By Inbal Braunstein, MD
I was honored to be chosen as a grant recipient for the AAD’s Resident International Grant program last year, and headed off to Botswana from June 25 to July 20, 2012, to work at the Princess Marina Hospital in Gabarone. During my time there, I worked primarily at the outpatient clinic at Princess Marina and also saw inpatient adult consults, as well as pediatric consults at the Baylor International Pediatric AIDS Clinic. There were also four outreach sites in surrounding towns, and I traveled to one of them each week.
I applied for the program after learning about it from Carrie Kovarik, MD, head of dermatology for the Penn-Botswana Partnership, and from my co-residents who had participated. I was excited about the opportunity to care for patients who needed more access to dermatologic care. Additionally, I wanted to learn more about skin conditions we don’t often see in the United States, and about the approach to the treatment of common conditions in a resource-limited setting. The program turned out to be a tremendous learning experience for me, and I learned far more than I could have ever anticipated.
It was amazing to take what I am learning in residency and apply it somewhere else, a half a world away from home. The most challenging aspect was dealing with my patients’ spectrum of health issues with extremely limited medical resources.
Refractory eczema was a particularly common problem. I learned from talking with my patients that many were bathing two to three times per day due to social norms and the hot, dusty climate. It was important for me to explain how bathing this frequently can traumatize sensitive skin. Many patients thought it was really funny and ridiculous when I suggested bathing less frequently (not unlike reactions I get back here in Philadelphia), so it was incredibly helpful when one of the Motswana nurses at Princess Marina helped reinforce this message by explaining it clearly in a pamphlet written in Setswana, the local language.
A nurse folds eczema pamphlets that are written in the local language. The pamphlets explain to patients how to treat eczema, and that bathing two to three times a day can aggravate this skin condition.
The distances patients would travel to come to the clinic were amazing. They often arrived early in the morning to get in the queue to see a dermatologist and would wait patiently for up to four hours. It was an incredible reminder of the privilege it is to be a physician and to have people so value your time and expertise.
Every Thursday, we went to an outreach site. These sites were two to three hours away from Gabarone and were a way to reach out to people without the resources to travel. Knowing how long they have to wait for another dermatologist to come to town (four to six weeks), we couldn’t turn anyone away, and we typically evaluated 30 to 40 patients each time. This was the most exhausting day of the week, but it was a fantastic experience.
It’s important to make sure people who need us can reach us, because we’re not on every corner.
I also saw some severe dermatological conditions, including toxic epidermal necrolysis. I’ve never seen anyone die from this condition in the United States, but while I was in Botswana I cared for a 19-year-old woman who passed away after developing this condition from an antiretroviral medication. She faced many challenges in her clinical course, but if there is one lesson I can take away from this tragic story, it is a renewed sense of gratitude for the amazing teams of medical professionals, including nurses and medical assistants, who we are so lucky to work with in the United States. The network of care providers can make all the difference in the world to a patient.
At Princess Marina morning rounds, I had the chance to join the internal medicine residents and medical students to hear about the latest admissions (a good opportunity to find out about the latest interesting rash on the wards) and participate in the didactic sessions, both as a learner and as a teacher. This was an incredibly valuable experience and a chance to learn more about the other issues at play in the lives of these patients.
Once I was back in Philadelphia, I had the chance to continue to explore global health issues through a global health course offered to residents from internal medicine, dermatology, radiology, and other specialties. The course culminated with a trip to Washington, D.C., to meet our representatives and voice our concerns with regard to many of these issues, both globally and locally.
My experience in Botswana and through the global health course shed light on the many similarities between global health outreach and community health outreach. I’ve been volunteering at a local clinic for uninsured Hispanic patients in Philadelphia and find myself using many of the same strategies I used in Botswana to maximize the efficiency of treatments and minimize the costs associated with them.
The AAD’s AccessDerm program is another example of a way to increase access to dermatologists locally. Here in Philadelphia, local primary care physicians in resource-limited clinics can upload images and clinical data from patients who need dermatologic help. With the power of teledermatology and mobile applications, dermatologists are able to reach out to help more patients.
To anyone who’s thinking about participating in the Resident International Grant program, I would say: Go for it! Bring an open mind and a good camera! Beyond the clinic, there is beautiful culture and landscape to enjoy and appreciate. It has been almost a year since my trip, but I constantly reflect on my experience and hope to continue to grow into a better physician because of this amazing opportunity.
Apply for the Resident International Grant program by April 30. Applicants will learn the results of their applications in May and November. Those selected will complete their rotations between January and June 2014. Learn more about how to apply here.
Inbal Braunstein, MD, is a dermatology resident at the University of Pennsylvania Health System in Philadelphia. She worked in Gaborone, Botswana, from June 25 to July 20, 2012, through the AAD’s Resident International Grant program.
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