Making the Most of Medical Missions KAAP Conference Deborah A. Kroeker, MD September 28, 2012

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1 Slide 1 Making the Most of Medical Missions KAAP Conference Deborah A. Kroeker, MD September 28, 2012 Slide 2 Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Slide 3 Objectives Describe possible effects, both positive and negative, of shortterm medical mission work Describe the impact international rotations can have on medical students and residents Discuss guiding principles for effective short-term medical mission trips

2 Slide 4 Outline I. Making a case for Medical Missions The Need for Medical Missions Benefits of Short-term Medical Missions professionally Benefits of Short-term Medical Missions on learners II. Pitfalls in Short-term Medical Missions III. Guiding Principles for Medical Missions Slide 5 Definition definition of global health: The study and practice of improving health and health equity for all people worldwide through international and interdisciplinary collaboration. Battat, R., et al. Global health competencies and approaches in medical education: a literature review. BMC Medical Education (1): Slide 6 The Need 2 Nearly 9 million children die annually before reaching 5 years old In Sub-Saharan Africa in 2008, 1 in 7 children died before age 5 Common causes of death include pneumonia, diarrhea, malaria and AIDS MDG goal: Reduce child mortality by 2/3

3 Slide 7 Number of under-five deaths in 2010 (thousands) 7 Sub-Saharan Africa (3709) Southern Asia (2,526) SE Asia (349) Eastern Asia (331) Latin America and the Caribbean (249) Western Asia (165) Developed Regions (99) Northern Africa (95) Caucasus and Central Asia (78) Oceania Slide 8 The Americas 14% of the world s population 10% of the global burden of disease 42% of the world s health workers >50% of global health expenditure Sub-Saharan Africa 11% of the world s population 25% of the global burden of disease 3% of the world s health workers <1% of global health expenditure THE HEALTH WORKFORCE IN THE AMERICAS VERSUS SUB-SAHARAN AFRICA Source: WHO, 2006 Slide 9 Benefits of Short-term Medical Missions 8 Service to the non-medical nationals Medical care work towards a more equal distribution of healthcare Basic medical education Promotion of public health Feeling of being recognized by outsiders 13

4 Slide 10 Benefits of Short-term Medical Missions 8 Service to medical workers in the country Provide medical education to people who have limited access to CME Teach new skills Provide needed supplies, medication and equipment (even ambulance supplies!) Provide a break for long-term healthcare providers Partner on research projects Slide 11 Benefits of Short-term Medical Missions 8 Growth professionally New skills Cultural sensitivity Communication skills History and physical exam skills Gain insights into the complex interactions between the government, local hospitals and community health centers and how the economic, cultural and political environment influences healthcare Slide 12 Benefits of Short-term Medical Missions 8 Personal growth New cultures and new experiences Expanded worldview Deeper interpersonal understanding Renewal of enthusiasm for medicine

5 Slide 13 Benefits of Short-Term Medical Missions on Learners 81% of IM residents at Duke said their international rotation exceeded expectations and had the most significant positive impact on their medical training 6 Slide 14 Benefits of Short-Term Medical Missions on Learners Exposure to diseases not endemic to the US 6 Exposure to advanced stages of diseases 6 Indications of increased knowledge and training in tropical diseases 1 Slide 15 Long-Term Impacts of Short-Term Medical Missions on Learners 6 Residents who take international rotations are more likely to: Choose primary care medicine Work in underserved areas Work with multicultural populations Obtain a public health degree

6 Slide 16 Outline I. Making a case for Medical Missions The Need for Medical Missions Benefits of Short-term Medical Missions Professionally Benefits of Short-term Medical Missions on Learners II. Actions that can be harmful in Short-term Medical Missions III. Guiding Principles for Medical Missions Slide 17 Outreach in Ecuador Slide 18 We work under the pretense of promoting community autonomy and health sustainability in rural communities without access to healthcare, but can any positive difference in community health through the efforts of our volunteer medical teams be noticed? For the local rural communities that we temporarily serve, have any of our interventions subsequently reduced the burden of illness or death? Has individual or communal quality of life been enhanced? Have the social, economic, and educational boundaries been addressed to realistically implement some sustained beneficial impact? After our team leaves Rancho Pedro, [the site of the short-term mission trip] is the community really better off, or do they simply wait for the next foreign medical team to arrive? 9 --Wilson, J, et al. Rules of Engagement: The Principles of Underserved Global Health Volunteerism. American Journal of Medicine.

7 Slide 19 Actions that can result in Harm 9 Creating local community health dependency on external medical teams Embarking on medical volunteerism without first considering alternative or supplemental activities to improve local community health Having inadequate pre-travel preparation and education Slide 20 Actions that can result in Harm 9 Relying on medications, equipment, and other supplies donated externally rather than what is locally available Dispensing inappropriate medications (e.g. vitamins, NSAIDS, antibiotics) Performing surgery and other invasive procedures without adequate patient follow-up to address possible complications Donating medical equipment that is not required and is beyond the capacity of local providers or healthcare center and without a plan for maintenance Slide 21 Actions that can result in Harm 9 Overreaching or mismatching providers medical knowledge base and skill sets Not incorporating or recruiting the services and expertise of local providers Focusing on the medical and scientific interests of the visiting team rather than the needs and requests of local providers Being unfamiliar with local languages, cultures, or system of beliefs Being unfamiliar with prevalent regional diseases and management strategies used by local providers

