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I agree with both Mike and Dawn that there is no one size fits all approach and each person learns best differently. Some may prefer learning from someone who thinks out loud whereas others may prefer to be more actively engaged. In addition, some may prefer when clinical teaching is done kindly whereas others may not mind if the person is kind as long as the clinical teaching information is there. I believe that is what makes clinical teaching in LMIC settings so difficult, because you can’t just take the same clinical teaching approach as you do in other settings. Each clinical teaching session needs to be tailored to the local needs of the community.
Question #2: 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 of exemplary clinical teaching that is translatable to education in LMIC settings is the habit of activating the learner. The best teachers are the ones that can engage the learners’ interest and make sure that they actually want to learn. Otherwise, you can be the most knowledgeable teacher and give millions of lectures but if your students are not willing to learn then they will glean very little knowledge from you. From my own personal experience, I have experienced it on both sides as a learner and a teacher. As a senior resident in my residency, I spend a lot of time teaching interns how to perform their resident duties. One of the things that I make sure I incorporate is asking them when I begin working with them to make a learning goal for the week. That way, that actively engages them to learn and also I am able to hear what they are interested in learning and help give them clinical teaching in those specific areas. I think with virtual learning, we have seen the impact on education greatly. It is much harder to engage someone virtually than in person and I think personally for me, I have always had difficulty learning virtually. Now that all of our residency program didacts are done virtually, I have had a much harder time learning from those didactic lectures.
Question #1: 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 believe that there are a few main barriers to expansion of faculty development programming in LMIC settings. First off, the quality of education and access to healthcare resources are more limited. I also feel like the amount of effort directed towards the expansion of faculty development programming in LMIC is not there possibly due to financial concerns or the amount of time that it will take. The article did mention some great ideas on getting past these barriers and I do believe that generosity has a multiplier effect and even one great highly skilled educator can make an impact on hundreds of potential faculty.
Mark, I agree with your response to question 2. However, it remains to be seen how these changes can be implemented. I believe it needs to be done on a larger scale on a government basis. Perhaps governments and institutions can invest financially in recruiting primary care providers knowing that in the long run, the financial burden on society will be less.
Question 2: How could low-resource communities better make use of community health workers?
I think that low-resource communities need to recognize that the initial cost of making use of community health workers in the short term will reduce the financial burden on the community in the long term by decreasing the number of diseases that are easily preventable or treatable. It is a slippery slope, because you want to be careful with giving community health workers too much clinical responsibility. However, I can safely say that in low-resource communities, any medical help is gladly accepted and a systems approach needs to be taken to incorporate community health workers in the community. Of course, on a wider level, policy changes need to be made to allow community health workers to be better utilized but efforts should continue to be done to make better use of community health workers.
Question 1: What additional elements would be necessary for universal health coverage to be effective?
From the article, it states that the problem is not access to healthcare but the quality of healthcare people are receiving. Therefore, to make universal health coverage effective, a stronger focus needs to be placed on education and evidence based medicine. I believe the reason why the quality of healthcare is poor is because it is easier to simply prescribe antibiotics and give patients a clear diagnosis as opposed to working a patient up further or being okay with not having a clear diagnosis. This is possible because health literacy in these areas are also low so someone coming in with anginal chest pain and being diagnosed with pneumonia will not know that they are being misdiagnosed. In addition, patients do not understand that there are hundreds of viruses that can cause viral illness that do not need treatment with antibiotics. However, for many patients, that answer is not sufficient and may be perceived also as reviewing poor health care. I think the protocol exercises we are doing are great tools that healthcare providers can use if they are unsure what to do. Overall, it will be a difficult and long process but constant effort should be made to increase the knowledge base of all medical providers.
Dawn, I agree with you wholeheartedly on question one. My only question is where these funds would come from for these interpreters. The other issue is if there are multiple languages required it may become much more difficult. For example, in India, there are multiple dialects that are spoken so it may be difficult to have an interpreter available who can speak all those languages. Additionally, in NY, at times I have come across certain languages where it is literally impossible to find an interpreter such as Farsi and Ukrainian. Those aspects make it difficult but I definitely agree that having those resources would be the main way to break the cross-cultural barrier.
Q2: What prevention interventions could best help reduce consequences of complex humanitarian emergencies?
In the article, it noted that the outbreaks associated with complex humanitarian emergencies had greater odds of being a vaccine preventable outbreak. Thus, prevention strategies should be focused on mass vaccination programs so that these outbreaks may be decreased in the future. Another thing the article mentioned is that complex humanitarian emergencies can be prevented and I believe that efforts should be made in this area as well. Just as we learned from the disaster management lessons, these emergencies can be prepared for so that the impact is much less.
Q1:What actions can healthcare providers take to decrease cross-cultural barriers?
I think it is difficult in resource-limited settings to decrease cross-cultural barriers. The three examples cited in the article were to “be creative and expansive about addressing language barriers, be alert for and responsive to mental health challenges, and be mindful of stereotypes.” From my experience, the language barrier is the biggest obstacle to decrease cross-cultural barriers. Where I practice in NY, I have a predominant spanish speaking patient population and unfortunately, my Spanish is not at a level where I would feel comfortable in the medical setting so we utilize interpreters. Even from my basic understanding of Spanish, there are times where I can understand the miscommunication between the interpreter and me and that gets very frustrating at times. Therefore, even professionally trained interpreters may have difficulty with breaking that cross-cultural barrier. One way to lessen that barrier would be to somehow utilize in-person interpreters because that would definitely decrease miscommunication. I think it is also very important to be mindful of stereotypes but not in the way that was mentioned in the article. I feel like certain cultures express things in certain ways and knowing those tendencies or stereotypes may actually help you to treat your patients with the proper medical care they need.Q1: What actions are most important to improve global nutrition?
