A Global Elective for Georgetown Residents Teaches Ethics and Character — Along with Medicine
Posted in GUMC Stories
SEPTEMBER 18, 2015—Fifty years ago, Marilee Cole, MD, spent a college gap summer helping to build a schoolhouse in Chad. To get there, she traveled through Cameroon, “falling in love with it,” Cole remembers. “There is every geographic landscape there — the Sahara desert, tropical rain forests, mountains, coastline. The people were so wonderful, and so diverse, with lots of tribes and lots of culture — some of it primitive, such as animal worship and belief in witchcraft.”
Cole promised herself to return one day. Thirty-three years later, after earning her MD and diploma in tropical medicine and hygiene and spending decades as an internal medicine professor at Georgetown University Medical Center, she followed through. In 2000, Cole spent a month in mountainous Kumbo at the 250-bed Banso Baptist Hospital (BBH), which also treats outpatients and has a research and teaching agenda.
BBH is a bright spot in an area of the world that is woefully ill-equipped to provide medical care to its residents. Cole knows the statistics by heart — they mean a lot to her. “Sub-Saharan Africa has a heavy burden of disease and few physicians. Specifically, these countries have 13 percent of the world’s population, 24 percent of the total burden of disease and 1.5 percent of the world’s physicians.
“There are 19 physicians per 100,000 people in Cameroon, an annual health expenditure of $117 and an average life span of 51. In the U.S., those figures, respectively, are 242, $7,910 and 80,” she says.
For four years, Cole spent every March volunteering at BBH. Her stories captivated the residents working with her at MedStar Georgetown University Hospital (MGUH). They wanted to go with her.
So she brought them.
In 2004, Cole worked with BBH, and by extension its parent non-governmental organization (NGO), to develop the Georgetown Global Health Elective in Cameroon. Her goal was to “create an international clinical rotation model that is an ethically sound, non-exploitive and safe clinical experience.
“Georgetown residents are very interested in social justice and they aim, in a culturally sensitive way, to achieve equity and improve healthcare worldwide,” Cole says. Between 2004 and 2013, 18 internal medicine residents, four pediatric medicine residents, two medical students and five faculty members joined Cole at BBH in Cameroon.
Volunteers receive no more than two days off during the intense month-long program. In addition to seeing patients in the hospital and in the clinic, they are on call every fourth day and on weekends. Volunteers also present seminars and attend lectures led by American faculty and BBH staff. Topics covered include global public health, as well as tropical and internal medicine based on local epidemiology and evidence-based management of common diseases in Cameroon, such as HIV/AIDS, malaria and tuberculosis.
The “guests,” as they are known, are also coached in cultural sensitivity — the things they should not do, such as blow their noses into tissues (considered vulgar) or crossing their legs while sitting (viewed as a power move). “Once they understand that only the leader, the head honcho, crosses his legs, residents start watching each other and give their fellow residents a little kick if they cross their legs,” Cole says.
An equal exchange of knowledge
After mentoring Georgetown volunteers for 10 years, Cole knows the transformation these doctors will experience. To start, the volunteers shadow a Cameroon physician for several days. Next, they begin to care for a small cohort of patients at BBH with oversight from the on-site American faculty supervisor.
But evaluating and treating patients is challenging, given the prevalence of severe unfamiliar communicable diseases, limited laboratory and pharmacy assets, and the mix of 270 tribal languages and cultures serviced by BBH.
“In the beginning, the residents see a lot of patients dying of diseases they know could be treated in the U.S., and this is very distressing to them. They have a really tough time, and by the end of the first week, many become very discouraged by the whole experience — wondering if they could make a difference,” Cole says.
But by the second week, the residents start understanding how to treat the infections that plague the region. They are also able to effectively treat maladies they know well — mainly, chronic disorders that are common in America yet just emerging among Africans, such as obesity, diabetes, hypertension and kidney disease. As a result, the Cameroon physicians begin consulting the Georgetown resident volunteers on treatment for these “developed world” diseases.
“That opens up an opportunity for an equal exchange of medical knowledge on different topics of interest,” Cole says.
Having less access to laboratory tests teaches the Georgetown volunteers to put greater emphasis on a basic physician skill — a physical exam that relies on the power of observation and touch. “I am always shocked at the fact that these residents really do not know how to do a good physical exam, but they learn very quickly — this will work much to their advantage when they eventually go into practice,” Cole says.
“It is delightful to see how they then work to solve problems, educate themselves and demonstrate leadership,” Cole says. “Their early feelings of despair and hopelessness were frequently replaced by a sense of innovation and teamwork.”
A life-changing, career-shaping experience
As a resident in Cameroon in 2009, Ram Srinivasan, MD, MBA, said his experience “was a life changer… it shaped the course of my career in many ways.” He and his wife, also a resident accepted into the program, diagnosed and treated conditions they were unlikely to see in the Western hemisphere, such as complications from malaria and other tropical diseases. “It was such a learning experience,” he says.
“The other thing that was really different and refreshing is that we became true general doctors who treated kids, adults, even saw and participated in deliveries of babies, assisted in the OR and did whatever was needed. It was the true vision you had of what a doctor was when you were a kid, aspiring to one day be part of the most noble profession of medicine,” Srinivasan says.
Srinivasan is developing a telemedicine program for intensive care units across the U.S., and potentially other countries as well. “I hope to one day return to the continent of Africa with an affordable solution that can assist the health care program there,” he says. “As the world becomes more connected with the Internet and technology, my hope is that we can do more with less once again.”
Nila Dharan, MD, says her experience in Cameroon in 2007 “shaped my interest in public health and international infectious diseases.” She now sees patients and conducts research in tuberculosis as an assistant professor in the division of infectious diseases at New Jersey Medical School, Rutgers University.
“It was an eye-opening experience. We learned first-hand about how medicine is practiced in the developing world where resources, supplies and equipment are very limited,” Dharan says. “The dedication of the doctors, nurses and staff was inspirational, and we learned an immense amount from them.”
A mutual love affair…
Cole conducted a study that evaluated the experiences of both the residents and the Cameroon physicians. The findings — presented in June at CENTILE’s Second Annual Colloquium for GUMC Educators in the Health Professions and published in June in the Herald Scholarly Open Access Journal of General Practice and Medical Diagnosis — reveal a program with strengths that significantly outweigh weaknesses.
Among many points of agreement between the Cameroon and Georgetown physicians is that the elective should be longer — six weeks at least. The Cameroon physicians ranked “clinical teaching” by the Georgetown resident volunteers as the “most positive” aspect or strength of the program.
Though Cole retired from Georgetown five years ago, she continues to travel to Cameroon and to direct the program, which she describes as the highlight of her professional life. She also consults with medical faculty from other universities who are interested in developing a similar global health experience.
The relationship between Cole, the Georgetown residents and the BBH physicians “is sort of a mutual love affair.” It is very much a give and take arrangement that results in many transformations in the way that medicine is practiced.
“We love them as much as they love us,” she says.