Internships in Guayaquil, Ecuador

Staff members were kind, welcoming, and extremely helpful day to day. Hospital placements and community outreach were better than I expected, allowing interns to immerse themselves in hospital and community culture. I was able to make lasting connections with the people I worked with and experience so much more than I anticipated, while still adhering to ethical standards. This is a very difficult line to walk and IMA did it very well. Overall, this was an incredible experience and exceeded my initial expectations. Interning at Coast General Teaching and Referral Hospital (CGTRH) provided the opportunity to observe the psychology department directly, as well as the entire hospital through a psychological lens. Psychologists have a unique role in the healthcare setting because they see patients in every section of the hospital. As a psychologist, with academic focuses in neurology and education, learning about the educational models and cultural beliefs that guide clinician practices provided insight into the systemic workings of the hospital as well as the different types of relationships between patients and providers. This experience yielded a better understanding of the psychological education system, knowledge of the daily workings of a hospital, and an increased perception of the mental healthcare system in Kenya. One thing that stood out is how new psychology is as a field of study. The University of Nairobi offered the first psychology degree beginning in 1999 (Department of Psychology, n.d.). Prior to that, the first psychology classes were offered to healthcare professionals beginning in 1989. Today, psychology is recognized as a degree at 30 institutions across the country, with four different tracks; general psychology, counseling psychology, medical psychology, and psychology with an IT (technology) focus (KUCCPS, n.d.). The formal psychology department at CGTRH was created in 2020. The department is still so new that it is not discoverable on the hospital website (Coast General Teaching & Referral Hospital, n.d.), so the remainder of the given information was provided verbally by psychologists working in the hospital (CGTRH Psychology Staff, personal communication, June 2024). Prior to the pandemic, there was one psychiatrist in the hospital, and a majority of his case load had to do with secondary conditions, such as addiction, insomnia, and anger management. This is a result of a combination of understaffing in the hospital; i.e. a psychiatrist was only called for the most outwardly disruptive cases, and that mental health was, and still is, largely stigmatized. It wasn't until the pandemic hit, and a majority of the neurotypical population was faced with social isolation, that the general public began to accept that mental health conditions, such as depression and anxiety, can arise in otherwise healthy individuals. It was at this time that the previous psychiatrist was reaching retirement age, but realized that there was nobody else in the greater Mombasa area who was certified to replace him. As a result, the hospital paid two students to become certified psychiatrists in order to replace him, but the previous psychiatrist had to work an additional four years past when he wanted to retire, until these two students were able to complete their degrees. In addition to hiring two new psychiatrists, the hospital hired three full-time psychologists, to assist with the growing case load. In addition, there is one visiting psychologist, who works for the government, and a number of students, interning at the hospital, who are still among some of the first psychologists in the country. Currently, the hospital has a large outpatient clinic, several specialized clinics; such as the Gender-Based Violence Clinic (GBV) and the Comprehensive Care Center (CCC), and conducts daily rotations in the wards. Speaking with the Kenyan psychology students about their educational experiences has allowed the ability to learn more about the psychological education model in Kenya. From talking with students, it appears that the lessons taught in the classroom model those taught in the U.S. pretty similarly. The main difference is that because this is still such a new field, there is not a whole lot of guidance in the clinical applications; i.e. students complete a two month clinical rotation during their fourth year of schooling, where students are working alongside certified psychologists in the workforce. Many of the students expressed stress during these rotations because they did not feel they had the guidance needed to effectively handle the given cases. Since there is a language barrier, all IMA interns were paired with a Kenyan student or provider during our rotations. We were also given two comprehensive tours of all departments in the hospital, with both general healthcare and psychology specific focuses. The Kenyan interns, however, were expected to go off on their own from day one and handle cases independently. The interns were not explicitly trained on how to make people feel comfortable while asking questions. Consequently, many of the students struggled to get patients to open up to them; i.e. if someone was not immediately forthcoming with information, students would move on to the next patient without really asking a lot of follow-up questions. From an outsider's perspective, as reported by many of the patients, it appeared that these