Forum Replies Created
-
Posts
-
Anthony, I appreciate what you said about individuals in the host country needing a stake in the endeavor. I agree and think that when both parties invest (whether that’s time, staff, finances, other resources), the bidirectional learning is facilitated and trust can really be built for sustainable relationships. It generally seems that if one party consistently appears to be providing aid to the other, this can negatively impact long term relational dynamics.
Question 2. Thinking out loud and activating the learner are habits in the article I found could be easily translatable to education in LMIC settings. In my first year of practice, I was at a community hospital in a somewhat rural setting. We definitely didn’t have grand rounds or residents and had limited formal continuing education opportunities that were in person. However, several physicians I worked with would encourage me to share my clinical reasoning out loud, and they would as well. This really guided me in learning what information was important, where my knowledge deficits were, and how I could apply this to patients and different clinical scenarios. I believe this is translatable as these techniques do not require significant resources – just motivation and willingness in both parties.
Question 1. Some barriers to expanding faculty development programming in these settings include limited opportunities to participate in educational conferences and not having education related criteria built in the academic culture – much less as incentive for further promotion. There also may not be a supportive professional community already in place as other priorities take precedence. Especially in low to middle income settings, health care professional shortages are not uncommon and the time and investment needed to further expand may be severely limited and have inadequate support (including financial). Time and effort is also needed to form trust and relationships to facilitate development, but as there may not be immediate, visible benefit, it can be discouraging. This article acknowledged and addressed some of these challenges including variation in academic cultures and incentives, local capacity building and working with lower resource institutions with an openness to bidirectional learning.
Jonathan, I agree with you on periodic performance evaluation. It seems to me that in many professions, there are benchmarks in place to ensure quality (and productivity). What I have seen in practice in the medical field, however, is surprising lack of accountability. Not everywhere, but there is certainly much variability in quality of care amongst providers. I recall that in training, we had to take so many exams yet once out in practice, there is much more autonomy. In order to uphold quality of care, perhaps there could be some metric or way to keep track of the quality of clinical practice (and not just for reimbursement purposes!)
Question 2. I live in Philadelphia, where the patient population is very diverse and there is significant variability in education level, socioeconomic status, among many other factors that directly impact health care outcomes. Many of the providers I work with are not from the city – they frequently live in the suburbs or had moved from other states and cities. As a result, there can often be a huge disconnect between providers and the communities they serve. I can see community health workers in a role assisting patients identified as needing additional support – perhaps those with less education and understanding of their medical conditions, the elderly, those who live alone, or those who are chronically ill and/or are less likely to follow up due to a variety of factors. They could arrange home visits, assist with accessing available resources (thankfully we have many in this city), provide counseling, and help bring the most pressing issues to light for local health care systems to address.
Question 1. One of the purposes of universal health coverage is to increase access and improve the health of those who disproportionately affected. This may include those with limited access, whether due to geographic location (especially rural areas) or inability to purchase health insurance coverage, for example. However, this article pointed out additional considerations such as quality of care and patient outcomes. Universal health coverage and even increasing affordability and access, will do little to achieve the goals of improving population health, if the standard of care and quality of care is neglected. Having a system in place to measure objective and subjective outcomes (patient satisfaction, hospital admissions and readmissions, mortality rates, time spent per patient, amount spent on testing in relation to improved outcomes) will help guide the implementation of universal health coverage. Clinical practice should reflect the standard of care taught in training (and that itself may vary globally) and new providers should be paired with mentors rather than learning solo in a remote location. Patient volume and outcomes should be documented and perhaps in some places, a minimum requirement in place for license renewal.
Question 2. Prevention often seems secondary to response, as a response is intuitive and required when there is a disaster – although variable in effectiveness. However, prevention involves thinking ahead and implementing measures for a disaster that may or may not come. It also may not appear essential at the moment. I also believe there’s an element of immediate gratification with response, as results are usually more evident. But with prevention, we often do not see the benefits in the short term. Comparatively with COVID, many found mask wearing to be burdensome. But if there is recognition that without a mask, you would be hospitalized, intubated, etc. – most reasonable people would wear a mask without question. But even recently, we saw an emphasis on response (convalescent plasma, ventilators) over prevention – although I’m hopeful that is now changing!
Jonathan, I completely agree that extensive international travel is a major factor we need to consider today. COVID-19 has made this quite evident. With travel providing opportunities for outbreaks to spread even faster than before, unless our processes are updated and adapting, responding becomes much more difficult (and less effective) than prevention. As we move forward and evaluate global health, developed countries need to consider all other nations without delay to really reduce consequences of complex humanitarian emergencies.
Question 1. Complex humanitarian emergencies appear to be somewhat predictable as conflict infrequently develops without warning. As instability and conflict is recognized, plans for primary prevention could be prioritized. Having a plan for healthcare infrastructure and especially vaccine coverage, may help significantly reduce the subsequent expected rise in morbidity and mortality. The article suggests that epidemic outbreaks are greater in complex emergencies as compared to natural disasters, and that many of these outbreaks could be prevented by vaccinations. I think further emphasis and education on how this only affects regions experiencing conflict but potentially the international community (i.e. reintroducing polio outbreaks to neighboring areas) would increase funding and focus on primary prevention rather than secondary.
