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Medical Missions: What makes us think we’re qualified?

Created 07.11.12 by Alison Hayward
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Everyone knows at least one these days: medical providers who travel to developing countries to provide medical care to communities with little access to healthcare otherwise. “Medical missions” have become commonplace for students, residents, and practicing physicians. Allied health professionals are also frequently involved, with everyone from pharmacists to alternative medicine practitioners joining these trips. Many such trips are organized on an informal basis through networking, nonprofits, or church groups, and as such, involve little to no pre-departure training on practicing medicine in resource limited tropical settings. Participants may be expected to educate themselves on an ad hoc basis, or may be provided with some limited resources for study prior to the trip.

It has become clear that just being a doctor (or a physical therapist, or a pharmacist) does not qualify a person to practice in a developing country. And yet, there are physicians traveling from industrialized nations who are retired, have lapsed specialty certification, or are no longer licensed to practice medicine even in their own country. These people are administering medical care or even performing surgery on people living in poverty. Typically, they are lauded as humanitarians instead of questioned for such practices. This is not just an ethical issue, this is a social justice issue. Caring for patients in such scenarios requires a highly specialized body of knowledge and skills that American healthcare professionals simply do not possess without global health-specific education. We need to ensure that healthcare workers are not only licensed and qualified to work in their home areas, but any areas where they travel with the intention of providing medical care.

In the United States, we require all international physicians to go through an arduous course of USMLE exams and additional years of residency to be able to practice in our country. Yet we presumptuously believe that we can parachute in to settings completely different from those we trained in and immediately start treating patients. Despite the fact that we trained with ample availability of CT scanners, a panoply of lab testing options, and ready availability of consulting services, in an environment where tropical infectious diseases are rarely, if ever seen, we believe we can quickly translate our skill set to a location with no physician, minimal lab or radiology resources, perhaps without even running water or electricity. Yes, we do it because we want to help, but well-intentioned arrogance is still arrogance.

A typical justification for this practice is that in a resource limited setting, any provision of medical care is helpful because “it’s better than nothing.” That position is difficult to defend, since substandard care can end up harming patients. Healthcare providers who arrive in a resource-limited setting without proper preparation may end up monopolizing precious resources themselves, leaving less for the local population. Also, provision of free medical care by medical missions undermines what little local health system already exists. The healthcare worker who typically services the area now has his small income cut in half for the month, because his customers all decided to go get free care from the visiting medical mission. The pharmacist who sells medications can’t pay his child’s school fees because the medical mission gave away free medication to his customers. Finally, provision of free care by visiting health workers helps to create a ‘donor culture’ or ‘culture of helplessness’. It reinforces the belief of local community members that they are dependent on external aid, and undermines local self-efficacy.

Although it will be difficult to set and maintain standards for qualification to practice medicine in resource limited, global health settings, it must be done. Standards for qualification are ethically necessary. Academic medical centers, particularly those with offices of global health, should be at the forefront of creating and enforcing institutional adherence to these standards. Global health practitioners must prioritize the publication and dissemination of such standards in such a way that physicians in all specialties across the nation will be aware of them. Such standards will go a long way towards creating a culture of professionalism and respect for the challenges of practice in the global health field.

Have you ever considered or participated in a medical mission trip? Let me ask you – how much time did you spend considering how to get licensed to practice in that country before arrival? How many of you are taken aback that I suggest you need to be licensed to practice in a developing country, even if you are going as a volunteer on a brief medical mission? Why did you think it was acceptable to practice unlicensed in that location? Was it because of the remoteness and degree of medical need? Would you consider traveling to a rural area of the USA and hanging out a shingle as a physician if you had no American medical license or DEA number?

All right, I’m almost done grilling you now. But I do want your opinions. What makes us think we are qualified?

Alison Schroth Hayward, MD, is a board certified emergency medicine physician currently on the faculty at the Mayo Clinic in Rochester, Minnesota. In 2003, she co-founded a nonprofit called Uganda Village Project, and currently serves as the Executive Director. Her expertise in global health ethics has mainly resulted from making all the mistakes already herself, and trying to learn from them.