students didn't care to learn more about the patients. It, however, became quickly apparent that this was not the case at all, but rather students were not properly trained in asking questions in a way that makes people feel comfortable to share. For example, there was one young man who had been in the hospital for several months due to a machete accident, who previously was an orphan living on the streets. This particular gentleman had experienced a lot of betrayal; his adopted family physically abused him and he had to run away from home, some of the friends who he met on the streets robbed him of all his belongings in the middle of the night, and even his current friends never bothered to visit him in the hospital, which is something that he expressed really hurt him. Initially, he did not want to talk to anyone, and it took one psychology student sitting with him every day for weeks before he opened up about his situation. He told her that he felt as though many of the students were simply trying to check a box during rounds, but did not actually care to really get to know him. Although this was definitely not the intent of the other students, this was the impact of their actions. As such, it is so important when working with vulnerable populations to understand how our actions are perceived by others. It is not a fault of the students, because they are all still learning, but rather a gap in the education system. Another thing that was really interesting about the teaching practices, is that there is a wealth of knowledge with regard to mood disorders, such as depression and anxiety, PTSD, and other related trauma response conditions, but there is still a lot of unknown with regard to conditions such as bipolar or schizophrenia, i.e. mental health conditions that don’t have concrete triggers. In the past, mental health conditions were considered to be a result of witchcraft, in that there was an external reason why someone was acting in a particular manner, rather than a biological imbalance. While today this is not a widely accepted belief in the medical community, mental health treatment plans are often still focused on treating external factors. For example, there was a middle aged woman who was admitted to the ER after being hit by a tuk-tuk, but was referred to psychology due to disjointed thoughts and erratic decisions. This woman had late stage HIV, which she believed to be caused by bewitching by her husband’s second wife. While this on its own is not necessarily cause for concern, her actions that followed the onset of this belief are indicative of an underlying mental health condition. When this woman started experiencing these symptoms she ran away from home, leaving behind her three children, and moving to Mombasa to live on the streets and work as a sex worker. She claimed that this was a much needed vacation for her, and that she came to Mombasa to relax, but that she was still worried about her children. Her disjointed thoughts were likely attributed to her HIV, as it is quite common to experience mental disturbances if it is left untreated (National Institute of Mental Health, 2023), but her impulsive actions and observed mood disparities were characteristic of another underlying condition. Unfortunately, there are not enough beds in the hospital to admit psychiatric patients long term, so the treatment plan was centered around relieving HIV symptoms, and hoping that she would realize that her physical symptoms were a result of her condition rather than bewitching. The thing that was most interesting about this is that the mental health treatment practices are focused on treating physiological conditions and assuming that mental health will improve on a parallel basis. While this logically makes sense, someone with a true chemical imbalance is not able to think rationally in this way. The treatment for mental health conditions is still very neurotypical centered and there is still not a lot of knowledge about invisible disorders. A lot of this too comes down to limited resources, so there's not necessarily an easy fix, nor are physicians at fault, but it does illuminate a systemic pattern about how mental health conditions are treated. One aspect of the Kenyan mental health system that could be implemented in the American system, is that care is very patient centered. Despite there being limited staff members, once psychologists get over the initial hurdle of learning how to ask good questions, staff prioritize quality of care over quantity of patients seen. Most psychologists have regular patients that they see daily or weekly (depending on if they are in or out patients) and psychologists never rush conversations or go in with set expectations about appointment times. In the U.S. there are very clearly defined timelines for which a provider will spend with a patient, and once that time is done, the psychologist will leave, even if they are in the middle of a conversation. This, however, is not the case here, as there are no set appointment times and psychologists will stay with the patient until the conversation runs its course. This often means that practitioners don't end up getting to everyone, i.e. they are assigned more cases than they can ever get to in a day, and thus patients often have to wait to speak with someone, but with the knowledge that when it is their turn, they will have the undivided attention of staff members. For example, there was