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

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