I believe that improving global nutrition comes down to food security and safety. People need access to food and that food needs to be safe and free from any disease. Many illnesses are caused by contaminated food, in particular, the neglected tropical diseases. However, the very first step comes in obtaining food security for all so that every country in the world has enough resources to not worry about obtaining food. In order to do that, efforts need to be made to find a renewable sustainable food source that can be easily grown in any climate. This isn’t an easy task but I believe if the whole world puts effort in, it can be done. Looking at this pandemic we are currently in and seeing how a new vaccine was created in less than a year, I believe anything is possible. Dawn, you are right. When I think about global nutrition, I tend to think about malnutrition but it actually encompasses obesity as well; especially in the US, where obesity causes so many chronic diseases that create a huge burden on the country and the healthcare system. In places where obesity is a problem, efforts should be made on patient education at a young age to develop good habits. In my opinion, it will actually be harder to reduce obesity (or overnutrition) as opposed to increasing food security as reducing obesity will require people to change their behavior which is a very difficult thing to do.Q2: In your opinion, what are today’s greatest obstacles to progress in global health?
I honestly think the answer is simple. To put it bluntly, society is filled with selfish people who only care about themselves. This extends even more greatly to politicians who care more about how they are viewed rather than actually making change in the world. For example, if we look at the COVID vaccine distribution. The US has plenty of supply now to mass vaccinate the entire US population. Yet, there are other countries in the world who still do not have adequate supply of the vaccine and are now having another wave of COVID cases. If the US shared their vaccine supply with other countries. COVID cases worldwide would definitely be lower and perhaps India would not be going through this current wave. The only way I see this obstacle being removed is for a global council of sorts to create some sort of incentive for sharing supply to other countries. If other countries are incentivized to even share some of their resources, it can help greatly in progressing global health.Q1: What is the mechanism, in your opinion, through which WASH and promotion of nutrition complement one another?
I actually don’t think that there is a straightforward way that WASH complements promotion of nutrition. I agree with Dawn’s post that it may prevent many diarrheal illnesses which may promote malnutrition but water sanitation and hygiene are a separate issue from nutrition. Preventing diarrheal illnesses is just one small part of malnutrition and there are many vitamin and protein deficiencies that would not be affected by WASH. Instead of promoting WASH by itself, maybe the promotion of nutrition can be addressed as well.Q2: In your opinion, how should maternal healthcare be best expanded to protect women throughout their lives?
Maternal healthcare should have the same focus that developed countries take on protecting women throughout their lives. Screenings should be done for preventative diseases. Routine cervical cancer screenings can easily lower rates of cervical cancer. Routine STD testing can prevent diseases such as pelvic inflammatory disease and HIV. Efforts should be made to increase patient education as well and to encourage patients to obtain the regular preventive testing that they need.Hi Mark,
You brought up some good points.
For your response to question one, I do agree that changing people’s sexual behavior is very challenging and to do it on a global scale is just not feasible. I think that finding those high risk groups and educating them on PrEP use would definitely be more beneficial.
For your response to question two, I definitely agree that providers should receive more education on HIV in pediatrics so that these early cases of HIV do not get missed.Q1: From your perspective, what are the largest remaining barriers against worldwide HIV control?
I think the largest barrier we face against worldwide HIV control is diagnosing HIV early. From the article, it seems as though many HIV infections are caught late and the CD4 count is already less than 350 at time of diagnosis. If routine screening becomes more widely available and ESPECIALLY in high risk patient populations, more HIV infections should be caught earlier on and treatment can be started earlier on as well, leading to more control of HIV and lower mortality from HIV.Q2: Why, in your judgment, is pediatric HIV control lagging behind that of adults and what should be undertaken to reverse this status?
I think the reason why pediatric control is lagging starts with availability of testing. Many patients just don’t have testing easily accessible. The next step once testing is available is to educate the patient and clinical providers. Even today, there is a negative stigma associated with HIV. In the article, it mentions that more than 75% of pregnant women with HIV have access to treatment but one in five women are either not tested or not started on ART in pregnancy. Also, many countries are lacking in early infant diagnosis. This can easily be solved once testing is readily accessible so that in places where HIV prevalence is high, HIV POCT can be done at birth to identify HIV as early as possible.Hey Erika! I agree with everything that you said. Working on environmental changes and protecting land for agricultural use will definitely help to increase food security. I also agree that increasing the distribution of vaccines to resource poor countries will definitely help to eradicate measles on a global scale.
Q1: What system-wide changes, in your opinion, would most successfully increase world-wide food security?
A: I do not think there there is one single solution to increasing world wide food security. I think the main way to increase world wide food security would be to focus on increasing production of renewable food crops that are easy to grow and harvest. The reason why malnutrition has become such a huge issue is because the population is increasing at an exponential rate whereas the food supply is not really increasing. In fact, due to global warming and its environmental impact, the food supply is diminishing. I agree with working on decreasing the environmental impact and working on global warming. However, in order to see the effects of these changes would take an unreasonable amount of time. The fact that people are not willing to change their diet to reduce impact on the environment even though they are educated on the impact of the food system on the environment just goes to show that it will take more than educating the general public.
Question 2: What do you believe are the most substantial barriers to global measles elimination, and how can these be overcome?
A: The most substantial barrier to global measles elimination definitely starts with increasing efforts of global immunizations. Governments worldwide should continue to enforce immunizations in every country. Because we have an effective method of preventing measles with immunizations, efforts need to be made to globally vaccinate everyone to eliminate measles. When we look at the COVID pandemic, it goes to show that if governments work together, efforts can be made to vaccinate the whole world.
