Hello from Cusco!! It has been quite awhile since my last update.. partly because I´ve been adjusting to a new city, and partly because I´ve been in the same place for the past 3 weeks and have had less going on, and therefore less to write about.
But, life is good. Cusco is really an amazing place... but I must admit that I came vastly underprepared -- both in the fact that I simply don´t have enough warm clothes with me, and the fact that my intestinal bacteria was simply not prepared for this place and has left me with tummy aches, diarrhea, and various other illnesses over the past 3 weeks... I am beginning to think that my GI system will never be normal again. But, other than that, life is good --- different.. but good.
The past 3 weeks I have been working in Hospital Regional here in Cusco. The focus of this blog, I guess, will be mostly about medicine and my experiences in medicine here... so sorry if it bores you, but that´s been what has filled most of my time and thoughts. Hospital Regional is what people here consider the ´´middle ground´´ hospital. There is also a very nice hospital nearby called ES Salud for people who have government insurance (and therefore are government employees.. for ex, Harrys parents both have this as his father works for the university and his mom is a public school teacher). There is also a hospital for the ´´poor´´, but according to Harry, it actually is a better hospital than Regional because the docs are better, they have more supplies (paid for by the government), is a newer place, and overall the care is better. I don´t have any way of comparing because I´ve only been working at Hospital Regional... but after talking to other locals, that does seem to be the consensus. There, of course, are other private hospitals as well, but only wealthy go to these.
At Hospital Regional, most people pay out of pocket for their care, but others (about 10% of the population in Cusco) have what is called ´´CIS´´. CIS patients have a basic insurance and therefore receive some help from the government for their care.. but as I´m finding out, their coverage is pretty much lacking on all fronts and often leaves patients stranded and unable to pay for necessary lab tests or procedures. People qualify for CIS based on income. If they can prove that they live totally off the land and have virtually no income, they receive CIS for free.. if they have some income but not a lot, they pay about 30 soles, or about $10, each month for the services. In general, health care isn´t nearly as expensive here as it is in the US.. I did spend some time working at a local clinic outside the hospital (more on that later), and a doctor´s visit cost about 5 soles, or $1.50. An endoscopy in the hospital costs 80 soles, or about $35, and most patients pay this out of pocket if they´re able, or they plead with the doctor to give them a reduced rate because they simply can´t pay (I´ve witnessed these conversations multiple times, and you can just see the pleading and desperation on the patient´s face... the doctor usually does give in and give them a reduced rate).
((As a disclaimer here, I am going to share some experiences and I hope that my attitude doesn´t come off as purely negative because I have had very good experiences too... but the stories that I want to share are the ones that stick out in my mind.. which for better or worse are those that contrast most, perhaps, with the medicine that I know from the US.))
The hospital is quite an interesting place, and I remember being *very* shocked during my first days at the hospital... but now I´ve adjusted a bit and see things as more ´´normal.´´ For example, all of the hospital rooms are large wards with usually 6 beds in each area. Patient privacy doesn´t exist, and all patients are talked about in front of other patients. This occurs on rounds and throughout the day in clinics. For example, multiple times in clinic I´d be watching a procedure, for example an endoscopy, and the doc would find a really nasty gastric cancer or horrible ulcer, and then go on to briefly discuss it with me during the procedure with the patient right there as well (and on a side note, the patients receive NO sedation or anesthesia during endoscopies, colonoscopies etc... NONE... they just choke down the tube and are totally aware of everything going on and are gagging and barfing the whole time.. and they just have to sit there calmly when the doc finds something bad and they have to listen to his excitement about the finding without having any idea of what it means except that it likely is bad, especially when they hear the ´´cancer´´ word...). But anyway, we´d be doing an endoscopy and have this horrible finding, and there´d be two patients in the attached room through an open door, obviously within hearing distance, hearing about the finding as well. When the exam ends, the patient comes into the room where the other two patients were waiting, and sits down, and in front of the other two patients the doc explains that the person has stage IV uncurable gastric cancer, likely with metastases to blah blah blah, and there´s not much that can be done (especially because this patient can´t afford to see an oncologist to hear other options..), it´s really horrible. Then the patient just stands up and walks out with their spouse.. no treatment plan, no future appointments talked about, and basically a ´´good luck, this is your fate, I can give you some pain pills if you want.´´ It was pretty tough for me to watch one patient in particular with this situation, and watch his wife (both were about 75 years old) just start crying uncontrollably and nearly collapse... and then two minutes later without being offered much comfort or much more information, it was time to continue on with busy clinic and they just walked out hand in hand to face ´´fate´´ at home and alone.
