Defying Sterotypes

After a day at the beach with Dan and Shana's small group (who also happen to be my closest friends here), I had my last interview with a doctor. It was a really great interview, and just  great conversation in general.  My talk with Tati* was fascinating because she defies a lot of stereotypes--about Dominicans, about doctors, about the middle class in general.

She's worked in the same public hospital for her entire career, earning on average $15,000 per year. She'll show up in the middle of the night if a patient needs her--from the time they come in to the time they leave she takes her responsibility to her patients very seriously. She believes that listening to her patients and explaining their illness to them--even something serious like HIV--are both important parts of the healing process--of allowing her patients to lead normal, healthy lives. In this way, I sense that she's not the "typical" Dominican doctor who deals with cases on a crisis basis rather than a long-term basis. 

She never married, and lives with her mom and sister in a nice, middle-class neighborhood.  "With more people, you're more alone" she told me, so she doesn't regret not having a bigger family around her--something that's pretty counter-cultural in a country where extended families of 12+ people all living together is a common occurrence. She's the only Dominican I've ever met who has heard of Duke and follows Duke basketball with a passion that would warm any Cameron Crazy's heart. This afternoon we spent a good five minutes talking about Grant Hill this afternoon and all the other Duke players who have made it in the NBA. She spends every October in Miami and Texas visiting family which means that even though she doesn't completely understand football, she's a Dolphins fan.   

As a middle-class outsider, I often view the public system here harshly, hearing about all the horrible experiences that people have had--doctors pulling off toenails without anesthesia, turning away people who will take too many resources to take care of, etc.. Tati however, scoffed at the idea that she might want to work in any other sector of health. For her, private care is too money driven; she believes in taking care of people and treating them as a fellow human being in need of her help whether or not they have money.  In her view, if people had to pay for public health care, the whole idea of health care would be completely shot.

As a researcher, Tati is a somewhat frustrating anomaly--she loves working in the public sector, she doesn't think she'd get paid more elsewhere. Sure, they sometimes have to get creative, but at her hospital they use the resources they have and take care of their patients. But as a person, Tati gives me hope. She is a wonderful doctor with a huge heart who works in the public sector not because she has to, but because she loves it. Sometimes she yells at her patients because they're not following their treatment, or because they're making their blood pressure problem worse by drinking 6 cups of coffee a day, but she educates her patients and gives them steps to follow back to a normal life. Her answers to my questions don't fit easily into what I had expected or discovered thus far, but that doesn't make them any less valid. She's just going to make my thesis writing a little more interesting.    

*Tati gave permission for me to use her name in talking about and publishing my research.

Tying up loose ends

With 23 community interviews and meetings with 4 doctors complete, I'm coming to the end of my research here. The last few days I've been meeting with doctors--one for a nice hour and half long chat at her house, others for a quick 15 minute interview at their clinic--as well as getting ahead on some background research for my independent study. While I might go down to the barrio to do a few more interviews, in my last week here, I have a few very specific goals:

• Spend some time talking to Tati, a pediatrician who has helped out with STMMs before--I think she will have a unique perspective as she works in the public system here but has also spent quite a bit of time in the U.S.. (Plus she's a big Duke basketball fan, which makes her my favorite doc!) 
• Interview Maria and Giselle, the two people who have been helping me with my interviews. I not only want to have them answer the questions, but to get their impressions about the variety of people we've interviewed, questions or answers that surprised them, etc.

I think the only person I'll wind up doing a follow-up interview with is Fatima--I want to get a bit more of her perspective on private vs. public care and pay as well as her reasons for working in the public system. I think that because my questions were rather specific, even though they were opinion based, everyone had relatively straightforward answers.  If anyone said anything surprising or if they seemed confused, I asked follow-up questions at the time or tweaked the questions for the next batch of interviews. 

