Preparing to go on an
International
Medical Experience
Camille Bentley, DO, MPH, FACOFP
Chair, Global and Community Medicine
Purpose of Presentation
• Discuss motivations, tolerances, desired outcomes
for international medical experiences
• Present a preparation schedule
• Discuss anticipated stress points and how to deal
with them
• Present resources for additional information
Review your Motivations
• Altruistic and/or self interest
• To see the world and experience other cultures
• To develop communication skills using interpreters and foreign
languages
• To enhance medical skills while helping the needy
• To treat illnesses and surgical problems uncommon in the U.S.
• To practice in a simpler and more gratifying setting
• To get a new perspective on U.S. medical issues
• To find purpose and spiritual fulfillment
• To build lifelong friendships
• To test your ability to face new challenges
Consider your Tolerance
Level for New Challenges?
•
•
•
•
•
•
•
Travel uncertainties and risks
Uncomfortable living conditions
Unaccustomed food and cultural expectations
Language barriers
Disease and injury exposure
Frustration about limited ability to help
Diagnosing and treating based on limited information
What makes a Successful
Global Volunteer?
•
•
•
•
•
•
•
Interests consistent with the goals of the organization
Realistic expectations about what you can accomplish
The ability to expect the unexpected
Flexibility and Adaptability
Patience, Creativity, and Integrity
Openness/Receptiveness
Integrity
Questions to ask When Setting
up an International Rotation
Questions to Assess Program Content
• Is the program highly structured, or will I be organizing my own
schedule?
• What are my clinical responsibilities?
• What will be my duties as a student?
• Will I be with other students from the United States?
• Can I speak with someone in the department I am most interested?
• What types of outside programming is offered? Classes? Excursions?
Service projects?
• Is there an orientation? Cultural awareness training?
• How much community input is taken into account?
• What are the relationships of the people who work in the program
with those in the community? Are they integrated?
• What access will I have to textbooks and other medical resources?
Questions to Assess Housing
• Do you have dormitories for international students?
• What are the differences between the dorms specified for
international students verses those for regular students?
• Are homestays available?
• Are meals included in my housing options?
• Is their electricity? Running water? Cooking facilities?
Hot water?
• How far are the dorms from the hospital/clinic?
• If I have to walk to the hospital, will I feel safe walking?
• If I cannot walk to the hospital, is there readily available,
cost effective, and reliable transportation?
• Will I feel safe using the public transportation system?
Questions to Assess Safety
•
•
•
•
•
•
•
How are foreigners viewed in this country?
Have they been any recent kidnappings?
What is the current political situation in this country?
Is this country on the US state Department Travel
Warning list, if so will require additional RVU
documentation to get approved
How much contact will I have with the outside world
(internet)?
Will I be able to lock up valuables when I am absent?
What is this country's perception of women?
What are your Desired Outcomes?
Goes back to what is your motivation….
• New/improved skills and knowledge?
• Academic credit?
• Satisfaction that you can perform in
exotic/international/challenging settings?
• Self understanding of tolerance levels?
• Direction for future learning emphases?
• Experience level that opens doors for further
opportunities?
• Better understanding and appreciation of other cultures
and perhaps your own??
Deciding Where to Go
• Match you interests, goals and personal creed
-Clinical setting, local language, type of organization)
• Determine your budgetary and time constraints
• Explore the internet and RVU Global Medicine website
• Seek out someone who has been there recently
• Learn expectations for your work and free time
• Understand the principles and policies of the
organization
Deciding When to Go
• Better later in your training to be given more responsibility
• Choose the best season for the location
• Ask about anticipated personnel changes
• Anticipate potential disruptions and political instability
• Get the details about costs and payment dates
• Confirm local travel opportunities
• Check with your RVU Clinical Affairs coordinator
Deciding When to Go
• Better later in your training to be given more responsibility
• Choose the best season for the location
• Ask about anticipated personnel changes
• Anticipate potential disruptions and political instability
• Get the details about costs and payment dates
• Confirm local travel opportunities
• Check with your RVU Clinical Affairs coordinator
6-12 Months or More Before Leaving
•
•
•
•
•
•
•
•
•
Investigate options for suitable experiences
Foreign Language Skills- any required
Dialog with someone who’s worked there
Recruit student partners
Review RVU requirements for travel if related to rotation. Check
Website: Global Medicine
Discuss (select) the elective time thru your Clinical Affairs
Coordinator
Apply for funding support
Apply for a position on the trip
Apply for passport (and visa?)
4-6 Months Before Leaving
•
•
•
•
Finalize choice of venue
Provide all required documentation to RVU Global Medicine
Department in Pod B (Monique McKenna)
Undergo a health review and examination
Determine needed immunizations and begin series
o Check CDC recommendations at www.cdc.gov for
the country you are visiting.
o Check availability of vaccines and pricing at local
travel health department vs. student health vs. PMD
vs. a pharmacy such as Walgreens.
o Will your health insurance cover costs??
