Mexican Community Medicine, Part 4

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I hope you’ve had a chance to read the other entries in this small series. I really didn’t know how much I wanted to write about it, especially since much of what happened was variations on a theme, not too many outstanding individual stories. There were lots of frustrating moments to be sure. This is Mexico, not the United States, and where I was specifically was poor Mexico, which makes poor community hospitals in the states often times look like level 1 care centers.

It’s easy to see the differences that exist here and be freaked out. I learned quite a bit and got a lot of contact with some things I didn’t expect. I had friends that went to Red Cross facilities outside of the city and attended to suturing, IV placement, debridements, and births, all as 1st year students. I would have loved that kind of hands-on procedural experience, but there’s something I got at my poor little community facility: understanding. What started as shock my first day at what I thought were deplorable conditions and attitudes turned into acceptance when I left, that as much as I’d think the building needs to be tented and sanitized, the reality is that the clinic is that community’s place of healing for better or worse–and it does happen.

Over and over I saw the poor, simple people that one finds everyday in the streets of Guadalajara, and in them I found a new perspective. Having grown up in a Mexican-American family on the Texas border, I certainly didn’t think that all poor Mexicans were maids and gardeners, but even where I live, many poor Mexicans ARE maids and laborers. What one forgets is that just because they are a maid or a manual laborer doesn’t mean that they don’t have their own ideas, hopes, dreams. It’s not that I would think myself above having to talk to these people (language barrier issues aside); it’s just that there is often no time to shoot the breeze with the lawn man when I have tons of stuff to do for myself and family, as well as work or school, etc. Like it or not, it is a class distinction that prevents more intercommunication.

There is a truth, a “rightness” I found in the slow, relaxed pace of the Mexican medical system. No matter how bad the doctor, how trivial the patient’s problem was, time was always spent with the patient to learn everything possible. I was freaked out the first day when I overheard a doctor telling a patient that they were already getting filled up before Christmas saying, “Some days I have 15 patients scheduled!” I almost had to stifle a laugh, because that would be a fraction of what the average American PCP would see in a day (although these people only work until 2-3pm, but still). Taking my intro to clinical medicine, learning physical exams, etc. we all would groan at the exhaustive depth that we’d be responsible for to palpate a head for a head/neck exam, for example, or any number of exam details that seem uselessly laborious. Now I know: this IS the way it is done here–long, exhaustive exams performed talking to the patient the whole time, slowly discerning and rifting into the secret of things, as Thoreau would say, giving the patient plenty of time.

The American medical system would do well to look at a few things about the Mexican system[1] and allow PCPs to get reimbursed appropriately for their time. It’s not fair that a general surgeon gets reimbursed more for a 10 minute consult with a diagnosis and films in hand than the PCP who has spent many visits laboriously arriving at the diagnosis. I’m pretty sure I don’t want to do primary care for my own personal interest reasons, but it definitely needs to change. I think Drs. Centor and Rangel would agree.

The patient can be a complete simpleton, a good-for-nothing bum, a banker–whatever: the magic I learned is that for those minutes in the consultorio, that person is the most important person in the world whose needs require attention. The doctor is not the Armani-wearing, Porsche-driving stereotype portrayed on TV; the doctor is the servant while the patient is the person to be served. You read about things like this in good books on doctoring, how to treat patients, etc., and this probably seems crazily maudlin “newbie” for those in the trenches, but this really didn’t crystallize in 3-D until I had seen such astoundingly simple, poor people clearly have their day made simply by being listened to. I didn’t get to do much in the way of clinical interventions, but I did do a lot of talking, reassuring, physical exams, etc. and was amazed at both the feeling of appreciation of them for what (for me was little) I did, and for so many new doors that opened into lives that I would have never otherwise even paid attention to.

I have no intention of staying in Mexico; this is not my country. I am learning and training here, but I am a product of the American “system” in every sense. However, I would be foolish not to be positively influenced by the better things of what I see here. In the end, I will be a bicultural, bilingual physician who can relate to patients from Latin America as one of their own, while also seeing all the American patients with a perspective of having learned in an environment free from big pharma and drug reps, free from litigation and rampant lawsuits, and free from patients who think they know more than their doctors because they’ve memorized articles from eMedicine. Some may say that this is going to create problems for me when I return to the states in 3 years since I’ll be so “softened” by not having the experience of dealing with these things in a clinical setting day in and day out. Perhaps. But I say that these things can be quickly learned. I would think it’s harder to learn how to genuinely treat a patient with respect if it’s not instilled early, harder to learn to be a good listener, harder to learn how to be a good servant to the patients needs. I think the system here trains these aspects very well. I’m smart enough to fill in the technical and clinical differences myself when the time comes to transition back. It’s why I decided to become a doctor and not a scientist.

[1] I make many references to “Mexican,” because that’s my primary foreign experience, but I understand that this type of “old school” approach is not uncommon in many countries.

<-- Part 3

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  By John Calypso, January 6, 2006 @ 10:00 pm

  4- part series on Mexican Medical
  Obviously you are a good man. Generally, I have little use for the medical establishment; some of what you write supports this. You are a different story. It is heartening to know you are out there. I can only hope that more experience, success and wealth does not turn you to the other side.

  Part One where the woman was treated with such insensitivity is beyond appalling. There should be NO rules or reasons why this person should not be reprimanded for such incredibly rude behavior towards that young woman. There is NO excuse. I don’t know anything about you save what you write here – but I could not stand by and allow that man to continue.

  I will pray for you my friend that you are raised up to maintain noble values and further that you have the strength to champion your beliefs.

  Saludos,
  John Calypso
• 

  By jonmikel, December 30, 2005 @ 1:26 pm

  Are you at IMSS, ISSSTE or
  Are you at IMSS, ISSSTE or SSA?
  Have you ever been in a private hospital here in Mexico?

  Regards,
  Jon Mikel, M.D.
• 

  By enrico, January 6, 2006 @ 6:24 pm

  Generic affiliation
  I’m still learning all the acronymns, but I know it’s not IMSS. Everything we do in the community (outside the medical school) is through the Seguro Popular. Some things are covered directly by the Secretaria de Salud de Jalisco. During 3rd year rotations, some go to rotations through IMSS, some stay in our university private hospital, I’m not exactly sure how it’s all divided up.

  From what I’ve seen (as a patient, too) private hospital experiences vary. Some are adequate, their main benefit are private rooms, while others are far more lavish. I’m sure as I stay here I’ll appreciate the nuances of what each has to offer.

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