Mexico Medical Student |

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

Merry Christmas to all. I hope as many readers as possible are spending Christmas with their families/loved ones and not at work. Hannukah starts today, happy happy to those celebrating the Festival of Lights.

To spread some holiday cynicism cheer, I’ll post an email from a long time ago. I think it’s apropos given the domestic spying program that’s being unleashed on us. I know, because black helicopters fly over my house all the time. That’s why I wear the tin hat.

You’d better watch out,
You’d better not cry,
You’d better not pout;
I’m telling you why.
Santa Claus is tapping
Your phone.

He’s bugging your room,
He’s reading your mail,
He’s keeping a file
And running a tail.
Santa Claus is tapping
Your phone.

He hears you in the bedroom,
Surveills you out of doors,
And if that doesn’t get the goods,
Then he’ll use provocateurs.

So–you mustn’t assume
That you are secure.
On Christmas Eve
He’ll kick in your door.
Santa Claus is tapping
Your phone.

[Supposedly written for and sung at a US Department of Justice,
Office of Legal Counsel Christmas party during the Carter
administration.]

Merry Christmas!! :^)

It’s Festivus for the Rest of Us! I didn’t get a pole this year, but I aired my grievances as always. Heh.

I go check out the stats for the Best of Medical Weblogs 2005 and imagine my shock to find yours truly listed among the nominees for Best New Blog for 2005! Niels Olsen, a displaced Tulane medical student I’ve mentioned here several times who runs the blog The Haversian Canal (himself a nominee!) did the honors…thanks! What a surprise after being offline for a while!

It’s almost beyond pithy to say it’s an honor just to be nominated, but I really mean it. I have zero expectations of winning/placing/etc.; I am just happy to see my site listed with so many other excellent sites that I read regularly, but it’s also really cool that I’ve discovered a few new really stellar sites because of the nomination process. If anybody feels the same way after clicking the link to my site and bookmarks/”RSSes” it, then I’ve already won as far as I’m concerned.

Voting is the 3rd-15th of January 2006 at MedGadget. Do yourself a favor and check out the sites on the list and add some of these great sites to your regular reading if they aren’t there already.

Just a quick note to let everyone know that I’m back in the US! Woohoo! We got in this last weekend, making the trip in one long day, but I have to say the trip was much, much better this time than the first time because we knew better what to look for/avoid. I thought I’d have some goodies to share from the road, but it really was totally uneventful. The next day, I got up and was surprised how much energy I had considering the previous day (hell, week), but the day afterwards into the 3rd day, I was just a trying to do as little as possible. It’s not that I was so physically tired, I just lost all drive to do anything. Since then, things have been mostly consumed with getting business/financial things done (lots of phone calls, so that was on hold ’till we got here), last minute Christmas shopping, etc.

Regarding my much-advertised gastronomic festivities, I started badly by consuming like 3 fast-food meals (from different places, of course) in first two days. I think I reached my quota already. I know, I’m such a wimp, but after being relatively “clean” with respect to outright crap/unhealthy food for the last 5+ months, I just can’t take the burger/fries thing to the same degree (and I’m totally OK with that). On that same subject, everyone has told me I’ve lost weight, which is really surprising, because I don’t really see it. Claudia has said it a couple of times, but she sees me every day, so I didn’t think it was that big of a deal, but even Claudia’s doctor here who would otherwise have no reason to say anything of the sort to me said it. As long as I’m not a complete couch potato and don’t go nuts with the holiday (hell, just decently good) food, I’ll keep the streak going. I’ll have a little of lots of different things, I will. (ok, that Yoda sentence came out of nowhere)

So I’ve done quite a few things on my list (see below) already, but the next two major things I want to do outside of the holiday days themselves (in relaxed fashion, of course) is work on the blog, computer tasks in general, and go to Houston for a few days…we’ll see how things go. I’ll post more on other stuff shortly.

This blog is taking over my life, BORG like. I google my own name because I needed to quote some research I have published and I needed the info from karger publishers. So I google, and for “Raul Benavides” my first citation is on the 2nd pages of the search, with the first actual link to my work on the 3 or 4th page. “That’s OK, since raul benavides is not uncommon a name, being on the 2nd page means I get hits on my work.”

but, guess what Is the #2 overall hit on page #1:

The “ass clinic” post on this blog.

