NU-AID: Child Health Family International, Puerto Escondido

Experience abroad is an extremely influential tool that should be part of every medical student’s instruction. Seeing other countries’ healthcare systems helps us understand our own system in a new light; a further perspective can actually bring things more in focus. I love traveling and exploring new cultures, so I jump on any opportunity to do that while also learning and practicing medicine. I wanted to go to Mexico because I wanted to work on my medical Spanish and there was an established program there already. I want to be able to connect with the Mexican patients here in Chicago, and going to experience Mexican culture while improving my Spanish abroad was a great way to do so.

 

In terms of my career aspirations, I hope to practice healthcare in an underserved setting and give care to those who are most in need of it. Seeing some of the work physicians and community health workers do in Puerto Escondido has solidified this goal of mine. I am inspired by individuals who do the work they do in an effort to improve the lives of others, rather than for material gain or personal prestige.

 

During the trip, we spent time in community health clinics, the local hospital, and also a week with midwives from the region who were in town for a recertification workshop. The most meaningful experience I had was our last week when we worked with the midwives. We ran the curriculum and taught things like normal labor, warning signs, prenatal care, etc. However, in most cases the midwives had had much more time with mothers and babies than we did in terms of deliveries and practical experience. As a result, the week was an interesting collaboration between their practical experience and our scientific knowledge, and both the midwives and ourselves were able to share our respective expertise with the other group. We even were able to hear (and feel) about some of their traditional medicine techniques such as massage.

 

While the Mexican healthcare system doesn’t have the amount of resources that we have in the United States, there are many great things about the public oportunidades program that we saw while there. The system in Mexico is highly focused on preventative care, which is the most financially viable and effective delivery system in spite of the resource limited settings. Patients receive financial incentives to come to the clinic every month for check-ins and the system is linked to education and food programs for children and mothers. Preventative medicine is the model of the future for the United States, and we have a lot to learn from the way care is delivered in places like Puerto Escondido.

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NU-AID Experience in Puerto Escondido, Mexico

My global health trip in Mexico through NU-AID this past summer was one of the most rewarding and formative experiences in all of my years in education. With the support of CGH, I had the privilege to travel with eight other medical school classmates to a small, coastal town called Puerto Escondido located in the southern state of Oaxaca. Three weeks of clinical rotations, daily Spanish classes, and a four day reproductive & maternal-fetal health workshop with traditional midwives provided a unique classroom in which I learned skills that would never have been acquired in the lecture hall.

 

Each day in Puerto Escondido presented its own unique challenges, but simultaneously taught important lessons as well. Reflecting back on my experience, I realize that the month I spent in Mexico has impacted not only my career, but allowed me to mature as an individual in ways that I had not initially expected. For example, clinicals pushed my boundaries in both medical and Spanish knowledge, and forced me to improve other routes of more subtle communication such as body language. The learning environment required me to jump in and actively participate, despite the number of mistakes and mispronunciations I made on a daily basis. Standing on the side lines in Mexico simply was not an option. My willingness to initiate my learning were noticeable. In my first day back at my individual preceptorship in the U.S., my mentor commented that I was more confident and engaged when interacting with patients. Whereas I was hesitant to jump in and make mistakes previously, I was much more comfortable stepping outside my comfort zone after doing so day after day in Puerto. And after four weeks of speaking solely Spanish to patients, being able to communicate in English was a luxury.

 

In addition, adapting to the language barrier required me to be resourceful and cognizant of my own weaknesses. Being the trip leader of the group, I initially took it upon myself to the carry a large portion of the burden and be the key point-person with the local healthcare providers. But with my Spanish being on the lower end of the spectrum within the group, I quickly realized the error of my pride and also the benefit in deferring to teammates who were fluent or native speakers. So much of medical school is self-centered: getting that top test score, coming up with a novel research idea, or acing the boards. But the “I have to be a star” approach does not apply itself to becoming a successful physician. I learned that the defining trait of leadership is not the ability to take control of the reins, but rather the recognition of when to hand off the torch. As a future medical professional, humility and the awareness of where, and when, I can contribute will be key in the team-oriented approach of today’s medicine.

