Otolaryngologists on Medical Missions

“The popularity of short-term experiences in global outreach is rapidly increasing,” said Gayle E. Woodson, MD, a volunteer otolaryngology consultant at Space Coast Volunteers in Melbourne, Fla., and a visiting professor at Kilimanjaro Christian Medical Centre in Tanzania. “Service in low-resource settings is appealing to many in the healthcare field for a variety of reasons.”

Short-term mission trips—where physicians go in, help, and then leave—address the immediate burden of patient care, whereas longer trips—where physicians create programs and train local physicians to take over after they have gone—address the ongoing need for care.

The Need for Medical Outreach

“The countries that host mission trips often have an overwhelming burden of need for surgical services. Having both types of mission trips helps reduce these areas’ short- and long-term needs,” explained Andrew A. Winkler, MD, associate professor and director of facial plastic and reconstructive surgery at the University of Colorado School of Medicine in Aurora. “A child with a cleft lip or cleft palate needs their surgery as soon as possible and cannot wait years for training programs to finally affect accessibility.

“The accessibility issue is larger than simply not having enough skilled surgeons. Often, these patients come from rural, underprivileged, and poverty-stricken areas. There is no governmental support, and they cannot afford out-of-pocket expenses or travel. There will likely be an ongoing need to provide mission-type surgical support to these patients,” added Dr. Winkler, who has organized and worked on nearly 12 medical mission teams.

According to Travis T. Tollefson, MD, MPH, professor in the department of otolaryngology–head and neck surgery and director of facial plastic and reconstructive surgery at UC Davis Health in Sacramento, Calif., short-term surgical mission trips follow a vertical model of global surgery in which “a specific patient problem is addressed by a team prepared for a burst of activity, using evidenced-based approaches to streamline throughput and emphasize patient outcomes,” he says. “Some examples of the ideal patient problems treated with this approach are hernia camps, cataract surgery, and cleft lip repair.”

Meanwhile, a horizontal global surgery model can be thought of as “parallel programs that incorporate into the local healthcare delivery system, often through the ministry of health. Countless successful models are based on partnership, advocacy, systems, and infrastructure improvement,” said Dr. Tollefson, who has served as medical director and team leader for several non-governmental organizations (NGOs) that collaborate with healthcare agencies in South America, Africa, and Asia.

“The mixture of these two models is implemented in more and more global surgery teams and is called a diagonal model. The NGO utilizes a needs assessment, a local surgeon, and public health experts to create longitudinal plans to address the overall health system approach to disease and surgical disease burden,” Dr. Tollefson said.

Running medical mission trips requires funding. “The best organizations have administrative staff both in the United States and in country that can coordinate and make things go as smoothly as possible,” Dr. Winkler said.

Missions Trips Versus Training Programs

Cristina Cabrera-Muffly, MD, associate professor in the department of otolaryngology–head and neck surgery at the University of Colorado Anschutz Medical Campus in Aurora, suggested that educational missions, in which physicians train local doctors and teams on specific surgical techniques or management, are more helpful than single mission trips, where the physicians do the surgeries and then leave. Dr. Cabrera-Muffly participated in a mission trip to Guatemala during her residency training. Scheduled annually, the mission provided otolaryngological care to those who didn’t have access otherwise.

“Even if physicians go every year to the same area to perform surgeries, this can lead to patient care issues between visits,” Dr. Cabrera-Muffly said. “That being said, if single mission trips are the only possibility for patients to get life-saving or quality-of-life-improving surgery, it’s better than nothing.”

Gregory Basura, MD, PhD, associate professor in the department of otolaryngology–head and neck surgery and the division of otology/neurotology–skull base surgery at the University of Michigan in Ann Arbor, helped build a dedicated fellowship for ear surgery at Groote Schuur Hospital, University of Cape Town (UCT), South Africa (https://www.entnet.org/humanitarian-efforts/university-of-cape-town-otology-fellowship/). The fellowship was started by Tashneem Harris, MBChB, MMed, a consultant in the division of otolaryngology in Groote Schuur Hospital at UCT, and Johan Fagan MBChB, MMed, the Leon Goldman professor and chairman of the division of otolaryngology at UCT.

