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Reese, I agree with your input regarding Thinking Out Loud. I find this very helpful as a learned and I practice it regularly as a resident. Usually, I employ this when I junior resident or medical student has presented a plan I don’t necessarily agree with. Rather than disagreeing and presenting my plan. I usually try to walk through my thought process and how I arrived a different plan.
Q1 Dr. Burdick describes qualities of effective programming and global collaboration. What barriers exist to expansion of faculty development programming in LMIC (low and middle income) settings?
I see the primary barrier to the expansion of faculty development being minimal in-person learning, workshops, conferences and clinical practice. We are fortunate to live in a time with relatively free flow of information and people around the world can learn just about anything with any device that connect to the internet. However, in order to feel confident with those skills you need to be able to practice with others that have more experience than you and can provide feedback and encouragement.Q2 Which habit of exemplary clinical teaching is translatable to education in LMIC (low and middle income) settings? Can you provide an example of effective implementation from your own experience? I think the habit this is very translatable to education in LMIC setting is “Keep it Simple”. This is an incredibly important concept in medical education. The example that comes to mind is from an internal medicine physician and mentor I have learned from. He would always tell me to take complex cardiac patients and break their heart problems down into four simple aspects of the heart. He reinforced that all patients with heart problems, I should consider 1. The function of the heart (Do they have heart failure?) 2. The perfusion to the heart (Do they have coronary artery disease?) 3. The flow of the heart (Do they have valvular pathology?) and 4. The rhythm of the heart (Do they have an arrhythmia?). These all are interconnected but those four principles have always helped me take something that seems overly complex and simplify it.
Austin, I agree with your discussion around creating a “culture of care”. Culture of care should also including a culture of teaching. Everyone in healthcare around the world should be eager to teach others regardless if they are professional medical students or if they are community healthcare workers.
Question 1: What additional elements would be necessary for universal health coverage to be effective? I think universal health coverage will need to lean on teamwork. The independently practicing healthcare workers operating in isolation will likely be severely limited in their ability to impact communities compared to an equal number of workers with equivalent training that are working in teams. Universal health coverage will require organizing problems according to who may be able to assist best. Complex patients with multiple problems, limited functional reserve or requirements for procedural care would likely need to be diverted to any limited amount of medical officers or doctors available. While community healthcare workers are assigned to assist with common disease management, preventive care and education tasks. In this way, someone may see a community healthcare worker one year for their immunization and the next year they may see a physician if they have a complex medical problem requiring evaluation. For the medical officers around the world, a strong emphasis during training should be placed on future teaching and training of other healthcare workers. One of the greatest benefits of having a doctor available may be in overseeing and teaching others how to care for patients rather than direct patient care. This should be an assumed responsibility of all physicians and not an expectation of only a select few in academia.
Question 2: How could low-resource communities better make use of community health workers?
Using community health workers to help with treatment and disease management in addition to preventive health would create significant growth for universal health coverage in low-resource communities. In order for this to occur, community health workers would need to have increased training and oversight from more experienced healthcare workers such as doctors. One option would be to financially incentivize a percentage of the few medical school graduates from countries to pursue a career in community health. Their job would require them to be assigned a certain number of communities, to go to these communities and train community health workers, and to periodically re-visit these communities to continue ongoing training programs. They would be responsible for a panel of communities and community healthcare workers similar to how doctors are traditionally responsible for a panel of patients. This would provide better quality and more standardized training to community healthcare workers so they can be given increased responsibility.Luc, I agree with your response to Q1. It is important to include the person in the decision making process. It needs to be a shared decision making process in order for medical care to be effective across cultures.
Question 1: What actions can healthcare providers take to decrease cross-cultural barriers?
I think it is extremely important to always take the extra time to ensure adequate interpretive/translation services are available for visits. Too many times I see miscommunication because the time was not taken to ensure this. Language is so important to culture and that needs to be the foundation for all interactions. Secondly, it is impossible to think all healthcare providers will be completely competent in all cultures. However, we should work hard to become culturally competent and conscientious with regard to the cultures with which we work. If there is a large population of people from a particular culture within our care network then we should do our best to learn more about that culture. Third, I think it is very important to always be honest about our personal understanding of things. I think it can be helpful to use language such as “it is my understanding” so as to not assume too much. This can make a more inviting environment for open conversation rather than miscommunication.
Question 2: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?
Probably the simplest answer to this is water, sanitation and hygiene. Water is so important to ongoing health that during humanitarian emergencies it can become significantly more important. The primary way to decrease risk associated with disaster is to provide sustainable water access to all. Additionally, immunizations continue to be of utmost importance in the world. A fully immunized society will be much more prepared to face widespread disease outbreak in times of disaster.Gabriel. I agree with your discussion of war being a primary problem in the pursuit of global health. It is hard to provide basic preventive health care when people are at war with each other. Reacting to mass problems such as war or natural disasters put everyone on their back foot.
