More valuable in International Medicine? Emergency or Family Medicine?

[RuralPhysician8]

A friend of mine brought up the subject of international medicine today and ended up at the question of which medical specialty is most valuable in healthcare compromised countries. Family Medicine or Emergency Medicine? Of course different regions have different needs. War torn countries would likely benefit more from emergency medical care; however, a country with little conflict, but excessive proverty may be best improved by the increased availability of primary care. So, lets put the question in the context of developing countries experiencing at least mild armed conflict (civil mainly), excessive poverty, frequent epidemics, and an increasing population. And let us suppose that the medical facilities are few and far between, of humanitarian organizations in the U.S., Canada, countries in Europe, etc... , provide mainly outpatient care, but have decent inpatient resources, have decently equipped pharmacies, and are staffed by no more than four physicians with variable quantities of nurses, pharmacy technichans, EMTs, etc... .

One of my favorie books, Six Months in Sudan, was written by an emergency medicine physician, if I remember correctly, and he was able to tackle a diversity of issues the Sudanese where experiencing; however, I cannot help but feel as thought a family medicine physician would likely have greater experience and skill in OB/GYN, preventitive medicine, pediatrics, etc... . Althought I am likely a bit biased, since my main interests are within primary care medicine. What does everyone else think? I thought this would be an interesting conversation.

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[Mt Kilimanjaro]

A friend of mine brought up the subject of international medicine today and ended up at the question of which medical specialty is most valuable in healthcare compromised countries. Family Medicine or Emergency Medicine? Of course different regions have different needs. War torn countries would likely benefit more from emergency medical care; however, a country with little conflict, but excessive proverty may be best improved by the increased availability of primary care. So, lets put the question in the context of developing countries experiencing at least mild armed conflict (civil mainly), excessive poverty, frequent epidemics, and an increasing population. And let us suppose that the medical facilities are few and far between, of humanitarian organizations in the U.S., Canada, countries in Europe, etc... , provide mainly outpatient care, but have decent inpatient resources, have decently equipped pharmacies, and are staffed by no more than four physicians with variable quantities of nurses, pharmacy technichans, EMTs, etc... .

One of my favorie books, Six Months in Sudan, was written by an emergency medicine physician, if I remember correctly, and he was able to tackle a diversity of issues the Sudanese where experiencing; however, I cannot help but feel as thought a family medicine physician would likely have greater experience and skill in OB/GYN, preventitive medicine, pediatrics, etc... . Althought I am likely a bit biased, since my main interests are within primary care medicine. What does everyone else think? I thought this would be an interesting conversation.

It depends on your reason for being there. Assessing acutely ill patients? EM (in conjunction with a surgeon, radiologist, etc). Providing primary care services and training local providers to do the same? FM.

I have heard a missionary doctor say that the only useful specialties for long-term global health work are surgery and FM. But I think it all depends on how you structure your program and what the local health system is trying to achieve/what you are trying to accomplish.

 

[Barcu]

Eh. The specialty matters, but the individual skills matter more. As well, I don't think EM is as helpful as many other specialites. Most people coming into these clinics aren't coming in due to trauma or with problems that are helped by an EM skill set (though some of their procedures are useful).

The two I've heard are the best are FM and gen surgery. If you are an FM who knows lots of procedures and gyn, then you are in a great position. Many of these problems that can't be treated medically have some surgical solution that can help or at least alleviate symptoms, so some surgical expertise goes a long way.

 

[WTEngel]

Eh. The specialty matters, but the individual skills matter more. As well, I don't think EM is as helpful as many other specialites. Most people coming into these clinics aren't coming in due to trauma or with problems that are helped by an EM skill set (though some of their procedures are useful).

The two I've heard are the best are FM and gen surgery. If you are an FM who knows lots of procedures and gyn, then you are in a great position. Many of these problems that can't be treated medically have some surgical solution that can help or at least alleviate symptoms, so some surgical expertise goes a long way.

