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Cross-cultural Exchange Hopes to Improve Healthcare Quality and Equity


Physicians must complete continuing education to keep their licenses and stay current with the latest medical practices. But what if they had the chance to take time away from their clinical duties to focus on intensive training to enhance healthcare quality?

The Scottish Quality and Safety Fellowship (SQSF) looks to “strengthen clinical leadership and improvement capability” of National Health Services Scotland healthcare professionals. It attracts fellows from nine different countries and is open to clinical practitioners who directly influence patient care, as well as professionals in medical, nursing, pharmacy, AHP, healthcare science, and ambulance fields who contribute to improving patient care and safety. Scholars participate in remote learning trips as part of the fellowship program. Fellows are encouraged to contribute their new knowledge to their government’s national and local healthcare agencies.

Dr. Meryam Sugulle and Dr. Leona Carroll, both SQSF fellows, visited the Johns Hopkins Center for Health Equity (CHE) in early May 2023. Dr. Sugulle is a consultant obstetrician and clinical lead at Oslo University Hospital Ullevål in Norway and a temporary associate professor at the University of Oslo. Dr. Carroll is a general practitioner and primary care lead for Mental Health and Older People’s Services at the Midlothian Health and Social Care Partnership, NHS Lothian, Scotland, UK.

During the May CHE Jam Session, Carroll and Sugulle gave presentations on Scotland and Norway’s healthcare systems and outcomes. Carroll highlighted that Scotland’s health system is vulnerable due to budget cuts resulting from the UK’s austerity measures. Meanwhile, Sugulle shared that in Norway, patients’ education levels appeared to affect the quality of healthcare received and any disparities that may arise from race or ethnicity.

The duo spent a week meeting with various faculty members from different campuses of Johns Hopkins University. However, their main goal was to exchange ideas and knowledge about healthcare across diverse cultures.

Carroll’s main goal for her visit to Johns Hopkins was solidifying the concepts she learned during her fellowship program. She hoped to gain knowledge from top experts, specifically about the benefits of human factors, which, she said, was of increasing interest in the Scottish healthcare system. Meeting with Ayse Gurses, the director of the Armstrong Institute Center for Health Care Human Factors, was a highlight for Carroll as Gurses emphasized the significance of human factors at Johns Hopkins Medicine. Carroll intends to apply what she learned and promote the importance of human factors in her workplace.

Sugulle’s goal was also to apply the knowledge she gained during her fellowship to the healthcare systems at home. She was particularly interested in the Center for Health Equity’s research into healthcare disparities and methods to develop meaningful, evidence-based solutions.

Sugulle acknowledges that Norway’s policymakers, researchers, and practitioners were aware of inequity and working to combat it but feels that a comprehensive approach was lacking. While policies and strategies exist to reduce inequity, they are scattered and must be consolidated. Sugulle recognizes the importance of addressing structural issues in addition to the individual needs of those in her daily practice – which was why taking time out for the fellowship was so important.

Carroll observed that American clinicians and staff prioritize a patient-centered approach, emphasizing the importance of understanding what matters to the patient and their goals.

“While our countries face common challenges, such as social determinants of health, healthcare providers can only do so much to address these issues,” Carroll said. “Despite the best access to healthcare and clinicians, outcomes may not improve due to external factors beyond our control. It can be challenging to convey this message at a political and policy level.”

Sugulle noted that while significant differences exist between the US and Norway, community engagement is essential and is still similar for both health systems.

“An example of community engagement in Norway is the community’s involvement in postnatal care, which could improve with increased engagement. However, this would require integration and coordination with hospital services,” she said.

Carroll remarked, “As a General Practitioner (GP), during this trip, I was surprised by some aspects of the American healthcare system. I did not realize that people may have to travel long distances to find a GP, as this is not how it works in the UK.”

In the UK, Carroll explained, the government handles ensuring everyone has reasonable access to a GP.

“Even when a practice is at full capacity, it cannot completely close, and the health board will step in to ensure people have access to healthcare. It is not ideal but differs from long waiting lists or extensive distances. I am grateful to work as a GP in the UK, where we do much more in the community,” Carroll said.

Carroll also noted that in her country, “Specialist clinics do not have incentives to increase their lists, and we do not want people to receive care in the wrong place. We want everyone to receive proper care, and there is a lack of incentive for them to go to secondary care rather than return to us.”

For Sugulle, it was the realization that systemic racism was still affecting modern healthcare delivery that she found shocking.

“During my tour, I had an epiphany moment where I realized that political determinants significantly affect social determinants. It surprised me that the political determinants in the US have had such a long-reaching impact in the past. This differs from my experiences growing up in Germany and living in Norway,” Sugulle said. “Yes, it took 120 years to develop the national insurance system as it functions now, but it wasn’t influenced by the 400 years that came before it.”

Carroll found commonality in these historical precedents.

“The historical disparities that have persisted in the United States since its creation, particularly regarding class hierarchy and control--these disparities have led to the suppression and oppression of marginalized groups, including formerly enslaved people,” Carroll said. “While this may seem astonishing, it has had lasting consequences that still affect society today. As someone from Scotland, similar issues exist in my country, particularly in post-industrial cities like Glasgow. Even with attempts to create new housing, these areas often lack access to green spaces, food, and safety, leading to adverse outcomes for impoverished people.”

However, both physicians believe that gathering more data will better inform which efforts will significantly decrease health disparities among marginalized populations.

Sugulle suggested that in Norway, the focus should be on data collection to identify the areas that need attention. Carroll agreed and said action must occur on two fronts.

“Using the data, we must address extreme economic deprivation and engage in inter-policy discussions that involve all sectors, including health, economics, business, housing, and the environment,” Carroll said. “While we know some things about the challenges faced by black and minority ethnic groups, there is still much we do not know, and we need to gather more data to understand the obstacles these groups face in accessing healthcare.”

Both women were thankful and delighted by their visit to the Center for Health Equity and remarked that their experience exceeded their expectations. They said they felt overwhelmed by the warm welcome and the time people took to interact with them, making the experience phenomenal.

“We had the opportunity to learn so much from people who shared their thoughts, concerns, and reflections rather than just presenting their projects,” Sugulle said.

Carroll agreed and lauded the bi-directional learning format of the program, where both sides could inquire about each other’s work and perspectives.

Author bio

Mary A. Spiro, MS, is a Communications Associate at Johns Hopkins School of Medicine who provides communications support to the Center for Health Equity, Urban Health Institute, and Dr. Lisa Cooper, MD, MPH.