The Family Medicine Man

Blog 10. IESS Batan Hospital. Quito, Ecuador.

A typical set-up outside the patient consulting rooms.

Again, we shadowed the family clinician Dr. Alvear, who, just like yesterday, was great about giving us pointers and including us in his consultations. There were no house visits today, but we did get to meet second-year medical students who were studying in la Pontifica Universidad de Catolica de Ecuador. These students were in their early twenties, and had just begun rotations with Dr. Alvear, who is also an alumni and professor of the university.

A quick aside on medical universities in Chone:

The medical students were our age, and appeared to be just as excited, young, and eager as most college students — a huge contrast to the more serious, older medical student population in America. Dr. Alvear introduced us to the students, who were very receptive and just as eager to talk about health in Quito and curious about the strange American students and health in the US as we were about them. I noticed that women were pretty well-represented in the group; 3 men and 3 women were in our rotation today.

We learned from the students that they were attending the University here in Quito, and that they were just finishing their second year. To obtain a medical degree requires six years, and then follows two years of residency. Unlike in the US, these students are allowed to go directly to medicine after high school. In their first two years, they learn the basic sciences: physiology, anatomy, biology, and so on. The next four years are spent on clinical rotations and learning about the specifics of each field of medicine. Sometimes, after obtaining their general medical degree from medical school, students can rotate in a rural setting and learn about rural health (sort of like a scholarship or a specialization here; we heard this from the doctors in Chone). Otherwise, they can specialize in fields as diverse as dermatology to neurosurgery, just like in the US.

Fun fact: because the university is religiously affiliated, Pope Francis visited the school literally the week before I came. SUPER cool stuff. My friends said that they saw Pope Francis zoom by in a bulletproof glass box doing the queen wave on the top of a motorcar. Not that anyone would have tried to kill him, because the Ecuadorians love him, apparently. Although I guess they could love him enough to kill him, you know? Anyways, am now only a little bit salty I never got to see him.

An aside on the teachings of the day:

Dr. Alvear proved to be just as amazing of a professor as a physician.

Physician-side:

Saw patients with Type II Diabetes (all of the patients we saw today), and a patient who had benign prostatic hyperplasia, called BPH for short (or hiperplasia de prostata, HPB en corto) which is an age-associated enlargement of the prostate gland that causes difficulty urinating, and can lead to bladder stones, infection, and reduced kidney function. This is very common in the US as well, affecting 3 million males annually.

We had another woman who had irregular thyroid function, so Dr. Alvear prescribed a TSH test, which simply measures the amount of thyroid-stimulating hormone in the blood through a blood test.

A woman also came in with hypertension, diabetes, and edema (swelling) around her ankles and feet. This can mean a lot of things, as heart disease and kidney and liver failure can result in excess fluid and buildup of edema; for Dr. Alvear, it was a cardiovascular concern and he prescribed some lab tests for the patient.

Professor-side:

Very, very interesting lecture from Dr. Alvear today. His main theme for the day was reminding us and his students that we should always see ourselves as a future patient. That way, we will come to understand how patients feel, which will inform the patient-physician relationship, which oftentimes can determine the outcome of the treatment for the patient.

He had us do an exercise: he started out by handing everyone a slip of paper and asking whether the pre-med Facebook page had been set up. The answer was yes. Satisfied, he then gave his next directions: draw a self-portrait of your entirely naked self, write your name on the bottom, present the drawing to your fellow students, and then post it on the Facebook page. Obviously we were all horrified at what we had been asked to do. But, his smooth face imperturbed, the Doctor just nodded for us to continue.

The point of the exercise was to help the Ecuadorian students eradicate the taboos of their culture in regards to the human body and sexuality, and to understand embarrassment when we scrutinize the different parts of our body, despite how easily we can talk about sex in a scientific way. In this way, we can start to understand what patients feel when they come in for a physical exam, especially when they need to address problems with their sexual health. He then went on to explain that sexual health and sexual satisfaction is a huge component of human life, and one question that physicians rarely think to ask is: "So how has your sexual life been? Is everything satisfactory?” He attributed sex and sexuality as a cause of a lot of symptoms, and he explained that things like erectile dysfunction, extremely common in over 50% of Ecuadorian men and extremely embarrassing for them to talk about, especially in the heavily machismo culture of their country, is often not talked about or self-treated because physicians forget to ask about sexual health. Even as a premed student coming from a supposedly liberal and free culture like America's, I was just as embarrassed at the thought of showing my naked self-portrait as the Ecuadorian men and women.

He then went on to ask the students, “What is the last thing we [family physicians] tell the patients before they leave?” We were all stumped by the question, suggesting “Take care of yourself” or “Don’t forget to make your follow-up appointments” until he finally took pity on us and said, the words rolling off his tongue: “Remember to eat healthily: three meals a day, at consistent times, with lots of fruit and nutrients [the Ecuadorians are not terribly big on vegetables in their diet].” In spanish: “No olvide de alimentarse bien.” In Ecuadorian Spanish, “alimentarse” seems to be a bit more comprehensive than just “eat nutritiously”; it also implies leading a healthy lifestyle, which, defined by Dr. Alvear, includes getting eight hours of sleep at night and working out 5 days a week.

It’s interesting that he chose this last phrase to part with — alimentarse, of course, still heavily suggests healthy eating, and I think it shows what Ecuadorians struggle with in their health: their diet. Diabetes is rampant in the country, and so is hypertension.

The doctor, of course, did not stop there. He then asked whether the group had eaten breakfast that morning. Nearly half of them hadn’t. He asked at what time they had their last meal. The times ranged from 8 pm in the evening to 2 am in the morning. He then asked whether people managed to keep their mealtimes consistent. Everybody looked down at their sneakers. He asked how many people managed to work out five days a week. Only my fellow American pre-med raised his hand — not even Dr. Alvear raised his. He then stated the obvious: it is even difficult for doctors to maintain their own health, and for the patient-physician relationship, patients will always be looking towards their doctor as an example. Thus, we should all see ourselves as future patients rather than future doctors.

He then threw a volley of scenarios at the medical students, asking in each scenario if he should prescribe drugs at the end of each scenario. I was floored by how readily and unanimously the students said no each time; they all responded that drugs would only treat the symptoms, not the source of the issue. Really, absolutely stunning response — most medical students, forget it, most physicians would have said to prescribe the drug back home in America. I say this with almost 100% certainty, based on the other physicians I’ve shadowed before — there’s so much more of a drug culture in the US healthcare industry than in Ecuador. Why? Why the discrepancy? I’m a huge proponent of treating the cause of illness (and I think most people with common sense are, including physicians in the US) and it’s not a novel idea. But why does it seem to stick in Ecuador and not in the US? I really, truly believe that this eventually comes down to a question of culture — the health culture of Ecuador tends to reflect the familial culture of Ecuador itself — one that is based on an approach of holisticness and integration into an external system. The US, especially with the advent of Obamacare, has always been focused on individual wants and desires, and now that healthcare is based on, essentially, consumer satisfaction, drugs are the easiest way to make a patient feel better, and so drugs are what patients expect to receive and doctors expect to prescribe at the end of a visit or scenario. This is totally fascinating to me, and I know I’m speaking in general terms here, but I do realize that this is also a blog post, so I’ma save the rant for now. There will definitely be a comparative health and health systems rant — hopefully an educated one — in the future.

I freaking love Dr. Alvear. He is THE man when it comes to holistic medicine.

xoxo,

Diana