What Global Health Taught Me About American Primary Care

Colleagues who hear that I trained in tropical medicine assume the lesson I brought home was how to practice in scarcity. How to make a diagnosis with a stethoscope when there is no MRI. How to improvise.

That is not the lesson. The lesson was the opposite. Working where resources were scarce taught me to recognize the failure of abundance.

Abroad, when a treatment plan failed, the bottleneck was usually material. The drug was not on the shelf. The lab could not run the assay. The failure was visible, and everyone could name it. When I came back to an American exam room, the shock was not how much technology we have. It was how often we mistake ordering care for delivering it.

Issues 008 through 010 of this publication described what the Liverpool diploma teaches and where the conditions it trains for actually are. This essay runs the other direction. It is about what I carry back into an exam room in Nebraska, and what I learned there that I did not expect.

The Friction Budget

The first thing I do differently happens before I touch the order set. My first question is not clinical. It is logistical: what happens to your job, or your childcare, if I ask you to come back Tuesday morning fasting?

American training treats a patient's trips to the clinic, the lab and the imaging center as free and unlimited. They are neither. Global work teaches you to treat every return visit as a scarce reagent, one that may be out of stock next week. I have started to think of this as a friction budget. Every patient has one, and every plan spends it.

So when follow-up is fragile, I bundle. A patient who lost half a day of hourly wages, or caught two rides to sit in my exam room, does not get a workup staged across four visits. I draw the labs today. A non-fasting panel in the tube today beats a fasting panel ordered for next week that never happens. If a procedure can be done in the room, I do it in the room. And I build the contingency into the visit: start this today, and if it is not better by Friday, the second prescription is already at the pharmacy. Call the nurse line. Do not pay for a second visit to be told what we could have agreed on now.

The medication history changes too. I do not read the list in the electronic record and ask whether the patient is taking the lisinopril. I ask which of these they are stretching, splitting or sharing, and what they have already tried from home or from a family member. That question catches the half-dosed insulin and the antibiotic or steroid brought from abroad before I misread what is in front of me.

And I test differently, in both directions. If the history and examination have already carried me past my treatment threshold, I skip the confirmation cascade: the viral respiratory panel, the imaging for uncomplicated mechanical back pain, the staged referral before a real empiric trial. A test that cannot change what I do is a cost with no return. At the same time, my threshold for the conditions American algorithms forget is much lower. Latent tuberculosis, H. pylori, occupational exposures. I listen for the epidemiologic history first, because abroad that history was most of the diagnosis.

The Failure of Abundance

Our guidelines are written for an imaginary patient. That patient has unlimited paid leave, a reliable car, health literacy in English and, functionally, a personal secretary.

We take a working patient and hand them a seven-step plan that is fully guideline-concordant: three specialist referrals, two prior authorizations, a fasting lab and a portal message. Then, when they drop a step, we chart "non-compliant." We have assigned a project-management workload that most of us could not execute ourselves, and we record the predictable result as a defect in the patient.

Carl May, Victor Montori and Frances Mair named this in the BMJ in 2009, in their argument for minimally disruptive medicine. Treatment imposes work, and that work competes with everything else a person's life already demands. When the work exceeds the person's capacity, the plan fails, whatever its evidence base.

Global practice made that argument concrete for me. I now try to weigh what I privately call the number needed to burden alongside the number needed to treat. Regimen complexity is not a neutral backdrop to good medicine. It is an iatrogenic harm. Often the highest-level clinical move in an American exam room is not adding the newest evidence-based agent. It is subtracting steps until the plan fits inside a human life.

One Afternoon

What follows is a composite. It is built from patterns across many clinic days and does not describe any single patient.

A middle-aged man who works at a meatpacking plant comes in late on a Friday afternoon. He has had weeks of worsening epigastric pain, early satiety, and he has lost twelve pounds. He came in only because his supervisor threatened to send him home. Missing another weekday shift means losing attendance points he cannot afford to lose.