Most people coming into Emergency Rooms in the United States are not coming in due to trauma or for what people generally consider the "EM skill set" either.

I guess it depends on where you are, but in my experience, family medicine, primary care, and internal medicine skills seem to be commonly used in the ER, the only difference is that the EM physicians generally do not have the benefit of having followed that patient (unless they are "well known" to that particular facility.)

I would agree, the high acuity EM physician working at a facility where the knife and gun club regularly meet is going to feel less at home in a rural or austere clinical environment, but I think they can acclimate better to the clinical environment than the FM or Ob/Gyn can to the polytrauma / high medical acuity.

This is all anecdotal, and simply an opinion, though.

 

[Nymphicus]

Family medicine, by far.

 

[mehc012]

I'm not really sure preventative medicine is what we need to be focusing on in a country where there are already widespread existing health problems (disease, war injuries, untreated chronic problems, poverty-related illnesses).

That being said, EM depts these days see far more than their fair share of what ought to be primary care patients...and they tend to be those who eschew regular primary/preventative care. In that sense, I feel that the EM doc would be a good choice, not because of their trauma experience, but because of their experiences with a similarish patient base.

An EM doc will be familiar with seeing the large range of ailments and injuries which result in true, actual emergency health conditions (heart problems), as well as a reasonable sample of "you'll live" type issues that still impede quality of life (I messed up my knee) and straight-up run-of-the-mill issues (colds, flu, etc...)

An FM doc will be familiar with many of the same things, but their spectrum is much more heavily weighted towards preventative and run-of-the-mill while the ER would tend to encounter more cases on the emergency end (and be more used to triage/prioritizing). In a country with widespread health problems, I would want to tackle the extreme end of the spectrum first.

I personally think EM would be more beneficial, then, of the two options given. Then again, I am definitely biased from having been dirt poor myself; I must admit that I cannot think of what you would actually go to a PCP for, other than peds. I guess if I needed abx for strep or a UTI or something?

 

[mcloaf]

In peace: FM.
In conflict: gen surg.

 

[Barcu]

Most people coming into Emergency Rooms in the United States are not coming in due to trauma or for what people generally consider the "EM skill set" either.

I guess it depends on where you are, but in my experience, family medicine, primary care, and internal medicine skills seem to be commonly used in the ER, the only difference is that the EM physicians generally do not have the benefit of having followed that patient (unless they are "well known" to that particular facility.)

I would agree, the high acuity EM physician working at a facility where the knife and gun club regularly meet is going to feel less at home in a rural or austere clinical environment, but I think they can acclimate better to the clinical environment than the FM or Ob/Gyn can to the polytrauma / high medical acuity.

This is all anecdotal, and simply an opinion, though.

I'm not really sure preventative medicine is what we need to be focusing on in a country where there are already widespread existing health problems (disease, war injuries, untreated chronic problems, poverty-related illnesses).

That being said, EM depts these days see far more than their fair share of what ought to be primary care patients...and they tend to be those who eschew regular primary/preventative care. In that sense, I feel that the EM doc would be a good choice, not because of their trauma experience, but because of their experiences with a similarish patient base.

An EM doc will be familiar with seeing the large range of ailments and injuries which result in true, actual emergency health conditions (heart problems), as well as a reasonable sample of "you'll live" type issues that still impede quality of life (I messed up my knee) and straight-up run-of-the-mill issues (colds, flu, etc...)

An FM doc will be familiar with many of the same things, but their spectrum is much more heavily weighted towards preventative and run-of-the-mill while the ER would tend to encounter more cases on the emergency end (and be more used to triage/prioritizing). In a country with widespread health problems, I would want to tackle the extreme end of the spectrum first.

I personally think EM would be more beneficial, then, of the two options given. Then again, I am definitely biased from having been dirt poor myself; I must admit that I cannot think of what you would actually go to a PCP for, other than peds. I guess if I needed abx for strep or a UTI or something?