I have this great picture of a sign on the wall of one of the rooms... it basically says that patients are expected to bring their own toothbrush, toothpaste, drinking water, toilet paper, and comb because those are not provided by the hospital. Patients rely heavily on family and friends to bring them these necessities that we would just expect the hospital to provide in the US. The wards are open air to the outside... and at night temperatures sometimes drop below freezing but are always at least in the 40s.. there´s no heating, and patients are only supplied one sheet and one heavy blanket for the bed they sleep on... family members usually bring many blankets in order to keep them warm. There are no bathrooms in the wards, there are just two toilets for their entire floor of about 30 patients, and there is little privacy. There is also no soap (anywhere.. not in the bathrooms, the rooms, the nursing stations.. nowhere!) , no warm water, and no toilet paper or toilet seats.
I think one of my biggest initial surprises was watching how morning rounds are conducted. I´ve spent time with many different services in the hospital (more on that in a little bit), but rounds are always the same and equally astounding each morning. Basically, there is one ´´intern´´ ((medical education here consists of a test after you graduate high school at age 16.. if you do well you´re admitted to medical school. Med school is 5 years, with your 5th year as your ´´intern´´ year. During your intern year you basically run the hospital with little help from any attending or other interns during the day except for during a few hours of morning rounds -- and there isn´t much teaching that goes on, it is more like negative enforcement.. why didn´t you do this, why didn´t you do that.... Then, after your intern year you are sent somewhere into the countryside to basically be the only doctor in a huge community.. and there you learn more skills, mostly, it seems to me, by trial and error. After that you return to the city to complete your specialty training, and then you go out and practice.)) Anyway, rounds almost always start at 8:30am after a morning report lecture by one of the interns. Then, a group of one or two staff, 2-3 interns, 5-6 medical students from cusco (usually in their 3rd or 4th year), 2 nurses, 1 pharmacist, and one person always supervising, and me...enter the ward room and stand at the foot of a patient´s bed. If that isn´t intimidating enough, the patient isn´t even addressed.. instead the intern tells the story of the patient, or the events from overnight or results from various tests to the group, and the staff makes adjustments or asks questions and then moves on. The patient isn´t asked how they are feeling, where the pain is etc, nor are they really informed of the next steps in their care or the progress of their illness. Occasionally there is a physical exam, but that´s the exception not the rule.. and never before the exam are they warned about what´s to happen.. usually the doc just pulls back the covers, lifts up the shirt and pushes on the abdomen without so much as a ´good morning´. This was very surprising to me, but the patients seem to deal with it ok, perhaps because that is the only sort of care they´ve known throughout their life. It just seems very impersonal to me, and I feel like they probably do miss a lot of important information by ignoring the patient. I´ve also noticed that most patients don´t have any visitors with them... so in many cases, familis aren´t really involved in decision making or informed of what´s going on with their loved one. You can certainly tell, however, that those who do have visitors seem much happier and seem to get better faster.
