Medical missions expand horizons
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Packing their luggage to return home from a medical mission trip, physicians often take with them a new perspective on practicing medicine.

“It makes you more grateful. I think that’s important. And I think it makes you more tolerant. It makes you more sensitive to the conditions people live in,” said Brett Coldiron, MD, AAD president and clinical associate professor of dermatology at the University of Cincinnati, who has volunteered in villages along the Amazon River in South America and in South Africa.

Such trips grow physicians’ compassion and help them to relate to their patients, said Christopher Harmon, MD, of Surgical Dermatology Group in Birmingham, Ala. “It’s easy to get disproportionately passionate about the color of your iPhone or draperies in your house, and this pushes back on that perspective a little bit and introduces gratitude for work, food, and shelter and for a lot of the infrastructure that we take for granted in our everyday lives.”

Early mission work may motivate residents to continue volunteering later, according to John Strasswimmer, MD, PhD, who practices at Delray Advanced Mohs Surgery, is president of Dermatology Missions, Inc., and volunteers at a local free clinic.

“It will change the course of their careers, maybe just a degree or two degrees, so that 10 years down the road, when they find themselves well established academically or in a private practice setting, they then might actually be able to make that jump and go back and participate in an overseas type of environment or in one of our very needy environments here in America,” he said.

Dr. Strasswimmer, who has volunteered in Africa, founded Dermatology Medical Missions to provide resources and other assistance for dermatologists who would like to pursue medical missions. He explained that, through these volunteer efforts, residents connect with other physicians, which may lead to future mission opportunities. “These are friendships that can be nurtured and kindled, and you never know where these are going to lead,” he said. [pagebreak]

There are a number of ways in which dermatologists can volunteer, regardless of how long they have been practicing. “I didn’t start doing these missions until three or four years ago,” Dr. Coldiron said. “It’s never too late to get involved. And it’s extraordinarily rewarding.”

Answering the call

Residents who want to make volunteerism an early habit can participate in two Academy programs, the Resident International Grant (RIG) program and the Native American Health Service (NAHS) Resident Rotation Program. Last winter, Shane Clark, MD, then the chief dermatology resident at Ohio State University (today he is the physician-owner of Twin Oaks Dermatology in Wooster, Ohio), flew to Gabarone, Botswana, as a senior resident, eager to put his medical skills to work in the medically underserved area. Although reluctant to leave his pregnant wife behind for five weeks, he was committed to the mission, sponsored by the RIG program.

“My impetus for providing care in Botswana is fundamentally an extension of my motivation to become a physician — to provide care for those in need, to make a difference,” said Dr. Clark, who also participated in a mission to Ghana as a medical student. “We are so fortunate to have relatively good access to quality medical care here in the U.S., but that’s simply not the case in much of the world. There are very, very few dermatologists practicing in Botswana and, in fact, in many parts of the globe, yet dermatologic or skin issues are typically the number-one reason why patients seek physician care.”

Learning flexibility

On these trips, physicians sometimes end up handling unexpected tasks, said Lana Long, MD, who is in private practice at City Dermatology and Laser in Cincinnati and is married to Dr. Coldiron. “We went to the Amazon thinking we’d be doing a lot of dermatology, for instance — a lot of tropical medicine, a lot of tropical disease,” she said. “But it turns out they don’t even have fresh water, so our son and some other of the team members spent a lot of time getting clean drinking water for people.” [pagebreak]

Dr. Harmon has participated in multidisciplinary medical mission trips in developing countries since 2000, bringing physicians, his office staff, and even his family. “Doing this kind of service work with your family gives a chance for your spouse and your kids to be a part of helping and treating patients, and we found the significance of that to be pretty life-changing for everyone,” he said. “You come home from this trip much more profoundly changed than you do after a week of snow skiing as a family.”

In addition, Dr. Coldiron said, these experiences enable physicians to temporarily escape many of the business and insurance pressures that weigh them down. “When you’re a medical student, you wanted to go help people, and this is an opportunity to do that, generally unfettered,” he said. “It’s very refreshing. It charges me up.”

Trial by fire

Residents volunteering with the RIG program had no shortage of people to help — Botswana has one of the highest rates of HIV in Africa. This results in numerous skin diseases, said Jeremy Davis, MD, chief dermatology resident at Case Western University School of Medicine in Cleveland, who traveled to the country last year through the RIG program. Being there, he said, offers the opportunity to provide necessary care to an underserved population. In the course of seeing these patients, he noted, residents may also see infectious diseases and advanced pathology that are uncommon in the U.S.

Jeffrey Tiger, MD, a Mohs surgery and procedural dermatology fellow at Roger Williams Medical Center in Providence, R. I. and former Peace Corps volunteer, provided dermatologic care during a one-week rotation in the Navajo Nation in Arizona. “It is an excellent clinical experience because the residents work as dermatology consultants for the local health care providers,” he said, noting that this was his first experience working without a dermatology attending directly present. “There is a great feeling of independence and autonomy, but also the stress that goes along with that responsibility.” [pagebreak]

Serving in an outpatient department of Princess Marina Hospital in Botswana, Michelle Scott, MD, a dermatology resident at the University of Pennsylvania, worked independently from other clinicians in the facility, forcing her, as a resident, to take full ownership of her medical decision making. “It’s given me a lot of confidence, and I have come to appreciate how thorough and extensive my training has been. It has also made me appreciate the existing medical research and the access we have to the published literature to help inform our decision making,” said Dr. Scott, who participated in both the RIG and NAHS programs, as well as the Peace Corps and other mission trips.

