Pediatría, Ginecología, y Medicina General

The last week was busy, fun, and productive.  Each day we were met by patients patiently waiting for us on the porch of our clinic.  It was fun to have kids in the clinic this week, even though it means a bit more crying and general chaos.  They keep things interesting and the parents are especially appreciative for the care.  We didn’t see too many kids we would actually consider sick (there were lots with colds, fevers, and worms), but the visits gave us a good opportunity to do some important education: Boil water to decontaminate it, especially for the babies.  Not all illnesses require medications (the local clinics are infamous for handing out pills for everything, so people come to expect it – in fact, I often wonder if they think we aren’t very good doctors because we don’t give prescriptions to each patient).  Just because a medication is available in the farmacia, it is not necessarily safe.  For example, a “baby aspirin” (often used in adults for heart disease protection) dissolved in water is not a good treatment for an 18 month old with a fever.  Unless sanitation in the household can be drastically improved, the kids are likely to get worms regularly and probably require treatment a few times a year. 

On the adult side, we continue to struggle with how best to manage chronic diseases in our clinic.  The majority of adult patients we saw had diabetes, hypertension, gastritis / GERD, musculoskeletal pain, or some combination of some or all of those.  While we have a pretty well-stocked pharmacy at the clinic, we don’t have enough to provide year-long prescriptions to each patient.  When patients come to us, they are often out of their meds for an undetermined amount of time (often they say they ran out last week).  Our approach is to discuss the disease with them, give them about a month’s worth of meds, and encourage them to follow up at the local Centro de Salud.  Our hope is that they can see if the meds are working, change dosing as appropriate, and receive the prescription.  Health care is purportedly free here, but I never cease to be shocked by how inaccessible it is.  Even the patients that do follow up to get refills on their medications report that the clinics are frequently out of basic medications (contraception, blood pressure meds, diabetes meds).  The balance of providing needed services while refraining from undermining the established system remains a challenge.  I encountered more than one patient that had visited the clinic in December when the last team was here, was started on a medication, and then ran out without following up until we were there last week.  There’s an inevitable belief that the “American doctors” know more than the local doctors, so we tread lightly when trying to discuss missed diagnoses or incorrect medical advice that has been given.  We try to remain aware of the sustainability of our interventions – we are wary of prescribing medications that require any sort of concerted follow up and we center everything around what can we actually treat (for example, do we really need that biopsy?  Will it change our management?).  Even though care is “free” in the government system, patients are often required to pay for lab tests, ultrasounds, etc.  One patient told me how she tried to get prenatal care at the Centro de Salud, but when she was unable to afford the blood tests they ordered they refused to see her for the remainder of her pregnancy.  Working within this system is a challenge. 

Probably a third of the patients we saw were pregnant, and obstetric care continues to be my favorite part of medicine.  The special draw for these patients was that we were offering ultrasounds.  The excitement they expressed at seeing the ultrasound (often their first, despite many previous pregnancies) made the work so much fun.  I had the extra treat of getting to have Geoff and Jeremy join me for some of the ultrasounds, which was a first for them as well.  Their excitement and awe might have been even more adorable than that of the women!  Getting to work with them this week was a wonderful experience as they were eager to learn and ready to do whatever they could to help – a perfect combination.  I think it was probably good practice for me as I move into residency where I’ll frequently need to balance learning and teaching. 

When we had made some free time to step out of the exam rooms, we had fun playing soccer with the kids on the porch, grabbing a bite to eat (Coral and I started making bakery runs each morning – only part of this was in the hopes that the woman would let us in the back to learn how they make everything!), and enjoying each other’s company.  The team was great, and with so many people to lend a hand everything ran smoothly.  (In contrast to last month, when I felt like we were constantly struggling and stretched in 5 directions at any given moment!)  It was bittersweet as we wrapped up clinic Friday and prepared it for the next group to visit, probably in June.  Should be quite the adjustment back to the hospital medicine we spend so much of our time pursuing during training.  Lucky for me I have no more inpatient rotation between now and graduation – although it might not be as great for my patients (and attendings) that have to bear with me come July…