If I could pick patients, they would be Native American Guatemalans

Spent a sweaty week operating in a hilltop Hospital Nacional in Guatemala a while back.

A patient gave me a hat in thanks for her surgery.  It’s a full-brimmed canvas safari number – I’m sure Hemingway shot a rhino in one.  I’m just mature enough now to value sun protection and always grateful, sometimes to the point of pain, for gifts from those who have almost nothing.  I was also given a painting of the neighboring volcano, a tee-shirt depicting a local politician, two kisses, many back-breaking hugs, and endless expressions of muchisimas graciasplus the quiche version of same.

The biggest gift of all, though, was the respect our patients gave us.

You’ve heard of doctor shopping.  This is when a disappointed patient leaves the ER or the doctor’s office in search of a doctor who understands them better.  How about patient shopping?  Doctors have a choice too.  They engage in patient shopping in various ways.

  1. Specialty (ie, a plastic surgery practice has a different clientele than a trauma surgery practice)
  2. Location of practice
  3. Private vs hospital-employed vs public health practice
  4. Exclusion of payer types (eg, Medicare/Medicaid) or limiting to cash-only

If I were to hand pick a patient clientele, they would be Native American Guatemalans.  By dint of history, DNA, culture, nature, nuture, or whatever, our patients and their families treated our mission group as royalty, priests, or benevolent dignitaries.  We were like travelers of long ago, scaring them and making them laugh with our strangeness.  Medicine is a world of hopes and mysteries for them, not a world of choices.  I sensed their prior patient experiences, if any, hadn’t fostered a sense of consumer entitlement.  They trusted us implicitly, even when things went wrong.

We had a complication. On post-op day three after a vaginal hysterectomy, I had to tell Maria’s family she would need another operation. I worried about her mere survival. I approached the family as I do in America—firm in my judgment, apologetic that a complication had occurred, and prepared to explain (defend) the sequence of events to date. There was no need. “I’m sure you know best,” said the husband.

I found Maria’s husband again after surgery, I explained that indeed she had suffered a near-catastrophic surgical complication, but that I expected she would recover. “Thank you Doctor, thank you,” he said. Sisters and nephews thanked me. I felt guilty from the gratitude, like I had gotten away with something.

At home, medicine has been demystified in the age of information, packaged and marketed in the age of conspicuous consumption, and cynicized in the age of litigation.  When a bad medical outcome occurs, it is reflex to research.  Why?  We are trying to tell  malpractice from mere bad luck – in a world where bad luck is increasingly exposed as bad choices, bad training, bad equipment, bad people, and other controllable bads.  Good science, good will, and good processes have raised our expectations such that any post-op event is suspect.

So, our spirits soared in Guatemala.  We were trusted and thanked and bestowed with gifts.  Between our team and our patients formed an intoxicating chemistry.

The gynecologist and I fussed and fretted over Maria, our only complicated patient, all week.  She improved.

On our departure, my last goodbye was to Maria.  I brought the incoming surgeon (my replacement) to the bedside to explain her case and introduce patient and doctor.  The gynecologist and team medical director joined us.  Maria, her husband, and their children looked star-struck by our visit.  They thanked us yet again for Maria’s two operations.  They expressed their honor in our last-minute visit and told their children we had come from far away to help their mother.  Maria asked for a kiss.  I held her naso-gastric tube to one side and complied.  I wished all patient hand-offs were this heady.

During the swerving mountain bus ride to Antigua, I watched shepherds and soaked up a glory which seemed to belong to another century.  As we approached the airport, my mind wandered back to home and work.  Guilt crept in.

Chris Porter is a general surgeon and founder of OnSurg.com.  He blogs at On Surgery, etc.

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  • http://makethislookawesome.blogspot.com/ Pamela Curtis

    If I had done that, I’d be dead. I had secondary adrenal insufficiency. I finally got to a doctor who told me, “I don’t think you jave this, but I’ll run the test anyway just to set your mind at ease.” He came back and apologized. “I don’t understand how you’re not in a coma. Your cortisol was at 1 and then *dropped* to 0.5. That’s *textbook*. We need you on prednisone yesterday.”

    Yeah, I’d be nice if I could just put my faith and wonder in doctors. But I can’t with my experience. I wasn’t listened to and it could have cost me my life if I’d acted like the patents you mention. 

    It’s a two-way street, Doc. Everyone wants to own the road. That’s not realistic, in my opinion. Y’all are human. Be okay with that, please. 

  • Ybi Girl

    I agree with Pamela.

    I am an N=1. I cannot afford to make a mistake with my health, unlike the MD who chooses to play statistics with my life and wellness.

    Having lived in Guate for 4 months and probably visiting the town where you worked, your “quick trip in, and out” would leave you with a warped perspective of life in a Central American country.  You wonder why those “Indian” in Guate treated you with respect? It’s because they are used to a patriarchal, racist system where Whites and lighter skinned “Spanish” descendents are to top of the social scale. Their behavior was expected and a normal part of social interactions in a developing nation.

    If you truly want to understand what happened during your visit, you need to get away from your handlers and see how most indigenous communities work. Then you’ll learn something.

    After 40 years working through multiple long term health issues (where I was correct and the (tops in their field) MDs were wrong) and a Med Mal case* , I’ve been called a drug addict**, crazy, aggressive, and demanding – something that THIS SYSTEM CREATED – I, too, was once naive, like the families you met in Guate, but I’ve since learned that our system is bad for both the MD and the patient.

