Better support for women

If you’ve worked in global health, you’ve seen it happening: the steady trickle of smart, talented women out of the field. The 34-year-old fellow whose young marriage comes under strain from long stints in Cambodia. The junior faculty member who can’t manage a pregnancy or a new baby in the least developed parts of the developing world. The assistant professor, who has already put family plans on hold for her career, struggling to conceive or follow a fertility treatment regimen while spending months away from home.

Women constitute more than 80 percent of medical students seriously considering global health careers. These problems seem small to them when they start out as first year medical students at a median age of 24. Four years later, however, women disproportionately abandon these aspirations, largely because of concerns about how to balance a global health career and family life. As they finish their residency training, they are in their early 30s. If they sub-specialize, they get uncomfortably close to 35 – the much-feared “advanced maternal age.”

Where can they turn for advice? There are few female role models to inspire them. Less than 25 percent of leadership positions in global health at the 50 top US medical schools are held by women.

This is not unique to global health; there is dramatic attrition of women as you go up the career ladder in most fields of science. But women who dedicate their careers to improving healthcare in some of the poorest countries in the world face added challenges that their US-based colleagues mostly do not. The biggest of these is personal safety. More than one-in-four female trainees conducting international fieldwork have been sexually assaulted in the field, most often by their superiors. Once again, they have nowhere to turn. The mechanisms for reporting these incidents are inadequate or nonexistent in many research sites abroad.

During Sunday’s Grammy Awards, President Obama asked all Americans to make a personal commitment to help keep women and men safe from sexual assault through the “It’s on us” campaign. The pledge has four parts: (1) to recognize that non-consensual sex is sexual assault; (2) to identify situations in which sexual assault may occur; (3) to intervene in situations where consent has not been given; and (4) to create an environment in which sexual assault is unacceptable and survivors are supported. Nowhere is this message more urgent than in global health.

When conducting work in international settings, the usual support networks are absent. Your friends and family are thousands of miles away. The lack of fellow women makes solidarity – such an important asset in an environment where sexual harassment and assault are common – all but impossible. Even with supportive and understanding mentors, they are located on a different continent. A garbled Skype connection is not the optimal medium to discuss these sensitive issues.

These challenges are manageable. Targeted efforts to increase female leadership in business and politics have produced successes. [Barsh McKinsey 2012, UN Entity for Gender Equality and Empowerment of Women 1995, Interparliamentary Union 2012]. A network of mentors, including both US and international female colleagues, could provide a woman with someone to turn to, no matter where she is in the world. We must develop pathways for those based abroad to report sexual harassment or health and safety issues – a process that their domestic colleagues may take for granted. We have identified the problem and now we must take action on a personal, institutional, and governmental level to support these women who work to improve the lives of those in need around the world. It’s on us.

A patients legacy

As physicians, we have the unique privilege of meeting and interacting with thousands of people throughout our careers. Every once in a while, though, there are certain patients who really make a lasting impact and forever change us – as caregivers and as human beings. Ed was one of those patients. He also became one of my dearest friends.

Ed, a Korean War veteran, was an amazing man. He was a dedicated father, a devoted spouse, and lived a life that was an example of faith and service to others. I first met him years ago through his daughter. He had moved to my area in order to live near his children and needed a new cardiologist. Fortunately for me, his daughter asked me to take him on as a patient.

Ed had an ischemic cardiomyopathy and suffered from complications of congestive heart failure (CHF). He was fairly well compensated on medical therapy but continued to have worsening CHF. During the course of his illness, we eventually implanted a biventricular ICD and his symptoms improved significantly. As with most patients with CHF, over the years, he began to have more frequent hospitalizations for CHF exacerbations.

Through it all, Ed was always cheerful and never complained – in fact, it was sometimes difficult to monitor his symptoms due to his demeanor. Ed always put others before himself. His wife, suffering from her own chronic illness, was the focus of his final days. He loved her deeply and wanted to be sure that she was comfortable and well cared for.

Men like Ed are few and far between – I was honored to care for him. My professional role as his cardiologist is what provided me with the fortunate opportunity to be a part of his life and develop a relationship with him and his wonderful family. Medicine is best practiced when relationships and tight bonds are formed between doctor and patient.

As I left the chapel where the Catholic Mass celebrating Ed’s life was held, I could only wonder if I would ever have the chance to meet another “Ed.” Many patients are experiencing access issues, and many doctors are spending more time typing and glaring at computer screens. Connections like I had with Ed are becoming harder to form. I fear sometimes that medicine is becoming more about the system than it is about listening and caring for those who suffer from disease.

Ed taught me many things during the time that I cared for him. He taught me humility, kindness, and selflessness. I have never met anyone quite like him. Most importantly, he taught me the value of relationships and time. Even in death, he inspires me to be more to each of my patients. Ed never stopped caring for others; he never wavered in his commitments to his God, his wife, and his children. It is my hope that I can stand firm and continue to fight for my patients and their right to receive exceptional care. That is how Ed would see it – of that I am sure.

Innovations in medical education

Traditional medical school training is too expensive, takes too long, and is not addressing the primary care needs of the country, a complex problem with many moving parts. Medical students burdened by mountains of debt and unable to begin earning until well into their late twenties or early thirties often gravitate to higher-paid specialties and practices in urban settings.

