Global health hospitalists

More physicians are focusing on a particular country, and frequently a particular hospital, to bring about lasting change.

The man was in his early 40s and had been losing weight when he arrived at St. Therese Hospital in central Haiti last October.

“He clearly had a huge mass in his belly, which we could feel,” said Palav Babaria, MD, who had examined the man the previous week. “What we could feel was maybe eight to 10 centimeters.”

Photo by Thinkstock
Photo by Thinkstock.

But without a computed tomography (CT) scanner at the government hospital, there was no way to know if the mass was malignant, she said. The man's best option, his family was told, was to somehow raise the $100 to $200 required for a scan at a private hospital located more than two hours away.

Lack of resources is something Dr. Babaria became accustomed to after that first month in Haiti, part of her one-year Global Health-Hospital Medicine Fellowship through the University of California, San Francisco (UCSF). St. Therese also lacks an ultrasound machine, and some drugs, such as cholesterol medications, aren't available. Other medications, like intravenous antibiotics, can run out, she said.

Physicians pursuing a hospital medicine career are particularly well suited to challenges like this, given their system-wide focus on improving patient safety and quality care, said Phuoc Le, MD, MPH, co-director of the UCSF Global Health-Hospital Medicine Fellowship. Launched in 2012, the fellowship is one of the first created for hospitalists in global health, according to Dr. Le.

“I definitely believe that it takes time on the ground to really start changing systems and to develop really meaningful relationships with people,” Dr. Le said. “You can't do it with a one-month rotation during or after residency. You can't do it with mission work.”

Spending a stint in another country has increasingly become part of the educational experience for a medical student. By 2012, 30.4% of medical students reported at least one global health experience compared with 27.5% in 2008, according to the Association of American Medical Colleges' annual medical school graduation questionnaire.

But those experiences are often episodic and relatively short. Dr. Babaria is part of a new cadre of young physicians who seek to focus on a particular country—and frequently a particular hospital—in order to improve treatment protocols in ways that can potentially enhance care for local patients long-term.

Expanding options

Opportunities for hospitalists interested in global health are increasing. Like UCSF, the University of Chicago launched a global hospital medicine fellowship in 2012. For now, the commitment is one year, with fellows spending roughly half their time in Haiti, but the fellowship will soon be expanded to two years, according to Evan Lyon, MD, the fellowship's director.

The University of Miami Hospital has a similar fellowship in the works. Vincent DeGennaro Jr., MD, MPH, a hospitalist who has spent considerable time working in Rwanda and now is in the process of relocating to the University of Miami, said that he plans to start a two-year program there by mid-2013.

At this point, all of these fellowships are relatively small in scope, with no more than a few physicians accepted annually. But the work that's done in those fellowships is immersive and can have far-reaching effects.

Dr. Babaria, one of the first two UCSF fellows accepted from about a dozen applicants, will spend seven months in Haiti during her one-year fellowship. She devoted the first several weeks primarily to observing and conducting a preliminary needs assessment of St. Therese Hospital.

To date, she's started a couple of projects, including one to streamline the wait for routine blood test results, which can stretch a week or longer. Some of the hurdles involves resources. The machine can break down; the requisite chemical reagents can run out.

She's also targeted human factors, Dr. Babaria said. Writing an order and getting it to the laboratory can entail numerous handoffs. By fall, she was piloting a test project to eliminate steps, with the doctor writing the lab order and handing it directly to a nurse. “I think there is a lot of low-hanging fruit like that, where you can improve the efficiency of the hospital and get the results back faster,” she said.

Other options

Shorter-term global health programs also are available—typically attracting a mix of general internists and hospitalists—to pursue during residency or afterward.

At the University of Minnesota in Minneapolis, the Global Health Pathway is designed for senior medical students, and internal medicine and medicine pediatric residents, said Patricia Walker, MD, DTM&H, who directs the pathway, which falls under the University of Minnesota's department of medicine.

Practicing physicians, including hospitalists interested in learning more clinical tropical medicine, can take the university's seven-week online global health course, and complete an overseas clinical rotation if they choose to get certified through The American Society of Tropical Medicine and Hygiene, she said. The global health course also offers an intensive laboratory and simulation center experience every May at the University of Minnesota, including a mock refugee camp experience, she added.

“Our mantra in the program is that global is local in health care,” Dr. Walker said. “The reality is that even if you are a physician who never leaves the United States, the world is at your doorstep. The medical education system in the U.S. has not kept pace with both the speed of travel—in other words, the Ebola virus can be here in 24 hours—and the number of people moving around the world. We hear from hospitalists and other practicing providers that training in clinical tropical medicine really helps them feel more comfortable taking care of patients both here and abroad.”

