Unintended Adventures on Horseback

It was not lost on me that this was taking place in La Valle de la Muerte. It seemed fitting that here, surrounded by red stones, in a valley where the elderly had supposedly come to die in ancient times, I had lost something so valuable–so invaluable. As the 30 minute mark passed, I felt myself becoming less optimistic. The winds were continuing to pick up, blowing a constant wave of sand over my hopes of finding my wedding ring.

La Valle de la Muerte (The Valley of Death)

Ori and I were at the halfway point through our morning tour on Horseback, and currently located about 6km outside of San Pedro de Atacama. There was only about a 10 minute portion of our 3.5 hour ride that took place on the sand dunes, and of course that was where my ring had chosen to fall off of my finger.

Happily making our way up the Valle de la Muerte on horseback

Riding the dunes above Valle de la Muerte

There were three of us, Ori, our guide Karen, and myself. Very fortunately, I felt the ring as it slid off my finger, tugged by the reins of the horse, and I even heard it as it struck something—the sand? My foot? But upon looking down at the sand I couldn’t see any sign of the ring. Karen, our guide, told me to stay still, lest the horse stomp on the ring and drive it deep into the desert sand, and I did my best to stay calm, knowing my ring was somewhere nearby. After 5 minutes of her fruitless search, I dismounted and joined Karen in looking. She led the horses to the side, hopeful that they would not bury the ring deeper, and we sat and dug, using our hands as sieves, looking for the ring I had lost.

Just before I lost my ring, we had stopped so the horses could rest

We were surrounded by Karen’s 5 dogs, who had followed us on our ride (as they apparently always do) who were lying around in the area we were searching. Could they be making things worse? At one point, one of her dogs began emulating us and digging—fortunately he was not in the area of interest.

After 20 minutes Karen told me she would soon have to return to town. I could stay and continue looking, it would be about a 90 minute walk back. I looked down at my nearly-empty bottle of water. Ori had water too, and more than me, should she and Karen return, leaving me to hunt for the ring? I told Ori there was no way I would leave without the ring. It had to be within 5 feet of were I was standing. I would not, could not accept that it had been lost.

Ori dismounted to help out in one final search. I found four rocks and marked out the area of interest—a 15×15 foot excavation site. We continued to search, the three of us together. How deep should I dig? I left the immediate area of interest to look from afar, kneeling down, my cheek on the sand, hoping to see the glimmer of the ring on the surface of the sand in an area we had not looked. No luck. I returned to the 225 square-foot area I had marked and began methodically looking for the ring. An organized approach would be best. I starting in a corner, working systematically. I then felt an impulse to move towards the center, where Karen was looking. I don’t know why. That just seemed like the right spot. I was merely two feet from her, sliding my hand through sand we had certainly sifted through before, when at last I felt something round, lifted it up, and saw my ring. The same ring I had pulled out of a bowl of rice during my wedding ceremony in India just 5 months ago. Something made this episode of rummaging around a bit more nerve wracking.

Ring in hand, I shouted out “lo tengo, lo tengo!” and held it to my chest as I let myself fall backwards into the sand. It was at that point that I took a good deep breath, realizing it was my first normal breath since the ring had slipped my finger.

The Scene of the crime: I finally found my ring just to the right of where that dog is lying. You can see the sand was all turned over in the search!

Anyone no a good place to re-size a ring in Boston?



Ori and I spent 3 days last weekend in the port town of Valpariaso. This city of 200,000 came to prominence in the 1800s as ships from Europe would make their first stop in Valparaiso after rounding Cape Horn, en route to California for the Gold Rush. The city lost much of it’s maritime significance with the opening of the Panama Canal about 100 years ago, but it is still a mecca of art and culture in Chile, and is also the seat of Congress.

Not going to write a long post here, but wanted to share some photos that we snapped over the weekend while wandering the narrow, hilly streets of the Cerros (hills) Concepcion and Allegre. These areas, UNESCO world heritage sites, are beautifully preserved, with strict guidelines about what changes can and cannot be made to buildings there. Our Bed and Breakfast was on Cerro Concepcion, on a street that felt like it belonged in Greenwich Village–with many artsy cafes, galleries, and boutiques.

The food in Valpo was excellent, albeit expensive. We enjoyed wonderful seafood, Italian food, and tasty cookies called Alfajores, often from a restaurant high on a hill offering beautiful views of the colorful city and the ocean below. Definitely a city to check out–we’d love to go back!

