Introduction
When deciding elective destinations, I searched for a placement where I could make a contribution, whilst gaining confidence in my clinical skills in a challenging environment with limited resources. Clinica Esperanza on the island of Roatan, Honduras had all this and so much more! The clinic functions as a combination of primary care and emergency medicine, in part due to the fact that the local hospital with an A&E has not received medical supplies for over 6 months.
Reflection
One of the most challenging parts of working in a foreign environment, yet also one of the major benefits, is the vast cultural differences that inevitably exist. Roatan is no exception. Learning more about such differences was one of my elective objectives, and one that was most certainly achieved. I was soon struck by the fact that the typical age of first pregnancy is 18, malnutrition is widespread with limited opportunities for work and an endemic obsession with sugary, fizzy drinks. I saw that it is not enough to simply take a history and examine a patient. The area they live, the job they do and their religious beliefs are completely intertwined with their health outcome. For me, this was a learning point that I will undoubtedly take with me everywhere I go.
I relished the opportunity to practice health promotion in a place where few patients achieve more than a primary school education. One example of this was a patient we diagnosed with type II diabetes for the first time. This diagnosis required me to educate the patient about nutrition, such as avoiding fried and sugary foods, as well as trying to warn her of the potential complications, her treatment options and invite her questions, all of which while talking in a foreign language. I found this to be surprisingly rewarding, especially when she returned for a follow-up appointment the following week with much improved glucose levels, and bringing stories of the changes she had made to her diet.
There were certainly aspects of the placement which far exceeded my expectations and even surprised me. One example was having the opportunity to gain new perspectives towards global health and learn about the differences in medical practices across the world, such as the local ‘bush medicine’. In an area with a large obese and Afro-Caribbean population, there is an unusually low incidence of cardiovascular disease. Whilst of course there are many factors that can cause this, I learnt not to be too quickly dismissive of remedies that have been used for thousands of years.
One of my learning objectives was to practice clinical techniques such as cannulation and suturing. Unfortunately I do not feel I had sufficient opportunities to fulfil this objective, owing to the fact that the clinic functioned mainly as a primary care unit, and thus most emergencies went to the emergency room at the local hospital. However I don’t believe this negatively impacted on my experience but it does mean I will endeavour to gain more exposure to such procedures during my DGH placement.
I was, however, very pleased to have the opportunity myself to make a difference to the clinic, one that will hopefully be sustained long after I leave. I was delighted to be awarded a bursary from the RCOG to allow myself and Rebeca to complete a research project during the elective placement. The recently introduced cervical screening programme was highlighted as an area that is underfunded and in need of improvement. The haphazard introduction of this programme has meant many patients may be being missed due to the opportunistic recruitment of patients, as well as results not being delivered appropriately. Through developing a new data collection system, as well as retrospectively collecting data from the smears already completed, we have identified patients who need to be recalled for urgent follow up, as well as making recommendations that hopefully ensure that the limited resources of the clinic are directed more effectively, thus allowing more patients to be helped.
During my elective, I found that the impact of poverty further compounded in a health system requiring patients to pay for consultations, investigations and medications. Decisions weren’t made solely on the basis of what would be best for the patient and, having been educated within the luxury of a National Health Service, I found this particularly challenging. However, I recognise that in a time of austerity and budget cuts, we will all have to factor limited resources into patient care. Thus, having more confidence in my ability to diagnose, or at least treat empirically without expensive investigation as well as recognising when these are justified will benefit all of my future patients.
The impact on my professional practice
The time I spent at the clinic has undoubtedly changed my professional practice, as well as my own outlook. Early on in our placement, we had an emergency situation of a young boy who was desperately ill. Seeing a team pull together so seamlessly, needing few words to communicate whilst battling with limited resources was incredible, despite the heart-wrenching circumstances. On a daily basis I had to adapt to the limited availability of tools we so frequently take for granted, which left me with no option but to develop my clinical accumen. Further, being able to work in an independent manner but with plenty of supervision from experienced doctors encouraged me to hone my decision making skills, and gave me confidence.
I enjoyed the diversity of the patient presentations and had the opportunity to work in gynaecology, saw many paediatric patients and managed a vast array of general medical patients. Communicating complicated information in another language was a difficult but important lesson. I realised that the challenge of working with patients from different cultural and ethnic backgrounds is so much more than just a language barrier, and this is even more relevant when working back in the UK. I will endeavour to understand how to approach topics such as sexual health or alcohol drinking in each new community I work with.
Limitations
If I returned to the clinic, which I certainly hope to do, I would change some of my objectives to allow me to gain even more from the opportunities we were presented with. One would be to learn more of what is normal. Seeing such an array of patients daily is the perfect opportunity to practice many clinical exams, such as using otoscopes and ophthalmoscopes to be able to appreciate physiological variants as well as pathology. Clinical knowledge can also be gained in the specialities of tropical diseases and nutrition. Members of the clinic run nutrition classes in the community and I would have liked to be involved in running such classes.
Another area which can be developed in this environment is decision making skills. The wealth of support from experienced doctors encouraged me to be independent whilst still being safe within my personal limits. Whilst at the clinic I took part in a community outreach programme, where members of the clinic go to local communities and give nutrition classes, hand out food parcels and education to prevent delayed presentation when illnesses develop. I would love to have done it more often. We have suggested that the clinic includes a weekly visit to the community in the volunteer program in the future.
Conclusion
I believe I was able to contribute to the clinic through our research project, and providing recommendations which will be used to apply for funding for an HPV testing programme. Further, each volunteer gave a teaching session, and I contributed to the shared knowledge of hypertension, and was able to highlight differences between UK prescribing practices, and the USA.
I would like to continue to help the clinic by raising awareness of their work. I will have the opportunity to do this when I present our research to the RCOG, in the hope of encouraging visiting gynaecologists to choose a placement in Roatan, which could allow the re-opening of the birthing unit at Clinica Esperanza, and provide expertise that could be used to train local doctors in techniques such as colposcopy and ultrasound.
I had many exciting, unexpected and educational experiences during my placement at Clinica Esperanza and would thoroughly recommend it to any medical student considering an elective in the developing world.
Brooke Calvert ( UCL)