8 Slide 22 Actions that can result in Harm The GOLDEN Rule vs The Golden rule: Slide 23 Outline I. Making a case for Medical Missions The Need for Short-term Medical Missions Benefits of Short-term Medical Missions professionally Benefits of Short-term Medical Missions on residents II. Pitfalls in Short-term Medical Missions III. Guiding Principles for Medical Missions Slide 24 Guiding Principles for STMMs Service Sustainability Professionalism Safety

9 Slide 25 Service 9 Develop relationships; listen! Be flexible and respond to needs of patients and local healthcare providers 11 Ensure team is prepared: works together, familiar with cultural beliefs, common medical problems, and the local healthcare system 10 Healthcare providers should use (not exceed) their level of training Ask the long-term workers what you should take them Slide 26 Sustainability 9 Develop relationships and Listen Use medications accessible locally or those on the WHO Essential Medicines List for Children Partner with other nongovernmental organizations and governmental health agencies Education: training the trainers e.g. Helping Babies Breathe Partner with locals on research projects: 10/90 gap Develop outcome assessments of patient care activities, patient safety, quality control, and overall mission impact 10 Slide 27 Professionalism 9 Practice the same ethical patient care standards as you would at home Obtain approval from local health organizations within a 20 mile radius Make sure the local health clinic is doing at least as well after the mission as they were before Provide appropriate supervision of students and residents; ensure quality of care When indigenous people train learners from the US, ensure they are compensated When conflicts arise, listen and respond respectfully Communication in the local language is imperative 12 Be culturally aware and respectful

10 Slide 28 Safety 9 Confirm housing, transportation, safe food and clean water prior to travel Protect yourself against diseases through appropriate use of mosquito nets, antimalarial medications, taking N95 masks, taking gloves, etc. Learn the customs, beliefs and local laws that influence the practice of medicine and interactions with patients Prepare an exit strategy in case of emergency Register the trip with the US embassy Slide 29 Guiding Principles for STMM s Choose an organization with a mission statement you support Return to the same site for repeat STMM s work Work on prevention and treatment together Civil strife, war, health sector reform, or even the lack of consistent electricity may profoundly affect (treatment) goals the combination of prevention and treatment is more synergistically powerful than either alone. Continue being involved after return home through advocacy, education and political involvement Slide 30 Helpful Personality Traits for STMM s Tolerant/Open-minded Good listener Reflective Humble Patient Able to work with people in diverse fields and with varied backgrounds Have or be able to develop relevant expertise Be aware of power differentials Be historically, culturally and politically aware

11 Slide 31 Choosing the Best STMM What do you want to gain from the STMM? What length of time are you considering? What language skills do you have? Do you prefer to work and travel independently or to be part of a team (security, travel arrangements made for you in exchange for conforming to the group s plans) What do others who have worked with the organization say? Is there financial integrity? What kind of preparation and debrief do they provide? What could your significant other do while there? Slide 32 Opportunities to serve in STMM: Clinical Medicine in areas without healthcare Clinical Medicine Slide 33 Opportunities to Serve in STMM: Provide relief for people doing Long-Term Missions e.g. Shirati Hospital (Tanzania)

12 Slide 34 Opportunities to serve in STMM: Disaster-Relief e.g. Haiti 2010 Slide 35 Opportunities to serve in STMM: Public Health 1. Home Visits 2. Health Surveys 3. Discussions with villagers 4. Research 5. Changes Slide 36 Opportunities to Serve in STMM: Medical Education

13 Slide 37 Overseas Opportunities listed by the AAP: Overseas Opportunities geared towards medical students or residents: Resource Exchange International: US Physicians travel to other countries to teach physicians Medical Education International Help establish/grow a residency program in a developing country: Global Health rotation for residents Opportunities for International Involvement Slide 38 Sponsor a refugee family in Wichita (i.e. thru EWARM) Educate yourself about health and human rights issues around the world: UNICEF Advocate for improved community health (i.e. supporting water fluoridation, etc.) Collect medical supplies to donate (American Medical Resource Foundation, Inc, AMSA s recycling program, etc.) Donate to the Friends of Children Fund (AAP-sponsored) Participate in the Institute for International Medicine s (INMED) self-paced online courses: International Public Health, International Health Leadership, Diseases of Poverty, International HIV medicine, Disaster Medicine Management Educate yourself on key Global Health topics through online modules: Opportunities for local involvment 3 Slide 39 Short-term Medical Mission Teams Can be Life-saving participate wisely!

14 Slide 40 Sources Cited 1. Thompson, M, et al. Educational Effects of International Health Electives on U.S. and Canadian Medical Students and Residents: A Literature Review. Academic Medicine. 2003;78: Millennium Development Goals Why Do the Millennium Development Goals Matter? Brochure 4. Section on International Child Health 5. Medical Volunteers Association: Preparing for Medical Service Overseas 6. Drain, P. K., et al. Global Health Training and International Clinical Rotations During Residency: Current Status, Needs and Opportunities. Academic Medicine (2009);84(3): Levels and Trends in Child Mortality, Report Estimates Developed by the UN Interagency Group for Child Mortality Estimation 8. Steffes, B. Medical Missions: Get Ready! Get Set! Go! Linden: Wilson, J, et al. Rules of Engagement: The Principles of Underserved Global Health Volunteerism. American Journal of Medicine. 10. Health impact assessment and short-term medical missions: A methods study to evaluate quality of care 11. Mayo Clin Proc Mar;75(3): Short-term international medical service. Woods JE, Kiely JM. 12. Textbook of International Health pg Brain Gains Slide 41 Questions and Comments?

APM Perspectives. APM Perspectives

APM Perspectives. APM Perspectives APM Perspectives APM Perspectives The Association of Professors of Medicine (APM) is the national organization of departments of internal medicine at the US medical schools and numerous affiliated teaching