 

So much of what I learned abroad goes beyond the typical selling points of global health. Being placed in unaccustomed and foreign situations shed light on areas for improvement that I would have never been cognizant of in the U.S. I left Mexico with a newfound appreciation for the tremendous hardwork local practioners put in to taking care of patients despite limited resources. While I may not have pushed explored new fields of technology or science in a research lab, I honed my skills in the “art of medicine” through my time involved in global health this past summer. My experience in NU-AID was truly priceless and an extremely positive step in my path toward becoming a future medical provider.

blog mexico post

 

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“Hey you two, come with me.”

Ryan and I looked up at the tan, long-haired man standing over us, gesturing towards his white pickup truck ready to take us to an unknown destination. We were sitting in the one-room airport of Puerto Escondido, enjoying air conditioning that we later learned only existed in two places – the airport, and the friendly local HSBC bank. We had been expecting a woman to meet us at the airport, so both of us exchanged confused (and admittedly worried) looks.

“You’re the American medical students right? C’mon, Sol is expecting you.”

As we rode in the back of Roger’s truck down the main dirt road that traveled through Puerto Escondido, we watched as palm trees, huts, and small touristy cafes rushed by. This was our home for the next four weeks, and before I knew it, I was having dinner with my host family, figuring out how to take the bus to my clinic the next day, and making sure that I packed plenty of sunscreen and sunblock in my bag (along with my white coat and stethoscope of course).

Our daily schedule generally involved a combination of four things: morning clinic from 8-12pm (which, depending on the clinic schedule, meant that we had to wake up anywhere between 6 and 7:30am), a late lunch, Spanish class for two hours, and free time in the evening to explore the small streets of Puerto. I hung out on the beach, picked up surfing, sampled tlayudas and pozole from the various food stands that dotted the city, and even had the chance to go Salsa dancing downtown with some locals. Although we worked hard, especially during our fourth week for the midwives workshop, we definitely had time to enjoy our stay in Puerto Escondido (and then some)!

Prior to this trip, I had had very limited Spanish exposure, with the exception of the occasional awkward clinical encounter at my ECMH. Although I had taken four years of Spanish in high school, I had not kept it up during college and as a result arrived in Mexico unable to even articulate what I needed at the airport check-in counter. Thankfully, my Spanish came back relatively quickly once I immersed myself in a Spanish-only environment – through the daily classes and forcing myself to use only Spanish with my host family and in everyday encounters, I brought my Spanish ability up to a relatively proficient and workable level.

This definitely came in handy during clinic, where depending on the site I saw patients in primary care, pediatrics, or OB-GYN (with local supervision of course). My experience varied greatly depending on the doctor that I was following – in other words, some were great teachers and mentors, while others were less so. Nevertheless, I believe that I came away from the program with a thorough, first-hand perspective on healthcare delivery systems in Mexico, ranging from how doctors evaluate first-time patients to how doctors conduct followup visits, pre-natal care, surgical management, and how insurance payments work as well. In our downtime, the local doctors candidly chatted with us about our experiences going through American healthcare training and swapped stories and ideas with us.

To be honest, my goal going into this summer was to do no harm – I was well aware that my training as a M1 was unlikely to bring significant benefit to the patients that I would have the privilege of seeing. I am happy to say however, that even as a M1, Feinberg had prepared me well to evaluate patients with uncomplicated primary care concerns, and that my Spanish ability allowed me to function in clinic, at least on a basic level.

But the highlight of our experience in Mexico was by far our fourth week workshop with the traditional Mexico midwives. Using materials and props that we brought with us (along with substantial help from our partners in the Mexican public health department), we conducted a week-long workshop that covered topics ranging from pre-natal care to complicated births and nutrition. I recall acting out a particularly arduous birthing scene with a fellow student and seeing the faces of the midwives light up into smiles (probably because of how ridiculous we were being). But they were having fun, and judging from the feedback, they also learned a thing or two that they hopefully brought back to their communities. Students really took the time to sit down with and bond with the midwives over the course of the week, and I felt surprisingly nostalgic by the time it was all over. And I know I wasn’t the only one. I know that at the very least, some cultural goodwill was exchanged that week, and probably valuable medical information as well.

As Roger drove us back towards the airport along the same dusty road, four weeks later, I re-played the month’s happenings in my head – a whirlwind of clinic shadowing, figuring out how to read Spanish charts, interviewing concerned mothers in the PICU, taking brief breaks for tostadas and horchata behind the hospital, working with midwives, going surfing, meeting locals at the watering hole, etc. What a month it had been, to say the least.

