Global Expansion of Family Medicine
Global Expansion of Family Medicine
Family Medicine as a discipline offers solutions to many of the world's healthcare challenges, such as access, cost-effectiveness, integration rather than fragmentation, and equity. For this reason, across the globe Family Medicine is being adopted.
Barriers to medical care may be a primary determinant of health for the Maasai people of southern Kenya. This retrospective study reviewed data collected by members of two non-profit organizations: Hands for Health and Kilimanjaro Hospital. Paper-based surveys were completed during interviews with leaders of the thirteen Maasai villages served during our international family medicine clinical rotation in January 2017. The most commonly reported barriers to health were transportation/distance to providers, lack of providers, and lack of insurance/ability to pay for care. The most commonly reported needs for health improvement were better access to medical doctors/nurses/etc., clean air and water, and transportation. The Massai of southern Kenya believe their general health could be most improved by better access to medical care and health education. Many of their perceived health concerns may be readily treatable or preventable if such access were improved.
Building A Central and North American Collaboration to Develop Family Medicine Training and Practice
Primary care is essential to improving health in all, but especially in low-resource countries. However, few in Central America recognize or train family physicians. Through a series of meetings starting with the Society of Teachers of Family Medicine (STFM) in 2016, blossoming at the World Organization of Family Doctors (WONCA)/Pan American Health Organization (PAHO) meeting in San Jose, Costa Rica, and solidifying further at the American Academy of Family Physicians (AAFP) Global Health Workshop in Atlanta, a group of family physician faculty from North America and Costa Rica joined with interested Guatemalans, Hondurans, and Nicaraguans to share resources for the purpose of developing family medicine across Central America. With the support of this collaboration, we are taking steps to introduce family medicine and develop residency training with host countries. We will share our progress in Guatemala and Honduras, and outline opportunities for furthering development of family medicine, while inviting participation in the planning and execution of a 2018 Central and North American Conference on Family Medicine, sponsored by the Universidad Rafael Landivar of Guatemala.
In Haiti, dental care is almost non-existent among children and adolescents. There is a ratio of approximately one dentist to every 35,000 Haitians in Haiti. Dental hygiene is critical in preventing periodontal disease and tooth decay. According to the Academy of General Dentistry, there is a relationship between periodontal disease and stroke/heart disease. Our goal is to educate children and adolescents about dental hygiene principles, and to help them prevent dental decay and other periodontal diseases using community resources. We plan to conduct health education conferences about dental hygiene for children and adolescents from different schools. Through funding from our non-profit organization, Haitian Vision Foundation, we distributed dental kits containing toothbrushes, toothpastes, and dental floss to these students. By providing dental education to children and adolescents, we aim to decrease periodontal disease among Haitians and achieve overall improvement in global health in an impoverished community.
Designing a Point-of-Care Ultrasound Workshop Through a Multi-institutional and Organizational Collaboration for Family Medicine Physicians in Kenya
Point-of-care ultrasound (POCUS) has the potential to allow for affordable, reliable, and rapid diagnosis in low-middle income countries (LMICs) that otherwise lack the means for diagnostic imaging. In Kenya, family medicine physicians are well-positioned to utilize POCUS in ambulatory and emergency care settings, but lack formal training in the use of this technology. To fill this need, the Kenya Association of Family Physicians partnered with University of Massachusetts Family Medicine, Contra Costa Family Medicine, and four Kenyan family medicine training programs to bring a two-day POCUS training workshop to Nairobi, Kenya, in May 2017. The workshop trained 44 family medicine postgraduate trainees and physicians, representing most family medicine residencies all over the country, and was the first of its kind in Kenya. The goal of this presentation is to describe the logistics and implementation that were involved in organizing a multi-institutional/organizational POCUS workshop to family medicine trainees in Kenya.
