It’s 8:45 p.m. in rural Chiapas, Mexico. A cool blanket wraps around the previously warm day in the small farming town of Honduras. With a syringe of medicine in his front pocket pasante, Dr. Ivan Martinez does a steady jog up a steep hill to see about a patient’s chronic pain.
Nestled in the Sierra Madre Mountains, there are few flat places. At the door, he’s immediately and warmly greeted by multiple family members. They are each eager to provide Dr. Martinez with a different perspective on the patient’s illness while he does an extensive physical exam. Twenty minutes later a decision is made, and the medicine is administered. He quickly drinks a sweet coffee the patient’s wife. Dr. Martinez has been thinking about dinner for a couple hours now, but he also needs to secure a projector from the local Seventh-Day Adventist pastor for a community movie night. He’s hoping to show a film that might facilitate discussions on mental health, a major contributor to local morbidity. An hour later, with the projector secured and a couple “mini-consults” completed, he takes a breath, “Cenamos (dinner)?”
This is the day to day of a pasante who has reached the halfway point of his social service year. While responsible for the entire town’s health care, he has only been Dr. Martinez for about six months. As a safety-net in the Mexican health care system, first-year physicians are placed at rural locations without otherwise easy access to a doctor. For most patients, pasantes are the entry point to all medical care. While Dr. Martinez’s ultimate interest is in psychiatry this year, he is managing everything from pregnancies to Parkinson’s disease. There is a single room in the clinic with three shelves of medicines to choose from. Despite limited options, the treatments are frequently adequate and simplify many visits. It is a stark contrast to first-year physicians in the U.S. who have heavy supervision, with exhaustive options on treatment, testing, and consults. While at times it would be nice to have more help, the responsibility empowers the pasante. Dr. Martinez is this community’s physician.
As Dr. Martinez makes his way through Honduras, some may wonder if he is also running for office. At over six feet (a foot taller than most patients) he stands out and rarely misses an opportunity to offer a broad smile and conversation. Frequently, he is securing medical and dinner appointments simultaneously. He says all of this interaction helps him to know the complete picture of the patient. With multiple generations living on the same street or under the same roof, he often doesn’t need to take a family medical history. As one observes these interactions, it is hard not to be reminded of the romanticized picture of the old country doctor. Yet his job has significant challenges. Aside from his lack of experience his patient population also confronts him with poverty, insecurity, and varying levels of education. More than 75 percent of the population earns under $5 a day.
In high-resource settings, physicians are now being trained to be more cost-conscious. For pasantes, this thinking extends far beyond making sure tests are clinically relevant. A young mother’s symptoms suggest a potential brain aneurysm. The diagnostic approach is an emergent head CT scan. Yet several steps lay ahead. The closest CT scanner is five hours away. Perhaps if he can get the patient to the closest centro de salud (a slightly bigger clinic), he can transport the patient in their ambulance. Someone from the community secures a car, and after making it the centro de salud, the question becomes if the family will be able to pay for the CT scan. It is pointless for the one ambulance in the community to be used if they ultimately can’t pay for the scan. As family members are on the phone with friends and relatives scraping together these funds, the pasante starts to think what if we do find an aneurysm? Will there be a neurosurgeon and funds to repair it? If not why are we asking this family to pay for a scan? All the while uncertainty of the patient’s diagnosis remains.
Dr. Martinez said it took about three months to get comfortable in his role, which is interestingly about the time many U.S. first-year physicians start growing into their role as interns.
The following day as the sun leaks through the cracked doorway of the town meeting hall a handful of patients begin gathering. They have come for Curso de Triángulos, a group therapy session for patients suffering from depression. In addition to pharmacologic treatment given in clinic, the courses are designed to provide both therapy and a confidential community support group for mental health. Some are more vocal than others, but Dr. Martinez manages to get everyone involved. Today he has placed four pieces of paper on the ground with the words situación (situation), pensamiento (thought), emoción (emotion), and acción (action). Patients physically walk through these aspects of an experience they’ve encountered. They process how their happiness is influenced by not only the event but their own reaction.
Through this process of slowly walking through a problem together, they gain a deeper understanding of themselves and form a greater level of support for each other. This exercise mirrors the relationship of the pasante and the community. While imperfect at times the relationship is a close one built on many steady visits together both inside and outside the clinic. The pasantes guide the health care of the community, and the patients guide the pasante’s learning. In a few months, Dr. Martinez will move on, and these same patients will walk again with another newly minted physician. Their health and the physician’s growth a partnership.
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