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Reflections from Ayder Referral Hospital in Ethiopia

On Sunday (2/1), I headed approx 600km north to Mekelle, where I will be staying for the four weeks of my medical rotation. Mekelle is a “large” city by Ethiopia standards, with a population of .~200,000. It is located in the Tigarian region of Ethiopia (the northernmost part) and the surrounding area has a rich history of old stone churches, which I will hopefully have the opportunity to visit these next couple weeks.

So far, I have been in Mekelle for a week and am finally starting to get the hang of living here. The first week was definitely not easy though. I came to Ethiopia by myself, and while I knew there would be challenges, I did not expect quite so many. Given that Mekelle is a smaller town and in general Ethiopia is not very touristy, I can count count on my hands how many foreigners I have seen since coming here. Additionally, most people outside of the hospital do not speak English (most speak the national language Amharic and/or the local language Tigarian), so trying to communicate with the locals at stores and for transportation has been quite difficult. I’m slowly learning the Amharic words I need to get around, but my accent is apparently pretty bad.

 

After much confusion, I have finally learned that Ethiopians do not run on the same calendar or clock as the rest of the world. To start, it is actually the year 2007 in Ethiopia, not 2015. While it is also February here, February is the 6th month of the year not the second. Additionally, there are 13 months in their calendar, hence the country’s motto, “13 months of sunshine.” The days of the week here are also 7 days off, so if it’s the 19th in the rest of the world, it’s the 12th here. So if you’re still following me today is 6/16/07 in Ethiopia while its 2/23/15 everywhere else. Finally, the clock is 6 hours off from ours, so sunrise is 12am and midnight is 6pm. Thankfully, the calendar does not apply to most things touristy, but unfortunately does apply in the hospital, making a system that is a bit hard to navigate at baseline even more confusing

While there certainly have been challenges to living in a country very foreign to the U.S., I have been amazed at how welcoming people are. Instead of yelling “farenji” (foreigner) at me, which I tended to get in Addis, people will use their broken English to say hello and shake my hand followed by a shoulder bump (the local greeting). The little kids here especially get a kick out of trying their English on me.

Another great part about being here has been my medical rotation. I am rotating at Ayder Referral Hospital, which was recently built in 2007. The hospital itself is gorgeous, and is extremely modern when compared to the hospitals I was exposed to in Uganda several years ago. The residents however tell me that Ayder is atypical for an Ethiopian Hospital, and most hospitals in the country are not nearly as nice. I am rotating on the general internal medicine wards and have gotten great exposure to tropical diseases that infrequently (if at all) occur in the U.S. For the medial nerds out there, here are a few of the diseases I’ve gotten to see: visceral leishmanias (Dx of approx 25% of our patients. They all tend to have massive splenomegaly – it’s pretty crazy), malaria, miliary tuberculosis, and rheumatic heart disease. Ayder Hospital has many more resources than I was expecting and a lot of our patients are receiving first-line treatment for diseases, which is sadly not always the case in sub-Saharan Africa. The biggest challenge in the hospital has been trying to hear what people are saying. It seems to be the culture that everyone talks very softly, and combining that with a heavy English accent, I usually only pick up about half of what is said on rounds.
Overall, living in Ethiopia has definitely posed it’s challenges up to this point, but also a good learning experience

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South African Healthcare and Rolling Blackouts

During this past April, I had the privilege of working for four weeks in a public hospital in Stellenbosch, South Africa.  One of my closest friends from medical school joined me in Stellenbosch, and two other Northwestern students spent their month at a nearby tertiary hospital near Cape Town.  Stellenbosch hospital accepts patients who cannot afford private insurance – the large majority of South Africans.  It was described to me as a low-acuity hospital from which complicated cases are referred, although I found many of the cases they chose not to refer to be quite dire and complicated.  Eight doctors trained in primary care led the medical team of nurses, therapists, and “Sisters” – a term that refers to a highly qualified mid-level of either gender.  While these doctors were trained in primary care, their clinical duties were boundless.  On one day, a doctor may run the pediatrics or OBGYN ward, and on another day, that same doctor may perform an amputation.  These doctors administered anesthesia, performed surgery for ectopic pregnancies, managed the emergency department, and of course were well-versed in infectious disease drugs.

