In this passage from my book La Clinica—A Doctor’s Journey Across Borders, I had just reached the end of six months of volunteering at a medical clinic in the mountains of Mexico prior to beginning medical school. I had volunteered to help at this clinic as an antidote to the unpleasant years of premedical education I had lately completed. Like Gross and colleagues,1 who recently described premedical education as more like overcoming obstacles than a voyage of self-discovery, I was seeking a more relevant introduction to medicine than what I could get from premedical courses. The year was 1972, a time of political upheaval over the unpopular Vietnam War and a time when students like me were furiously searching for promising causes to which they could direct their passion and idealism. On this, my last day at La Clinica, I was making a house call to an elderly man with abdominal pain who believed that my hand, placed on his stomach, would have some miraculous, magical effect. The man’s son was not so much concerned with my hand as with the bag of medications I had hauled with me from the clinic. Couldn’t I just give his father something from my bag? As I pondered my action, the weight of previous similar encounters where I had felt coerced into accommodating a patient’s request for a treatment in spite of my reservations suddenly became unbearable. I hesitated and tried to refuse, suggesting another alternative—a long mule ride down the mountain where other, more knowledgeable volunteers could examine the man. But in the end, I massaged the old man’s stomach and left several medications, yielding to the entreaties of the family and patient.
Our clinic had been started several years before by American volunteers, some with little medical knowledge, who dreamed of creating a utopian community beginning with the clinic. Medical care would be available to all, regardless of ability to pay. And anyone might serve in the role of doctor because there were donated medical books, equipment and medications, and eager instructors. Boys from the village served as dentists and assisted at the clinic. Because the medical profession was perceived to hoard its knowledge and drive families into financial ruin to pay for treatment, those doctors who decided to volunteer at the clinic were expected to teach village health workers and volunteers rather than just treat patients. On this last day at the clinic, as I was about to embark upon my own formal medical education, perhaps my hesitation to provide uncertain symptomatic treatment grew out of the recognition of how my own identity and responsibilities were about to change, and diverge from La Clinica’s model.
Now, years later, I look back upon La Clinica with some fondness, and some sadness. There are days when I yearn for the simplicity of medical care there, without paperwork, without fear of malpractice, and without anxiety about patient confidentiality. At La Clinica, it was common for a patient to invite me home for dinner, take me horseback riding, or present me with a small gift of eggs, cheese, or a sweet pastry. But there were also patients—people who had invited me into their homes—who died because I lacked the knowledge or resources to help them.
I initially decided to write La Clinica to tell the stories of the volunteers and villagers as they built the clinic into a model that would become famous throughout the world. Before I had begun, though, as La Clinica and several volunteers encountered financial, political, or personal problems, I had to reconsider both the validity of the model and its impact upon my own career and personal priorities. I finally decided that describing the failings of La Clinica was probably at least as important as the stories of its successes. The volunteers and villagers, with all of their flaws and bad decisions, seemed more believable and more likely to inspire others than some unreal ideal.
Today, volunteers travel across the globe in an attempt to help people with desperate medical needs. Academic medical centers have initiated international educational and clinical projects that require them to send faculty and staff thousands of miles away. For many, the experience will be life-changing and memorable, as it was for me. But what happens to the villagers, the traditional healers, and the families who open their homes and hearts to foreign visitors? What happens when we pack up our medicines and return home? Will the people we leave be better off than when we first encountered them? The passage reminds us that such questions must be considered by all who would enter a foreign culture to provide medical care, even with the best of intentions.
David P. Sklar, MD
Dr. Sklar is associate dean for graduate medical education and professor of emergency medicine, University of New Mexico School of Medicine and Health Sciences Center, Albuquerque, New Mexico; (firstname.lastname@example.org).
1 Gross JP, Mommaerts CD, Earl D, De Vries RG. Perspective: After a century of criticizing premedical education, are we missing the point?. Acad Med. 2008;83:516–520.