How to practice medicine in a rural third-world mission clinic - Brazil

"We are not in Kansas anymore."

Paramount to practicing medicine overseas is an understanding of how different the people we serve abroad are from our patients back home.  Villagers in a remote location may have no western concept of time, and therefore saying "one pill every eight hours" is meaningless to them, since the average patient won't own a clock. But, since they live in an agricultural society, they do understand the movements of the sun, which you can reference in your instructions.       Keep it Simple   Most villagers have no knowledge of a microscopic world, nor understand that the "more is better" philosophy of pharmacokinetics is flawed. You must give them simple, explicit instructions regarding their medicines, and anticipate their creativity for noncompliance. I often say something like "one pill a day-no more, no less-until all the pills are gone." I will have them repeat my instructions verbally, since many are illiterate and won't follow written instructions.

"One to a customer, please"

As a general rule, I only write a prescription for one medicine per patient. They may additionally receive a bag of vitamins or analgesics, but no other medicine. The reason is that most villagers have a primitive understanding of pharmacodynamics and microbiology. They can easily confuse 2 sets of little white pills, inadvertently taking the wrong medicine. We can limit their ability to harm themselves by limiting our treatments to one medicine. Remember, first of all do no harm.

"First of all, do no harm."

Don't employ medicines that require close monitoring or follow-up lab work. Once the mission team leaves, oftentimes there is no one who can monitor for side effects. Don't leave the villagers to deal with the specter of adverse drug reactions.

Remember Quantity

The average day at the clinic brings more patients than the doctor can see. Many people have traveled great distances to see you, and may not have access again to a doctor or dentist if we don't see them.  It's imperative to keep up the pace to impact the greatest number of people in the shortest amount of time. Focus your history-taking and physical exam. Don't ask lengthy review of symptoms (since they will always be positive). Don't get bogged down in a 30 minute contemplation of the possibility of a disease you can't treat, when you could have seen 10 people with diseases that you could have treated. With proper triage skills, each doctor should be able to see 75 people a day.

Remember Quality

While each patient encounter can't last 30 minutes, the reason for the clinics are not to generate numbers, but changed lives. Occasionally God will move you to get involved deeper. Central to her problem was guilt over being the town prostitute. The physician and translator were able to lead her to Christ, and she left the clinic a well woman-something no SSRI could have done.

Remember Pharmacokinetcs

Many of the people we see abroad are of small stature, with a low body fat count, and (without a lifetime exposure to OTC pharmaceuticals) don't have a P-450 system that's all revved up. So, often times you can get away with a lower dose of medicine than in a comparable American patient. Most villagers are pharmacologically naive, and will respond to simpler treatment. For instance, an Otitis Media may respond to 250mg Amoxil in South America, whereas you would use 500mg of Augmentin in the U.S.

"Common things are common"

This little phrase has helped me a lot in my career, whether practicing medicine in the U.S. or abroad. Just because you're in a tropical environment doesn't mean that a stuffy nose is a case of Crimean Congo Hemorragic Fever. Remember that the human condition is after all a human condition, regardless of where you live.

Read up on Anticipated Problems

Just resign yourself to seeing more cases of intestinal parasites, scabies, and lice in your mission's clinic experience than you have in the last 20 years of private practice. A little focused reading beforehand can go a long way diagnostically.

Remember the Basic Tenets of Medicine

Though you may not be able to do an MRI Scan in a village without electricity (or have access to an MRI Scanner for that matter), the basic elements of the medical evaluation, the history and exam, are still your best tools in assessing the patient. Your strength as a doctor today is still the same as it's been for centuries-the bond of the doctor/patient relationship.

Try Home Remedies

You may be able to teach a villager how to utilize something in his environment to treat their ailments-such as aloe vera for minor burns. These kinds of remedies will last long after the prescription medicine you gave them is gone.

Treat One Complaint

Patients in a mission's clinic will overwhelm you with a litany of complaints. Since they haven't seen a doctor in so long, they will want to tell you everything, and will have unrealistic expectations that you can magically fix everything (not unlike our patients in the U.S.). Pick out one problem that your skills and formulary limitations will allow you to treat competently. Ignore the rest. The temptation is to treat everything, which leads to more harm than good for reasons we've already discussed. Remember that Christ left many diseases untouched, focusing rather on a few things that He could impact significantly.