Healthcare is a right in South Africa, and the demand for care outpaces the supply of medical staff and medical supplies.  When we entered each morning through the hospital doors, we were greeted by a long line of patients to the emergency room who had often already been waiting for hours and hours.  Medical supplies that we take for granted in the US, such as gloves, were often missing.  The patients’ restrooms contained no toilet paper; instead, patients were rationed a few sheets before entering the bathroom.  Additionally, South Africa has electricity in short-supply.  This industry is completely run by the government with no healthy private competition.  So, it is solely the government’s ability to properly supply electricity to its citizens.  But with the current infrastructure implemented by the government, it is impossible to supply ample power to the whole country.  Consequently, communities experience up to three two-hour blackouts per day.  One of these blackouts occurred while a doctor and I were in the operating room in the act of inserting a scope for a gastroscopy.  Suddenly, the operating room went completely dark.  Thankfully, within a few minutes, the backup generator kicked in.  This event terrified me while I was in the operating room, especially when I was first-assist on an above the knee amputation, relying on light and electricity to control bleeding.

While there was a glaring undersupply of medical supply, the doctors’ efficiency was nothing short of amazing.  Without ideal supplies for casting, the doctor who ran the orthopedics clinic often created make-shift plaster casts that he could whip up in minutes.  The doctors ran a tight ship, especially when it came to their ambulatory emergency department.  They stressed the importance of being able to immediately classify a patient into a certain category of severity.  They had a color system and deemed any non-worrisome patient “green”.  This skill was crucial as Stellenbosch hospital would need to refer patients to tertiary centers.  These tertiary centers trusted the doctors’ judgment at Stellenbosch hospital as to patients’ disease severity, and those doctors wanted nothing more than to retain the trust and relationship.

The racial and economic disparities still echo loudly from the Apartheid.  Poor communities called “townships” house many poor citizens in close proximity to larger, wealthier communities.  In juxtaposition, these communities highlight racial disparities.  Several of the doctors at Stellenbosch hospital ran weekly clinics at one or more of these townships and were kind enough to let me and my classmate spend our day with them from time to time.  There we encountered a large amount of infectious disease that I had only read about in textbooks but never thought I would encounter, including Mumps, intestinal parasites, active tuberculosis, and an inordinate amount of HIV/AIDS.  The HIV rate in the adult population has been estimated at just fewer than 20% in South Africa.  So importantly, the dissemination of antiretroviral therapy and education plays a crucial role in South African healthcare.  Practicing in these clinics was a profound experience where I felt that I got to see the huge impact that primary care can make in areas of need – except for when the power would shut off and the clinics had to completely shut down, as they had no backup generator.

My month in South Africa was a dream I thought that I would never get to experience.  I learned about a different culture and healthcare system, and I now have a new appreciation of many aspects of American healthcare.  The sights and sounds of South Africa were beautiful and inspiring.  I am thankful because without the generosity of the global health initiative, I would not have had the privilege of experiencing what I can only describe as my favorite and most rewarding period of medical school.

