Preparing to go on an International Medical Experience

Camille Bentley, DO, MPH, FACOFP Chair, Global and Community Medicine

Purpose of Presentation

• Discuss motivations, tolerances, desired outcomes for international medical experiences • Present a preparation schedule • Discuss anticipated stress points and how to deal with them • Present resources for additional information

Review your Motivations

• • • • • • • • • • Altruistic and/or self interest To see the world and experience other cultures To develop communication skills using interpreters and foreign languages To enhance medical skills while helping the needy To treat illnesses and surgical problems uncommon in the U.S.

To practice in a simpler and more gratifying setting To get a new perspective on U.S. medical issues To find purpose and spiritual fulfillment To build lifelong friendships To test your ability to face new challenges

Consider your Tolerance Level for New Challenges?

• • • • • • • Travel uncertainties and risks Uncomfortable living conditions Unaccustomed food and cultural expectations Language barriers Disease and injury exposure Frustration about limited ability to help Diagnosing and treating based on limited information

What makes a Successful Global Volunteer?

• • • • • • • Interests consistent with the goals of the organization Realistic expectations about what you can accomplish The ability to expect the unexpected Flexibility and Adaptability Patience, Creativity, and Integrity Openness/Receptiveness Integrity

Questions to ask When Setting up an International Rotation

Questions to Assess Program Content

• • • • • • • • • • Is the program highly structured, or will I be organizing my own schedule? What are my clinical responsibilities? What will be my duties as a student? Will I be with other students from the United States? Can I speak with someone in the department I am most interested? What types of outside programming is offered? Classes? Excursions? Service projects? Is there an orientation? Cultural awareness training? How much community input is taken into account? What are the relationships of the people who work in the program with those in the community? Are they integrated? What access will I have to textbooks and other medical resources?

Questions to Assess Housing

• • • • • • • • • Do you have dormitories for international students? What are the differences between the dorms specified for international students verses those for regular students? Are homestays available? Are meals included in my housing options? Is their electricity? Running water? Cooking facilities? Hot water? How far are the dorms from the hospital/clinic? If I have to walk to the hospital, will I feel safe walking? If I cannot walk to the hospital, is there readily available, cost effective, and reliable transportation? Will I feel safe using the public transportation system?

• • • • • • •

Questions to Assess Safety

How are foreigners viewed in this country? Have they been any recent kidnappings? What is the current political situation in this country? Is this country on the US state Department Travel Warning list, if so will require additional RVU documentation to get approved How much contact will I have with the outside world (internet)? Will I be able to lock up valuables when I am absent? What is this country's perception of women?

What are your Desired Outcomes?

• • • • • • • Goes back to what is your motivation….

New/improved skills and knowledge?

Academic credit?

Satisfaction that you can perform in exotic/international/challenging settings?

Self understanding of tolerance levels?

Direction for future learning emphases?

Experience level that opens doors for further opportunities?

Better understanding and appreciation of other cultures and perhaps your own??

Deciding Where to Go

• • • • • Match you interests, goals and personal creed -Clinical setting, local language, type of organization) Determine your budgetary and time constraints Explore the internet and RVU Global Medicine website Seek out someone who has been there recently Learn expectations for your work and free time • Understand the principles and policies of the organization

Deciding When to Go

• Better later in your training to be given more responsibility • Choose the best season for the location • Ask about anticipated personnel changes • Anticipate potential disruptions and political instability • Get the details about costs and payment dates • Confirm local travel opportunities •

Check with your RVU Clinical Affairs coordinator

Deciding When to Go

• Better later in your training to be given more responsibility • Choose the best season for the location • Ask about anticipated personnel changes • Anticipate potential disruptions and political instability • Get the details about costs and payment dates • Confirm local travel opportunities •

Check with your RVU Clinical Affairs coordinator

6-12 Months or More Before Leaving

• • • • • • • • • Investigate options for suitable experiences Foreign Language Skills- any required Dialog with someone who’s worked there Recruit student partners

Review RVU requirements for travel if related to rotation. Check Website: Global Medicine Discuss (select) the elective time thru your Clinical Affairs Coordinator

Apply for funding support Apply for a position on the trip Apply for passport (and visa?)

• • • •

4-6 Months Before Leaving

Finalize choice of venue

Provide all required documentation to RVU Global Medicine Department in Pod B (Monique McKenna)

Undergo a health review and examination Determine needed immunizations and begin series o Check CDC recommendations at www.cdc.gov for the country you are visiting. o Check availability of vaccines and pricing at local travel health department vs. student health vs. PMD vs. a pharmacy such as Walgreens.

o Will your health insurance cover costs??

