Abstract
In this essay, I borrow the idea of universal precautions from infection control and suggest that family physicians use a set of considerations, based on the mnemonic UNIVERSAL, to nurture cultural humility, enter a metaphoric “space-in-between” in cross-cultural encounters, and foster global fluency. These UNIVERSAL considerations I base on my experiences in global family medicine, attending to economically poor and socially marginalized patients in both international and domestic settings. They are informed by readings in transcultural psychiatry, medical anthropology, development studies, and primary care. I invite others involved in global family medicine to reflect on what they have learned along their own professional paths, so as to enhance their therapeutic abilities as global family physicians, wherever they may be.
- Medical Anthropology
- Cross-Cultural Comparison
- Global Health
- Medical Education
- Physicians
- Family
- Primary Health Care
There are many available paths to practicing global family medicine.1⇓⇓⇓–5 I have walked mine for over 25 years in safety net clinics and corrections health in the United States. I have also practiced and taught medicine, public health, and medical anthropology for extended periods of time in various international settings. My experiences as a global family physician have not only fed my sense of feeling fortunate in having found a gratifying professional niche,6 but also helped me sustain a sense of professional meaning during a time of often confusing organizational change. They have confirmed for me that family medicine is a vital component of any rational system of health care, whether at home or elsewhere around the world.7⇓–9
My work as a global family physician has also confirmed that it is extremely challenging for any of us to see beyond our enculturation, the net sum of historic, environmental, and interpersonal influences that both socialize us to think in particular ways and limit our abilities to perceive, comprehend, or engage with people who think, communicate, and act in ways differently than we do.10 That we come from an economically and politically powerful country and have been trained in an increasingly fragmented professional culture risks that we may not aptly understand the complexity of the concerns that people in the majority world face, the needs they have, or the burdens under which they toil.11 Indeed, practicing family medicine effectively in any context means paying attention to issues whose origins and solutions lie beyond the strict confines of a biomedical worldview.
Toward Global Fluency
To enhance our abilities as capable and competent global family physicians it is important that we enter a metaphoric space in between us and our patients,12 a place where ideas and actions are cocreated and conurtured with others through expressions of respect, trust, and equanimity. Such a space-in-between can enhance cultural humility,13 an accurate and honest relational worldview born not from a position of subservience but from the recognition that other points of view are worthy of consideration.
Given that the opportunities to grow our professional competencies as global family physicians may occur throughout the course of any particular day, it is important that we are prepared to explore these issues at a moment's notice. Borrowing from the use of universal precautions as an effective approach to control infection and promote health,14 I suggest we adopt a set of UNIVERSAL considerations to limit cross-cultural misunderstandings and foster global fluency, the ability to dialog honestly with patients, family members, professional colleagues, and community partners, regardless of the location or situation in which we may find ourselves.
The UNIVERSAL Mnemonic
The 9 principles that follow (Table 1), each represented by 1 letter in the mnemonic UNIVERSAL, are based on my experiences and informed by readings in transcultural psychiatry, medical anthropology, development studies, and primary care. My intent is not that they promise simplistic secrets for success in global family medicine, but prompt reflective inquiry to help family physicians anywhere cultivate a curious, open, and engaging stance vis-à-vis their patients and the communities in which they live.
UNIVERSAL Considerations in Global Medicine and Global Health
These UNIVERSAL considerations include:
Unlearn
Consciously put to the side, at least momentarily, the preconceptions and beliefs with which we enter into encounters with others, acknowledging that other people regularly hold other points of view, sometimes poles apart from ours. Put to the side differences such as history, class, and background, opening up a willingness to listen and accept at face value those diverse perspectives. Put to the side the power that comes from having a MD or DO (or even PhD) after one's name, allowing a human connection to form before a medical one.15
Notice Context
Although other family doctors may have different views on the meaning of “family” in “family medicine,” I think of “family” as a metaphor for the context of all that is not strictly biomedical in our work, representing the psychosocial aspects of the biopsychosocial model that acts as a foundational guide to holistic patient care.16 In other words, recognize both the obvious and nuanced dimensions of “family,” incorporate these dimensions into diagnosis and treatment, and care for patients as individuals at the same time mindful of their presence in families and communities. Practice family medicine.
