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.