References
Battat, R. et al. Global health competencies and approaches in medical education: a literature review. BMC Medical Education 2010, 10:94
Burdick, W., Hauswald, M, and Iserson, K. International Emergency Medicine
. Academic Emergency Medicine 2010 Jul;17(7):758-61.
Hauswald, M. Response to: International Emergency Medicine and Global Health: Training and Career Paths for Emergency Medicine Residents. Annals of Emergency Medicine 2011; 576–577.
Morton, M and Vu, A. International Emergency Medicine and Global Health: Training and Career Paths for Emergency Medicine Residents. Annals of Emergency Medicine 2011; 57:520-525.
Panosian, C. and Coates, T.J. The New Medical “Missionaries” — Grooming the Next Generation of Global Health Workers. New England Journal of Medicine 2006; 354:1771-1773.
Redwood-Campbell, L. et al. Developing a curriculum framework for global health in family medicine: emerging principles, competencies, and educational approaches. 2011, 11:46.

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  1. Craig says:

    As a son of a mother who coordinated surgical care for children with cleft lips, you are a monster to deny this and other sorts of care to persons with no access who would give anything to come to the US for these same treatments.

    1. Larry bravo says:

      You’re a fool, and your simultaneously patronizing and self-pity driven response is laughable.

  2. maria says:

    Dr Hayward, thank you for such insight. I’m reading your article both as a daughter of a government physician/educator and as a practicing physician myself from a third-world country where we regularly see foreign medical and allied medical personnel performing “life-saving” missions. While we are certainly grateful for the “life-altering” surgeries that our patients receive; there have also been countless times where I have been astounded at the lack of preparedness that the first-world trained doctors have in dealing with the complicated cases that they receive. I cannot help but observe how “knife-happy” some of them are, and this sinking feeling based on their comments and interactions during surgery and post-op care, that they’re only coming here to sharpen their skills on already-complicated cases. And also for something to write on their CVs or get tax breaks from. And leave us local doctors, to manage complications and fatalities right after they’ve thrown off their gowns. Oh yes, vicariously and by my own experience, I have seen patients bypass pre-op clearance so the “foreigners” have patients to operate on, and then not even checking post-op if their patient is still alive. Our local societies are not blameless either, in their adulation and equation of “foreign-trained” with “better care”, and the frustration that the funding comes out from governments only when foreign doctors come, when the same amount of money could be re-channeled into preventive care of our community. For example, I have worked in small community hospital where the surgical suite is repaired to “prepare” for foreign missionaries who will only use it for 3 days while the X-RAY and ultrasound machines are left un-repaired for 2 years due to “no funding” and we let our patients go to the city 3 hours away just to get a simple x-ray. But still, we are grateful for the surgical supplies left behind. Perhaps, a bigger conversation is needed on how we can better serve our patients.

  3. maria says:

    and it’s laughable to assume that “anybody would give anything to go to the US” to get these same treatments because medical tourism in other countries are big industries, including my own country. and yes, i trained in a hospital where a lot of the medical tourists are Americans, but we also had translators for French and Nipponggo patients.

  4. Tom says:

    This is a very interesting question, but I think it is important to look at the steps required in order to perform a medical mission. This is not an exhaustive list by any means.

    In order for these missions to occur several steps must be taken: 1) an agreement between the mission group and the governmental health agency of the country of interest must be established; 2) physicians who practice in the country of interest accompany the students; 3) American physicians associated with the group typically, yes typically, have loads of mission experience in the region that the group is heading and can communicate in that regions language.

    To address #1: these countries visited (at least in my experience) have a very poorly run and funded government health care system. They understand their limitations and are welcoming of outside assistance because of this. It is also important to realize that many of these countries have incredibly rural villages which are 100% reliant on mission health care. I haven’t been on a trip where these remote villages are not the 100% focus of the group, so saying that the local pharmacist can’t put their kids through school is rather misleading, because they aren’t missing the clientele they never had.

    #2: The accompanying “in country” physicians are of enormous benefit for many reasons: 1) they build trust between the locals and mission group; 2) they are a wonderful source of information for the students; and 3) they themselves become educated by another culture, build their professional network, and become more complete physician’s who can serve their population.

    #3: This is an imperative point to never overlook. It’s called role modeling, and is probably the most influential part of becoming a physician. You find someone who you want to be similar to. How they practice and carry themselves has an enormous impact on the students, other physicians, and locals. This is especially important when you’re in a foreign country. I have only accompanied highly professional, prepared, and respectful physicians on my trips.

    As far as a requirement for standards are concerned, where do you start? Is it ethical to withhold care from thousands of communities until standards are developed? You mention leading academic medical centers with areas in global health should be at the forefront, but how would you remove the 1st world bias that is the foundation of your argument?

