Author:  Rob Mitchell

Editor:  Chris Elliot

 

There’s no defined pathway for junior doctors aspiring to a career in global health. If you’re motivated to work in humanitarian assistance or international development, it can be hard to know where to start.

I don’t pretend to have all the answers. But over the course of my specialty training, I’ve been contemplating the nexus between global health (GH) and medical education, and how doctors can gather the requisite skills to work in resource limited environments, complex emergencies and development settings. I’ve also spoken to many wise and experienced colleagues, and attempted to distil their advice. This post puts some of my musings on (metaphorical) paper.

Although my own global health career is in its infancy, it’s already apparent that there are unsafe and unethical ways to go about GH training. Unfortunately, I’ve witnessed several examples of well-intentioned students and doctors inadvertently causing harm during overseas placements, and I’m keen to help others avoid similar mistakes. Getting it wrong puts host communities, training institutions and trainees at risk.

On that background, here are a few thoughts on how to safely and effectively develop your skills and career in GH.  This is just one recipe, so I welcome your comments and contributions.

 

 

My path

I thought I’d start with my own story – not because it’s unique or admirable, but because it provides context for the discussion below. Feel free to skip over if you don’t care for my self-indulgent reflections (I probably would if I was reading this blog)!

I’m a senior registrar in emergency medicine (EM) at Cairns Hospital, and have trained in a diverse range of EDs along the East coast of Australia. The focus of my GH interest is emergency care development in the Pacific.

While at medical school, I undertook an elective in Madang, Papua New Guinea. It was an illuminating experience – it highlighted the challenges of medical practice in a resource constrained setting, but also the profound socioeconomic disadvantage that exists just beyond Australia’s borders.

The following year, my girlfriend, Bec, and I had the opportunity to use our holiday during internship to assist with data collection and analysis for a medical development project in Timor Leste. It was an instructive experience. I’m not sure we contributed much, but we gained insights into effective (and ineffective) development practice.

Following from that experience, Bec and I realised that, if we wanted to work in developing settings, we needed to expand our skillset. Medical school and internship doesn’t really prepare you to deliver care or develop capacity in a resource constrained, cross-cultural environment.

We subsequently undertook Masters of Public Health and Tropical Medicine, including a field-based subject in East Africa. At the same time, we moved interstate to increase our exposure to tropical medicine and Indigenous health.

After completing primary exams, and having worked as a registrar for two years, I thought I might have something small to offer. Somewhat fortuitously, it turned out there was an opportunity to return to Madang as a Visiting Clinical Lecturer in Emergency Medicine – supervising students from Divine Word University within the ED at Modilon Hospital.

The placement was facilitated by AVI through a partnership agreement with ACEM. Thanks to a remote supervision arrangement, I was able to have six months accredited to my EM training.

When I got back to Australia, I experienced a sense of guilt that I got more out of that assignment than I was able to contribute. It heightened my awareness of the tension between the needs of Australian trainees wanting to undertake GH experiences, and the ethical responsibility to minimise harm on host communities. A desire to identify solutions led me to undertake a Churchill Fellowship focussed on safe and effective global emergency care training.

Fast-forward a few years, and my (now) wife and I have just returned from a second AVI assignment, this time in the Solomon Islands. The project was focussed on clinical supervision, educational development and quality improvement at the National Referral Hospital in Honiara. It was another richly rewarding experience, and again created opportunities for learning and reflection.

I’m now at the end of my specialty training, and am contemplating how to combine domestic work as a consultant with capacity development abroad. There doesn’t seem to be an easy way of doing so, but there are many positive examples to follow. I’ve been heavily influenced by mentors and continue to draw on their advice and guidance.

 

 

Start with reflection

So that’s my story. There are many others, including interesting and compelling tales from the likes of Natalie Thurtle, Ramona Muttucumaru and Rob Moodie.

