Inside Medicine: Should care in foreign countries differ?

03/29/2012 12:00 AM

03/28/2012 1:40 PM

In the United States, we have 2.3 doctors for every 1,000 people, but in places like Tanzania, Africa, there is only one doctor for every 20,000 people.

Our medical students and residents are increasingly committed to going to economically poor nations to volunteer and provide health care. They are willing to live in very primitive conditions in exchange for having a chance to do things in those countries that they could not do back home.

Their goals are to help people – and to expand their skills. Often, they provide care without the supervision of a qualified doctor. This frequently is at the urging of the local hospital or clinic where they really need people to provide care. When they return home, many tell stories of being the most experienced person at the site. Some are even asked to run a clinic or provide a special service.

To be frank, while the trainees are well-intentioned, they are practicing above their skill levels. At home, we would not let them do these procedures, or make treatment decisions because they have not yet acquired sufficient skill and training. More important, treatment decisions that may work in the United States, where people receive follow-up testing and regular visits, might not work in a country where there's no transportation, no one on-call for emergencies and no continuity of care.

Some scholars of global health argue that students should treat patients in developing nations with exactly the same limitations they have back home. If they can't prescribe drugs at home or suture, they shouldn't do it elsewhere. They question the ethics of practicing medicine on people who have the misfortune to be poor.

Other scholars feel just as strongly that some care is better than no care, and medical students and residents should try all they can to help people as long as they feel comfortable and knowledgeable. A research paper in the Journal of Medical Ethics asked how local health-care providers feel about these foreign students coming down and practicing medicine above the level they would be allowed at home.

Interestingly, in this one study, the vast majority of local health-care providers wanted the students to do what they felt comfortable doing as long as it was medically necessary. It didn't matter to them whether or not they were supervised. For example, in many countries, the patients don't need doctors to prescribe medications such as antibiotics or pain killers or stomach treatments. Patients can just go and pick up the medicine at a local pharmacy.

So, if a medical student suggests a specific drug so that a person avoids a dangerous or ineffective alternative drug, then the patient is getting better care than he normally would. It didn't matter to the local providers that the students can't do the same at home.

To what standard should medical trainees be held? Should they work only at the same level they do at home? Are we taking advantage of people in other countries because they have no other alternative?

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