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.