Research? Volunteer? Shadow? Travel? Relax?

By: Mark Clapp, Neal Viradia, Emily Gifford, Poonam Patel, and Suzanne Weaver

What should first-year medical students be doing over the summer-their “last free summer?” As early as August, we-impressionable MS1 students-were being bombarded with opportunities and advice for things we should be doing during our break between first and second years. For some of us, the decision was easier than it was for others. International health projects were at the top of the list for many students at the University of North Carolina. With UNC-established projects in such countries Mexico, Honduras, and Africa, the possibilities seemed limitless. However, a small group of students were attracted to India and the Himalayan Health Exchange Project.
The Himalayan Health Exchange is a humanitarian organization which provides medical  and dental care to under-served people living in remote regions of the Indian and Nepal Himalayas.  These areas lack tremendously in medical resources and are often cut off from the rest of the world due to harsh weather conditions like snow in the winter, and the expeditions provide a great service to the local people. The style of volunteering with the Himalayan Health Exchange expedition is organized around mobile walk-in clinics.  A team of health care professionals including medical students and other volunteers set up “health camps” in local schools, monasteries or clinics. As medical students, our roles include working with and assisting the local and volunteer physicians in these health camps. The goal is to provide general medical and dental care, and provide free medicine to the expected 1,200 patients.  A typical clinic will start at 8:00AM and end at 4:30 PM during which we will work the the med team to see and treat patients.  At the end of every clinical day, the group will meet for a formal hour of discussion time.  The expedition takes us through the Greater Himalayan Range and the Trans-Himalayan region of Spiti. The Medical/dental camps will be held at 4 villages and at the 10th century old monastery of Tabo. These camps are being organized at the request of the department of health, Himachal Pradesh Government. 

So why India? What attracted over ten first-year medical students from UNC to participate in the Himalayan Health Exchange? The reason varies from person-to-person. To better tell our story, five students on the Spiti trip have contributed their experiences, including their trip preparations, excitement, and challenges they expect to face. We are really looking forward to our travels and will be telling you more about our trip, experiences with the program, and our additional Indian travels once we get back! (more…)

Stephen Keddie explains more about what is involved in this initiative and give some advice on how to set up a teddy bear Hospital wherever you are

 Teddy Bear Hospital Newcastle was set up in 2005 by a group of medical students as part of the International Federation of Medical Students’ Associations (IFMSA), co-ordinated by Medsin- a network of students with an interest in health. Medsin’s activities aim to promote health as well as to act upon and educate students about health inequalities in our local and global communities. (more…)

  Anna Shore presents the benefits of a more global attitude to health education

Ease of travel, the impact of the internet, large multinational corporations, population migration - all good examples that we live in an increasingly globalised society. The need for health is common to the whole of the world’s population, and it is unsurprising that medicine too is starting to become more global in its outlook.

Many areas of medicine bear evidence of this change, including undergraduate education. (1) Medical schools in the UK and overseas are starting to respond (2), and it is possible to spend a year studying for an intercalated degree in International Health at selected universities. (more…)

  Johnny Boylan discusses what is happening in the UK and beyond

There is clear evidence that, throughout the world, people from ethnic and cultural minorities experience inferior health care compared to the majority, dominant population. In the United States this applies to African-Americans,  the Hispanic population and American Indians; in France to people of North African descent; in Germany to Turkish migrant workers; in Turkey to the Kurds; in Israel to Jews from Ethiopian, North African and Russian backgrounds; and in the United Kingdom to people of Indian, Pakistani and West Indian origin.(1)

This international healthcare issue has led to an increased awareness of the need to educate medical undergraduates in equality and diversity issues (2): for example in Britain in 2007 when the BMA produced their guidelines on Equality and Diversity Education. (3) In addition there is evidence that such educational programmes have positive outcomes and that participant attitudes changed over the period of the teaching. (2) (more…)

Whether you are a new medical student or not, this letter from Daniel Sokol hits the mark

Congratulations!  How many others would love to be in your shoes, tracing the footsteps of Hippocrates, Jenner, Lister, Osler, Fleming and other greats of medicine. (1) The path ahead is indeed long, but was it not Confucius who reminded us that even a journey of a thousand miles begins with a single step? (2) (3)Why this letter?  I have some advice which you may find helpful.  A secret?  Not really.  The talking fox, in The Little Prince, had a real secret: “It is only with the heart that one can see rightly; what is essential is invisible to the eye”. (4)

My simple message concerns the moral dimension of medicine.  Medicine is fundamentally about human beings and, whenever humanity is involved, so too is morality.  Why?  Because, as social creatures, we have duties to each other.  I have a duty to treat you in a particular way.  I shouldn’t lie to you, or steal from you, or insult you for no good reason.  And we also have duties to ourselves.  We must treat ourselves with respect and dignity.  As a medical student, and later as a doctor, you will be dealing with patients, relatives and colleagues.  More specifically, you will strive to help patients who are by nature sick and vulnerable.  For the patient, the awkward shift from health to illness is not the only change.  The clinical environment itself can be impersonal, unfamiliar and often confusing. (5)

The task is all the more complicated because whenever we try to help patients, whether through words, drugs or procedures, we risk harming them.  An aspirin tablet can trigger an anaphylactic reaction; a caesarian uncontrollable bleeding.  The sharp sword of Damocles hangs precariously over doctors and their patients. (6)   As time is limited and resources scarce, you may also deprive others of needed assistance.  If you decide to drain Mr Smith’s abscess now, the injured Mr Jones will have to wait in pain a while longer.  More dramatically, giving a heart to a patient with severe cardiomyopathy (an abnormality of the heart muscle) may entail the death of another patient in desperate need of the organ.  For all these reasons, medicine is a deeply moral endeavour, often involving conflicting moral principles. 