Yes, much more significant than my 2-3 published research articles is the blog entry here on my days dealing with anal warts..

damn you, “The Internet”

I wish Al Gore had never invented you, you mock me so.

At 5:00AM (laugh, yes, it’s a dream) hopefully we’ll be on the road to Texas! Whether we get there in one day or split it up, I doubt I’ll be online at all until Sunday at best. I’m sure there’ll be plenty to write about regarding the trip, hopefully all fun and interesting and not venting about horrible experiences.

Until I’m stateside…

I hate moving with a passion. Actually, there is one small, important silver lining to almost all voluntary moves, and that is the reality of starting fresh somewhere new, even if it’s just down the street. Therefore, the worst kind of move is the move back home or to a place in which one has physically already lived, because there’s nothing new to look forward to. Anyway, I digress…

There isn’t a finger on my hands that isn’t either cut or has the cuticle painfully torn. Rather than make myself sound ignorant in anatomy by saying “I am sore in muscles I didn’t know I had,” I’ll just say I hurt all over. I partially twisted my right ankle on Monday evening, and the compensation that’s happened ever since has made both legs (knees too) hurt. I feel like an old man…it’s bilateral knee replacement time so I can kick ass in shuffleboard at the local assisted living center.

All I have to do now is a few details at the old place and turn in the keys. Cable/Internet (hence this post) was on right on time, as was the phone. The new place is having some maintenence problems, but nothing that can’t be fixed in a few days. I just found out that we are the first renters for this owner since he just bought the house, so while there’s more wrong than we would have thought given how nice it and the neighborhood are, they are willing to take care of everything because it’s a discovery phase for them too. All in all we’re very happy with the promise of new things to come.

Well, that’s all I wanted to say for now…just updating y’all that we’re alive and kicking, still in GDL and hopefully going to be hitting the road Friday now. There’s no need to kill ourselves to get home to Texas +/-1 day when we’re going to be there 3 weeks for sure. You know there’ll be yet more “Tales from the Mexican Highways” posts when I get back, but until then, I might a post or two by the weekend, but most of my energy is on finishing the move process and then packing to get out of here. Be safe, everyone travelling, and I’ll write more soon. Cheers!

My semester is done! I actually made it through the semester, illnesses and all, incredible life stresses (more on that will be shared soon) and all with all As and Bs. I’m pretty excited. You may now refer to me as “eighth of Doctor,” thank you very much.

With the end of the semester comes the wholly deserved, golden chalice of reward that we all look forward to (and as I’m constantly reminded by party-pooper types I know further in their careers, what will never again happen outside medical school): a near month of vacation! Woohoo! The immediate future is consumed not as much by celebration of semester’s end, but the frantic packing of moving from our crappy apartment to a nice, 3-bedroom house with room to spare. We’re stretching our budget taking it, but staying here was no longer an option, for reasons I shall, again, share later.

As for my vacation, I can’t help myself but make a to-do list, so I thought I’d share as I think “out loud” about what I plan to do:

• Rest.
• Spend time with friends and family that I miss.
• Never use the alarm clock.
• Finally spend lots of quality time with my wife without having to look at my watch or check the calendar for test dates
• Eat lots of food I miss. From Whataburger to family home cooking, to just about every damn “ethnic” food I can get my hands on, particularly when I travel again to Houston, I will be hitting Vietnamese, Thai and Lebanese places with a vengeance that will be the stuff of legends…”Mommy? Tell me the story when that crazy fat man took our restaurant hostage claiming to be a Mexican prisoner of war…please?”
• Relax.
• I’ll take my G5 home, brick that it is, so I can finally use the downtime to organize the my files into a workable “system” for future medical school semesters. One amasses mega amounts of info, and just throwing it into a “MedSchool” folder in your Documents folder, even if you subdivide by subject, simply doesn’t cut it when you add the CDs of info that other students pass around. Also, backup strategy for the above, because I already lost some documents.
• Sleep.
• Move my primary email to Gmail once and for all. I will still publish the same old address, I’ll just use GMail behind the scenes. Unlike before where I am chained to a computer in a computational lab or a work computer all day (vs. home), in med school I’m all over the place, and I want the mobile flexibility.
• Watch TV with impunity without shame or guilt, but that’s hard because even out of school, I feel I have to be doing something always, even if it’s just “self” projects.
• Shop for stuff that we can’t get here and load up, including stuff for our new house.
• Maybe, just maybe, spend some shadow O.R./clinic time with my surgeon friend/mentor
• Seriously, re-do this blog so that it resembles something usable. I think Drupal may not be the way to go after all, and I’ll probably go back to using WordPress since all my grand plans for a site that makes people weep with options and resources for music, culinary resources, medicine and science is just too much for me to handle if I want to be responsible scholastically.
• Read some fiction for a change
• Did I mention sleep?