Timely access to care, improving quality of services, and workforce development are important domains to be considered by all partners in global health collaborations. Community health professionals identified the need to improve outcomes in the area of safe maternity care. We are currently in the process of enhancing these medical services by expanding prenatal care to include both vaginal and cesarean deliveries. Additionally, we are addressing workforce development by offering the first regional Advanced Life Support in Obstetrics (ALSO®) course as an effective means to disseminate knowledge and skills to maternity care providers. In partnership with our in-country colleagues, we will establish a program to maintain skills and assess the impact of interventions. Our partnership establishment and growth will be summarized, and a description of our vision to expand services and invest in the betterment of the community will be shared, highlighting lessons we are learning along the way.
Development of a WhatsApp Ultrasound Consult Group to Improve Patient Care and Longitudinal Ultrasound Training in a Global Health Context
Ultrasound is used in many health care settings, including extremely resource-limited areas. However, the skill of ultrasound practitioners varies widely, often due to limitations in longitudinal training. For several years, the Contra Costa Regional Medical Center/University of California, San Francisco (UCSF) Global Health Fellowship has supported ultrasound training in multiple countries. In 2017, they started a novel program using the instant messaging service WhatsApp to provide longitudinal support for ultrasound practitioners in various settings. By creating a WhatsApp consult group, members can post cases and receive real-time feedback and consults on their ultrasound findings. The consult group currently consists of practioners in Malawi, Kenya, and the U.S. There is specific focus on supporting two Malawian ultrasound techs working in separate and isolated rural health settings. The program connects hospital staff in resource limited areas with family medicine physicians experienced in ultrasound. The program improves diagnostic utility and patient care, while supporting local capacity building.
For more than five years, our team of family physicians, social workers, and local community workshop facilitators has worked intimately with the Guatemala-based non-governmental organization (NGO), Mercado Global (MG). Our objective has been to help the MG artisans self-identify areas of health needs, and then work with them to improve health literacy and health maintenance. Each expedition has been aimed at empowering MG facilitators and artisans, through health education, to take active roles in maintaining their own health and that of their families and communities. During our most recent visit in February 2017, we developed and implemented two new educational modules. The topics were Diabetes and First Aid (chosen by MG artisans). The information was disseminated using a “Do-It-Together Health Education” model that entailed assessing the base knowledge of our audience, presenting simple but critical health facts on each subject in a fun and interactive way, and adjusting care plans to suit the cultural context in an effort to facilitate adherence.
Family Doctors are our Rising Stars for the Future: A Discussion With Leaders of Family Medicine Expansion in Malawi, Guatemala, and the U.S.
Swedish Medical Center and Providence St. Joseph Health and Services will be launching their first Global Primary Care Leadership Forum this fall. These institutions are deeply engaged in supporting family medicine development in Malawi and Guatemala, both of which are at an early stage of their development. Through this forum, three Malawian and three Guatemalan doctors will participate in a seven-week rotation, where they will be students in a global health leadership course. They will acquire knowledge and skills unique to the U.S. setting, build relationships with family medicine colleagues from other countries, teach about their experience with global family medicine development, and participate in the AAFP’s Global Health Workshop. This session will be a platform for discussions whereby Malawian, Guatemalan, and U.S. family physicians share their experience of building the clinical and cultural infrastructure to grow family medicine in their context.
Family Medicine Cares International: Patient Care, Service, Medical Education, and Faculty Development in Haiti
The American Academy of Family Physicians (AAFP) Foundation’s signature program, Family Medicine Cares International (FMCI), has a long-term commitment to the country of Haiti. The FMCI program’s volunteers provide patient care, service, and medical education each year during a week-long delegation trip. The medical education mission of the program includes both direct teaching to physicians, residents, and students, and an ongoing faculty development program for the two Haitian family medicine residencies. This workshop will present information about the entire FMCI program, but will emphasize the faculty development mission—specifically, the design, organization, implementation, and evaluation of the faculty development program. We will also discuss faculty development as a sustainable, capacity-building activity in a resource-limited area. Lessons learned from our four-year experience, future plans, and potential for exportability to other developing countries will be reviewed.
