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We're going to continue our theme on the blog of encouraging medical missionaries. Today's guest blogger is Susan Post. Susan is the Director of Esperanza Health Center, a bilingual primary care center in North Philadelphia. She lives in the community where she serves and is integrated into the lives of neighbors who are also patients and friends.  Many of the people in her community face significant difficulties related to poverty, and Susan has a unique perspective to share with us today.   What Does Suffering have to do with Sustainability? The readers of MedicalMissions.com are diverse in age, profession, stage of life, and geography. You might be a student considering medical missions, or maybe you’re seeking God’s calling on your life, or maybe you’re like me and you’ve been in ministry for a while.  Wherever we are in our lives, we need to consider sustainability and how God helps us to stay faithful to Him in the places He calls us.  People often begin ministry enthusiastically and then get surprised when difficulties arise and they’re unprepared to face them. Sometimes people even leave ministry because they have difficulty addressing sustainability.   I come to you as a fellow journey person, together with you asking God to show us how to find and strengthen our ministry sustainability during these times when the work is uncertain and often difficult.   In the book of Philippians, Paul describes the suffering of Christ and the power of his resurrection. Lately I find myself dwelling on what it means to “share in the fellowship of his sufferings”.  Typically, we move on to talk about the power of His resurrection, but I have been feeling the need to be honest about how hard it is to share in suffering.  I began to see that the sharing of God’s sufferings – my neighbors, patients, and even mine, were integral to the power of the resurrection that we all long to see.  These are not polar opposites, but rather complementary.  The overall picture, even including our own weakness, leads us to see our Savior’s glory in a magnificent way.  Sometimes our trials are actually the route to experiencing God’s resurrection glory – a route we wouldn’t want to miss, and, if it were up to us, we might try to avoid.    Once I started talking with colleagues about suffering, some honest conversations began.  Tears were often shed as we discussed the pain of failures the wounds from serving.  It was a privilege to hear their stories and see their sacrifice, but in many cases, on the brink of brokenness themselves.  I realized then that there is something vital about going deep in our ministry, but also going deep in sustainability.  It’s not a matter of having our own inner strength to just move on. In fact, sometimes I think it is the opposite.  As the years of ministry go by for me, I see how God is at work in the difficulty. He sees well before I do my own weaknesses, places of potential, and actual failure. I see how His glory is always tied to weakness and He is at work in ways I often cannot see.  If I can move with Him during the difficulties of ministry, His glory will be more realized and I will find the sustainability He has already set in place for me.   Ministry difficulties                                             The Work itself – ministry itself is tough.  There is great joy in it, and it is amazing to get to be part of seeing God at work in our world.  But many days, it is also hard. When the patient doesn’t recover When a patient with substance use disorder relapses When a patient manipulates When you witness the affects of childhood trauma on an adult The cycle of suffering that life brings people in poor communities The constant limitations that finances or other resources can put on ministry When the church doesn’t understand your ministry   Fatigue and Loneliness – As a leader, I often feel quite lonely even though I have a significant number of great people around me.  But at the end of the day, when hard decisions have to be made, it is up to me.  The effect of fatigue sometimes makes it hard to see clearly all that God would have us see. It is hard to walk by faith rather than by sight when the sight in front of you looks so big and you’re so tired.  Failures - Failures can come in many different packages.  Sometimes there is little fruit, despite a lot of trying and hard work.  Sometimes we make mistakes or misjudgments.  Sometimes we have relational conflicts with others that we work with or those we are serving.  Sometimes sin brings personal and ministry failure.  When God recorded Peter’s denial of Christ, Peter must have felt himself to be the biggest failure.  But God didn’t see Peter that way.  In fact, Jesus commissioned Peter into further ministry after that all happened.  Losing our Passion – When we begin to experience burnout, we may begin to see our patients, coworkers, or even the community, as the enemy.  Sometimes we can lean toward pride or self-dependence, not realizing it is always only God who brings the fruit.  And we might not even realize we have become proud in that way.  We can also lean toward self-protection. That often happens when we count the cost and don’t believe something is worth working toward.  There is certainly wisdom in counting the cost, but generally God tells us that we don’t have to self-protect if we are trusting Him in what He has called us to do.  A fine line, but an important one to consider.  We can also feel distant from the Lord which can cause us to lose our passion. Personal Challenges – Ministry can be hard when we are going through other personal hardships – grief, family concerns, health issues, financial concerns, which can distract us from our work.  We might be suffering, but the ministry is still there with decisions to be made and patients to be seen.  It can be difficult to contribute during a time when your heart is broken, but the demands of ministry are there all the same.  Lack of confidence – There are always times in ministry when we realize that we can’t do it by ourselves.  