Practicing Medicine in Rural Third-World
Practicing Medicine In A Rural Third-World Mission Clinic
Adapted from Grant Correll
“We are not in Kansas anymore”
Need to have a basic understanding of the people you will be serving and how they differ from patients in the U.S. For example, if it’s an agricultural society, medication instructions should be based on movements of the sun “one pill at sunrise and one at sunset” instead of “one pill every 12 hours”.
Keep it Simple
Medication instructions should be simple but explicit, as there may exist a “more is better” philosophy of pharmacology. “One pill a day-no more, no less-until all the pills are gone.”
“One to a customer, please”
Try to limit the number of prescriptions per patient as most patients were not accustomed to managing a poly-pharmacy. Aim for one Rx med, a bag of vitamins, and some analgesics. Remember first, do no harm.
Aim to be low maintenance
Avoid medications that require close monitoring, follow up lab work, or have a long list of adverse drug reactions.
The clinic will often attract more patients than can be seen in a day. Many will have traveled great distances and not have access to other health care providers if you don’t see them. It’s imperative to keep up a pace to impact the greatest number of people in the shortest amount of time. Focused history and physical with a limited review of systems. Focus on diseases that you can treat instead of 30 minutes on possibility of diseases that cannot be addressed.
While each patient encounter needs to be brief, remember your goal is to change lives.A few minutes of education (aloe vera can be used for a burn) can impact a patient for years (far more beneficial than a 90-day supply of pills).
Many of the people you will treat are “pharmacologically naive”, i.e. without a lifetime of OTC exposure or P-450 systems in overdrive, so lower doses will cause the same response. Example: 250mg of Amoxil works great vs 500mg of Augmentin that you would give in the U.S.
“Common things are common”
Just because you’re in a tropical environment doesn’t mean that a rash is Chikungunya fever. Common human diseases (candida and scabies) are common, regardless of where you live.
Remember the basic tenets of medicine
MRIs are great but the basic elements of the medical evaluation, the history and physical, are still your best tools in assessing the patient.
Treat one complaint
Since most patients haven’t seen a doctor in a long time, they will often want to give you a list of complaints and expect you can magically fix every one of them (similar to our U.S. patients). Pick out one to two problems that your skills and formulary limitations will allow you to treat competently. Forego the rest.
You can’t go wrong with vitamins and analgesics
Parents often bring their children in for “checkups” and they are simply looking for assurance that their child is healthy. You will often hear complaints that they child is too small, weak, not growing or not eating, when it appears to be a healthy child. A bag of vitamins is normally the best remedy.Most adults will have pain in one or more joints which is understandable considering the amount of manual labor involved in every day life. Ibuprofen 200mg or Acetaminophen325mg go a long way (remember OTC naive).
Learn to say “no”
You may be confronted for non-medical requests (monetary, visa sponsorship, or even marriage proposals). It is completely appropriate to simply say “no”. It is usually well received and respected.
Take a Break!
Often the first time at the clinic is overwhelming and you want to do as much as possible in the little time you have but be careful you don’t burn out. Take breaks and re-charge your batteries.
Don’t show favoritism
You’ll be bombarded with people asking to break in line because they have to get to work or school, or bring an extra family member in with them for treatment who didn’t register along with everyone else. Even police officers or the local clinic workers don’t have a greater right to healthcare. Showing favoritism can cause huge problems, even physical altercations between patients. Be fair and stick to basic principles of patient flow.
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. Although some exceptions like scabies could be appropriate, in most cases it is a bad idea to prescribe without taking the patient’s history and physical.
Remember, what we can accomplish in a one week mission clinic is very limited and temporary but with long term commitment to a community, progress can be measured and individual lives impacted. Most volunteers gain more from the experience than the patients who are treated. So while you are there, take the time to soak it all in, and appreciate the unique opportunity you find yourself. Enjoy and Best wishes, Marisa Rea, PA-C