In 2022, the otology fellowship became the first such fellowship in Africa. The 12-month program trains otolaryngology surgeons, who then return to the state service in their home country, allowing them to train other surgeons in their department. “My role from the genesis of the fellowship was to give weekly otology/neurology/audiology and vestibular lectures with two site visits to UCT per year to help train the fellow,” Dr. Basura explained. “The day-to-day on-site training is overseen by fellowship director Dr. Harris.

“In my experience, a ‘mission trip’ is when providers go to an underserved area and contribute, typically at the individual level,” Dr. Basura continued. “These programs aren’t typically designed to teach the local providers specific skills, and essentially are service based. Conversely, a ‘medical educational partnership’ is designed to build a specific rapport with the local providers to facilitate education or training on managing the problems at hand and to build a lasting partnership that will be [continuously] sustained.”

Service trips can have advantages, says Dr. Basura. “Service trips allow you to provide a specific service, typically in a high volume,” he said. “The disadvantages are that there’s typically no sustainable transfer of education or teaching, and if there are surgical or other complications that occur after the team leaves, there can be a deficiency of physicians left behind who can manage the problem. Long-term partnerships have the advantage of sustainability built on a transfer of education and empowerment of local providers with skills that can be used for generations. The disadvantage can be that it takes longer to build these partnerships and acquire these skills.”

Meeting Local Needs

In a 2022 paper published in the journal Globalization and Health (doi:10.1186/s12992-022-00815-7), the authors recommended that short-term medical mission teams work with host partners to ensure they meet local needs. Tracey and colleagues evaluated a best practice guideline document for short-term medical missions in Honduras, Malawi, and the Philippines. A total of 118 participants from the host countries reviewed the guidance, highlighting the need to increase the “capacity development of local health workers and provide continuity of care for patients in the local system.” They suggested that this could be achieved by collaboration between mission teams and host partners.

Mission trips have the potential to become medical tourism, and the motivations expressed by volunteers generally relate to their own sense of fulfillment. These include the need to ‘give back’ and learn about other cultures and how to practice with less.

“It has been argued that the driving force for international medical programs is to provide opportunities for people who want to volunteer, rather than focusing on the specific needs of the communities,” Dr. Woodson said. “A major issue is that well-intentioned outreach has the potential to do more harm than good. Short-term mission trips have the greatest potential for this.”

“I have enjoyed participating in short-term missions. They are a good way to get one’s feet wet. But my long-term effort in developing a training program has had a much greater impact,” said Dr. Woodson. “We have taken residents along, and they found the short-term experience rewarding and educational. However, we always emphasized that the visiting U.S. residents should focus on teaching, and not detract from Tanzanian resident experience.”

Ethics and Guidelines

The American College of Physicians (ACP) developed guidelines for short-term global health clinical experience and published their recommendations in 2018 (Ann Intern Med; doi:10.7326/M17-3361).

“First and foremost, the purpose of any outreach must be the improvement of health and wellness in the community being served. Ethical standards must never be compromised,” Dr. Woodson said. The ACP guidelines also state that providers shouldn’t exceed their training or qualifications. While there may be exceptions in the case of exigency, “if you aren’t qualified to do a procedure in your home country, you shouldn’t do it in a low-resource country.” Mission trips aren’t the place for students and residents to learn new procedures. “Humanitarian outreach must complement local practitioners and institutions, and not hinder local resources,” Dr. Woodson added.

Patient safety is the top priority within the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Position Statement: Global Humanitarian Outreach (https://www.entnet.org/resource/position-statement-global-humanitarian-outreach/). Input and participation of local healthcare professionals are essential, the AAO-HNS notes. “A successful global humanitarian outreach effort ideally should eventually eliminate the necessity of its own existence,” according to the statement.