a young girl who came into the outpatient clinic due to anxiety induced muscular pain. Whenever the daughter experienced a lot of anxiety, typically centered around academic performance and exams, she would develop debilitating pain in her legs, which prevented her from walking or performing other necessary tasks of living. The girl was accompanied by her father, who was also experiencing a lot of anxiety around the situation. The father was the only person supporting the daughter, as everyone in the family had dismissed her pain as psychosomatic, and essentially her just being dramatic. Typically an outpatient session runs about thirty minutes, give or take, but this particular session lasted over two hours. Although the session was for the daughter, we spent a large amount of time speaking with the father, as he expressed a lot of guilt and wanted help in deciding how to handle the situation moving forward. We were able to speak with both family members individually, and then bring them back together to have a facilitated conversation in which they could share their respective grievances and come up with a plan of action for moving forward. This personalized care model, in which providers really take the time to get to know patients, is so incredibly important because it builds trust between patient and provider, and helps to make patients more likely to follow through with treatment plans. Providers take the time to explain why they are doing what they are doing, and really break down each step of the process, which is a critical step in building genuine therapeutic relationships. Something that was really emphasized at the hospital, that is also emphasized a lot in my psychology classes at home, is the interconnectedness between mental and physical health. At home we talk a lot about spheres of wellness; physical, mental, social, intellectual, environmental, spiritual, vocational, and financial (Northwestern University, n.d.). These factors all work parallel to one another in order to make a complete and well person. When one factor becomes depleted, imagine the cup metaphor, in which each sphere is represented by a cup of water. When one cup of water (sphere) becomes depleted, all of the other cups must give some of their water to the empty cup, meaning that all other spheres become a little bit depleted as well. This is especially important in the hospital because if someone is in the hospital, by definition, their physical wellness cup is depleted. As such, it is crucial for people to take care of their mental health and fall back on their support systems in order to have the strength and energy to recover physically. It is so incredibly important to speak with patients and allow them to know that there is someone out there who cares about them and wants to see them get better. This is especially true for patients who don't have family members and/or are struggling financially, because multiple of their spheres are depleted at once, which means that there is even less water (energy) to be distributed. Many people who are in the hospital give up mentally long before they give up physically, and as such psychologists play a critical role in patient outcomes. For example, there was an older woman in the oncology department, who was undergoing radiation treatment. The first day we met her she was very withdrawn, talking about how she thought she was going to die, and how she didn’t see a point to traveling to the hospital everyday anymore. We spoke with her and her husband at length, allowing her to talk through her fears, and validating that it was worth it to continue treatment. Over the next several days she slowly came out of her shell and began to appear brighter. By the third day she was walking around the center, instead of sitting in the corner, and was even laughing at jokes. She confirmed that she wanted to continue treatment and that she was feeling much better after our conversations. The main reason being that she previously did not feel like she had an outlet to express her concerns, since she didn't want to further burden her family, and was bottling it all up inside. As a result, the psychology team was able to help her and many other patients realize the importance of their life, and remember that they are not alone in their fight, which can often be the make or break moment in a person’s recovery journey. Interning at CGTRH provided the opportunity for immersion in daily hospital routines, allowing the ability to forge genuine connections with patients, observe noticeable improvement in patient outcomes, and learn about the educational and clinical psychological practices in Kenya. This placement allowed the possession of a deeper understanding of healthcare as a whole, an increased conception of the interconnectedness between the body and mind, and a greater appreciation of the importance of patient centered care in psychology. Additionally, working as a team with providers has fostered the ability to form compassionate therapeutic and professional relationships, as well as a deeper understanding of the factors that inform clinical practices. The knowledge obtained from this experience will guide any and all future work in the field.