Kimberly, I agree with you on having courses available for providers on interviewing and bridging those cultural barriers. We’ve all seen either ourselves or colleagues in practice where things haven’t gone well, and sometimes even a lack of awareness. Also if these were either mandatory and standardized, just as HIPAA or PPE education is — that way providers are not having to choose between staying updated on the latest evidence with their area of practice versus cross cultural communication. I also like the thought of greater diversity. I’m glad to see that current medical student bodies are increasingly diverse, but there is still quite a ways to go. I agree that diversifying those in medicine will help a lot with cross cultural barriers with both providers and patient care.
Question 2. I think this article shows how we could use more evidence and studies to see what additional strategies can increase the effectiveness of short term trips. Feedback not only from students and personnel participating in the trip, but especially from the communities would be helpful. Every year there are many short term trips but it seems as if we could use greater evidence-based data to form protocols to increase the effectiveness of these trips. It can be very resource-intensive to establish a short term trip, but having existing sites and long-term relationships established could really help with ironing out inefficiencies. This may also help come up with ways to best partner with local health care systems, which would be more collaborative. Utilizing local resources and providers as the article mentioned, can help decrease unintended burdens and redirect the focus on the community’s needs and for maintaining sustainability.
Question 1. I think one of the first steps is increasing awareness and having a greater recognition of cultural barriers. Aside from language, there are so many opportunities for miscommunication and what is culturally acceptable and not acceptable to people. Practically speaking, this can be difficult to implement at times given the way our health care system is structured, but I believe that taking the extra time to listen, ask more open ended questions rather than relying on assumptions, can help decrease cultural barriers. Asking questions that build a relationship initially rather than simply addressing the symptoms directly may be helpful. A heightened awareness of body language and noticing what is indirectly communicated may also help with the provider patient relationship. Being open to learning about different cultures, habits, and lifestyles will assist with decreasing these barriers. On a system wide level, I believe incorporating mandatory education with interview examples and practicing utilizing interpreters effectively could be requirements by hospital systems or in training. Just as how to appropriately performing physical exams well is a learned skill, using language interpreters and effectively communicating with patients from a different culture should also be a basic competency factor for those in healthcare given how diverse and multi cultural our population is. This also might be too much to ask, but I’d love to see if reimbursement and incentives could be restructured to reflect this. I’m reminded that unfortunately, consults in the hospital are less likely to be seen or staffed by a physician in a timely manner if they know an interpreter is required, given the extra time commitment. If clinics increased the time allotted for patients requiring an interpreter, I believe this would increase quality of care and help bridge the inequalities we see. I’m thinking of how a 20 minute clinic appointment is given to a healthy patient with a single diagnosis for me to address (then I have time to address preventative care), but also that same time slot could go to a patient who hasn’t been seen in 2 years, with multiple chronic illnesses, maybe an acute illness too, who also has 2 family members and requires an interpreter.
Anthony, I completely agree with your statement on the vast inequalities found among the nations of the world. It is a cycle difficult to interrupt, given how connected education, health care access, finances, and government support contribute to the overall health of a nation. Ultimately, this circles back and affects funding for further progress and the gap in global nutrition and health continues to widen. In my specialty of electrophysiology, I think about those who have access to device therapies and ablations, the reliance on current technology, compared to millions who have minimum access to basic cardiac care, even for emergencies. The gap is wide and I personally do not see it shrinking. However, if anyone has seen this gap bridged or has examples where this is changing – I would love to know.
Question 2. The diversity in geographical, political, and economic situations make progress difficult, as there is rarely a single targeted solution that can effectively address the differences in obstacles to improved health. Specifically, aligning global leaders and governments do not often have the same subset of priorities. An increasing burden of non-communicable diseases as well as infectious diseases and malnutrition in developing nations, adds to the burden for achieving progress. Chronic illnesses such as diabetes, hypertension, CAD, will continue to increase and take a toll on the current health care system. The ongoing resources required for prevention, management and long-term consequences (strokes and kidney failure) for example, will prevent progress in global health. As others have mentioned, the inequalities among the nations exacerbates the differences in priorities. I honestly feel that COVID-19 will make this even more obvious in the upcoming year, as we begin to see some countries achieving vaccination in the population whereas others have limited, if any access, to vaccination.
Question 1. Global nutrition is a broad issue that is interconnected with many other factors including but not limited to political, social, economic, and climate factors. For improving nutrition from a global standpoint, the greatest deficiencies should be identified. From this article, it seems that sustainable agriculture and food production, as well as education on malnutrition (including preventable infectious diseases/contamination) could go a long way. I’m reminded of the video from this week’s assignments that describes malnutrition not being so much the lack of food necessarily, but nutritional deficiencies especially affecting children. Recognizing that access to nutrition should be a basic human right should lead systems, agencies, and especially leaders to provide basic public education on health, nutrition, contamination — as well as access. Food production and consumption should be restructured, with incentives and resources as needed, to create a long-term sustainable and nutrition-rich distribution. In a world where there is increasing niche expertise and specialization, the interconnectedness of these factors in impacting global nutrition must guide the changes for significant improvement.