My staff and I have spent much of our careers traveling to developing countries to provide knee replacements. After a nine year hiatus from visiting Panama, our team from 3B Orthopedic Group at Jefferson Northeast returned this fall. These trips are always emotional. And they also offer lessons about how people from different cultures cope with illness and disability.

Most notable, the Panamanian patients we saw, as well as those we have treated in other Central American countries, don’t want to take narcotics. These drugs are traditionally reserved for those with cancer or other extremely painful conditions – much as they once were in this country.

Supplies of opioids are short. Some patients choose not to take these drugs so they are available to those who need them more, while others want to avoid the stigma of being in a condition to even need them.

Pain is tolerated much differently in these patients than in those we see in this country, often because the people in countries such as Panama have no other choice. Access to medical care is limited, especially in contrast to Philadelphia with urgent cares, pharmacies, doctor offices, and hospitals on almost every block.

After bilateral total knee replacements, patients in Panama take two Tylenol, perhaps two the next morning, and then prepare to walk home or ride in a car on unpaved roads for hours. Their pain and disability have been so great for so long that it is as if their “thermostat” for pain is set at another level.

Though we don’t have anything like our urban surgical facilities, we have never had a patient treated on a mission trip suffer a post-surgical infection. While I like to believe that is due to our extremely careful approach to surgery, another factor is the lack of antibiotic dependence in these cultures. Patients’ natural immunities are stronger when they don’t receive antibiotics for every sniffle.

A 74-year-old woman traveled more than four hours with her family to Panama City, Panama, for the chance to have a knee replacement. She had been living with her son for several years because she could no longer take care of herself, her right knee was so painful. Before surgery, she told us in Spanish that she prayed to God that she would be chosen for the surgery, she so wanted her independence back. She was full of smiles and good cheer after the surgery, happily posing for a photo. She even asked us to return in the spring to do her other knee.

Panama has made great progress in the decade since our last trip, both in surgical technique and also in social systems. Several of the surgeons we first met now have children who are themselves orthopedists, even heads of hospital departments. Interestingly, the majority of these surgeons are women. In the U.S., though more women than men enrolled in medical school last year, only 4 percent of members of the American Academy of Orthopaedic Surgeons (AAOS) are female and only 30 percent are actively practicing five years after graduation.

International medicine is an extremely gratifying experience, though it also comes with great challenges: language barriers, infection risks, operating facilities, supply logistics and geography. None of that seems to matter when we are rewarded with the smiles and gratitude of our patients.

Robert E. Booth, Jr., M.D. is the medical director of 3B Orthopaedics at Jefferson Health