After one year in the consultation process for the development of a family medicine residency program in Honduras, and after several attempts, we have advanced to a more concrete position to share current status and discuss the future. Family medicine has been implemented in most Central American countries, except Honduras. With support from the Pan American Health Organization (PAHO) and the Universidad Nacional Autónoma de Honduras (UNAH), an integrated commission visited Indiana University and had a working visit to learn about family medicine firsthand, and determine the steps to follow for the development of the first program in Honduras. Through this presentation, we will describe the current and previous consultation processes and share recommended structure for consultations reports, as well as open the discussion to share participants’ own expertise and advice for the future of the project.
Concordant with the Ethiopian government's plan to extend health care to its growing population, Addis Ababa University (AAU) initiated a family medicine residency in 2013. Gossa, et. al., previously summarized in the journal, Advances in Medical Education and Practice, family medicine's development in Ethiopia. Substantial development has occurred since that report, including: a Ministry of Health (MoH)-defined curriculum and defined scope of practice for family medicine; a national professional society (The Ethiopian Society of Family Physicians; two graduating classes from the AAU residency; two graduates now serving as AAU family medicine faculty (one as the residency program director); and the MoH’s continued commitment to expanding family medicine training nationally. Many strengths, challenges, opportunities, and threats remain, including many anticipated, yet failed to materialize, as well as many new emerging ones.
As in much of the world, development of the Family Medicine Academy lags behind other specialties in Southeast Asia. As the region embraces the WHO-sustainable development goal of “health for all at all ages” and universal health coverage, we have seen a realignment of government priorities to reconsider family medicine. It is essential that local leaders in family medicine are prepared to influence the Ministry of Health in the formation of primary care regulations, and the development of programs to train primary care doctors. We have developed a three-pronged approach to the development of local leaders in Vietnam, Myanmar, and Cambodia, involving faculty development, clinical service delivery, and policy development, with varying results. In each setting, the context varies, but our strategy has resulted in palpable change in line with our goals. We will share our approach and our successes and setbacks in each country.
There is a severe shortage of primary care physicians worldwide, especially in low- and middle-income countries. Clinicians, especially those with less experience, may feel uncomfortable managing certain situations independently, and may benefit from the available support of a physician with more experience. Advancement and availability of telecommunications technology has enabled this support to be accessible, not just in person, but also remotely from across the globe. We describe a case of a 45-year-old female presenting to a clinic in Kenya with unilateral leg swelling. Diagnosis and management of deep vein thrombosis was conducted by a local provider with support of a U.S.-based primary care provider volunteering within a telemedicine organization, The Addis Clinic. In presenting this case, we illustrate how asynchronous remote teleconsultation promotes capacity to provide primary care globally. We also discuss challenges to providing quality care with asynchronous remote teleconsultation, and ways to overcome these challenges.
Christian Medical College of Vellore (CMC) in India has robust student and resident family medicine education programs lead by an academic department of family medicine. The specialty of family medicine in now recognized in India, clinical family medicine care is recognized as high-quality, and community-based research is beginning. This level of accomplishment results from 24 years of progressive work with partners from several countries and institutions. We will discuss the benefits, challenges, contributions, failures, and successes of engagement with multiple international partners over more than two decades. Examination of this model will provide strategies and approaches that can be applied for progression and maturation of family medicine education and practice in countries and regions where it is not well established.
This is an ongoing quality improvement project aimed at improving health care outcomes at a health care facility in rural Ghana, through home visits targeted at patients at increased risk of readmission following their discharge from the hospital. High-risk patients are identified at presentation using pre-established criteria. The patients’ socio-demographic data and follow-up information are then transferred into a database, which is reviewed weekly and cross-referenced with the outpatient appointment records. Patients who miss their follow-up appointment are then noted and scheduled for home visits, during which barriers to health care access are identified, medication compliance is evaluated, and the patient’s health is assessed. We hope to share some of the successes of this project so far, as well as challenges encountered. This will be an opportunity to highlight some of the unique obstacles that may be encountered in the implementation of quality improvement projects in resource-constrained environments.