All happenings within the hospital and clinics are done on paper.. no computers, no EMR.. just paper charts. And usually the patients are responsible for keeping track of their records because as various labs and tests are ordered, patients have to use outside labs, clinics and pharmacies because sometimes the hospital doesnt have the resources to offer what the doctor requests.. and the patient is responsible for understanding and keeping track of everything. The hospital does have a CT and MRI machine (which suprised me, a lot!).. since about a year ago... but they are all printed results, and printed xrays.. nothing is computerized. Also, which I find quite peculiar and at times hilarious, the doctors all have their individual stamps which they use for EVERYTHING.. its like an obsession.. stamp this stamp that.. bam bam bam, baddaBING baddaBOOM.. go pee in a cup (STAMP!), go talk to this person (STAMP!), thanks for coming today (STAMP!). I dont know, I guess I´m searching hard for humor in what otherwise often seemed like somewhat desperate situations.
Before coming to Cusco I had arranged with the US contact for the hospital (a¨Peruvian doc who now works at HCMC), to spend 3 weeks working in the hospital, a week on 3 different services.. and then one week working at a ´´Posta Medica´´, or rural community clinic, in a town called Ollantaytambo in the Sacred Valley on the way to Machu Picchu. When I arrived I quickly realized that life would not be that organized, and instead I have spent the past 3 weeks bouncing around quite a bit between services without continuity and have felt like I´ve not been able to settle down into a routine, nor develop any meaningful relationships with any staff members. And that bumbs me out a lot, of course, because my expectations were to help out, learn a lot, and perhaps be lucky enough to make some professional contacts.
My days have consisted of working from 8am til noon.. just 4 hours a day. I´m not complaining about the hours, but I did have very good intentions before coming down here that I´d really be able to help out, learn a lot of things, work hard... it just hasn´t happened that way. Instead nearly everything has been purely shadowing.. PURELY SHADOWING.. and that´s incredibly frustrating for me as I do feel like I can communicate with patients and do good exams and come up with diagnoses and treatment plans and really be of service. I cannot overemphasize how much I hate standing around and watching (and this is why my ADD has led me to emergency medicine..)...and how frustrating it is to feel like you´re worthless and just a bystander, though you know you have the skills and training to be of use. Despite repeated attempts to improve the situation, nothing has changed and I´ve basically given in to the system and watch from the sidelines, trying to at least learn by observation from the interesting and unusual cases...
In the last 3 weeks..
I´ve spent 3 days with the neurology service and their very fiery female neurologist. I´m not a huge neurology fan, but we did have some very very interesting cases of neurocistercercosis (a pork parasite that gets into your brain and causes seizures and other nastiness..) -- something that´s absolutely never seen in the US. We usually did about 2-3 hours of morning rounds on patients --- a whole range of stuff including neurocistercercosis, strokes, epilepsy and pain issues, and then went to her clinic located in the hospital where she saw a variety of neuro things.. but mostly headaches and back pain. She´s a crazy character but did do some teaching which I appreciated. She´s also clearly overworked as the demand for neurologists here is much much higher than the supply.
Spent some time with a very fun and interesting GI doc (one of the highlights from these 3 weeks)... who is also the president of the medical school here in Cusco. Interestingly enough, he also has a TV program that shows at 8am on saturday mornings, so one morning I checked it out and it was quite good although a bit bizarre as he lectured on about random medicine topics. Anyway, in his clinic saw lots and lots and LOTS of patients with diarrhea (oh man, how I empathize!!!).. as well as lots and lots of stomach pains, reflux etc. Like I mentioned above, he did lots of endoscopies (all without anesthesia), a few colonoscopies, and wrote lots of scripts for omeprazole and antibiotics. One of the craziest things that I saw, however, was something not for the light of heart and I warn you as you read ahead. During one busy day in clinic we were talking to someone about something, and an intern knocked on the door and told the doc that he had a patient that urgently needed to be seen (a common occurence in clinic.) In walked an 18 year old man, who from the looks of things was in very bad shape. He walked slowly, shuffling his feet, shoulders hunched, eyes only towards the ground in front of him, avoiding any contact with others. He was invited to sit down and explain why he needed a GI consult. In a slow, soft, and broken voice he explained that two weeks ago he was walking home in the dark and was jumped by about 5 men his age. They proceeded to steal everything off his body, beat him up, and then raped him repeatedly. Since that time he has had horrible rectal prolapse to a point where he cannot lead a normal life because he cannot control bowel movements and he is afraid to eat because it may later cause public embarrassment. And he is clearly totally full of shame after all that has happened. I also think that he was quite embarrassed that I was in the room listening to his story. Horrible horrible horrible... the patient was referred for surgery, but his psychological needs were not adequately addressed... Though I haven´t seen him again, I think about his situation often and I just hope that everything turns out ok. It´s really horrible to see how bad some people can be toward others... and how important the role of the physician is to help with the sequelae.. both in physical, but also emotional and psychological, needs.