    All in all, as students we have to learn from someone, whether it is that old lady who comes into the ER every two weeks, or from someone in a third world country who has no access to their own country’s health care. In order to become a well rounded, knowledgeable, and complete physician, I intend to continue to learn from both, and I think it is a responsibility of all current and “soon to be” physicians to do it in a prepared and respectful manner.

  5. Freesia says:

    I would first like to point out that sor far the people who agree with Dr Hayward’s assessments are the locals (myself included) who I should think are more attuned with the real impact of medical missions.

    That being said, first let me say that we are not being ungrateful when we criticize medical missions. The healthcare situation in poorer countries is so dismal it would be stupid to refuse outside help.

    This, however, is what i have a problem with: Medical missions enable the culture of dependency which I think just cripples these poorer countries even more.

    I will never forget attending a “workshop” where an 18 year old american girl was teaching adult local men how to use a condom, demonstrating on a wooden penis. The looks on the mens faces conveyed the ignominy of the situation. All this happened while the local doctor stood by and watched with a beam of pride on his face. They had come because the doctor had rallied them but apparently this kid knew more than he did about STD’s and how it affected the lives of these.

    Tom was quick to point out that “these countries visited (at least in my experience) have a very poorly run and funded government health care system. They understand their limitations and are welcoming of outside assistance because of this”…. and that the medical missions get permits from the governments.

    Well I have this question for you Tom, why are these governments not more involved in investing in the local health infrastructure? Goodness knows they can afford it going by the nicely padded swiss banks accounts top level government officials tend to have. Point is they accept your “help” because it enables them to use the countries resources for their own selfish ends. Would you as an American stand for your government accepting foreign aid while the top officials tuck away millions for themselves?

    And if the international aid organizations and missions want to help why are they not more involved in training? Why are some of the millions flushed down the drain of international aid not invested in helping more locals go to medical or nursing schools, get them more involved in the health care professions? It will create jobs as well as solve a pertinent healthcare problem.

    Maria raises vey pertinent points which i think just about sums up the impact these missions can have. Raising the standards of health care in poorer countries is not something that is going to be accomplished by foreigners (and I do not mean this in a disparaging way) who are not really invested in that country. It is going to be done by the citizens , the people who need the help the most. The same people who are continually being told they need help, they are too poor and should listen to what the whiteman says to do. Where is the empowerment in this?

    1. shobhana says:

      freeesia: I totally agree with you, i am myself a second year medical student in India.I cannot emphasise the the point enough – that the “millions” tucked in swiss banks would be better used by making the practise of medicine a more lucrative option than it is!! There is a huge efflux of doctors to foreign countries,never to return ! These doctors have been educated in government subsidised colleges,so they are essentially taking away whatever the governement spent on them….

  6. Owlegrad says:

    Very insightful article, I am sure many people that have gone on medical mission trips felt a sting of truth in this (myself included).

  7. Jett says:

    This article does bring up a lot of good points. It was one of the big topics this past year with the medical missions I went on. I think it really depends on the trip you go on. I personally love the trips i went on because it was primarily students and we are there to learn and to give at the same time. It was truly a blessing on all ends. Our sponsoring doctor does follow up on the serious cases that were presented. The learning aspect is great because we see things on these trips that you will rarely find outside the textbooks. Our faculty members which are all practicing professionals were there teaching us and evaluating every single case that was presented. Overall, it is a great teaching tool for students and does build confidence and the student’s own lines of practice especially when you can’t do the first line treatment.

    I do agree, there is some harm and we need to be cautious of it. There should be more precautions that needs to be taken whenever possible. I do agree with Tom’s post with those characteristics, so I say we need to develop these missions to be responsible for their actions and to properly prepare physicians and student in cultural stigmas in the country, language, healthcare problems, and even common practices within the country. I say let students learn and we can only do our best to help one another. Maybe one day I can change a little kid’s life and they will become the next world renown doctor, no matter if they came from USA or from one of these missions.

  8. alex says:

    Welcome to America, where nothing is too big or small for someone to decide that more documentation, paperwork and forms are required. I look forward to the day when medical volunteering includes dozens of pages of paperwork, yearly maintenance of medical mission certification (mommc?), “360 degree evaluations” and whatever else the clipboard wielders of the world can think up.