This can be positive if it brings us to depend on God, but sometimes a lack of confidence can cause confusion and an inability to move forward.  We see this in scripture too, especially after failures, but, in the case of Elijah, even after victories.    When Healing Comes We are broken people, serving broken people, in a broken world.  We all need healing. And when things get difficult, we may begin to doubt. We doubt our calling, we doubt ourselves, or even doubt that God is good.   One passage of scripture that has given me a glimpse into how God sees this can be found in the book of John, chapters 13-17.    These chapters resonate because they portray Jesus as he faced his most difficult days at the end of his life.  He knew he was leaving His father’s work in the hands of his disciples, and that this would be his last time to talk to them before the traumatic events that lay ahead. We can look at what God did to prepare His followers on earth for “difficulty in ministry”:   He remembered who He was and what God was doing.   3 Jesus, knowing that the Father had given all things into his hands, and that he had come from God and was going back to God, 4 rose from supper. He laid aside his outer garments, and taking a towel, tied it around his waist.   Jesus stepped back to remind himself of the truths He knew – The father had given all things into his hands, He had come from God, and was going back to God. Reminding Himself of who He was and what God had called him to do gave Him the strength, fortitude, and humility to move forward – to wash the feet of those He knew would deny and betray Him.   There are times in ministry when we don’t know what God is doing – and that is God’s design.   Peter balked at Jesus washing his feet.  It makes sense that Peter would not think it proper or right for his teacher, his messiah, to wash his feet.   Peter declares, NO, Lord, you shall never wash MY feet!  Jesus responds kindly to Peter saying, “You do not understand what I am doing now, but afterward you will understand.”  Is God perhaps saying this to you right now? We need to trust Him and give Him a YES, even if we don’t understand right now.  Who am I to think I have a plan that is better than His?    We are partners with Him in the work   We certainly know this in our heads – we go into ministry to participate in God’s work in our world.But it is very easy to forget when the ministry gets tough or when you feel you need to add more of yourself to make it work.I think Jesus knew our propensity for this and so he told his disciples, and us, over and over again in these chapters that we are doing His Work, and in that there is great joy, love, and grace.   Abide in me, and I in you. As the branch cannot bear fruit by itself, unless it abides in the vine, neither can you, unless you abide in me. 15:4   This is to my Father’s glory, that you bear much fruit, showing yourselves to be my disciples. 15:8   Serving Jesus is an intimately loving relationship   We serve in ministry because we are built to be involved in God’s purposes and plans for His kingdom.What Jesus shows us in these scriptures is that this is .He lovingly expresses this until His last breath in the book of John.   John 14:1-3“Let not your hearts be troubled. Believe in God; believe also in me. 2 In my Father's house are many rooms. If it were not so, would I have told you that I go to prepare a place for you? 3 And if I go and prepare a place for you, I will come again and will take you to myself, that where I am you may be also.   I used to read that scripture and think, wow, I’m going to go live in a mansion that Jesus prepared for me.But it’s not about the it’s about being with Him.It is about a beautiful intimacy in which we will never be alone.   Sustainability for Life There are a few things that can help sustain us as we seek to live out sustainable ministry in light of God’s love. Re-Centering - Re-centering is to ask God how he sees your life situation. One way to do this is to try a prayer of examen each day. When you read Luke 24, Jesus meets the disciples on the road to Emmaus.  Jesus asks them what is happening and then he opens up the Word to the disciples to show them that their story is really part of a bigger story that God is doing.  To try the Prayer of Examen, tell Jesus about your day. Pour it out to Him. Then listen.  Have Jesus re-tell your story WITH HIS PRESENCE in the story. As we do this, we gain eyes to see what God is doing, and it will likely look very different.    Rest and Recreation – We need to rest.  We need to move out of the work and accomplishment mode so that we can recharge, refresh, and restore.  If you are like me and you love work, you will need to be intentional in this area.  Rest and recreation, or re-creation, are not just napping on Sundays and keeping your ministry hours in check.  There are far more ways to rest: Stay intentionally involved with those who restore you. Find beauty – nature, music, art.  Exercise What brings you rest and refreshment?   Reckon– the definition of reckon is to count, calculate, conclude, think.  Stop regularly and reckon, dwell on God’s truths.  Allow them to become part of your frame of reference throughout your day.  Slow down.  Contemplate, meditate on Him and what you know of Him.     Intimacy with God - I had a sabbatical last year, for 6 weeks, and I happened to be celebrating my 60th birthday.  I walked El Camino de Santiago, a 500-mile pilgrimage starting in the Pyrenees Mountains in France.  During this journey, these truths were imprinted on my heart: The purpose of our journey of life is to walk with and to Jesus Abide in Him Take time to rest in His presence Psalms of Laments – Allow Him to be your comfort   Worship – Lastly, all of this allows us to live lives of worship.  Worship moves our focus from ourselves onto God’s character. It relieves the burdens that we carry as we cast our earthly concerns on Him. The persecuted church around the world throughout history has relied on worship as a way to sustain through the most difficult times, and we should too.