The program was more than I could have ever expected. When I first arrived in Mombasa, I did not know what to expect. I was not even sure there was going to be a sign from IMA waiting outside of the airport for me. But when I stepped out from the airport I was greeted by an IMA staff member with kindness and hospitality. The staff at the residence was more than helpful by doing laundry daily, providing excellent meals, and willing to help with anything us interns may have needed help with. The program mentors were always very easy to approach and some I have become close with after my time in Kenya. I appreciate everyone's kindness and help during my time in Kenya. At the hospital, I learned more about healthcare than I expected. The doctors were kind, and willing to spend the time to teach us how they were treating the patients. Many of the medical staff also provided us insight on the healthcare system in Kenya. The community in Mombasa was welcoming and everyone I met was nice. When doing the Women's Health clinics, I could immediately see the impact we had on the young women we talked with. I distinctly remember meeting a young girl at one of the school we went to for a clinic and she was asking me if I was a doctor. I explained that I was in school to become one and she looked at me with such excitement and explained that she dreams of becoming a doctor one day. Seeing the girls hope in her eyes to become a doctor makes me realize how much of an impact we have on the schools we attended. I made sure to tell her she could do anything she set her mind to, because I truly believe that. That exchange I had with the young girl is the best example of how much I see we have made an impact on the community, not only by teaching about Women's hygiene but also showing that these girls can pursue the careers they choose to. The experience I had with International Medical Aid was one that more than exceeded my expectations. When I first discovered IMA, I was unsure of how much I may learn or experience, but after reaching Mombasa, I discovered a program that taught me far more about healthcare than I could have imagined. Not only did I learn about the overall experience as a healthcare provider, but also what healthcare looks like in Kenya and some of the differences in the healthcare system between East Africa and America. I have gathered a new appreciation for healthcare providers, especially those in the Coast General hospital. Coming to Coast General, I was not sure what to expect especially on the Physical Therapy side because many of the other interns there were pursuing Pre-Med or Pre-PA. But I met many Physical Therapists that welcomed me with such kindness and taught me a great deal about what it means to be a Physical Therapist. During my days in Coast General I rotated between six different in-patient Physical Therapy areas of the hospital. Each rotation I worked with a different Physical Therapist and learned something new that I will continue to value through my time as I pursue a career in healthcare. I began my first three days in the medical ward of the hospital with Omar. Omar was kind and welcoming, and a wonderful teacher. He showed me to every patient that he had in the ward and discussed with me the details of their prognosis and how a Physical Therapist would treat the patients. Many of the patients we saw in the medical ward were stroke patients. Omar spent time with me and the other Kenyan Physical Therapy students discussing the physiology of a stroke. He taught me many details on stroke patients such as the etiology, risk factors, the two types of strokes, the clinical presentation, and how a physical therapist may help a patient’s condition when presented with a stoke patient. After this discussion, we went to see some of the stroke patients and Omar continued to ask me questions about how I think we should proceed when presented with a stroke patient that had developed hemiplegia. His openness to my own learning experience while I shadowed him in the hospital is something I more than appreciate. Some of the things that PT would do with a stroke patient would be passive physiological exercises. The goal of this exercise would be to maintain joint range of motion, blood circulation, muscle tone and more. The only reason I am able to list these details is because of Omar and his openness in sharing with me his own knowledge. I have shadowed Physical Therapists in America, but I had never been met with such eagerness to teach than the therapists I met in Mombasa such as Omar. After my first three days in the hospital, I had already gathered a new respect for not only Physical Therapists overall, but also the ones I had met at Coast General. The next rotation I had in the hospital was in the surgical ward with the Physical Therapist Joanne. In this ward I saw neurological and general surgery patients who suffered from things like cervical spine fractures, traumatic brain injuries, and severe burns. The PTs would often ask me questions to understand more of my own knowledge on the different cases that we saw. Most of the questions I was unsure of, and the PT would send me home with homework to do some research on the condition of the patients we would see. Even for the Physical Therapist to have me do research outside of the hospital is something I appreciate because it shows even though they have just me they still care for me to learn. One of the more memorable patients we saw in the surgical ward was Nickson. Nickson was a burn patient who suffered from severe burns on both of his legs. I had learned that he had been in the hospital for five months and is still far from fully