What might we do differently to solve the primary care shortage, particularly in rural areas? And what can we do to reduce the expensive supply side economics of healthcare – where, for example, having too many surgical specialists can drive up either the volume of elective surgeries or the cost of each procedure?

Both of us are passionate about medical education (MedEd) innovations that support the need to better engage students, rekindle their love for medicine, and move away from the traditional pedagogy to andragogy (utilizing principles of adult learning) where the doing trumps memorizing?

Here are four innovations we particularly like:

1. Democratize the opportunity to study medicine.

The US has a highly competitive pre-medical school admissions process that ensures, by and large, that only those with the best grades and MCAT scores have a real shot at being accepted. Will students skilled at rising to the top in this type of intense competition be happy practicing general medicine in a small town far from the intellectual excitement of academic medical centers? And, given the widespread availability of technology to put advanced medical knowledge at the fingertips of practitioners no matter where they work, we wonder whether “best grades, best MCAT scores” is a reasonable predictor of who will become an effective primary care doctor. Are there other factors that should be considered if we are to address the primary care shortage?

The National Health Service Corps offers scholarships if applicants commit to primary care in an underserved area (two years of service for the first year of financial support, and one year for each thereafter). Although financial incentive programs like NHSC can help students who might not otherwise have been able to attend medical school, there is no evidence to date (in part because there haven’t been that many published studies) that these types of programs lead to long-term commitments of healthcare workers to practice in these areas.

Enter Escuela Latinoamericana de Medicina (ELAM), a Havana-based medical school that is one of largest in the world with close to 20,000 medical students from 110 countries. The students come from Latin America, the Caribbean, Africa, and Asia. Currently, just 91 are from the US.

What really makes ELAM different is their focus on enrolling the students from the poorest communities who are committed to returning to practice in those areas. They want women, people of color, and people who speak the language of the poor communities. Tuition and room and board are free, and the students receive a small stipend.

There’s a concept: Train people from communities who are committed to returning to those communities to practice medicine. This differs from the standard US approach of parents paying for medical school or students incurring expensive loans. Basic economics, and experience, indicate that this approach graduates physicians who want largely urban, well-paid, specialist practices to give them a chance of paying back those loans before they retire.

2. Virtualize MedEd course work

NextGenU offers medical education via MOOCs (Massive Open Online Courses). By partnering with leading universities; professional societies; and government organizations like the Centers for Disease Control and Prevention (CDC), Grand Challenges Canada, and the World Health Organization, NextGenU gives students credit for their online coursework. According to the organization’s website, the courses are “competency-based, and include a global peer community of practice, and local skills-oriented mentorships…and, “initial data show that NextGenU’s training performs comparably to traditional American medical schooling.” All courses are free of cost and free of advertising.

Not only can NextGenU have profound impact by democratizing the US medical education process, it is also helping the developing world by training local people who otherwise might not have been able to go to medical school. For example, NGU has a partnership with Sudan to train 10,000 new family physicians in five years.

3. Use Simulation to Teach Diagnostic Skills

i-Human Patients teaches diagnostic skills via its i-Human case player that simulates a wide variety of cases using virtual patients. The program presents users with what are called undifferentiated cases, meaning the student does not already know the patient’s current diagnosis or medical history. That must be elicited by asking the right questions. Participants perform a virtual physical exam that includes listening to heart and lung (breath) sounds. They can order and interpret labs and construct a differential diagnosis, or a list of possible diagnoses. They do all of this without the need for in-person patients, whether standardized or not.

Thus far, the company has about 100 clinical cases in their toolkit. These are written by clinicians, many of them on staff at academic institutions. The cases can be customized to meet the teaching needs of the different training programs. In addition, medical educators can craft their own cases and share them on the site. This flexibility allows hundreds of cases, each with varying levels of difficulty and different learning objectives, to be available online. Students and practicing clinicians can access from anywhere in the world. Here is a link a recent video interview with i-Human Patients CEO Norman Wu.

4. Learn to Solve Complex Cases via Crowdsourcing

CrowdMed pairs “Medical Detectives” (retired physicians, medical students, other health professionals, and anyone with something to contribute) with patients with hard-to-diagnose conditions on a platform that incorporates a “patented prediction market system” that collects bets and develops a list of the most likely diagnoses and solutions.

Students learn to review the history, physical data, and lab data from cases that have been worked up by many different doctors over many years. This is similar to what medical students and residents do once they are treating real patients. The difference? They learn, in real time, from more experienced physicians also working the case on the same platform.

Here is a link a recent blog post and interview with CrowdMed’s CEO, Jared Heyman. (Full disclosure, Pat has been a CrowdMed Medical Detective since 4/2014.)

We are just at the beginning of the health tech revolution, so we expect many more innovations to be deployed into the Medical Education marketplace. Health technology innovators and others who see opportunities to transform medical education are creating and applying their creativity to make MedEd better, faster,and cheaper.

Do you have a MedEd innovation you’d like to share? Let us know. We’ll cover your suggestions in a future piece. Stay tuned for a future blog post on creative approaches in medical schools – from team learning (and grading) to choosing medical schools for their emotional intelligence and providing leadership training.