Question 1: What actions are most important to improve global nutrition? I think one of the most important actions we need to take is to support locally grown and farmed foods. We need to encourage this for the benefit of local economies but also for the better nutrition of the population. If food is grown locally, there is less of a motive for taking shortcuts in the producing and processing periods. If food doesn’t need to be shipped far distance, there will be less preservatives used. When farmers are local there will be more of a motivation to produce healthy crops rather than factory farming that pumps out large volumes of food for distribution to “abstract populations” and people they may not feel connected to. This can be supported by helping build sustainable infrastructure such as roads and waterways to promote farming long term. There is also a large cost to our current level of meat consumption. I think finding alternative high protein foods will be more sustainable for the long run and I think technology will be able to help with this endeavor.
Question 2: In your opinion, what are today’s greatest obstacles to progress in global health? Nationalism. If diseases were triaged based on importance from the perspective of the entire planet, I think we would make huge strides in combating diseases such as measles, TB, HIV and malaria. Unfortunately, most of the resources continue to be available in areas no longer affected by measles and TB. Instead our resources are going towards the seemingly endless types of medications for heart disease, COPD, depression/anxiety or devices for elective surgeries. It’s not that these diseases are not important, it is just a problem of triaging problems within nations or even within subset classes within nations rather than as a unified human population.
Lois, I’ve noticed a common theme in some of your responses and discussion comments during group and I love how you have summarized it in this sentence, “ensure schooling for young girls and literacy for women in small groups which empower and educate them to understand the power and value of their own lives.” Perfectly stated. Could not agree more.
Question 1: What is the mechanism, in your opinion, through which WASH and promotion of nutrition complement one another?
I think these two interventions complement each other very well because of the importance WASH plays in the meal team and that directly relates to nutrition. We can also see how the absence of these interventions can be related. Without WASH, nutrition can be even more important with the illnesses associated with poor hand hygiene. Health, growth and development are more connected than disconnected. Without health, growth and development can be very difficult to achieve. In fact, when evaluating a child that is behind on development the first step is often to look for long term health problems. They may be completely developmentally “normal” but if they spent the first 4 months of their life fighting diarrheal illness which has now put them “behind”. It only makes sense to have interventions like WASH be in conjunction with nutrition interventions.Question 2: In your opinion, how should maternal healthcare be best expanded to protect women throughout their lives?
Maternal healthcare needs to start with education from the day girls around the world are preschool age. I strongly believe in the power of education to improve the lives of girls and women. The more education is pushed throughout youth, the less unplanned pregnancies will occur and this is the first step in protecting women through maternity care. Additionally, women will have more power and control in their family planning dynamics within their homes. After education, then the very basics need to occur during pregnancy. Labor and delivery may be the only time a woman encounters a healthcare professional so every opportunity during that time needs to be taken to provide appropriate immunizations, cancer screenings and chronic disease management and the care can’t end once the newborn is delivered. There should be a focus on supporting mother’s through not just child bearing but through the postpartum period and through raising children, grandchildren and care needs to continue through old age.Myrna, thanks for mentioning provider/patient follow-up. Another example of the importance of continuity in medical care. The relationships established in primary care can be the difference in someone getting the care they need.
Hi Reese, thanks for you response to Q2. I agree that maternity care is often not prioritized and I like that you included the fault of the practitioner. Often times, I’ve seen, in these types of situations doctors will not order testing because they think it is very unlikely. This brings in a lot of bias because not everyone with HIV disease will have risk factors readily apparent. HIV testing should be universal, the testing is inexpensive and the risk of not diagnosing is too great for both the mother and infant.
Question #1: From your perspective, what are the largest remaining barriers against worldwide HIV control?
From my perspective, stigma remains the largest barrier to defeating HIV. We have the science and tools for prevention, surveillance and treatment. It is a matter of mobilizing that technology effectively. Stigma around HIV runs deep. I have had patients tell me they would complete all the routine STI screening lab work I have ordered but they refuse to be tested for HIV. I have also had pregnant mothers refuse HIV testing. Stigma is a barrier at the patient level. I also think all physicians should have a basic understanding of PrEP.Question #2: Why, in your judgment, is pediatric HIV control lagging behind that of adults and what should be undertaken to reverse this status?
In my judgment, testing and surveillance needs to be universal in labor delivery wards around the world. POC HIV testing should be optimized and inexpensive and provided as standard of care to all L&D wards. On admission, all mother’s should be tested. Oftentimes, at least in the US, HIV testing is done in the 1st trimester (if at all), but there is an opportunity for infection during pregnancy for those in serodiscordant relationships. That is why I think all mothers presenting in labor should be tested and a plan for treatment established prior to discharge. Also, all newborns should have POC HIV testing and a plan for treatment established. We can’t afford to be reactive with HIV in children. We need to catch it every single birth.Lucio, thank you for bringing up the appropriate training of healthcare workers regarding NTDs in question 2. This is extremely important and part of the reason I am trying to continue to educate myself by taking this course and training.
Lois, I agree with your response to Q2. Particularly your thoughts about leveraging limited resources to combat multiple disease within communities. This would help in so many ways. It is like treating the community as a whole similar to how we try to treat the patient as a whole. More effective to try to tackle multiple problems then being too focused on one problem.