healing. One of the main tasks of the Physical Therapist when helping Nickson was to apply pressure on his knees to help him fully extend his legs as that what something he was unable to do after being burned. Watching the patient-therapist interaction is something that I have appreciated. I learned though my shadowing the importance of a Physical Therapists encouragement and support especially with a patient that is undergoing severe pain in the process of physical therapy. In addition, there were time it seemed to me that the therapist should have stopped the pressure on the knees to help Nickson fully extend them, but what I have learned is that there would be no progress in his injuries if he was met with insufficient exertion. The experience I had seeing the work Joanne was doing with Nickson made me appreciate the mental strength of a PT. It is hard to see someone suffering in any form, but to be able to have the ability to encourage someone to continue to help themselves and get better takes much strength. Each day I would return to see Nickson I could see the progress being made and it filled me with optimism and hope. Although I could see his pain, I could also see how the work of a Physical therapist can truly help someone’s recovery process. The other rotations I was able to do were in orthopedics, Peds, NBU, and the surgical and medical ICU. These rotations each taught me something new about the importance and purpose of Physical therapists. Each therapist I shadowed showed me something new about how important a physical therapist is when it comes to someone’s recovery or stability. The ability to shadow in several different specialties of physical therapy allowed me to see what I may be more interested in as I continue to pursue a career in physical therapy. The area that I enjoyed the most was orthopedics. During my time in the orthopedic ward the physical therapist was more than willing to teach me about the duties of a physical therapist when it comes to orthopedics. The most memorable aspect of ortho was seeing difference in physical therapy management between pre-surgery versus post-surgery. In addition, seeing the x-rays of the bone fractures before and after surgery seeing the check x-ray. There is so much that the physical therapist taught me one the protocol of therapy when it comes to a patient with a fracture. On the third day in orthopedics there was a new patient with a femur fracture and the therapist asked me how I would begin to help the patient. From what I learned in the past days in orthopedics I was able to share with her what I thought would be important for a physical therapist to have the patient do. To be able to shadow a PT who was willing and able to teach me about the responsibilities of a physical therapist is one that I greatly value. My time at Coast General, shadowing each of these therapists has allowed me to learn far more about physical therapy than I could have imagined. With IMA I was able to attend weekly Women’s health or hygiene clinics that allowed us interns to connect with the community and provide knowledge of various topics. I was able to attend two Women’s health clinics where we attended secondary schools in the community and discussed the female reproductive system as well as educated the students menstrual hygiene. The clinics gave me an opportunity to have a better understanding of the limitations girls face not only in Kenya but globally when it comes to menstrual hygiene. During the clinic we made sure to keep the girls engaged by asking questions to have a better understanding of their knowledge on menstrual hygiene. Most of the girls had a basic understanding, but I could immediately see the impact we had being there and giving the girls more insight on this important topic. Each one of them had many questions to further their knowledge on Women’s health and continued to show their excitement at our presence at their school. After the clinic was over, we were able to hand out pads to the girls. As an American who has grown up privileged to have access to something like pads, I truly gathered a new appreciation for the opportunity to be able to supply these young women with something that can truly help them feel more comfortable with their natural cycles. Not only did I see how educating the girls on Women’s health and supplying them with pads impact them, But I also saw how our presence as students ourselves made an impact. At the second Women’s Health clinic there was a young girl who asked me many questions after the lecture was over and one of them was if I was a doctor. I explained to her I was currently in school to be a doctor, and she looked at me with so much excitement in her eyes and said she dreams of being a doctor one day. This exchanged showed me how much influence we may have on these young girls we can have just by coming to their school. Through reaching out to the community in Mombasa, we had a significant impact on the girl’s lives. The opportunity that IMA gave us to be able to have such an impact on the community is one that has allowed me to have a new appreciation for my own experiences in life and even more being able to share this knowledge with these young women. During my time in Mombasa, IMA presented us interns with several different global health lectures where we learned about the history of pre- and post-colonial Kenya, disease burden in Kenya, and the Kenyan healthcare system. Through