Extending the Mission: Family Medicine and Global Health

(Initially written for the Society of Teachers of Family Medicine Foundation's newsletter, The Wire)

I was born in the Dominican Republic, but only lived there for a few months. As a child, I lived 10 of my first 16 years in Latin America: four in Venezuela, four in Argentina, and two in Panama. After graduating from the VCU School of Medicine in 2000 and completing my Family Medicine residency in Blackstone, Virginia in 2003, I joined my first international medical trip: from my experiences growing up and my interest in returning to Latin America as an adult, the opportunity to work overseas as a physician—in a profession focused on service and on providing care for those in need—was exciting, and the experience was fulfilling. I recall waking on the first day for clinic, seeing the rugged hills of rural Honduras stretching to the highway, and seeing our patients lining up for care, having arrived on foot, by horse, or by shared vehicle. I recall my anxiety and excitement over the nature of medical care in this setting: no x-rays, no labs beyond urinalysis or pregnancy test, no specialists or specialized diagnostic equipment. We took care of patients by taking a good history and completing a careful physical exam: the H&P, our clinical judgment, and help from colleagues were our only resources. As just-graduated resident, this was thrilling and validating: thrilling because I had to rely on my skills, and validating because my Family Medicine training from a rural residency program allowed me to provide the care these patients needed.

Since that first trip, I have since led 14 medical trips to Santo Domingo, the capital of the Dominican Republic. The first trip was set up in 2005 alongside undergraduates from the College of William and Mary, my undergraduate alma mater. This trip was what I would now consider a “duffle bag medicine” project--we had put little thought into how we would fit into the local health care system, and we had little consideration of sustainability or our long-term impact. After that trip, we refocused and regrouped, and returned to the Dominican Republic with a long-term commitment to provide medical care and work to improve community health in a sustainable manner. I have continued to lead medical trips to the Dominican Republic since then, in collaboration with the Dominican Aid Society of Virginia (DASV), William & Mary’s Student Organization for Medical Outreach and Sustainability (SOMOS), and VCU’s HOMBRE organizations. We now travel to the DR twice a year, and we provide direct medical care and work with the community to address underlying challenges to health and wellness.

These medical trips are still highlights of my year. Despite being a lot of work to organize, I return from these trips renewed and reinvigorated by practicing medicine without regard to CPT or ICD-9 codes, billing sheets, required documentation, etc. On these trips, medicine is reduced again to its essential components: the dyad of patient and physician, within the setting of the patient’s family and community. Beyond the personal value, though, I believe that participating in global health projects extends the mission of family medicine to communities overseas and to medical school and residency trainees who travel with us as part of our team. The way I see it, global health work aligns with the following key components of the specialty of Family Medicine:

• Thoughtful and appropriate medical care: we provide care for acute illnesses and chronic disease, we deal with mental health issues and preventive check-ups, and we help identify patients who can be cared for in our outreach clinic and those who need formal care and follow-up within the local healthcare system.
• Community development and social determinants of health: as explained in the bio-psycho-social model of care that is at the center of Family Medicine, illness and disease do not exist in a patient in isolation. Rather, health, illness, and disease exist in the context of the patient’s surroundings as well as their own individual risk factors. On these trips, as physicians and healthcare providers provide direct healthcare, SOMOS and other team members work with the community to identify the community’s healthcare priorities and develop community-drive, sustainable solutions.
• Teaching: whether we are teaching our patients or our trainees, teaching is at the core of what we do in Family Medicine. Each of the medical trips to the Dominican Republic incorporates trainees at multiple levels: undergraduate pre-med students, medical students in the pre-clinical and clinical years, medical residents, pharmacy students, and pharmacy residents. These trainees have experiences that resemble my first trip to Honduras: cast loose from technology and readily available resources, they learn to listen to patients, to focus on the clinical setting, and to work through difficult situations with limited resources. These experiences stand to make them better physicians and providers in the future.
• Research and scholarship: in the process of providing clinical care and working on community development projects, we have the availability to engage in research and scholarship that will improve our ability to provide medical care for acute and chronic illnesses in the community as well as better understand the organization of the community itself. Our experiences can inform others, and we readily share our knowledge with others doing similar work.

In closing, global health projects are both well within the scope of practice of Family Medicine, and are aligned with our specialty’s goals and vision. At the practical level, Family Medicine residents and physicians are ideal members of global health trips: with our community focus, our scope of practice and our whole-person orientation, Family Medicine physicians can take on any role on these trips without regard to patients’ age or gender: no accommodations and no restrictions needed. The alignment of the project’s needs and Family Medicine physicians’ abilities is notable, and it makes leading and participating on these trips rewarding and renewing, and continues to validate my choice to enter Family Medicine 13 years ago.

The value of mentorship

I entered medical school in 1996 with a vague interest in primary care.  During my M1 year, I focused more on my studies than on my career path, and sought to spend time with my wife (having just been married a month before medical school).  My M1 Foundations of Clinical Medicine (FCM) community preceptor placement was in a family medicine office in South Richmond, but I received little hands-on experience, and it did not help clarify my path.

    Everything changed in my M2 year.  As part of our school’s rural interest group, I had met Dr. Augustine (Gus) Lewis, who had taken on his father’s practice in rural Aylett, Virginia, and I was matched to his office for my M2 FCM placement.  Dr. Lewis was a family physician committed to his community and patients, and they were committed to him.  He knew patients by name, and he knew many of their families and stories.  He focused on patients’ needs, and took their social situation into account when recommending care.  He had a comprehensive, whole-person focus.