View from Paseo Gervasoni

Cerro Alegre, as seen from Cerro Concepcion

Funicular "Concepcio" the oldest in the city, built in 1883. This one was 69 meters long and had a pitch greater than 45 degrees! You don't need to consult a compass to know, that's steep!

View of Valpariaso from the top of funiclar Artilleria

Don’t hate me– I had a great weekend

I had several “pinch me so I know this is real” moments during this past weekend. With Oriana here now and us feeling so at home, it’s hard to believe we are in the southern hemisphere–a hemisphere in which I am pretty sure I only knew one person just 5 short weeks ago (An HMS Classmate in Buenos Aires for the year, in case you were curious). It’s hard to believe that I am here learning so much and earning two full months academic credit, and yet having so much fun at the same time. It is hard to grasp this now, as I sit in my apartment, and it was even harder to comprehend on Saturday as I was whitewater rafting my way down the River Maipo, south of Santiago. It’s also hard to know that I almost backed out of this trip at the last minute, out of concerns about the logistics not coming together. That would have been such a shame!

Anyway, after 5 weeks here in Chile, I finally left the smog behind and made my way out of Santiago for the first time this past Saturday. The trip wasn’t a long one–Ori and I went to nearby Cajon del Maipo, a trip of only 90 minutes to the south, and only 30 minutes beyond where I work every day in southern Santiago. In fact, Cajon del Maipo is so close you can get there by public transportation! All you need is a 1 dollar metro fare and 3 dollars for a shared taxi (collectivo) to drive you the last thirty minutes!

Cajon del Maipo (Canyon of Maipo) is a rural area just outside of Santiago, and a favorite weekend-escape for Santiaguenos hoping to get out for some cycling, hiking, boating, skiing, or just exploring small towns. We limited our experience to a rafting trip accompanied by lunch in the town of San Jose de Maipo, so we definitely still have an excuse to go back.

The morning started with us arriving at the rafting place a bit early, around 9:30 for our 10am trip, and we found all the people working there putting the equipment together while blaring the equivalent of Chilean MTV. They looked like a fun crowd, and were friendly and suggested we pop next door for a snack and then return. We entered the neighboring restaurant/supermarket/town center, basically one of two stores that seemed to be open on the tiny 1-block strip that constituted the heart of this town, and plopped down to a champions breakfast of a pino empanada (barbaqued beef, onion, hard-boiled egg and an olive inside). We were at one of four tables in the front of the restaurant and could see people coming and going, and it seemed like the business was mostly regulars–everyone seemed to know the septegenarian behind the counter, who had some good banter with the customers. It was a nice feeling to be in such a community, and certainly a far cry from the anonymity that comes with spending most of our time in a city of 6-7 million here.

When we returned to the rafting company at 10, we found two other couples there to join us, making six for the group. One was a couple in their 20s from Santiago, but they were “just friends”…there are many gradations of friendship here, and it takes a lot to call someone your boyfriend or girlfriend…first you are “andando” (literally ¨walking with¨, this is casual) then you are “pollolos” (this is the boyfriend/girlfriend equivalent) and then you are “novios” (which I learned meant boyfriend/girlfriend but here it is reserved for being engaged) . Anyway, apparently this young couple was still in an early stage of their relationship. The other two people were a couple from Ecuador who were in their 60’s. If they could do the rafting, so could we!

This was my first time rafting in about 10 years, and Ori’s first time ever. We suited up in our wetsuits (the water is 7 degrees celsius, about 45 fahrenheit), neoprene booties, windbreakers, helmets, and life jackets, and then we were ready to go!

All geared up and waiting to head out on the river! Guess we didn't need sunscreen afterall (except for the faces of course!)

We piled into the van with our guides and gear and drove 12km up the river to where we would start our trip. There we met another company, whose two boats worth of customers would be joining us, making us three rafts total. Each raft had a guide, and there were also 3 guides on kayaks who made there way down the rapids with us, one going ahead to scout out the route, and two trailing behind to pick up anyone who fell into the water.

Before we headed out on the river we had a 5 minute safety instruction. In Spanish. Perfect for Ori, with her 5 days of Spanish classes under her belt. Actually, the instructions were pretty self explanatory, and the guy giving them was funny, so there wasn’t a lot that was lost in translation. In fact, it was a great way for ori to lean more vocabulary, with words and phrases such as “forward,” “backward,” “weight to the left/right,” and so on.

