With Match Day around the corner and graduation coming shortly after, I find myself frequently reflecting on my nearly four years of medical school. Without a doubt in my mind, I can say that my favorite month was spent abroad in Guatemala. As a fourth year student on my international elective, I had the opportunity to work for four weeks in various pueblos and a local clinic for women and children outside of Quetzaltenango, Guatemala. In this short time, I learned the basics of a new healthcare system, I significantly strengthened my Spanish, and I saw hundreds of patients, many of whom I know I helped in both an acute and sustainable fashion. Still these experiences certainly come with a price, and for me that was the constant ethical dilemma I faced while seeing patients.
Several months before leaving for Guatemala, an acquaintance brought up an uncomfortable topic: healthcare tourism. As I detailed how excited I was to perform new procedures and have some autonomy in patient care, he asked me in an aggravating tone, “Why would it be appropriate to treat patients abroad when you technically aren’t qualified to see patients here? I mean, you don’t even have your MD yet.” I felt exasperated trying to answer the question, but it was mostly because I saw his point – why would it be okay?
In our busy clinic in Guatemala autonomy was not only encouraged, it was often required. At times there were lines of patients snaking around the building. Women gossiped as they balanced their babies on their backs, understanding that it might be hours before they see any health professional. The one doctor that staffed the clinic was humble and entirely grateful for medical student assistance. She made herself available for questions, but she also made it clear that if we had the knowledge to care for the patient, she would prefer not to be consulted. The volume of the clinic was enormous; there were far too many people to help.
And so I did just that. I was happy to see babies with upper respiratory infections, verify that they were adequately hydrated, provide free Tylenol for fevers, and let them go. I loved seeing children with diarrhea and belly pain that arrived with a stool sample that confirmed a parasitic infection – I gave them appropriate medicines and they left with grateful smiles. I also saw many women with UTIs, followed up with appropriate screening and antibiotics, and sent them on their way. Still there were times when I felt entirely unsure. Whether it was a language barrier or simply a lack of knowledge, I was not always the right person to help, and that scared me. I never hesitated to ask for help in these situations, but I also had to question, what diseases might I have missed in this way? Most days I worked alongside another medical student, but certainly two fourth years do not equal an attending. Those frustrating comments returned to me, “Why is it appropriate for a medical student to treat patients abroad?”
Of course many individuals in the clinic and in other writings have a good answer for this: because these patients would not be seen otherwise. If I could ease a bit suffering and provide an ounce of education wasn’t this more helpful than not? The opposite argument came to me from a German medical student, in her third of six years of medicine training. She contentedly chose to work in the pharmacy department. When I asked her why she didn’t want to see patients, she spoke simply, “I’m not comfortable with it ethically. I don’t have enough training.”
Her comment shook me, and I began to seriously question my own comfort level.
I think these ethical questions are easily applicable to experiences abroad, but they certainly apply to our own clinical scenarios in America. Many medical schools, including my own, have free clinics that are run by students. In these clinics, we see primarily homeless or low socioeconomic patients with greater autonomy than we might in another outpatient setting. We also ask these patients to wait for longer times to ensure adequate opportunity for teaching from the attendings that assist in the clinic. Our education is deeply reliant on learning from experience, and often the first ones we practice on are the poor, the needy, and the underserved.
As I continue to reflect, I still do not have an answer or rule of thumb that will work for everyone. But I did manage to mostly come to terms with my ethical dilemma in Guatemala by setting some personal ground rules. If I ever felt uncomfortable or unsure of a clinical decision, I would ask for help. If I had never done the procedure before, I would ask for supervision. Additionally, I made it a goal to learn as much as I could about the culture, specifically medical and spiritual beliefs, and I would remain sensitive to these throughout any clinic visit.
Questioning the training model under which we operate is important for any educational process, but I argue that this is vital in medicine. Given the rigid hierarchy in many institutions, this is often difficult or nearly impossible. Still I urge other students, residents, and attendings to step back when they feel uncomfortable and ask why. When there are lives on the line, our job is not always to simply provide care, but also ask the hard question of whether we are the best ones to do so.