The dynamics of global health in hospital medicine

As my Division of Hospital Medicine has grown — now to about 60 faculty — I spend part of my time figuring out what direction we should go in. At times, the path is obvious. It didn’t take Wayne Gretzky to recognize that we needed expertise in healthcare IT a decade ago, or in cost reduction more recently.

The story of how we became the nation’s leading program for “global health hospitalists” is a very different tale. I’ve just returned from visiting our program in Haiti with three of our faculty members and two fellows, and so it seems like a good time to tell this story.

Since we created our hospitalist program nearly two decades ago, we’ve pushed our faculty to find an area of interest beyond their clinical work. (Our former chair Lee Goldman, a cardiologist, dubbed these areas “diastole” and the name has stuck.) This has been a winning strategy: most have found such an interest, in areas as diverse as quality improvement, curriculum development, and palliative care. This has extended our impact, created more satisfying and sustainable faculty jobs, and often generated new sources of funding.

Many of my ideas for faculty diastoles have come from finding connections between hospital medicine and obvious bedfellows like patient safety, leadership training, or pneumonia. When I interviewed Madhavi Dandu, a warm, self-effacing former UCSF resident, in 2005 for a faculty position, she described a Venn diagram I’d never considered: hospital medicine and global health. The logistical advantages were clear: since hospitalists have no continuity practice, they lack the ongoing outpatient obligations that would preclude a prolonged trip to Africa or India. And inpatient work paid well enough that, for a committed young physician, a few years of combined domestic and international practice seemed feasible.

I hired Madhavi because I thought she would be a great addition to our division. The idea that we were launching a new branch of the hospitalist field did not cross my mind.

In 2008, Sri Shamasunder, a charming young physician with passions for global health and poetry, joined us after completing his residency at Harbor-UCLA. Then three years later came Phuoc Le, a charismatic med-peds resident from Harvard who had unusually robust global health experience through stints in China, Tibet and Malawi. At Phuoc’s interview, I learned that his first memory, at age five, was of falling out of a boat into the South China Sea when his family fled Vietnam. He too joined our team.

In retrospect, it should have been obvious that we were no longer a division with three faculty members interested in global health. We were a division with a global health program.

You see, something amazing had happened — not so much to hospital medicine but to young American physicians. Paul Farmer, the MacArthur Genius-award-winning physician-anthropologist who founded the organization Partners in Health (PIH) and was famously profiled by Tracy Kidder in Mountains Beyond Mountains, made me keenly aware of this recently when he wrote,  “When I started my medical training at Harvard in 1984, there were three other students (of the 150 in our class) who reliably expressed interest in global health. A quarter-century later, that number has swelled to 50.” We’ve seen precisely the same thing at UCSF. Since I’m in the business of hiring exceptional young academic physicians, I should have realized that the talent pool had shifted, and not just a little.

Once we had this critical mass of three faculty members, the word went out: UCSF was the place to go if you wanted to be a global health hospitalist. In the next couple of years, nearly half our best applicants for hospitalist faculty positions wanted to focus, at least partly, in global health. Before I knew it, we had 12 faculty with this as their main “diastolic” interest.

It was gratifying to see how quickly this group organized itself (into the “Global Health Core”), began forging connections with other parts of UCSF’s substantial global health community, and secured a handful of leadership roles in our institution. I encouraged them to come up with group projects, and they quickly decided to build the nation’s first fellowship in global health-hospital medicine. With some divisional support, the fellowship launched last year. We are currently selecting our third class, and each year we’ve had dozens of applicants for two slots. By every measure, it’s been a great success.

My concerns about this endeavor — the lack of money and the risk of burnout — are not novel. For faculty whose passion is implementing electronic health records, improving hospital quality, or managing clinical services, there is an obvious funding stream: a large academic medical center that needs these things done well. For folks who want to run training programs, there are funded slots within the medical school (competitive and underfunded, certainly, but something).

But in global health, it’s hard enough to find dollars to support physicians who want to practice or run programs abroad. It’s even harder when they want to do so as a part-time gig. And it’s harder still when their clinical expertise is in an emerging generalist field, rather than in areas like TB or HIV. I worried — and still do — that most of our faculty’s time abroad would be uncompensated, a model unlikely to be sustainable over a long career.

