Trust

Dick (volunteer family practitioner) and I were talking this evening about what it is like to take care of patients here. He said he noticed that I talk a lot about the issue of not being trusted by my patients and he hasn’t felt that way in other sites or heard other docs who work internationally complain of such an experience. In fact, he said when he worked in India for 2 years, because care by a gringo was so esteemed, the charge for his visits was set higher than the charge for the local physician who had been practicing some 40 years.

It’s hard for me to decide what the most frustrating thing is about practicing medicine here but certainly vying for the distinction is that patients/families don’t trust that what I am saying is true. Yes, that happens in the States but here it’s part of every visit, to some extent. And it beats me down.

Here’s a recent example. Three days ago Francisco, Angel’s 7-month-old nephew, developed a cough. The next morning his mom asked me to examine him. She’d already tried a "small amount" of Bactrim that morning to see if it’d help but she said it didn’t. As I checked him out, his 3-year-old brother was coughing in the background (as are most of us here in the house). Francisco had a normal exam; just a clear, runny nose. He had developed a fever earlier in the day and Ana had treated him with Tylenol. I reassured her that he just had a cold, like his brother, and I’d keep checking on him. I did give her some cough medicine with the caveat that most parents feel like it doesn’t make a big difference but she could give it a try. [For the pediatricians gasping here (mostly residents), I have to break to explain a line of reasoning that has kept me sane in this setting. Parents here absolutely will not accept “reassurance” alone with no prescribed medicine. If one refuses to give relatively benign things like cough medicine, as I tried for a few weeks when I first arrived, the parents will definitely seek out a nurse or a pharmacist and will 80% of the time get an antibiotic like Bactrim and 100% of the time get a multi-component cough medicine. I have decided that keeping that from happening is important enough to justify my giving a cough medicine].

I asked her tonight how he was doing. “Oh, he’s better than before. I had to take him to the doctor because he still didn’t sleep well last night” (cures are expected to be immediate even when it’s explained they won’t be and seeing several practitioners - of all types - for one illness if it doesn’t resolve right away is not uncommon). “It turns out that he has an allergy in his throat so they had to inject him.” “I think they injected him with the same medicine you gave, since it started with dex-something, and now he’s doing better”. Given that I gave him dextromethorphan and it’s not an IM med, I’m thinking they gave him a dexamethasone injection. Steroid injections are common. He’s just 7-months-old and has a cold!

So, 1) This poor baby got harmful and unnecessary treatment and even more frustrating is that this type of treatment is ABSOLUTELY the rule rather than the exception 2) His mother is convinced that I missed the allergy in his throat because the assumption is always that more treatment, especially injections, are better 3) This baby will improve quite soon as his cold runs its course but the improvement will be attributed to the shot and the same cycle of bad and harmful care will continue.

I try to not let these things get to me. But they do get to me because some manifestation of this happens nearly every day and often many times a day. It is not uncommon that a few days after I make a diagnosis and start a treatment, a patient’s parent tells me they found out what the illness actually was and got a different treatment and the child is now better. As if they just want me to know that I missed the diagnosis (usually something like “empacho” or “mollera caida” or non-entities like strep throats in 3-month-olds). Though I know I am practicing the best medicine I know how to practice and whatever goes on around me was happening before I came and will keep happening after I leave, I just have to ask myself, why am I fighting this one-man battle? Until there are high standards for the training of practioners here plus checks and balances on the medicine practiced, bad care will continue to dominate and patients will have trouble distinguishing good from bad.

But the abundance of practioners of questionable quality (at best) doesn't explain why patients and parents don't seem to trust me. Is it that I'm not from their culture?, Is it that I'm young?, That I'm female?, That I don't speak Kaqchikel?, Is it an issue with conventional medicine in a place where traditional healers and traditional Mayan health beliefs dominate? I think it's a mixture of my being white and my representing conventional medicine where Mayan health beliefs dominate (haven't perceived any issues with my gender or my age).

White people are associated with Ladinos. Ladinos have a long history of severely oppressing the Maya. Until the last 20 years or so, Mayan people almost never entered professional fields such as medicine. Even now, it's rare for a physician to be Mayan. Ladino physicians rarely choose to practice in the poverty-stricken regions where Mayan people live and, even if they do, charge too much for the vast majority of Mayans to be able to consult with them. So, most Mayans have limited exposure to conventional medicine and much more -- lifelong -- exposure to traditional healers. Those who have seen physicians have undoubtedly been exposed to inadequate treatment with substandard work-ups, in part because of resource scarcity but in part because of physician prejudice against patient. On the other hand, I'm sure Ladinos do command some respect that Mayan physicians don't simply because even the oppressed may internalize the message that the oppressor is superior.

The biggest issue, I think, is the one of not accepting conventional medicine. Part of the reason for this gets back to what I just mentioned: it's new and unfamiliar. Part is because practitioners are generally not of good quality (I'm being frank). "Pharmacists" (very limited training - months) and "nurses" (also, very limited training) act as conventional healers but without the education to do so well. They err on the side of dramatic overtreatment with harmful medicines like gentamicin and, while they are pretty consistent in their diagnoses (sore throat and bronchitis are very common), they are quite inconsistent in their selection of medicines (Bactrim, cefadroxil, steroids). So, the experience with conventional medicine must often be disappointing. Also conventional medicine struggles to gain favor in the face of traditional beliefs that do seem to work because nearly all illnesses improve over time (especially in kids) and because unseen phenomena like viruses and antibiotic resistance and subclinical medication toxicities are hard for people with no formal education the grasp.

So, why would I try to care for patients in this setting? Mostly because it's unavoidable since I'm here and people do seek me out (even if I were to withdraw from the clinic and just take a teaching role with the health promoters -- have considered this a lot) but also, I guess, because I hope that there is some good that comes to the people from practicing the best medicine I can in this setting and demonstrating to them that they do deserve it.