Once out on the river we spent about an hour and twenty minutes making our way down the 12km section that we would raft. The river had mostly class I-II rapids for the first half, and several class III-III+ rapids in the second half, providing a nice warm-up followed by an exciting finish. What was most notable, I thought, was that even in the areas between rapids, there were no truly calm-parts of the river. Unlike the rafting I had previously done in Oregon and California, it felt like we were always moving along at a good pace.

 The two rapid highlights came in quick succession about 2/3 of the way down the course, and our guide had us row to the shore to discuss them before we made our way down. The first rapid “Big Wave” was the most technical he explained, as we MUST enter to the right and quickly make our way to the opposite side of the river to avoid a large rock further downstream. If we were to hit that rock, he’d yell “peso izquierda” to have everyone dive to the left and keep the boat from tipping. Fortunately that wasn’t necessary.

The second rapid, hardly separated from the first, was graded a class III-IV and was called ¨fu–ing wave.¨ Need I say more?

Check out my rowing mechanics!

The entire rafting experience was a blast, and as I said at the outset, I had some introspective moments on the trip where I couldn’t help but reflect on how cool it was to be spending a Saturday morning whitewater rafting in South America, 5,000 miles from home. Sure beats my typical weekend in Boston!

After our day of rafting we enjoyed a lunch of turkey sandwiches with avocado that I had brought with us in the town square at San Jose del Maipo, and then made our way back to Santiago for a much-needed afternoon nap. That night, we had a dinner of typical chilean food (pastel de choclo and cazuela de pollo) and turned in early to be ready for our big day the following day.

Sunday we awoke, ate breakfast at home, and then headed to Parque O’Higgins for Lollapalooza Santiago. Santiago first hosted Lollapalooza in 2011, and is the only city other than Chicago to feature this festival. It was a two day festival with roughly 60 bands performing, but we only attended the second day.

On our way in, about 12:30 in the afternoon and it was HOT!

The festival was simply a blast. We went with our friend Alex, who is here teaching English for a year and a half, and all of us had a great time. There were six stages total: two large stages for the big rock groups (mostly from the US), two smaller stages featuring local acts, a kids stage, and a large indoor arena that hosted all of the electronic music acts.

We started out by seeing Foster the People, and they were awesome. Given that they are so new (formed 2009) they have a limited repertoire and so they played every song off their album Torches, which Ori and I love to blast in our apartment in Boston. They gave a great performance, and while I like all their songs, I think they did best with Warrant, Miss you, and Pumped up Kicks. Pumped up Kicks was the last thing they played, and about four minutes in, at a point where the song normally ends, they broke it down into a more techno/trance version that they continued to play live. It was a perfect way to end a fun set–I’ll have to post the video I have somehow.

Following Foster the People, Ori, Alex and I had lunch and some much-needed liquid (it was blazingly hot in the direct sun, standing in a large crowd) and then made our way to see Band of Horses for a bit, before Ori and I broke off from Alex to see Crystal Method, the first electronic act we would see in the indoor arena. I have to say, this was probably the most amazing, adrenaline packed experience I have ever had at a concert. I love listening to electronic music, but had never been to a live show and mostly just listen at home (and to be honest, haven’t listened to as much recently as I used to.) Whatever experiences I had had prior to Sunday paled in comparison to the experience of being in a cement arena, partially underground, surrounded by roughly 10,000 fans listening to the Crystal Method as their beats were pumped out by an incredible sound system and would then echo off the walls of the arena. Oh, and did I mention the music was synchronized with an audiovisual display? Or that Foster the People came onstage with Crystal Method for yet another remix of Pumped up Kicks? (our second time hearing the song that day, but this version was very different, and very cool.)

The Movistar Arena, where all the electronic shows played
not my photo: http://www.infobae.com/adjuntos/jpg/2012/04/600x0_525091.jpg

The only thing that could have made our experience watching Crystal Method better was that Ori and I sat off to the side, rather than being in the pit where everyone was dancing, which meant the visuals were not  aligned for us. Fortunately we would fix this later when we returned to that arena for the headlining group that night to see the British duo “Above and Beyond” who were just amazing. We quickly danced away the 90 minutes the played, with an energy and excitement that was just exhilarating. I’m definitely going to buy their album “Group Therapy,” which Ori and I both felt was a perfect name that summed up the experience of carelessly dancing the night away surrounded by a crowd of thousands. (It was also interesting to read today’s NYT piece about the increasing popularity of electronic dance music shows in the US, and their new profitability: (http://www.nytimes.com/2012/04/05/business/media/electronic-dance-genre-tempts-investors.html?hp)

Other shows at Lollapalooza were good, but didn’t measure up to Foster the People, Above and Beyond, or Crystal Method. MGMT gave what I thought was a somewhat lackluster performance, certainly a disappointment because I had really been looking forward to them, and the Foo Fighters just felt a bit too high school to really listen to anymore. Ori and I were certainly in the minority in having that opinion, as there were far more people watching the Foo Fighters than there were who joined us for Above and Beyond. Their loss.