Be Inquisitive
As the use of electronic medical records proliferates and measurement science advances,17⇓–19 there will be increasing pressure to practice check box medicine (providing data for population-based inquiry). Resist this influence. Check or tick boxes may be useful for certain procedural activities and analyzing large data sets; their structure, however, obviates the kind of sensitivity to learning about the individual and cultural differences with which patients present, anywhere in the world.20 Adopt a questioning approach to patient and community concerns, regardless of setting.21
Recognize Human Vulnerability
Vulnerability in the face of illness is perhaps the 1 quality common to all people across boundaries of geography, ethnicity, and time. Recognize this. How vulnerability manifests in people may vary greatly, as does the counterbalancing quality of hope. Explore how they are both commonly expressed in practice environments, understand that even within communities people's expression of suffering and resilience differ, and use the power of this knowledge to enhance therapeutic efficacy and care.22
Open our Eyes
Perception, integration, and application: these are 3 important stages in the development of any habit of practice, whether in global medicine or public health, especially when acknowledging and attending to the effects social determinants have on health. Perception, the first stage, is not as easy as it sounds; there are many factors that distract us from seeing what is evidently right before our eyes.23 Exercise the senses to engage the mind in honest, realistic, and inclusive assessments of upstream causes and downstream effects on disease and illness.24
Build Lasting Relationships
Continuity is a core value in family medicine as practiced in the United States.25 It is no less important abroad. Especially when work in international settings may be of relatively brief periods of time, spread out over years and years,26 the personal relationships one develops may be the most lasting result of one's efforts,27 particularly in areas made volatile by the ugliness of politics, the shock of violence, or the atrocities of war. Although intercontinental communication has been made easier during the last few decades, maintaining relationships at a distance may also be 1 of the most problematic parts of global health work. Make nurturing ongoing relationships part of any global endeavor.
Grow in Solidarity
Simply put, work with patients, families, and communities, not just for them. Although much has been written, and eloquently so, about solidarity as a manifestation of social justice in the delivery of medical care at home and around the world,28 social justice is not something we blithely give to people. Solidarity signifies recognizing, in partnership with others, the structural forces that contribute to poor health outcomes, just as it signifies recognizing, with others, the structural barriers that negatively affect our abilities to attend to those forces. Solidarity signifies working with others to lessen the adverse influence of these factors, as we all are able. As such, remember this: solidarity is something we share.29
Appreciate our Interdependency
Remember, too, how our day-to-day worlds are intimately connected to the worlds of those for and with whom we work and are increasingly connected to those outside our immediate influence.30 That we live, in the United States, in an increasingly pluralistic society,31,32 that globalization has altered traditional patterns of goods and jobs,33 that we must pay attention to clinical conditions only until recently encountered on the other side of globe,34,35 and that we must face the looming specter of climate change are all evidence of this reality.36,37
Learn
Ultimately, the process of working in global family medicine is one of learning. True learning implies welcoming a definitive change in some aspect of our lives: incorporate this deliberate intent into the process.38 Build on what we know by inviting other practices and knowledge into our observed awareness; cultivate a sense of mystery and wonderment in the face of new understandings; nurture the ability to reflect on it all; and, develop deep connections through relationship and relationships39: these are our tasks as global family physicians.
Further Considerations
Some may read this essay and respond that the practice of global family medicine is principally one of diagnosis and treatment across the breadth of medicine from birth to death. I do not disagree with the fact that we must be adept at applying in the science of medicine as it applies to our discipline. I do contend, however, that we have options as to how we conduct the technical and scientific aspects of our work, and that we are more successful when we do so with care and compassion, inviting the engagement of others.
Others may note that the UNIVERSAL considerations above are not focused solely on international work. I agree. The changing dynamics of our world demand that global family medicine be practiced everywhere, whether in North America or on other continents. Issues of access to care, resource availability, and appropriately trained personnel are not solely concerns outside the United States. They exist everywhere.
Still others may suggest that the power of our market-based medical-industrial complex is just too great for family medicine to thrive across the globe, and that our privatized, high-technology, subspecialty-based model should be replicated elsewhere. I completely disagree. Strong evidence—our dismal record at successfully lowering overall rates of morbidity and mortality at home40 (even with extraordinarily high medically related expenditures in contrast with other countries41), coupled with ample validation of family medicine's role as an appropriate alternative to this failure42,43—belies this suggestion. Although all global medical practitioners risk being sucked into the vortex of transmitting inappropriate models of medical care to environments where they are neither sustainable nor feasible—such actions can actually do grievous harm to the general health of the population by encouraging priorities incompatible with the local realities of those most in need—global family physicians have the potential to understand this susceptibility and minimize untoward consequences.
Conclusion
As encapsulated in the UNIVERSAL mnemonic, I have summarized the lessons I have learned on my professional path as a global family physician. I hope these lessons prompt others to reflect on what they have learned on their own paths, for each of us who has contributed to the work of global medicine and public health has our own unique history. As we recall the experiences that have taught us, let us also remember that the real work of family medicine occurs neither in a moment's passing nor alone. In family medicine, we do best by working alongside patients, family members, community partners, and other professional colleagues, over time. Let us remember that, and may it guide our paths as agents of healing,44 wherever we may be.
Acknowledgments
I thank Katherine Culhane-Pera, MD, MA; and Calvin Wilson, MD, for their critical comments on previous revisions of this essay.
Notes
This article was externally peer reviewed.
Funding: none.
Conflict of interest: none declared.
To see this article online, please go to: http://jabfm.org/content/30/1/104.full.
- Received for publication February 19, 2016.
- Revision received May 16, 2016.
- Accepted for publication May 31, 2016.