Biopsies and Philosophizing

This morning I discovered that Dan was taking a little girl from one of the VivaKids centers to the capital to see a dermatologist for a rash/tumor that she has on both sides of her face and on her leg. Being the medical nerd that I am, I asked to come along to the consult and got to see the private side of Dominican medicine in practice. I admit that my perception of Dominican public medicine has been colored negatively based on horror stories that I've heard, but in a visit to a private physician, I wasn't entirely sure what to expect--Dan and Shana love their private doctors here, but they had never been to a dermatologist, so this was just one on the list recommended by the U.S. embassy.
My immediate reaction to the doctor was not a positive one. First of all, she had drawn on eyebrows--something that freaks me out. Secondly, the receptionist had written the wrong name on a form and rather harshly sent be back out to get the little girl's name written on the form instead. In the five minutes that it took to rectify the situation, the doctor had done a cursory examination of the little girl's face and bluntly pronounced it to be a genetic non-curable disease that would continue to take over the girl's face and body. If it had been caught earlier, she explained, they could have surgically removed the lesions and they would have stopped spreading. The mother, understandably in shock, told of her experience with another doctor in San Pedro who had told her that it was simply a rash and had given her creams to put on it. While in all likelihood, this dermatologist is correct and the other doctor was wrong, she didn't sympathize with the fact that this poor mom had done the right thing--gone to a doctor, paid for the creams that were supposed to help her daughter--and was now being told that it was all wrong and that it was too late.

When Dan and I began to question her about which disease specifically she thought it was, she offered to do a biopsy to prove that she was right (for RD$2000 more, about $50). Dan agreed to the biopsy and we went back to a little surgery room where the girl's mom and I held her down while the doctor administered local anesthesia. Here the doctor became a little more compassionate and assured the little girl that the worst was over and that the next part wouldn't hurt. After a quick biopsy (during which the mother looked away nervously and I watched closely), she cauterized the wound and put on a very sloppy bandage that took over the entire side of the girls face. She then very casually handed me the container with the biopsy in it and told me that we would have to take it to a lab several miles away. It's not every day that you get handed a skin biopsy. 

We went back into the consultorio and talked with the doctor a little more, got directions to the lab and the names of some possible diseases that it could be. Being the pre-med nerd that I am, I've spent the last hour and half looking up the possible diagnoses she gave us and find myself wondering if she couldn't have done a few more preliminary checks to properly diagnose this--for instance, one disease is associate with scoliosis, something relatively easy to test for--the kid just has to bend over. The other possible diagnosis seems ludicrous to me as it involves vericosities and birth marks, neither of which this girl has. While I don't doubt that the doctor is a qualified professional, and I would guess that the test results in a week will prove her right as to the disease being genetic, my overall impression of the visit was not positive. Maybe that's just her personality, and I need to be mindful of my own bias against medical practice here in the DR, but I came away with the impression that the doctor was there to do her job and make her money, but that she didn't really care about the patient or the effect that the facial deformity the disease causes could have on the rest of this two-year-old's life.

I came away from today wondering a lot of things about the medical training system here in the DR. I have appointments to talk to doctors tomorrow evening, so I'm trying to wait to reserve my judgement until after interviewing them, but my overall impression is that there's something fundamentally flawed (or to be more academically correct, different) about the mindset of healthcare professionals here. Maybe I'm naive in thinking that doctors should truly care about their patients or at least attempt to empathize with them and value their experiences, but that's how I think medical professionals should operate. Our car ride back from the capital was filled with discussions about exactly this--about the short training period for doctors, the young age at which they can start practicing, the overall education system that relies heavily on rote memorization and doesn't develop critical thinking skills or deductive reasoning, the cycle of poor education and poverty that develops when the teachers aren't trained properly--lots of uplifting things. At the same time though, we talked about the need to meet a community on its terms in order to be effective in creating change--the need to work with existing structures, rather than tearing them down.  

