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The Wards Less Traveled

Practicing medicine off the beaten path

The New Physician March 2007
SEA SICKNESS


Believe it or not, positions for cruise ship physicians are readily available to those with the right training and the willingness to be cut off from traditional medical facilities for weeks at a time. “You don’t want to be practicing on a cruise ship if you don’t have confidence in your skills, because you are really isolated,” says Dr. Robert Wheeler, member and former chair of the American College of Emergency Physicians (ACEP) Section for Cruise Ship and Maritime Medicine. “There are no specialists down the hall to consult with, so you have to be willing to deal with problems on your own.”


Cruise medicine has come a long way just since 1996, when the ACEP formed the first organized body to set quality guidelines for this type of practice. Before that, the international cruise industry was “pretty disorganized” in its standards for providing on-board medical services, Wheeler says. Cruise ship physicians once came from a variety of specialties, from pediatrics to dermatology. Nowadays, most have backgrounds in emergency or internal medicine, and the ACEP recommends that they have three years of training beyond medical school graduation and be board-certified in their specialty. “It’s not always possible [for cruise lines] to require board certification, since many countries do not have the same formal training or certification systems,” he adds.


Another very important qualification for a cruise ship physician is to be comfortable socializing with passengers. “There is a very social aspect to the job,” says Wheeler. “You wear a uniform and are very visible—some people don’t like that.”


For many cruise physicians, the job is a temporary junket, often coming between residency and a permanent practice. “Some want to do a bit of traveling before starting their career,” Wheeler explains. Although the pay varies by cruise line, it’s not too shabby, considering food and board are taken care of. “On larger lines it can reach $8,000 to $10,000 per month.” Doctors are independent contractors with contracts lasting from two weeks to four months. “A full-time position is working eight months a year.”


Wheeler, an emergency physician in Amherst, New Hampshire, cruised part time as a ship’s doctor for 20 years while still maintaining his land-based practice. “I’d save up my vacation time and go out for two to four weeks.” But it’s nothing like a vacation, he adds. “It can be very tiresome—it’s a seven-day-a-week business, and on smaller ships you may be the only doctor on board. But for the most part, it’s a reasonable tour of duty. You meet a lot of interesting people, and there is usually time to enjoy the travel.”


But the ship’s medical ward can be as busy as any family medicine clinic. On a typical cruise, about 1 percent of all people on board will visit the doctor each day. So on a voyage with 2,000 passengers and 1,000 crew, that’s 30 patients a day, every day. Fortunately, Wheeler says, “About 80 percent to 90 percent will be nonemergent,” presenting with sore throats, chest colds and so forth. But because they are on vacation, “they really want to get better, and they do—very quickly!”


Another 10 percent to 15 percent have minor emergencies, such as broken bones or lacerations, and the remainder are “really sick,” he says, with conditions like heart attacks, stroke or intestinal bleeding. “They consume a lot of your time, but overall we can treat 99 percent of patients without disembarking them.”


Most physicians come on board with no experience at all in this type of medicine. Medical student and resident experiences are scarce, because most cruise lines can’t provide teaching because of lack of space. One exception is an elective co-sponsored by the ACEP and Yale University School of Medicine’s emergency medicine department. The four-week elective is available to fourth-year residents in U.S. or Canadian emergency medicine programs, and some third-years who have completed two years in the ER. It is administered through Vanter Ventures, which also recruits medical personnel to the cruise industry.


The elective provides experience in managing minor and major cases in the medically isolated environment of a cruise ship under the supervision of the senior medical officer and the back-up of a telemedicine consultant on the Yale Emergency Medicine faculty. The rotation also exposes new physicians to the issue of prevention and early detection of communicable disease outbreaks like the norovirus, which has become a high-profile concern among cruise passengers.


Physicians interested in cruise ship medicine might be concerned about norovirus, but the illness needs to be put into perspective, says Wheeler. “Certainly, in the past few years we have seen more [norovirus] than ever all over the world. The feeling is that the virus is mutating and becoming more infectious.” And yet, the media doesn’t often cover shore-side outbreaks, which are far more common. “Look at it this way: About 1 in 12 people get this every year generally, compared to 1 in 3,000 who contract it on a cruise ship.” And the virus moves so quickly through the body, most people suffer only for a day or two. In any case, cruise ship doctors log every person who comes to the infirmary with gastrointestinal distress, “so we can catch every one of these people.”


Intrigued by shipboard medicine? Wheeler says that jobs are plentiful. “The cruise industry has grown 8 percent to 9 percent annually in recent years, so if [you] are qualified, there’s a good possibility of getting these assignments.”


INTO THE WILD


Far from the world of all-you-can-eat buffets is the world of freeze-dried MREs (Meals, Ready-to-Eat) and wilderness medicine. Practicing in the wild can encompass everything from snakebites and heat exhaustion to altitude sickness and diving-related disorders—but it’s always an emergency.


