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!

Brayan

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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,

Brian

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,

Brayatan

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.

Ciao,

Brian

Welcome to the Adventures of Brayan in Chile

Hi Everyone,

I’m celebrating the two-week anniversary of my arrival in Santiago Chile by finally getting around to making the blog I promised myself I’d keep. I’ve had a great time here so far, and can’t wait to tell you all about it!

I’m going to write a big catch-up post summarizing my first two-weeks here and try to post it sometime tonight. After that, I’ll try to keep things more regular with a steady diet of fiber blog posts over the remaining 7 weeks that I’ll be here.

Given this is my first foray into the blogosphere, I would love to hear from you as you are reading these posts, and welcome any tips on how to make sure the blog is entertaining to read. Also, let me know if you’ve been in this neck of the woods before and have suggestions about what I might do. Oh and as for the name, everyone here seems to spell my name “Brayan”…still haven’t made up my mind as to whether I’m insulted.

Hasta Luego,

Brayatan (Another alternative for Brian, combining “Brian” and “Jonathan”)

Brian on Cerro San Cristobal