Chris Hamerski, MD, a third-year resident, was nervous. In Uganda with the Global Health Scholars Program at the University of California, San Francisco (UCSF), he and a fellow resident were scheduled to accompany a physician and a social worker on a Hospice Uganda home visit.
Now back at UCSF between shifts on his current inpatient rotation, Dr. Hamerski recalls his reluctance: “Going into someone’s home is such an intimate experience, and I was a little worried about how we were going to be viewed.”
He needn’t have worried. Despite the startled reactions from young village boys who stopped in their tracks and put down the water jugs they were carrying to stare at the visiting Caucasian doctors, the patients were “very welcoming and gracious, and happy that someone was there to look after them,” he says.
In addition to his time with Hospice Uganda, Dr. Hamerski also worked at Mulago Hospital in Kampala and the Reach-Out Mbuya Clinic, set up to serve patients with HIV/AIDS. “I found the clinic to be very uplifting and inspiring,” he says. “I think it actually works better than clinics in the U.S. because it was an all-in-one clinic, with a holistic approach to the patient.” Not only do patients see a doctor and obtain refills on the spot of their antiretroviral drugs, he explained, but they also have access to a social worker and can obtain money to send their children to school or a micro-loan to help start a business. “It was definitely inspiring to see patients living with HIV doing well in the community,” says Dr. Hamerski. “It made you feel that the clinic was making a difference and having a positive effect on the health of the community.”
Hospitalists, residents, and directors of global health programs stress that international health experiences not only broaden physicians’ perspectives but improve their approach to diagnosis and use of resources when they return to working in U.S. hospitals.
“In their one-month immersions, people have the ability to see and effect change in a more direct way,” points out hospitalist Madhavi Dandu, MD, MPH, assistant clinical professor of medicine and director of UCSF’s Global Health Scholars Program for the Internal Medicine Residency.
Nearly 60% of American medical schools offer global health electives, according to a 2004-2005 survey by the American Association of Medical Colleges—and demand is increasing. The value of a stint abroad for any physician is irrefutable, says hospitalist Tracy Minichiello, MD, who founded the UCSF Global Health Scholars program.
Dr. Hamerski chose to do the global health elective because he wanted to “be more excited about medicine. At the end of residency, it can be a little hard to keep that positive outlook.”
Residents and physicians who complete international health elective courses (typically lasting one or two months) say the experience can greatly influence career choice. Many participants choose to practice with underserved populations or go on to specialize in global medicine.1 But even physicians who do not continue on to a career in global health reap huge benefits as practitioners.
Dr. Dandu has experienced those benefits, both as a resident and now as a visiting director of programs. Through participation in global health electives, she observes, “there is a palpable rejuvenation that occurs, a reminder of some of the enthusiasm that comes from practicing medicine with a little less of the structural issues that make the U.S. healthcare system difficult.”
Less Can Teach More
The Global Health Track of the University of Pittsburgh Internal Medicine Residency Program emphasizes “a generalist perspective, cost-conscious practice and back-to-basics diagnosis”—competencies that dovetail with the mission of hospital medicine.
“The major component of an international health elective is to really improve their [residents’] clinical skills,” notes Thuy D. Bui, MD, director of UPMC’s Global Health Track and medical director of the Program for Health Care to Underserved Populations. This clinical skills improvement is facilitated by the often-limited resources in host countries. “There is no CT, and there are no fancy blood tests, so they [the residents] really have to rely on their clinical acumen to make the diagnosis,” she says.
Dr. Bui has observed that when residents return from a global health elective (the UPMC program has centers in Malawi, India, Japan, Honduras, and Italy), they are “better at picking the right test, knowing when to be more aggressive [with treatment], and are more comfortable with ‘watchful waiting,’ rather than following up every single abnormality they detect in blood work or other imaging studies.”
Franziska Jovin, MD, is medical director of inpatient services at the University of Pittsburgh Medical Center (UPMC) Hospital Medicine Program. Originally from Romania, Dr. Jovin attended medical school in Germany, did her internship in the United Kingdom, and completed her residency in the U.S. During her residency, she returned to Romania on an international elective.
“I think the biggest thing you gain from doing an outside elective is that you learn to really practice medicine the way it used to be in the old days,” she says. “You rely much more on your clinical exam—and get better at it—because at the end of your exam, you have to formulate a differential diagnosis and a treatment plan without always confirming your hypothesis with a test.”
Practicing in another healthcare delivery system can also expand physicians’ perspectives on use of resources. Even though healthcare is funded by the government in many developing countries, says Dr. Jovin, patients still have to pay a large fee for the tests doctors order. “When patients have to pay for the studies that you order, it is much less likely that you will order a battery of tests, and instead concentrate on the test with the highest likely yield first,” she says.