The pathway includes the nine-week global health course, most of it completed online, to provide medical students and physician residents a better grounding in relevant diseases, as well as training in cultural differences. Participants also complete a one- or two-month rotation outside the United States. The University of Minnesota has clinical relationships with several countries, including Costa Rica, India, Tanzania, Uganda and Thailand, where they offer a two-week companion course every two years.

Since 2000, nearly 300 physician residents have participated in global health pathway activities, including 70 who have completed the pathway, according to data through October 2012.

Part of the pathway's training involves a vital shift in mindset and assumptions, no matter where the doctor eventually practices, Dr. Walker said. If a patient is admitted through a U.S. emergency department with a fever, she said, “any good hospitalist needs to ask them, ‘Where were you born and where have you traveled?’”

Respecting differences

Besides being flexible and open to different cultures, hospitalists practicing in developing countries must learn to shed their American presumptions, Dr. DeGennaro said. “They have to be willing to learn another culture and willing to put the American culture on the back burner when they are abroad, especially American medical culture,” he said.

Well-intentioned physicians might need to be trained to best offer their expertise without undercutting local medical practice in some way, according to the global health program leaders interviewed. “You listen to what they need and want, because you are there for a short time,” Dr. Walker said. “They are there for their entire life.”

A doctor sent to a village might be tempted to sit down and immediately start treating people, in the face of daunting medical needs, Dr. Walker said. A better long-term approach, though, would be to find a local clinician in a nearby village to partner with, and start treating patients together. In that way, the clinician might gain additional skills to apply after the U.S. physician leaves, along with perhaps the added luster of having worked alongside an American doctor, she said.

Once hospitalists gain a sense of how a particular facility functions, they can suggest strategies for improvement, with an eye toward patient safety. Dr. DeGennaro, who has blogged about his experiences in Rwanda, has worked on various initiatives, including educating nurses to record the time and type of medication that has been administered to a patient. He also promoted the labeling of syringes when only a portion of the medication has been used. In that way, he said, it will be known what the syringe contains and the number of milligrams remaining.

ACP Associate Member Alex Millard, MD, chief resident in the department of internal medicine at the University of Virginia Medical Center in Charlottesville, spent two month-long stints in Uganda during his residency. For part of the time, he and another physician resident from Uganda studied the incidence and related risk factors of peripheral vascular disease in people with type 2 diabetes who visited outpatient clinics, said Dr. Millard, who was in Uganda as part of the University of Virginia School of Medicine's Global Health Leadership Track.

Dr. Millard, who plans a career in hospital medicine, also relished the opportunity to ease inpatient suffering during his time at Uganda's Mbarara University of Science and Technology. He treated patients with end-stage AIDS, including those struggling with wasting syndrome and “every neurological complication you can imagine.” He also cared for young adult patients with end-stage heart failure, the results of undiagnosed heart valve malfunctions dating back to childhood.

“The outpatient burden there is huge,” said Dr. Millard. “So to have somebody who is just focused on taking care of the sickest of the sick in the hospital is really beneficial.” (See Table for a list of the most common causes of death in low-, middle- and high-income countries.)

Other benefits

U.S. hospitalists enjoy some inherent advantages if they want to pursue extended work in another country, Dr. Le said.

The shift structure of a hospitalist's schedules makes it easier, compared to some other physician specialties, to accumulate blocks of time to practice elsewhere, he said. One avenue for new physicians is to land an academic appointment at an institution that accommodates time away. Dr. Le pointed out that roughly one-fifth of the 50-some hospitalists at UCSF devote some time to global health initiatives.

Academic programs that open their doors to global health enthusiasts also will benefit from building a hospitalist staff with diverse clinical experience, including potentially a facility in several languages, Dr. DeGennaro said. Plus, globally savvy hospitalists will likely be able to practice adeptly without as much of a reliance on high-tech diagnostic tools, he said.

Dr. Millard agreed, saying his time in Uganda had sharpened his clinical skills. “Watching [Ugandan clinicians] properly do physical exams—you can't help but learn from that,” he said. “The first time I was there we didn't even have a functioning chest X-ray.”

Now before he orders another test or imaging scan, he takes a step back and asks: “‘Is this necessary? Is this going to change my management? Is this going to change patient outcomes?’”

In short, Dr. DeGennaro said, “When you come back to the United States, you are going to trust your eyes, your ears and your hands more.”