Surveys Find Growing Interest Among U.S. Physicians in Working to Improve Global Health
Ryan Greysen, MD, MHS, is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and an assistant professor of medicine at the University of California, San Francisco (UCSF), Division of Hospital Medicine. He works closely with the Global Health Hospitalist program at UCSF to help train fellows and conduct research in quality improvement for hospitalized patients in developing settings. Phuoc Le, MD, MPH, is an assistant clinical professor of medicine and pediatrics at UCSF. He co-directs the Global Health-Hospital Medicine Fellowship at UCSF, directs the Global Health Pathway for the Pediatric Residency, and is director of international rotations for the Internal Medicine Residency.
U.S. medical education has entered a golden era of growth in global health interest and involvement, but surprisingly little is known about global health after training is completed. In 1978, only 6 percent of graduating medical students reported experiences in global health (GH), but today more than 25 percent participate in global health activities during medical school, and 66 percent plan to participate in GH work during their career. Since this "surge" has started with trainees, many of the recent studies on global health work have focused on medical students or residents.
Interestingly though, we have much less information on what happens after the trainees become full-fledged physicians. Do they continue to engage globally either as professionals or volunteers? If so, do they focus on clinical work, education, research, or health policy? We recently conducted a pair of surveys to answer these questions in two specific groups of doctors: those who have received research and leadership training through the longest- program of this kind in the U.S. (the RWJF Clinical Scholars program) and those who have joined the ranks of the medical profession's fastest-growing sub-specialty: hospitalists.
"We are optimistic that the altruism and dedication that fuels the global health interests of many physicians will be translated into sustainable contributions to improving health equity in the neediest areas worldwide."
Physicians in our first study (RWJF Clinical Scholars) were mostly faculty at medical schools and about half were trained in internal medicine. Nearly half of all respondents (44%) reported some global health activity after residency; however, the majority of this group (73%) reported spending ≤10% of professional time on global health in the past year.
Among those active in global health, more than 80 percent reported at least one scholarly, educational, or other product resulting from this work. They also felt their domestic and global health activities were highly synergistic, with 85 percent agreeing that their global health activities had enhanced the quality of their domestic work and increased their level of involvement with vulnerable populations, health policy advocacy, or research on the social determinants of health. Despite these perceived synergies, qualitative data from in-depth interviews revealed personal and institutional barriers to sustained global health involvement, including work-family balance and a lack of specific avenues for career development in global health.
In our second study focused on hospitalists (internal or family medicine, pediatric, or subspecialty physicians with hospital-based practices), we found that one-third had been involved in global health since becoming a hospitalist (although 50% had done so beforehand). Additionally, 40 percent indicated that they planned to participate in GH teaching, research, clinical care, or policy work in the next two years. While the global health activities of hospitalists were more focused on clinical roles such as infectious disease (65%), chronic disease (53%), or public health and prevention (39%), they described similar challenges faced by the RWJF Clinical Scholars. These challenges included under-recognition at home for their work abroad. As one participant explained, "Colleagues at home do not appreciate or understand what I'm doing when I'm away."
To our knowledge, these are the first studies in the past 30 years to present specific data on the frequency and characteristics of GH activities for U.S. physicians who have completed all their training. A study in 1984 surveyed 1,267 organizations likely to hire health professionals to work internationally and estimated that 1,417 out of 450,000 physicians (0.32% of all physicians in the United States) were working in international health. Our study is different in that it focuses on physicians who are primarily U.S.-based rather than internationally-based, but we think it captures an important trend as more and more physicians are engaging in global health activities of some kind on a part-time basis.
Indeed, another problem reported by participants in both our studies was difficulty with developing an overall career plan integrating global health experiences and, more specifically, a lack of role models and mentorship for career development. Fortunately, more opportunities in this realm have developed since we began our surveys in 2010.
First, there are now several fellowship (post-residency) programs for physicians interested in global health careers. In 2012, UCSF started the first fellowship program for hospital medicine in global health and there are now similar programs at the University of Chicago and University of Florida. Harvard also has a program for hospitalists focused on pediatrics through the Children's Hospital of Boston. Beyond hospital medicine, there are general medicine fellowships at Montefiore and Rush. For those desiring more focused training, there are short courses offered by Cornell, Harvard, and the University of Arizona, and intensive programs leading to a Diploma in Tropical Medicine and Health such as the Gorgas Program in Peru. Finally, UCSF is also offering a global health "Bootcamp" for faculty at any U.S. medical school who wish to take leadership roles in ongoing global health programs at their universities.
Beyond formal training, there are more opportunities for mentorship by peers and leaders in the field of global health available through a variety of professional societies. As one example, the Society for Hospital Medicine established a Global Health section in 2013 which convenes each year at their annual meeting to provide networking, mentoring, and idea-sharing. Another example is the Global Health section of the Society of General Internal Medicine. Finally, there is a Global Health Delivery Online community for those who aren't a member of one of these societies or just want more interaction in addition to these meetings.
In conclusion, while many challenges still face young physicians wanting to integrate global health into their careers, there are more opportunities developing each year to meet these needs. With continued development in this area, we are optimistic that the altruism and dedication that fuels the global health interests of many physicians will be translated into sustainable contributions to improving health equity in the neediest areas worldwide.