These are good points, and I do agree to some extent. ER docs do see a fair number of primary care visits, but that doesn't mean that is what they are trained for (they aren't). Nor does it mean that they are the best ones to handle these types of cases. The mentality is to deal with the problem and get the patients out asap. That's not necessarily what an international physician should be doing.

I think people underestimate how important dealing with chronic conditions is in developing countries. As I said, most problems are not acute (just like the US, but our ER system is not used effectively). Having a FP doc is better because they can handle acute cases (many rural ERs don't have EM physicians) and they have additional skills in dealing with gyn issues, adults and children, as well as with chronic diseases. Even without longitudinal follow-up, these skills are absolutely vital. If they have surgical skills, even better. And this is where gen surg comes in. Some chronic conditions can be alleviated with surgery (like for pain) even if it's not a perfect cure. This is especially true if there can't be follow-up, which would make meds an less desireable option.

The goal of international medicine isn't to see as many patients as possible and manage short-term conditions. It is about teaching patients how to stay healthy, even with one visit. An ER doc can do this. I'm not saying they don't have the skills. However, FP and gen surg are in a better position than EM.

 

[Nymphicus]

3 points.

#1
A well-trained family medicine physician can do much more than prescribe antibiotics or diagnose a UTI.

#2
The large, large majority of people in "poor, conflicted, war-torn countries" don't die of gunshot wounds. They die of malnutrition, parasites, chronic illness, and a host of other, often preventable, diseases that we don't often see as much in the US because they are preventable.

#3
The overarching premise of the EM specialty is to triage and stabilize emergent cases and refer to the appropriate service. The services and resources that the EM specialty was built on will most likely not be available in the situations that the OP describes.

 

[mehc012]

3 points.

#1
A well-trained family medicine physician can do much more than prescribe antibiotics or diagnose a UTI.

#2
The large, large majority of people in "poor, conflicted, war-torn countries" don't die of gunshot wounds. They die of malnutrition, parasites, chronic illness, and a host of other, often preventable, diseases that we don't often see as much in the US because they are preventable.

#3
The overarching premise of the EM specialty is to triage and stabilize emergent cases and refer to the appropriate service. The services and resources that the EM specialty was built on will most likely not be available in the situations that the OP describes.

#1. I just want to be clear that I don't think FM doctors are incapable...I just can't think of a situation where I have ever considered going to one other than for vaccines or abx. I was only putting that out there to highlight my bias when discussing this issue, because I really don't know what most people take to their family docs.

#2. I agree that trauma really should not be the focus of int'l medicine, not only because of it's relative rarity when compared to chronic problems, but because it would require a specific sort of setup to be in any way efficient at combating trauma-related deaths.

#3 I feel that the triaging experience is a) more than FM docs have in analogous emergency situations, and b) an important skill to have when dealing with a nationwide backlog of patients. Furthermore, while the ER might have been intended to only deal with emergencies, in practice an EM doc will encounter a fair number of primary care issues themselves.


We can argue that the illnesses seen in Int'l med situations are not ones US docs would encounter, but that would apply evenly to FM and EM docs.
Perhaps a stronger argument for FM vs EM is the relative dependence on nurses, support staff, and monitoring equipment; an EM doc will almost always be working out of a hospital, while the FM doc is more used to limited equipment and independence.

Honestly, I think int'l medicine is a rather unique area and doesn't fit either particularly well...and again, this is just my argument if you are limiting the choices to EM vs FM.

 

[galaxyx]

If you're trying to decide between FM & EM because international medicine is you're career goal, I think there's more to it to which specialty treats patients in impoverished countries better.

Which specialty is going to give you the life that makes you able to practice when/where you want to practice.

If you become an FM and want to develop/build your own practice in the states, you're going to have a hard time to get away to practice your international medicine.

If you're not concerned about job stability or long term jobs, doing locums work in either FM or EM can give you the flexibility to take large chunks of time for your international work.

There's more to think about than which specialty is "ideal for an un-ideal" situation

 

[RuralPhysician8]

If you're trying to decide between FM & EM because international medicine is you're career goal, I think there's more to it to which specialty treats patients in impoverished countries better.

