“Puedo tomar su presión? Puedo tomar su pulso?” I butchered in Spanish, over and over again. Sometimes I received a smile and laugh in return, sometimes a look of confusion, sometimes a placid unfolding of the patient’s arm. I pumped the cuff up repeatedly and listened intently over the screams of playing children and the chatting of a long line of patients.
My spring break experience was a unique one, taking place in a rural school in Yaviza, Panama. I traveled down with a team of 24 medical students, one physician assistant student, 14 nursing students, and seven attendings from Penn State to run a three-day free clinic with the organization Global Brigades. We served just under 600 patients, offering doctor consultations, free medications and health education to anyone who walked through the door. We even set up a modest lab that provided urinalysis, KOH scrapes, Gram staining and EKGs.
Considering the trip on a superficial level, not only did we fulfill a primary care preceptorship requirement but we also “helped” a community in need. Our group was fascinated by all of the unique individuals that walked through the door, patients with everything from cutaneous leishmaniasis to tinea versicolor to massive abdominal hernias. We saw several cases that merited only a single lecture slide as rare “third-world” diseases, and many that had progressed much further than one would expect in a place with adequate access to health care. On the other hand, we addressed more universal needs such as pregnancy, hypertension and scabies, while working under some of the best physicians and teachers that Penn State has to offer. It was a great learning opportunity and a chance to work in a huge interdisciplinary team.
However, the experience does not always sit well with me. I come from a background of global health work and research as well as a masters in public health, and this is an example of exactly what not to do, the definition of medical tourism. Students with incomplete training come in for just a few days, see a bunch of “awesome” or “exotic” diseases, distribute a dozen suitcases’ worth of medications, and then patients fend for themselves until the next brigade comes along in a year. Luckily, our clinic had the supervision of seven Penn State physicians, but typical brigades are operated by dozens of undergraduates and only one or two Panamanian physicians.
One of my biggest questions is this: is this the most efficient use of our money? Students pay nearly two thousand dollars each to travel to an underserved country and put on merely a three-day clinic. I was one of the fundraising chairs and know that the money for drugs and supplies were in addition to all of the expenses students pay out of pocket. Our trip totaled well over $100,000 when all the expenses are added up. Couldn’t this money be better spent to train and employ a full-time physician in the community, one that could offer continuous and culturally relevant care?
Another concern of mine is the adequacy of our care. We did our best to have a Spanish speaker in every consultation, but translation was often limited and clinicians occasionally missed the full story. Many patients came with handfuls of complaints, many of which we inevitably missed. Chronically diseased patients were given a month of medication, which will not last until they see another brigade in six to twelve months. And by the third day, we were running out of the most needed medications, and patients were given a script to a far away pharmacy to which a patient would be unlikely to go. Additionally, the most complicated patients in the most need of quality, coordinated care were often referred away due to our inability to help them on the spot. Patients who clearly needed a thorough workup and treatment course would be sent “to the city,” which was hours and many bus fares away — nearly impossible obstacles to many of the impoverished patients we were seeing.
A final dilemma that continues to bother me is this concept of medical tourism. A case of cutaneous leishmaniasis was diagnosed — and the room filled up with dozens of students peering over each other’s shoulders to get a look at a frail man in his eighties and to capture a picture of the lesions. A student in scrubs with a stethoscope kneels down with a cute Panamanian child, whose name the student hasn’t even tried to ask, for a picture that will make them look like a hero on Facebook. A massive hernia is revealed that a 92-year-old-man has been walking around with for a decade — students crowd around, chattering in English that the man can’t understand. Pretenses of American health care fall, personal space and privacy is neglected, and cameras snap unsolicited. Does this become acceptable just because we are providing three days of temporary health services in a medically underserved area, a band-aid to a gushing wound?
These are all questions I struggle with, and yet I would still admit that it was a positive clinical learning experience for me and I would recommend it to the next underclassman. However, it reminds me that we need to focus on systems building and medical education in underserved countries, and not just merely run temporary clinics. As students, we gain exposure to a new culture, valuable clinical cases, and a different reality than our own. Even so, we need to recognize that we are not the answer for these patient’s problems and the country’s health care, and if anything we are worsening the situation by providing a crutch. These patients need a caregiver that can speak their language, educate them in a culturally relevant fashion, and coordinate their care longitudinally. Systems building may not be as sexy nor as easy as throwing a huge free student-run clinic, but it is the only way to create sustainable change.
Am I telling medical students that these spring break trips are a bad idea? Not exactly. Students just need to go into the trip realizing that the trip is more about selfishly furthering their own education, and if they were harshly honest with themselves, that they are making little to no real impact on these patient’s lives. Undoubtedly, our money could potentially be used in better ways. In the end, our clinic was an important learning experience for my classmates and myself, but I just hope to remember that we were helping ourselves more than we really “helped” the Panamanian community.