Week 4 and Some Final Thoughts…

Feels nice to be home! After settling down for a couple of days I’ve had the opportunity to do some reflecting about the trip and the my experiences. Firstly, the travel and the Ecuadorian landscape is amazing! Definitely beyond any of my expectations.  The spanish classes were helpful also, I know more now that I did before I left. The healthcare experience was also interesting.  It many ways the hospitals and clinics in Quito looked very similar to the facilities I’ve seen in the states. When I was in Ghana several years ago, I saw a marked difference between their healthcare delivery and a dramatic lack of resources and infrastructure.  Healthcare in Quito had many aspects and was riddled with politics and that seemed to be brought up by most of the healthcare professionals that we interacted with. Like I mentioned before, the healthcare payment and malpractice changes brought about by President Correa.  With the new healthcare changes all Ecuadorians that go to the government clinics can receive care regardless of whether they can afford it.  Ecuador has around 15 million people and less than 5 million people have insurance so this health care change really helps many people.  When individuals go to the government clinics all components of the visit is free. Women that want contraception can received free implanon or IUDs and they can also potentially receive free medications if they have them in stock. Their list of medications is limited but in a country where 2/3’s of the population is uninsured and cannot afford healthcare I felt this was a step in the right direction.

View from the top of Pinchincha Volcano
View from the top of Pinchincha Volcano
During a presentation, I asked another physician their opinion on why the teenage pregnancy rate was so high and the condom use so low. She used this word “machismo” and from her description/explanation I took this to mean, the male dominated culture and the idea that children and procreation was a sign of power and virility.  In addition to this, she stated that men are just not interested in family planning (even though it is offered for free to all people by the government). We had one patient in the family medicine clinic that was 34yo and had 8 children ages 16 to 5 months.  The appointment was actually for the women’s daughter (who had extensive and neglected medical problems), but the family doc did a decent job of trying to educate the mother and get her back for family planning with OB/Gyn during the daughters appointment.  Visits with multiple complaints and lack of follow-up is a common problem in Ecuador as well as the US. The particular clinic that I spent my time in was more similar to an urgent care than a traditional family med clinic.
Posing with the Llamas
Posing with the Llamas
Additionally, I heard from several people about the influx of Cuban doctors and how they were “bad” or “used to be okay until now.” I guess Castro started a program in which individuals (from any country) can go to medical school in Cuba for free if they promise to work in an undeserved community in Cuba or their respective country. I guess to help with the shortage of primary care doctors especially in the rural areas (the same type of problem we have in the states) many Cuban doctors have been immigrating to Ecuador to help.  Oddly enough, it seems as though some in the healthcare community have less than open arms to these physicians. There are two sides to every story, but I usually find it problematic to make broad sweeping characterizations of groups of people especially when you’re presenting to a group of medical professionals from another country…
Meeting the Shaman
Meeting the Shaman
Back to the increase in malpractice punishment for physicians… When I was in the Amazon before I traveled to Quito, we had the opportunity to meet with a Shaman and hear about the traditional customs, etc. I am all for holistic, homeopathic and integrative medicine, but I think the particular Shaman we met, was perhaps less substantive and more for show. I understood enough of his discussion to realize the gaps and discrepancies in his story, but nonetheless, some Ecuadorians utilize Shamans often and in many cases prefer their traditional treatment to Western medicine.
Basilica in Quito
Basilica in Quito
During the final week I was able to spend time in a family medicine clinic. This clinic is also a part of the ministry of health.  Most of the complaints in the clinic were the usual problems – colds and other ailments that required conservative management. At least with this doctor, it was nice to see that he did not prescribe antibiotics unnecessarily. We were told with the increased malpractice laws that doctors were starting to practice more defensive medicine and were also turning away complicated patients and surgeries in order to decrease the risk of potential lawsuits.
Over all this trip was a great experience.  Some aspects were a little unorganized once I finally made it to Quito, but that’s a part of traveling with any program, you learn to roll with the punches. I will be a family medicine resident in a couple months and I am grateful for the additional Spanish and the opportunity to learn more about a culture different from my own. I’ve always been committed to helping underserved populations and expanding my worldview and through this program I was able to do both!

