Final week!

Interns

I wasn’t able to meet with Dra. Magaly so I decided to continue my rotations at Hospital Civil.  My first two days were with Labor and Delivery. L&D is an experience no matter where you are, but being in a Spanish-speaking public hospital multiplied that experience a ten-fold. Within the first two hours I was there, I saw five deliveries (that I will not describe for the sake of weak-stomached readers), and by the end of the day also got to return to the OR for a Caesarean section. I’m glad that I waited until the second week to go to L&D because it was the busiest department I visited and it was easy to feel lost and out of place. I did apply my method of asking to do as many things as possible, no matter how trivial (putting a diaper on a newborn), to build a trusting relationship and slowly be allowed to do more (catching the newborn!).

Saw these murals after a quick
hike around my neighborhood.

The next two days I went to internal medicine which was a bit more difficult to find a way to be helpful. I ended up shadowing a resident as much as I could. The nice part is this made me follow the resident when he went to get labs done, consulted with radiology, and so on which is harder to keep track of when you have to stay on the floor. It's a part of the medical process which is important to witness, and it was interesting seeing it from a Mexican perspective.

 For my last day, I went back to my favorite: peds! It was the perfect way to end because I was able to follow up on some patients I had met the previous week. Also, the realization that I still loved peds despite being in such a different environment solidified it as my go-to specialty.

I completed 30 hours of Spanish classes!

It’s crazy how quickly time went by and I got way more out of this experience than I could have possibly imagined. I previously shied away from short missions trips because I was afraid I wouldn’t be able to fully immerse myself in the culture and really get something out of it while giving back. This trip with CFHI was perfect because my role often fell at the same level as it would be in the US which made it easier to feel immersed into the environment. A month was also the perfect amount of time to get to know plenty of people, learn medical knowledge in Spanish, and get to know the area well enough that I would feel comfortable visiting another time (which I can't wait to do). I absolutely recommend it to any other med (or nursing) students!

Let's be touristy

This was the last week that the Minnesotan nursing students would be in town and my last weekend, so I joined their group touring multiple tourist locations around Oaxaca. This included Hierve el Agua which is possibly the most beautiful place I have ever seen, the Tule tree (largest tree in the world),  Teotitlan (authenthic Zapotec rug makers), the Mitla ruins, and a Mezcalaria. 

Hospital Civil

Last Thursday, I spoke to Dra. Magaly about what I would be doing once I switch to the Hospital. She was wonderful about asking me what my interests were (mostly Peds and maybe Surgery, at this point). So she said I could spend my first half of the week in Surgery and the other half in Peds . At the hospital, my go-to was Dra. Mayda Cruz with whom I set up a schedule of 2 days in Surgery, 2 days in Peds, and 1 day in ED. I was excited and prepared for a hectic week.

I had to report at the hospital at 7am but luckily, it was only 10mn away by bus and this bus stopped right across the street from my house. As soon as I arrived, I could tell the patient volume had tripled from my experience at the Centro de Salud. I never got the time to, but I wanted to count the amount of people waiting outside. My guess: >100.

In the hospital, like the ones in the US, there are multiple levels of medical staff: medical students, nursing students, PT students, interns (although in Mexico they are not considered doctors yet), fellows, and so on. Everyone who is still a student wears all white. And, although I forgot to ask, it appears everyone buys their own white coat so there’s not much consistency in length either. What am I getting at? It’s quite difficult to tell who’s who so unless you manage to get close enough to read name tags, it’s hard to tell who you’re interacting with. The only reason this was a problem  is that as a new student who doesn’t speak/understand Spanish fluently, it’s hard to know who to follow and ask for help, especially when everyone is running around frantically.

My days at surgery went fairly smoothly as I had already done a surgery rotation at my home school. I observed an open appendectomy, a knee surgery, and a brain tumor extraction. Even though I didn’t get to scrub in (because of the high amount of residents that participate in each surgery), the surgeons were always receptive to my questions and helping me learn.

Dr. Jacobo

Next, I did two days with pediatrics. I worked with Dr. Jacobo who ended up being my favorite preceptor my whole trip. He was one of the few who allowed me to be more involved in the patients’ care and pimping me the same way that preceptors would in the US. He also brought me along to a couple presentations by residents. I was pleasantly surprised by how much I could follow along!

My last day of the first week, I spent in the Urgencias (ED). As EDs tend to be, it was crazy busy. There are patients and doctors everywhere and if you blinked, you could miss everything. I tried my best to be useful, and was able to keep practicing procedures I had previously learned at school such as inserting Foley catheters.

