As a gastroenterology (GI) fellow at Dartmouth, I (Suzannah) twice had the opportunity to teach and learn about the practice of GI in Rwanda during 2 health missions (2018–2019). One of my mentors, Dr. Steven Bensen, participated in Rwanda’s Human Resources for Health (HRH1) in my fourth year at Geisel School of Medicine at Dartmouth. I was inspired by the clinical care and training that he and fellow HRH GI clinician-educators, including Drs. Dirk van Leeuwen (Dartmouth) and Frederick Makrauer (Brigham and Women’s), provided through a collaboration with Rwandan colleagues and GI Rising, a non-profit NGO they formed to fund their mission. Their efforts have now led to Rwanda’s first postgraduate training program, a self-sustaining fellowship in gastroenterology and hepatology.
While there I grew academically and professionally, with responsibility to teach and train students and residents while I provided consultations and patient care as a de facto junior faculty member. I learned to evaluate and triage patients with unfamiliar and advanced pathology within a limited-resource setting as I navigated language and cultural barriers. The opportunity to address issues of system-based practice and recommend my own solutions was always encouraged by Dr. Makrauer. After graduating this past June, I realized that my time in Rwanda was one of the most defining, energizing and educationally important experiences in fellowship. I returned from Rwanda a better endoscopist, physician, teacher, and person. For instance, nearly all of our procedures were performed unsedated due to culturally-based patient preferences. As training my Rwandan internist colleague in endoscopy was a major responsibility, I learned to efficiently teach techniques, which often involved visual inspection and biopsy of gastric masses, while performing unsedated procedures. As a consequence, I came to appreciate the sedating power of reassuring communication—quite a challenge for me given my limited French and Kinyarwandan vocabulary.
The value of global health experience in medical training is increasingly appreciated. International health opportunities offer deep exposure to global disease, cultural differences, and the opportunity to improve care for patients back home. These experiences provide the means for reducing global healthcare inequities by educating local practitioners2. “Western” residency programs and medical schools have developed global health electives3, though in fellowship, opportunities remain limited. Jirapinyo’s 2017 national survey of GI fellowships, with co-investigators Drs. D.D. Proctor (Yale) and F.L. Makrauer (Harvard) found that although 60% of responding program directors and fellows had prior global health exposure prior to fellowship and that 75% of fellows would be interested in a volunteer experience abroad during fellowship, only 17% of fellowships had global health-activity in their curricula4. Benefits most often cited were the challenge of “system-based practice” in different cultures and resource-settings, and the strengthening of leadership skills. The main barriers cited were funding and scheduling.
Jirapinypo’s study raises key questions about emphasizing global health experience in GI training. For residents and fellows, determining a career path is nearly unbearable; we set ourselves into a forward track filled with research commitments, timelines, networking, advanced fellowships, and mentorship. We have on-call requirements, clinic and consult schedules, and unfinished research papers sitting accusingly on our desktops. We also have personal lives and family commitments. While it may “feel” interesting, global health involvement during postgraduate training is not yet an ABIM requirement. With variable program support, it becomes a challenge to squeeze these experiences into lives already full of expectations. We can always start participating in global health later. How hard can it be to just do abroad what I do in the USA? Why should global health be a priority now? The ideal timing for a global health experience may not be identical for all physicians.
As trainees deciding where global health fits into our career planning, we as fellows should first define “global health.” One of the most cited definitions, developed by Koplan et al., is “an area for study, research, and practice that places a priority on improving, and achieving equity for, the health of all people worldwide5.” Many of us recognize this commitment as deeply entwined in the mission to serve as global citizens. Effective participation in meaningful activities requires new skills since the practice of healthcare in another country may significantly differ from the US experience. Fellowship is invaluable protected time used to learn the requisite knowledge base, an ideal time for a trainee to function abroad within an unfamiliar medical structure and integrate cultural awareness while mentored by international and local experts6.
