Friday, July 4, 2014

Global Health Credentialing

Yale medical diploma awarded Asaph Leavitt Bissell, Class of 1815

There is a trend in the global health literature calling for an authority to credential those who undertake medical humanitarian missions in low-income countries (LICs). The argument is that there is no oversight as to the medical or cultural competencies of these providers, and that harm ensues from well-intentioned but incompetent individuals.

Of course, patients in LICs deserve the same standard of care as those in high-income countries (HICs), accepting the different infrastructure, equipment, drugs etc. However, I feel that there are several arguments against a global credentialing hegemony.

In the US, licensed physicians can legally perform any medical procedure no matter their training. Hospitals require credentialing, but a physician can set up a private clinic and practice plastic surgery despite having trained as an ENT doctor. How can we insist on higher standards for those giving their time and skills to help those overseas?

Although there are anecdotes of incompetent visiting practitioners practicing sub-standard medicine in LICs, these incidents are rare. Conversely, incidents of malpractice are relatively common in the US despite our rigorous licensure process. More harm is perpetrated by well-funded, well-publicized organizations without a coherent perspective on global healthinternational development, or ethics

Medical volunteers are usually self-financed, and take time away from families and jobs. To add bureaucratic requirements for further training, examinations and paperwork would add further financial burden to volunteers and/or their organizations, and undoubtedly dissuade many from engaging.

In these financially strained times, charitable donations are increasingly limited. Endowing an overarching organization with standards-setting power is inviting manipulation of the global health agenda to one party’s financial advantage or philosophy. Patients gain much from a diversity of groups offering a broad range of services and philosophies.

How could such a credentialing institution actually prevent an individual or organization from travelling and treating patients? It is paternalistic to imagine that HICs need to protect the citizens of LICs. The governments of LICs are best placed to institute appropriate restrictions on an organization or individual’s scope of practice. For example, The Republic of Ghana requires visiting medical practitioners to obtain a Ghana medical license before they can participate in medical care - a perfectly reasonable and achievable standard, set by the nation and citizens concerned.

I believe a more reasonable alternative to a credentialing agency is an extension of the system currently practiced by many of the more successful humanitarian groups. Such organizations use an in-house credentialing process that mirrors that of an American medical institution. This prevents those few cases of ‘cowboy’ surgeons, and protects the organization from accusations of malpractice. I would suggest that these organizations could share credentialing information. If they agree to a credentialing standard, then once a practitioner is credentialed with, for example IVUMed they could work with ReSurge without further paperwork. Such a cross-credentialing service would encourage new volunteers to enter into this work with a well-established, philosophically coherent endeavor, and not the inexperienced groups that generate such bad press.