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Experience in Uganda

By: Saahir Khan

I want to pursue a career as a physician-­‐scientist in Infectious Diseases, so I
went to Uganda to see a range of diseases that I wouldn’t see in the US. I also wanted to gain some exposure to how clinical research is performed in the developing world, as I may work on projects in the future that take place in this setting. During my rotation at Mulago Hospital, I saw both the opportunities and the challenges inherent in pursuing these goals.  Mulago is a public hospital that caters to patients who cannot afford to go to the private hospitals. It is a tertiary referral center for the city of Kampala and surrounding communities. I knew the resources available to provide care to the patients would be limited, but I didn’t realize to what extent diagnosis and treatment was dependent on how much money the patient’s family could afford to pay. Everything except the most basic laboratory tests had a cost associated with it, even routine procedures such as chest X-­‐ray, abdominal ultrasound, blood cultures, and sputum analysis. More expensive tests such as a head CT were unaffordable for most patients. As far as treatment, some drugs such as antiretrovirals and TB medications were provided free of charge through international programs, but oftentimes basic interventions such as saline and antibiotics
were given at lower doses in order to conserve resources. Life-­‐saving interventions such as platelets and plasma were often unavailable, and intubation wasn’t an option given the high cost of ICU level care. Nursing care seemed to be non-­‐existent.
As a result of these limitations, many patients died preventable deaths. Five
patients next to each other who were receiving oxygen through nasal canula all died because the oxygen canister ran out in the middle of the night, and there was no monitoring or nursing or alert any physician. The nursing care that was available was often sub-­‐standard and sometimes hurt more than helped. A nurse gave quinine to a 9-­‐month old instead of gentamicin because the vials looked similar, resulting in a cardiac arrest with resuscitation complicated by hypoxic ischemic encephalopathy with permanent brain damage. I often saw the nurses giving dextrose-­‐containing water instead of normal saline as if they were equivalent interventions, even though low sodium was often a reason for us giving saline. The lack of availability of head CT for most patients resulted
in lumbar puncture becoming the diagnostic procedure of choice for any headache or altered mentation suspected to be infectious, as long as a cursory neurological examination didn’t show any gross deficits. Many times, I expressed hesitation when I felt as if there may be an intracranial pathology that would make a lumbar puncture dangerous, but a lumbar puncture was usually performed anyways as that was the only available diagnostic procedure. In one case, we came back the next day to find that the patient had signs of brain herniation, and she died a day later. Initially, I reacted to all of this with shock and disbelief. The Ugandan housestaff seemed unconcerned with all of these preventable deaths, to the point that residents didn’t bother to try to find out the
circumstances surrounding them. I had begun the rotation with the motivation of helping people, but by the mid-­‐point of the rotation, it was very hard to stay motivated, as it seemed that our efforts were futile, and the patients would die from the systemic problems and lack of resources.  However, I eventually realized that although the outcomes were generally poor, it was possible to make a difference for individual patients. The last day, I had three patients who all needed emergency interventions. One needed intubation,
which I knew would never happen, so I just tried to keep her comfortable as she died of acute hypoxemic respiratory failure. Another needed neurosurgery, and when we couldn’t contact anyone who could help us, I wheeled the patient down to the neurosurgery ward and talked to anyone who came by until I found someone who agreed to take the patient. A third patient was in acute leukemic crisis with platelets of 4000 and needed a peripheral smear read and a platelet transfusion, and the lab at Mulago said they couldn’t do either until the next day, so I took the patient’s blood sample to the cancer institute 20 minutes away, got the attending there to look at it, and he accepted the patient and helped her get the emergency treatment she needed. In the US, we’re trained to focus on the preventable deaths, but in Uganda, you have to focus on the patients who were saved in order to
maintain a positive outlook.  In addition, although I didn’t directly participate in clinical research during my rotation, I did have the opportunity to observe research that was taking place on the ward. There were teams of researchers from the US collecting samples for a clinical study on treatment of cryptococcal meningitis, and the patients enrolled received superior care for the particular condition under study as a result of a protocol mandating effective treatment and availability of resources. However, any other conditions they had were still subject to the limitations of the health care system in Uganda, and having the study team seeing the patient often made the Ugandan housestaff feel as if they didn’t need to see the patient. Nevertheless, I think the patients in the study benefitted from their participation. One significant event that occurred during my rotation that
illustrates the challenges of clinical research in the developing world was a government raid on a US-­‐funded clinical research center focused on developing an HIV vaccine, which occurred under the pretense of a recently passed anti-­‐homosexual law. The research center pulled out of Uganda after that raid, as did many other US institutions. While it’s sad that the actions of the government ultimately resulted in less aid for suffering patients, I agree with the need to take a stand against bigotry and provide a safe working environment.
During the rotation, I would often wonder how to make a difference in a
limited resource health care setting like Mulago hospital. From what I observed, I saw three ways that outsiders can have a positive impact on the health care system. One is simply providing resources. A group of medical students from Sweden organized friends and family back home to raise money to provide 500 mosquito nets for the hospital. Another is educating the Ugandan physicians. A Canadian philanthropist initiated a training program in advanced trauma procedures staffed by a rotating group of Canadian orthopedic surgeons that helped the Ugandan surgeons improve their skills and patient outcomes. Finally, clinical research can often serve the dual purpose of helping patients directly and creating knowledge that can be applied to help future patients. Since a clinical rotation doesn’t directly fall into any of these categories, I would encourage future students to recognize that the purpose of this rotation isn’t for the patients you’ll be treating but for your own development as a physician.

 

 

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Finishing Out Fourth Year Abroad

Victoria Konold, M4

I had my last day of medical school as a Feinberg student last week, not in Chicago, but in the rural town of Malinalco, Mexico. One of the main reasons I chose Feinberg for medical school was the strong global health program, and so I decided to finish out my fourth year of medical school with 2 months of global health rotations in Ecuador and Mexico, organized by our Office of Global Health and funded by the Global Health Initiative. And let me tell you, it made for an interesting send-off.