These individuals illustrate that there are many pathways to GH practice. They also provide insights into the barriers to working in global health, and how they can be overcome. It’s widely acknowledged that it can be difficult to marry an interest in GH (and a desire to work abroad) with domestic commitments and training requirements.

So, as a junior doctor aspiring to work in GH, where to begin?

Self-reflection is a good place. It’s worth asking yourself some probing questions. What are your motivations to pursue a career in GH? What aspects of GH capture your interest? How do you think you can best contribute to global health equity? How well is your personality suited to practice in cross-cultural, volatile or isolated settings?

You may have seen the Japanese diagram in the Figure below. It appears in all sorts of career guides, and it’s an incredibly helpful conceptualisation. If you can identify your global health Ikigai, you’re off to a flying start.

 

Ikigai: A Japanese concept meaning ‘a reason for being’

 

Get educated

There are many facets to GH, and you may be unaware of the spectrum of opportunities. A good way to start is by reviewing the websites of GH training organisations, such as the Consortium of Universities for Global Health and the Global Health Training Centre.

A useful source of advice is the MJA’s Guide to Working Abroad for Medical Students and Junior Doctors, which provides comprehensive guidance on building a career and undertaking meaningful experiences in GH.  Acknowledging my bias as a co-author, it’s an extremely valuable resource!

There are also a growing number of free online courses focussed on global health (from Harvard University, for example). Not only do these provide insights into career options, they will expand your knowledge on important GH topics. Some cities also have regular networking functions for aspiring GH practitioners, such as Global Ideas in Melbourne.

The more you learn about GH, the more it becomes evident that GH practice requires a specific skillset that is not acquired through a generic medical education. This includes knowledge of key global and public health topics (eg, global burden of disease, social determinants of health and globalisation), technical competencies (eg, capacity strengthening, program management and research) and ‘soft skills’ (eg, effective communication, sociocultural awareness and commitment to social justice).

There are many pathways to acquiring this ‘toolkit’. Although a combination of organised education and supervised field experiences is generally required, postgraduate courses are a popular means of developing some of the more generic technical skills. Australia is fortunate to have an abundance of Graduate Certificate, Diploma and Masters programs that include subjects relevant to GH.

Completing a Master of Public Health is a popular option, but there are many others. It’s worth thinking about the type of GH work you are interested in, because you may be better served by a more focused coursework program (eg, health economics, epidemiology or international development) or research degree.

 

 

Ethical responsibilities

Regardless of what type of GH career you aspire to, many junior doctors are keen to participate in rotations or assignments in low- and middle-income countries. Indeed, much of the appeal of working in GH is undertaking field work in ‘exotic’ locations and cross-cultural settings.

But I’d caution you against voluntourism. The risks are well documented, and there is enormous potential for harm.

One option to develop the requisite experience is to undertake supervised rotations in cross-cultural and/or remote settings in Australia. Working in culturally diverse, isolated or disadvantaged communities within our own border can help you develop technical and non-technical skills relevant to GH practice.

If you choose to work abroad, you can minimise the risk of harm by observing ethical principles, practicing self-reflection and ensuring appropriate supervision. The Guide to Working Abroad includes 10 broad principles for GH training experiences (see box), but specific ethical guidelines for GH placements undertaken as part of postgraduate training programs have also been published. In addition, I highly recommend an online learning module from Johns Hopkins and Stanford Universities on Ethical Challenges in Short-Term Global Health Training.

One way of safeguarding against these risks is to deploy with a recognised humanitarian or development agency. Depending on your particular interests, popular options include MSF, ICRC and AVI. These organisations have strong values, well-developed risk mitigation strategies and extensive experience.

Increasingly, there are also opportunities for vocational trainees to undertake supervised rotations abroad as part of their training (examples include RANZCOG, ACEM and RACP). Several placements accredited by Colleges are part of long-term partnerships with health services abroad, an ideal model for simultaneously developing capacity and facilitating meaningful GH experiences for trainees.  These types of relationships also provide a platform for promoting equity and reciprocity in global health training.