I spent various days with general medicine... honestly nothing too out of the ordinary or super interesting there...a lot of the same bread and butter stuff... as well as various days with Pulmonology/Infectious Disease, who together take care of a LOT of tuberculosis patients and occasional hospitalized HIV patients. The TB patients were interesting to me, simply because I have only seen a couple in Minnesota... and many of these were full blown TB with old ladies coughing up nasty bloody chunks, and young men with horrible looking chest xrays.. and a whole range in between. It was also interesting to hear the doctors discuss among themselves the different tiers of treatment.. a legitimate concern here because of repeated exposures, noncompliance, or incomplete treatment. One patient (23 year old man... younger than me...), actually, was going to be flown to Lima to receive multi-drug resistant TB treatment because the hospitals in Cusco simply can´t care for him.. and luckily he has the money to pay for it.
Also spent one day with Obstetrics.. though it was a bit disappointing because I had been asking to do it for 3 weeks, and finally my last day in the hospital they let me do it.. and the service was slow with only one pregnant lady that MIGHT deliver that day (and wasn´t going to happen during the four hours I was there in the morning).. plus I also happened to be basically weak and crippled by my own GI explosion problems, so I wasnt in the best of moods to be waiting around all day when all I wanted was water, bed, and bathroom. On morning rounds, though, of the patients who had delivered in the previous few days, it was very interesting to see that all of the babies were sleeping in bed with their mothers.. there is no nursery (though there is a small NICU for those who need it), and mothers are expected to breast feed as formula simply isn´t an option there. Very different than the US way.. but interesting because I remember from my outpatient pediatrics rotation during last December in the US, one of the peds docs told me that she´s hoping for a change of culture in the US so that babies are allowed to be with their moms more during their first few days INSTEAD of being in the nursery. I remember her commenting to me that 3rd world countries have it correct... and it was interesting for me to see this US doc´s wishes being done as the norm here in Cusco.
For a nice change of pace I was able to spend 3 days outside of the hospital and go to the local public clinic called Wanchaq. Here I basically just shadowed med/peds clinic (which again was frustrating as shadowing is the WORST)... but I did have some good experiences here because of the quality of, in particular, one doc. And now as I reflect I realize that the benefit of the clinic wasn´t the medicine, but it was the relationship that I developed with him instead. I actually worked with this doc 2 of the 3 days and he´s a super chill guy in his 40s who told me that in addition to working mornings in this clinic, he (like most other physicians in Cusco) has his own private clinic in the afternoons. His clinic, however, is one of the only alternative medicine clinics in Cusco. Now, i´m not really up to date nor involved in alternative medicine at all, but I was curious so I continued to ask questions. He told me that there he practices acupuncture, raki (sp?), and on a consistent basis refers patients to local curanderos (aka shamans, local healers, etc..) who use herbs, animals, smoke, chants, traditional healing etc to cure patients. VERY interesting... because he is a highly-experienced medically trained physician who still sees the benefit and results of traditional healing. He told me that he is often looked down upon by his colleagues for his beliefs in traditional healing, but he continues to see positive results for his patients and truly believes in the need for spiritual and emotional healing, as well as physical healing, so he continues this work! He also told me all about his