Grupo Medicos Dakota

Six members of the M.D. Class of 2016 build an intercontinental bridge with the people of Chimbote, Peru.

By Denis MacLeod

At the School of Medicine & Health Sciences Medical Doctor White Coat Ceremony in August 2012, six members of the M.D. Class of 2016 donned their white coats as first-year medical students. They had just completed their first week of orientation to medical school and their first week of classes in the SMHS’s nationally recognized patient-centered-learning curriculum, where biomedical and clinical sciences are taught in the context of patient cases. Their first patient case was taught by SMHS Dean Joshua Wynne, concerning Ben, a young man who developed osteomyelitis of his lower leg.

Almost four years later and over 4,000 miles away from Grand Forks, they carried to Chimbote, Peru, what they learned from Ben and other patients to complete a final elective before graduation. The formal title of the elective is International /Developing Nation Medicine. As a part of the School’s service-learning initiative, the course’s stated goal is “to provide education and experience in the unique challenges and strategies of healthcare delivery for people in a developing country.”

The elective was the idea of Ashley Marek, M.D. Class of 2009. She had visited Chimbote in college on a service mission.

Years later, as a first-year medical student, Marek contacted the SMHS’s Assistant Dean for Medical Accreditation and Chief Medical Accreditation Officer Stephen Tinguely, M.D., and said, “I know you've been to Chimbote, and so have I. Before the end of my medical education, I would like to go back. Will you help me organize a senior elective?” In the late 1990s, Marek had heard Tinguely talk to a church group about his experience in accompanying a group of Fargo Shanley High School students to this same mission.

“That's how we formed this senior elective experience about nine years ago,” he said.”

“We've been having a group of students from UND in their senior year somewhere between three and eight students who select this opportunity for service learning and international public health experience.”

Tinguely accompanied most of the early groups of medical students. He has been to Chimbote six times. He is the main preceptor for the fourth-year students who select the elective.

The educational foundation of the senior elective was based on advice from Napoleon Espejo, M.D., a family medicine physician and director of Family Health Care, the community health clinic in Fargo, N.Dak. Espejo grew up in Chimbote.

He married Laura Christenson, the sister of Mark Christenson, M.D., who is the medical director of UND’s Student Health Services and assistant clinical professor of family and community medicine on the Northeast Campus in Grand Forks. Christenson also serves as the head of the medical committee for Friends of Chimbote, a mission started by Father Jack Davis of the Diocese of Fargo over 30 years ago.

Students interested in the Chimbote elective have to apply to the Friends of Chimbote organization, where staff members review the applications for approval. “All of our students who apply have been accepted,” Tinguely said.

“In the spring, we have an informative session for first- and second-year students to tell them what the elective is about,” Christenson said.

“The students get involved with the LAMA Group, Los Amigos Medical Aid, when they are in Chimbote,” Christenson said. The LAMA group coordinates medical missions to serve the medical needs of the poor in Chimbote.

“A lot of the groundwork for what the med students do is coordinated by social workers with ACAF,” Christenson said. “They have some interpreters who assist students.”

ACAF is the Asociación Civil Apoyo Familiar (the Civil Association Supporting Families), a faith-based, non-governmental Peruvian organization that was formed in 2005 by mission founders Father Jack Davis and Sister Peggy Byrne to administer mission programs, manage employees, oversee funding provided by Friends of Chimbote, and maintain compliance with Peruvian laws and regulations. Friends of Chimbote is ACAF’s partner based in West Fargo, N.Dak.

“Students go to Chimbote wondering if they will do any good, and they do,” Christenson said. “However, the concept of reverse mission is probably the most important lesson imparted by the elective: having students see what it is like to live in poverty with inadequate medical care and bringing that knowledge back to the United States to inform people and to also enlighten students’ future practice as physicians when they treat impoverished patients.”

The students selected the elective for varying reasons.

“I felt like this was an opportunity to open my eyes to a completely different scope of disease treatment and prevention before returning to the United States and resuming my training under the traditional U.S. philosophy of medicine,” said Eric Dowling from Moorhead, Minn. “I wanted to share some of the knowledge that I've gained with patients and caregivers in Peru as well as observe how they practice with their limited resources.”

Ian Roche of Grand Forks “chose this elective to have the opportunity to live with and learn from the people of Peru.” Roche had been on a trip similar to this before medical school and wished to have medical service work be a part of his future practice. “I saw this as a wonderful way to experience a new culture and assist people with health and medical concerns.”