The hospital was in general busier than the clinic and if I didn’t try to participate I could easily have ended up standing in a corner all day unnoticed. This helped me learn to be more assertive as a medical student, not just in Oaxaca but back in the US as well (where I would be getting graded for it!).  Something I appreciated, both in the hospital and clinic, was the relaxed culture. No matter where in the hospital I was, everyone dropped everything at 11am for breakfast. This was a great time to talk to the physicians and students to get to know them and the healthcare system better. 

Week dos summary

This week I was joined by a group of about 20 nursing students from Minnesota. Two of them lived in the house with me, which was nice to have other people to hang out with during the evenings. [By the third week, an undergrad student joined us from New Mexico. It was basically a sorority house!] I also felt more comfortable going out later at night now that I had other people (at no point did I ever feel unsafe while in Oaxaca per se, but better super safe than sorry). There is a nice amount of night life concentrated on one block and a large amount of people out and about at all times, which added to our fun (and safety).

 On Saturday, I took a bus to Monte Alban. One of the larger, popular ruins about 10K from the center of Oaxaca. I decided not to use a tour because I wanted to be able to visit at my own pace. The place was absolutely breath taking and I definitely recommend it. The views are spectacular and the rich history is mind-blowing. They also have a museum with a cute café overlooking the mountains. ! The bus and entrance didn’t cost much and gives you two hours before picking you up, which is plenty of time. Do it, do it, do it!!!

Side note: while at Monte Alban, a man decided to give me a "personal tour" and shared some interesting history with me. This was nice until he wanted to lead me to unpopulated areas and I decided that is not how I wanted my trip to Mexico to end. The message here is it's fine to travel alone as long as you always remember: safety first!

Xoxo, cont.

This week was a more positive version of my previous week. Last Thursday, I had a meeting with the medical director of the program Dra. Magaly and she asked if I wanted to switched to a different Centro de Salud. I decided to stay in Xoxo since I was getting used to their system. I really appreciated how much she valued my input on my experience. Although staying at Xoxo, I switched to a preceptor who worked at a slightly slower pace allowing us to have more discussions, and the third year medical students from UABJO started their shadowing as well. I was able to help out with H&Ps as well as discuss assessment and plan. Since I did not attend the program with any of my classmates, it was nice to have the UABJO students as peers.

Third year students

My current preceptor often had families come in for obligatory check-ups due to being on Seguro Popular (the universal healthcare for low-income populations). I noticed that any patient about 13-years-old and up was given a quick, minimal eye contact statement: “If/when you have sex, you could end up with a child. So use birth control.” As expected, the patient would be extremely embarrassed by the subject matter, especially since it was being brought up in front of their parent, and would not inquire any more information. And that may explain why 5 years and 3 pregnancies later, these same patients end up having the birth control conversation all over again.

That being said, something I did appreciate is that the family doctor worked very closely with the psychologist in the same building. In fact, when I brought up my concern about the lack of communication with the patient, my preceptor told me that it is part of the patient’s appointment to rotate through a psychiatrist (and dentist!) where the patient is able to express any issues on the emotional side of their medical care. On one hand, I think this is great because there is definitely a distance between family doctors (or any doctor, really) and psychiatrist in the US. This relationship allows mental illnesses to be investigated right away and it adds one more person in your care team. On the other hand, I still believe that the person in charge of your care should be the one having the first conversation to check the patient’s understanding.

Something else I noticed more this week was the HIPAA culture—or the lack of. One differing factor, that at first did not seem that important, is that here, the doctor (or nurse, medical student…) calls the patient into the room. Which is just a miniscule difference from how the US does it where the patient waits in the room for the doctor. So why is this incredibly small difference worth mentioning? Because the patients are used to walking into the room, sometimes they would do so without being asked to. Allow me to set the scene. The doctor is in the room with a patient when another patient knocks to ask about a quick clarification on their medication, their next appointment, or sometimes something else slightly more personal. The doctor answers their questions for a minute or two, and then returns to the original patient. In other words, at some point there are two unrelated patients in the same room talking about their personal medical care. Add the open paper records to the mix, and you have an American medical student cringing in the corner (me!).

Now, at no point did I feel like the staff was disrespecting the patients’ information, but there was definitely a large departure from the heavy need of patient privacy I am used to in the US. Unlike when I brought up my questions on patient-doctor interaction, I felt like it would be a bit rude to ask about privacy laws so I looked them up instead. A quick Google search informed me that in 2010, Mexico created the Federal Law for Protection ofPersonal Data in Possession of Individuals. It seems like a law that applies to the general public more than one specific to patient privacy therefore I am not positive how exactly the latter is handled and can only speak from what I observed. It's definitely something I plan on looking more into!

