International Medicine

I returned from a medical trip to Haiti a little less than a week ago. I went through an organization called Project Medishare that aims to provide access to healthcare to the people of the rural, central plateau through local clinics and mobile clinics set up by international volunteers, like us.

I have been on a similar trip before to Costa Rica and Nicaragua, and both times I was struck by the EXTREME poverty around me. How much can sporadic primary care change the lives of people living under a faulty social structure? Although there may be a fairly constant stream of mobile clinics coming through somewhere close (and by close, I mean within 60 miles) to their vicinity, it's not like they have the same doctor who knows their history or even a different doctor that can look up their past medical history in a chart. Every time they see a new (most likely foreign) doctor, they have to start all over -- building a relationships, recounting their symptoms -- all through the barrier of non shared languages. Yes, translators help -- in fact, they are essential, but it's still not as good as being able to speak to and understand your patient.

It's an internal struggle doing international work -- am I really making a difference? Am I providing an essential service? Am I just doing this to make me feel better about myself? Am I doing more harm than good -- prescribing medicine without follow up, without knowing if the patients knows how or why they are taking their medication? I'm not the first person to face these struggles, there have been journal articles examining the effectiveness of international medical work, and even the different articles can't come to agreement-- are we doing something good or bad?

After my experience, I would say we aren't doing anything bad, and we are actually mostly doing good, AND occasionally, we're even doing something life changing. The medications we prescribe and give to our patients are mostly drugs most americans can get over the counter -- pain medication, antacids, multivitamins, etc... There is the occasional antibiotic, but honestly, antibiotic prescription abuse probably occurs more in the US than in Haiti. The doctors are very careful about prescribing anything that needs follow up --ex: anti hypertensives. And yes, it is hard to tell with a lot of the patients if they are actually sick or just describing the symptoms they know will get them the medication they need for when they really are sick and the american doctor isn't there. But when I think about it, so what if they are faking it? They are doing what they need to do in their circumstances. If I didn't have regular access to medicine, I'd probably do the same thing -- why not get some medications and get seen by a doctor while they are there? Also, I think having the doctor look at you and say "Your physical exam is normal" can provide a lot of psychological benefit.

The "life changing" patients -- the ones that have decompensated heart failure, glomerulonephritis, severe infection, early stage dementia, failure to thrive, or AIDS -- that maybe 1-3% we see, we can help them. We might not be able to be the hospitalist administering their care, but we can make sure they get that referral, that money, that transportation to get to a hospital and get taken care of.

And you know what? that 1-3% makes it completely worth it.

Patient Autonomy

When I was in clinic today, my preceptor (Dr. M) told me about a patient he saw last week. An 86 year old man came into the office with his son and daughter because of altered mental status. His children reported he has been getting progressively more confused and the patient could barely stay alert during the office visit. At one point, they had given him coffee to try and help him stay awake, and he felt asleep holding the coffee, ending up spilling it on himself.

Altered mental status in an older patient is never a good sign, so Dr. M discussed going to the emergency room with the family. The patient was insistent that he didn't want anything done to him and he certainly didn't want to go to the emergency room. Dr. M and the family compromised and decided to do blood work in the office that day and set up an appointment to get a CT scan the next morning (to rule out stroke, etc...)

The blood work came back the next morning with HUGELY elevated liver enzymes and some other minor elevated electrolytes. Dr. M immediately called the daughter to advise them once again to go the hospital. He even arranged for a hospitalist to admit them directly, so they wouldn't have to wait in the ER. The daughter said the previous night had not gone well, so she would discuss it with her brother and father. She later called Dr. M back that day to tell him her father had passed away, not wanting to go to the hospital.

This story bothered me. At the core of it, lies the issue of medical ethics. One of the four pillars of medical ethics is patient autonomy -- you can't make a patient do something they don't want to do, but as their doctor, you feel a certain level of responsibility for their well being. So what do you do? Can you force someone to go the ER? If someone has resigned themselves to death, but you know there is an easy way to save them, do you just let them die? I think it's one of the bigger lessons in medicine that I'll have to learn -- to accept that you can't control everything, sometimes it's the disease and other times it's the patient's will.