Monthly Archives: July 2012

Growing recognition of the potential in short term trips

By Lawrence Loh, MD MPH

In the June 2011 issue of the American Journal of Medicine, a piece by Wilson and others explore potential guiding principles that could be used to engage further development of short-term global health volunteerism.

Rules of Engagement: The Principles of Underserved Global Health Volunteerism
(may require access via institution or subscription)

The piece starts out with a recognition that such trips offer “unique personal experiences for volunteer healthcare providers” but that the concerns of longer term, meaningful, lasting benefits for the community remain. After reviewing potential benefits to participants as well as potentially harmful actions, the authors propose four categories of ethical principles–service, sustainability, professionalism and safety–that could serve as a framework for such short term trips.

Our group is extremely encouraged by the appearance of this work in published literature. It may represent a shift to recognition of short-term efforts in academia, which could hopefully engender more interest and solutions to make sure that we get improve the quality and quantity of such efforts. That said, the paper itself still represents the old paradigm in more than a few ways:

  1. In the first table that describes the potential benefits realized by trainees going on these trips, the authors identify:
  • Opportunity to encounter diseases not typically encountered in United States
  • Opportunity to see more advanced stages of select diseases not commonly seen in United States
  • Opportunity to improve physical examination skills and procedural skill sets (via less reliance on laboratory, radiology, or consultation options)
  • Opportunity to understand the fragile socioeconomic relationship among local government, hospital, and local medical clinics
  • Greater awareness of cultural sensitivity and importance of patient communication

    Save for the fourth bullet, this list still comes from the lens that presupposes all medical trips are solely to improve training and healthcare delivery in the developed world. It is ultimately speaking of the benefits received by trainees as being what they ultimately bring back to practice in the U.S. or wherever they hail from. It doesn’t look at the  potential benefits of medical trips to individuals as they develop a greater awareness and ability to include global health experiences in their future careers.

    The same Wisconsin study we looked at two weeks ago showed that interested young professionals are keen to incorporate some form of global health into their future careers – away from the day to day at home. In that sense, getting to go on short term medical trips means they have the chance to forge connections with a community abroad, and continue to contribute to a cause that they personally feel worthwhile and experienced in dealing with.

    Some other possible benefits: networking and developing important connections that could transpire into ongoing global health experiences and career work. Identifying a personal niche in global health that could guide their work and their inspiration. Valuable research and publication opportunities that could kickstart a career. Mentorship from experienced preceptors as to how to best balance their desire to make a difference with the need to grow their career and specialty at home.

    2. In discussing the harms, there was no balancing of the viewpoint by discussing potential benefits of such trips to these communities. Indeed, stand alone trips likely have a greater balance of harms, but there is always that potential that the community could benefit from coordinated efforts, or from a sudden, passionate commitment by a changed young professional to devote a good chunk of their career into helping the community they’ve been welcomed into.

    Inasmuch as these trips can harm, figuring out how they can genuinely help communities (and what is the best way to make that happen) should become a greater academic focus – look for the successful models. The authors do make this point in their final discussion, concluding that provision of vaccines, basic sanitation and hygiene, and other such initiatives may actually have a more lasting benefit than acute care models.

    3. The ethical principle of “doing no harm” is discussed as the very basis of much of this work. And in a world where many of these short term trips amount to nothing more than medical tourism, moving to “doing no harm” is definitely a worthwhile and worthy goal. But supposing we do manage to minimize the harms within the community and in the care delivered to these populations. Leaving our ultimate goal as to “do no harm” in that sense implies that while benefit would be realized by the U.S. organizations and trainees carrying out the work, the receiving community would not benefit beyond just not being left in a worse off position than they were before. In that sense, the ideal of social justice and equity may still represent the ultimate ethical underpinning of our work; as Bruce Springsteen famously said, “Nobody wins until everybody wins.”

It is encouraging to see academic literature grow on this subject. It will be curious to see how things will unfold over the coming years, as a new generation of global health leaders comes forward with passion and ideas.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.

Short term volunteer trips abroad: an answer to the challenge of incorporating global health into one’s career?

By Lawrence Loh, MD MPH

Finishing a recent residency rotation in New York City, I had the opportunity to speak with some of the residents there about their plans for the future. All of us final year residents had plans to head back to some combination of clinical work and public health, but those of us with global health aspirations seemed a little bit more cynical about the possibility of pursuing our chosen field. In describing her plans for the future, one of the residents mentioned she would be signing up with Doctors Without Borders (MSF), despite significant debt load and familial obligations. We also talked about the likelihood she would be engaging in work that was not commensurate to her training – starting out from the “very bottom” of the totem pole, as it were.

