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.