 

1.  Recognise that patients’ rights are universal

Patients’ rights are based on the concept of fundamental human rights, as articulated in the 1948 Declaration of Human Rights and enshrined in international law (6).  The World Health Organisation (WHO) has achieved international consensus on a minimum standard: ‘that all patients have a right to privacy, to the confidentiality of their medical information, to consent to or to refuse treatment, and to be informed about relevant risk to them of medical procedures’ (7). The World Medical Association (WMA) has also adopted a Declaration on the Rights of the Patient (8).  Both the WMA and AMA Codes of Ethics express more fully the responsibilities of doctors to patients – both individually and collectively (9,10).

 

2.  Put your host community’s interests first

Though this Guide will help you select and arrange a placement abroad, ultimately it will be your hosts who invite you to practise in their community.  It is they who should define your role, and it is essential that you ask a few key questions before you undertake professional activity:  What are the community’s needs?  Is there a gap that needs filing?  Practicing in this way will make your work abroad meaningful for both you and your hosts.

 

3.  Give local trainees priority

Australian junior doctors will require some level of supervision and training while undertaking a placement.  This should never be at the expense of local trainees.

 

4.  Emphasise education

While doctors working overseas will gain an enormous amount from the experience, they will also be able to contribute in return.  Make an effort to work with local staff to identify, and then fill, skills and information gaps.  There should be an educational and capacity-building element to all of your professional activities.

 

5.  Think long-term sustainability

Just as you will take new knowledge and skills home, there will be opportunities for you to have an impact on your host community beyond your departure.  This about ‘big picture’ issues (e.g. prescribing choices, clinical decision making, resource management, staff recruitment and training and data collection) and how, based on your Australian experience, you can empower local staff to create enduring structural change.  Whatever your role, consider how you can promote local ownership and self-reliance.

 

6.  Do not use the ‘developing world’ for practising your skills

The ‘developing world’ provides doctors with a unique opportunity to learn new and innovative ways of understanding health and illness, practising medicine, and performing procedures.  But this does, not mean you should use your host community as ‘guinea pigs’ on which to hone your skills.  If you wouldn’t do it back hom, don’t do it abroad.

 

7.  Practice quality medicine

Working in an under-resourced setting invariably means that you will have to practise differently.  The aim should always be to provide the highest standard of care to the greatest number of patients with the human, pharmaceutical and equipment resources available.  Be creative in how you approach clinical problems and use local colleagues to guide you towards the best decisions.

 

8.  Know your limits

You should never expect to have all the answers and, for the safety of you, your local colleagues and your patients, you need to know when you are reaching your limits both personally and professionally.

 

9.  Have a focus

The clearer your role is, the better you will be able to fulfil the needs and expectations of your host community.  Define a job description before starting, and review and refine your responsibilities as your placement continues.  It is easy to fail into the trap of doing ‘a little bit of everything’, but it is to everyone’s advantage that you focus on your strengths, and where the community need is greatest.

 

10.  Consider the broader implications of your presence

The presence of a foreign doctor in a community has implications – perhaps far beyond what you might expect.  Cultural, social and educational differences all result in power imbalances and a degree of social disruption.  Acknowledging this reality is the first step to pre-empting and identifying relevant issues. Remember:  first do no harm.

 

Principles for Working Abroad

Reproduced from Parker et al. MJA (2011); 194 (12): eS1-95

 

Choose your own adventure

It can be challenging to acquire GH knowledge and skills while undertaking residency or specialty training, but it’s far from impossible. There are as many pathways as there are career options, and no two journeys will be the same.

My own strategy – a combination of formal education and field experiences – is a well-trodden path, but it’s just one example. The AVI assignments I’ve undertaken have been the most rewarding experiences of my specialty training, and I hope that you have similar opportunities.

If and when you work abroad, remember that you’re a privileged visitor. If there’s one thing you should pack, it’s humility.

 

Follow Rob on Twitter @robdmitchell