Immunizations and Pricing Estimates
(Estimates are from 2013)
Less than 10 years old:
• Adult Hep A
$75.00 per dose (x2)
• Adult Hep B
$75.00 per dose (x3)
• or + TITERS
Less than 2 years old:
• Typhoid (IM)
$75.00
Less than 5 years old:
• Adult Td booster
$40.00 or Tdap $65.00
• Oral Typhoid
$130.00
Other vaccines: Country specific (see CDC website)
• Yellow Fever
$140.00 (good for 10 years)
• Jap/Enceph.
$280 per dose (2)
• Meningitis
$140 (good for 5 years)
• Adult IPV Polio, one time booster $65.00
• Malaria Prophylaxis
$40-$340
Required by RVU for all student international travel
3 Months Before Leaving
•
•
•
•
•
•
•
•
Plan itinerary and buy travel tickets
Continue to complete RVU paperwork for your file
Complete any paperwork, etc. for hosting organization
Request medication, financial donations
Attend team preparation meetings
Study the host country’s history and geography
Study the host country’s language
Develop knowledge of their cultural mores
1 Month Before Leaving
• Make arrangements to maintain your home, school and/or
work life
o Pet care, bill payments, house sitting, class notes, exam
review, etc.
• Prepare for resumption of academic duties when returning
o Anticipate fatigue and reverse culture shock
• Confirm what you are expected to bring
o If provided, check the Packing Guide
• Purchase trip specific items
o Luggage, fasteners, travel size toiletries, etc.
General Packing
1. What items do I need to bring with me (mosquito net,
etc.)
2. What medical supplies and personal items should I
bring?
3. What will the weather be like?
4. What is the dress code, both for working in the program
and in the community? How can I dress to be culturally
sensitive?
Personal Care and Hygiene
•
•
•
•
•
•
•
Climate and custom appropriate clothes
Comfortable shoes and sandals
Rain jacket, swimming suit
Toilet paper, face tissue
Toiletry items, plastic bags
Headlamp
Personal towel and washcloth
Illness Prevention Items
• Antiseptic hand cleanser, face masks and disposable
gloves for work environment
• Insect repellant, mosquito netting
• Sun Screen, lip balm, hat
• Water purification tablets or filter
• Malaria prophylaxis medication*
• Pepto-Bismol tablets
* If recommended by CDC.
Items and Medications for
Personal Medical Kit
•
•
•
•
•
Band-Aids, gauze and tape
Scissors, tweezers, safety pins
Mole skin, felt pads, superglue
Epi pen for allergy, if needed
Anti-emetic such as Tofran or scopolomine
patches
• Antibiotic, steroid and antifungal creams
• Eyes and nose drops if used
Personal Medical Kit – cont.
• Diarrhea treatment (quinolone, Pepto Bismol,
Imodium)
• Pain medications (acetaminophen, NSAIDS)
• Respiratory treatments (decongestants, antihistamines, etc.)
• Altitude sickness prophylaxis (acetazolamide)
• Motion sickness treatment (meclizine,
scopolamine, tofran)
• Personal chronic and rescue medications
Comfort Items
•
•
•
•
•
•
•
Pillow, sheets, sleeping bag, tent
Ear plugs, blind fold
Extra glasses, sunglasses, contacts supplies
Personal music, batteries
Snacks, chewing gum
Flashlight or headlamp
Personal journal, books
Professional Tools
•
•
•
•
•
•
•
Electronic thermometer & covers
Stethoscope and BP cuff
Oto/Ophthlo scopes
Mini-reference books or PDA
Latex gloves of your size
Camera, watch
Copy of credentials
1-2 Weeks Before Leaving
• Begin packing to discover needed items (plan to
travel light)
• List trip itinerary, contact numbers and back-up
plan details and give copies to U.S. contacts
• Gather and repack meds and items to be donated
• Review luggage restrictions and items not
permitted
• Replenish travel medical kit
Night Before Leaving
• Try to get a good night’s rest
o Finish packing early
o Avoid alcohol and stimulants
• Confirm flight times
• Have travel clothes, tickets, and passport laid out
• Allow ample time to reach airport: Group check in
is 3 hours prior to international flight time.