    As a teacher and physician, Dr. Lewis was generous with his time and knowledge, and engaged me as an active learner.  He also could have chosen to practice anywhere, and chose rural Virginia.  I realized that one could be an up-to-date, knowledgeable, patient-focused, community-oriented physician in rural Virginia.  His example became a guide for me during my own training and career, and I am glad to consider him a colleague and friend.

    I am honored to consider Gus a mentor, a colleague, and a friend.  I was glad when he received the Medical Society of Virginia Foundation's 2013 Salute to Service Award for Service to the Profession.  You can hear some of Gus's story in his own words here.  I could not imagine a better recipient, or a better role model.

Some thoughts on healing

Late last year, I led a session for our MS1 students in which we discussed the idea of healing.  We used this article as a jumping off point in the discussion.  The article goes through a process of defining healing, but the core concept is that of healing as a transcending of suffering.

Healing is a complicated issue.  Not everyone heals the same way, at the same pace, or to the same level.  Healing can be fast or slow, complete or incomplete and it can be very hard to recognize how to heal.  The traumas and the stresses that people face can be so severe that it might be difficult to identify the best way forward, and to determine what steps need to be taken.  Sometimes these steps might be harmful, might create problems of their own.  Sometimes when in the depth of a crisis we strike out, or we lapse too far inwards.  The hope is that we can find some way to move past those harmful actions and find a true way forward--even if that way is diminished.

Healing is made more difficult because of what people heal from.  If they are healing from a physical suffering, an emotional injury, a loss of control or some loss of wholeness, they will heal differently.  Until we can accurately identify the source of the suffering, then the path to healing will be extremely difficult.

I think this is an important reason why people seek medical care as part of their healing.  Sometimes we can help, with medications, or surgery, or some other treatment.  Often times, our role in healing is simply our presence helping patients and families through the difficult times, advising and treating where we can, and bearing witness and sharing in the process.  The assurance that someone will be there to care and to help may be an important step in peoples' healing.

What is the Value of the Doctor/Patient Relationship?

(In response to Abraham Verghese's TED talk)

Verghese's talk centers on the process of the physical exam, but I think the central themes are that of ritual and connection.  In the healing relationship that physicians (should?) attempt to develop with our patients, the ritual and roles of healer and patient--those who are present to aid and to care and those that are seeking assistance and caring--enhance the physician's presence to beyond a source of a prescription or a recommendation for a treatment.  Instead, the ritual helps establish a connection between the two parties, and the connection enhances the benefit of any recommended treatment be it medication prescriptions, physical therapy, or counseling.  If a great deal of illness is suffering, then it is the trust between patients and physicians that helps the dyad seek to overcome that suffering.

I have long held tight to the concept of the "therapeutic use of self", that as healers we can use our presence to be an important part of helping patients heal in some form.  Verghese's closing--that physicians will not abandon our patients, that we will see them through whatever trial--beautifully summarizes this idea.

Unfortunately, we are in a situation in healthcare where it is very difficult to live up to Verghese's ideal.  I certainly cannot give 1 hr for a patient to tell me their history, and then another 1 hr visit just for the physical.  Our office gives us 20 minutes for each visit (whether a new or an established visit), and this is generous: many other offices give 10-15 minutes.  I can try to approximate Verghese's approach by taking advantage of the continuity of care primary care offers: I can see patients back repeatedly, and even if I cannot gather all this information at once or develop the desired connection as quickly, I can still work to gain my patient's trust and to preserve the healing relationship heading forward. 

In a healthcare system that rewards productivity, physicians will be pushed to be productive.  Often this means seeing more patients, ordering more tests, sending for more studies…and often times the therapeutic use of self is left aside in the hustle.

Relationships are critically important, and so are patients' expectations and experiences.  In the case of research around the placebo effect it appears that how much benefit a patient receives from certain interventions depends on their experiences.  If we as physicians are caring, kind, patient, and truly interested, might we enhance this benefit?

I believe the issue at hand is that we have a healthcare "system" that is not a system, and that does not really care about "health".  If we cared about health, we would emphasize the importance of the doctor/patient interaction, we would give the time needed to allow this relationship to develop and be supported, and we would find a better way to value the work being done.

A Change in Course (and, hopefully, a renewal)

Looking back at this blog, I am embarrassed at how long it has been since I have updated it.  Life has gotten so busy that I hardly ever think to jot down any thoughts here, even if I should have some thought I think worth sharing.

Now that the ACA has been protected by the Supreme Court, by a Presidential election, and by a finally effective roll-out, I don't feel that I need to tout the law's benefits as loudly as I have been...and I appreciate those of you who have stuck through me during all this time.

I am hoping to bring this blog back to its original intent: to speak about medicine, and healing, and the challenges and rewards of working with medically-underserved communities.

In the past year, I have also become increasingly interested in the intersection of evidence-based medicine and patient-centered care.  I suspect that some of those thoughts will come into discussion on this blog.

Since my last post I have been teaching more.  I am teaching students in our school's honors program that prepares students to work with medically-underserved communities after they complete their training, and I am teaching the entire medical school class about the important elements of the doctor/patient relationship.  I hope that my increased engagement there will renew my energy and desire to share ideas here.

I am also helping teach a "Medicine and Literature" course on our undergraduate campus.  As part of that class, we have an active discussion board.  In order to get this blog back online, and to avoid doing the double work that would quickly end this attempt to restart things, I will start by cross-posting some of my thoughts from that discussion here.

Hopefully, you will see more on this blog soon.  Thanks to all those who might have been bearing with me.