Health care systems in limited-resource settings face numerous challenges, including inequity in geographic coverage access, cost, limited qualified health care providers, and poor coordination of primary care. An expansion of family medicine residency (FMR) programs in such countries could result in the improvement of the delivery of health care. The non-governmental organization (NGO) Zanmi Lasante/Partners in Health and the public sector have developed an FMR program at the Hospital Saint Nicolas of Saint-Marc, Haiti. The goal of this indigenous program is to train high-quality family physicians who are capable of transforming the health system through their practice and by taking leadership roles in their communities. In this workshop, the Saint-Marc, Haiti, experience will be presented and used for discussion. Through brain storming and small group activities, participants will learn tips on building collaborations and working with partners to design and implement a FMR program in low-income countries.
Healing Peru is an American-based nonprofit with the goal of providing healing and relieving suffering to the remote Andean communities in Peru. In the past years, Louisiana State University New Orleans Health Science Center and other volunteers from the U.S. have joined this mission. We noticed the loss of valuable information for patients and health care workers due to lack of medical records. In 2017, we decided to use the Fast Electronic Medical Record (FEMR) software to effectively collect and store patients’ health information. We gathered demographic information, vital signs, chief complaints, past and family medical history, history of present illness, physical exams, assessments, plans, and treatments. Implementing this EMR in the rural setting was a challenge. We will discuss advantages and disadvantages of the EMR in a rural setting and evaluate possible improvements for future years.
Recent advancements in information and communication technologies have elevated telemedicine as a promising tool for serving health needs in isolated and underserved populations. While telemedicine has been successful at increasing access to certain subspecialty care in the global setting, its role in enhancing primary and general health care has been limited. The research team hypothesized that using a novel, simple-to-use, cost-effective telemedicine technology, and training community health workers who can facilitate its use, could enhance the delivery of primary care in a resource-poor community. Given this hypothesis, the research team conducted a health needs and assets assessment among a medically-isolated population; an acceptability and feasibility test of an intervention involving telemedicine technology and community health workers; and evaluated the intervention by assessing effects on the study population’s rate of health care utilization and self-reported barriers to health care.
Navigating the Fulbright Nehru Application: The India Application Experience as a Fulbright Specialist–A Strategy For Knowledge Exchange
The goal of a Fulbright program is to allow for an exchange of knowledge between the host and grant recipient. The Fulbright specialist program offers year-round opportunities of two to six weeks, which is beneficial for medical providers unable to leave their practices for an extended period of time. It also offers an opportunity for a host who needs an experienced partner for a limited time. A Fulbright specialist has five years to collaborate with a host institution. The Fulbright India program is unique, since the government of India is involved with the decision making, as well as contributing to the funding. Education is one of the key pillars of the India-U.S. strategic dialogue, with both governments encouraging academic exchanges and collaborations. An overview of available Fulbright programs in India, and how to navigate the cultural and corporate structure to successfully collaborate and submit a Fulbright Nehru grant will be presented.
Partnerships With High-income Country Academic Centers That Support Post Graduate Training Programs in Family Medicine in Sub-Saharan Africa: Key Themes For Success
To identify best practices for academic institutions that support developing capacity for family medicine training in sub-Saharan Africa, a search of literature using key terms Africa, family medicine, family physicians, internship or residency, and graduate medical education was conducted, resulting in 56 articles. Of these, 13 were in development of post-graduate training programs and were reviewed for key themes. Literature on family medicine program development from eight African countries was identified. Articles on multiple countries were also reviewed. Key themes identified were: the need for a local family medicine champion; institutional support; governmental support; local and international partnerships; funding; and faculty development and retention. Academic institutions that engage in the development of family medicine training in Africa should start by identifying and supporting a local champion. Successful partnerships are defined by sustained funding, institutional and host government buy-in, and host partner faculty development and retention.