Immunizations and Pricing Estimates

(Estimates are from 2013)

• •

Less than 10 years old:

Adult Hep A • Adult Hep B • or + TITERS

Less than 2 years old:

Typhoid (IM) $75.00 per dose (x2) $75.00 per dose (x3) $75.00 • • • • •

Less than 5 years old:

• Adult Td booster $40.00 or Tdap $65.00

• Oral Typhoid $130.00

Other vaccines: Country specific (see CDC website)

Yellow Fever $140.00 (good for 10 years) Jap/Enceph. $280 per dose (2) Meningitis $140 (good for 5 years) Adult IPV Polio, one time booster $65.00

Malaria Prophylaxis $40-$340 *Required by RVU for all student international travel

3 Months Before Leaving

• • • • • • • • Plan itinerary and buy travel tickets Continue to complete RVU paperwork for your file Complete any paperwork, etc. for hosting organization Request medication, financial donations Attend team preparation meetings Study the host country’s history and geography Study the host country’s language Develop knowledge of their cultural mores

1 Month Before Leaving

• Make arrangements to maintain your home, school and/or work life o Pet care, bill payments, house sitting, class notes, exam review, etc.

• Prepare for resumption of academic duties when returning o Anticipate fatigue and reverse culture shock • Confirm what you are expected to bring o If provided, check the Packing Guide • Purchase trip specific items o Luggage, fasteners, travel size toiletries, etc.

General Packing

1. What items do I need to bring with me (mosquito net, etc.) 2. What medical supplies and personal items should I bring?

3. What will the weather be like? 4. What is the dress code, both for working in the program and in the community? How can I dress to be culturally sensitive?

Personal Care and Hygiene

• • • • • • • Climate and custom appropriate clothes Comfortable shoes and sandals Rain jacket, swimming suit Toilet paper, face tissue Toiletry items, plastic bags Headlamp Personal towel and washcloth

Illness Prevention Items

• • • • • • Antiseptic hand cleanser, face masks and disposable gloves for work environment Insect repellant, mosquito netting Sun Screen, lip balm, hat Water purification tablets or filter Malaria prophylaxis medication* Pepto-Bismol tablets

* If recommended by CDC.

Items and Medications for Personal Medical Kit

• • • • • • • Band-Aids, gauze and tape Scissors, tweezers, safety pins Mole skin, felt pads, superglue Epi pen for allergy, if needed Anti-emetic such as Tofran or scopolomine patches Antibiotic, steroid and antifungal creams Eyes and nose drops if used

Personal Medical Kit – cont.

• • • • • • Diarrhea treatment (quinolone, Pepto Bismol, Imodium) Pain medications (acetaminophen, NSAIDS) Respiratory treatments (decongestants, anti histamines, etc.) Altitude sickness prophylaxis (acetazolamide) Motion sickness treatment (meclizine, scopolamine, tofran) Personal chronic and rescue medications

Comfort Items

• • • • • • • Pillow, sheets, sleeping bag, tent Ear plugs, blind fold Extra glasses, sunglasses, contacts supplies Personal music, batteries Snacks, chewing gum Flashlight or headlamp Personal journal, books

Professional Tools

• • • • • • • Electronic thermometer & covers Stethoscope and BP cuff Oto/Ophthlo scopes Mini-reference books or PDA Latex gloves of your size Camera, watch Copy of credentials

1-2 Weeks Before Leaving

• • • • • Begin packing to discover needed items (plan to travel light) List trip itinerary, contact numbers and back-up plan details and give copies to U.S. contacts Gather and repack meds and items to be donated Review luggage restrictions and items not permitted Replenish travel medical kit

Night Before Leaving

• • • • Try to get a good night’s rest o Finish packing early o Avoid alcohol and stimulants Confirm flight times Have travel clothes, tickets, and passport laid out Allow ample time to reach airport: Group check in is 3 hours prior to international flight time.