Sometimes I see things changing for the better, people who feel listened to by their local doctors, good teachers who are willing to go against the usual style of teaching because they know it's better for their kids. And then sometimes, like today, I'm left with an overwhelming desire to just come fix everything and make it work in the way that seems best to me--and when I realize that's not possible, I want to draw a circle on the wall and write "bang head here."

But enough philosophizing for today--here is something that I have learned for sure: No matter what country I'm in, no matter what I order, my digestive system will always feel crappy after eating McDonald's.

What surprise reveals

Something that has surprised me in recent interviews is people that people have responded to the question of "What does it mean for a doctor to respect you?" and "What does it mean for a doctor to listen to you?" by saying that one of the most important things is for a doctor to explain things to them—not just sending them off for this analysis or that test, but explaining the why behind their treatment. It makes sense—asking for an explanation is simply asking to be treated like an intelligent human being who wants to understand what is going on with her body.  I have to confess, I am embarrassed by my surprise, as it exposes the fact that I too assumed that the people I was interviewing weren’t educated enough to desire an explanation for their course of treatment or to want to know how the disease affecting them works. Or in the very least, I was assuming that they while they might desire an explanation, they would not be able to articulate the giving of an explanation as a way of showing respect. I wonder if local doctors (who actually have a degree in medicine, unlike me) also tend to assume that their patients either don’t really want to know the details of their disease or that they’re insufficiently educated to understand.  As I prepare to begin my interviews with doctors, I’m adding three questions that will hopefully shed some light on the patient-doctor dynamics when it comes to sharing information.

1. Do you think that your patients can understand the illnesses that they have?
2. Do you think it’s important to explain to the patient what illness they have?
3. Do you think it’s important to explain to your patients the justification for their treatment—why they need to go have a certain test done, or why they’re taking a certain medication? 

 

Motorcycles, my relationship status and med school applications

In the last couple of days, I have:

• Been reunited with old friends over brownies, during church services and while talking to their parrot at their store
• Learned about a part of the U.S. that I wasn't sure actually existed--the replica of the Dominican Republic in the Bronx. (My friend who's been living there has actually practiced less English living in the U.S. than she did here in the D.R.)
• Discussed and debated the merits of immigrating to the U.S. (specifically to the Bronx)
• Ridden sideways on a motorcycle because I was wearing a skirt
• Called a friend with a motorcycle to come get me and take me home without thinking twice (I used to be terrified of motorcycles)
• Received lots of hugs from the little deaf boy at church who seemed very excited that I was back (and very intrigued by my peppermint scented hand sanitizer)
• Been asked by three different guys who were "just trying to get to know me" whether or not I had a boyfriend. Note: none of them agreed to participate in an interview after finding out that I do indeed have a boyfriend.
• Attended a lecture on sexual health given in Spanish with some very disturbing accompanying pictures
• Submitted my primary applications to medical schools! 

 Some things for prayer:

• Sleep! It has been extremely hot here lately which has meant that I've been having trouble falling asleep at a reasonable hour. Yesterday, that really started to take a toll on me and I wasn't feeling too well.  Today has been better, but the heat doesn't seem to be abating much. 
• Perseverance! As I get close to my initial goal of 25 interviews, it's hard to be motivated to keep going out every afternoon. I need to remember that more data is better and will in the end be more helpful as I write my thesis. 
• Trust! I submitted my primary application to medical schools about an hour ago, which means it is now time to wait and trust that God knows where I'll wind up, even though I don't

Goals for my last 3 weeks

I'm realizing that my time here in the DR is quickly coming to a close--I have less than 3 weeks left to do research! Here are some things I need to do in the coming weeks:

Next week:

• Visit the primary care clinic in the barrio
• Make an appointment to talk to doctors (especially the cardiologist if possible) at the primary care clinic 
• Call the doctors who have participated in STMMs and set up appointments to talk to them
• Go over all interviews and see if there are any follow-up questions that I want to go ask

Future weeks:

• Meet with doctors 
• Do follow-up interviews if necessary
• Plan some sort of thank-you for the people who have been helping me with my research

Interviews Day 5 + TB and STIs

I'm now up to 19 interviews total, which is far more than I thought I'd have at this point (my goal was 25 total!).  Since more results are more instructive, I will continue doing interviews, though it is nice to know that I won't have any trouble reaching my goal. 

