2019-07-16 MDB Reflection Megan Quinn

My clinical time in Nepal was not what I expected. I went into this experience expecting to experience the unexpected. After months of missed communication with administration from the hospital where we were supposed to be working, we arrived on a hot and dusty Wednesday morning and were… unexpected. Our first encounter with the busy physician responsible for international visitors was brief. Through chatting with the other visiting trainees, we gleaned that department had a fairly packed and rigid schedule: morning conference at 9 AM, rounds in the ward and the PICU and NICU followed. Resident and medical student lectures took place at noon and was followed by afternoon handover at 2 PM. In the times between, residents and interns took care of work on the wards and prepared presentations, or saw patients in the OPD.

All of this activity occurred regularly and on schedule and as I observed day after day, functioned to train efficient and knowledgeable residents and medical students. But neither the schedule nor the residents made accommodation to include international visitors. Rather, those international visitors assigned to the Pediatrics department seemed to float on the periphery, gathering what information we could from the snatches of English conversation that we overheard during rounds or conference, or from the brief updates we would occasionally solicit from busy interns and residents.

After observing the daily flow for several days without making progress toward being fully part of it, I felt myself becoming more and more frustrated – a feeling that I had have before in making the adjustment to new global sites and global partners. And, perhaps more importantly, a feeling that is a signal to me to step back and evaluate the root of my frustration. The system at our clinical rotation site is set up to train Nepali pediatricians – to understand the pathophysiology and epidemiology of disease in their region; to think critically about the resources available to obtain a diagnosis (incorporating the financial limitations of the patient’s family and the systemic limitations); and to weigh the risks of therapy compared to undertreatment.

As one of a cycle of short-term visitors, my lack of knowledge of many of these elements, in addition to the language limitations disrupts this system. To accommodate my limitations to better include me in the daily flow would require taking an intern away from their work, or the payment of an additional staff member to serve as an intermediary. Both of these options stress a system that is already fraught with sparse manpower and financial resources. To operate as a clinician independent of one of the residents would compromise the care delivered to the patients and be both medically and ethically unsound.

Though the experience is not what I expected, I did not come away empty-handed. Instead, as an observer I was better able to reflect on the role that international medical students, physicians, and health care providers can play in global health. In this system and many others like it, perhaps my most important and least detrimental contribution is to be an engaged observer, rather than a direct participant. In this role, visiting providers can contribute an outside perspective in to a system, and in turn incorporate their observations in to the care that they provide to their patients and the systems in which they work. This for me is the richness that global health brings to practice.

Meg earned her bachelor’s degree in biology from Amherst College before volunteering on an intensive sustainable development project in Sierra Leone. As a medical student at Emory University, she continued to work on health in low-resource settings during several surgical trips to Haiti. She received her MPH in global health from Emory, then as a Fogarty Fellow, investigated the role that pediatricians play in preventing childhood injuries in Hyderabad, India. She is now a second year resident at LPCH.

Her rotation in Ecuador was supported by the Mary Duke Biddle Scholars Program.