Friday, March 26, 2010

From Janina: La Clinica

One of my goals for my time in Santiago was to see a variety of clinical settings, including both outpatient care and the private sector. It took me a few days to sort out how to even ask about these activities because, as it turns out, the clinics in the DR are referred to as “los consultorios” and the private hospitals are called “las clinicas.” So, after several attempts to ask if there were clinics (las clinicas) in the public hospital (the answer being no, which initially made me concerned that there was actually no outpatient care for uninsured patients, but actually meant that there were no private hospitals in the public hospital. Obviously!), I successfully arranged to accompany Dr. Medrano, my host, to his outpatient clinic in the private hospital, La Clinica Corominas.

This turned out to be an incredibly informative experience as the patients that Dr. Medrano saw seemed to be the demographic that I see most often in my clinic at Columbia. In fact, one elderly woman who came for her first visit accompanied by her daughter had just been sent back to the DR by one daughter who lives in the Bronx because behavioral problems related to her dementia were becoming to difficult to control. Dr. Medrano asked the daughter in his office, had she received a CT scan of her head? Lab tests? Where and when was this diagnosis of dementia established? The daughter knew her mother had been hospitalized several times in the US (St. Barnabas, perhaps?), but, unlike in the DR, she had not been sent home with her records so there was really no telling what kind of evaluation she had. This was an interesting flip side to the patients who I have seen in my clinic in Washington Heights, recently arrived from the DR. I have one patient who was diagnosed with colon cancer in the DR, treated with surgery and chemotherapy and then came to the US for further care. She arrived with a giant package of records and letters detailing her previous care. Her oncologist in New York was even able to get her pathology slides shipped from the DR for review. Practically speaking, this experience made me realize that, when my clinic patients tell me they are headed for a long stay in the DR, I need to print out their important medical history (medication lists, recent labs and studies) to facilitate their medical care if they need it while in the DR. But in a grander sense, seeing the struggle of this family with roots in both DR and New York City to find the best setting for their ailing mother, brought to light the incredibly complex relationship between NYC and the DR and the way this straddling of worlds plays out in the medical sector.

Another way in which I had the chance to glimpse more of these links between New York and the DR was through my extraordinary host family, the Vargas. I stayed in the home of Maggy Vargas and her two children, Miguel, a young lawyer and Leiny, an intern at the University hospital. They were incredibly generous hosts and best of all, welcomed me into their large extended family, most of whom still live in Santiago (though others live in Washington Heights, of course. Everyone seemed intimately acquainted with the Wendy’s on 165th and Broadway). The matriarch of the family, La Abuela, is 91 years old and spends her days napping and sitting in a rocking chair on the terrace of her 2nd floor apartment above the cafeteria owned by her family. She had twelve children, about half of whom I had the chance to meet, including Maggy (my host mother), Jacqueline (who owns a salon in Santiago), Tete (who I believe owns the cafeteria and lives in an apartment connected to her mother’s), Altagracia (who actually lived in New Jersey and New York for at least 15 years. Her daughter, Glory, was born in the US and lived their for her first 15 years but returned two years ago to Santiago, a difficult transition according to her aunts) and Eduardo, who remarkably received a kidney transplant at Columbia twelve years ago (I believe from Tete) and now travels twice a year to New York for his follow up appointments.

Overall, I didn’t even come close to processing the many ways in which the DR and New York City are linked in families like that of the Vargas. I heard stories of how travel to the US provides opportunities for education, work and medical care (even kidney transplants!). I also heard how returning home provided security as well: free university education, work in the family business, family support unlike anything I’ve seen in the US. What a fascinating relationship between two very different countries! I feel very lucky to have had the opportunity to see a little of the DR side of things, to hold in my mind and heart when I interact with patients in the ER, the clinic, the wards, or even my neighbors at 173rd St. and Haven. One final image that I will carry with me from this experience: as I got ready to board my plane back to New York City, I noticed the remarkable number of elderly people in wheelchairs preparing to board with me. What kind of flight has 15 people in wheelchairs? Are they returning from a visit to family in Santiago? Are they traveling to the US for medical care? Are they my future patients? If they are, at least now I have gained a tiny sense of where they might be coming from, why they may have decided to make this journey, and a little bit of what they may be leaving behind.

Thursday, March 25, 2010

From Janina: Los ancianos en sus casas (The elderly in their homes)

On my second day in Santiago, I traveled with one of the geriatrics residents, an attending, a medical student and a nurse to visit the homes of four geriatric patients who had been referred for evaluation. The patients had been seen in the ER of the hospital or admitted to a different service (like the orthopedics service for a broken hip) and then referred to Geriatrics for a home visit. In most cases, this visit happened months later.