“I chose to participate in the Peru elective because I always had wanted to travel abroad for a learning experience,” said Bismarck, N.Dak., native John Roller. “However, I had never followed through on this wish. I realized that this would be one of my last opportunities to have a study abroad experience, so I wanted to embrace this experience. I also was drawn to the fact that the trip was centered on participating with a non-profit organization that served the poor of the community. So much of our fourth year is spent focusing on ourselves and positioning ourselves for our future residency and career. With all this attention placed on yourself, you can become a little self-centered. So I thought the Peru trip would be a great way to break away from this ‘me-first’ thinking and spend my time totally dedicated to serving those in need.”

So what were students’ expectations before the trip?

“I had few expectations as the information provided prior to starting the rotation was somewhat ambiguous,” Dowling said. “This gave me a sense of intrigue and allowed me to come into the mission with an open mind. I knew the community would be poor and living conditions would be vastly different from what I'm used to.”

Roche said, “To be honest, I went in with low expectations but carried with me a desire to learn, educate, and work with anyone that was willing. With this in mind, I had an absolutely wonderful time. We had the opportunity to do home visits, host educational talks on numerous occasions with men, women, and children in a number of nearby communities, focusing on topics that were relevant to their particular concerns.”

“I didn’t have a lot of expectations for the trip,” Roller said. “The only thing I hoped for would be that most of our time would be spent interacting with people in the community, and I was thrilled that that was actually what occurred on the trip. Before the trip, I had prepared myself with the mindset that the medical work that we would be doing on the trip might not be exactly groundbreaking or life changing. I think the group as a whole did a good job of internalizing that we were not going on the trip to save or change the community of Chimbote. Instead, we were going to learn about healthcare in a different cultural and socioeconomic environment by working with the dedicated healthcare workers already present in Peru. But I was surprised to discover the numerous opportunities we had during the trip to utilize our medical knowledge and directly serve the people of Chimbote.”

Work responsibilities

“We initially would split up into those who would work with hospice and those who would work at the clinic,” Dowling said. “The hospice group was divided into working at the hospice building and doing home visits. The clinic group was divided into working with the physician, working with the psychologist, and doing triage. In the afternoons, we would do house visits with the social worker. We found the house visits to be more worthwhile and started doing these more frequently.”

“Students are able to work with the hospice program,” Christenson said. “I believe it is the only one in South America. It’s an incredible facility. You go inside, and you don’t feel like you are in Chimbote anymore. It is a huge benefit for the students to be exposed to hospice while working in Chimbote.”

“The hospice concept in Chimbote is different than it is in the United States,” Christenson said. “In the U.S., people want to die at home, because home is more comfortable and is a nice place. In Chimbote, it’s almost the reverse, because dying at home sometimes means you’re on the floor without a bed. The hospice in Chimbote is a residential facility where for some patients it might be the first time they have laid in a bed. They’re able to be comfortable while undergoing a terminal illness and can die with some peace and dignity with their family around.”

On March 4, 2016, ACAF posted the following to Facebook to accompany the YouTube video GRUPO MEDICOS DAKOTA: “Medical students spent 3 weeks working with us: sharing their knowledge and experience with us, since their arrival they took care of the health of those who have so little. Thank you to our friends from the University of North Dakota.”

Highlights

“The highlights year after year come from the students who end up spending time in people’s homes,” Christenson said. “They start helping out and see exactly the circumstances people are living in and how they deal with their illnesses.”

“The staff that we worked with were amazing,” Dowling said. “They were patient with us as we acclimated to this new environment and receptive to feedback on how to enhance our impact. Throughout our month in Chimbote, we formed lifelong friendships with those whom we lived and worked with. The people of Chimbote were also a highlight of my experience. They were always excited to greet us as we passed in the street, and the patients that we saw were always enormously grateful. One instance that stands out in my mind is one day after we finished at the makeshift clinic in a village outside of Chimbote. A family at a nearby farm invited us over to socialize and indulge in some of their delicious fruit. They excitedly herded us around to show us their exotic plants and animals. This was one of our final days in Chimbote and having the chance to bond with locals and our coworkers was a perfect bookend to our experience.”