Exhausted, after an incredible weekend, I returned to work in the Consultorio on Monday and Ori returned to her Spanish courses. It’s been a tiring week, given that we had scarcely a moment to rest this past weekend, but we are now very much looking forward to heading to Valparaiso tonight, where we will spend the next three nights in a bed and breakfast!

I’m about to bring this post to a close, but wanted to first share one last picture along with some advice: if you ever go to a foreign country where there is a popular national dish that rhymes with your name, order it. In our case, this meant ordering Chorillana (rhymes with Oriana) and it was an experience. Fries. Steak. Chorizo. 2 fried eggs. Onion. And, as a dish for two, of course it comes paired with a liter of Chilean beer to share.

We ate a salad the next day.

A Classic Chilean dish for those with Heart Disease

The end of the homestay

I have now been in Chile for four and half weeks. I’m more than halfway though my 8-weeks of clinical work, and just about halfway through my 9 weeks here overall. This past Friday afternoon, Oriana finally arrived here in Santiago to join me for the remaining month. She is taking intensive Spanish classes at a school just around the corner from our apartment, and will continue to do so while I finish out my time working at the consultorio. Having her here is wonderful, in many ways. Nothing compares to exploring a city with someone so close to you– it is far better and more fun than wandering around on one’s own. Whether it’s been eating a nice dinner outside or just aimlessly wandering around the city, we’ve been having a blast since she arrived. It’s made it particularly fun that in this case I already had four weeks of “local” knowledge when she arrived, so I have been able to show her what I have liked so far, and jumpstart our time here together, so to speak.

While the remaining month promises to be awesome, last Friday not only marked Ori’s arrival, but also my departure from the home in which I had been staying for the previous four weeks. It was a great arrangement, as I blogged about in my earlier post, Living in Las Condes. I must say that pre-trip, I had some trepidation about doing a homestay–it was something I had never done before, and it felt a bit like a roll of the dice…would I like the person I stayed with? How would the food be? Would it be awkward to live in someone else’s space, help myself to food from their fridge, and, per the agreement we had, let them do the cleaning and my laundry?

Perhaps most importantly, I wondered how much I would have in common with the person whose house I would live in. Obviously a large and welcome part of the experience of living in another country is to meet people who are different than you, and to see how their lives, values, beliefs and goals compare with yours. This, after all, is the essence of really experiencing and enmeshing oneself in another culture, as opposed to just passing through it. With that thought in mind, I knew I was not hoping to live with someone exactly like me, but still, it would be nice if we had things in common and were able to get along well, wouldn’t it?

Another question I had pre-homestay was born out of the story a friend of mine told me about her experience during a homestay in Costa Rica when she was in college. This friend had felt that the experience was overall positive, but told me that in her case, it was clear that her participating in the homestay was an essential source of income and livelihood to a large, poor family living in a small home. She described them opening up the “master” bedroom to her, so that she could live in relative luxury, while multiple family members spanning several generations crowded into an adjacent room, forfeiting their space in the name of income from a wealthy foreigner. This had been unquestionably awkward and uncomfortable, and was not an experience I was hoping to emulate.

Fortunately things worked out differently in my experience–all for the better. My host “mom” is an established professional working for an international corporation, with a gorgeous apartment that has two extra bedrooms and plenty of extra space. This meant that I was not the only visiting student; there was also a college student from Luxembourg here studying linguistics. Having two of us in the house made things more fun, gave me someone to explore with, and allowed me to avoid feeling like the lone-intruder in someone else’s territory.

My host mom was very gracious and helpful throughout my stay. Some things were awkward–such as letting her do all of my laundry and wash all of the dishes–but my experience was very positive, fun, and educational. She also made acclimitazing much easier, helping me with things such as getting a cell phone and finding my way on the metro–things I could have done on my own but what have taken me more time to figure out. In addition to her direct help, living with her, paired with my experience working with Chileans during the day, meant nearly every word I spoke, from waking to sleeping, was in Spanish.