For fellows who find that a temporary separation from their home, family and program is not feasible, a local longitudinal global health experience, such as working in a GI clinic for a local underserved population, may accomplish the same goal. For example, I worked in a refugee clinic at Yale New Haven Hospital, where I frequently saw patients with GI issues, such as hepatitis B or C, or parasitic intestinal infections. The Indian Health Service offers rotations for trainees at hospitals and health centers on reservations throughout the United States (https://www.ihs.gov/careeropps/studentopportunities/residencies-and-rotations/).
For fellows with the ability to volunteer abroad, first speak with your family. Review your interests, hopes and goals for the experience—“Do I have helpful language skills?” “Do I have a connection with a colleague or friend with global health experience in another country?” “Do I want to work with medical students and residents?” “Do I want to teach endoscopy?” “Do I have a specific interest in gastric cancer or infectious liver disease?” Meet with your program director to discuss your goals and outline your rotation, including time commitment. Be sure to ask—what do they need? Seek rotations of at least a month or several weeklong trips for greater continuity. Consider existing programs with experience involving GI fellows. For example, the Yale/Stanford Global Health Scholars Program (https://medicine.yale.edu/intmed/globalhealthscholars/program/), the “GI Rising” Rwanda rotation (https://www.gi-rising.org) associated with Dartmouth-Hitchcock Medical Center and the Brigham and Women’s Hospital, and Ampath (https://www.ampathkenya.org) at Indiana University are established programs committed to bidirectional education between US medical institutions and their partners abroad. Dr. Proctor’s article “How to Get Involved in Global Health” outlines a more comprehensive list of other resources.2.
If an established global health program is not acceptable, seek out faculty mentors with ties to healthcare organizations abroad. Contact clinician researchers publishing in an interesting global health field. Remember that it only takes one person to form a connection. Once you make that connection, ask the site’s supervisor for program expectations. Ensure that the clinical responsibilities fit your training level and that your planned elective meets the requirements of your training program including course credits, salary, healthcare and malpractice coverage, and safety. Understand your host country’s requirements including a temporary medical license and visa. Make an appointment with a travel clinic 6 months in advance in order to ensure that you receive appropriate vaccinations and other disease prophylaxis. Educate yourself by studying the history, politics, and cultures of your host country. If you don’t speak its language of choice, learn important phrases and words.
Personally, my global health involvement has been a salve for burnout. I remember the raw, unblemished motivation to help someone that drove me to medicine. I am inspired and humbled by the Rwandan physicians I met—by their grace, diligence, and commitment to improving the health of their nation despite the sacrifices required of them. It is thrilling and deeply meaningful that my medical training enables me to share knowledge with physicians who will improve the lives of so many people. I hope to return to Rwanda and teach GI for years to come—and I hope some day soon Rwandan gastroenterologists will be also serving in another country, working toward improving healthcare equity.
The Human Resources for Health Program in Rwanda — A New Partnership | NEJM. Accessed December 9, 2021. https://www.nejm.org/doi/full/10.1056/NEJMsr1302176
Proctor DD. How to get involved in global health. Gastroenterology. 2019;156:542–544. https://doi.org/10.1053/j.gastro.2019.01.012.
Adams LV, Wagner CM, Nutt CT, Binagwaho A. The future of global health education: training for equity in global health. BMC Med. Educ. 2016;16:296. https://doi.org/10.1186/s12909-016-0820-0.
Jirapinyo P, Hunt RS, Tabak YP, Proctor DD, Makrauer FL. Global Health Education in Gastroenterology Fellowship: A National Survey. Dig. Dis. Sci. 2016;61:3443–3450. https://doi.org/10.1007/s10620-016-4308-x.
Koplan JP, Bond TC, Merson MH et al. Towards a common definition of global health. Lancet. 2009;373:1993–1995. https://doi.org/10.1016/S0140-6736(09)60332-9.
Chudy-Onwugaje K. Getting started in global health: a practical guide for gastroenterology fellows. ACG Case Rep. J. 2021;8:e00514. https://doi.org/10.14309/crj.0000000000000514.
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Luft, S., Makrauer, F. How (and Why) to Get Involved with Global Health as a GI Fellow.
Dig Dis Sci 67, 3485–3486 (2022). https://doi.org/10.1007/s10620-022-07577-7