South County Hematology and Oncology, in Chula Vista, CA

At the annual meeting in December 2008, on an evening when I had little to do, I wandered into an ASH-Health Volunteers Overseas (HVO) session, which described volunteer programs that ASH and HVO were recruiting members to participate in. I was motivated primarily by a desire to listen to something different, something to take my mind off of the daily grind, but by the end of the session, I felt so compelled by the presentations and by the possibilities they represented, that I volunteered on the spot for two weeks with a new project in Peru. I traveled in October of 2009.

HVO’s mission is education; with this in mind I must admit that I had some trepidation about my usefulness as a clinician in practice. I had not been actively involved in clinical teaching for 10 years, while most of the other volunteers I encountered had university appointments, research projects, and active academic practices. I was delighted to find, however, that the variety of clinical practice in Peru provides excellent opportunities for a variety of volunteers.

I spent the first week at Rebagliati Hospital in Lima, a national referral center and teaching hospital, offering services including autologous and allogeneic stem cell transplantation. As a tertiary center with a hematology residency and 15 sub-specialized hematologists on staff, this site provides excellent teaching opportunities for those in academic hematology.

As a community clinician, I found the work at the regional hospital in Arequipa, where I spent my second week, to be more rewarding. Hematologists on staff (and at a third volunteer site in Cusco) manage a broad range of hematologic diseases in both adults and children and train students from two local medical schools.

My role was not as much didactic as it was collegial. Hematologists in Peru train one year in general medicine and three years in hematology. I found their knowledge of hematology to be excellent, and thanks to the Internet they have access to much of the same information that we do. The main differences in patient care arose from their inexperience in general internal medicine (and a heavy reliance on consultants) and from the limitations of the system.

We spent many hours, as one might with colleagues at home, discussing approaches to difficult clinical situations. On some occasions, I was able to offer insight; on other occasions, I was the one learning. For example, what do you do in a resource-poor setting with a thrombocytopenic patient who may be having a CNS bleed? What if there is no MRI, a CT scan cannot be done until tomorrow, and the only way to get platelets is if one of the medical students will volunteer to get apheresed? What do you do with a patient with relapsed myeloma when your only treatment options are steroids, cyclophosphamide, and bortezomib? What is the best second therapy for ITP if your general surgeons do not perform splenectomies? What do you do when your hospital buys rituximab from the lowest-price source, and you suspect it’s no good, because none of your patients have ever had a response to it? And, just like at home, what do you do with a patient

who can’t speak your language and you can’t speak his? There are no academic answers to these questions, just the best judgment of smart and caring clinicians.

I returned to the United States with a new respect for clinicians who work in difficult situations and a new appreciation for all of the marvelous things our medical system can do. My colleagues in Peru gained some new insights, but more so, I think they gained in the knowledge that all of us have dilemmas and challenges, and no one has all of the right answers or tools.

Perhaps something in this article has resonated with one of you among the ASH membership. If there are any clinical hematologists with a sense of adventure or a desire to “give back,” there are colleagues around the world who would benefit greatly from sharing experiences with you. Volunteer … you’ll be glad you did.

Feeling Inspired?

Plan to attend the HVO Volunteer Experience session at this year's 53rd ASH Annual Meeting in San Diego, CA, December 10-13, 2011.