All team members must adhere to the strictest medical, surgical, and ethical guidelines. “Unfortunately, one hears many sad stories about unethical behavior on mission trips. A surgeon shouldn’t do overseas surgeries that they cannot do in the United States. There are more nuanced violations as well, however,” Dr. Winkler added. “I have heard stories of groups paying in-country ‘social workers’ sums of cash to collect and deliver cleft patients to them when they are there. On the one hand, at least the patients are getting the surgery they need, but how that happens seems to stray into unethical territory.”

Other issues to consider include the satisfactory explanation of each type of surgery, informed patient consent, and giving adequate postoperative instructions in the patient’s native language. “Another example is choosing patients who have the highest likelihood of success to the exclusion of others. Training trips must not give the impression that this short education provides any type of certification,” Dr. Winkler noted.

“Ideally, there should be a statement of ethics for each organization that team members must agree to. I also believe that these organizations need to be transparent bodies appropriately registered with local/federal government, instead of small groups organized at a local church or hospital,” Dr. Winkler said. Larger organizations are often better equipped to assess on-the-ground safety and to work with local government agencies, and are more likely to be required to adhere to standards of medical care, he added.

Sustainable Programs and Partnerships

Dr. Basura recommends identifying the partnership’s goals early on and making short-, mid-, and long-range plans.

“Most medical educational partnerships are built through reputable programs and individuals. By partnering with established outreach programs like those from established medical schools, for example, there’s a higher likelihood of sustainability,” Dr. Basura explained. The goals for the receiving area or country and a plan for long-term independence need to be discussed early, however. A partnership can turn into a ‘dependent’ relationship that can be worse than what was in place prior to starting the initiative. Ethics are always a concern, and the nature of the partnership must be clear up front, with clear ethical intentions established.

Involve nonprofit organizations with clear intentions. “In my experience, it’s best to connect universities between the developed and underdeveloped worlds. This creates an established expectation that education and time are the basis for the partnership—that there’s no ulterior motive like money, religion, etc.,” Dr. Basura said.

The success of a program’s efforts to create sustainable change is unlikely to be measurable before the seven-year mark, said Dr. Tollefson, citing the eight steps for leading culture change from Seattle- and Boston-based Kotter International Inc., a consulting and training firm that helps organizations manage change. Dr. Tollefson uses these steps to determine whether change has been successful (https://www.kotterinc.com/methodology/8-steps/).

“The ethos of a volunteer global surgeon can be seen in their consistency, presence, and curiosity for what surgeons are dealing with while the volunteer is back home at their own institution. We have had a glimpse of supply chain woes in North America during the COVID-19 pandemic. Yet, we often fail to grasp the impeccable care and resilience that our colleagues in low-resource settings practice day to day,” Dr. Tollefson said.

Preparing for Outreach

Once you’ve found or created an opportunity for humanitarian service, you’ll need to investigate the requirements for visas and professional licensing, along with vaccinations and travel medicines.

“There’s a big difference between providing care in another country versus another state. To practice in another state, doctors need a medical license in that state. The specific requirements are different for each country. While credentialing may be easier to secure in more socioeconomically disadvantaged countries, less robust regulation can open a pathway for substandard medical care,” Dr. Cabrera-Muffly said.

Dr. Tollefson explained that many institutions are implementing preparative programs to deliver information to volunteers on transparent cultural competency, language acquisition, and local mores. “I believe the strongest example of this that I have seen first-hand is the remarkable mandatory preparation for Peace Corps volunteers.” (You can view the Peace Corps’ process at www.bit.ly/PeaceCorpsTraining.)

He added, “Over my last two decades of experience, I have been humbled by my own struggles in austere environments, in political difficulties, and in overcoming other obstacles to success in global surgery. This is the story of surgeons who have given their lives to making healthcare better in low-resource settings, and I needed to learn that daily disappointment and setbacks were opportunities. The unfathomable experience of connecting to families and healthcare teams in low-resource settings is unmatched.” 

Katie Robinson is a freelance medical writer based in New York.