Emily West 2017-06-09 01:40:49
I first learned about the American Academy of Dermatology’s Resident International Grant as a fourth year medical student and was eager to participate as a future dermatology resident. Through the program, residents provide inpatient and outpatient dermatologic care to patients in Gaborone, Botswana, and the surrounding region. My prior work in various health care venues — both domestically and internationally — had revealed challenges that were inherent with working in under-resourced settings; nevertheless, once I was stationed in Botswana, I found myself surprised by the daily adaptations that were required to provide efficient and sensitive care. The bulk of dermatology practice occurs in Garborone, at Princess Marina Hospital (PMH), one of the largest public sector hospitals in the country, but each week, dermatology services are extended to one of several outreach clinic sites a few hours away. Each day as soon as the hospital doors opened, dozens of patients would begin to form a queue in order to be seen. Some had appointments and some needed to book appointments, while others needed expedited or urgent evaluation. In many instances, patients described extensive commutes to the hospital, at times more than 10 hours on public transportation each way to spend fewer than 10 minutes with me during their office visit. With patients taking up to two or three days out of their life away from their families, income, and livelihood to see me as their provider, I felt strapped with a greater duty and need for humility than I had ever previously experienced. The high patient volume and at times high acuity often required assertive advocacy on behalf of patients. Our team was consulted on a young boy with HIV who was admitted with widespread bullae and mucosal erosions — which was initially concerning for severe erythema multiforme or Stevens-Johnson syndrome. In spite of our explanations, daily demonstrations, and clear recommendations, we struggled to craft a management regimen that was clinically appropriate, acceptable to the primary team, and manageable for the providers to enact. I was devastated to find him one day with a large dry diaper adhered to his back with coagulated blood that left a massive area of denudation when painfully removed. Only after a formal meeting with the inpatient team and a detailed review of various protocols did the patient consistently receive appropriate supportive wound care. At times I felt like an overly aggressive outsider, trying to impose views that were not in line with the institution’s standard of care. Rounding each day, however, I felt crippled when faced with our very sick little boy who was in agony and deserved much more than the pittance of wound care he was receiving. This experience highlighted the inherent challenges of engaging in a health care system for only a brief period of time, trying to optimize patient care in the absence of longstanding relationships with other providers, or knowledge of the function — and at times dysfunction — of the hospital’s operations. Emily West, MD, is a dermatology resident at the University of California in San Francisco. I left Botswana a stronger clinician than when I arrived. Swift and efficient follow up is not available to the same extent in Gaborone as it is in the U.S. — patients may not have telephone access or the money to trek from their remote home village back to PMH. Considering what would be best for the patient, I often made therapeutic decisions without the luxuries of time or confirmatory diagnostic results. The need for routine dermatology services was extraordinary, and I only wish I had more than a month to dedicate in order to overcome some of the barriers faced as a short-term provider. I am honored to have worked with the patients at PMH and I am immensely grateful to the AAD for providing me the invaluable opportunity and support. Emily West, MD, is a dermatology resident at the University of California in San Francisco. Help improve dermatologic care to those in underserved areas through education and service by taking advantage of one of the following AAD international grant programs: Resident International Grant Program Native American Health Services Resident Rotation SkinCare for Developing Countries The Academy works with Health Volunteers Overseas (HVO) Learn more at www.aad.org/members/volunteer/international-volunteerism
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