Teaching Family Medicine in the ED
To Kim Bullock, MD, the emergency department — or ED — is the perfect place to teach medical students about family medicine with a dash of global health.
At first blush, the notion seems slightly nonsensical — family medicine is what one learns in an often hectic part of the hospital designed to treat emergencies? And how does global health figure in?
Bullock can explain, but first, some background. She is director of the Health Resources and Services Administration (HRSA) fellowships, director of community health division and assistant director of service learning in the Department of Family Medicine at Georgetown University School of Medicine. She is also an attending physician at Providence Hospital in Washington, DC, a clinical partner, which has been serving disadvantaged communities for over 151 years.
About a decade ago, Bullock received a seed grant from the family medicine department to teach 4th year medical students about the similarities between family and emergency medicine in the Providence ED. Given the program’s immediate success, it became a four-week elective — Emergency Medicine from a Family Practice Perspective — for two or three medical students at a time. The elective, held every month, quickly became an official rotation at the School of Medicine. And while Georgetown students are given top priority, medical students from across the country have also sought this elective to learn about emergency medicine with an expanded lens.
Bullock’s 4th year elective is apparently the only program of its kind in the country that has a focus on emergency medicine as practiced by family practitioners.
“Family practitioners do not usually practice in the hospital ED, except in very rural or frontier areas,” says Bullock. “So much of the practice in the ED is primary care. Not that much of it involves life saving practices. The rest requires the services family doctors are used to providing.”
The ED serves as a safety net for many patients, she says. “Patients come with a variety of complaints, as they would to a family physician, if they had one. In the ED, physicians need to identify the patients who urgently need care, as family practitioners also do.
“This course is not preparing family doctors to be ED physicians, but honing the skills that many ED doctors use to treat non-urgent patients,” Bullock says.
A Willingness to Teach
To further broaden the students’ learning experiences, Bullock opened the elective six years ago to an exchange of medical students from other countries.
“This achieves a bigger perspective, which is to provide a world view in how medicine is practiced across the globe, Bullock says. “American medical students learn American medicine. I think mixing in students from other countries gives students a richer mindset as they approach problems when they start to practice.
“It really is a global world now, and an international health care village,” she says.
Two recent medical students, one from Trinity College in Dublin and the other from Kings College in London, appreciated being exposed to an American ED during their August rotation.
Yazan Haddadin sought Bullock’s program because he wants to practice medicine with a multiethnic urban population — the kind he sees in London as a medical student. And he also wanted to see how the U.S. varies from the United Kingdom in terms of provision of health care.
He sees the difference in many ways, but one glaring example is the number of tests that American ED physicians order. “Because of universal healthcare, a lot of the treatment protocols are based on evidence-based research in the U.K, which also takes into consideration of cost versus benefit,” Haddadin says. In his rotation in the U.S., he says the “just-make-sure approach dominates practice.
“Patients don't want to feel like they're being denied the most expensive tests, even though they're absolutely unnecessary, and doctors want to safeguard themselves in case something goes wrong and a lawsuit is on hand. I've had a few discussions with doctors about that issue,” he says.
What Haddadin found to be extremely valuable at Providence was the education system. “Doctors are incredibly nice and enthusiastic when welcoming students. Their willingness to teach is fantastic,” he says. “For once I didn't feel like I'm in the way, but rather part of the team. I was the first to interview patients and try and come up with a management plan, which I got to discuss with doctors.”
Practicing Population Health
Breanne Bailey has long sought an international approach to healthcare. She is an American studying medicine in Ireland because of her interest in global health. “I wanted the opportunity to live abroad and expand my knowledge base of government-run health systems and compare their differences to the U.S. model,” she says. “Eventually I would like to work to enhance how we deliver healthcare in this country based upon what I have learned from working in other systems.”
She says Providence Hospital is like Irish community hospitals. “The approach to treating patients not only for their physical health concerns but also for their psychological and social well-being is highly stressed in Irish medical training and something that I see practiced by those who staff the ED department here.”
"The most unique training experience was having the opportunity to work with so many HIV-positive patients," she adds. "As a medical student there is no more memorable way to learn about a disease than working with a patient who can tell you first-hand about their condition and how it affects them on a day-to-day basis.”
When their day ends in the ED, the students in Bullock’s program keep up the conversation through an online discussion board that includes Georgetown as well as international medical students, family medicine residents, and Georgetown School of Medicine faculty. This exchange has been running for four years, and in August, it featured discussions about the high cost of drugs in the U.S. and abroad; the fact that synthetic opioids are used a lot in American EDs, but are not allowed in the U.K.; a frank discussion about whether every adult patient should be asked about their sexual history; and if the elderly should be probed about possible recreational drug use and abuse. Students can continue to post on the private board long after they have left Bullock’s program — Bailey and Haddadin were avid posters during their time in ED, and now overseas again, they still are.
“As an educator, this is an exciting time to offer a program like this,” says Bullock. “The world is changing, and we all need to evolve as we practice health care in this global village. This program moves us a little forward in that direction.”
By Renee Twombly, GUMC Communications