The first patient we visited was a woman in her 80s. She had been admitted for a seizure and was now back home with her family taking various medications to prevent further seizures. The most eye-opening aspect of this visit was the home environment in which this woman was living. She lives in a small house in a neighborhood full of what appear to be new apartment complexes. But her house did not appear to be new and was, in fact, bursting at the seams with people, mostly small children and their young mothers. In her bedroom, where we found her lying in bed at 10am, there were two large double beds pushed together to fill the entire room and it appeared that at least four or five people were sleeping in the two beds. When we arrived, she got up and immediately became extremely agitated, complaining of unrelenting pain in her legs and back. I got the feeling from her young relatives (who were also her caretakers) that she was often agitated in this way. The visiting doctors seemed very concerned that there was a large element of dementia with behavioral problems contributing to her current state. They wrote for refills of her seizure medications and a referral to the geriatrics clinic at the hospital. I learned at this point that the referral means that one of her relatives must travel to the hospital to make the appointment and then return on the day of the appointment with the patient, a daunting series of events given how many young children for whom the caretaker also seemed to be responsible. Most remarkably, though, throughout the whole interaction, the grandmother yelling and gesticulating, the concerned doctors discussing her case and making recommendations, a small boy of 2 years or so slept peacefully in the middle of the room.

Our second visit was to the home of a gentleman of 101 years, a patient well known to the geriatricians, who is visited at home only because he is wheelchair-bound and it is too difficult for him to travel to the hospital. He was perched happily in his wheel chair on the veranda of his family’s small house, enjoying the breeze, sheltered from the sun, smiling brilliantly. The doctors checked his blood pressure, joked that his girlfriends had come to visit him, and chatted with his daughter (also his caretaker) as she swept the floor of their living room. It struck me at this point how much nicer this man’s life seemed to be than many of the elderly patients I have met in Washington Heights. Elderly Dominicans in the US may find themselves isolated in a dreary apartment (not to mention the often dreary weather outside: certainly no verandas in our neighborhood like this one!), their family members working most of the day, sometimes cared for by a home health aid, sometimes alone. This man seemed so content, even in spite of his limited mobility. It was obvious to me why some of the patients we care for want nothing more than to return to the DR. Why should they care if they will no longer have easy access to a cardiac cath lab or hemodialysis? They can sit in the breeze, surrounded by family, and enjoy the time they have left on this earth.

The final two patients we visited, however, shattered this utopian (and na├»ve) view of the life of elderly patients in the DR. Next we visited a man in his 70s who had been admitted to the hospital several months previously. He was now gravely ill. According to his family, he had been bedbound for 2 years, but for the last several days had now stopped talking and eating, and was bleeding from both his upper and lower GI tract. When we arrived, he was lying in bed in a large wooden shack, covered in a mosquito net, obviously because he did not have the strength to swat away the many flies in the room. Our exam revealed an emaciated man, eyes open, breathing shallowly, with dried blood on his mouth and teeth. The nurse and resident set about examining his back, which caused him obvious pain, though he could only grimace and didn’t make a sound. On his backside was a giant gaping sacral ulcer. The doctors immediately began discussing his condition with his family and recommending they bring him immediately to the hospital for hydration. Unfortunately, this was not the kind of family who could call an ambulance for assistance (ambulances also must be paid for their services in the DR). As the discussions continued, it was revealed that his daughter and caretaker was one of eight children, all of whom seemed to have different opinions on what was best for their father and also, whom should pay. Obviously, this man looked like he needed quite a bit of help, but, to me, he also appeared to be close to death no matter what interventions we might make. Having seen the emergency room at the public hospital, it was difficult to imagine putting this man through the agony of transporting him there and waiting on a gurney in the halls before he could be admitted. I think if I saw this man at home or in the emergency room in New York City, I would immediately refer him to home hospice, but this service does not exist in Santiago. As we left, more and more family members of all ages were gathering in his shack to discuss their next steps. I got the sense that there were many layers of family dynamics to which I was not privy that would determine his fate. The main caretaker promised they would organize transportation to the hospital, but as of six days later, when I left Santiago, the man did not appear.

The final home visit was to a more rural area, though still within the city limits of Santiago. The patient was a woman in her 70s who lives with several of her daughters in a large airy house surrounded by fields, gardens and animals. We actually needed to be escorted to her house by one of her daughters on a motor scooter since street signs were scarce in this area. The patient had been admitted a few months previously for pneumonia. However, when we arrived, we learned from her family that she had collapsed two days earlier and had been unresponsive since then. We found her laid out comfortably in a large bed, surrounded by innumerable family members, several bibles and pictures of Jesus and a priest (not to mention a candle which nearly set my white coat on fire as I entered the room, obviously not paying enough attention to my surroundings). The woman appeared entirely comfortable, but did not open her eyes or react to stimulation of any kind. Her blood pressure was elevated, but otherwise her exam was only notable for her altered mental status. The doctors discussed among themselves. They thought it likely she had had a stroke, probably catastrophically, from which she would not wake up. She was not able to eat or drink. Again, the doctors recommended the family bring the patient to the hospital for evaluation and hydration. Again, I worried that we would do her more harm than good by taking her from her home into the chaos of the hospital, but it seemed unheard of to the doctors and her family that they could tolerate her being unable to eat or drink. Her family seemed genuinely motivated to bring her in, though she did not actually appear at the hospital until five days later. She was still unresponsive and unfortunately, at the time that I left Santiago, still awaiting a bed in the emergency room. Her case was marked on the white board the residents use as their list of currently admitted patients with a special symbol and the words “muy mala” (very bad).