Dinner during my homestay was always the centerpiece of the evening. While I am only working 9-5, with my 90 minute commute it was more like 7:30-6:30, which meant I had about 5 hours between when I came home and when I would typically go to bed. This sounds like a lot of time, but somehow it would quickly evaporate, each night, into a ritual of talking about our days while the host mom, the other student and I cooked together, set the table, ate dinner at a relaxed paced (often accompanied by wine or champagne) and then worked together to put everything away. Dinner here was not something to get over with, a meal that had to be eaten, it was something to plan an evening around, to sit and enjoy eating, and an opportunity to get together and talk. I cannot say the same about my typical dinners in Boston, which are often relatively rushed, and often served with a side of HBO.

Speaking of the food, it was delicious. It was pretty much all either Chilean or Chilean-inspired, and I had the opportunity to try several things I had never seen or heard of before. Beyond that, even things that were familiar, such as fruits and vegetables, looked and tasted slightly different here.

Here are some snapshots of a few of my favorite dishes from the past four weeks, along with brief descriptions of each:

A wonderful dish of corn, basil, and chopped onion, all put in the blender and then baked. We had it as a vegetarian dish, but you can also get it with ground beef or chicken inside. Yum!

A "pancake" made with freshly shredded carrots, combined with an egg, and then all fried together in a frying pan on low-heat

Breakfast on the weekends consisted of fresh bread from the bakery next door, with salami and cheese, and, if I was feeling indulgent, some dulce de leche spread (the brown tub in the picture). We also had delicious melon, a different color day after day. Yum!

Chicken in a spicy, garlic curry...probably not very Chilean, but damn was it good!

Beef roast, cooked in a pressure-cooker with a wine and mushroom sauce. Served with guacamole, a fresh salsa, and black beans that were cooked, pureed, and then fried...the beans are a Guatemalan specialty

This was how we celebrated my last night of the home stay. The guacamole was delicious! The avocados here aren't uniformly the best I've ever had, but some have been great. This bowl was from just one avocado the size of an eggplant!

With the bittersweet end to my homestay came the exciting beginning of living with Ori. I would like to say I found our new apartment quickly and easily, but I probably spent too much time obsessing about finding exactly the right place before I settled on this one. The ending was a happy one, however. We love this place!

Here’s a teaser image for now:

You can see the kitchen counter we dine at, with the living room behind, followed by our balcony and view of the city. We love this place!

The apartment spans the 24th and 25th floors of a 2008 building in Providencia (the year of construction is important because it means it was around to be tested by and survive the 2010 8.8 earthquake! Now it has also survived this past Sunday’s magnitude 7.2 quake!) The apartment is gorgeous, with a living space below, a lofted bedroom above, and a corner location with a wrap-around balcony that offers 270-degree views of the city. Ori and I wonder if we will ever be able to afford such a place in the US (we are both leaning towards no).

That will have to be my stopping point for now. I am just about to start an afternoon session of adult primary care.

Hasta luego!


Is that crazy-talk, or do I just not understand Spanish well-enough?

I had a rough morning seeing patients on Monday. Sleep deprivation definitely played a role–I was tired from being out late Friday and Saturday nights, celebrating my match results and Saint Patrick’s day, respectively. Oh, and I was up late Sunday night too, reading about Lisbeth Salander and why she likes to play with fire. Anyway, yes, I was tired, but I think fatigue was only a part of the story. The main reason my Monday morning was so hard was that I had a full morning of psychiatric visits.

As I near the end of my fourth week here, I’ve come to the conclusion that psychiatric visits are the hardest types of encounters to conduct in a foreign language. This probably shouldn’t have come as a surprise to me. Even in English, I had to take a course to learn how to “talk like a psychiatrist” and recognize speech pathologies. Executing a good psychiatric encounter and mental-status exam is hard in any language, because the content of such conversations can be sensitive, and the words a clinician selects to address a patient carry much weight–they can serve a therapeutic role if used well, and can be damaging if used poorly. Moreover, the presentations of various pathologies may be subtle, so the clinician must listen carefully and take note of any clues that a patients’ pattern of speech or thought process may yield. In practical terms, this means paying attention to the rate, rhythm, volume, and prosody of a patient’s speech. Let’s look at why this is tough to do in a foreign language…

Task 1: Determine whether the patient is making sense

At the age of 28, I feel like I know enough English that I should be able to understand someone who is speaking to me in English. Even 5 years ago this was true. So if someone comes up to me and starts talking about the lawnmower they saw driving a rose-petal on the moon, I can feel pretty confident that they are wrong, and moreover, not well.

