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Global health, whatever your definition of it might be, seeks us out across the world – and this is true for patients as well as systems issues alike.  As an example of the latter, in the weeks preceding my journeys to India and Haiti I agreed to have a series of clinical observers shadowing me during my work as a hospitalist.  Such clinical observers exist within a vague space of the American medical system, not formally within training programs, but granted access to clinical experiences for a range of reasons.  In the case of many physicians and medical students from abroad, the goal is to have clinical exposure within an institution to garner a letter of recommendation, and perhaps to have an inside track at being hired for residency.  For a smaller group, an observership might be a way to see some new clinical or systems approaches to take back to their home institution – such possibilities are typically limited by the understandable concern on the part of academic hospitals about taking on liability for people who are not employees or students under their aegis.  Thus most observers are not allowed direct patient contact (history taking, examining, operating), though they are allowed to observe patient interactions.  The rules vary from institution to institution, reflecting an absence (to my knowledge) of a nation- or state-wide regulation of this practice, beyond that of only allowing appropriately licensed individuals to provide medical care.

I must admit, the process of having an observer is an exhausting one.  These are people you need to get to know, to incorporate into already busy days, and to ideally have some sense of as physicians within the very tight constraint of no significant patient contact.  The three with whom I dealt (2 Nigerians and 1 Rwandan) are very pleasant, and I think their chances of finding a spot at an American residency are quite good.  But it was hard at times not to begrudge their presence, as every minute spent talking to them was frequently a minute spent not preparing myself for leaving the hospital (as patient care was going to take however long it would take!).  Without an obligation or renumeration for the process, I suspect that the process is similar viewed by a lot of other physicians across the country – likely the reason that it is not straightforward to arrange such opportunities for visiting physicians.

But let us now flip the perspective.  What is the benefit for physicians who allow us to shadow them in resource-limited settings?  What benefit accrues to my colleagues in Haiti or in India for letting myself (+/- a pair of residents and a medical student) sit with them, watch them chat with patients, and slow down their clinical progress with our questions or with translation for our ignorant ears?

The parallels are not precise, of course.  When I have observers with me, I hold all of the power – my letter and advocacy will determine whether this experience is of benefit to them in their applications to residencies, and there is nothing that they offer me financially or educationally (strictly speaking, though there are occasional interesting discussions, etc). So they rely on my goodwill to allow the occasion to occur, and to provide sufficient space for me to experience them as full people. The doctors I work with in Haiti and those we visited in India may reap indirect benefits from our visits – having lectures from Gopal, garnering the prestige of being associated with an American institution, getting financial and material support from Physicians for Haiti, or building relationships with an eye towards obtaining such things in the future.  Which is not to say that any of these are necessarily benefits, let along benefits to outweigh the inconveniences caused by our presence.

After reflection from my recent series of experiences, I am much more appreciative of the labors our partners put into providing us with worthwhile experiences, and more attuned to the need to counterbalance the opportunity costs of hosting us with real benefits.  Too, as I consider medical education in resource-limited contexts and the invariable need for the presently ongoing projects in global health to find appropriate spaces to bring our partners to us to learn in our setting, just as we learn from them in theirs, I think it’s clear that there will need to be changes made to the observership standards within Boston hospitals.  For example, observers need to be allowed to examine patients – only with the permission of a patient, of course, and it is reasonable to ask that this be done only under supervision.  But to place our supposed partners in a role with limited capacity for education while we benefit from lax or absent regulations within their health system demonstrates once more the inequality in our positions.

And where we find inequality, we should strive to shift back to a fair balance.

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