attending the lecture on pre- and post-colonial Kenya I was able to grasp a better understanding of the culture and history of Kenya. The lecture taught me of some cultural differences between America and Kenya. One of these differences is the number of ethnic groups in Kenya compared to America. Kenya is a diverse country with 44 ethnic groups and almost all speaking at least two languages. This to me represents the rich culture of Kenya and during my time in Kenya it is important to think about how diverse the country is. Another difference is the economy and poverty in Kenya. While Kenya is continuing to develop as a nation, it was clear to me not only from the lecture, but also during my time at the hospital that there is a great deal of poverty. Many patients at the hospital were unable to financially support themselves to receive treatment they needed from the hospital. This challenge is something I saw the healthcare providers have to navigate as they are trying to care for their patients, but without financial support sometimes they are unable to. In addition to the differences in economy, I also learned of the history of Kenya. Learning about the history of Kenya is something that was important to me during my time with IMA. In order to fully immerse myself into the culture of Kenya, learning of the history is an important step. Through this lecture I was able to better understand the experience of Kenya through history and how it came to be the way it is today. The lecture is one I value and remember during my entire time in Mombasa and still even after I have left that has given me an appreciation for the culture of Kenya. An additional lecture topic that I found to be important to understand during my time with IMA is the Disease Burden in Kenya lecture. During this lecture I was able to grasp more knowledge on the main diseases that are seen in Kenya. I found this lecture to be the most important to use as a resource when in the hospital so I could understand more of what the healthcare providers are mainly treating, one of these diseases being HIV/AIDS. HIV/AIDS is a disease that many patients in the hospital have and as I learned in the lecture has one of the highest mortality rates in Kenya. The lecture also mentions that over 50% of males in Kenya have HIV. This statistic alone exemplifies how prevalent HIV is in Kenya. Learning about these facts made me have a better understanding of what healthcare providers may have to deal with in the hospital and even in the community in HIV prevention education in order to slow the rates of infection in Kenya. In addition, diseases such as malaria, TB, of the respiratory system, skin diseases, and more are extremely prevalent in Kenya. Many of the patients in the Coast General hospital had these diseases and the doctors in the hospital are the ones that have to diagnose and treat these illnesses. It is important to understand how prevalent these diseases are in Kenya in order to understand how the doctors may try to manage these various illnesses. Of course, these are not the only illnesses of the disease burden in Kenya, but they are some of the ones I most frequently saw patients within the hospital. The lecture on Disease Burden in Kenya allowed me to understand the challenges that healthcare providers in Kenya often face and how they may manage the spread of these diseases. The last lecture I was able to attend was on the current state of healthcare in Kenya. This lecture was particularly insightful because I was able to grasp a better knowledge on the working of Kenya’s healthcare system. In Kenya there are three different categories of healthcare which when comparing to America is similar. Where I found more differences between America and Kenya is with the funding, accessibility, and outcomes. American spend much more on healthcare than the citizens of Kenya, but in Kenya many more citizens are paying out of pocket which can become difficult for the patients who cannot afford their needed healthcare services. In the Coast General hospital, this issue of being unable to pay medical bills was prevalent as many of these patients were not allowed to leave the hospital or did not get the service they needed until the bill was paid. It is important to consider the challenges that many healthcare providers must face when working in a hospital such as Coast General where they may be unable to care for a patient due to their economic status. Through this lecture I was able to understand more of the differences between Kenya’s healthcare system and America’s. My experience with International Medical Aid was one that I will never forget or take for granted. To be able to have the opportunity to immerse myself in a new culture is one that has allowed me to grow as a person. Being in the Coast General hospital for the three weeks I had there taught me to be more grateful for the life I have been gifted with. In addition, it has pushed me to want to give back to communities as well as be open minded to new experiences. The list of lessons I have learned during the internship could be endless, but mostly it has taught me what it means to be a physical therapist. The Therapists I worked with were kind, generous, and careful to be sure they gave the patients all the help and support they needed. There is not enough gratitude I can express to be given this opportunity to learn and grow during my time with Internation Medical Aid.