First week summary

On the non-medicine side of things, my first weekend there I wanted to take a trip to the Monte Alban ruins but unfortunately woke up Saturday morning with a tough cold. I decided that since it was the weekend, it was the perfect opportunity to indulge in all the tea my family could provide and hide under mountains of blankets.

Los Tios
I could write an essay about the
amazing meal I had
at this restaurant.

That’s something I haven’t talked about in detail yet: my home stay! We were told we would be placed with a middle-class family, but that “middle class” in Oaxaca could be closer to low income in the US. In other words, “keep your expectations low.” I did exactly that, and thus was pleasantly surprised when my room was about the same size as my room back home. I was hosted by a lovely retired couple who lived with their daughter and grandchildren. My actual room/bathroom was located in the Senora’s sister’s home which was next door, and then I would only go into my host family’s home to eat. They provided me with breakfast and lunch, then dinner was on my own (which allowed me to explore the hundreds of restaurants downtown).

Torta de quesillo

Because I had to leave the house by 7:15am to be at the clinic on time, my family had their maid leave me a packed breakfast of fruit and cereal (or a sandwich). Once I would finish at the clinic at 1pm, I’d be back home by 1:30pm and eat lunch around 2-2:30pm. The program warned us that lunch was usually eaten at later times in Mexico, so I expected that I would have to adapt, but my family was super accommodating. They would ask if I was hungry as soon I’d get home in the afternoon. If I wasn’t too hungry, I would wait a bit so that I could sit with them at the table and get to know them better. I emphasize this because I think they really appreciated me using whatever amount of Spanish I knew to hold a conversation with them. This in turn helped me practice my Spanish!

After lunch, I’d rest/do my homework for my Spanish class which was from 4-6pm. Because there was no one else in my program, my classes were 1-on-1. Which was great for my learning’s sake, but sometimes would be a bit intense if I was tired, because there’s no spacing out when you’re the only student in the room! Luckily my teacher, Manuel, was wonderful. The placement test I took last weekend put me in intermediate which is the level I was when I last took a class in college, so it wasn’t too intimidating. The classes were split with one hour of grammar and one hour of medical vocab – a little long and exhausting, but definitely learned a lot every day. Sometimes I would hear the medical vocab I had just learned while in the clinic!

Overall, the first week was adjustment week where I got to know the family, the town, and my bus route to the clinic. All of it went smoothly, so I was excited to see how the rest of my stay would be.

Centro de Salud, Xoxocotlan

I spent my first week in the Centro de Salud at Xoxo (aka Clinic), which is about a 20mn ride from the Centro (Downtown). Luckily one of the teachers at Becari (the language school CFHI works with) went with me the day before I was to start because, if not, I would be lost with the bus system. Let me tell you how their buses work. First, it’s quite difficult to tell whether a stop even is a stop because only a few have any type of sign. While waiting at said stop, if you don’t wave at it, the bus won’t stop for you. But how do you know if it's the bus you want? Multiple location names are scribbled on the windshield (or sometimes all yelled out by someone standing by the bus door). So, somehow you have to read the different stop names on the windshield of the bus to decide if it’s the bus you need in the split second before it drives past you. Then when you’re on the bus, the only way to signal that you want to get off is by a button next to the door in the back (in other words, if you’re sitting in the middle you need to get up and walk to the back with plenty of time to spare).  But you can’t know when you’re getting off because it’s not announced! So it’s a gigantic, fun guessing game. All that being said, surprisingly, I got used to it pretty easily. And luckily, people here are very nice and will help make sure you get off the bus in time.

Back to the clinic. The Centros de Salud are public doctor offices mostly attended by the population covered by Seguro Popular which is their universal healthcare for low-income populations. My favorite thing was the variety of medical issues I saw. That being said, the majority were pregnant women. What shocked me was seeing teenagers pregnant with their second or third child, which meant that by the end of the first week I had memorized my preceptor’s “have you thought about birth control?” speech. My preceptor's approach on issues like birth control or chronic diseases like diabetes, for example, showed me how important the reinforcement of patient education was here.

While my preceptor was very nice, my role was a bit too observant for my own liking. I understood that my Spanish wasn’t the best so there was only so much I could do, but she was moving at an intense speed (probably because of the high volume of patients) that made it difficult for me to participate even if I tried. Nonetheless, whenever I asked any questions she made to sure to answer. I hoped I would be a bit more helpful the next week.