Throughout your training, you will be exposed to the scientific and technical components of medicine.  You will wonder at, and on occasion curse, the sheer volume of medical and biochemical knowledge acquired over the centuries.  We have come a long way from the days of supernatural explanations of disease, and Galen’s long-standing belief that illness was caused by an imbalance of four humours.  The ethical aspect will not feature as much as the technical and the temptation will be to dismiss ethics as irrelevant, unimportant or inconvenient to the immediate task of helping the patient. 

My message is this: do not yield to this temptation, however strong, but take the ethical issues in medicine as seriously as you do the technical ones.  This doesn’t mean devouring textbooks on medical ethics.  It means simply seeing ethics as integral to the proper care of your patients.  Just as you want to increase your understanding of the factual aspects of medicine, so should you want to deepen your moral understanding.  Your ability to perceive moral issues, to reason through ethical problems in search of a solution, and to act upon your decision is inextricably linked to your future success as a doctor.   

I have on occasion heard your peers say that ethics is merely a matter of law.  You should of course consider the law when deciding how to act, but the law is no moral panacea.  While morals may form the basis of law, there is much that the law permits but that morality forbids.  A student who laughs at the misfortune of a dying patient is not acting unlawfully, but may still be morally at fault.  Law often represents the lowest acceptable measure of morality.  As a member of the medical community, you should be striving for a higher standard.  Sometimes, the law is silent, or permits several options.  Should you breach a patient’s confidentiality if you believe your silence may endanger someone else?  The law offers no easy solution.

You will be faced with many diagnostic and therapeutic mysteries in years to come.  Medical journals are replete with case studies involving rare cases of tetanus, typhoid or other diseases whose unusual symptoms stumped the medical team.  Biomedicine is a young discipline and much remains to be found.  You will also encounter ethical puzzles.  What should you do or say if you made a medical error that no one else noticed?  How should you deal with patients’ cultural or religious beliefs at odds with your own?  How should you handle racist or abusive patients?  How should you evaluate a patient’s quality of life or the futility of a given treatment?  Like the medical ones, these problems will need to be diagnosed and resolved, and may require skill, creativity, humility, wisdom and courage.  In ancient times, whether in Greece or China, doctors were philosophers.  Today, a good doctor - and a good medical student - remains a practical philosopher.

So here endeth the lesson.  I’m aware that I haven’t discussed how to resolve moral problems.  This will, I hope, be taught to you in the coming months.  My intention here is more modest: to remind you, at the outset of this lifelong journey, of the profoundly ethical nature of medicine which in this technical age is too easily overlooked.  The ethical aspects are neglected because, unlike physical abnormalities, they are difficult to see.  The fox was right: what is essential is invisible to the eye.

Daniel K. Sokol L
Lecturer in Medical Ethics and Law
St George’s, University of London
Cranmer Terrace
London SW17 0RE
daniel.sokol@talk21.com

 Endnotes

(1) An excellent introduction to the history of medicine is Roy Porter’s Blood and Guts: A Short History of Medicine  (2002), published by W.W. Norton and Co.

(2) Confucius was a Chinese thinker living in the 6^th century BC.  For a concise summary of his life and philosophy, see http://plato.stanford.edu/entries/confucius/

(3) Sir William Osler (1849-1919), while Regius Professor of Medicine at Oxford, addressed medical students as “fellow students”.  For Osler, all doctors, however experienced, were students of medicine, always learning more about the many facets of medicine.

(4) For more on this inspiring little book, see http://en.wikipedia.org/wiki/The_Little_Prince

(5) I have written frankly about my own experience as a patient in the British Medical Journal (2004, 328:471. http://www.bmj.com/cgi/content/full/328/7437/471).

(6) The Roman writer Cicero recounts the story of Damocles.  In the story, king Dionysius allows the envious Damocles to experience, for a short time, the life of a powerful ruler.  As Damocles is enjoying a lavish banquet, he notices, hanging directly above him, a sharp sword suspended by a single horse’s hair.  This was meant to represent the illusory appearance of comfort and the ever-present danger that Dionysius faced as a king.

Taken by Shannon Brennan

An elective period in the developing world has been a rite of passage for many western medical students for decades.  But there is growing recognition of the ethical dilemmas associated with these experiences - in particular the extent to which visiting students act as a drain on scarce resources for clinical training and supervision. Christine Henneberg spent an elective period with Child Family Health International, a San Francisco-based organisation which aims to challenge and inspire health professional students while making a positive contribution to host communities. 

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 Jon Mendelson explains more about this innovate school

It was a jolting ride over the rocky desert to the Bedouin village. A small group of first-year medical students and a family physician trekked off the main roads to visit a local Arab Bedouin patient half an hour from the city limits. Scattered mostly around the northern Negev Desert in Israel, many modern Bedouin retain some of their ancestral nomadic desert lifestyle. Others have moved into towns, leaving much of their old way of life behind. In the rural areas, extended families live in small communities of tents or tin houses, with their flocks of animals corralled by the side of their homes.

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Rupert Major shares some of the experiences of this link which could help to reduce the “brain drain”

Ethiopia has had a bad press.  It is one of the five poorest countries in the world.  You might imagine famine, political unrest, wars around the borders ……however, visit one of its major cities, Gondar, in North West Ethiopia and think again.  This former capital of Ethiopia and city of historical importance has a population of 150,000 people.  Its 350-bed university hospital serves a region of more than 3 million people.

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