No, the thread is mainly for discussion purposes. I will admit though I am interested in practicing in underserved areas (U.S. and Latin America) and my top three prefered specialties are...

Family Medicine : I enjoy having a broad spectrum of diverse cases and getting to know people.
Emergency Medicine: Again, I enjoy having a broad spectrum. I am a night person and can see myself doing 8pm-8am shifts and I do enjoy a bit of adrenaline.
Internal Medcine Hospitalist: Once again, I would not mind the night shift here there; the diversity in patients is also attractive.

Honestly though, I am more focused on surviving undergrad right now. I will stress out over a residency when I get into medical school. 😀

 

[Goucher2013]

Consider preventive medicine as a career. I've spent years in places with minimal healthcare, and the problem was the lack of a local system, not the lack of a visiting foreign doctor with specific skills. Do you want to want to help locals build that system, or hand out meds? Consider whether your current career goals would allow you to have a truly long-term impact on the people you want to help.

If you're serious about international medicine, plan on doing electives abroad, for instance EM in Johannesburg or general surgery in India. You won't just pick up low-tech skills, but get a feeling for whether you have the stomach for this kind of thing. Or do Peace Corps before med school (certainly helps you stand out a little). Any kind of short volunteering as an undergrad just doesn't cut it in comparison to the responsibility and commitment that you need to discover if you want to stick with this stuff.

 

[RuralPhysician8]

Or do Peace Corps before med school (certainly helps you stand out a little). Any kind of short volunteering as an undergrad just doesn't cut it in comparison to the responsibility and commitment that you need to discover if you want to stick with this stuff.

I am hoping to go on at least two mission trips to Latin America. If I go the Peace Corps route, what would be my duties? I would volunteer as an EMT; however, there are no certification programs in my area. Do the Peace Corps offer training to those willing to serve as far as medical related positions go?

 

[Barcu]

I am hoping to go on at least two mission trips to Latin America. If I go the Peace Corps route, what would be my duties? I would volunteer as an EMT; however, there are no certification programs in my area. Do the Peace Corps offer training to those willing to serve as far as medical related positions go?

Peace corps doesn't do medical stuff that I know of.

If you really want to work medically overseas, just get through med school and residency. You will be so much more useful as a trained doc, and you can look for arrangements on your own terms.

 

[RuralPhysician8]

Peace corps doesn't do medical stuff that I know of.

If you really want to work medically overseas, just get through med school and residency. You will be so much more useful as a trained doc, and you can look for arrangements on your own terms.

I see, most of my skills rest in the sciences so those are the only positions I could handle comfortably in a new environment; however, I also do not mind basic manual labor if I am ever asked to do some minor carpentry work on a mission trip or just carry a couple things I would be more than happy to.

 

[Goucher2013]

Peace corps doesn't do medical stuff that I know of.

If you really want to work medically overseas, just get through med school and residency. You will be so much more useful as a trained doc, and you can look for arrangements on your own terms.

Yeah, Peace Corps is more for learning whether you have the stomach for long-term overseas work as well as to strengthen your med school application. Last I checked, Peace Corps was taking volunteers who had slightly more specialized skills, such as placing business majors with ecotourism communities. But as a whole, you're not there as skilled labor. My wife did sanitation, which is the closest you'll get to medicine, in the guise of public health. Actually, I stand corrected, there are multiple health-related opportunities.

But a big caveat: no one in her cohort were under any illusion that they had any long-term impact. Your training's too basic and your clout with the community usually minimal. Many volunteer veterans I know counsel future volunteers to see the two years more as an opportunity to learn to live with discomfort, to learn a language, to meet interesting people -- anything other than having a serious impact.

Still, to me it comes down to how professional you want to be about international medicine. There are plenty of docs out there who don't really know what they're doing when they go to the developing world. Being able to fix people doesn't mean you can fix communities. In fact, it's amazing how often the best intentions can backfire.

