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PAEA Annual ForumOctober 2010

Abraham K, Carlson R, Quincy B, Schempp A, Trompeter JShenandoah University

Winchester, Virginia

Describe the process of developing and organizing a university-sponsored medical mission trip.Outline the goals of the medical mission trip for the program, students, and patients.Delineate the roles of the different program faculty

d t d tand studentsDiscuss the effectiveness of the interprofessionalapproach in the clinic settingIdentify the common challenges encountered in international medical mission trips

The birth of an ideaIn 2005, campus chaplain communicated a desire for a health professions mission tripMeetings began in September 2005 for a trip in May 20062006Chaplain had a contact with El Ayudante, a missions agency in Nicaragua

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Initial goalsStudents evaluate patients with faculty oversightInclude pharmacy students and faculty

Planning ProcessgRecruited PA and pharmacy students, faculty and community physiciansConsulted with NGO regarding the common types of health problems and the medications needed

Lessons learnedNeed 9 months of planningNeed for leadership teamFundraising challengesSpecify medicine and supply donations

Given the opportunity, students rise every time!

Pre-tripMeetings

Information sessionDistribute applications & covenants

Team Team Lessons on Nicaraguan culture & languageMedical training Team building

Medications and SuppliesInventory donations and make purchasesPacking day

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ExecutionDivided into 3 teams of 16 or 17

8 PA students; 2 pharmacy students; 2 PT students1 PA, 1 Pharmacy and 1 PT faculty member1 physician and 1 pastor

Transported medications and supplies via individual suitcasesEl Ayudante planned the schedule and provided food, lodging, interpreters and ground transport

Lessons learnedStudents do not like paperworkCollect money before committing to airline ticketsCollaboration among students benefits all experience levelsOrganize every detail but be flexibleCooperation with Ministry of Health requirements aids with Customs clearance

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Provide quality health care and patient educationProvide personal and professional growth growth Utilize faculty role-modelingFoster interprofessional approach Enhance cultural competence Promote sustainable change through preventative health education

Maintain collegial relationship with El AyudanteEnhance the standing of El Ayudante with the communityySupport El Ayudante’s bridge with Nicaraguan Ministry of Health

Inspire life-long service to underserved populationsExposure to epidemiologic variations in low resource settingsProvide quality healthcare to patients with limited access Benefit from faculty role modelingBenefit from faculty role-modelingIncrease their understanding of the role of other health care disciplines in the health care teamIncrease confidence in their knowledge base and clinical skillsBuild lasting relationships with peers and future colleagues

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Be received with dignity and compassionReceive accessible health care at no cost Receive education on preventative measures to improve healthTo have positive interaction with health care providers

Shenandoah University is United Methodist AffiliatedAffiliation with El AyudanteOne spiritual life leader for the tripUniversal inclusionPre-trip planning

Ice breakers, thought provoking questionsDuring trip

Facilitate reflections, personal development and processingDevotions

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Pre-trip planningFundraising EventsEducate participants during pre-trip

timeetingsPacking Day

One PA faculty member per teamPre-trip planning

Overall organization and supply order, coordination with NGODuring trip

T l d hiTeam leadershipClinic logisticsCoordinate with the interpreters, pharmacistSupervise/precept the PA StudentsFacilitate debriefing sessions

One pharmacy faculty member per teamPre-trip planning

Oversee packing day, medication order, formulary During trip

Supervise pharmacy and pharmacy studentsMonitor medication needs between teamsPurchase medications in country Coordinate treatment plans

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One PT faculty member for tripPre-trip planning

Application Process, order PT supplies During trip

Supervise/precept PT studentsCoordinate with NGO for clinic locationsProvide training for local healthcare personnel Facilitate debriefing sessionsCoordinate treatment plans

Prior to TripRaise funds, packing day, pre-trip meetings

During the tripProvide patient carepSupport peersParticipate actively in all activities

Physician Assistant3 Pairs of 1st and 2nd yearTriage & direct patient care

Pharmacy2-3 students per teamDispense medication &therapy education

Physical Therapy6 students per tripProvide therapy in hospitals, schools for children with special needs, and medical teamsProvide education for local healthcare personnel

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INTERPROFESSIONAL CLINICAL EDUCATION

Collaborative approach to health care practice will improve health care deliveryOne way to accomplish this:

Integrate additional interprofessional training g p gopportunities in education for health professionals

Institute of Medicine, 19881

Shugars et al., 19912

Council on Graduate Medical Education, 19943

American Association of Colleges of Nursing, 19954

Simulate and facilitate interprofessionalpractice Promote awareness/understanding of other health professions’:

R l d ibilitiRoles and responsibilitiesScopes of practiceEducational preparation

Promote appropriate professional interactionsExpand critical thinking skills/abilities

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Difficult to coordinate courses/schedules across programsMultidisciplinary ≠ I t f i lInterprofessionalDifficult to simulate clinical environment in the classroom

CoursesPatient-Centered Cases

Western University of the Health Sciences, Pomona, CARosalind Franklin University of Medicine and Science, Chicago, IL

B i S i d R h Basic Science and Research coursesInterdisciplinary Patient Care Experiences

Community Health Centers/Free ClinicsWachs et al, 1998; Brown et al, 2003; Goodrow et al, 2008

Mission Trips

Students/professionals:observed other disciplines providing patient managementperformed patient examinations collaborativelycommunicated regarding most appropriate interventions for specific patientsshared cases during debriefing sessionssocialized during travel, meals, accommodations, cultural activities, etc.

