I definitely learned an enormous amount about the process of applying for IRB approval in addition to the skill set required for qualitative analysis of interviews. Shadowing in the clinic gave me a much broader understanding of the challenges and barriers to effective care in the Guatemala City setting. It was both heartening and shattering to see patients confront their lives as HIV positive individuals in a country with a less than accepting view of those with positive diagnoses.
I think that I used the clinicians and staff at the clinic as role models for dealing with obviously hopeless odds. The clinic was very well run and there was a distinct sense of teamwork among the physicians and other staff working there, which is something I think is incredibly necessary when dealing with a devastating disease. I was incredibly impressed with the leadership and the application of clinical care. I definitely think I left Guatemala with a much more nuanced understanding of these challenges and the mindset necessary to confront a harsh reality day in and day out.
As a future physician, one of my goals is to combine my clinical experience with my background in public health to improve the quality of care provided to underserved communities. Thus, in addition to the clinical experience, working at El Centro exposed and helped me gain a better perspective on the challenges these communities face in accessing and receiving appropriate care. The clinic was overstretched, poorly funded, and desperately in need of new equipment - supplies as common or in excess in the U.S. as latex gloves, were scarce in the clinic. Despite these significant limitations, it was impressive to see how the clinic was able to provide care and impact people's lives. El Centro reminded me of why I decided to go into medicine and further confirmed my desire to continue to work with underserved communities.
Every walk to work I noticed something new, the city's features, often mundane to its residents, were curiosities to me. Being immersed in someone else's culture allows you to compare and contrast it to yourself. It makes the world feel bigger and more complex. Mixed feelings of sympathy, guilt and pride are hard to explain. The more I am exposed to cultural and social extremes, the more passion I find to pursue and practice medicine, a field that will allow me to (selfishly) feel my endeavors are not merely selfish. I do feel a little spoiled and pretentious saying by traveling to a developing nation I am able to see what I take for granted, but it's undeniably true. As an American medical student, the experience of traveling to India, has begun to break down barriers of communication that may exist from failing to understand the lives of others (motives, values, morals) are invariably different. To consider how human experience can vary greatly due to such trivial things, yet I have the opportunity to be a physician in one of the wealthiest countries in the world, presents me with the challenge to do something meaningful.
My global health experience was a public health and community medicine program based out of New Delhi, India. It essentially showed us different aspects of public health within the country and the problems that different organizations and government programs try to address. The program gave me and the other 5 participants a very raw and first-hand exposure to the "front lines" of public health, touring us around New Delhi to the field sites of the different programs, which were often run-down slums. We would interact with the government/organization workers as well as the people these programs served. At times it was very intense to see and hear the problems that the masses face in a place as overpopulated as India. And as is always the case, the most affected by this lack of adequate public services are the poor, the sick, and the uneducated. The branches of public health that we learned about was disease prevention (chiefly HIV and Tuberculosis), sanitation and toilet scarcities, public hospitals, mother and child health and development in rural areas, homelessness and its relation to immigration, adolescent health, women's health, family planning, marginalization of the lower castes, among other things. The program gave us a good idea of the diversity of problems that can exist within the realm of public health and how hard it can be to tackle them when resources are very limited. It goes without saying then, that the government programs that we saw had a very difficult battle ahead of them. Many of them were working out of abandoned buildings, some without electricity for over a year, using the extremely basic tools and equipment available to them. It was truly inspiring, however, to see the conviction and dedication with that these people were putting into their work given how difficult it is.
The program certainly reminded me and solidified the fact that I want to work abroad and with underserved populations in the future. It also brought to my attention the absolute dedication that this kind of work requires, because it is by no stretch of the imagination easy and it certainly does not pay well. It was good to recognize this and see that I still feel up to the challenge that it poses. India was an extremely different and rewarding adventure for me which has kept me motivated to become the most competent physician I can be.
My flight from JFK to El Salvador went without a hitch. But when I deplaned for my connecting flight to Cusco, Peru, I had a mini ‘panic attack.' I questioned why I even decided to do this in the first place. Why you ask? Because everyone around me was ONLY speaking Spanish! I had taken Spanish before but I was NOT comfortable with the language. My Spanish was nowhere near conversational and I was afraid I wouldn't be able to find my connecting flight. I grew up surrounded by people that speak English so it was quite a shock when I couldn't understand what anyone was saying. There were people all around me yet I felt alone. When I worked at Bellevue, we would get many patients that couldn't speak English. It never dawned on me how scary it is when people can't understand you, especially when you are sick and in need of help. This experience definitely alerted me to how some patients must feel and I'll have to keep this in mind for future patient encounters. I'll have to be more welcoming and patient so they will feel more at ease.