Promoting Patient Safety and Quality Improvement Through Collaborative Faculty Development: A Success Story From Nigeria
The Bingham University College of Medicine and Health Sciences and the Bingham University Teaching Hospital (formerly the ECWA Evangel Hospital) in Jos, Nigeria, have become regional sponsors of residency program and medical school faculty development, as well as providers of continuing education for practicing family physicians and other practitioners. The collaboration of this institution with the larger international medical community has continued to flourish beyond its roots as a small mission hospital. This session will share insights from an ongoing faculty development partnership with American-based relevant resources, resulting in the promotion of the highly relevant topics of patient safety and quality improvement in the Nigerian context. The process of constructing appropriate cross-cultural faculty development workshops will be outlined, and workshop participant feedback shared. Successful learning activity features for the Nigerian context will be identified. A needs assessment revealing opportunities for further partnership will also be discussed.
Regional Networks: An Approach to Enhance Global Exposure for Medical and Health Professional Students in Africa
Students from Africa have limited access to global health opportunities in developed countries due to cost and other challenges. With significant differences in health concerns and health care settings across regions of Africa, African students can gain a “global” experience on the continent. Regional networks offer exchange opportunities to students, and help to develop future African physicians and health care providers to serve the health care needs of their patient populations while strengthening their communities and building the African healthcare workforce. GEMx serves as “facilitator” of African student exchanges through a Charter, technology and GEMx student grants.
Seven Years Teaching Family Medicine in Africa (And Why I Want You To Help Me Build a Medical School In Western Ethiopia)
The process of teaching family medicine in Africa is transformative in a number of ways. It opens our eyes to our role in the world, and what we are capable of accomplishing. It illuminates the need for greater understanding of the specific challenges to teaching medicine and transforming health care leaders in Africa. It clarifies health care disparities in our own communities at home, to which we were previously blind. Finally, teaching family medicine in Africa makes it clear that education is one of the most important and significant gifts that we as American family doctors can give to the world. By building a medical school in western Ethiopia in a refugee dense population, we can provide hope, security, education, health care transformation, and promote peace in a conflict area of the world.
The Dominican Republic has the highest rates of maternal mortality in the region at 106 deaths per 100,000 live births. One of the most vulnerable populations affected are women who migrate between the Dominican Republic and Haiti. We sought to understand Haitian women’s experiences, behaviors, attitudes, and access to perinatal care and delivery services in the Dominican Republic. A semi-structured interview guide was created with 24 total questions. Thirty-seven total interviews were conducted, lasting an average of 23 minutes. The emerging themes included lack of birth certificates, language barriers, and anti-Haitianism. These themes reveal two simple interventions that can immediately be implemented: the Haitian women should be better aided in obtaining birth certificates for their newborns, and the Ministerio de Salud Pública should employ Haitian Kreyòl interpreters in their hospitals. Lastly, more research should be done to elevate the voices of the Haitian community living in the Dominican Republic.
A common barrier in providing care to rural and underserved communities is the lack of trust of health care providers. To address these concerns, we propose a collaborative approach that promotes multidisciplinary care in global surgery efforts. We conducted a retrospective cohort study of patients cared for by CINTERANDES Mobile Surgery Unit in five underserved communities in Ecuador between January to July 2016. In a five-month period, five mission trips to remote locations were conducted, 559 patients were evaluated, 96 underwent surgical procedures, and 463 were treated for acute and chronic illnesses. The ratio for surgical-to-medical care was 1 to 4. Immediate appreciable changes provided by surgical interventions can positively influence the perception of health care within remote communities. This creates an opportunity for strengthening primary care actions in underserved communities using a multidisciplinary approach.
