3. Instruct participants to view each photo and answer the questions on a notes page:
    1. What do you see in the picture?  
    2. With which images do you connect and why? 
  4. Transition to a group discussion.
    1. Group discussions on online platforms can be challenging due to a loss of normal conversational cues and conversational flow
    2. Facilitators may need to be more direct to evoke conversation
    3. Consider having a way to go through each image so they can be discussed (for example, using screen sharing of the presentation).  
    4. Consider going through each slide and asking for comments- either ad hoc or round robin style
  5. Facilitator’s role in the discussion:  
  6. Ask open-ended and follow-up questions to allow the dialogue to flow from the participants. 
  7. Identify themes or highlight differing perspectives (for example, if there are similar images in both the burnout and resiliency categories). 
  8. Help participants understand how their own context influences their perception of the images. 
  1. Look for opportunities to highlight and normalize shared experiences (debunk the “I thought it was just me” myth). 
  2. End the session with a conversation about how this exercise might spark individual or system-level change and what that could look like. 

Photovoice Assignment Facilitator’s Guide 

(for in-person learning experience) 

Pre-Group Session:  

  1. Send out assignment 1-2 weeks prior to planned group session. 
  2. Give instructions for participants to email the photos and their descriptions to you several days before the group session. 
  3. Prior to the session, create a visual display of the images and captions.   
  4. Think of this as a gallery walk experience- all the images should be on display at the same time in the space. 
  5. This could be done by simply printing the pictures and captions and fixing them to large post notes on the walls of the room. 
  6. The pictures and captions should be grouped with burnout images in one area and resiliency images in another. 
  7. Depending on the number of participants, 1-2 hours will be needed. 

During the Session: 

  1. Create a safe space and discuss possible trigger warnings with the option for individuals to take a break if needed. 
  2. Give the participants dedicated time to walk through the images and captions:
    1. 20 minutes is a good estimate but more time may be needed depending on the number of participants. 
  3. Instruct participants to view each photo and answer the questions on a notes page:
    1. What do you see in the picture?  
    2. With which images do you connect and why? 

**Consider having a handout with the above questions and space for note-taking.  

  1. Transition to a group discussion- consider having a way to go through each image so they can be discussed- you may want to use a PowerPoint of the images to facilitate the discussion. 
  2. Go through each image asking participants to share their thoughts and reactions.
  3. Facilitator’s role in the discussion:
    1. Ask open-ended and follow-up questions to allow the dialogue to flow from the participants. 
    2. Identify themes or highlight differing perspectives (for example, if there are similar images in both the burnout and resiliency categories). 
    3. Help participants understand how their own context influences their perception of the images. 
    4. Look for opportunities to highlight and normalize shared experiences (debunk the “I thought it was just me” myth). 
    5. End the session with a conversation about how this exercise might spark individual or system-level change and what that could look like.  

Download the Resiliency Photos

Download the Burnout Images