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Participants had an improved awareness of/respect for the unique skills and scope of practice of each discipline

“I really understand what it is that a PT has to offer”it is that a PT has to offer“I was so thankful to have the pharmacists there to check my dosing. I was really impressed with how they made drug substitutions based on availability and even compounded right there in the middle of nowhere ”

Participants had increased comfort level with interprofessionalcommunication“Traveling to Nicaragua with multiple disciplines made me realize how important it is to work together to fulfill the patients’ needs. As we

k d id b id i h h PA worked side by side with the PA students, it made it easier to refer patients as well as discuss possible diagnoses in order to quickly develop a plan of care. The PA and pharmacy students took the time to teach me about examinations and how to decide on the different forms of medication appropriate for each patient.”

Participants were more likely to make appropriate referrals.

“I was challenged with opportunities to intervene with physical therapy that I would never have thought of if I had not been working side by side with my peers in that specialty.” “I am very thankful to have had the opportunity to work so closely with PT students and pharmacy students, and I hope that I am more aware of when a referral would be appropriate.”

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Patients received more comprehensive care“My experience with the PT and pharmacy students in Nicaragua allowed me to observe first hand how integrated our approach can be when choosing treatment options for patients. As a second year PA student, I had focused on more medical care up until that point. I felt that we were able to give more complete care to the people of Nicaragua, whereas years before, all we could offer for back pain or other orthopedic injuries was NSAIDs and counseling.”

Cost TimeLogistics

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Financing8-11

Accepting health risk9

Managing stress9

Accepting limitations8,9

Utilizing appropriate skill g pp pset, experience, responsibility8,9

Overcoming language andcultural barriers9

Accepting direct and indirect costs9

Ensuring improved care for host community9host community9

Maintaining moralobligation and ensuring “First Do No Harm”9,10

Addressing gaps in local healthcare9

Maintaining standards of care in community11

Understanding limitations ofacute focus11

Understanding the training Understanding the training level and experience ofproviders9

Coordinating logistics9

Facilitating orientation ofparticipants9

Explaining mutual expectations8-11

Providing chronic disease management and follow up care11

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Ensure health disparities are not exacerbated or exploited9

“Patients must always be treated as ends in h l h d”10themselves, not means to another end”10

Maintain goal of truly benefiting host and evaluate whether that is being achieved8,10

Promote partnering with community rather than medical tourism10,11

Work with existing medical and public health infrastructure10,11

Develop long-term partnerships with locals who want to help and need external help to function10,11

Find “local champion”10

Encourage mutual and reciprocal benefits9,11

Promote stability: faculty, host, location8

Reevaluate frequently:8 Are goals still being reached and how?

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Using guiding principles and defined goals helps overcome the challenges and involved process of developing a successful medical mission trip. An interprofessional team

h d b happroach provides better patient care within the limited scope. The end result is a mutually beneficial experience to patients and participants.

1. Institute of Medicine. The future of public health. Washington, DC: National Academy Press;1988.

2. Shugars D, O’Neil E, Bader J. America: Practitioners for 2005, An Agenda for Action for US Health Professions Schools. Durham, NC: The Pew Health Professions Commission; 1991.

3. Council on Graduate Medical Education, US Department of Health and Human Services. Recommendations to Improve Access to Health Care Through Workforce Reform. Washington, DC: Health Resources and Services Administration; 1994.

4. American Association of Colleges of Nursing. Position statement on interdisciplinary education and practice. Washington, DC.; 1995

5. Wachs J, Goodrow B, Olive K. Community partnerships: Education of health science students, service to the community. In B. Behringer (Ed), Involvement of Communities in Health Professions Education: Experiences from the Community Partnerships for Health Professions Education Programs, 1991 –1997. Battle Creek, MI: W.K. Kellogg Foundation; 1998.

6 Brown D Behringer B Smith P Townsend T Wachs J 6. Brown D, Behringer B, Smith P, Townsend T, Wachs J, Stanifer L, Goodrow B. Graduate health professions education: An interdisciplinary university community partnership model. Education for Health.2003;16(2), 176 – 188.

7. Goodrow B, Scherzer G, Florence J. An Application of Multidisciplinary Education to a Campus-Community Partnership to Reduce Motor Vehicle Accidents. Education for Health. 2004; 17 (2), 152 – 162.

8. Suchdev P, Ahrens K, Click E, Macklin L, Evangelista D, Graham E. A model for sustainable short-term international medical trips. Ambulatory Pediatrics. 2007;7: 317-320.

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9. Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008;300(12):1456-1458 (doi:10.1001/jama.300.12.1456)

10. Wall LL, Arrowsmith SD, Lassey AT, Danso, K. Humanitarian venture or ‘fistula tourism?’: the ethical perils of pelvic surgery in the developing world. International Urogynecology Journal. 2006;17:559-562. (doi:10.1007/s00192-005-0056-8)

11. DeCamp M. Scrutinizing global short-term medical outreach. Hastings Center Report 37. 2007;6: 21-23.