Clearly, even non-English speakers can be delusional. That means here in Chile I must be able to detect a delusion in Spanish, but as a foreigner, it’s harder for me to be as confident about detecting a fixed false belief. First of all, there are many times that someone says something to me in Spanish that I can’t understand, and most of the time, it is due to a language deficit on my part, not a psychotic break on theirs. Put another way, if someone says something that doesn’t make sense to me, the prior-probability is higher that is is my fault, than theirs. Secondly, beyond merely being able to literally translate and understand what one is saying, a clinician must navigate idioms in whatever language he or she is conducting an interview. Think of the English example “It was raining cats and dogs”–if you didn’t realize that that is a saying, you would surely think anyone who uttered it must be crazy, and reach for some haldol. Finally, working in a foreign country is tough independent of language barriers because delusions must be considered in cultural context. In order for a belief to qualify as a delusion, a person’s fixed-false belief (that’s the definition of a delusion) must not be consistent with culturally held beliefs. For example, people who believe that god communicates with them by writing on 30-60lb golden plates that he then buries underground in New York aren’t called crazy, their called Mormons.

A great south park episode if you've never seen it

Task 2: Is the patient speaking with a normal voice?

A key component of a psychiatric evaluation is taking note of the rate (how fast), rhythm (what’s the cadence)  volume (how loud), and prosody (the sing-song aspect) of a persons speech. A related aspect of the exam, ‘thought process’ involves assessing whether a person seems to be thinking, and thus speaking, in a normal, linear, goal-directed way, versus speaking in a circumferential or tangential way.

Just as it is hard to assess the content of speech in a foreign language, making assessments about rate, rhythm, volume and prosody is also difficult. For one thing, the type of Spanish spoken in each country differs, so what I am encountering here in Chile is different than what I heard during my two weeks in Guatemala, which, in turn, was different than what I had experienced years ago in Spain, and even that differed from what I was taught in school. Beyond inter-country differences, there are also interpersonal variations in the way people speak Spanish. Some speak faster than others, some slower. Some louder, some softer. Some with a sing-songy rhythm and sound, others in more of a monotone. Again, recognizing what is outside of the normal range of these variables would be obvious to a native listener, as it would be to me in English, but when I hear someone who is speaking fast in Spanish, its hard for me to be confident in saying it is pathologically fast. Instead, my default, as above, is to assume there is something wrong with me, and that I simply am not adept enough in Spanish to keep up. Again, this statistically makes sense: on the population level, only 1-2% of people ever have manic episodes, and even those episodes are typically few and far between. Thus, when someone is speaking Spanish at a faster rate than I would like for them to be, should I really assume they are sick?

Task 3: Using subtle, empathic, appropriate language

Aside from the diagnostic challenges posed by interviewing psychiatric patients in a foreign language, there are also therapeutic challenges. Think for a second about what you imagine (or know) a great psychiatrist to be like. Chances are you are picturing a man or a woman (if it’s a man he’s wearing a sweater vest), listening intently, asking the “right” questions, speaking in a comforting tone, reflecting thoughts back at you, and saying just the right things to guide you through the encounter. Am I right? Well, that’s what I picture, and when I am having a conversation with a difficult psychiatric patient, or any sensitive conversation with any patient for that matter, I  want to fit into this role. Gary Larson does a nice job of capturing it in this Far Side cartoon:

Gary Larson nails it again

Needless to say, conducting sensitive, important, and potentially high-risk conversations well in Spanish is no less important than it is in English, but it is certainly much harder for me to do. What is a walk in the park in English can quickly become a tight-rope walk in Spanish, in which I carefully move forward, a clear goal in mind, but find the sentance I am unttering flanked by drop offs on either side as the conversation could be derailed at any time if I were to arrive at a word I do not know, or an idea I cannot express.

Advice from my mentor here

I mentioned to my mentor here that I have found psychiatric encounters be (in many but not all cases) more difficult than others, and she had some good thoughts. First of all, she said, it is natural that doing anything in another language is harder, so if something is hard to discuss even in English, then of course it will be hard to do in Spanish. This was reassuring but not terribly helpful. However, a more-insightful comment came next, when she pointed out that the fact that I was feeling less than 100% confident about making a psychiatric diagnosis based on evaluations of a patient’s verbal signs and symptoms represented  a great opportunity for me to look to other behavioral or affective clues about psychiatric well being. This wasn’t a solution to my problem, but it was important for me to realize that yes, language aspects of psychiatric evaluations are harder to do in a foreign language, but many of the cues clinicians take from patients come in non-verbal forms; from posture, to tics, to affect. For example, I remember several psychiatrists saying to me that you can always tell when you are with a depressed patient because they can make you and anyone else in the room begin to feel depressed.