most common consult -- ´´susto´´ -- in children.. or children getting ´´scared´´, for example after a fall, or loud noise, or fight between parents, or scary interaction with animal... and then the child is crabby or loses weight or doesn´t develop well etc for a long time. The patient´s parents will have the kid evaluated for every diagnosis in the book, but no treatment works. The family is referred to him as a last ditch effort, and he diagnoses these patients as having ´´susto´´... a completely non-medical diagnosis.. and refers them to a curandero. He says that most of these patients know an old grandmother or someone who also knows how to cure these things and are happy to give it a try... and then the child gets better!! I was skeptical, but this guy was very convincing and told me some pretty incredible stories. I think I was also convinced because on our 2nd day together there was a lull for like an hour between patients and we started chatting about life, and all of a sudden he asked me when my birthday was. I told him, and he said.. ´´ahh that explains things.´´ WHAAA i asked him??? And he went on to basically describe my life, my interests, my personality, my family, my life goals... I mean, I was like TOTALLY freaked out. He said that he was able to just read my vibes and that he expected great things to come from me. It was very sincere, and I was very flattered --if not a bit overwhelmed as well-- but actually felt a very positive and trusting relationship with him. Because of that, I began to share with him my goals and dreams for my future.. including thoughts of working in international public health (maybe coming back and living in Peru in the future??).. and also described to him how next year during my year working on my Master´s of Public Health at the U of Minnesota that I have to do a public health project. From there, we started talking about the state of public health in the Cusco area and Peru in general, and he gave me all sorts of ideas about things that I could do and get involved with.. and he incorporated many purely medical things into the conversation too.. giving me ideas about how I could get involved both as a PHYSICIAN, but also as a PUBLIC HEALTH expert. And that´s exactly my goal. It was very exciting... but I also realize the complexity and difficult road that lies ahead if I do chose to proceed with this path. He, however, offered me his help and encouraged me to keep in touch.. something that I´ll definitely do as I´m more than elated to have such a great resource, and caring person, as a contact within the community.
On paper as I read back over what I wrote about my time so far in Cusco, I realize that though overall I feel disappointed in my experience because it hasn´t ´´met´´ my expectations.. I do realize that I´ve seen a lot and perhaps the goal of all of this is less to add to the medicine that I know and have learned and prove that I can be a good med student, and more to see a different way that medicine is practiced..... AS FRUSTRATING AS THAT HAS BEEN!!!! But there certainly have been highlights, as I have already shared. In talking with Harry about my experiences, he continually reminds me that I need to be more patient.. and I think he´s right... something that my Wanchaq doctor friend also told me!!!! I also want to emphasize that I´m not trying to complain about the hospital and the state of health care in Peru.. as I´ve only seen one hospital, and only for certain hours during a 3 week span.. and that´s certainly not representative. I´m just trying to put together a picture and compare it to what I know, for better or worse, in order to be constructive and give depth to what I´ve experienced.
I have one week left working in health care in Peru.. and for that I´m going to Ollantaytambo to a smaller clinic, where I´m hoping for more independence and more patient care. For part of the time I will be working with my amigo Erik (another med student from u of minn), so that I´m sure will be a hoot.
