Clinic week

For the third week of the Interhealth program, students were placed in clinics and hospitals in Quito to shadow and work with Ecuadorian doctors. I chose to work in outpatient pediatrics with Doctora Carmita Flores; Dra Flores is a general practitioner, and the majority of her patients are women and children. I was interested in this placement because I thought it might offer an interesting comparison to the private pediatric clinic I worked in for two weeks last year in Raleigh.

The clinic is a public Centro de Salud (“health center”), which is part of a network of hospitals and clinics funded entirely by the Ecuadorian government. Since the institution of a new health care system in Ecuador in 2008, the medical services, medications, and laboratory tests offered there are completely free to Quito residents within the clinic’s catchment area. They also provide vaccinations – for both people and dogs! The volume of patients seen is fairly high (15-20 patients per doctor in a four-hour work shift), but the center does not make appointments ahead of time, so patients line up as early as five in the morning to be sure to see a doctor that day. There are private and semi-private clinics and hospitals in Ecuador as well, and those residents who can afford it can choose to pay for shorter wait times and potentially better service. I was happy to have the opportunity to work in a Centro de Salud, though, as I am interested in eventually working in public clinic in the U.S.

Dra Flores was warm and welcoming to me and Kristyn, the other student (also from UNC) assigned to her, and seemed to enjoy our questions. Because my Spanish speaking skills are still in their infancy, my role was more that of an observer than an active participant, although I was able to perform small tasks like calling the next patient, taking vital signs, and occasionally looking in a child’s ears or listening to their lungs. I did see some interesting things, such as an adult case of chicken pox, and I observed my first gynecological exams. However, the most valuable aspects of the experience were the opportunity to practice my medical Spanish, and to learn about and observe the practice of medicine with an Ecuadorian physician.

The most obvious point of comparison is the relative lack of resources in the Quito health clinic, even compared to a public clinic in the United States. There was no roll of paper on the exam table to be changed between patients; instead, a single sheet lay on the table which was never changed or washed in the week I was there. On the other hand, patients do not have to worry about the cost of their visits or treatment. From what I could tell, this did not impact the doctor’s treatment of or recommendations for the patient, at least not at the outpatient level; I do know that there are certain surgeries in Ecuador that are covered by the government and others (such as knee and hip replacements) that may not be. But it was refreshing to know that anyone who wanted or needed to could come to the doctor regardless of their income or health insurance. In addition, the government places a fair amount of emphasis on public health measures such as vaccination, follow-up appointments after illness, and nutrition; every pregnant woman in Ecuador and every child under two can receive free dietary supplements containing necessary vitamins and nutrients.

It was interesting to observe the style of doctoring practiced in Ecuador; although I only worked with one physician, conversations with many of the other students in the program suggest to me that my observations are fairly typical. In many ways, the way in which Dra Flores approached patients was the opposite of what we are being taught in medical school. In my classes last year, much emphasis was placed on the doctor-patient relationship, understanding the patient’s experience, validating their concerns, working with them to encourage behavior changes (such as changes in diet or use of birth control), etc. So it was strange to watch a physician sit across a desk from the patient, rarely making eye contact and focusing instead on her paperwork, firing off questions in rapid succession, interrupting the patient, and handing down imperatives such as “you need to lose weight – walk one hour every day and don’t cook with oil,” as if simply telling the patient to do so would make it happen. She performed interviews and exams with the radio blaring, burned incense in the office, and did not hesitate to answer her cell phone in the middle of a patient’s visit. This approach struck me as quite paternalistic and even disrespectful, so I was surprised to hear patient after patient at the check-in desk asking for Dra Flores. It was a good reminder of the fact that I interpret information based on the cultural context I know, which may not be at all applicable to a medical clinic in Quito.

One other aspect I found myself thinking about during this week is the fact that, although the health care is free and in theory available to all, there are still many Ecuadorians who are not reached, such as the indigenous people who work in the urban markets who may not speak Spanish or be able to take a day off from work to wait in line for the doctor, or people living in rural areas without access to transportation such as those we saw on many of our mobile clinic health brigades. I was glad to have both experiences included in the program, as it helped me to get a more rounded picture of the health care system in Ecuador, and to observe how even “free” health care is not a panacea. It reminds me to be patient with health care reform in the United States, as every system has its strengths and weaknesses, and while I believe that everyone has a right to health care, achieving such an ideal is easier said than done.