Tag Archives: Family Medicine

Working for Health Equity –Together

By Lloyd Michener, MD

Family medicine groups have responded wonderfully to the COVID-19 pandemic, providing critical clinical services, and helping staff testing and vaccination sites. As COVID-19 underscored the depth of the disparities across our states and communities, family physicians have also taken on local and national leadership roles in health equity efforts, efforts to achieve health equity are now expanding rapidly, and the approaches and even the language used are changing as well.

As a particularly horrific example, a new report from the US Civil Rights Commission calls for equity in maternal health, noting that Black women in the United States are 3 to 4 times more likely to die from pregnancy-related complications than White women in the United States. The report calls for coordinated prenatal, maternity, delivery, and postpartum care that manages chronic illness and optimizes health, and points out the role that states can play in supporting equitable health, including Georgia, New Jersey, and North Carolina. Maternal health equity is an opportunity for family medicine, partnering with our health systems, our communities, and our states, to make a difference.

At the same time, academic health centers (AHCs) are increasingly engaged in health equity efforts, seeking to build and strengthen community partnerships for health. As David Skorton, CEO for the Association of American Medical Colleges, stated:

“the traditional tripartite mission of academic medicine — medical education, clinical care, and research — is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine’s missions. This means going beyond “delivering care” to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed.

It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities.”

https://journals.lww.com/academicmedicine/pages/articleviewer.aspx?year=9000&issue=00000&article=96573&type=Abstract

This is a new challenge for many AHCs, and a place in which family medicine can make a much-appreciated difference. A private, research-intensive school headlined such an example:

In many ways, the COVID-19 pandemic forced positive changes in how medicine is practiced in communities and at academic medical centers, with family medicine departments working at the front lines to provide care and forge relationships with community partners, according to a Duke Health review.

https://corporate.dukehealth.org/news/pandemic-response-shows-path-improved-health-care-future?utm_source=newsletter&utm_medium=email&utm_content=The%20pandemic%20shows%20a%20path%20toward%20a%20better%20health%20care%20future&utm_campaign=dukedaily2021_09_20

As these partnerships grow, the language shifts. Family medicine is growing accustomed to the idea that we have a role in the ‘social determinants of health,” while community organizations may use a broader, more positive framing of the “vital conditions of health” which is inclusive of the intersections of health and safety, work, transportation, education, civic muscle, housing, and the environment. Family practices can have important roles in this larger effort, both as trusted sources of care and information, as one of the community hubs that link individuals and families to needed services, and as respected advocates for needed policy change so that all communities have the opportunity to thrive.

Guidance on how to partner and support community health equity is increasingly available, including, to cite just a few:

It is noteworthy that every one of these draws from diverse groups and sectors, as working effectively with community organizations towards health equity requires partnerships far beyond any one discipline, profession, or sector.

Within all this complexity and challenge, family medicine has a wonderful opportunity to serve as builders of bridges to and with our diverse communities, many of whose members come to us for care. By expanding our vision so that we are engaged with communities around their priorities and needs, we can help build on their strengths, add our own and those of our academic colleagues, to our shared goal of achieving health equity.

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?

Family Medicine Educators Need to Lead on Eliminating Race-Based Medicine

Andrea K. Westby, MD

Andrea K. Westby, MD

The practice of medicine—the traditions, diagnoses, treatments, and guidelines—is ever-changing, with new research and information flowing into clinical care at a pace that rivals the turbulence and abundance of a mountain stream in the spring. We now acknowledge human papillomavirus infection as the primary driver of cervical and now oropharyngeal cancer. Hormone replacement therapy is no longer routinely recommended for postmenopausal women. Rate control is preferred over rhythm control in atrial fibrillation. Prostate cancer screening is no longer reflexively ordered for adult men.

However, as we look back at the past hundred years, our profession has been glacially slow to release the vice grip that the concept of biological race has had on our science and our medical practice.

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