It’s 8:45 PM 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 into the Sierra Madre Mountains there are few flat places. As we’re nearing the top of the hill he gives me a summary of the patient’s history and how he’s approached the case so far. At the door he’s immediately and warmly greeted by four of the patient’s family members. They are each eager to provide Dr. Martinez with a different perspective on the patient’s illness. He hears from everyone as he does an extensive physical exam. Around twenty minutes later a decision is made and the medicine is administered. We quickly drink a sweet coffee the patient’s wife had placed at the patient’s bedside. Dr. Martinez has been thinking about dinner for a couple hours now, but he also needs to secure a projector from the local 7th Day Adventist pastor. He is planning to invite the community for a 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 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 healthcare, he has only been Dr. Martinez for about 6 months. As a safety-net in the Mexican healthcare 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. Referrals to specialists are possible but are also difficult and expensive. This means that patients are managed locally whenever he can. There is a single room in the clinic with three shelves of medicines to choose from. At least half of these are not the standard government supply but are supplemented by the Partners In Health (PIH) affiliate Compañeros En Salud (CES). Despite the limitation in options the treatments are frequently adequate and simplify many visits. This can be helpful with so many patients to see and most decisions left only to Dr. Martinez. It is a stark contrast to first year physicians in the U.S. who have heavy supervision, with exhaustive options on treatment, laboratory testing, and consult teams. While at times it would be nice to have more help, there is an empowerment to the sole responsibility of a patient’s care. It is clear that 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 to the many patients we pass going to and from the clinic. Frequently, he is securing medical and dinner appointments simultaneously. Like many pasantes Dr. Martinez lives with a local family, but gets his meals at various homes in the community. 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% of the population earns under $5 a day. Most patients walk to appointments or have limited access to transportation. Some are close but others live miles away. He has to close the clinic at some point in the evening but it is difficult to tell some patients to come back another time.
In high resource settings physicians are now being trained to be more cost conscious. This means more thought in regards to the tests and procedures they order. They are trained to ask themselves why they are ordering a test or procedure and how the result would change management. For pasantes this thinking extends far beyond making sure tests are clinically relevant. At times the questions and answers are sobering. A young mother’s symptoms suggest a potential aneurysm in the brain, a condition that can be rapidly fatal. 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 does have some resources others pasantes do not. As a member of Compañeros En Salud he has more medication options, access to electronic clinical resources like Uptodate, and can provide logistical resources for those who need to travel for more complicated treatments such as continued cancer care. Additionally, he has educational sessions and occasionally in person help from fellows and residents visiting from institutions in the U.S. This extra opinion can help with revision of tough cases and offer a break from solo decision making. He 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. Perhaps his most valuable resource are the acompañantes. Largely members of the local community these individuals follow-up with patients in their homes, review medications, and often identify barriers to the patient’s care. They also help patients navigate the referral process.
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 that is part of the care 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.