The most important thing that I learned from this trip was to be open to new things. I am really happy that I was able to give myself fully to Peru and its culture and people. It's so easy to be absorbed in your life and never think about how other people live. By being open and trying new things, I was able to appreciate that people's lives are different. I think this speaks to what we were taught in ICM about cultural competence. It is impossible to learn and live among all the cultures of the world. But if you are open to other's people lives and lifestyles then you can at least understand a little bit of what people are going through. And through this understanding, you can create a treatment plan that doesn't ignore their culture but incorporates it.
When I first arrived at the clinic in a nearby town I was not expecting the healthcare system to be up to the standards of the United States, but after just a few minutes in the clinic I knew things would be totally different. It was really eye-opening to see such large numbers of patients waiting to see the physicians, despite the fact that the physicians would only be able to spend a short time with the patients and only had limited supplies in the clinic. In fact, the physicians were given lists of medicines that would be available in the clinic for the week, and once supplies were exhausted, the patients would no longer be able to get the medicines they needed. The issue was not that local pharmacies did not have the medicines, the problem was that many of the clinic's patients were so poor that they could never afford to purchase medicines, and they lied solely upon the free treatments and medicines that could be provided by the government-run free clinic.
The idea of preventative medicine seems to be being pushed by the medical community, but it is clear to see how resistant many patients are to adopting simple yet powerful everyday tools. Basic things that currently need to be stressed are the importance of proper nutrition and hygiene, and the importance of performing simple tasks like showering with clean water often, brushing teeth, cutting dirty nails, and making sure that small cuts and scrapes are adequately sterilized to prevent recurring infections. Healthcare education is certainly something that is not highly stressed in schools, and especially in some of the poorest and secluded areas populated by mostly indigenous people, acceptable healthcare precautions and treatments are heavily dominated by home remedies that oftentimes may lead to further problems.
One of the most unique aspects of my trip was volunteering at Centro de Salud. Volunteering at Centro de Salud gave me a special insight into the everyday doctor's visit in a developing country. The clinic caters to one of the poorest populations in the country- those who have a government insurance known as CIS. I thought it would be very interesting to compare my experience here to ECHO Clinic. At the Centro de Salud, I rotated throughout different parts of the clinic, which included the laboratory, general medicine, and obstetrics/ gynecology. It was obvious from the outset that the equipment and supplies in the clinic were very limited. Oftentimes, lab tests were performed without the use of gloves. Doctors would rarely wear gloves while examining patients. In the lab, each lab specimen was processed individually under a microscope, rather than through a machine. The level of cleanliness at the clinic was far inferior to what one would find in the poorest communities here. Despite these shortcomings however, it was evident that the clinic provided a valuable resource to the community. While the quality of procedures was certainly substandard, many of these patients would have gone untreated without this clinic as a resource. This made me more aware of the great disparity in services available to the poor in a developing nation and certainly made me more appreciative of the services we have available here.
I was also able to appreciate the patient-doctor level as well. In shadowing different physicians, I was able to see how each established his/ her repoire with patients. Despite the language barrier, I felt that I was able to observe differences in how each communicated. As a future physician, this made me think about how I will interact with patients.
One of the main lessons I gained from my experience in South Africa was an appreciation for the many challenges that exist with conducting research in a developing country. Although these challenges were quite troublesome at times, dealing with them was a very eye-opening experience. Being in uncomfortable and sometimes even dangerous environments allowed me to better value the comforts I have back in the US. Realizing that these conditions are a reality for millions of people was difficult to accept, but also enhanced my motivation to put as much effort as possible into my work in the hopes that it could one day contribute to the betterment of these people's lives.
My time in South Africa has impacted me as a future physician in ways I probably cannot even begin to recognize. Through my experiences in the hospitals and clinics, I was able to catch a glimpse of how medicine is practiced in a foreign country with limited resources trying to combat a growing epidemic. The burden of the disease is greater than I understood before I arrived, and I was honestly a bit shocked by some of the things I witnessed. For example, I met an 18-year old male with tuberculosis and HIV who, upon first glance, appeared no older than 12. His body was emaciated and he had to breathe pure oxygen because his lung capacity was so diminished. Putting a face to the disease really shifted my views on the potential impact of my work, and I do hope to one day return to South Africa when I am further in my training and can make a larger impact on the people I went there hoping to assist.