Based on how bummed and drained I felt after a morning of seeing patients with depression, I guess I was already doing a good job of absorbing the feelings of my patients–the depressed where making me feel depressed! At least that transcended language.

Ciao for Niao,


The Alto–Life in the Consultorio, and how Chilean medical schools differ

This is my third week working at the Centro de Salud Familiar San Alberto Hurtado in the Puente Alto neighborhood of Santiago, Chile, and so far everything has been WONDERFUL!

Photo from the website--I haven't taken my own because I was advised not to travel with a camera in this neighborhood (but so far no close calls!)

As I mentioned in my last post, Puente Alto is in the southern section of Santiago, and is a poor neighborhood of roughly 750,000 people. It takes me about 90 minutes to get there from the opposite site of town, with a 20 minute walk, two different subway trains, and finally a ride in a collectivo to reach the clinic from where I exit the metro. There is also a bus I could take, although the neighborhood isn’t supposed to be the safest, so I was advised it would be safer to take a collectivo. So far I have’t had any threats or seen any crime, but as you can see above the clinic is surrounded by high electrified fences, and if you could see the houses outside, you’d see they all have locked gates and barred windows. Lonely planet cites these types of features as signs of a bad neighborhood here (well duh).

Here is a map of the districts of Santiago. Again, I live in Las Condes (top right) and as you can see Puente Alto is all the way to the south (about 35km away):

Anyway, the consultorio (clinic)  is actually only 4 years old, having been built in 2008. It is run by the Pontificia Universidad Catolica de Chile, one of the preeminent universities in Chile, with funding from both the government and the university. It is essentially a free clinic, as all of the patients there receive government-subsidized healthcare called FONASA (more on the plusses and minuses of this system in a later post–so far it mostly seems like a great thing). The consultorio is also a teaching site for the medical school at Universidad Catolica, so all of the physicians who practice there are faculty, and there are also medical students and residents who work there, although their roles are not exactly the same as medical students and residents in the US.

Medical school is quite different here than it is in the US. Whereas we first go to college and then to medical school, students here enter into 7 years of medical school immediately after highschool. They call this carrera, and the structure is similar for other professions, such as law (i.e. direct from highschool, no college first). This means that by the time medical students here are in their final year, they have had much more clinical experience than we get during medical school in the US, but they have not had the same broad-education that we get in college. In fact, you can actually graduate from medical school here and begin practicing right away as a generalist, without pursuing any further training. Many, however, instead opt to pursue a veca, their equivalent of residency, in order to get more training. The range of opportunities for vecas parallels what we have in the US, and they are roughly the same number of years.

One of the great things about my experience at Consultorio San Alberto Hurtado has been that there are 6 medical students in their final year (7th) at Universidad Catolica who started working there on the same day as me. They are there on a 7-week family medicine rotation, so they will be there for all but one of the weeks that I am. Having them around has certainly made things much easier, more comfortable, and more fun. They are all male (75% of medical students here are) and have interests ranging from pediatrics to anesthesia. Of the six of them, I work closely with three as we are all on the same team, but in general I see all of them every day. Chilean Spanish is notoriously difficult to understand, and there are two students who I have a particularly tough time understanding, although it is certainly getting easier. Another one of the students speaks a Spanish that is much easier to understand than the others, and when I mentioned this to him, he said “of course, I am originally from Cuba and only moved here for medical school.” I guess that solves that mystery.

Back to the clinic– it is divided into four large sections, one administrative (yellow) one urgent care/minor surgery (red), and two sections that do the bulk of the primary care visits (blue and green). There are tens-of-thousands of patients enrolled in primary care here, and I have seen people as old as 90 and as young as 1 week.