As soon as the move is done, and loose ends are tied up, it’s a 14 hour road trip back to Texas through Mexico’s mountainous highways (mostly downhill, going from 5700 feet to ~5), probably starting Thursday of this coming week. I can’t wait!!

Earlier this year, the president of the AAMC wrote this piece about filling the workforce gap with regards to the coming physician shortage. The piece focused on the various sources of non-allopathic/non-US-trained physicians and what roles they play. I have more than a couple of problems with this piece on how Americans who go to non-American schools are portrayed. For example, in describing foreign physicians going to foreign schools then coming here to practice, Dr. Cohen writes:

The contributions made by physicians born and educated abroad cannot be overestimated. In addition to shoring up the U.S. physician supply generally, foreign-born IMGs have contributed disproportionately to the ranks of primary care physicians and to those practicing in underserved areas, to say nothing of their contributions to medical school faculties and to medical science. Given our country’s tradition of welcoming immigrants seeking a better life and given our dependency on immigrant physicians to meet our workforce needs, we must continue to support the integration of foreign-born IMGs into the U.S. medical profession…Can we, in good conscience, continue to drain so many highly educated professionals from countries that need them even more than we do?

That’s all nice and true, but here’s what he wrote about American IMGs:

We know precious little about [Carribean and other] schools but believe that they are, at best, highly variable and, at worst, wholly inadequate. Nevertheless, many students emerge from their “off-shore” experience in good enough shape to obtain ECFMG (Educational Commission for Foreign Medical Graduates) certification and to compete successfully for a place in an accredited residency. These facts raise several additional questions: (1) What obligation do we have to toughen the ECFMG certification process to bolster confidence that those passing muster have overcome the presumed deficiencies in their undergraduate education? (2) What obligation do we have to go even further and try to improve the quality of the education obtained by U.S.-born IMGs? …

Now this raises my hackles a little. Why are foreign-born, foreign-trained physicians treated with such gushing appreciation–even concern for the ethics of taking them from their needy countries, oh my!–while the American-born graduates of some of those same schools treated as second-class professionals with something to prove? All IMGs practicing in this country took the same ECFMG exam (or did Fifth Pathway, as I will do), so why does being American or foreign make a difference? In almost all cases, Americans IMGs have more schooling, having gotten their bachelors degree before going to medical school in any case.

Dr. Cohen seems to beleive that we American IMGs had “deficiencies” that kept us from going to an American medical school, and in some cases he’d be correct (what the true worth of the measurements used to determine “deficiencies” is another matter), but let me make something very clear: in many foreign countries, Mexico included, there is little or no barrier to entry for medical school. You may not have the cash for a private school like the one I attend, but there are public schools that place little emphasis on pre-selecting students. The system works such that with each year, lots drop out or fail; the system is design to allow the wheat to separate from the chaff along the way as the spaces get fewer and fewer. So yes, a Mexican general physician did have to pass everything along the way, but there is no equivalent to the USMLE or any other nationwide exam to pass to ensure that there is a minimum standard is met unless they are seeking residency specifically. Most doctors here don’t or can’t do a residency due to the space limitations and the huge competition involved. That’s just Mexico. I train in the second largest city of Mexico with more than 7 million people (read: patient diversity), not some tiny island somewhere or a country with no appreciable resources.

I find it appalling that someone in Dr. Cohen’s position would be so biased against the very potential talent sitting under his nose, falling over himself trying to open the door wider for those from other countries, while being more concerned about tightening the requriements for letting us, already and continously taxpaying citizens of this country, come back. Dr. Cohen does address the possibility for increasing U.S. school capacity, but only as an afterthought. I would have expected a more enlightened, or at least fair, approach in all honesty.

Thanks to Niels for the link and the article reference.