    I remember seeing one of the best 5 or so cleft surgeons in the world go 15 hours a day, day after day and fix dozens of kids over the course of a few weeks. He only knew how to repair clefts and had NO CULTURAL COMPETENCE TRAINING!! I now realize that he was just displaying “well intentioned arrogance” and was not, in fact, qualified to be doing those surgeries. Thankfully someone is finally here to address such travesties.

  9. Freesia says:

    ” Overall, it is a great teaching tool for students and does build confidence and the student’s own lines of practice especially when you can’t do the first line treatment.”

    Lets keep things in perspective here shall we? These are peoples LIVES. If you see medical missions first as a teaching tool which enables you to learn a thing or two which you have not seen in textbooks while “saving the lives” of some poor person then sorry, I have to question the so called altruistic motivations of these missions. I suppose this explains why the organizers of seminar I observed let an 18 year old girl lecture grown men on sex and life, while one of their own stood by and watched. The opportunity for her to “…build confidence…” was more important than these men’s sense of dignity.

    “I remember seeing one of the best 5 or so cleft surgeons in the world go 15 hours a day, day after day and fix dozens of kids over the course of a few weeks. He only knew how to repair clefts and had NO CULTURAL COMPETENCE TRAINING!! I now realize that he was just displaying “well intentioned arrogance” and was not, in fact, qualified to be doing those surgeries. ”

    Unfortunately not all medical missions consist of acts like this and not all of them go off without a hitch. I do have a question. If in the course of his 15 hour a day surgery spree this surgeon made an error due to sheer exhaustion and actually harmed one of these children, what parameters had been put in place to address this? Or does the fact that he was on a medical mission and the surgery was free mean he is not to be held accountable? After all the kid would have to have lived with a cleft had he not stepped in to save her.How about we switch roles for a bit. A surgeon from another country is on a “medical mission” in the US. Operates 15 hrs a day for a couple of days straight. Ends up hurting a patient….. Hmmm…

    Look at the fuss Americans make about healthcare quality and availability. Does the fact that medical missions are in fact charity mean no attention should be paid to quality? It’s almost like you are saying since we a essentially beggars we have to take whatever is given and that is exactly the kind of attitude that bugs me. Again if you care so much about improving the quality of health care why not focus more on enabling the people to take care of themselves? Why is training not a priority?

  10. Tom says:

    To simply address your question Freesia about how to get these governments to spend money as they should – your guess is as good as mine. It’s all about reaching these people in need. Dr. Hayward discussed the ethics of missions and the potential harm, but what are the ethics of withholding treatment? Of course one could argue that by not performing mission trips we are choosing not the “seek” rather than withholding, but that’s an entirely separate discussion. In my opinion, potential harm and discomfort certainly outweighs certain harm and discomfort. And telling a corrupt government how to spend their money? That again, a topic for discussion with the UN and why they have decided that many of these countries are for labor only – they have essentially implemented a worldwide caste system. Have you seen their educational system? Ugh it’s brutal, but acceptable for their chosen path according to the powers to be.

    Also, your scenario about our reactions to a doctor who works 15 hours a day, hurts a patient, and has little consequence in the US?…walk down the street to the free clinic. They are all over the place. But these people are homeless, so the outcry isn’t an issue (I haven’t seen one in the media anyway). One of those “as long as it’s not in my backyard” American ideologies. It’s sad, but it’s life right now.

    Finally, these medical missions are education first, whether you like it or not. These medical students aren’t running around without supervision, they have a preceptor who watches over them, and if they think the student may, MAY do harm, they step in and take over the case. It’s not sheer chaos, and there is not a shred of malicious intent or view of these people as lessors. I don’t know what to tell you about the 18 year old girl blabbing at the mouth, but that’s how our society views women now, and sadly, how women view themselves. They can say, do, and act anyway they want without consequence, yet another topic of discussion. If you stood by and watched that, then you’re just as guilty as she.

  11. Freesia says:

    Well then make up your mind Tom. Are medical missions about “…reaching these people in need” or are they “…education first, whether you like it or not “?

    I would really like to know because from where I stand it is more about the needs of the western students to have their cultural exposure and see their cases not found in text books and to satisfy what ever savior complex they might have.

    You say …”Dr. Hayward discussed the ethics of missions and the potential harm, but what are the ethics of withholding treatment?”