My interest in working with global populations started early- I grew up in a family where one side was Caucasian, college educated, and had multiple doctors in the family, whereas the other side was Spanish-speaking, needed food stamps despite the adults working multiple jobs, and never went to see the doctor. Seeing the difference between these two sides of my family encouraged me to concentrate on treating underserved populations, and especially Spanish speaking ones. And although I majored in Spanish and lived abroad as an undergrad, I never felt my grasp of Spanish, and especially my medical vocabulary, was enough to actually treat one of my patients in their native language. Similarly, my time volunteering at free clinics taught me a little about treating underserved populations, but I felt what I was learning was superficial. My goal was to be well-equipped for treating underserved Spanish-speaking populations in the US, and I knew I needed more exposure to get there.

And so I stepped off the plane in Quito, Ecuador a couple months ago, ready for an immersion in medical Spanish and an experience in rural indigenous health. After a week of intensive Spanish classes that was essentially a review of all the grammar I ever learned, we were dropped at the edge of the Amazon rainforest in rural Puyo, Ecuador to work with a physician in a 2-room clinic who was treating the indigenous Shuar population. This month was certainly an education in physical barriers to health: many of the people we treated did not have basics such as clean running water, and some even hiked 5 hours through the jungle to come see us. To combat this, several mornings were spent traveling to one-room school houses in the middle of nowhere, where we brought the kids their biannual antiparasitic, gave them all screening physicals, and a health talk where we addressed everything from where to get your potable water (NOT from the river), to the symptoms of Dengue fever (which it turned out, the kids knew better than those of us from the states).

During this rotation I also experienced some social barriers to health: as a native group, the Shuar has a strained relationship with the government, and this was particularly obvious during a meeting I went to between the Shuar representatives and the Ministry of Health regarding a cow that had died exhibiting signs of rabies, but had been eaten by several people in town before rabies tests could be done. The issue was how to treat whom for rabies, and how to handle future cases and prevention, but both sides were frustrated; the government because the village had not informed anyone of a possible outbreak and had let the animal be consumed, and the village because the government refused to vaccinate them all because of cost and availability of the vaccine. All together my time in Ecuador taught me, in a very visceral way, how healthcare is determined by so much more than a diagnosis and the right medications, and gave me some ideas as to how we can address these barriers to health.

Just as quickly as I found myself in the Amazon, I landed in urban Mexico City for a rotation that focused more on vocabulary building and history-taking skills at a large hospital. However the most interesting part of my time in Mexico turned out to be the last week, which I spent in rural Malinalco, a small town a couple hours and a world away from cosmopolitan Mexico City. Here I gave clinic completely on my own in Spanish, and found that I could do it (with the supervision of the Mexican doctors on site, of course). This was a big confidence builder for me- one of my main goals at the start of medical school was to be able to conduct a whole clinical encounter in Spanish without help, so that I could truly treat Spanish-speaking populations as a physician. And here I am about to start residency, and I find I met my goal, thanks to the 2 months of medical Spanish immersion.

Despite this month’s focus on using Spanish clinically, I still learned a lot about socioeconomic determinants of health. My most interesting patient of the whole rotation was a patient who could not read, and so was injecting himself with an oral solution, having misunderstood how he was supposed to take his medication for a chronic condition. Predictably, he was not feeling well, and I was shocked: at home I would have never considered that the underlying problem in a patient’s “non-compliance” was not being able to read the instructions on the prescription, and so this was a first for me. So I went over the patient’s medications again, and wrote a new prescription with color-coded drawings indicating the time of day and which pills to take- after this it was clear that we were on the same page, and he showed up as planned 2 days later so I could see how he was doing. This was exactly the sort of case I came here to learn from, and it will definitely make me think twice the next time I am trying to figure out why a patient is not doing as well as I expect them to be doing.

The language skills I learned on this rotation and my experiences with patients who face a variety of barriers to health will be something I take with me into my residency, where I hope to continue treating a global population closer to home. I am now more confident treating patients in Spanish and hope my use of the language and understanding of where some of those patients are coming from will improve the therapeutic relationship I can have with these patients, and help to make healthcare more accessible to them.

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