I encouraged our faculty to be entrepreneurial, and they listened. They recently secured a $100,000 gift from an anonymous donor who was taken with their passion and effectiveness. They’ve applied for numerous small foundation grants, and have had some early successes.

One of the challenges, I’ve found, is that the hospital medicine/global health elevator pitch is tricky. A prominent faculty member at a New York public health school once told me, “As our faculty drive from Manhattan to JFK on their way to Uganda, they pass through 25 neighborhoods that desperately need their help.” Some global health people counter this with a “global-local” argument — namely, that the skills one develops in global health are highly relevant to caring for domestic underserved populations. An even more novel argument is that, by learning to practice in resource poor settings (where there isn’t an MRI in the whole country), trainees and faculty are better positioned to practice in the bending-the-cost-curve style that America now needs. Clever, but global health remains a tough sell.

***

With about one-fifth of my faculty and fellows focused abroad, I thought it was important for me to see what they actually do. And so last week I accompanied Phuoc, Madhavi, and Sri on a trip to Haiti, to visit our fellows Robin Tittle and Varun Verma and to meet with our clinical partners there. It was an eye-opening experience.

Haiti is a desperately poor country. The ditch-lined roads are a mess; our van averaged one flat tire a day traversing the potholes. In fact, the essential driving skills appeared to be weaving (sometimes around goats), honking, and tire changing. On the roadside one sees women carrying baskets of plantains on their heads, schoolchildren in starched uniforms holding hands while walking miles to school, and teetering concrete shacks with roofs of tin or fronds.

Our first stop was Cange, where Paul Farmer launched PIH with a Haitian priest, Fritz Lafontant, in 1983. On tours of Cange today you hear “this is where Paul did X,” with a “Jesus walked here” reverence one usually associates with tours of Jerusalem. The organization he launched, and still heads, is an extraordinary thing, helping tens of thousands of people in eight countries.

Our fellows work in several sites in Haiti. We rounded with Robin and her Haitian colleague, Dr. Pierre, at the PIH hospital in Hinche. She told me that the most surprising and frustrating part of the work was its unpredictability. One day you have oxygen available, the next day you don’t. Or you run out of IV antibiotics. Or you perform an LP but the results don’t return for several days. In other words, the Haitian medical system is a graduate class in supply chain. You know the stuff you need is around somewhere, just not where and when you need it.

The medical wards in Hinche were comprised of a few large rooms, each housing about a dozen cots. As we rounded from bed to bed, the scene toggled from fascinating to shocking to poignant in the space of a few feet. One woman had what appeared to be nephrotic syndrome and perhaps a rheumatologic disease. (Without serologies, it was impossible to be sure.) Robin decided to start her on prednisone. Another patient’s nine-year-old son had dropped out of school to stay by his mother’s bedside – he swatted flies off her motionless body, her head covered by a flimsy blanket, during our rounds. (Robin told me that the child often accompanies her while she sees other patients; HIPAA is nowhere to be seen.) The police had brought in a prisoner with a debilitating disease, shackled him to his bed, and then fled. The patient was incoherent and lying in feces. A clean patient and set of bed sheets signaled the presence of a caring and responsible family, and this gentleman had none.

We saw one middle-aged man with a wasting illness whose chest x-ray showed a left lung field that was nearly completely opacified. Robin needed a CT scan to sort out whether this was pneumonia, a collapsed lung, a pleural effusion, or a tumor. The nearest scanner is at the brand-new PIH hospital an hour away in Mirebalais. A couple of days before we visited, the patient was sent to Mirebalais and got his scan; he returned to Hinche with a CD of the images. But Hinche lacked the software that would have allowed the doctors to see the films. So, days after the CT was done, Robin still didn’t have the result. (At least he received the right test. She had sent another patient a few days earlier who returned with a CT of the wrong body part.)