This session will present the need for healthcare workers to understand that their response to women who are being abused can make a crucial difference in whether the patient feels safe or shamed. Behavior that can incite fear will be identified: Physical gestures, facial expressions, distance, tone of voice, etc. This session will also discuss how showing skepticism, insensitive questioning, and telling the patient what to do can shut down the opportunity to help her . Helpful ways to communicate concern, respect, and autonomy to make her own decisions, will be identified.

The idea that missions is about going and doing for people in other countries is being replaced by seeing missions as a relay race. We need to train indigenous Christ followers with skills their people need so they can meet real needs in their communities as a door opener to share the Gospel. This training must be focused, in-depth, and self sustaining so that we do not create dependency.

A surgeon in training may be feeling called to and exploring a future career in medical missions or may simply be desiring a heart for God; to serve Jesus Christ unconditionally in a US based practice with or without short term missions service. This session will focus on the practical ways that students and residents pursuing a surgical sub-specialty, including general surgery, can fan the flame of God's gifting and calling in obedience to the Great Commission. What are the critical spiritual disciplines in a walk with Christ during training that protect and nurture such a mindset, even during a demanding and stressful surgical residency? What type of volunteering activities or short term missions service play a key role in maintaining a passion for missionary service? Are there resources available which will help develop a heart for and understanding of evangelism and disciple-making in the life of a short or long term missionary? Will share perspectives from several surgeons who are actively serving in missions today.

This session will explore the value of healthcare education as a form of mission experience, both in the short and long term, as well as to inspire and equip participants to explore healthcare education opportunities as an answer to God’s call to missions.

This is not our grandparents' world, with clear First, Second, and Third World nations. Accelerating worldwide social, cultural, and political changes call for reflection and alteration of our missionary strategies.