Wednesday, March 24, 2010

From Janina: Eight days in Santiago de los Caballeros, Dominican Republic

To be honest, I am actually at the end of my stay in Santiago, but since I was only here for eight days, I had a hard time hiding myself away to write when I had so little opportunity to explore and experience the city and culture of the Dominican Republic (DR). Santiago is the second biggest city in the DR, much much smaller than the capital, Santo Domingo, but still with nearly one million inhabitants. It is located in the north of the country and is known for its surrounding agriculture, mostly tobacco. While here, I am based at the Hospital Universitario de Jose Maria de Cabral y Baez, the large public hospital serving the poor of Santiago and its surrounding countryside. My host is Dr. Martin Medrano who runs the residency here in Geriatrics. Like all physicians who have finished their training here, he has a practice in the private sector, but he also spends his mornings at this teaching hospital, advising residents and contributing to teaching conferences. He also collaborates with a group of physicians at Columbia on a project to explore the genetics of Alzheimer’s disease, which is how I came to be put under his supervision. He has organized an extraordinary mix of experiences for me, including inpatient and outpatient, private and public, as well as home visits.

On my first day here, I was taken on a tour of the hospital. I had the chance to see the emergency room, crowded beyond anything I have seen in New York and so hot as to be suffocating, not to mention the smell. I saw the wards, with patients and their families sitting together on the simple beds. I stayed into the evening with my “host sister”, Leiny, who is an intern rotating in internal medicine right now and who was on call. At 5pm, the geriatrics resident on call announced we were going to round on the patients. There seemed to be about twelve patients on the service, eight beds in the geriatrics unit (1 room for men, 1 room for women) and a few others scattered in different wards. I was excited to finally hear the stories of the patients, their diagnoses, their current unresolved issues, and the plan for their care. However, as it turned out, what actually happens on evening rounds is that the resident and intern visit each patient, decide which labs the patients needs in the evening and morning, the intern then makes a list of what she must do overnight while the resident makes a list for the family of which labs they must pay for, in advance, so that the intern can draw the labs and the family can pick up the results with their receipt. In about half of the cases, the family members of the patients seemed genuinely surprised and concerned that they were required to pay again for more lab tests and several remarked that they would not be able to pay. According to the residents, there is an office in the hospital where families can go if they cannot pay for the medical services their relative needs, since this is a public hospital and the patients here are the most destitute in the area. However, I also observed on many occasions, in the morning, that the labs simply had never been run because the family could not pay.

This system presents an interesting contrast to our system, where we often think about the consequences of the expensive lab tests we are ordering on uninsured patients who are unlikely to be able to pay, but, at least in the hospital, we never require the patients to pay upfront for what we think they need. One slightly bizarre consequence of the system I observed at Santiago public hospital was that the patients and their families tend to act as the file cabinets of medical information regarding the patient’s care in the hospital. They pay for the lab tests and then carry the results with them, including xray films and ultrasound images, in large envelopes, waiting for the doctors to stop by and glance at the results. God forbid, the patient is seen at one of the smaller community hospitals and then sent to the central hospital for a higher level of care. In this case, I saw one family arrive with at least five of these envelopes, unsure of what they contained and completely baffled by the idea that the doctors would want to repeat some of the lab tests, requiring them to pay again (in this case, the patient had been diagnosed with a deep vein thrombosis before transfer and placed on a heparin drip).

I overheard an interesting conversation between some of the geriatric residents regarding what to do about patients who say they cannot pay for the evaluations that the doctors deem necessary. First of all, the residents seem automatically suspicious of anyone who says they cannot pay and doubtful that they cannot pay, but just don’t want to pay, especially in the case of the geriatric patients who the residents feel are being neglected by younger members of their family. However, one of the residents gave an impassioned speech at the end of one of the morning teaching conferences about how the doctors cannot let the inability of the patients to pay influence which tests they request (even if the tests will likely never be done), because they should always proceed with their care based on what is medically best for the patient independent of their resources. This is, in fact, a conversation that I have had more than once in the primary care clinic at Columbia, which is one place where patients can be turned away from certain evaluations if they cannot demonstrate insurance or pay in advance. I have been taught the same philosophy that the geriatrics resident in Santiago was expressing: that I must first always design the plan that is most medically appropriate for the patient to ensure that I am in no way shortchanging the patient by not considering all options. Then comes the hard part. What is actually realistic for the patient? Can the CT scan be delayed until the Medicaid application comes through? Can a more affordable medication be substituted for the ideal? (how many times do I google the target $4 drug list in any given week?) Can the patient be referred to Harlem Hospital where uninsured people are guaranteed care even though all their previous care has been with us at Columbia? I still feel completely uncomfortable in these situations, and hope I always will, until the situations themselves can be eliminated by better health care structure in the United States. However, the Geriatrics resident in Santiago had an interesting justification behind her philosophy that was one I had not considered before. She said, “If my patient needs an MRI but doesn’t appear to have money, I don’t just not mention the MRI. You never know who has a niece in New York City who can be called upon to help.” And so began my fascinating tour of the many links between the Dominican Republic and my home, New York City.