When the electricity goes out, I suddenly have no idea what to do with myself. This morning I was looking forward to sleeping in, having a relaxing morning, and going into the clinic late. It was supposed to be a glorious day. But as the neighbors' crazy dogs barked as usual at 9am, the ceiling fan in my room suddenly stopped turning. I looked up and thought to myself "damn." I laid there getting hotter and hotter by the second, so I pushed the covers off and decided to go ahead and check my email and news for the day on the internet. Whoops! No wireless connection. And my computer was almost dead, and whoops! It wouldn't charge. No electricity. Gosh...ok, let me go ahead and take my shower. Uh oh! No electricity for the heater, so no hot water (and very little pressure).
As I stood under the cold droplets of water and pretended I could actually call that a shower, I thought about all the things I couldn't do without electricity. I've been so spoiled and dependent on it here, I forgot how much I lose when it goes away. As I got dressed and went to eat my breakfast, the yogurt was warm, the juice was warm, the water was warm, the cream chesse for my bagel was warm, my friggin apple was warm. And the fan I usually put directly in my face so as not to sweat out of my business casual wasn't working either.
So I left the house miffed and already sweating, on my way to work where there were so many patients and for some reason the AC wasn't working. It is SO hot here and people who know me, know that in this type of climate I usually look like Shaq right after a championship game (that went into overtime and everything). At one point, one of the ladies in the pharmacy stopped in front of me, smiled and asked, "Do you need some juice?" There was probably steam coming off my bald head.
Anyway, I thought to myself, where could I go to change and cool off? - the gym! of course, they have ice cold water there, plenty of Powerades for sale, fans all over the place. I arrived at the gym with a little swagger in my step. After changing into more comfortable clothes and starting in on the first machine, the electricity went out again! So I worked out in the dark heat for about 45 minutes. The water cooler was even hot. No Powerade today.
I moved on to a place I usually stop to get lunch. I ordered some fried chicken, platanos, and rice, and asked for two huge pineapple juices (one of the times I wish there was a "super size" option). For some reason I wasn't cooling down. The pineapple juice did nothing. I walked home a sweaty mess, saying a small prayer that the electricity would be back by the time I got to the house. I entered the door and flipped the switch and there was light. I almost fell to my knees in gratitude, but I was afraid I'd be too tired to get up...
Thursday, July 21, 2011
Tuesday, July 19, 2011
The Return to DR Part 2: The Culture of Caring
I saw my first patient last week. Since the day I arrived at CEPROSH, I have been saying I'm a student. It's the first thing I usually say in introducing myself. I never want to give anyone a wrong impression, especially seeing the number of patients that visit each day. But there I was, being given a patient chart. A lady came from very far only to find out the doctor couldn't make it that day. She really wanted to see someone, anyone. I tried to say no to the ladies working in the pharmacy, but relented after awhile. So I sat in the big doctor chair, called her in and tried my best. I'm still so amazed at the immediate trust one is afforded as a physician. She launched into the details of her life, and spoke to me about her recent surgery, showing me the scars. She also asked me to feel her ribs where she felt pain. She brought out her many bottles of medication from her purse and told me how often she takes each one. I wrote down everything she told me for the next time so the doctor would know exactly what needed to be done. I explained to her that I was still a student, but that made no difference. She hung on my every word. She had such kind eyes, eyes that reminded me of how right I was to choose this path.
The next day I finally got the chance to shadow at the clinic the other day. For about a week and a half, I've been walking past patients to the room where I sit down to do my work. They usually look at me quizzically, surely thinking things like, "Is he a doctor?" "Why is he carrying patient records?" "He doesn't look Dominican" "Why is he sweating so much?" In thinking about the experience of people living with HIV here in Puerto Plata, it has certainly felt impersonal going through records and collecting data points on these patients while hearing nothing about their life stories. They were becoming simply coded numbers, drug regimens, and clinic visits. So I was really excited when Dr. Queto peeked her head in the door of my room to say hello. She's a short "gordita," as one of the patients affectionately called her, with a young face and an easy smile. She certainly has presence when she enters a room though. I immediately asked if I could shadow her for the day and she happily agreed. You can tell she loves to teach. She's passionate about her work, you can see that in the intensity of her eyes.
As Dr. Queto sat at her desk, I could tell she was preparing herself for the stress of the day, peaking at the stack of about 15 patient folders on her desk. We spoke for a little bit about my project, my first year in medical school, as well as her impressions of care at the clinic and her experience thus far. Then she called in the first patient - a skinny, dark skinned middle-aged man carrying a bunch of bags, looking a bit tired from his trip that morning. Dr. Queto looked at his record and noted that he hadn't been to the clinic since November of 2010. She asked him why he hadn't been in so long, and when he didn't provide an answer, she basically yelled at him for 10 minutes. She raised her voice shot lasers at this patient with her eyes. I thought about all the cultural competency and doctor-patient relationship stuff we learned over the first year - she was basically doing the opposite of everything I learned. I almost laughed at one point because I thought she might be joking.
