Empathy Throughout the world, Vermont Medicine Magazine, Larner College of Medicine at the Univeristy of Vermont

Feeling Empathy at Work throughout the World

Vulnerable. Humble. Sometimes even angry.

These are some of the emotions medical students have expressed after returning to Vermont at the end of a global health rotation through the Larner College of Medicine’s Global Health Program in partnership with Western Connecticut Health Network. It takes time, but these feelings often coalesce into a changed outlook on their chosen profession. Many come to a deeper understanding of how different health care systems and socioeconomic structures affect patients’ lives. Most are changed by their experiences, and especially by the patients they care for, leaving them both awed and humbled by the responsibility inherent in becoming a physician.

The Larner College of Medicine/Western Connecticut Health Network Global Health Program, established in 2012, continues to grow in size and scope. It allows medical students, residents, fellows, and faculty from the Western Connecticut Health Network and the College to travel to five partner sites in Uganda, Russia, Vietnam, Zimbabwe, and the Dominican Republic. The program is unique in its emphasis on bi-directional exchange: Medical students and faculty from the U.S. travel overseas, but physicians and other health professionals from partner institutions come to the U.S. and visit other sites across the globe to experience medicine in diff erent cultures as well.

Students are asked to reflect on their experiences in writing. Many talk about difficult situations they encounter, bringing up questions about power, privilege, and the role of the physician. Some write about experiencing the death of a patient — sometimes for the first time — and come to poignant realizations about their work. Many of these reflections are published on the College’s Global Health Diaries blog. The following are excerpts from recent posts.

Doctors and medical students examine a patient at Mulago Hospital in Kampala, Uganda.

The Calling
BY MAJID SADIGH, M.D.
Dr. Sadigh (above, right), the Trefz Family Endowed Chair in Global Health, directs the UVM/WCHN Global Health Program and is a driving force behind its success. The following, which reflects the principles behind the global health program, was part of a speech he gave at the 2016 Global Health Celebration hosted by the College.

The practice of global health connects us to people of diverse perspectives and colors, and upon reflection, to ourselves and the lived experience. We learn to respect differences and recognize shared humanness. We cultivate pure human connections rooted in empathy, unhindered by superficial separations created by classism, racism, colonialism, and structural oppression. We are invigorated by the fortune of understanding others through their histories, strengths, weaknesses, fears, and failures. We learn about ourselves by reciprocating that vulnerability, by being exposed openly. In that openness we discover weaknesses, impurities, prejudices, and deficiencies in our own substance. We are then driven to improve our humanness — to become more caring, more compassionate, more aware, and more giving.

Tragedy and suffering born from human rights inequalities, particularly health inequality, social injustice, and poverty are illuminated on a grand stage under a beam of light. All that is usually hidden is revealed. We stand united on the stage to advocate for those who have been enshrouded behind the curtain. Their tragedies teach us something about resilience, and we find hope in their strength. Their stories tremble through the comfortable encasement of our privilege until it cracks. We learn to care about something outside of ourselves.

In discovering the roots of empathy, we rediscover what calls us to the field of medicine. In its essence, this profession is a calling. At the service of the underserved, we follow that calling.

Turning Vulnerability into a Great Inspirational Tool for Global Health
BY ROBERT KALYESUBULA, MBCHB, MMED, FISN
Uganda, August 5, 2016
Each of us has a point of vulnerability that is often heightened by an unfamiliar environment. What differs from one person to another is the level of resilience. Participant resiliencies vary and are often hard to predict before they face real life experiences. It is very important
to be aware of, and appreciate, vulnerability when it surfaces. When the clinicians come to a foreign country for the first time they need to be patient and not too hard on themselves. They need to take time and be willing to learn not only the medicine but also the culture and
environment where they have gone to work or study. They should be willing to be silent but curious observers who may not be able to contribute much at the outset. However, every lesson should be used to learn and be prepared to give back when the right moment comes. For the medical student, it may be going back to finish their residency so that they can gain more skills in order to return and treat the patients who enabled them to learn so much.
Great global health participants look at every patient as an opportunity to learn something new, not only in medicine but also in culture. They use their experiences as a platform for building empathy, which is the essence of medical practice. Vulnerability of patients and students should stimulate us to look deep in ourselves and draw from the inner strength to make ourselves and, more importantly, our patients better.

Necessity is the Mother of Invention
BY OMKAR BETAGERI ’19
Parirenyatwa Hospital, Harare, Zimbabwe - July 15, 2016
One of my first thoughts upon viewing the medical system was that I incorrectly thought that a system without money needed for an adequate number of resources could not maintain prompt and effective continuity of care necessary to treat patients. Though some of these limitations can be a barrier to care, what I have learned is that the word “adequate” is truly relative, a term that is redefined within the context of Pari. In the vein of “necessity is the mother of invention,” the medical practice here at Pari has developed many ways to combat the limitations that they seemingly face. The medical system has evolved its strengths in a way unique to Zimbabwe, which is what I feel makes this system inherently special and a pleasure for international students and faculty to visit.

