Clinical skills: In a setting where you lack basic amenities like x-rays, quickly ordered labs, and sometimes even proper sutures and syringes you consequently pick up some of the more basic and readily applied skills. Some of these skills include listening more accuraely for pathologic breath sounds, HEENT exam, listening for fetal heart tones with a stethoscope, Leopold maneuvers to assess the baby’s positions, and most of all, wrestling resistant pediatric patients and still getting a full physical exam. Stuff John Cena would take notes on. In one day I learned more about pediatric physical exams than my entire peds rotation back in Chicago.
Exposure to pathology: Being exposed to so many sick people with advanced diseases really helps sharpen your clinical diagnostic skills. Not only were there large number of sick patients but people with advanced disease because they would not see a physician earlier at the start of their symptoms. Also living in a pathogen laden environment like Ecuador people tend to pick a lot more of those disease causing bugs.
Improvised skills: Sometimes you just don’t have what you need. But this doesn’t mean you can’t continue being a doctor. Working as a future Army physician in a deployed setting I’m sure I’ll have to face this same situation and Ecuador really opened my mind to what you can do when you don’t have everything you want.
Relying on physical exam versus studies: We didn’t have access to instant xrays, ultrasounds, and practically no CTs or MRIs. Since we couldn't just send a patient to get these special tests done you have to not only become very competent in your physical exam skills but learn to trust them and to create a treatment plan that won't leave you second guessing yourself later.
Swimming without the safety net: Lastly the big lesson I learned was working for proper patient care when you don’t have that safety net of a physician around you. There were times when we didn’t have an attending physician looking over us, or even in the room. Times like this we would have to be the main doctors for the clinic and only during tough cases we would consult the medical director... if he was there. The first time this happened I was absolutely worried, however by the fourth week we felt comfortable and confident enough to run the clinic and do our best as senior medical students. And yes, I’m pretty sure that would have been against all sorts of laws back in the United States but hey, welcome to Ecuador.
WHAT I APPRECIATE MORE
First and foremost, electronic medical records: Being able to turn on a computer and find all sorts of doctor notes, labs, and imagining on a patient is incredible! If we had a patient who even knew what medications they were on we were ecstatic!
Sterile fields: Can someone please get me a sterile field? Every time I had to suture a patient it was a new experience. Sometimes if the wound was large enough and we lacked saline solution I would have to wash out their wound with the backyard hose (seriously) and then rinse it with sterile saline solution and then get to work in the clinic to sow them up. And even then keeping all your tools and suture line sterile was a nearly impossible task. Sometimes you just have to combine a little bit of careful hand movements with a whole lot of prayers. I call this Ecuadorian sterile field.
The importance of structured learning and continuing eduction: Becoming a doctor is not simply getting a degree after four years of medical school. It’s more than just a three or more year residency. It’s learning every day and bettering yourself to become a competent and efficient doctor. Ecuador in some regards lacked this where I was located. I worked with some great physicians who constantly pushed themselves to be better physicians and it showed. Others you could tell lost that continual education and actually made me worried when watching them practice. For me going to a residency where I have competent mentors means that much more to me, and after I graduate I hope to continue learning from those better than myself.
Having access to labs, imaging, and results make you a better doctor: Very often we didn’t have access to these things. When a patient walks into your clinic they have a diagnosis and it's your job to figure it out and treat appropriately. So many times you would long for that one test that would confirm your suspicions, but instead you have to combine your physical exam findings, personal experience, and a whole lot of doctor intuition. When you have access to these diagnostic tools it helps greatly in being able to identify syndromes and symptoms. Eventually as you get used to seeing patterns you might not even need to order those same tests. Unless you practice in the United States and our litigious society and end up practicing defensive medicine, but that's a topic for another day.
The medical experience I had in Ecuador was unforgettable and priceless. I am so happy that I was able to work alongside the physicians at El Centro de Salud and learn so much from them. It made me a better physician. It strengthened my confidence. And it gave me a deeper perspective of medicine and it’s application. I can’t wait for the future opportunities I will have to serve as a physician in another setting like Ecuador and know that this rotation will serve to make me better than before.