One of the most established programs is found at Stanford University School of Medicine, which in 2003 founded the world’s first fellowship in wilderness medicine, designed for physicians who have completed residency in emergency medicine. A primary goal of the fellowship is to promote research leading to a better understanding and prevention of wilderness-associated diseases, and to improve clinical care, rescue techniques and injury prevention.


Fellows also have the opportunity to pursue a wilderness experience through such organizations as the Himalayan Rescue Association in Nepal and the National Geographic Society in Belize.


Stanford’s Division of Emergency Medicine also offers one of the few electives in wilderness medicine for medical students. It is offered during the spring semester and includes didactic sessions, outdoor hands-on skill-building workshops and field trips.


Wilderness medicine specifically addresses the physiology and pathophysiology of humans as they encounter environments that are considered to be “wildernesses.” In these varied environments—from the desert to the tundra to the bottom of the ocean—health professionals encounter rarely seen medical problems like high-altitude pulmonary edema, wild animal attacks and even sea snake envenomation.


But can you make a career of it? “Wilderness medicine is more of an avocation than a vocation,” remarks Dr. Eric Weiss, director of the Stanford fellowship program. “People get into it because it combines their passion—their love for the outdoors—with a profession.” That love could focus on skiing, mountain climbing, scuba diving, hunting, rafting, or any number of outdoor sports.


It also appeals to students and physicians who love the challenge of practicing medicine in an austere environment, “whether at an Everest base camp or volunteering in a remote village with Medecins Sans Frontieres,” But it’s not a full-time living, Weiss points out. Even those providing emergency care in national parks will have a regular hospital or primary care practice.


Most of those in the field have emergency medicine or primary care backgrounds, “which can be a natural segue into wilderness medicine because they need to know a lot about other specialties. They will be called to handle wounds, eye injuries—even pregnancy complications,” says Weiss.


There seems to be no limit to the kinds of assignments a wilderness physician could pursue. Recently, Weiss was asked to serve as the physician for a major film production company filming a movie in the Sahara desert. Although he had to decline, he says it’s an example of how in-demand these services are. “Anyone working outdoors more than one hour from medical care needs [access to] this expertise,” he asserts.


Much of the demand for these skills is for posts that aren’t as sexy as being an expedition doctor, but “the expertise is extremely helpful in working overseas in refugee camps where there is a modicum of equipment. You have to know something about travel medicine and be able to be comfortable living in austere environments,” Weiss notes.


For the more exotic wilderness medicine assignments, getting in the door requires some proactivity. “A lot of it is word of mouth, knowing people in the community and networking,” says Weiss. He recommends that interested students or physicians attend conferences, especially the annual National Conference on Wilderness Medicine. He also suggests networking through the Explorers Club and the National Geographic Society.


In the meantime, students can take classes in such topics as Wilderness Advanced Life Support to hone their skills. “Certification isn’t required to practice, but such classes are very helpful to learn the fundamental principles,” he says.


A wilderness medicine elective can also be a refreshing break from a grueling medical school course load—and a lot of fun, in the experience of Dr. Jordan Safirstein, who completed a one-month program during his fourth year at the University of Utah School of Medicine. He initially chose it for “the opportunity to ski and learn some cool medicine,” but ended up finding “an amazing opportunity to use medical knowledge for something other than tests and patient management. We were taught to use practical medical knowledge for our own benefit and the benefit of others who might be on outdoor excursions with you.” The course, he says, highlighted major injuries and ailments encountered in the field, and also went over major climbing-associated injuries and how to deal with them in the wild.


Although Safirstein is currently doing a fellowship in interventional cardiology, he still considers wilderness medicine a developmental aspect of his training, and daydreams about using it again, some day, some way. “Perhaps [the experience] would enable me to gain more training so that I could eventually do something like base-camp physician at Everest.” He says he “would 100 percent recommend this to others. And it was also a wonderful chance to visit and learn about Utah—and ski the heck out of it!”


STREET BEAT


It may seem like a stretch from a mountaintop to a homeless camp under an urban bridge, but wilderness medicine and street medicine do overlap. Both require physicians to provide care on the spot, often outside, and without the immediate security and comfort of a hospital staff and high-tech equipment.


Providing structured care to the unsheltered homeless is a fairly new innovation that can be traced to the vision of Dr. Jim Withers of Pittsburgh, Pennsylvania. In 1992, Withers, an internal medicine physician, began providing medical care to the homeless directly on the city’s streets. Partnering with formerly homeless individuals, and initially dressing as a homeless person, he gradually earned the trust of this transient and wary patient group as he made nighttime rounds in alleys and under bridges. More clinical volunteers soon joined in—medical students, residents, nurses, mental health professionals and others—and Operation Safety Net (OSN) became one of the nation’s first targeted, full-time street medicine programs, inspiring imitation all over the United States and abroad.