The day after we visited Hinge, we toured Mirebalais, and came upon the lone CT scanner. “Oh,” Robin said excitedly,” maybe I can see my patient’s scan!” The technician pulled it up on the screen and it showed a surprising finding: most of the infiltrate was fluid, surrounded by a thick rind. In a remarkable, nearly comical blending of low tech and high, Robin pulled out her iPhone and videoed the CT as the tech flicked through its many cuts. When she returned to her hospital, she’d show the video to a surgeon to convince him of the need for a chest tube.

Having worked at a county hospital for many years, I’ve seen medical deprivation … American style. I cared for patients at San Francisco General who waited months for elective surgery or a specialist’s consultation, others who routinely received their primary care in the ER, and many who continued to suffer the ravages of mental illness because there were no available treatment facilities. But the idea that young people would routinely die of respiratory failure or renal failure for lack of a ventilator or dialysis, or that there isn’t a single oncologist or ER doctor available to any of the three hospitals I visited, or that there are no opiates anywhere … meaning that patients dying of cancer pain often receive nothing stronger than Tylenol; well, this was a level of hardship I’d never previously witnessed.

Still, the attraction of practicing in this kind of setting became more real to me during the trip. There is something pure about helping people who truly need you, without the boatloads of specialists and the embarrassment of technological riches we depend on in the U.S. There is something profound about seeing a young child’s smile when you’ve helped him, or his mom, recover from an infection that might have been fatal without you. The faculty members I accompanied — Phuoc, Sri, and Madhavi, and Evan Lyon of the University of Chicago, are warm, humble, charitable people who laugh easily and clearly get great satisfaction from making a difference. These U.S.-based global health people share a special bond with each other, and with their Haitian caregiving “partners.” The American say — over and over — that they are members of teams led by Haitian clinicians and administrators; they are not running the show. They say this without a hint of condescension or noblesse oblige.

It was gratifying to see that there actually is a role for global health-hospitalists. Our fellows, for example, are truly acting as hospitalists, managing wards full of hospitalized patients and bringing their skills in systems improvement to bear. That said, QI seems a little too high on the Maslow scale when you can’t get a serum creatinine measurement or a reliable oxygen supply.

***

On the last evening of the visit, our group stayed at Club Indigo, a slightly dilapidated beachside resort that used to be a Club Med before the Haitian tourist industry was devastated by the AIDS epidemic. (Both the Haitians and our American faculty speak of the injustice of the original AIDS risk categories, the Four H’s: homosexual, heroin users, hemophiliacs, and Haitians. It turns out that, rather than Haitians being a source of HIV, the party line at the time, most Haitians who developed AIDS had been infected by U.S.-based gays, since Haiti was a popular tourist destination in the 60s and 70s).

As we sat in Indigo’s open-air bar, the sounds of the surf audible, a nearby bat whizzing back and forth like a child’s toy, my colleagues recalled the first days after the Haitian earthquake, when their instinct drew them to the ravaged nation. Phuoc, still in his residency, was given a huge role managing patient transport. The airport had been commandeered by a hodgepodge of military troops from several countries. There was such disarray that you could drive onto the tarmac from the street. He described taking patients to the U.S. Navy’s floating hospital ship, the U.S.S. Comfort; the experience of walking through a door separating the hellish scene of downtown Port Au Prince into a glistening American-style hospital facility was profoundly disorienting.

Over a few weeks, he saw death on a shocking scale, as well as little victories, like reuniting a mother with her infant who had been cared for on the Comfort. On one Medivac flight to Children’s Hospital of Philadelphia, he was authorized to take one patient up and he smuggled on another. On another trip, he spent the night in a Fort Lauderdale hotel room with a desperately ill child and her parent. As I sat listening to these stories of caring and heroism, I found myself increasingly awed by what these individuals do, and by their commitment to making a difference.

The dynamics of global health in hospital medicine — and in the rest of U.S. healthcare — is topsy-turvy. Like a hydraulic system, the energy is coming from the pool of people who want to do this work. They are creating force as they enter a funding pipeline that is nowhere near wide enough to support them. After my trip to Haiti, I can’t honestly say that I’m any closer to figuring out where the money to support this work will come from.

But I’m glad that it’s a part of what we do.

Bob Wachter is professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this article originally appeared.

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