Common Stress Points during an
International Experience
•
•
•
•
•
•
•
Communication difficulties
Trip itinerary changes
Connections in country
Financial issues
Personal safety risks
Illness complications
Stolen or lost items (i.e. luggage, cameras)
Communication Stress Points
during Travel
• Know how to communicate with home and destination
people
o To notify about schedule changes
o To announce safe arrival
• Have phone numbers of alternate contacts
o Carry info on how to use local phone system
• Know location of destination and home addresses of
contacts
• Travel with language support materials or people
Communication Stress Points
during Clinics
• Be realistic about your communication abilities
• Discuss with interpreters the preferred mode of working
together
o Ask for info on cultural factors, home remedies and
alternative practitioners
• Be willing to help wherever needed
• Limit constructive criticism
• Be open to the recommendations of experienced clinicians
Flight Connection
Complications in Country
• Know how to make contact if not met at the airport (Have
phone numbers and coins)
• Have a back-up plan
o For transportation, e.g.. Bus station location and
schedules
o For lodging, list of hotels
• Bring some local cash in case exchange locations aren’t
open
Financial Issues
• Learn beforehand the best methods to get local cash at a good rate
o Travelers checks and credit cards may not be accepted
• Carry financial items in 2 or 3 places
o Wallet (petty cash)
o Money belt (large bills)
o Neck and/or belt pouch (passport, exit fees, tickets, bank and credit
cards)
• Have a copy of your passport, insurance info, credentials and itinerary
in separate locations from originals
• Carry a calculator to determine fair exchanges
• Don’t pack valuables in check-in luggage
Personal Safety Risks
• Stay alert for dangers
• Know the rules to avoid danger
o Use the buddy system
o Avoid danger areas and times
o Don’t flaunt money or valuables
• Protect against sexual misadventures
• Call out early for help
• Don’t fight to protect what can be replaced
Illness Complications
•
•
•
•
•
Anticipate exposures that make you ill
Avoid risky activities
Always carry your travel medical kit
Know the best sources of in-country medical care
Carry travel and evacuation insurance
After You Return
•
•
•
•
Expect reverse culture shock
Take advantage of debriefing opportunities
Plan enough time for rest and reflection
Have a party with those who’ve had similar
experiences
• Give constructive feedback to advisors and
rotation planners
• Complete required paperwork for RVU and make
arrangements to get a post trip TB test within 3
months.
Culture Shock and Reverse Culture
(Re-Entry) Shock
10 Symptoms of Reverse Culture Shock
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
You're bored by family, friends and old routines after your excitement and
challenges abroad.
You find that others do not want to hear much about your experience.
You are irritated by the inane questions about your experience and answer
sarcastically.
You feel that you can’t fully explain your experience or its importance.
You feel that your experience abroad is distinct from the rest of your life.
You are unable to apply your new knowledge and skills to your job, school, or
life.
Your relationships with family and friends have changed.
You think people misunderstand or see the “wrong” changes in you.
You feel alienated and experience “reverse homesickness” for your host
country.
You constantly criticize your own culture in comparison with where you’ve
been.
Ways to Prevent Reverse Culture Shock
• DO NOT leave home without tying up all loose ends, both professional
and personal.
• While away keep track of changes in your family, friends and work via
social networking
• Before leaving your host country say proper goodbyes to the people
there, take lots of photos, and other items to retain the memories, keep a
journal.
• Expect to go through a readjustment period
• Consider who you can count on for emotional support when you get back
(i.e. family and friends)
How to Overcome Reverse Culture Shock
• Understand that it is perfectly normal and that you did expect it to occur.
• Give yourself the permission to relax, reflect on your experiences, and
ease back into your home culture.
• The longer you have been away, the longer it will take to “catch-up”.
• Talk to others who have had the same experience, they can understand
what you are going through. Reestablish rapport with friends and family
by showing interest in what they are doing
• Expect some negative feeling about your home country and culture,
comparison is natural, however, be careful of being Overly Critical.
• Revisit host country and culture through reading, listening to the music,
eating the cuisine, and introduce friends or colleagues to the culture.
• Accentuate the positive
Remember, that this is not necessarily
a once in a lifetime experience.
You can travel internationally
throughout your life.
You Have Readjusted to Society When
You Don’t:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Carry toilet paper with you wherever you go
Turn off the water between lathering and rinsing in the shower
Have to think carefully about which way to look before crossing the street
Panic if you swallow water in the shower
Examine all your food for insects and/or Eat a salad without thinking about
who washed it and where it came from
Gawk at the variety of food in the grocery store
Feel strange sleeping without a bed net and/or ear plugs
Smell like DEET
Dream in a foreign language
Obsessively watch for potholes, stopped trucks and animals while driving
Ignore your pile of accumulated mail
General Resources for Travel Information
• The Global Healthcare Volunteer’s Handbook, what you need to know
before you go, by Kenneth V. Iserson, MD
• CDC: www.cdc.gov/travel
• U.S. Dept. of State: www.state.gov
• Library of Congress Country Studies: memory.loc.gov/frd/cs
• CIA World Fact Book: www.odci.gov/cia/publications/factbook
• Lonely Planet: www.lonelyplanet.com
• www.AMSA.org (Toolkit for going abroad)
• Where There is No Doctor: A Village Health Care Handbook, by David
Werner
Resources for Medical Electives
• RVU Website: Global Medicine, list of sites and contacts
• AMSA.org (Student International Health Opportunities)
• info@projects-abroad.org
• WorktheWorld.org