Week 3, Part 2, Teenage Pregnancy

The rate of teenage pregnancies here is pretty high. While working in the maternity hospital the average age that I saw was around 16, but there were some as young as 14 and the oldest female I remember seeing was 23.  I asked the attending why he felt the teenage pregnancy rates were so high and he said that firstly the fathers of these women did not allow them to take birth control and secondly, men just do not like to wear condoms. There are significant discrepancies in education levels in these families and this hinders approaching reproductive health in an effective and pragmatic manner. We have the same problems in the states, but our levels are significantly lower than here.  In Ecuador in 2012 there were 77 (births per 1000 for ages between 15-19) while in the US that same year the adolescent birth rate was 31. I thought, that Catholicism might’ve had more of an impact, but in response to my questioning, the attendings did not seem to think that was the main culprit.  The majority of people here are technically catholic, but the number of practicing Catholics is not as high.    All the contraceptive options are available here, but usually women present to the clinic after their pregnant as opposed to before… Which is less helpful…

Who wouldn't want a kid like this though!?
Who wouldn’t want a kid like this though!?

And no visit to Ecuador is complete without a visit to the middle of the world! That was our Spanish class excursion for the week!  There were actually some physics lessons involved… Water really does spin counter clockwise below the equator…

Mitad del Mundo!
Mitad del Mundo!

Week 3, Part 1 – Maternity Clinic

This first week of clinic started out pretty interestingly…. My homestay family came into my room at 6:45am and told me that my assignment had changed… and that I needed to meet with the coordinator at 7am… But I made it to the clinic in time and everything went pretty smoothly.
Maternity Clinic - Isidro Ayora
Maternity Clinic – Isidro Ayora
I spent this week in labor and delivery. Definitely received a decent overview of how things work. Basically I was just shadowing the doctors and residents. This maternity hospital is funded by the government. Some of the residents referred to it as a ministry hospital. Most of the patients are lower income and it is a large training hospital for medical/nursing students along with residents/fellows. The medical training here differs from the training in the US. Students complete 6 years of premed and then they complete an intern year followed by another year where they rotate around different hospitals and clinics throughout the country. I guess it’s similar to a year of service… After that year of service the doctors are technical licensed as a general practitioner. From there many go on to complete 3 years residencies in various specialties. Most specialties including IM, OB, Surgery, FM, Peds are 3 years from my understanding. Specializing past these is additional time. The public hospitals differ dramatically from the private ones in the environment, the attitudes of the staff and the type of care available to patients. For example, at this hospital they do not have epidurals, but it’s available at the private hospitals.
There is also a shortage of primary care physicians here and many of the individuals practicing in the primary care setting do not actually complete and IM or FM residency, they stop their training after their intern and service year. I found it surprising that doctors would discontinue their training after the two years because the mal-practice laws here are very harsh. The medical doctor of the program said that doctors can be placed in jail for malpractice until proven innocent. The current president discussed or perhaps is trying to implement even stricter rules for physician behavior which prompted physicians to threaten to strike here in which the current president (Correa) said that he would bring in Cuban physicians to fill the void. There are supposedly other healthcare changes that Correa is trying to implement, but I am not sure how successful that has been. It seems like healthcare reform is slow and challenging in many countries. The general population and the medical community overall seem to not welcome change…

Week 2!

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End of Week 2! This week I spent time volunteering with first graders and then had some Spanish classes in the afternoon. I began the week finding out that I matched which was exciting, but ended up making the week seem very long while I waited to find out were on Friday. With the kids, I was basically a teacher’s aid. Helped with assignments and art projects. The Spanish was pretty basic so I was able to keep up. Playing soccer with them at recess was a good time also. I got a better workout than they did. During one recess I got 6,000 steps! The kids in this school are not really learning much English. Most of the private schools where the wealthier kids go (like the children in my homestay family) have several of their classes completely in English. My homestay sister, Sophia, is 4yo and she’s basically fluent in English and Spanish already! It’s sad that certain opportunities are not available for everyone. The teacher I worked with did not know English at all. My Spanish was significantly better than her English, so she was not able to help the kids learn anything. Each day she had me record English words and phrases into her phone so she could learn them and hopefully teach the kids. We went through numbers, colors and family relatives.

