1. WILLIAM LOVETT M.D. SARAH SPADAFINA M.D. SEPTEMBER 8, 2012 Improving Sustainability in a Recurring Short-Term, International Family Medicine Experience

2. Some Background This talk developed out of many years of experience doing short term medical missions in private practice. Then the development of a short-term, international family medicine rotation for students and residents.

3. Why Talk About This? There have been frequent questions and criticisms about short term medical missions, many well founded. Many of the answers to the criticisms center around improving sustainability. Improved sustainability ensures that the benefit for students and residents continues into the future and provides a longer term impact.

4. Another Reason to Concern Ourselves with Sustainability AAFP Recommended Curriculum Guidelines for Family Medicine Residents and Global Health: Value should be placed on continued accessibility and accountability to his or her patients, especially with regard to the sustainability of health care delivery in international settings.

5. Increase in Interest in Global Health Experiences About 30% of U.S. medical school graduates enter residency with some international health experience. 2/3 of Family Medicine residency programs offer international electives At least 6,000 short term medical mission trips originate from the United States each year.

6. Concerns About Results and Outcomes Some Questions Are real needs being met? How does the short term group interact with the existing healthcare system? Does it create dependence? Does it lessen the incentive for the local government to fix problems? Does it create burdens for the host area? Does it contribute to a perception that the local physicians are inferior?

7. More Questions Do patients wait for the foreign physicians instead of getting care when they need it? Do the visiting physicians do any training of the local physicians in a collegial way? Do they coordinate with a group that has a long term presence? What do they learn from the local providers? Is follow-up care available? How good is the quality of care?

8. Questions about how to measure success. Is it, patients seen or prescriptions given? Or Is it, change in the incidence, prevalence or control of a disease? Or improvement in long term access to healthcare and interaction with the local healthcare system?

9. Sustainability Improving sustainability may provide the answer to some of the questions about short-term medical missions. Improving sustainability may improve health outcomes.

10. Sustainability, What is it? The capacity to endure or continue to fulfill a need; continued success into the future. Nourish- sustentar in Spanish Support or uphold- Sostener, apoyar or respaldar A long-term focus, including fostering independence by building local capacity.

11. Background Dr. Lovett did many short-term medical mission trips to Mameyes, Jayuya, Puerto Rico. These were two week trips to do primary medical care in a county sponsored and church supported clinic.

12. Background In 2008 the international experience within the residency program began. Dr. Hostetter, one of the residents, had an interest in global health and mission medicine. Dr. Hostetter and Dr. Lovett visited a clinic in the DR that was known to us. The daughter of a local (Lebanon, PA) ophthalmologist, who was a Peace Corps volunteer in the area, with the help of the Lebanon Rotary Club, was able to rebuild their clinic building.

13. Background Medical teams from the Lebanon PA area had gone periodically, providing acute care in “brigades”. The trip in 2008 consisted of two providers who went for 1 week and did acute care, but more importantly, evaluated the site as a location for recurring international trips.

14. Background Groups have returned yearly to the same location since 2008. They have included family medicine residents, medical students from the Penn State College of Medicine, faculty physicians from the family medicine residency, community physicians, nurses, interpreters and a cook.

17. Background During our second and third trips convenience surveys were done of families in the neighborhood, asking about health status, illness etc. These were carried out by resident physicians with the help of interpreters.

18. Health Survey Helped us learn about health needs in the community. Improved the cultural competency of the resident physicians and the whole team. Put resident physicians in contact with the community, working with local organizations and individuals. They learn about the area and even see first hand the problems of the local people.

22. Is Primary Care Different? Much of what we do is not amenable to “dropping in” (brigades) and doing a procedure like extracting teeth or removing a cataract, then leaving. Much has been written about the potential harm that can come from this approach. Even in the third world, follow up, relationships and ongoing care are extremely important.

25. Principles we have learned Return to the same location yearly or as often as you go. Bring only medicines and supplies that they already use or can use. Learn as much as you can about community needs.

27. Principles we have learned Go to a location that can provide follow up care and ongoing care. Collaborate with the local physicians and health system.

28. Principles we have learned Collaborate with the community and local organizations.

29. Principles we have learned Learn from local providers about local diseases and epidemiology.

30. Principles we have learned Expand your goals beyond evaluation and treatment to health teaching to the community and physicians

31. Principles we have learned Focus your efforts. Remember; local providers can probably do acute care better in their setting than you can.

33. Focusing our efforts We decided to “specialize” in hypertension and diabetes. We learned that the local primary care physicians were not treating these problems primarily, but were referring them to cardiologists or endocrinologists. The obstacles of travel/distance or money made it difficult for many of the patients to get adequate treatment.

34. Principles we have learned Work within their system. Obtain permission. Follow the rules. Try to be a part of the community while there. Don’t live apart. Teach about the community before going.

35. Continuity and Sustainability Proximity-Helps to keep travel costs down. Rotary Support

36. Continuity and Sustainability Working with a local organization; the women’s club.

37. What Factors Affect Sustainability? Politics/Safety Environment/health issues Medico-legal climate Financial burden of the mission Medical environment of the location Facilities Support there

39. What ideas have we generated from doing this talk? Try and communicate better with the Dominican physicians between trips. Try and measure outcomes better. Not only BP outcomes, but survey local caregivers about outcomes. Keep better records that can be kept in their charts. Do more teaching.

40. Other Ideas and Dreams Partner with other family medicine residencies that would be interested in going to the Dominican Republic. Partner with family medicine residencies in the Dominican Republic.

43. ANY QUESTIONS? Thank you!