His mission experience helped Dr. Clark recognize that he was ready for independent practice. “I learned to trust my diagnostic acumen because in the U.S. I think we always have that crutch of another test, often a specific test to truly back our decision or buy time to deeply contemplate, but there that’s simply not the case,” Dr. Clark said.

Residents reaped other benefits. Julia Kasprzak, MD, dermatology attending at the University of Wisconsin School of Medicine and Public Health, enjoyed working with the local people and an array of specialists in the dermatology clinic in Princess Marina Hospital and outlying cities. “It was great to collaborate and learn from each other,” she said.

“I think the best part was simply [having] the opportunity to treat, to help, to hold the hands of so many patients who otherwise just would not have been treated,” Dr. Clark said. He also educated other health care providers. “Hopefully, the assistance I provided was longer lasting than simply my five weeks in Gaborone,” he said.

Overcoming obstacles

As the residents interviewed for this article developed new skills, they also coped with an enormous volume of patients, a lack of resources, language barriers, and the emotional experience of confronting overwhelming poverty and disease. [pagebreak]

“There was one night after clinic that I received a hospital consult on a patient who was unresponsive and very ill with vesicles all over his body. Since it was a Friday night, many of the hospital staff were gone,” Dr. Kasprzak said. “There were no diagnostic tools available to me that late at night, so I had to use my best clinical judgment to determine how to manage and treat the patient.”

Dr. Davis often felt defeated at the end of the day by the never-ending stream of patients. “About half of the time that I was there, I was the only dermatologist and so there were patients coming from all over the country,” he said. “They would line up in the morning with their charts and I just wouldn’t stop until they were all seen because I knew that if I did, there was nobody else to see them.”

Residents also needed to make the most of the resources they had while providing care in a remote location with limited supplies. “There was very little dermatology-specific equipment, and each clinical site had different supplies, so I had to be flexible and use different types of equipment to get the job done,” Dr. Tiger said. “Basically, the residents that participate in this program are providing high-level dermatologic care in a family practice office.”

In Botswana, the enormous burden of HIV — which alters the presentation of skin conditions — and limited diagnostic toolbox and treatment armamentarium complicated care, Dr. Clark said. “This can turn even the simplest of cases into an exercise in mental gymnastics. That was without a doubt just the toughest clinical challenge,” he said.

In most cases, he did not receive biopsy results. “I think when I was there I only received two or three of my biopsies back,” Dr. Clark said. “So you basically have to treat on a presumptive diagnosis.”

To facilitate continuity of care, Dr. Tiger exchanged email addresses with the clinicians he worked with so he could help them develop a treatment plan when biopsy results came in after his return home. “I enjoyed preparing detailed plans for the primary care providers who were going to be continuing the care of these patients,” he said. [pagebreak]

Moreover, Dr. Kasprzak said, it was difficult to witness the impact of AIDS on the entire community. “Seeing children with HIV/AIDS — on a personal level it was hard to see that struggle,” she said. “You feel a little helpless at times.”

Social influences

Volunteers may also have to navigate an unfamiliar social environment. During her NAHS rotation, Dr. Scott said, a teacher brought in a slightly malnourished adolescent boy with pustules covering his hands and feet, who was clearly neglected. She felt comfortable providing medical care, but she didn’t know how to manage the underlying social problems. “A lot of times they’re coming in with these medical conditions that are really stemming from larger social issues that they have,” Dr. Scott said. However, she explained, it’s difficult for newcomers to address those underlying problems because they are unfamiliar with available resources.

In addition, Dr. Scott was stunned by the poverty she witnessed on the Navajo reservation. “I’ve never visited a reservation, so it was just really striking to me and in a way very frustrating,” she said. “There is so much need locally and we forget about that.”

Cultural beliefs also influence patient care. “Obviously every place and every people have their own culture and their way of interacting, and as a visitor you have to be conscious of these differences and adaptable. These differences play out not only in your interaction with the patient, but also with your interaction with staff and colleagues,” Dr. Scott said.

Cultural influences may dictate whether a patient will follow instructions. “I had to put myself into their position, think about all the aspects of their lives, and try to come up with a recommendation that would help them,” Dr. Davis said.

Long-lasting benefits

“It has been an eye-opening and humbling experience to go on these trips. They not only make one realize how fortunate we are in the United States, but also serve as an inspiration to continue volunteering,” said Dr. Kasprzak, who would like to create a future program providing dermatology volunteer opportunities.

“It affected me in a way that I didn’t really expect,” Dr. Davis said. “I came out of it really with a sense that I wanted to continue doing that as much as I could. I definitely plan on going back in whatever ways I can.”



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