While on elective in Romania, Dr. Jovin practiced in both an outpatient clinic and a hospital setting. She learned that physicians can “stay basic” by using equivalent generic medications to treat conditions such as hypertension. “Here in the U.S., you can use the latest ACE inhibitor or calcium-channel blocker and spend a lot of your patient’s money,” she says. “When money becomes an issue in order to effectively treat a patient, you’re much more cost-conscious.”
Another eye opener for those who go abroad is the chance to observe differences in practice and learn about physician training. “In many countries there is very little structured training after graduation from medical school,” notes Dr. Jovin. “Young doctors learn by following more senior doctors around; it is more an apprenticeship-type training. In many rural areas, fresh medical school graduates may be practicing alone with very limited diagnostic and treatment tools.”
Tanyaporn Wansom, MSIV, a fourth-year medical student at the University of Michigan Medical School in Ann Arbor, is the 2007-2008 chair of the Global Health Action Committee for the American Medical Student Association. During her 2006-2007 stay in Thailand (as an NIH/Fogarty Global Health and Clinical Research Fellow at the Research Institute for the Health Sciences, Chiang Mai University), she was especially impressed with the broad range of diagnostic skills possessed by her supervisor, an infectious diseases (ID) fellow. “For example, I know how to do a lumbar puncture if I am worried about the possibility of meningitis,” she says. “I know how to put the [cerebrospinal] fluid in a tube and send it to the lab. But there, my ID fellow knew how to do all the stains herself, and was able to make immediate diagnoses. There are strengths to the specialization of the American healthcare system, but it is amazing to go abroad and see what other doctors can do.”
This impression is echoed in evaluation forms from the UCSF Global Health Scholars Program, says Dr. Dandu. “One of the common comments is, ‘I’m incredibly impressed by my colleagues abroad because of their amazing physical exam skills,’ ” she says. She believes the exigencies of medical practice in the United States (reliance on testing, adherence to reporting, and regulatory requirements) often mean residents and physicians do not have “the space to focus on the physical exam or the patient’s history. And sometimes, with the way we practice medicine here, it can take longer to see the fruits of what we do and see. In their one-month immersions, people have the ability to see and effect change in a more direct way.”
Wansom, who is Thai-American, was motivated to work abroad by her curiosity about her ancestral roots and her commitment to working with people living with HIV/AIDS. She found the physician-patient relationship quite different in Thailand. “Patients look up to you, almost as they would a deity,” she says. “Sometimes it is hard to get their real input on what they are feeling. You may think, because they are nodding, that they are agreeing with everything you say and are totally compliant. In fact, the opposite may be true.”
It is this kind of sensitizing experience that can improve clinicians’ skills when they return to the States, says Dr. Bui. At tertiary care centers such as UPMC, a large transplant center, hospitalists are likely to encounter people from all over the world. “If they have interacted with people from a different culture, they can deal with our [mix of] inpatients better,” she says.
Another significant benefit of traveling to developing countries is that residents get a chance to treat diseases rarely seen in the United States, says Dr. Bui. For instance, she says: “A resident who had treated patients with dengue fever during his clinical elective in India would be quick to include this differential in a returning traveler from Central America admitted to our hospital with fever, headache, myalgia, and a rash. Having seen some of those diseases during their international elective, residents are more comfortable with managing those kinds of diseases, such as when treating travelers who come back with malaria.”
“Global health electives have tremendous impact in terms of allowing people to experience firsthand the inequalities that exist in global health, and the social and political determinants that cause them,” says Wansom. Those who have the experience “get a snapshot as to how another healthcare system with limited resources is able to provide care to its people and [are] exposed to disease processes and situations that you may not be familiar with from training in the American medical system.”
International health programs at medical schools are growing to accommodate increased demand for overseas experience. UCSF’s residency program formalized residents’ experiences and developed partnership agreements with programs in other countries—ensuring sustainable benefits to hosting countries. The Global Health Scholars Program has sites in Uganda, Saipan, China, and Kenya.
Dr. Dandu believes electives abroad can also offer hospitalists and hospitalists-to-be insight into hand-offs. “One of the central issues for hospitalists is how we help people transition into and out of the hospital,” she explains. “Many of us, as hospitalists, struggle with the fact that we sometimes lose track of our patients when they leave the hospital. One beautiful aspect of many international programs is that residents have an experience with a more holistic approach to care.” TH
Gretchen Henkel is a frequent contributor to The Hospitalist.
- Ramsey AH, Haq C, Gjerde CL, et al. Career influence of an international health experience during medical school. Fam Med. 2004 June;36(6):412-416.