Everything she said made sense - she wasn't malicious or anything, just saying the obvious things about adherence to meds and the importance of CD4 checks in a much more animated manner. After the patient left the room, she explained to me that she had to talk to him that way or else nothing would change. She explained that patients here, especially ones receiving free care, completely take it for granted sometimes. The gentle reminders don't help. They need to be reminded of the service they're being provided, of the importance of taking charge of their health. Apparently, people here expect their doctors to be more paternalistic. There's less of an expectation to give the patient options and serve as an emotional support. This approach contrasts sharply with the move in the US to provide patients with choice, ensure they have a positive experience during their clinic visits, and make them partners in all healthcare decisions.
It got me thinking, there are different cultures of caring that may work in some places and not in others. Is it always better to handle patients lightly, to politely ask them to change their behavior? Is the model of the doctor-patient relationship I'm learning in school applicable in different countries? Fascinating questions...
But Dr. Queto had varying styles with each patient that came in. Some she laughed with, some she scolded, some she was more impersonal. She certainly commanded respect from them all though.
As for the patients, they had such varied lives. The man who lost 8 pounds in one week and looked terribly frail. His viral load was extremely high and his CD4 count miserably low. Dr. Queto struggled to figure out what to do next - the generic drugs don't work as well with patients sometimes (they're still on the the three drug regimen here). He sat looking defeated as she tapped her foot thinking of ideas. There was the woman who brought in fruits for the doctor, extremely grateful and excited to go over her treatment. Everything was okay, but she complained of frequent seizures. Dr. Queto and I discussed whether it could be a complication of HIV, or unrelated epilepsy. Then there was the man who surely suffered from depression. He sat staring at his shoes as his mother answered many of the doctors questions. We listened to his lungs and looked at his X-ray, his TB had been getting worse over time. He didn't seem to care about what we were saying. I wondered how challenging it must be to treat HIV and depression, since so much of the patients prognosis is linked to their compliance with medications and indeed their desire to keep living.
All in all, it was a good experience. I was able to put some faces to those patient charts, and move from the research side back to the human side.
The next day I finally got the chance to shadow at the clinic the other day. For about a week and a half, I've been walking past patients to the room where I sit down to do my work. They usually look at me quizzically, surely thinking things like, "Is he a doctor?" "Why is he carrying patient records?" "He doesn't look Dominican" "Why is he sweating so much?" In thinking about the experience of people living with HIV here in Puerto Plata, it has certainly felt impersonal going through records and collecting data points on these patients while hearing nothing about their life stories. They were becoming simply coded numbers, drug regimens, and clinic visits. So I was really excited when Dr. Queto peeked her head in the door of my room to say hello. She's a short "gordita," as one of the patients affectionately called her, with a young face and an easy smile. She certainly has presence when she enters a room though. I immediately asked if I could shadow her for the day and she happily agreed. You can tell she loves to teach. She's passionate about her work, you can see that in the intensity of her eyes.
As Dr. Queto sat at her desk, I could tell she was preparing herself for the stress of the day, peaking at the stack of about 15 patient folders on her desk. We spoke for a little bit about my project, my first year in medical school, as well as her impressions of care at the clinic and her experience thus far. Then she called in the first patient - a skinny, dark skinned middle-aged man carrying a bunch of bags, looking a bit tired from his trip that morning. Dr. Queto looked at his record and noted that he hadn't been to the clinic since November of 2010. She asked him why he hadn't been in so long, and when he didn't provide an answer, she basically yelled at him for 10 minutes. She raised her voice shot lasers at this patient with her eyes. I thought about all the cultural competency and doctor-patient relationship stuff we learned over the first year - she was basically doing the opposite of everything I learned. I almost laughed at one point because I thought she might be joking.
Everything she said made sense - she wasn't malicious or anything, just saying the obvious things about adherence to meds and the importance of CD4 checks in a much more animated manner. After the patient left the room, she explained to me that she had to talk to him that way or else nothing would change. She explained that patients here, especially ones receiving free care, completely take it for granted sometimes. The gentle reminders don't help. They need to be reminded of the service they're being provided, of the importance of taking charge of their health. Apparently, people here expect their doctors to be more paternalistic. There's less of an expectation to give the patient options and serve as an emotional support. This approach contrasts sharply with the move in the US to provide patients with choice, ensure they have a positive experience during their clinic visits, and make them partners in all healthcare decisions.