One thing I found exciting was how the children were learning about recycling and caring for the environment. I don’t remember what things we learned in school 22 years ago, but I feel like that was something I learned about later in life. Trash/littering is definitely a problem here and they have beautiful landscapes that should be maintained and protected. Learning this type of information while they’re young will help them better achieve those goals. One thing I found disappointing about the school were their snacks! The kids sometimes packed healthy snacks/lunches from home. But when the school provided snacks it was a large milk and cookies. Several of the kids were overweight and setting the groundwork for future medical problems. Sweets are okay in moderation, but I felt the kids were eating a little too much. I wonder if food industries and lobbyist affect the school meals to the same extent they do in the US…

On Wednesday afternoon we took an excursion with Angel to the Historical district and when through churches and the cultural center. The goal was to communicate in Spanish while touring the historic monuments. It was difficult to formulate complicated questions in Spanish. We learned about the indigenous Ecuadorian revolution with help lead to independence from Spain in the early 1800s and some of the interplay between Peru and Columbia and Ecuador in shaping the region. We were not able to take the tour of the presidential mansion, but that is on the to do list for this week. I truthfully have not had much exposure to South American history and it was interesting to see how this region took shape.

Match Day! On Friday, I found out that I will be doing Family Medicine at The Ohio State University. After a long week, I am glad it ended with some good news!

Week 1, Part 2

Another interesting thing we talked about this week during class was contraceptive options for people here. I figured contraception options would be limited with 75% of individuals being Catholic, but in the cities there is high rate of contraceptive use and this has increased over the past 10 years. The average family living in the city only has a couple children. Catholics in the US use birth control at the same rates as Christians so I guess I should not be surprised of its use here. In the rural/indigenous areas there is less contraceptive use and therefore higher birthrates. All the contraceptive options we have in the US are available here with condoms and OCPs being the most commonly used. Abortion is strictly prohibited. I asked whether talking about sex/sexuality with patients was taboo and I was told that in the past it was, but now it is acceptable to have these types of conversations between patients and physicians. It will be interesting to see what actually happens during the clinical encounters. I am pretty sure they are still more conservative about sexuality than the places I’ve trained in Columbus, but it was good to hear that they are making progress.

Angel, Me and Shannon another program participant.
Angel, Me and Shannon another program participant.

Angel, our Spanish instructor is a renaissance man of sorts. He was in the Ecuadorian Army for 10 years, played professional soccer, was a scrub nurse, and has a bachelors in linguistics. He offers unique perspectives on politics and the medical field in addition to being an effective Spanish teacher. Ecuador was established in 1830 as an independent country. It is a representative democratic republic. Just like politics in any country, there seems to be varying opinions on the political leaders. Our homestay mother is not a fan of the current president and it’s interesting to hear the varying viewpoints. It was interesting to find out the one of the ex-presidents of Ecuador is a professor at Harvard. He was ousted in a military coup in 2000 before he came to the states. His name is Dr. Jamil Mahaud. Angel fought in the final war against Peru in 1995 in which Ecuador ended up winning additional territory, but Angel said that Ecuador was forced by the UN to return the territory back to Peru. You could sense that he was disappointed in the outcome of the war and how impactful the loss of some of comrades was. Angel and I worked out one evening this past week and he definitely schooled me during our 40min run.  I think part of the issue was the higher altitude here, but I think the other part was all these wonderful pastries on every corner…

Week 1, Part 1.

Finished up my first full week of the program. A ton of Spanish and a fair amount of adjustment took place this week. My brain is on Spanish overload. Taking 7hrs of Spanish classes daily was definitely more taxing than I thought. But that part of the program is over. Not sure if I know more Spanish now or just realized how much I truly didn’t know. We went through basically tons of Spanish grammar and all the tenses. Next week we are doing only medical Spanish vocabulary and conversational Spanish. I hope things will come a little easier when I’ve had more time to process all the information we went over.