You can't go Wrong with Vitamins

In the pediatric clinic, parents often bring their children in for "checkups" and they just want assurance that their child is healthy. This is understandable when you live in a village where the infant mortality rate is 50%.  You will frequently hear the parents say their children are too small, weak, or not growing enough, when you perceive it to be an otherwise healthy child. In this situation, you can't to wrong with vitamins. I usually give each child a one month supply of vitamins. Every patient in the adult clinic will complain of pain-understandable, when you consider that they've spent a lifetime doing back-breaking manual labor. You can't go wrong with an analgesic here. I typically give every adult 30 pills of Ibuprofen or Acetaminophen.

Learn to say "No"

You will be barraged with impassioned pleas for everything from requests to do the miraculous, to monetary donations, to the occasional marriage proposal (to help them migrate to the U.S.). Although not a problem for my toddler daughter, most physicians on their first mission trip have a hard time saying no. Remember you're only human and can only change a little bit of the misery they will encounter living in an impoverished nation. Most of the time, they will accept a diplomatically phrased "no" with fatalistic resignation.

"Thanks for coming, but…"

When a medical/dental brigade comes to town, it's like the circus has just arrived, and we are the clowns. People will clog the clinics trying to see the spectacle, but also impeding the patient flow. Encourage them to move along.

Don't Create Beggars

Typically when we hold a clinic we charge a nominal fee-usually done so at the request of our national co-workers. I once asked why they wanted to charge people who are so poor. They responded, "Our greatest natural resource is our people. If you give it to us free, you make us beggars. If they pay for the clinic services however, their dignity remains intact."

Take a Break!

Remember that Christ left the crowds of needy people to rejuvenate and reorient. Since we aren't divine, we shouldn't expect our endurance level to be any better. Often first timers are so moved by the poverty they see, they want to do as much as possible in the little time they have in the clinic. However, they will actually get more done if they take regular breaks to recharge their batteries.

Don't Show Favoritism

Even on the way to the outhouse, you'll be bombarded with people asking to break in line or for a clinic ticket for someone who didn't register along with everyone else. Just because someone is the local schoolteacher or politician doesn't inherently give them a greater right to healthcare. Showing favoritism can spark a crowd to riot-literally! Remember that Christ said we shouldn't be a respecter of people ñ i.e. placing the rich man on the front pew of the church (which often doubles as the exam table in a mission's clinic).

Only Treat the Patient You've Seen

You will get requests from patients to send them home with extra medicine for a sick relative who couldn't make it to the clinic. As a general rule that is as bad of an idea in the 3rd World as in the U.S. Without taking the patient's history and doing an exam, it's hard to get an accurate diagnosis, let alone prescribe an adequate treatment. Studies in the U.S. have shown that even for common conditions (i.e. candidal vaginitis, UTIs etc.) patients usually make the wrong diagnosis-even more true when abroad. The potential for doing harm to a patient you've never seen is great, and that could undermine the testimony of the entire clinic.

Remember, only Christ will Make the Difference

I see doctors who sign up for a mission's trip with great aspirations for curing the ills of the world's poor, becoming horribly frustrated and disillusioned as to how little of an impact they really had. Everyone they treated for parasites will get them again. For every tooth a dentist pulls, another one will become rotten. Realistically, what we do in a short-term mission's clinic is very limited and very temporary. In truth, it is usually the volunteers who gain more from the experience than the villagers they treat. But the purpose of such a trip is not to revolutionize the country's healthcare infrastructure. Even the most extensive humanitarian efforts can only impact the individual so deeply, but Christ can leave a permanent impact on a village in a way that no prescription can.

As a physician in the U.S., I take care of some of the richest people in the world, but find that they struggle to no lesser degree with the deeper issues of life (that are too often labeled as a mental health diagnosis or as an expression of psychosomatism). Ultimately many of their problems are spiritual in nature, and require a spiritual solution.  People in the 3rd World are often more receptive to spiritual discussions than our patients in the U.S. For, as Scripture says, "God has made the poor to be rich in faith."  Often we can do our best healing with a kind word and empathetic prayer.