This past Saturday we started our 3 days of clinic in the school in Paraiso. As usual, we had our students working in many areas: registration, vitals, shadowing in the consultorio (exam room) with the providers, and working in the pharmacy. In order to make sure we could see as many patients as possible, we also has 2 Dominican doctors working with us. One of the doctors spent much of the day engaged in political and publicity-related actions, while the other (Dr. N) actively saw patients.
Soon after we started seeing patients, we saw problems develop quickly with Dr. N. The student working with him came to me and asked if she could move to another role because she was very uncomfortable with how he approached patient care. He dismissed patients’ concerns, declined to address some (or many) of their symptoms, and was not responsive to our student’s questions. At one point, when a patient asked for a specific medicine, the doctor pushed the pen and medication slip towards the patient, telling them that if they were the doctor they should just write their own prescription. We switched another student to work with Dr. N, and received the same reports: Dr. N approached patient care in a paternalistic manner, did not listen to patients, did not ask many questions to explore symptoms, did not examine anyone, and tried to get out students to agree with him when he told patients that doctors know best and patients should follow directions.
I don’t think it is an exaggeration to say our students were astounded and offended by Dr. N’s approach to care. After returning to the hotel that afternoon, we held an important team meeting. We needed to decide how to address this situation and provide the kind of care we felt was appropriate and still see as many of patients as we could. Students’ concerns included potential harm to patients as a result of Dr. N’s approach, the possibility that the community might lose faith in us, and the fact that the students’ hard work preparing for this trip might be wasted if patients did not receive necessary care and appropriate medications.
We decided to change the way we set up the consultorios. We moved students around, took one from registration, and set up tables in the consulorio where Radha (our PharmD) and I were working together and have students take histories, perform physicals, and think about plans of care before presenting the patient to us. We could then confirm any part of the history or exam that we needed to and help finalize the recommended plan of care. We could teach patients about their medical conditions and their care, and review and educate patterns about their medications. We could provide patient-centered care in the way that we have been trained and in the way we feel is proper. We let Dr. N know that, given how busy he was with other obligations, we would be OK without him.
This shift worked extremely well. With the students working in pairs to see patients we saw over 100 patients the day after making the change. Students were more satisfied and patients seemed happier with their care. We even managed to get a few house calls done…something we couldn’t do with Dr. N because Radha and I needed to be onsite to address issues that arose from his work. We used the same system yesterday as we finished up in Paraiso.
Dr. N is not a bad person. He is working in a public-sector position, and seems respected by his peers. But his approach to medicine is paternalistic and, to us, disrespectful of patients and how patients experience their illnesses. He had no interest in empowering or teaching patients. He was the center of the visit, not the patient. I suspect, based on my limited observations, is that this approach is common among many physicians here in the DR: the approach to care is fundamentally different from what we try to do in the US, and students are trained very differently here. Dr. N seemed taken aback when our medical students asked questions and tried to understand what he was doing…and he never answered any of their questions.
I am extremely proud that our students recognized this issue so quickly, and I am happy that they understood it to be a major issue. This tells me that we are training students who are looking at medical care from a patient-centered perspective, who partner with patients to provide care (instead of simply telling patients what to do), and who will work to humanize medica, care for patients they work with in the future. I am also proud that we came together as a team to discuss these concerns and that we settled on a solution as a team…and that the team pulled together to make things right.
Working to provide care overseas in marginalized communities means that you will need to overcome challenges of various kinds. In this case it was a community partner that was not living up to our expectations. When challenges arise, it is important to figure out how to overcome them without burning bridges you might need later and in such a way that it strengthens the team. I think we were able to do both.