Her response was one almost of resignation: “Well, that’s just the way it has to be, right? If they want me to pour tea for them, then I’ll do that. Whatever it takes to get your foot in the door.”

Therein lies the great irony for most young professionals pursuing work in global health and development – unless your family is independently wealthy and with the right connections, you’ll spend an immense amount of your personal time and finances to gain mixed experiences that will potentially land you that (often poorly) paying first job in some sort of long-term arrangement for the sake of “getting yourself in the door.” And for many, that’s a dream too far – and many global health aspirants end up throwing in the towel and embracing “reality”, giving up their pursuits abroad for the sake of staying home and paying back their seemingly insurmountable educational debt, and maintaining their certifications and ties that are so critical for ensuring they can do so effectively.

Yet every global health career day you go to, every fair that you visit, the same stories come out. The same unfollowable tales from those who have “made it” (almost a la Hollywood or entrepreneurship) – these folks either had a lucky break, a person who paid them a living wage in pursuing the dreams abroad, or a family that let them do unpaid internship after unpaid internship until they landed that first position. They sold all their worldly possessions and moved to Africa for 10 years, gaining that experience, sacrificing family, earning potential, and time, to succeed in finding a job that filled their passions and skills.

It really shouldn’t be like that.

The current global health workforce set-up and “road map” to success strings along young professionals who may have the skills and passion to succeed, but lack the resources or support to do so. It results in the privileged gaining those posts and those positions, regardless of their abilities or skill set – but simply because they’re the only ones who can pour enough money and time into building those networks and those collaborations. And perhaps this is like “anything else” in life, but moreso in global health does it seem truly like whoever has the money and whoever knows the right people has play.

So where has this paradigm led organizations today?

In a news article published in the Canadian Medical Association Journal (CMAJ) just a year and a half ago, MSF in Canada described their recruitment shortages and the pending crisis in recruiting Canadian physicians.

Médecins sans Frontières seeks for more Canadian physicians

The comments from the MSF recruiter are incredibly interesting. On one hand, the recruiter recognizes that high debt loads, the demands of residency and life in Canada affect the ability of young Canadian physicians to go abroad for more than 1-2 weeks at a time. At the same time, the recruiter goes on to denigrate the work of interested young physicians who can contribute that amount of time, calling them “tourists” and “people who are [only] interested in cross-cultural experiences, in doing a couple missions for their resume […] their primary motivations are not the humanitarian objectives of our organization.”

But in other articles, we know that humanitarian reasons and improvement of work abroad is a reason why many people pursue medical volunteer trips – regardless of how long they are. A survey of Wisconsin residents and medical students found that 82% of students wanted to continue incorporating global health in their future career, with 63% wanting to work with underserved populations abroad:

Needs assessment of Wisconsin primary care residents and faculty regarding interest in global health training

If that doesn’t sound like a disconnect, I don’t know what else there is.

MSF and the rest of the global health community needs to think long and hard about how things are. Taking six to nine months off for young physicians is not something those from less-financially advantaged backgrounds can do, in the face of crushing debt loads, familial obligations, timing, and training requirements. Short-term medical trips represent the only opportunity for these young professionals, ironically so, since despite the enormous financial and personal investments that go into it, such short-term work often represents the “placebo” of global health: both the receiving community and the visitors feeling “good about themselves” without anything ever really changing.

There needs to be a paradigm shift, a challenge, a purpose and improvement of such opportunities. The future of the global health workforce might be how well we as a society adapt to remote technologies, allowing people to be involved for weeks at a time abroad and remotely from home – by leveraging the internet, collaborative models, and shared resources and vision.To stick to the romanticized version of the solo doctor in Africa represents the potential waste of a huge groundswell of passion and talent from young physicians. At the same time, we know short-term work as it stands is also untenable.

It’s time to make these opportunities both accessible and valuable. We see the interest. Let’s figure out  how best to harness it, instead of turning people away – instead of having them just serve tea – and instead of leaving them to languish in “medical tourism” venture after venture. Young professionals have so much more to offer – in fresh eyes, passion, skills, and ability.

As we implement our coordinated model of short-term care, we hope to move the conversation forward in providing at least one innovative way to open those opportunities to those young professionals who want it and are good at it, not merely those who can afford it, while also ultimately benefiting those populations abroad that these short term trips aim to serve.

Dr. Lawrence Loh is Chief Medical Officer of The 53rd Week, and a physician in Toronto, Ontario, Canada.