It got me thinking, there are different cultures of caring that may work in some places and not in others. Is it always better to handle patients lightly, to politely ask them to change their behavior? Is the model of the doctor-patient relationship I'm learning in school applicable in different countries? Fascinating questions...
But Dr. Queto had varying styles with each patient that came in. Some she laughed with, some she scolded, some she was more impersonal. She certainly commanded respect from them all though.
As for the patients, they had such varied lives. The man who lost 8 pounds in one week and looked terribly frail. His viral load was extremely high and his CD4 count miserably low. Dr. Queto struggled to figure out what to do next - the generic drugs don't work as well with patients sometimes (they're still on the the three drug regimen here). He sat looking defeated as she tapped her foot thinking of ideas. There was the woman who brought in fruits for the doctor, extremely grateful and excited to go over her treatment. Everything was okay, but she complained of frequent seizures. Dr. Queto and I discussed whether it could be a complication of HIV, or unrelated epilepsy. Then there was the man who surely suffered from depression. He sat staring at his shoes as his mother answered many of the doctors questions. We listened to his lungs and looked at his X-ray, his TB had been getting worse over time. He didn't seem to care about what we were saying. I wondered how challenging it must be to treat HIV and depression, since so much of the patients prognosis is linked to their compliance with medications and indeed their desire to keep living.
All in all, it was a good experience. I was able to put some faces to those patient charts, and move from the research side back to the human side.
Tuesday, July 12, 2011
The Return to DR Part 1: CEPROSH
As I made my way through Latin America a couple of years ago, I always said I would return to learn more about healthcare delivery in this part of the world. My travels then were so focused on my own self-development, and music and politics and culture, that afterwards I was curious about some of the substantive global health issues I got a taste of as I bounced from place to place. This summer ("the last summer" as we say in med school) I made my way back to Dominican Republic, the last stop on my whirlwind tour. I arrived here about a week and a half ago and shockingly I'm already almost halfway through my stay. I'm only here for July though to get back for the big bro's wedding, and things generally move slower in this part of the world, so I'm taking the time to reflect on the past year, eat and sleep quite a bit, and do a lot of reading and writing. My romps to places like New Orleans (for Mardi Gras!!) and Namibia (for a FREE African safari trip with my sister) this past year at times made me question if I was actually in med school. So to be honest, I don't need to be all over the place; I'm happy just relaxing.
I'm staying in Puerto Plata, a vibrant coastal city on the northern side of the island, mostly known as one of those all-inclusive resort destinations in the Caribbean. I'm working at CEPROSH, an HIV outpatient clinic serving a large swath of the island since 1987, providing HIV care, testing, social services, education and prevention, and free antiretrovirals. I'm working with a doctor at Penn on this study looking at the impact of a free lab testing program initiated last year on patient compliance with recommended lab monitoring. It's pretty simple data collection from patient charts, not requiring a lot of mental effort at all. But it's certainly been interesting seeing the model they have set up at CEPROSH and how effective it seems.
Apparently, what originally drove the HIV epidemic in this part of DR was the sex tourism industry. While that is certainly still a player, the rates of HIV infection here seem to be driven by the same factors we've seen globally for the past couple of decades or so - women's lack of power when it comes to contraception in heterosexual sex, and the socioeconomic effect of marginalization (the poor, the migrants, etc.). CEPROSH is great because it employs people from the community, many of whom are HIV positive themselves. I had a brilliant conversation with one of the ladies who works in the pharmacy and helps me pull my patient charts. As we were in casual conversation about our lives, she asked to see my list of patients and pointed out her name to me proudly. Her eldest daughter is also HIV positive. This work means so much to her, and she told me of all the positive change she has seen over time. She explained to me how things used to be - the constant death around her, the lack of life-saving medicine, her own uncertainty. Things are different now - people come in every week to get their drugs and see one of the three doctors who come in daily. And CEPROSH staff like my friend in the pharmacy know who the patients are and truly care about them receiving the necessary, adequate services.
I look forward to shadowing the doctors this week or next. Things have been thrown off a bit due to a national strike about gas prices, jobs and the lack of a government response that shut down public transportation. This kept patients from the clinic the other day because it's simply too expensive to come to CEPROSH without public transportation for the patients. The global economic crisis is really taking its toll everywhere. Hopefully the schedule will return to normal though.
Outside of my project here, I'm staying in the home of one of the social workers at the clinic. Lucia is a sweet lady - always brings me some fresh squeezed fruit juice when I'm in the living room. Her 10-year old daughter Eliany has become my partner-in-crime. This little girl has so much energy. She has pigtails and wears glasses and has braces, and peaks her head in my door at random times of the day. She's obsessed with this one gospel CD, always singing the same songs. And we are constantly playing card games, which I always win even when I don't want to. Maybe I should tell her it's probably because she's not shuffling the deck well enough? I wouldn't want to break my hot streak though.