My week is divided up into a mixture of different half days, which means I am getting to see lots of different types of medicine, and things are never boring. To start with, I had an induccion, two weeks that started out primarily as a shadowing experience so that I could get to know the clinic, the medical record system (yes, they have electronic medical records, and yes, their computer system is better than any of the outpatient systems I have seen in the US!) and also get more comfortable doing everything in Spanish. I have to say, while I was looking forward to and at least somewhat prepared for talking with patients in Spanish, I had not given much thought to what it would be like to have conversations with doctors and others about patients in Spanish. It is one thing do take a history and perform an exam, it is another to present a patient, discuss a differential diagnosis, interpret tests and lab results, and describe your plan in Spanish. This was all very new to me, and I was happy to have some time at the beginning with less pressure to act on my own so that I could practice these aspects in Spanish.

The other great aspect of my orientation was the huge breath of clinical cases and types of medicine that I got to experience. I spent half days in adult primary care, adult cardiovascular/diabetes/lipid management, pediatric primary care, OGBYN primary care, adult and pediatric urgent care, and minor surgery. I also had the opportunity to do several home visits, one of the medical variety, and one that was more of a social assessment for a patient who had requested a government subsidy due to financial hardship (more on this in another post).

Working in so many different areas, I got to meet over a dozen different doctors–the majority of those who work in the clinic, and also to work with nurses who do some of the primary care (less complicated visits such as well-child checkups.) I also got to work with a matron and learn what they do. Clearly matrons do not exist in the US, so I really didn’t understand what their training was or what they do. Going into the experience, I figured”she’s a midwife, right?” Wrong. Matrons are basically primary care gynecologists; they do pap smears, breast exams, consults for every-day problems, and manage most pregnancies, even those with some complications. It seems the one thing they do not do, ironically, is deliver babies (so much for the midwife theory). They do participate in family planning, but this is a bit difficult given that the university does not permit prescription of oral contraceptives, and when it comes to abortions, they are illegal throughout the country, regardless of the indication (including risk of death to the mother! Santorum would love it here)

This past week was my third week, so I transitioned out of my orientation and joined the other medical students in seeing patients by myself. I still have a broad range of experiences, with each half day being distinct. I spend several mornings and afternoons doing adult and pediatric  primary and urgent care visits, and I also do a half day each week of minor surgery. I am no-longer doing OBGYN, but have the option to add this back later if I want to.

Stopping here for now–check back tomorrow for a description of what my level of clinical responsibility has been like here, and what I’ve been thinking about it (hint, I’m acting more like a doctor now than I ever did in an outpatient setting in Boston, and it’s been an adjustment and given me some time to think about what level of responsibility I am comfortable with at this point in my training).

Hasta luego,


Living in Las Condes, Santiago

Beyond knowing that I would be living and working in Santiago, I really didn’t know what to expect when I got here two Sundays ago. Santiago is a huge city of 7 million people (1 of 3 Chileans live here in the city) and even though it is far more developed, richer, and supposedly safer than other South American cities, there is still a tremendous geographic, cultural, and socioeconomic range represented here.

Fortunately my start here was easy. You could even call it “cushy.” I am doing a home-stay with a wonderful Chilean woman who lives in a part of Santiago called Las Condes. She’s in her mid 50’s and has two adult children who no longer live with her, so she opens up their two old rooms in her gorgeous, 7th floor apartment, to host foreign students. The apartment would easily qualify as a very nice place to live in a wealthy part of any US city–it is large, well furnished,  nicely decorated, and it has a balcony that offers a wonderful view of the city, as you can see here:

There’s also a pool down below, with a grassy area for sunbathing alongside. As you can see, my life here isn’t too rough–a far cry from my busy inpatient medicine or surgery days in Boston, that’s for sure:

There’s currently one other foreign student here, a college student from Luxembourg who is studying Spanish Language at Universidad Catolica–the same university through which my exchange is organized. Shes really nice and it’s fun to have another person to go out and explore with. Spanish will be her fifth language, not including pig latin.

In summary, Las Condes, Santiago is basically Los Angeles, California. I guess I need to be more specific…its like one of the wealthy parts of LA. There are wide streets full of expensive cars, several malls nearby, plenty of sushi restaurants, and people live in a mixture of apartment buildings and large houses. Without cues like street signs in Spanish and volcanoes visible in the distance, one would be hard pressed to identify this as non-US:

While I am living in a nice ritzy area, I am working in the opposite. I travel 90 minutes each way (two subway trains and a collectivo, basically a taxi) to get to the Consultario San Alberto in the Puente Alto community of Santiago. Puente Alto, home to a mere 750,000 people, is the poorest neighborhood in Santiago, and one of the poorest in the country. Again, think Los Angeles CA, although not Malibu or Brentwood this time.

It’s getting late, so let’s leave the discussion of how things have been going at the consultario for my next post.