Particular highlights for Roche were “family dinners with our host family and celebrating the birthday of Gracie, our host parents’ youngest granddaughter. One evening we came home for supper to find our host father, brother, and family friend out in front of the home playing guitar and a variety of pan flutes. This resulted in an entire evening of meeting, socializing, and singing with new friends and family.

“I also enjoyed going out into the community and doing home visits to triage the immense patient list that was put together by ACAF,” Roche said.

Roche said ACAF’s patient list “allowed a large number of people to get a medical opinion, albeit from a group of fourth-year medical students, but an educated opinion that hopefully was beneficial to the patient and the family.”

“Some highlights of the trip for me were how readily we were accepted by the organization we worked with, Friends of Chimbote, and the by the people of Chimbote,” Roller said. “The organization quickly made us feel like we were part of their family, and I will always remember all the help and support the leaders of the organization gave us. Another highlight is how the group worked together and changed the organization of our time in Chimbote in order for our medical knowledge to be best utilized. Early in our trip, we had the opportunity to go out into people’s homes and directly assess people’s health or answer health complaints or concerns people had. We were invigorated by this experience, but much of our time in the subsequent days was mainly working in a healthcare post doing more background help and assistance (checking people’s height and weights and blood pressure, stocking medical supplies, etc.). As a result, the group came together, saw the deficiency in direct patient care for our experience, and proposed a plan to the organization to spend most of our time going out into the community and performing health screenings or making house calls. Our supervisors in Peru were very flexible and embraced this suggestion, and the rest of the group’s experience in Chimbote was really rewarding. I was quite proud of the group being able to see the slight negatives in our experience and working to change them. My final highlight would be how well the group of us medical students worked together and got close during our time in Peru. We really did work well as a team and were willing to help when needed.”

As one of their final courses in medical school, what lessons did they learn?

“We struggled daily with the conundrum of how significant of an impact we could possibly make in a month's time,” Dowling said. “At times we felt cynical and that our greatest contribution was simply the amount of money that we were spending in the community. At other times, we felt like we were curing the community of all disease. It was challenging to find a way to make a significant, lasting contribution, and this became one of the major goals of our group. We eventually identified that treating local patients at the clinic was a small contribution and that venturing out to patients that couldn't otherwise get medical care was a more worthwhile venture. We also found that education was another way to quickly disseminate information and answer questions for the community. With the help of our volunteer coordinators, we identified areas in which information was lacking and prepared presentations about aging, nutrition, first aid, and the Zika virus. We hope that these presentations provided new and applicable information for our audiences and can continue to be shared with the community. And, lastly, to make a continuing impact in Chimbote, we wanted to enhance the experience for future students visiting Chimbote. The staff that worked with us went out of their way to make our experience more meaningful, and I am confident that our feedback will ultimately lead to a more gratifying experience for future students. We are also compiling a presentation for future visiting students on what to expect and how to do the greatest good in Chimbote.”

Roche also wanted to create a lasting impression and leave a positive effect on the people of Chimbote and the community around the Parish. He said the students talked about this many times as a large group. “But in the end, what was changed was us,” Roche said. “As a group, we came in with a hopeful agenda and wanted to conquer any and all problems we came across, but we soon found out that flexibility, an open mind, and a desire to learn accomplished more than we could have ever imagined.”

“I think the biggest lesson I learned,” Roller said, “is that the point of the trip was to connect with the people of Chimbote and witness their life experiences instead of following a strict schedule of completing different tasks. I am rather detail-oriented, and it initially bugged me when we would somewhat fall behind the schedule for the day. But then I realized that by all this worrying of staying on schedule, I was not being fully invested or present in the interactions with people I had. So I worked a lot on being more present in the moment, and that really helped improve my experience.”

“I am thrilled I was able to have a host family experience,” Roller said, “because I think this was the environment that I learned most about Peru’s culture and daily life. Our family was so gracious and generous in hosting us, and it was always fun to show our family aspects of our culture back in the United States while at the same time learning about their culture. For example, after eating many wonderful Peruvian meals, we wanted to cook an American meal for our family. Therefore, we cooked them a meal of baked mac and cheese and broccoli. It was funny and memorable to see their looks of concern and some trepidation when trying the mac and cheese when we knew we had many of these same looks when trying new Peruvian food. Also, our host brother was an amazing musician, and we enjoyed listening to him play Peruvian music with his guitar. The host family experience helped us truly feel like we were immersed in Peruvian life.”