The textbook reflex is a proton pump inhibitor, a fasting panel on Monday, an outpatient gastroenterology referral for endoscopy four weeks out, and a two-week follow-up.

The global instinct reads that plan as four separate weekday visits. If I fragment his care that way, I will not see him again until he arrives in the emergency department with an upper gastrointestinal bleed or a gastric outlet obstruction.

So we treat the Friday room like a district hospital intake. The full blood work and the H. pylori testing are drawn before he leaves the building. Care coordination comes into the room and fits the endoscopy around his shift schedule rather than ours. We ask what he has already been taking for the pain and where he bought it. He leaves with a single page, in Spanish, that tells him what happens next and when.

The single visit finds the bleeding ulcer and a severe iron-deficiency anemia. We found them because we assumed we had one chance.

What Did Not Transfer

Two habits failed when I brought them home.

The first was expecting patients with untreated disease to be new to care. In many global settings, a patient who reaches you late in a disease course has not yet been touched by a health system. Make the right diagnosis, start first-line therapy, and the response is often dramatic, and so is the trust. American patients in underserved settings rarely arrive new to care. They arrive exhausted by it. They carry fragmented medications from three unconnected urgent cares, debt from workups that never explained their symptoms, and a skepticism they earned. Early on, I brought field-hospital efficiency into the room: move fast, skip the low-yield tests, go straight to treatment. Sometimes it backfired. Without first hearing what the system had already done to them, my efficiency read as being brushed off.

The second was believing that clinical resourcefulness could beat bureaucratic gravity. Abroad, a cheap and pragmatic solution that fixes the patient's problem is simply a good outcome. Here, clinical common sense runs into prior authorizations, formularies and quality-metric checkboxes. Knowing the four-dollar generic does not spare me twenty minutes arguing with an insurance algorithm that requires a six-hundred-dollar prerequisite step nobody needs.

Two Settings, Two Lessons

The global lesson does not land the same way everywhere, and assuming it does is a trap.

At an urban community health center, the dominant pressure on patients is often economic and logistical: hourly shift work, language barriers, being uninsured or underinsured, and fear of a surprise bill. When I compress a workup into one visit, skip the low-yield expensive test and protect the work schedule, patients read it at once as advocacy. They can see that I am protecting their paycheck and their family.

In a tribal health system, the frame is different, and it has to be. Health care there is not charity and it is not a safety net. It is a treaty obligation, in a community with generations of memory: of federal underfunding, and of outside clinicians who rotated through and cut corners. A clinician who walks in with a resource-rationing mindset and skips a test without a careful explanation will be heard, rightly, as offering second-class care. The question in the room is fair: why are you not ordering the scan they would order in Omaha?

There, the global lesson that transfers is not rationing. It is humility. It is listening to the extended family before speaking. And it is making unmistakable the difference between "you do not need this test" and "we will not spend the money on you."

The same instinct that reads as advocacy in one room can read as neglect in another. What carries over from global work is not a set of shortcuts. It is the habit of asking what a plan costs the person who has to carry it out, and of taking the answer seriously enough to change the plan.

About the author

Peter Schindler, MD, PhD is an Assistant Professor of Medicine and Associate Program Director of the Community Health Center Family Medicine Residency Program at the University of Nebraska Medical Center. He practices at Winnebago Comprehensive Health System, OneWorld Community Health Center, and Nebraska Medicine. He completed a Primary Care Research Fellowship at McGill University and holds a BSN from the University of Wisconsin-Oshkosh, an MS and PhD in nursing from Emory University's Laney Graduate School, a Diploma in Tropical Medicine from the Liverpool School of Tropical Medicine, and an MD from the Medical College of Wisconsin-Green Bay. He is board certified by the American Board of Family Medicine. The Interprofessional publishes new essays every week at the intersection of medicine, nursing, and the clinical knowledge that lives between them.

Disclaimer. The views in The Interprofessional are Peter Schindler's own and do not represent the official positions of the University of Nebraska Medical Center, Winnebago Comprehensive Health System, OneWorld Community Health Center, Nebraska Medicine, or any other affiliated institution.