In Latin American countries they have a traditional schedule with breakfast occurring sometime between 6:30-8am (we always have ours at 7am), and then a break at 10:30 for café (coffee) or jugo (juice). Lunch is usually between 12-2pm and is normally the largest meal of the day for most families, unless there is a party or formal gathering during the evening. Most families have Merienda between 6-8pm, which is normally some rice, a light sandwich and more juice! They drink a lot of juice here and it’s fresh and delicious, but juice is something I had cut out of my diet, but for these next several weeks it’s back. This was a great chance to see different aspects of the city. Cena, which was the word that I learned in Spanish classes for super, is more of a formal and larger meal and usually occurs on the weekends (if at all). The meal is customarily eaten at 9pm or so.

We followed the traditional schedule most days. We start classes at 8am, and each day at 10am we took a break and walked to grab a cafe or jugo. This was a good chance to interact with local shops as well as try various foods. There are breads, pastries, ice cream and tons of junk food on every corner. Diabetes is something that is on the rise in this country as well. Chronic diseases like diabetes are the second most common cause of mortality here. The first being car accidents, which is not surprising and extremely apparent any time you’re near a road or car. (I’m a little more desensitized to the traffic conditions after two weeks, but there is definitely no such thing as the pedestrian right of way. And, it doesn’t matter if you’re elderly or 9months pregnant, if the light changes green and you’re still in the street, you could very well become a casualty or deafened by honking cars.)

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During one of the 10am breaks this week we went to a local market which had tons and tons of fresh fruit, meats, pasties, and meal options. With the climate and the ability to grow produce all year round, there is a steady supply and tons of options. It dwarfed any of the farmer’s markets that I’ve been to in Ohio. They have many healthy food options, but I can see from the portion sizes and the amount of carbs they consume during many of the meals how this could be problematic and lead to chronic disease. The meats here taste 100% better and the meats and produce are usually locally grown without the use of chemicals or GMOs as a rule. When you walk around the stores/markets, there are less “all natural” or “organic” signage as it’s unnecessary when the majority of those types of foods are produced in that manner.

First day!

IMG_5055_2Today was the first day of the Intensive Beginner Spanish program. The first week are doing Spanish classes for 7hours a day.  It’s a long time, but I feel like I’ve learned a lot already.  We are basically doing a semester+ of Spanish in two weeks. During week two, we are spending days at a local school working in the classroom an doing basic physical exams.  This school has 600 children of very low socio-economic status.  Then we spend the last two weeks doing some shadowing in a local clinic.

After being in the Amazon for 4 days and then getting to Quito before the program started, I feel like I’ve had a decent opportunity to get acclimated to the climate and the area.  There was another 4th year medical student that was coincidentally on the same Amazon tour.  She was in school in NYC and we had the opportunity to talk about her experiences working there as well as our experiences participating in global health programs. We met travelers from Scotland, Ireland, Austria and Holland during our excursion and it’s interesting to hear about healthcare in their countries.  In the US we spend so much, but the return on our investment is not as high as it needs to be.

I’ve been reminded this week of how difficult it is to get around in a place where you do not speak the primary language.  There were times in clinic when I would become slightly frustrated with interpreters and with the general fact that communication was extremely difficult when patients that did not speak English.  I have a better appreciation for the difficulty and the frustration these patients feel in their every day lives and with their medical care.

The spanish classes are not only to learn Spanish, but we also learn about Latin American culture and how to approach these populations in the healthcare setting. Family and religion are very influential factors in the lives of individuals in this region with seventy-five percent of the population being Catholic and many individuals living in multigenerational homes.  My homestay household has several ages and relatives living under one roof.

I’m interested to see how the program is going to shape up.  It’s off to a good start. I am looking forward to learn more about their healthcare access and equity.  I’m also interested in seeing their clinical environments. I’ve heard that physicians particularly in the government hospitals can be quite harsh with some even refusing to treat certain patients based on their ethnic backgrounds. We have similar issues in America.  Even less overt, implicit racism and micro-agressions create serious barriers to care for many in the US.