Yesterday I interviewed four more people, one of whom was young man--good for a little bit of diversity in my interviewee population. It's been interesting to see the responses I've gotten since adding the question "What is the purpose of short-term medical missions? What function do they serve in the community?" Several people have pointed to the fact that they are useful for poor people who can't afford even the minor fees associated with public health--a response I expected. However, several other people have pointed out the fact that operativos (STMMs) are community events where they go to see other people in their community.  Several people, including those who regularly receive medical care from private clinics, praised the operativos for treating rich and poor people alike--perhaps implying that rich and poor are generally treated differently in the realm of healthcare. 

I was also invited by one of my interviewees who is a promotora de salud (health promoter) in the community to a charla or talk that they were giving on TB and STIs, including HIV/AIDS.  Since attending this charla was purely tangential to my research, I really have no way of judging its effectiveness without knowing the goals and measures of effectiveness used by the program itself. I do, however have some observations and thoughts:
While the two women presenting did have accurate information, it did not appear to have been previously rehearsed and they were unable to answer several of the attendees' questions.  In my opinion, they also over-emphasized several insignificant points including the fact that HPV can spread via non-sexual contact (this has actually never been documented, but was included in the materials distributed by the Ministry of Health).  I am also curious as to the scope of people that these charlas reach--roughly half of the people in attendance were themselves promotoras de salud and the other half were people associated with the church in which the charla was given.  The people in attendance seemed to appreciate the opportunity to ask questions and the use of visual aids appeared to keep people engaged in the lecture. Though tangential, the charla was interesting and potentially relevant to my research in that STMMs also tend to provide some level of education in the form of charlas with the people that are waiting to be seen by healthcare providers.

Interviews Days 3 and 4

After a bit of time off helping the Gowers with a visiting mission team, I've jumped back into interviews. On both Wednesday and Thursday I was able to complete four interviews with more random people. Previously, we had been going to the houses of people that Maria knew, or who were members of the church--it was easier to get started with people we knew! These past two days, we've just been wandering through the barrio, finding people who are sitting outside and are willing to talk. From there, people in neighboring houses get interested, or the people being interviewed suggest a friend or family member who would be willing to participate. In this way, it's becoming more of true "snowball sampling."

A few interesting observations:

• After 15 interviews, not one person has declined to talk to me, or even seemed reluctant to spend 30 minutes of their time talking to a stranger. Lifestyles here are so much more unscheduled and laid back, and since they're just sitting outside in the shade anyway, they're glad to have someone to talk to. 
• Thus far, I have only interviewed one man--an older man who interviewed together with his wife. I'm trying to decide if that's problematic or simply reflective of the social make-up here. Households are largely based around the women of the family and men are generally absent, either due to work demands or other factors.  It also tends to be almost exclusively women who attend the clinics run by short-term medical teams, so it makes sense to be interviewing them.  
• On Thursday, 3 of the people I interviewed had the resources to go to private clinics. Interestingly, they were much more critical of the lack of organization in the public system and of the quality of care in the public system overall. I'm wondering if they feel free to criticize the system because they have other options, or if their higher level of education means that they can articulate the problems with the public system more clearly. (The people who use the public system don't like it, but often don't point out specific problems.) 

 I'm glad that I'm getting some more socioeconomic diversity amongst my participants, but since I"m not specifically asking about their socioeconomic level, I'm mostly having to infer that from their education, the type of house they live in, etc.

I also got some questions answered about the insurance system here--public vs. private which is helping me to focus my questions more sharply.