• Preparing for Global Health Work

    Why Family Medicine is a Great Fit for Global Health

    According to the World Health Organization (WHO), the greatest need in global health systems worldwide is the broad application of effective primary health care. As family physicians, you:

    • Are specifically trained to provide the care that is needed in global health—care that is comprehensive, continuous, integrated, community oriented, and team based. 
    • Focus on preventive and population-based health care, which brings a much-needed perspective to the hospital-based approach that is prevalent in many parts of the world.
    • Know how to diagnose and manage a wide range of health problems in an evidence-based manner, no matter what the population or locality.
    • Can train nurses and clinical officers in the developing world to improve the quality of primary care. We can also mentor local family physicians to serve as role models and leaders.
    • Can help populations with limited resources manage health problems effectively without the high-cost technology required by many other specialists.


    Considerations Before You Work in Global Health

    Many family physicians are interested in global health, but don’t know where to begin. It can seem overwhelming to sort through the many options. Reading the Family Practice Management article “Working With International Populations – Abroad or in Your Own Backyard" is a good starting point.

    Key considerations include the following:

    There are many possible motivations for working abroad. For example, you may want to serve, learn, and grow; to experience a new culture; to gain clinical, cross-cultural, or language skills; or to interact with different types of patients. Clarifying your personal motivations will help you select options that will be a good fit.

    There are natural windows of opportunity early or late in a family physician’s career that may more easily accommodate work abroad. For the mid-career professional, it is important to plan carefully, usually at least one year in advance, so you can minimize disruptions for patients and practice partners. With advance planning, time away can be covered by a locum tenens or coordinated with the recruitment of a new partner who is building his or her practice.

    In some cases, a sponsoring organization may dictate the location. In other cases, the choice of where to go may be based on personal factors such as desire to gain language skills; interest in a particular culture; or family or professional connections in a country or region. Political stability, transportation, communication, safety, and access to health care and schools are important considerations about a potential location.

    It is important to carefully consider your proposed job duties to be sure you have or can learn the required skills and that you will have sufficient backup to do a good job. Are your expectations and the expectations of your host realistic and aligned? It may help to talk with people who have worked at the same site and with the same organization to gather feedback on their experiences. Complete as much research as you can about the organization and its history before you go to be sure you are reasonably comfortable with the assignment. Life in most low-resource settings is not as highly structured and predictable as life in the United States, so flexibility is key. Expect the unexpected!

    Your Family
    Will you take family members with you, or will they remain at home? This decision may dictate length of stay, housing, schools, transportation, finances, etc. Do other members of your family have skills that complement yours? Are they interested in working on their own projects (e.g., a volunteer activity for a young adult) while living abroad? Living in a new country and culture can be a valuable learning experience and bonding time for the entire family. However, it can also result in additional stresses and challenges.

    Your Practice
    If you have practice partners, be sure to discuss your plan to work abroad well in advance to gain their input and approval. This will reduce disruption and resentment about the additional work that will be left behind in your absence. Find ways to provide reciprocal support for your partners if they need time away before or after your leave. After your leave is finalized, announce your plans to your staff and patients. Consider writing brief newsletter updates to send back to your practice and/or your local newspaper to stay in touch while you are away. After you return, seek opportunities to share what you learned with your local medical school, schools, churches, and/or community groups.

    Financial and personal considerations
    Plan ahead on your budget. Most family physicians do not make more money from global health work than from domestic work. You may have to pay considerable out-of-pocket expenses because many global health projects do not have funds to pay for your services. But, in return, you can gain rich life experiences and the satisfaction of working in areas of great need. Prepare yourself for an exciting adventure in global health. You won’t know for sure what will happen, but you can expect to be changed by the experience.


    Skills and Competencies for Global Health

    The skills and competencies that are necessary for global health work vary according to the varying medical needs and health systems in different parts of the world. For example, most family physicians in North America and Europe focus on ambulatory and preventive medicine skills. By contrast, in central and east Africa, the most necessary skills are hospital practice, complex obstetrics and gynecology, expanded surgical skills, and public health/community medicine. Specific countries and cultures will require particular skills and competencies, but the following are likely to be useful in a variety of global health settings.

