The small plane circled over the dirt airstrip once to encourage the children playing soccer and livestock to move off of the unpaved runway. The turboprop touched down on the rough gravel and dirt moments later, taxiing next to the cinderblock terminal. After disembarking from the plane and retrieving our luggage, we carried our bags to the dump truck that would be our ride to the Haitian mission compound, located seven miles of winding roads almost an hour away. This was my introduction to medicine in the developing world in 2005 during my fifth year of medical school in the six-year program at the University of Missouri-Kansas City.
There is growing interest in medical relief work among trainees at all levels within medicine, from medical students to residents and fellows. Since my initial trip, I have returned to Haiti four times to serve the eye care needs of the local population. Few experiences in my life have had a more enduring impact on my perspective than those trips. Expanding involvement to the youngest members of our profession in medical missions is not only possible, but desirable.
Northwest Haiti Christian Mission in St. Louis du Nord, Haiti. Patients queue up to see the team of physicians and other health care professionals from the USA.
We’re Not in Kansas Anymore
A number of benefits await students who venture into the developing world. Beyond exposure to a different social culture, experiencing a different medical culture and system of organization can be particularly eye opening and instructive. Indigenous physicians are frequently quite adept at dealing with scarcity; their resourcefulness contrasts starkly with the often inflexible demands of U.S. health practitioners. From re-purposing available instruments in the operating room to organizing staffing to provide more efficient care, there is much that can be gleaned from working alongside local providers. Native physicians will also have cultural insights that can be valuable to outside providers.
There are a number of crucial differences between practicing in the U.S. and practice in the developing world that must be considered. Medicine in the developing world is the ultimate test of clinical skills. Laboratory and imaging services are often limited or nonexistent, leaving the clinician with only their knowledge and experience to guide treatment decisions. This can be an anxiety-provoking experience, particularly for young physicians. Having advance knowledge of the resources available (if any) can be helpful in alleviating this concern for physicians in training. The flexibility needed to successfully provide medical care in the developing world is considerable, given the confluence of high demand, limited resources, and an unfamiliar environment and culture for providers.
It is also prudent to be aware of endemic conditions that are commonly seen in the developing world but are not often found in the U.S., such as malaria and trachoma. Gaining familiarity with the conditions that are likely to be seen in a given area can be a valuable preparatory exercise. While “tropical diseases” tend to get a lot of attention, in reality many of the conditions seen will tend to be the same diagnoses that are managed in the US presenting at a more advanced level of severity than is typical for the developed world.
Perhaps one of the most important (and often painful) lessons to be learned through medical missions is when not to intervene. On a recent trip, a young boy was brought to our clinic by his parents with an advanced retinoblastoma. Proptosis and obvious extraocular extension indicated near certainty that the child already had intracranial metastasis. The child was so dehydrated that even placing an IV was impossible at the time of his initial examination. While he was being fluid resuscitated, the team discussed possible options for this difficult situation. One possible choice was surgery to debulk the tumor and decrease the child’s discomfort, though his anesthesia risk was felt to be very high with essentially no chance of cure. It was also suggested that an attempt be made to send the child to the U.S. for chemotherapy or radiation. Ultimately this would require also sending a parent with the child, leaving the other parent to care for the family’s other four children alone for an indeterminate period of time. In the end, the team and family decided to forgo surgery or care in the U.S., and we gave them pain medication to help keep the child comfortable for his few remaining weeks.
The author (WAW) performing vision screening as a UMKC medical student in Northern Haiti in 2005. Expanding involvement to the youngest members of our profession in medical missions is not only possible, but desirable.
Some Basic Guidelines
Adherence to a few principles can save a considerable amount of time and trouble for trainees and instructors alike. The temptation to practice beyond your capability can be strong at times, but it is critical to remember the Hippocratic tenet to “first do no harm.” Poor outcomes weaken the trust of the local population in the ability of the medical team and can ultimately undermine the long term objectives of any mission enterprise. If you wouldn’t perform a particular procedure in the U.S., you probably shouldn’t outside the U.S.
Trainees should be given responsibilities similar to their level of practice in the U.S. Medical students can be tasked with performing history and physical exams, assisting with procedures, and accomplishing administrative and liaison tasks. Residents may perform some procedures within their area of training skill level with supervision comparable to what they would receive in the U.S.
Adequate supervision should be ensured. Residents and fellows may be able to work more independently, but assistance should be readily available in the event that unanticipated issues are encountered. This is equally necessary in clinic, ward and operating room settings.
Skills transfer can be a valuable component of any mission team, particularly for trainees. Ideally, the instructors should be experienced teachers who are well versed in the tasks to be learned and able to anticipate complications. Provisions for education, such as optical teaching attachments for microscopes and monitors for endoscopes, should be available. Often it is possible to use one operating room specifically for teaching, while the others are used by experienced surgeons. This removes much of the time pressure from the trainee, allowing them to focus their efforts on learning a new technique rather than the volume of patients that remain to be cared for.
Skills transfer can be a valuable component of any mission team, particularly for trainees. Often it is possible to use one operating room specifically for teaching, while the others are used by experienced surgeons. The author (WLW) teaching eyelid surgery in the operating room.
On one recent trip, Matthew Recko, MD, then the pediatric ophthalmology fellow at Children’s Mercy Hospital in Kansas City, was a member of the team. One of our oculoplastics specialists taught Dr. Recko how to perform enucleation procedures using a dermis fat graft technique. This technique is quite useful both in the developed and developing world, as it obviates the need for an expensive orbital implant and achieves a cosmetically superior result in children with a comparable safety profile. He accomplished several of these procedures on the trip, and was able to perform the technique without assistance by the time we had returned home.
Closing Thoughts
Teaching medical students, residents and fellows is a challenge regardless of the setting, and the developing world presents additional obstacles. In spite of this, it can be an immensely rewarding experience for trainees and educators alike. Planning and preparation, combined with adequate supervision, can ensure a beneficial experience for patients and learners alike. The insights gathered during these experiences last for a lifetime, engendering both compassion and perspective.
Biography
W. Abraham White, MD, (left) practices comprehensive ophthalmology in Kansas City. William L. White, MD, (right), MSMA member since 1995, practices oculoplastic surgery in Kansas City.
Contact: docabe@gmail.com