    If you want your patients to treat you with respect, stop treating them like a stock broker trading stocks. I am not a statistical package, I AM A HUMAN BEING. You need to listen to me, treat me with respect, and spend more than 15 seconds making a diagnosis. Then, and only then, will you get respect from me.

    *Calif. has a $250K cap on MedMal cases which hasn’t been increased since the 1970s, therefore my case proved to be financially impossible to win, regardless of the documented physical evidence in my possession. I was told by multiple lawyers that unless I lost a limb or died, no sane lawyer would take my case.

    **Want to really piss a patient off? Tell someone who has never even smoked a cig and lives the “cleanest diet” possible that she is a drug addict only looking for her next high. Yah, that’s a way to win friends
    and influence patients!

    • http://twitter.com/PorterOnSurg Chris Porter

      Indeed I only hope for respect in return for my respectful treatment of a patient. 

      In any service industry (I previously worked in food service and in tourism) you hope your patrons and patients understand that you’re trying your best. You hope they’re not transferring a grudge from a previous bad experience.

      While I appreciate your victim/aggressor explanation for the origin of the indigenous Guatemalans’ respectful demeanor, I prefer to think they’re just nice. And while that trip was indeed *medical tourism* for me (if you take the dim view) I prefer *first impression* to “warped perspective.”

      Patients are indeed their own best advocates. But I think entering an exam room with deep mistrust and stories of the providers who’ve failed you undermines your self-advocacy. 

      I hope your future experiences with medical providers are more positive.

      • Ybi Girl

        LOL…my docs love me once they realize I am in charge of my health. It is a relief for them to have such a motivated patient who will actually DO as they prescribe. And because my health history is so complicated, I usually end up with the top dogs who love challenging cases.

        Chris, you need to travel more, then you’ll understand that the poor live in the moment which is a much happier place than many of us live in the Western world. Get a backpack and go on your own. There is no better school than seeing the world.

        • http://twitter.com/PorterOnSurg Chris Porter MD

          I agree with your assessment of the poor living in the day. My Guatemala experience wasn’t with naive eyes. Besides Guatemala, I’ve operated in Sudan, Iraq, Tanzania, and Kenya, lived a year in east Africa, another in Argentina, another in Spain. I visit my parents in Mexico twice a year. Hablo español con soltura, which gives me an edge in understanding my environment.

          Have a look at my blog. http://porteronsurg.blogspot.com/ I hope you’ll judge me less harshly than based on the Guatemala piece written, not to trash my patients, but to evoke the idealism which led providers to healthcare. I love my patients stateside too – mine are an underserved and mostly impoverished population.

          Travel on! Peace.


  • Anonymous

    People are pretty much the same wherever you go – it’s their circumstances that make them behave differently.  If you took an infant from Guatemala and raised him in the USA the characteristics you hate in your  American patients would just as likely be exhibited in him too.  American’s entitlement society has allowed the bad side of human nature to show.

    You also need to be immersed in a culture in order to understand its people.  I am Mexican and some people feel sorry for us when we are the victims of racism.  Yet among us Mexicans there are those who look down on the indigenous peoples of Mexico because they don’t have Spanish blood in them and they don’t speak the Spanish language.  Human nature is what it is.  It is better to do your job because helping people the way you do is very noble – don’t rely on people to encourage you because they will let you down.   

  • http://emilyanon.livejournal.com/ EmilyAnon

    You know, if your American patients could pay their bills with a hat and a kiss, I’m sure a complaint would never cross their lips either.

    In all seriousness, your service, as well as the other medical caregivers who donate their time and expertise to the less fortunate is indeed something to be admired. And must be immensely satisfying.  You deserve to soak up all the appreciation given to you by your Guatemalan patients.  Cheers to all of you.

  • http://twitter.com/PersonalFailure Personal Failure

    If I just trusted every doctor who told me I was crazy and/or a junkie, I’d be dead right now. I have porphyria. It’s not the first thing anyone thinks of.

    When I think of every doctor who dismissed me without even trying, and then read this article, I can’t even. Just cannot.

    You know why we don’t trust you anymore? Because we shouldn’t. Because you make mistakes. Because you treat patients like trash and then expect your butt to be kissed for the favor.

    This article is obscene.

  • Anonymous

    Chris, I salute your efforts. I have also spent some time in Guatemala caring for the indigenous population of the western highlands, and it was an eye opening and enlightening experience for me. Thanks for the article, I enjoyed it. 

  • http://pulse.yahoo.com/_JYZSGDUXTNSTJUV5WJB3ZIY23M terminator

    hello chris, just got back from 30days in haiti. i know exactly what you are trying to convey.i have been doing 3rd world for 22 years. i love it.it gives you a spiritual boost to know you are appreciated so much. keep up the great work.( an ex-dr. without borders)…………

  • http://profiles.google.com/jrbwalk Rose walker

    In a way, longing for a simpler time is in all of us.  We have a friend who is a medical missionary in the heart of Africa.  Children are dying because of severe anemia.  They are trying to grow a plant there that has a high iron content to avoid death, not from malnutrition directly, but anemia. 

    The more we have, the less thankful we are.  Doctors aren’t magicians, but they do have knowledge that can save lives.  In a life/death situation, I’ll take a doctor over a priest, thank you… 

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