New Perspective

The Hospitalist. 2007 December;2007(12):

December 1, 2007 | The Hospitalist

Less Can Teach More

The Global Health Track of the University of Pittsburgh Internal Medicine Residency Program emphasizes “a generalist perspective, cost-conscious practice and back-to-basics diagnosis”—competencies that dovetail with the mission of hospital medicine.

Make the Most of a Global Health Elective

Look for a site that includes a hospital-based experience, where you’ll likely encounter a larger array of referrals and cases.
Prepare before your visit. Learn about the culture, politics, and socioeconomic aspects of your host country. Become familiar with the common medical problems you’re likely to encounter. Obtain copies of treatment protocols and learn about the nuances of healthcare delivery, including the customs and dialects of the region.
Be sensitive to the impact and sustainability of your short visit. Think about your continued role as a global health advocate and educate others about your experience when you return.
Contribute to and foster exchange. Bring prepared talks that can be featured at a journal club meeting. Offer review of colleagues’ papers in preparation for submission to journals. Schedule visits to ministries of health and professional medical meetings.
Study the checklist for going abroad at www.amsa.org/global/ih/toolkit.cfm.—GH

“The major component of an international health elective is to really improve their [residents’] clinical skills,” notes Thuy D. Bui, MD, director of UPMC’s Global Health Track and medical director of the Program for Health Care to Underserved Populations. This clinical skills improvement is facilitated by the often-limited resources in host countries. “There is no CT, and there are no fancy blood tests, so they [the residents] really have to rely on their clinical acumen to make the diagnosis,” she says.

Dr. Bui has observed that when residents return from a global health elective (the UPMC program has centers in Malawi, India, Japan, Honduras, and Italy), they are “better at picking the right test, knowing when to be more aggressive [with treatment], and are more comfortable with ‘watchful waiting,’ rather than following up every single abnormality they detect in blood work or other imaging studies.”

Franziska Jovin, MD, is medical director of inpatient services at the University of Pittsburgh Medical Center (UPMC) Hospital Medicine Program. Originally from Romania, Dr. Jovin attended medical school in Germany, did her internship in the United Kingdom, and completed her residency in the U.S. During her residency, she returned to Romania on an international elective.

“I think the biggest thing you gain from doing an outside elective is that you learn to really practice medicine the way it used to be in the old days,” she says. “You rely much more on your clinical exam—and get better at it—because at the end of your exam, you have to formulate a differential diagnosis and a treatment plan without always confirming your hypothesis with a test.”

Practicing in another healthcare delivery system can also expand physicians’ perspectives on use of resources. Even though healthcare is funded by the government in many developing countries, says Dr. Jovin, patients still have to pay a large fee for the tests doctors order. “When patients have to pay for the studies that you order, it is much less likely that you will order a battery of tests, and instead concentrate on the test with the highest likely yield first,” she says.

While on elective in Romania, Dr. Jovin practiced in both an outpatient clinic and a hospital setting. She learned that physicians can “stay basic” by using equivalent generic medications to treat conditions such as hypertension. “Here in the U.S., you can use the latest ACE inhibitor or calcium-channel blocker and spend a lot of your patient’s money,” she says. “When money becomes an issue in order to effectively treat a patient, you’re much more cost-conscious.”