On the weekends, we've visited her aunt and cousins. Her one cousin Lisa is one of the cutest little girls you'll ever see with her little afro, and her huge beautiful eyes. She's so funny - she's kind of gangster too. The other day she called me a "puta". I almost died laughing. I guess being five times someone's size doesn't mean they can't cock their head sideways and call you a bitch. I'm hoping she has no idea what she said - she's hardly 2 years old. Anyway...
The first year of medical school is a beautiful blur. Since my glorious year off in Latin America, I've moved to Philadelphia, made countless new friends, and learned a whole lot of medicine at Penn. I'm exactly where I want to be. Yet something pulled me back down here for my "last summer ever." And that something is global health office funding. With my twenty or so days left, I intend to delve a bit more into the physician and patient experiences respectively, and to finally get to the beach this weekend. I walked along the coast today and the water was so blue, the breeze so refreshing. The only thing that will keep me away is another torrential downpour like last weekend. Which was actually a bit of a blessing. It turned into a day of watching old Kuumba videos and finally getting into The Catcher in the Rye.
I'm staying in Puerto Plata, a vibrant coastal city on the northern side of the island, mostly known as one of those all-inclusive resort destinations in the Caribbean. I'm working at CEPROSH, an HIV outpatient clinic serving a large swath of the island since 1987, providing HIV care, testing, social services, education and prevention, and free antiretrovirals. I'm working with a doctor at Penn on this study looking at the impact of a free lab testing program initiated last year on patient compliance with recommended lab monitoring. It's pretty simple data collection from patient charts, not requiring a lot of mental effort at all. But it's certainly been interesting seeing the model they have set up at CEPROSH and how effective it seems.
Apparently, what originally drove the HIV epidemic in this part of DR was the sex tourism industry. While that is certainly still a player, the rates of HIV infection here seem to be driven by the same factors we've seen globally for the past couple of decades or so - women's lack of power when it comes to contraception in heterosexual sex, and the socioeconomic effect of marginalization (the poor, the migrants, etc.). CEPROSH is great because it employs people from the community, many of whom are HIV positive themselves. I had a brilliant conversation with one of the ladies who works in the pharmacy and helps me pull my patient charts. As we were in casual conversation about our lives, she asked to see my list of patients and pointed out her name to me proudly. Her eldest daughter is also HIV positive. This work means so much to her, and she told me of all the positive change she has seen over time. She explained to me how things used to be - the constant death around her, the lack of life-saving medicine, her own uncertainty. Things are different now - people come in every week to get their drugs and see one of the three doctors who come in daily. And CEPROSH staff like my friend in the pharmacy know who the patients are and truly care about them receiving the necessary, adequate services.
I look forward to shadowing the doctors this week or next. Things have been thrown off a bit due to a national strike about gas prices, jobs and the lack of a government response that shut down public transportation. This kept patients from the clinic the other day because it's simply too expensive to come to CEPROSH without public transportation for the patients. The global economic crisis is really taking its toll everywhere. Hopefully the schedule will return to normal though.
Outside of my project here, I'm staying in the home of one of the social workers at the clinic. Lucia is a sweet lady - always brings me some fresh squeezed fruit juice when I'm in the living room. Her 10-year old daughter Eliany has become my partner-in-crime. This little girl has so much energy. She has pigtails and wears glasses and has braces, and peaks her head in my door at random times of the day. She's obsessed with this one gospel CD, always singing the same songs. And we are constantly playing card games, which I always win even when I don't want to. Maybe I should tell her it's probably because she's not shuffling the deck well enough? I wouldn't want to break my hot streak though.
On the weekends, we've visited her aunt and cousins. Her one cousin Lisa is one of the cutest little girls you'll ever see with her little afro, and her huge beautiful eyes. She's so funny - she's kind of gangster too. The other day she called me a "puta". I almost died laughing. I guess being five times someone's size doesn't mean they can't cock their head sideways and call you a bitch. I'm hoping she has no idea what she said - she's hardly 2 years old. Anyway...
The first year of medical school is a beautiful blur. Since my glorious year off in Latin America, I've moved to Philadelphia, made countless new friends, and learned a whole lot of medicine at Penn. I'm exactly where I want to be. Yet something pulled me back down here for my "last summer ever." And that something is global health office funding. With my twenty or so days left, I intend to delve a bit more into the physician and patient experiences respectively, and to finally get to the beach this weekend. I walked along the coast today and the water was so blue, the breeze so refreshing. The only thing that will keep me away is another torrential downpour like last weekend. Which was actually a bit of a blessing. It turned into a day of watching old Kuumba videos and finally getting into The Catcher in the Rye.
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