For example, the most common day-to- day patient presentations at Pari are respiratory, gastrointestinal, or neurological issues that might require extensive imaging (e.g. TB, COPD, strokes, etc). However, I was lucky to partake in a tutorial with fifth year medical students this week in which students practiced their respiratory exam on a patient to formulate a diagnosis. The instructor called upon the students one by one to practice a component of the exam, such as examining fingertips for asymmetry, general appearance for signs of respiratory distress, lymphadenopathy, etc. It was a meticulous process in which students were assessed on their ability to be specific and recall information with precision. The students ultimately progressed to diagnose the patient with a pleural effusion and its location, solely on the basis of auscultation, chest movement upon respiration, and tracheal shift. The professor emphasized to the class that there was really no need for imaging in this case if the physician had conducted a proper physical exam, upon which the diagnosis would essentially present itself.

This type of comment embodies the philosophy of the teaching system here at Pari, where students are indeed taught how to utilize and analyze imaging modalities when possible, but are taught first and foremost how to use their hands, eyes, and ears to conduct a thorough physical exam which guides their diagnostic thinking. Also noted and emphasized by numerous instructors is the value of thorough history taking, in that, along with the physical exam, it can often elucidate the diagnosis.

There are aspects of this approach that resonate with the clinical philosophy at the Larner College of Medicine. For example, we already know history taking to be a critical part of making a clinical decision. Nonetheless, throughout the next few weeks at Pari, I recognize that I have a unique opportunity to really build upon my ability to use my hands, eyes, and ears to understand patients, simply by acting as
an astute observer of the skilled medical faculty.

Omkar Betageri '19

What Women Want During Labor: Cultural Competency in Uganda
BY JANEL MARTIR ’17
Mulago Hospital, Kampala, Uganda - June 10, 2016
Conversations regarding women’s global health rightly focus on reducing maternal mortality, family planning, and the provision of effective prenatal care. However, I find that these conversations are sometimes problematized by the notion that more developed countries think they know what is best for developing countries. This sort of medical elitism is dangerous and underlies the notion that global health is about the exportation of westernized values — namely and problematically — democracy and capitalism. This is unfortunate given that the discipline of global health was conceived within the ambitious idealism and self-determination spurred in the era of decolonization in the 1970s.

The practice of global health is not about the imposition of one’s cultural values on another’s as some sort of ideological imperialism. It is about keeping patients and communities healthy and safe, and recognizing that health is a right, not a luxury. Global health experiences are opportunities for learning, and it is important to remember that the exchange of knowledge and information ought to be bidirectional. Developed countries can learn just as much from what works in the developing world.

The Vietnamese Family Unit
BY LYNN SIPSEY ’18
Cho Ray Hospital, Ho Chi Minh City, Vietnam - December 1, 2015
Since returning from Vietnam, I have been unable to see U.S. hospitals in the same way. The halls here are clear, there are rarely more than two people to any room, no one is refused standard care based on their income, and visitors only populate the hospital during certain hours. While there is a noted difference in care, it is only a factor of resources and the system in which physicians are operating. What Vietnam’s healthcare system lacks in resources, it makes up for in ingenuity, resourcefulness, and the cultural importance of family.

In Vietnam, the family is truly a unit, both inside and outside the hospital. I have seen family members function as an IV pole, a fan, a ventilator, and perform all the duties (and more) of a LNA. Family members serve as a strong patient advocate, something which is desperately needed in the crowded and busy hospital. …One of the interns I spent much of my time with in the pulmonary unit left work early to take care of his mother who had woken up that morning with common cold symptoms. Her tonsils were inflamed, he reported, and he wanted to go home and collect a sample to run tests on. I was pleasantly surprised and told him that he was an extremely caring son. He, in turn, was surprised by my response, telling me that it was very common in Vietnam. “I am the doctor of my family and I must take care of them, so when they are sick, I am there.” In the United States, I explained, everyone usually takes care of themselves, and it would be frowned upon if I called out of work with a mild illness, let alone someone else’s. He looked at me in shock.

For More Information

To read more about the Global Health Program at the Robert Larner M.D. College of Medicine at The University of Vermont and the Western Connecticut Health Network, visit: med.uvm.edu/globalhealth

Ruth Musselman, M.D., Stefan Wheat '18, Richard Mendez '18 and Stephen Winter, M.D.

Mortality
BY RICHARD MENDEZ ’18
Parirenyatwa Hospital, Harare, Zimbabwe - September 22, 2015
I was excited to work in a hospital in Zimbabwe as part of a medical team. I knew the conditions would be different, but I was unprepared for the severe ailments affecting the patient population at Parirenyatwa Hospital (Pari). Reality set in quickly as I saw a young HIV-positive stroke patient seizing in the hospital bed. The patient began seizing during morning rounds and the diazepam we gave did not stop the convulsions. No other intervention was available, so the seizures continued. As the patient’s breathing became labored, the respiratory therapist came to the bedside and suctioned out the airway. As he worked, I noticed the tubing was filled with blood. I knew then that this patient was going to die. The death I was watching was not that of a quick trauma, but one of slow agony. It was a difficult death to witness.

…This new encounter with death reinforced my commitment to serving others. At the end of life, patients rely on physicians to relieve suffering and provide guidance for the social and spiritual issues at hand. The training we received at Pari went beyond the mere science of pathophysiology and treatment protocols; it provided us with insight into the very human experience of working with patients during their most precious moments. Through them, we learned something of the essence of mortality and grappled with the very real burden such an intimate experience with death can have on a person.

Photo L to R: Stefan Wheat '18, Ruth Musselman, M.D., Richard Mendez '18 and Stephen Winter, M.D.