We have been focusing on encouraging our missionaries here on the blog, and today, we want to discuss why this is so extremely important.  What Are We Facing? Over the last several decades, healthcare missions has experienced a steady stream of missionaries both entering the field and exiting the field (for retirement, job changes, etc.). This has created a net zero effect, a rate that has been mostly sustainable for those that are actively working in mission fields around the globe. But don’t get me wrong - medical missions has never been easy. The challenges of being on the field are a never-ending list of needs that outweigh resources available. And that includes the human resources. Nurses, doctors, physical therapists, surgeons…you name the specialty, and they are all desperately needed in cities and villages and towns and countries spread across God’s earth.   So what happens when a global pandemic shuts the world down for more than a year, and medical missionaries are left alone on the field? No short-term teams to bring much needed manpower and supplies. No mid-term professionals coming to step in so that a veteran provider can take a much needed week of vacation. Fewer students entering the field because of the uncertainty around the future of international travel, entry restrictions, and overall ambivalence toward the future.   When all of these pieces add up, they create an untenable situation. Veteran missionaries on the field are left without help, without relief. They are overburdened and cannot sustain the workload. They find themselves spiritually, mentally, emotionally, and physically burned out and unable to go on. And as they leave the field, less people are entering the field, creating a spiral effect of what some would say is a 20-25% decrease in overall medical missionaries on the field. Unless we do something to dramatically change this trajectory, it will only get worse as those on the field have less and less human resources to rely upon. They are sticking it out for now, but how long can they really last?   According to MedSend President and CEO Rick Allen, over the last seven years, MedSend, which strategically funds qualified healthcare professionals to serve the physical and spiritual needs of people around the world, has been setting record numbers of applications each year. But those record numbers still equal out to that net zero we talked about earlier – the same number of people entering the field as coming home from the field. But over the past year, instead of the average 45 applications that MedSend typically approves, there were only 18. They have seen significant burnout and trauma on the field in the past 18 months and believe that in situations like these, we need significant interventions to stop the bleed. According to Allen, MedSend “recognized that there were challenges, but this has magnified them.”   What are the Solutions? So what would help sustain our current workforce of medical missionaries? The obvious answer is more workers. We need more healthcare professionals to go to the mission field and fill the gaps. But maybe the current pipelines just aren’t big enough to stem the tide…Then what?   Some other ideas that leaders in medical missions are thinking through include more opportunities for short term help. And not short term as in 2 weeks, which is just more of a burden on the field staff. But short term as in 3 months, which could be a truly significant asset. Maybe talk with Universities about how to collaborate to get medical students to do one of their rotations at field hospitals in international locations. Another idea is to have a professionals rotation. Workers sign up for two weeks at a time, but they go on a regular rotation so that field staff aren’t constantly taking up all their time training visitors.   Organizations like MedSend also realize that they want to prepare new missionaries more thoroughly before they head to the mission field. So often young missionary doctors and nurses are sent to the field only to be a burden to the veteran workers as they learn language, culture, low resource setting skills, etc. The young, inexperienced professionals get discouraged and end up leaving the field before they’ve ever had a chance to really settle in and find their groove. The responsibility of training these new professionals is a project that Jim Ritchie, with MedSend, is going to try to tackle. Jim served 25 years in the U.S. Navy. He was an emergency medicine residency director and deployed twice to combat support roles in Afghanistan. In Afghanistan, he developed an interest in combat medicine ethics and the psychological aspects of trauma relating to physicians working in difficult and under-resourced environments. He knows a little something about the challenges faced by those of you entering into medical missions. Jim is going to lead the Longevity Project, preparing and supporting MedSend Grant Recipients to handle the burdens which are unique to cross-cultural healthcare. He works closely with the mission organizations with whom MedSend partners to support them in their challenging responsibilities.

In India, it is not easy to witness to Urban dwellers about the Lord. Cannot go from door to door. Most of the church planting has been done in rural areas.Home based care gives health care workers an opportunity to develop relationships with our Urban non-Christian neighbors. More than 60 million Indians go below the poverty line each year due to medical care expenses. Often the hospital admissions and investigations are unnecessary. Home based care can help reduce health care expenses. We present what our home based care company PISCES health and Wellness is doing in India.