Common Stress Points during an International Experience

• • • • • • • Communication difficulties Trip itinerary changes Connections in country Financial issues Personal safety risks Illness complications Stolen or lost items (i.e. luggage, cameras)

Communication Stress Points during Travel

• • • • Know how to communicate with home and destination people o To notify about schedule changes o To announce safe arrival Have phone numbers of alternate contacts o Carry info on how to use local phone system Know location of destination and home addresses of contacts Travel with language support materials or people

Communication Stress Points during Clinics

• • • • • Be realistic about your communication abilities Discuss with interpreters the preferred mode of working together o Ask for info on cultural factors, home remedies and alternative practitioners Be willing to help wherever needed Limit constructive criticism Be open to the recommendations of experienced clinicians

Flight Connection Complications in Country

• • • Know how to make contact if not met at the airport (Have phone numbers and coins) Have a back-up plan o For transportation, e.g.. Bus station location and schedules o For lodging, list of hotels Bring some local cash in case exchange locations aren’t open

Financial Issues

• • Learn beforehand the best methods to get local cash at a good rate o Travelers checks and credit cards may not be accepted Carry financial items in 2 or 3 places o o o Wallet (petty cash) Money belt (large bills) Neck and/or belt pouch (passport, exit fees, tickets, bank and credit cards) • • • Have a copy of your passport, insurance info, credentials and itinerary in separate locations from originals Carry a calculator to determine fair exchanges Don’t pack valuables in check-in luggage

Personal Safety Risks

• • • • • Stay alert for dangers Know the rules to avoid danger o Use the buddy system o Avoid danger areas and times o Don’t flaunt money or valuables Protect against sexual misadventures Call out early for help Don’t fight to protect what can be replaced

Illness Complications

• • • • • Anticipate exposures that make you ill Avoid risky activities Always carry your travel medical kit Know the best sources of in-country medical care Carry travel and evacuation insurance

After You Return

• • • • • • Expect reverse culture shock Take advantage of debriefing opportunities Plan enough time for rest and reflection Have a party with those who’ve had similar experiences Give constructive feedback to advisors and rotation planners

Complete required paperwork for RVU and make arrangements to get a post trip TB test within 3 months.

Culture Shock and Reverse Culture (Re-Entry) Shock

10 Symptoms of Reverse Culture Shock

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You're bored by family, friends and old routines after your excitement and challenges abroad.

You find that others do not want to hear much about your experience.

You are irritated by the inane questions about your experience and answer sarcastically.

You feel that you can’t fully explain your experience or its importance.

You feel that your experience abroad is distinct from the rest of your life.

You are unable to apply your new knowledge and skills to your job, school, or 7.

8.

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life. Your relationships with family and friends have changed.

You think people misunderstand or see the “wrong” changes in you.

You feel alienated and experience “reverse homesickness” for your host country.

10. You constantly criticize your own culture in comparison with where you’ve been.

Ways to Prevent Reverse Culture Shock

• DO NOT leave home without tying up all loose ends, both professional and personal.

• While away keep track of changes in your family, friends and work via social networking • Before leaving your host country say proper goodbyes to the people there, take lots of photos, and other items to retain the memories, keep a journal.

• Expect to go through a readjustment period • Consider who you can count on for emotional support when you get back (i.e. family and friends)

How to Overcome Reverse Culture Shock

• • • • • • • Understand that it is perfectly normal and that you did expect it to occur.

Give yourself the permission to relax, reflect on your experiences, and ease back into your home culture.

The longer you have been away, the longer it will take to “catch-up”.

Talk to others who have had the same experience, they can understand what you are going through. Reestablish rapport with friends and family by showing interest in what they are doing Expect some negative feeling about your home country and culture, comparison is natural, however, be careful of being Overly Critical.

Revisit host country and culture through reading, listening to the music, eating the cuisine, and introduce friends or colleagues to the culture. Accentuate the positive

Remember, that this is not necessarily a once in a lifetime experience. You can travel internationally throughout your life.

You Have Readjusted to Society When You Don’t:

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Carry toilet paper with you wherever you go Turn off the water between lathering and rinsing in the shower Have to think carefully about which way to look before crossing the street Panic if you swallow water in the shower Examine all your food for insects and/or Eat a salad without thinking about 6.

7.

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who washed it and where it came from Gawk at the variety of food in the grocery store Feel strange sleeping without a bed net and/or ear plugs Smell like DEET Dream in a foreign language 10. Obsessively watch for potholes, stopped trucks and animals while driving 11. Ignore your pile of accumulated mail

General Resources for Travel Information

• • • • • • • • The Global Healthcare Volunteer’s Handbook, what you need to know before you go, by Kenneth V. Iserson, MD CDC: www.cdc.gov/travel U.S. Dept. of State: www.state.gov

Library of Congress Country Studies: memory.loc.gov/frd/cs CIA World Fact Book: www.odci.gov/cia/publications/factbook Lonely Planet: www.lonelyplanet.com

www.AMSA.org (Toolkit for going abroad) Where There is No Doctor: A Village Health Care Handbook, by David Werner

Resources for Medical Electives

• RVU Website: Global Medicine, list of sites and contacts • AMSA.org (Student International Health Opportunities) • [email protected]

• WorktheWorld.org