Finally, remember that something like Peace Corps is only two years out of your life. We still plan our lives around post-World War Two life expectancy. These days, we have ten more years to play around with, and we're significantly healthier every step of the way. There's absolutely no rush for you to go to med school if you have more defined interests than simply, "I want to practice medicine". There are certain life experiences that will make you a significantly better doctor for the rest of your life and are well worth delaying med school for.

PS: Not only does Peace Corps not offer proper medical training, but you are expressly forbidden from using your prior education if you're a medical professional.

 

[Barcu]

Yeah, Peace Corps is more for learning whether you have the stomach for long-term overseas work as well as to strengthen your med school application. Last I checked, Peace Corps was taking volunteers who had slightly more specialized skills, such as placing business majors with ecotourism communities. But as a whole, you're not there as skilled labor. My wife did sanitation, which is the closest you'll get to medicine, in the guise of public health. Actually, I stand corrected, there are multiple health-related opportunities.

But a big caveat: no one in her cohort were under any illusion that they had any long-term impact. Your training's too basic and your clout with the community usually minimal. Many volunteer veterans I know counsel future volunteers to see the two years more as an opportunity to learn to live with discomfort, to learn a language, to meet interesting people -- anything other than having a serious impact.

Still, to me it comes down to how professional you want to be about international medicine. There are plenty of docs out there who don't really know what they're doing when they go to the developing world. Being able to fix people doesn't mean you can fix communities. In fact, it's amazing how often the best intentions can backfire.

Finally, remember that something like Peace Corps is only two years out of your life. We still plan our lives around post-World War Two life expectancy. These days, we have ten more years to play around with, and we're significantly healthier every step of the way. There's absolutely no rush for you to go to med school if you have more defined interests than simply, "I want to practice medicine". There are certain life experiences that will make you a significantly better doctor for the rest of your life and are well worth delaying med school for.

PS: Not only does Peace Corps not offer proper medical training, but you are expressly forbidden from using your prior education if you're a medical professional.

I agree with a lot of what you have said here. Peace Corps seems like a great program, and if you want to go for it, it certainly is a lot better than most of the other international programs out there. If you are ok taking some time off and most likely doing something non-medical, then the OP should go for it. I don't think people need to rush into med school either.

However, my point was that if you really want to work medically abroad, getting your MD and completing residency first is the way to do it. You can find better opportunities, actually use your skills, and you can make a very large impact. This is especially true if you were to get involved in education and training of foreign docs, which should be the major goal of international med.

 

[Mt Kilimanjaro]

The Global Health Service Corps is a joint program with the Peace Corps that recruits healthcare providers. It's fairly new, but was founded by John Kerry's daughter, so I would expect it to gain considerable traction during his time as SecState.

http://globalhealthservicecorps.org/

 

[Barcu]

The Global Health Service Corps is a joint program with the Peace Corps that recruits healthcare providers. It's fairly new, but was founded by John Kerry's daughter, so I would expect it to gain considerable traction during his time as SecState.

http://globalhealthservicecorps.org/

I heard about this recently. Seems to be an interesting program.

Important to note that you need to have completed a residency to participate.

 

[yehhhboiii]

Infectious Disease
Those guys know so much about microbiology and medicine in general.

 

[Goucher2013]

The Global Health Service Corps is a joint program with the Peace Corps that recruits healthcare providers. It's fairly new, but was founded by John Kerry's daughter, so I would expect it to gain considerable traction during his time as SecState.

http://globalhealthservicecorps.org/

Because it's apparently de rigueur among daughters of the rich and powerful, George W. Bush's daughter, Barbara, also founded a health NGO, the almost-identically titled Global Health Corps. Not that rich, white people all engage in groupthink about ways to improve the world...

Anyway, GHC is entirely kosher, offers fellowship opportunities abroad, and they seem to take people straight out of undergrad. So, this might be a viable alternative to Peace Corps, with a shorter commitment and greater focus on health:

Global Health Corps