1. Trabajo Común — Lessons learned from establishing a sustainable international medical mission experience Ciarán DellaFera, MS III and Jordan White, MD UMass Medical School January 21, 2011 ©2011 University of Massachusetts Medical School

2. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Objectives 1.International health and medical education 2.Addressing concerns about short-term mission trips 3.UMass Medical Mission history 4.Top priorities in organizing the trip 5.Turning a successful medical mission program into an medical education enrichment elective

3. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions International health experiences are increasing in popularity among medical students: –1978: 5.9% of graduating students –2007: 27.3% of graduating students –UMass: 58% of the class of 2009! Current opportunities include: –Student-led interest groups –Language courses –Global or International health concentrations/tracks –Electives –Fifth year of medical school –Short-term “mission” trips –Integration into the curriculum Why is international health important to medical education? ➝ Demand (Drain)

4. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Educators and students have called for more: 1.Teaching and training opportunities Burden of global disease Travel Medicine Immigrant Health (Cultural Competence) 2.Research regarding both student and patient outcomes 3.Integration into the core curriculum Value for all students Ensure sufficient resources Why is international health important to medical education? ➝ Supply (Drain, Houpt, AMSA)

5. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Students with clinical experience in a developing nation: Are more likely to pursue a career in primary care Are more likely to work in resource-poor settings Report having improved physical diagnosis skills with less dependence on technology Have increased compassion and cultural competence Have a greater understanding of global health (Drain, Thompson, Godkin ) Why is international health important to medical education? ➝ Benefits

6. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions However, there are limitations with many studies of this issue –Selection bias –Subjective evaluations Most experiences that have been systematically studied are: –Longer, or integrated into a longitudinal track –Based on resident experiences Research is limited in terms of the impact on host populations –Concern for potential negative effects Why is international health important to medical education? ➝ Research Limitations

7. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Self-serving: value only for volunteers Unmet expectations: what does the community need? Ineffective: temporary, short-term solutions Imposing burdens: ineffective care that leaves waste behind Inappropriate: not following standards of care Collaboration: distributed educational health system Shared expectations: patients, promoters, local health care providers, local mission team, medical volunteers Effective: local management of continuity of care Conscientious: local supervision of care plans, formulary, and supplies Appropriate: training, quality control, oversight, and shared responsibility lead to sustainable outcomes Concerns about short-term mission trips (Suchdev)

8. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — History Began in 2005 with 10 medical students In 2010, the mission composed of: –35 students 5 nursing students 23 first-year medical students 7 second-year medical students (including 4 trip leaders) –7 preceptors 1 NP, 1 RN 5 MDs (3 family, 1 medicine, 1 OB/GYN) –32 females, 13 males

9. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — Destination

10. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — HGBS Jean Luc Phanord land grant from Central Romano Corporation Construction began in 1989 Opened to patients on November 9, 1997 30+ beds 50 medical care professionals 35 trained technicians and staff 30 specialty departments 40,000 patients a year

11. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — GSMC Good Samaritan Mission Council — Batey Outreach –Regularly scheduled batey urgent-care clinics treating nearly 30,000 people in 107 bateys (yearly) –CAWST biosand water filter program –Trained batey health promoters Hypertension management Adopt-a-batey program Nutrition program Family planning

12. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — Trip Planning Fundraising Training –Skills sessions, medication and common diagnoses review Medication Packing –Revising to improve efficiency Data review from previous trips

13. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — 2010 Trip Info 2010: 852 patients seen by medical students in 8 bateys –Ages 1 month – 96 years 260 (30%) under 18 –472 female; 363 male Three days of surgery –Cervical cancer –Fibroids

14. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions UMass DR Mission — 2010 Trip Info Hypertension –319 people (54% of adults) with BP >130/90 Malnutrition, volume depletion Skin infections, vaginal infections Vague/multiple symptoms (“gripe,” “pain all over”) Joint pain, back pain Vision problems Dental problems Asthma

15. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Mission Program Priorities 1.Partnership 2.Shared Expectation 3.Quality Care 4.Effective Care 5.Appropriate Care

16. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions 1. Partnership BateyHGBS GS Mission Council Medical Students & Preceptors

17. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions 1. Partnership Batey Health Promoters Community Leaders Needs Assessment HGBS Medical Director Mission Project Supervision Care Guidelines Continuity of Care GS Mission Council Interpreters Transportation Room/Board Admin Support Staff Program Mgmt Medical Students & Preceptors People-Power Expertise Medications Resources

18. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions 2. Shared Expectations Patient-centered Care –Patients view Buen Samaritano as their medical home –Students initiate longitudinal care for Buen Samaritano –Clinical teams build a knowledge base of clinical events for both Buen Samaritano and UMMS continuous improvement

19. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions 3. Quality Care Pre-trip skills sessions 1 junior and 1 senior student at each interviewing station, with floating preceptors Referrals to hospital made for complex cases – funds for transport are available Follow-up arranged with local health promoters Graduate Nursing Student First Year Medical Student Patient Interpreter

20. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions 4. Effective Care Trial and evaluation of new programs –Patient ID Cards –Patient BP Treatment Card –Medical Record Cards –Pap Smear & Women’s Health –Formulary & Supplies Database

21. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions 5. Appropriate Care Student training tailored to batey medicine –Common dermatological findings –Treatments for common problems –Formulary review and medication dispensing –Clinic set-up and operations –On-site lab testing –Vital signs clinic

22. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Trabajo Común — Work in Common

23. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Optional Enrichment Elective Development Development of an optional enrichment elective for pre-clinical students: –8 sessions in preparation for the DR Trip –Interdisciplinary: open to and led by medical and nursing students –Goals: Improve patient care and education Explore the ethical issues surrounding the purpose, quality, and effectiveness of the trip Understand the principles related to health in the bateys Develop relevant skills in order to improve care on the trip

24. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Current Curricular Evaluation Student evaluations of past 4 years of trips collected by the Office of Undergraduate Medical Education/Division of Research and Evaluation –Standardized for UMass, competency-based –Quantitative information: Likert scales –Qualitative information: open-ended questions

25. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Current Curricular Evaluation Questions identical to those on evaluations of Physician, Patient and Society (PPS) PPS goals: –Enhance skills in the content and process of patient care –Integrate basic science material with principles of epidemiology, community health, and medical ethic –Create meaningful, healing relationships between students and teachers, students and patients, and students and the broader communities in which they work.

26. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Quantitative

27. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Qualitative Strengths, significant learning experiences Weaknesses, suggestions for improvement Surgical experiences: strengths, suggestions Additional activities that were helpful or meaningful and why Feedback/suggestions/recommendations for student leaders Value of interprofessional experience

28. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Research questions: curricular evaluation Assess educational experience –Can this trip provide a valuable learning experience for pre-clinical students? If so, how? Determine fit within curriculum –Does the trip enhance competencies already in the curriculum? Improve quality of care –Can this trip provide responsible, appropriate care? –Can an elective help to ensure that this happens?

29. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Optional Enrichment Elective Development Core CompetencySample course objectives 1. Patient CarePerform a history & physical and develop a management plan in a resource-poor setting 2. Medical KnowledgeDeterminants of health Care of common conditions Choice of antibiotics 3. Systems-Based PracticeWorking in teams to ensure that care is reliable and continuous

30. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Optional Enrichment Elective Development Core CompetencySample Course Objectives 4. ProfessionalismUnderstand the effect of culture on health Recognize and accept one’s own limitations (language, clinical skills) 5. Practice-Based LearningEnhance processes of care despite limitations 6. Interpersonal skillsCommunicate with patients and families within a given socio-cultural context Work with an interpreter

31. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Service Learning Community service, within an educational framework –Teach citizenship and social responsibility –Active, collaborative, applied, experiential learning –Development of cross-cultural, global, and diversity awareness and skills –University-community collaboration on social problems –Critical reflection (Crabtree)

32. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Potential Topics Case-based learning: simulate clinics Basic infections and treatments Epidemiology and data collection History of the bateyes Ethics of global health, particularly short-term trips Quality improvement Screening programs in developing countries Integrating with public health initiatives

33. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Potential Requirements Journal clubs Small QI projects –Are we reducing morbidity/mortality? –What happens with pap smears? –What is the evidence for treating HTN in this population? –Community Needs Assessment Reflective writing Short presentations or article reviews

34. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Summary Points International health is an important piece of medical student education, and it must be evaluated as critically as the rest of the curriculum Short-term medical trips are an accessible way to expand international health education and improve patient care –Certain principles should be followed to ensure an ethical, responsible, positive experience for students as well as the host community Developing an elective, informed by student evaluations, may help meet these goals

35. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions References 1.Drain, P., Primack, A., Hunt, D., Fawzi, W., Holmes, K. & Gardner, P. (2007). Global health in medical education: a call for more training and opportunities. Academic Medicine, 82(3), 226-230. 2.Mutchnick, I., Moyer, C. & Stern, D. (2003). Expanding the boundaries of medical education: evidence for cross-cultural exchanges. Academic Medicine, 78(10), S1-5. 3.Edwards, R., Piachaud, J., Rowson, M. & Miranda, J. (2004). Understanding global health issues: are international medical electives the answer? Medical Education, 38, 688-690. 4.Thompson, M., Huntington, M., Hunt, D., Pinsky, L. & Brodie, J. (2003). Educational effects of international health electives on US and Canadian medical students and residents: a literature review. Academic Medicine, 78(3), 342-347. 5.Maki, J., Qualls, M., White, B., Kleefield, S. & Crone, R. (2008). Health impact assessment and short- term medical missions: A methods study to evaluate quality of care. BMC Health Services Research, 8:121. 6.Suchdev, P., Ahrens, K., Click, E., Macklin, L., Evangelista, D., Graham, E. (2007). A model for sustainable short-term international medical trips. Ambulatory Pediatrics, 7, 317-320.

36. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions References 7.Federico, S., Zachar, P., Oravec, C., Mandler, T., Goldson, E. & Brown, J. (2006). A successful international child health elective. Archives of Pediatric and Adolescent Medicine, 160, 191- 196. 8.Crump, J. A. & Sugarman, J. (2008). Ethical considerations for short-term experiences by trainees in global health. Journal of the American Medical Association, 300(12), 1456-1458. 9.Roberts, M. (2006). Duffle bag medicine. Journal of the American Medical Association, 295(13), 1491-1492. 10.Crabtree, R. (2008). Theoretical foundations for international service-learning. Michigan Journal of Community Service Learning, Fall 2008, 18-36. 11.Houpt, E. R., Pearson, R. D. & Hall, T. L. (2007). Three domains of competency in global health education: recommendations for all medical students. Academic Medicine, 82(3), 222-225. 12.Committee on the US Commitment to Global Health (2009). The US Commitment to Global Health: Recommendations for the New Administration. National Academies Press.

37. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions References 13.Global Health Education Consortium. Accessed online at www.globalhealtheducation.org.www.globalhealtheducation.org 14.Godkin, M. and Savageau, J. (2003). The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Family Medicine, 35(4):273- 15.American Medical Student Association Global Health Committee. Accessed online at http://www.amsa.org/AMSA/Homepage/About/Committees/Global.aspx http://www.amsa.org/AMSA/Homepage/About/Committees/Global.aspx 16.Kaplan, J.P., et al. (2009). Towards a common definition of global health. The Lancet, 373, 1993- 1995. 17.Ware, J.E. (2002). SF-36 ® Health Survey Update. Accessed online at http://www.sf- 36.org/tools/sf36.shtml.http://www.sf- 36.org/tools/sf36.shtml 18.Vora, N., et al. (2010). A student-initiated and student-facilitated international health elective for preclinical medical students. Medical Education Online 2010 (15), 4896 – DOI. 19.Curry, L.A., Nembhard, I.M., & Bradley, E.H. (2009). Qualitative and mixed methods provide unique contributions to outcomes research. Circulation, 119, 1442-1452.

38. January 21, 2011 ©2011 University of Massachusetts Medical School Trabajo Común – Ethical, Sustainable, International Medical Missions Thanks to: Michelle Pugnaire, MD Vincent Miccio, MS III Olga Vladman, MD Moises Sifren Fred Tanner Dave Hatem, MD Judy Savageau, MPH and all the UMass DR volunteers!