    I am not saying medical missions do not fulfill an important role or that they should be stopped. I was born and raised in a third world country, schooled in their education systems, treated in their hospitals. Believe me I KNOW on a very intimate level the crucial role medical missions play and also what the shortcomings are. It does not mean it should become the wild west of medicine with little or no regulations. Again the question, are we supposed whatever western doctors so graciously dole out because we do not have better? I suppose that is ethical. Well. not in MY backyard.

    Permit me to remind you that the UN is dominated by western countries, so perhaps you should be asking your governments why “…they have decided that many of these countries are for labor only [and] have essentially implemented a worldwide caste system.”

    And your statements about the 18 year old girl makes no sense. The issue I was pointing out there is that the local doctor was probaly better educated and equiped to talk to these men about sex, STD’s and how it affects their lives. But he stood by and watched while a teenager did his job to the great discomfort of the participants. I was there as a journalist and had to give up that assignment to somebody else because I (to the great discomfort of my editor) was ready to skewer the whole set up in the piece I was going to write on it.

  12. Tom says:

    I’m pretty sure I have made my stance clear. These are educational opportunities first. People spend their personal money to take these mission trips to learn about something outside of their comfort zone all while assisting others. Did I ever deviate from that?

    “it is more about the needs of the western students to have their cultural exposure and see their cases not found in text books and to satisfy what ever savior complex they might have”. Yeah, pretty much. If this is such a slap in your face, I’d love to hear your take on the the tens of millions of American dollars spent, and the thousands of people who tirelessly worked, and still work, to help the Haitian people after the 2010 earthquake.

    I appreciate your passion, but I’m not sure how attacking me is going to get you anywhere. I never said that you or your countrymen/women were ever required to take aid, so spare me that nonsense. Also, save the crap about reminding me of the UN, who represents it, and what I need to be asking my government, because you are making an assumption about me and my activity in politics regarding these issues.

    About the 18 year old girl, why didn’t you stop it?

  13. Freesia says:

    I apologize if you feel like I am attacking you, Tom. I think I made reference to and quoted other commentators as well. You just happen to be the one person who decided to “enage” me for lack of a better term.

    And you misunderstand me. I am not saying mission trips should be stopped. That would be stupid. If they are to be done however, there needs to be rules, regulations, quality standards that puts the needs of the patients first. That is the issue I think Dr Hayward is raising, unless I have misunderstood the whole article.

    Please read this CDC page about the Tuskegee debacle.

    http://www.cdc.gov/tuskegee/timeline.htm/ .

    Keep in mind that this happened in the United States. What can you say to reassure me that scenarios like this are not being repeated during these mission trips?

    Maria is a practising physician in a third world country and a fellow commentator on this piece. I give you her words:

    “… While we are certainly grateful for the “life-altering” surgeries that our patients receive; there have also been countless times where I have been astounded at the lack of preparedness that the first-world trained doctors have in dealing with the complicated cases that they receive. I cannot help but observe how “knife-happy” some of them are, and this sinking feeling based on their comments and interactions during surgery and post-op care, that they’re only coming here to sharpen their skills on already-complicated cases. And also for something to write on their CVs or get tax breaks from. And leave us local doctors, to manage complications and fatalities right after they’ve thrown off their gowns. Oh yes, vicariously and by my own experience, I have seen patients bypass pre-op clearance so the “foreigners” have patients to operate on, and then not even checking post-op if their patient is still alive”

    Thoughts? Comments? Acceptable or not?

    We are not required to take aid. True. We were not required to nor did we ask to be colonized and our resources pillaged to fill up the coffers of western nations . We were not require to nor did we ask for western nations to step in and divide our continent amongst themselves like a cake. We are not required to neither do we ask for western nations to continue to manipulate local politics for their own ends. The troubles of “third world nations” as we are referred to are indelibly linked to the greed and arrogance of “first world nations” so you spare me that nonsense.

    And why didn’t I stop the 18 year old girl? Because I was there as a journalist. Impartial remember? Observe and report. Except, I was not allowed to write the article I wanted to becasue it would have cast the mission in a bad light.

  14. Doctor to be says:

    After reading this article and the ensuing comments below, I think you’ve all convinced me. I don’t think I want to have anything to do with the politics of a medical mission, so will be sure to avoid them in the future. Clearly, the help is neither needed nor wanted….

  15. De says:

    I have always declined requests from fellow anesthesiologists to accompany them on medical missions: I’m too busy, the trip was too expensive, or simply other things to do. Now I have a better excuse – I am not qualified. Yeah! That is the best excuse ever.

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