Domicilios: a Different Kind of Housecall

Blog 3. Chone, Ecuador.

Wow. Today was an absolutely amazing day. We began the day by driving to the hospital in Dr. Javier’s amazing, tripped-out car. Since it was a Thursday, there was a physician’s meeting, which was held in the middle of the hospital, and the nurses presented to the doctors on all the patients. Dr. Javier said that this happens once a week on Thursdays in order for the physicians to know patients, even ones that aren’t theirs, more intimately. There was a bit of a tiff with one of the nurses, in which Dr. Javier managed to chew out the nurse thoroughly and with absolute dignity. We then headed over to shadow a psychologist (psicologo), who was making house visits (visitas domiciles) today. This isn’t something the United States, which is a real shame, because it’s an amazing idea for comprehensive health. According to Dr. Marcias, the psychologist, this isn’t common in the Republic of Ecuador, but Chone is one of the few hospitals that allow house visits. So we jumped on the car and headed out to the barrios.

The nurse waiting at the car.

The concept of house visits: A family medicine team, including three physicians and one psychologist and two nurses, travel Mondays through Thursdays to different houses in Chone. Each day, a different physician makes his/her rounds. The car will take the chauffeur, physician, and accompanying nurse(s) to 4 or more houses a day. Today we went with the psychologist Dr. Marcias. An aside on psychologists in Ecuador: Immediately, whenever the doctor would see a patient, he would explain upfront why mental health is important in the recuperation process. In his words, Si todo esta bien con los emocionantes, todo sera bien con el cuerpo. The concept of comprehensive health is not new in the US, but despite all of our blustering, we have not incorporated our teachings in the health system — there’s such a stigma against psychologists and mental health that it’s almost laughable to think that a psychologist would go visit hospitalized patients. Dr. Macias also seemed to serve in the capacity of what we would call “counselor” rather than psychologist, except his knowledge was extensive and he understood everything about things like dementia, Alzheimers, Parkinsons, etc. He did an absolutely amazing job with the patients as well, because oftentimes, when patients started crying, he would gently tell them exactly what they needed to hear, clasping their hands, looking them in the eyes, speaking kindly. He had extraordinary person skills, and it was amazing to see the humanity and the worry he provided for his patients — it was clear that their health and recovery was his number one priority. Such bedside manner is extremely rare to come by in the US. An aside on home visits: The concept of home visits is also a very interesting one: it's for patients who can’t easily make it to the hospital, specifically for those too old or patients with disabilities, because the roads of Chone are far from ADA-friendly. Home visits also allow the physicians and nurses to see the living situation of each patient — for example, this came in particularly handy when we visited a patient with Alzheimer’s, whose sons were supposed to be taking care of him, but we found out that they rarely visit and that he, in reality, lived alone, and was separated from his wife. The patient’s son even came in and told the doctor that he visits about five days a week, but it was easy for the doctor to tell from the patient’s living situation that his son was lying. It’s also more comprehensive, and each patient gets the doctor’s full attention for at least 20 minutes, and it makes the home itself feel like part of the healing process. Of course it's more time-consuming to have to drive to different homes, but it actually seems less expensive than hospitalization: at home, physicians tend to use equipment that’s more readily available, and there’s no need to fight for space for the patient and no electricity or utility bills to pay. And in general, there’s less staff and personnel needed to watch after the patient, because the idea is that they can stay at home and be looked after by their relatives, as most patients usually are when we did the home visits. And a quick itinerary of the patients: Patient one: an elderly woman with white hair and a tremulous voice who had some form of dementia. Patient had hypertension. She began crying because she was afraid of dying; she said that there were so many people depending on her to live, including her husband and her three children and her many grandchildren. But Dr. Macias then told her, that’s exactly why she needs to keep living, and keep living earnestly, because all these people love her and depend on her. There is no way that she is going to die. Patient was greatly cheered by this, and my group and I were awed by Dr. Macias’ kind and gentle manner. Patient two: an elderly man with Alzheimer’s who lived alone. Patient did not have hypertension. When his son came over to his father’s house, the gentle Doctor grew very firm when he realized that the son was neglecting his filial duties in taking care of his ailing father and spent about twenty minutes chewing out the son. The old man seemed on the verge of tears very many times when he started speaking about his wife, who had left him, but then seemed to forget and would stare vaguely around him and at the doctor. Then he stood up and brought out his medications to the doctor. This was the hardest patient to visit for me; he seemed so elderly and fragile and alone, and I could tell that Dr. Macias was extremely frustrated that his patient could be getting better care than he was receiving if only his son were more accountable. Dr. Macias then began trying to convince the son that the reason he was experiencing pains was because he was taking poor care of his father, and that if he wouldn’t take care of his father for his father, he needed to do so for himself, for good deeds would help his own wounds heal better. Patient three: an incredibly elderly wisp of a woman who could barely walk. Patient did not have hypertension. She had chikunguya, and was reminded to go walking no less than one hour a day to prevent further muscle attrition. Patient four: an elderly woman in a wheelchair who had had serious brain damage and slurred her words. Otherwise, she seemed in good cheer despite having a case of chikunguya as well. Patient does not have hypertension. Amazing, amazing day of rotation, with an even more amazing physician. xoxo, Diana Z.