We were driven from Manali to Udaipur, a locale past the first range of the Himalayas where we resided at a campsite for the duration of the clinics. Each day we went to a nearby village where we set up a medical clinic to provide checkups to the local population. Over the course of 10 clinic days we were able to see over 1100 patients in various villages. The clinical experience involved serving at stations that included medicine, triage, pharmacy, OB, dentistry, and pediatrics. Medical students interviewed the patients with the help of an interpreter and presented it to the senior member at each of the stations. We were given a day off to explore the surrounding terrain at our leisure.
This trip gave me an amazing opportunity to learn about healthcare issues in remote areas of India. At the same time, it exposed me to a different culture and was definitely an experience that I will remember. The most profound effect it has had on me was probably the sheer feeling of actually being there in the Himalayan range and seeing people go about their lives there. I think that the setting provided a sensational backdrop to the clinical experience and put the whole thing in perspective.
I had difficult days at the clinic – patients would come in who were victims of discrimination, abuse, and malpractice or poor care. It was hard to see patients who were suffering – especially when the suffering could have been avoided. But I was also deeply affected and impressed by the positive environment fostered by the staff of the clinic. The people there taught me to care for patients, but also to maintain personal balance. That's certainly a lesson I want to take with me when I practice as a physician. And who knows? I found infectious diseases to be incredibly interesting. My time at CFLAG may have pushed me in that direction as well.
Most of my days were spent in the Emergency Department at Sundaram Medical Foundation (SMF). SMF's ED is a 14-bed private ED located in Anna Nagar, Chennai that sees 18,000 to 20,000 patients a year. Diabetes, tuberculosis, and malaria were surprisingly common within the patient population. It was interesting to learn and observe how healthcare works in India. The cost of treatment is significantly cheaper than the USA. For example, the price of an ED consultation is just 200 rupees ($3.30). However, only the wealthy can afford real medical insurance and thus most people pay out-of-pocket to the billing desk located in the center of the ED. Additionally, access to different medical treatments is much more limited. All of the staff was all extremely friendly and helpful. They treated me as part of the team. I was able to participate in rounds with the attendings, discuss treatment options, and observe different interventions, while weighing the pros and cons of each.
My research focused on different standardized triage systems. My fellow classmate and I worked with an EM resident on carrying out the project. The goals of the study were to validate and compare the Emergency Severity Index (ESI), a more subjective triage protocol, with the Modified Early Warning Score (MEWS), a completely objective triage protocol. Additionally, we set out to find a way to blend the two scoring systems – taking the best from each. Its ultimate purpose is to provide inexperienced triage nurses with a tool that would properly triage patients to the ED. We collected relevant data on roughly 1000 patients that presented to the ED over a 30 day period and are still in the process of working with a biostatistician to analyze the data.
Is there anything that I would change about this experience? No. I can honestly say that there is nothing I would want different. The good, as well as the bad were all necessary for me to have this formative experience that I will never forget.
My work mostly entailed doing pap smears in order to track and prevent women from developing cervical cancer and provide treatment for those women affected by this disease. The goal of the clinic is to provide these services to the underserved, so the majority of the patients that I saw came from very poor economic backgrounds and lived in the outskirts of the touristy city, Cusco. On a typical work day, I would get up as early as 5 in the morning and pile up into a van with a few other 2nd year medical students to drive out to various campaigns. After a two hour drive through the mountains, we would come to some of the poorest, basic villages surrounding Cusco and start to set up for the day: the set-up varied depending on the resources available on location, but many times, we would work without some of the most basic commodities that physician are accustomed to in the U.S. Depending on the volume of patients on the day of the campaign, I would end up doing anywhere between 10 and 50 pap smears per campaign. The constant patient interaction and my ability to speak Spanish served as a great instrument for acquiring new bedside manner skills and in general becoming a lot more comfortable around patients. My experience during campaigns will also certainly help to ease my transition into third year, next year, when such hours will be typical. However, more importantly, my experience working in such poor resource settings and yet seeing so many patients so grateful for the free pap smear tests helped me to re-evaluate my desire to practice internationally. This summer, I learned that while practicing medicine internationally would be quite more of a struggle than I had imagined, I would also be equally rewarding. My experience working in the clinic has encouraged me to consider taking a year off after my third year rotations, in order to further explore global health in an international clinical setting.