Withers’ purpose wasn’t simply to provide for the homeless—he had medical education firmly in mind. “I wanted to create an example for students of how to step over the boundaries of medical practice and care delivery to meet the needs of a group that is not user-friendly or well-served, and to see them in the context of their reality.”


Through the department of Medicine at Pittsburgh’s Mercy Hospital, OSN operates clerkships for fourth-year medical students, as well as rotations for primary care residents, some of whom have gone on to pursue street medicine full time.


Two of those graduates are Dr. Patrick Perri and Dr. Elizabeth Cuevas, who both chose the University of Pittsburgh because of its many service medicine opportunities. They became involved with Withers and OSN, and later matched in internal medicine at Massachusetts Medical Center to work with Dr. Jim O’Connell at Boston Health Care for the Homeless—“a mecca” for street medicine, Perri says.


The husband-and-wife team are now part of a full-time roster of 15 physicians, more than 30 mid-level health professionals and more than 60 nurses working for the organization. When not on the streets, Perri and Cuevas spend much of their time teaching students and volunteers the ropes.


“Teaching is a core part of the mission, and an unwritten rule [of this type of practice],” Perri says. “We are trying to target folks going into primary care or other careers with diverse patients, because they are going to encounter homeless and at-risk patients.”


“These kinds of service-learning programs are springing up all over the place,” Withers says, “and really need to be a component of medical education generally.” He believes that street medicine can teach every future physician—whether planning to go into a service career or not—how to be flexible and “live in the patient’s shoes.”


One newer medical-school-based program that emulates the OSN model is MUSHROOM—Multidisciplinary Unsheltered Homeless Relief Outreach of Morgantown. Established in West Virginia’s capital just over two years ago, “it was an entirely student-driven initiative,” says faculty adviser Dr. David Deci, who is also assistant professor and vice chair of West Virginia University School of Medicine’s Department of Family Medicine. “Students in our Family Medicine Interest Group wanted to take medicine to the city’s most marginalized residents.”


The most important part of orienting to this way of practicing “is that the whole goal is to develop trust among the homeless—it’s our greatest therapeutic tool.” Most are marginalized from mainstream care because of mental health problems or family dysfunction, which are commonly superimposed on drug and alcohol issues. They don’t trust the system—including the medical system—and many of them have been abused or degraded by people in authority. “That’s why we have to begin by developing relationships of trust.”


Many volunteers “think we will rush out there and start detecting diabetes or hypertension in the field, but most of our work is sitting around talking and being present, building their self-worth as human beings,” notes Deci. And while most clinic doctors have just 15 to 30 minutes to spend with each patient, “street rounds are open-ended. We take as much time as the individual requires.”



Street-care providers don’t just dispense medicine: Teams bring food, beverages, clothing, tarps and any other materials needed to support life on the street. “Interestingly, the ticket into the [physician–patient] relationship is often clean, dry socks,” he says, which are in more demand even than food.


MUSHROOM sends out two teams each day, including three or four medical students as part of a varying multidisciplinary cohort that also includes licensed physicians, social workers, clinical psychologists, nurses and even occupational therapists. Rounds take place on a regular schedule and in predictable places. “The homeless get into the habit of looking for us at certain times and in certain locations,” Deci explains. In Morgantown, those locations may be a main storm drain, abandoned buildings, under bridges and in riverfront camps. Still, the population is very migratory and will move around depending on the weather, police activity and individual needs. So the teams work with formerly homeless partners “who help us locate people.”


On rounds, volunteers carry medical equipment in backpacks and a large rolling cart, “which is like a tool chest on wheels,” Deci says. Most of the medical interventions are minor and can be handled with suture kits, saline and bandages. “It’s like making a house call, except the ‘house’ is a space behind a dumpster.”


But every once in awhile, a team will come across an acute medical crisis, so everyone carries cell phones to alert 911. Deci remembers one man he discovered behind an abandoned house suffering from end-stage liver failure and just hours from death. “The good thing is that we knew this man; we had been seeing him on the street and he trusted us. He allowed us to call an ambulance to transport him to the hospital, where the staff knew us as well.” One MUSHROOM team member was a hospice nurse, and arranged to enroll the man into a program providing a visiting hospice nurse to the homeless shelter where he was settled. “He got better and stayed sober; he’s told us he feels better than he has in years.”


Another man was discovered in a schizophrenic crisis. The team was able to contact local mental health services and get him an inpatient bed for treatment. “Our program has a lot of connections throughout the medical community in Morgantown, which has been essential to our success with this population,” Deci asserts.


Even if they practice on the street for just a few months, students learn lessons that can last throughout their careers. First- and second-years with experience in the program get to teach the third- and fourth-year newcomers, and the team works collaboratively in a way not seen in an academic health center, according to Deci.


“My goal is to provide them with structured and life-changing experiences. When they go on to work in an ER or hospital ward, they will be able to relate to poor and homeless patients, and not see ‘just another bum.’”
Martha Frase-Blunt is editor of The New Physician.