Refugees and Internally Displaced Persons (IDPs) face significant challenges to their health and well-being that are unique due to lack of necessary resources including food, water, sanitation, shelter, security, and healthcare. Caring for people in these situations requires an understanding of their unique needs as well as having realistic goals regarding what can and cannot be done for them. Our experiences in providing healthcare for the victims of disasters in Congo, Indonesia, Pakistan, Myanmar, Afghanistan, Honduras, Nepal, Kurdistan, and Turkey – both natural and manmade – highlight the need to be well prepared when serving in these difficult situations. We are called to serve “the least of these,” and the victims of disasters and crises certainly qualify. Often these events, though causing much hardship and suffering, create the possibility for doors and hearts to be open to the message of Jesus that otherwise would be closed. We must be both willing and well prepared if we are to serve well when we are called to respond to those in need.

The Changing Face of Missions in An Age of Pandemic: * Is to Help Christians see the Movement of the Holy Spirit in the Spread of the Global Church around the World in Spite of the Global Pandemic.

For the next few months, we are going to look at encouraging medical missionaries. We want to look at it from several different angles and get a real picture of what we can do to fortify those serving on the field – and we’re going to start with the development of God-honoring boundaries. We are excited to have a guest blogger today, Jim Ritchie. Jim served 25 years in the U.S. Navy and was emergency medicine residency director, deployed twice to busy combat support roles in Afghanistan. In Afghanistan, he developed an interest in combat medicine ethics and the psychological aspects of trauma relating to physicians working in difficult and under-resourced environments. He later taught widely on the subject. Upon retiring as a captain from the Navy in 2013, he became a medical missionary and moved to Chogoria Mission Hospital in rural Kenya, helping to start a family medicine residency with faculty from four mission agencies. He continued to encounter psychological trauma in cross-cultural medical missionary practice and was heavily involved with the growth of the hospital chaplaincy program, with whom he shared the theology of illness, healing, and death. In 2021, Jim and his family moved from Kenya to Virginia, where he now serves as VP of Partner Strategies with MedSend. We hope you enjoy reading some of Jim’s wisdom today! Boundaries Help Prevent Burnout Burnout is epidemic in the healthcare professions in the West, in part due to a work ethic that prioritizes the needs of the patients and places great responsibility for outcomes on the medical team.  When members of the medical team go to the developing world, we encounter far greater need, far fewer medical workers, and far less control regarding outcomes.  Burnout seems inevitable.  But when we embrace our God-given limitations and develop God-honoring boundaries, we can serve for full careers – staying healthy and with emotionally healthy families. Mistaken expectations We Christians can confuse ourselves by misunderstanding Scripture.  Some verses may seem to imply endless physical endurance: “They shall run, and not be weary.  They shall walk and not faint.” (Isaiah 40:31) or “I can do all things through Christ who strengthens me.”  (Philippians 4:13) But these verses are poetic metaphor and principle regarding hope in God and contentment, not a promise to be able to work without sleep. Instead, God gave us limitations.  We must sleep.  We must take time to build and maintain relationships.  We are not in control of life and death.  We are not omnipotent.  Ignoring our God-given limitations can be sinful.  Embracing our God-given limitations can be worshipful. Even Jesus, in His earthly life, embraced His limitations.  At times, Jesus sent the crowds away!  Sure, He worked hard, sometimes even through the night.  But at times, He stopped healing and went away, despite the disappointment of crowds of people.  And unless we think we are “Super Jesus,” able to work when He could not, we should do likewise. A swamp has no borders and no destination.  No boundaries.  The swamp is stagnant and breeds disease.  A river has banks and a destination, and it is powerful and life-giving.  The river has boundaries.  Setting Boundaries  Sometimes we can be hesitant to adopt boundaries, thinking that we are distancing ourselves from our calling. But healthy boundaries aren’t like a huge, imposing stone wall with razor wire on top, keeping us away from the people we’re called to serve.  Also, healthy boundaries aren’t like a line in the sand, able to be crossed with no effort.  Instead, healthy boundaries are like a substantial green hedge with a gate.  And you are in control of the gate.  At times, the gate is open, and we are in full contact with other people.  