I realize that this blog entry has gotten ridiculously long (but aren´t they all??).. but I do want to emphasize that as I only work 4 hours a day, I still have many hours outside of the hospital as well! Harry, of course, is a guide here and has restarted work.. meaning that he takes groups for 4-5 days around Cusco, the Sacred Valley, and Machu Picchu. He´s home most nights.. but I´m finding that I have to keep myself entertained most of the time and I´ve quickly realized that in a city where you are no longer a TOURIST, per say, life is very lonely when you don´t have many friends nor activities to do (or things to study, as I´m so used to having to do all of the time..). I´m really thankful that Erik has been around (and we spent a good chunk of time together for MATCH WEEK this past week... skyping with friends from home on Thursday and yelling and screaming as we found out he´s heading to california for residency and all my friends basically got their first choices as well.. couldn´t be happier or prouder for all of them.). I´ve spent a lot of time reading... and as I eluded to earlier, I´ve spent a lot of time being sick.. something I´m not used to and something I´ll never be happier about. I´m almost positive that I had giardia (though wasn´t officially tested, and probably didn´t adequately treat myself which is why I´m in the position that I´m in right now...which is... debilitated). I´ve had a whole range of things from intense muscle aches, joint pains, fevers, chills, headaches, and of course GI issues... so I guess I´m learning patient empathy as well :) It´s kind of fun as I sit in bed and read my tropical medicine book and try to empirically diagnose myself... but it´s also a bit stupid and I probably should suck it up and go to the doctor and do a poop test. We will see.
A few other highlights I´ll quickly share. One day Harry was working and giving a city tour to a family from the northeast US. It was a weekend day and I had nothing to do, so I tagged along for the day --pretending I was an intern for the tour company... a white lie, yes.. but Lent hadn´t started yet!!!!-- and had a blast, both relearning about the city and seeing Harry doing what he loves and is absolutely phenomenal at!! Plus the family didn´t mind that I was there, so that was cool. Also, last Sunday Harry was working so his parents decided that they wanted to take me out for the day, just me and them... they picked me up at 7am (too early after a later Saturday night out) and we drove to the Sacred Valley, stopping multiple times for them to show me cool things in the small towns, let me taste local (safe) food, and just take in the beautiful scenic valley. I was a bit nervous for the day long adventure with them, but it was actually a BLAST and we had a ton of fun, and they are really really great people.
Harry and I have had a lot of fun in the Cusco area. As I alluded to in a previous blog, he´s a motorcycle guy and we´ve taken countless spins around the city on his bike...and I love it!!! Though most of the time I´m clutching him holding on for dear life because people are such bad drivers here, we do wear helmets and so far the adrenaline has kept us safe. Don´t worry mom and dad, it´s always an adventure!!!!!
When we´re lucky to have nice evenings here Harry has taken me up to Saqsayhuaman (´´Sexy Woman´´-- an Incan site on the mountain overlooking Cusco) to have fabulous views of the night and stars and just to talk about life. On one Saturday we took an excursion to a less-visited area of the Sacred Valley and had a fantastic lunch near a large lake, then spent a few hours climbing around on Incan sites including a fascinating aqueduct system and went to a museum and saw the most massive armadillo skeleton that I´ve ever seen!!
Yesterday we had a crazy day with his family exploring the region (into the Sacred Valley to check out salt flats, a nice Incan site and beautiful scenery... and then ran into problems with ´´paros´´--strikes by the local people--, and had issues with policemen, road blocks etc etc.. and then came back to Cusco and ate a lot and then partied til late in the evening.. always and adventure, but I´ll tell those stories later :) It was AWESOME!!!! and Harry´s family is AWESOME!!!
We both have a few days off of work, so today Harry and I are taking the motorcycle on a 2 day adventure (I´m thinking of it as a mini ´´Motorcycle Diaries´´) to an area of Peru where I´ve never been before that Harry says is gorgeous and there are thermal baths and places to camp etc, as well as beautiful small towns and a few different ruins on the way. Should be awesome...as long as it doesn´t rain and as long as my butt can handle the 4 hours on the motorcycle!!
I start working in Ollantaytambo on Wednesday and will work there through Sunday. After, Harry and I have planned a 5 day trip to the mountains north of Lima to a town called Huaraz for our final days together before probably one of the hardest goodbyes... I leave for Ecuador on April 2nd.
Life is great, and passing too quickly. Here´s to hoping that life (and my diarrhea) slow down for my final 2 weeks in Peru.
Congrats to all my fellow med schoolers with matching... you´re always in my thoughts and couldn´t be happier for all of you!!!!
Hope all is well with everyone.
Love, Tarita