Although Haiti is ravaged by poverty and malnutrition, hypertension and diabetes are major health concerns. Haitians have no access to health care, unemployment or disability financial support, or home care. Our goal is to set up a sustainable health care clinic to screen and treat for hypertension and diabetes using community resources. As a part of our Haiti Vision Foundation, a non-profit organization founded and established by us, we would like to screen the population for hypertension and diabetes with a mobile clinic set up for four weeks per year. Once we have an established a diagnosis, we would like to create a model for treating them using patient education through nutrition counseling, providing medications, and following up using community resources. Our sustainable health care clinic model is aimed at screening and early intervention to prevent the long-term complications of hypertension and diabetes.
The Contra Costa/UCSF Global Health Fellowship and Malawi College of Medicine Collaboration to Strengthen the Family Medicine Rotation of Fourth-Year Medical Students
Malawi has one of the lowest gross domestic products per capita in the world. Due to this widespread poverty and limited educational resources, Malawi’s health care system is fragile. Although family medicine is a relatively new specialty in Malawi, the Ministry of Health has placed a high priority on primary care and family medicine. To improve primary care services, a formal family medicine rotation was introduced as part of the Malawi College of Medicine curriculum in 2009. Since 2014, the Contra Costa/University of California, San Francisco Global Health Fellowship has supported the Malawi College of Medicine family medicine rotation through ongoing student precepting, both at the bedside and in the classroom. The role of direct mentorship, role-modeling, community engagement, and precepting in the development of family medicine in Malawi will be discussed. The session will address informal ultrasound training for medical students and local staff, journal club for faculty education, and other innovative collaboration with Malawi College of Medicine stakeholders.
The Cuban Model of the "Patient-Centered Medical Home" Three Decades in the Making: How Cuba's Neighborhood "Consultorio" Truly Integrates Family into Medicine
In 1984, Cuba implemented the Family Doctor and Nurse Program into its national health care system to ensure primary care services in every neighborhood. This gave birth to the "consultorio," which literally epitomizes the patient-centered medical home (PCMH). A local house/apartment in the neighborhood is converted into a clinic where a family doctor sees patients almost every day. Nearly thirty years later, Cuba’s PCMH model continues to thrive, with a “consultorio” in every neighborhood, and each physician responsible for a designated set of families. Within Cuba’s holistic and integrated primary health care system, the family doctor plays a vital role in disease prevention and health maintenance. Despite its limited resources, Cuba’s excellent health outcomes belie the myth that equates resource-poor countries with poor health. On the contrary, it exemplifies how a system committed to equity, accessibility, and that embodies the essence of family medicine, ultimately leads to healthier communities.
The Efficacy of a Short-term Medical Mission in Providing Primary Care to a Syrian Refugee Camp In Jordan
There is a constant need for medical care in Syrian refugee camps. However, many volunteer medical providers are unable to commit to long-term volunteer positions. There are opportunities for providers to volunteer on short-term medical missions for as little as one week, but it is unclear whether such missions are effective. Following a one-week medical mission with the Syrian American Medical Society (SAMS) to the Zataari refugee camp in Jordan in January of 2017, a review of data on the number of patients seen showed that in two clinic days evaluated, a total of 138 patients—an average of 69 patients per day—were seen. Sixty-three percent of patients were age five or under. The overall team of 55 volunteers saw over 4,000 patients in one week. From these data, it appears that short-term medical missions can effectively deliver health care in Syrian refugee camps.
The Progress of Family Medicine Residency Education in the People’s Republic of China—A Personal Perspective from Wuhan
During the past two decades, the Chinese medical system has expanded rapidly, with technological advances and specialization. In the wake of this progress is an inadequate primary health care system served by less-qualified and poorly-trained doctors. Over the past decade, the central government has made great efforts to improve the quantity and quality of community medical centers and the general practice doctors who staff them. Though government initiatives have been well researched, publicized, and funded, there remain significant challenges in providing primary care to the Chinese people. Having lived and worked in Wuhan, China, for the past 17 years, the presenter has personally seen the changes in the medical system and witnessed the challenges faced by leaders tasked with facilitating change, and participated over the past five years in both faculty development and training of family medicine (general practice) residents.