    Organizational skills

    Skills related to teaching and program development (e.g., helping to develop continuing medical education [CME] programs for local physicians, establishing local or national associations of family physicians)

    Faculty development

    Skills to mentor and nurture new family medicine teachers

    Cultural awareness, and the ability to adapt to local norms and expectations 

    (e.g., accepting a more laid-back approach to productivity, accepting a community-oriented approach to decision making rather than an individualistic approach). Developing this attitudinal competency is key to being effective in a host culture rather than being marginalized.

    Excellent evidence-based clinical skills, with additional training on any clinical problems seen in the host environment that are not often seen in North America

    Public health training and skills 

    (e.g., a Master of Public Health degree or equivalent community experience). Although this may be considered optional, public health training can open doors in developing countries that are closed to someone who only offers clinical skills. A population-based, preventive health approach will often result in much better health indices than simply offering clinical services.

    Lifestyle and career that are flexible enough to allow for long-term or regular and repeated involvement in a selected global health area. 

    Family physicians who are serious about significant involvement in global health work may find that they must make difficult decisions regarding family, debt load, personal wealth, and career commitments.


    Procedural Skills

    In many developing countries, there is a greater need to perform and teach procedures at the primary care level than is commonly seen in North America. Although specific requirements will depend on a country’s economic level, health system, and physician availability, you should be prepared to perform and teach the following procedures if you want to serve outside of the United States:

    • Incision and drainage of abscess in any part of the body
    • Repair of complex (i.e., multi-layer) lacerations
    • Joint aspiration and injection
    • Lumbar puncture, especially pediatric
    • Administration of local and regional anesthesia
    • Interpretation of plain radiographs
    • Performance and interpretation of diagnostic ultrasound examination (e.g., obstetric, pelvic, abdominal, cardiac)
    • Interpretation of electrocardiogram (ECG)
    • Rehydration of dehydrated child (e.g., due to diarrhea or diabetic coma)
    • Achievement of central vein access
    • Biopsy of uterine cervix using acetowhite methodology
    • Placement of intrauterine device (IUD) and contraceptive implants
    • Management of prolonged and obstructed labor (Advanced Life Support in Obstetrics® [ALSO])
    • Management of preeclampsia, eclampsia, and postpartum hemorrhage (ALSO)
    • Management of closed fractures (i.e., casting, splinting, traction)
    • Performance and interpretation of common laboratory tests (e.g., blood smear, malarial smear, ova and parasites [O&P] stool test, urinary sediment)
    • Recognition of psychosomatic presentations common to the local cultural context

    Teaching skills You may anticipate doing global health work primarily in a clinical setting. However, you should also be prepared to teach local physicians, nurses, clinical officers, physician assistants, other allied health personnel, and medical students. In countries outside of the United States, the most critical role for a family physician is to train local health care professionals and support them in the development of family medicine programs. In addition to having excellent teaching skills so you can share knowledge and experience effectively, you may need the ability to do the following:

    • Be open to learning from local colleagues
    • Perform a brief educational needs analysis and propose appropriate topics
    • Provide personal medical mentoring in clinical settings
    • Present succinct, evidence-based didactic messages on needed topics (with or without PowerPoint)


    Global Health Opportunities Through the AAFP

    The AAFP desires to support members in their desire to serve in global health through leadership and advocacy, augmented by family medicine global health resources and education. As an organization, we seek to foster collaborations between AAFP members and agencies, foundations, educational institutions, training programs, and businesses in the United States and other countries. 

    Ongoing opportunities include:

    • Advanced Life Support in Obstetrics (ALSO®): Provider and Instructor courses for this important program are taught in 62 countries. These courses help health care professionals throughout the world to develop and maintain the knowledge and skills they need in order to effectively manage potential emergencies during the perinatal period.