And at times, we close the gate to rest, prepare, build relationships, and work on other responsibilities.  In establishing healthy boundaries, it’s important to identify the driving idea.  Is your life dictated by the work that needs to be done and by others’ expectations of you?  If so, the overwhelming needs and unrealistic expectations will strongly tend to drive you to overwork and burnout.  Or, instead, is your life guided by a recognition of your God-given limitations and assurance of God’s love?  If so, you can establish your own guidelines for healthy living and working.  Make yourself available for work and social activities within those guidelines. What are some reasonable boundaries for healthcare missionaries?  Most healthy boundaries reflect a sound theology of human limitations, which are then translated into specific practices. Healthy Boundaries One healthy boundary is a reasonable workweek.    We have many responsibilities as healthcare missionaries: patient care, teaching, communicating with supporters, mission agency communication and admin, growing in relationship with our spouse and children (when applicable, of course) and with friends, growing in relationship with God, learning language and culture, resting for sustainability, building community, participating in special ministries, meeting licensure and immigrations requirements, and many more.  If we allow patient care to dominate our lives, we try to cram our many other responsibilities into remaining time and wind up with spiritual and relational anemia and failed duties.  Instead, we can decide to structure our weeks for fruitful medical practice and healthy lives.  One pattern that has proven to be sustainable in several locations is a five-day workweek, with four clinical days and one day for other professional responsibilities mentioned above.  Allocate one day for community building or other ministries and one day for Sabbath.  This pattern may seem odd to Western healthcare missionaries, but, when adopted by the whole team, it has proven to be restorative and sustainable while providing healthy, vibrant missionaries on the field. Another healthy boundary is a limited queue of patients.  An unlimited queue of patients has become traditional in some settings.  But this pattern can lead to frustration, not only with the medical staff but also with patients.  Establishing limitations for the numbers of patients to be seen in a day is a simple acknowledgement of personal limitations and of other legitimate responsibilities.  A friend in a surgical specialty found herself in a hospital with a tradition of unlimited clinic queues, and she suffered through that paradigm for a time, along with the tired clinic staff.  But then she required a limitation of 30 patients per clinic and assigned a nurse to be the “gatekeeper.”  There was some initial pushback, but shortly this pattern became normal in the eyes of the staff and there was a new enthusiasm for caring for the patients.  This sort of limitation usually should be associated with a triage plan, so the neediest patients are included in the numbers to be seen.  The same idea can be put in place for ward rounds, limiting the time available.  It may not be possible to see every patient every day, and a stratagem for prioritizing the patients who are seen must be established.  But this boundary has proven to be life-renewing for many healthcare missionaries.  The same idea can be put in place for meetings, regarding duration, number, attendance, and time of day.  Do you want to see life return to a tired missionary’s eyes?  Cancel a meeting! Boundaries need boundaries.  Boundaries can divide teams if some members insist on boundaries and other members resist them.  This can produce resentment and accusation and guilt.  This is lamentable, especially because God loves unity in His people.  The Bible emphasizes the need for unity, and our witness to our community can be closely tied to our team relations.  It’s very important to consider boundaries as a team dynamic.  As often as possible, the boundaries should be agreed-upon by the entire team, especially the leadership.  This promotes unity and a bearing -up of each other's burdens. We have seen individual missionaries adopt so many boundaries that they do not integrate with their communities and do not become valued by the hospital leadership.  Even boundaries need boundaries.  The development of God-honoring boundaries is a critical skill for healthcare missionaries.  Such boundaries honor our God-given limitations, honor our many responsibilities, and honor our important personal relationships.  May God guide you in honoring Him in this way.

As we see an increasing number of culturally diverse patients in our practices, there is no doubt of the importance of cultural competency in medicine. Specific circumstances and miscommunications have been well documented. But how can we develop an eye to see where a patient’s values and worldview may differ from our own? We will review an approach to cultural competency highlighted by medical missions case studies.