Here in our neck of the woods in
central Veracruz, there are not such rigid divisions between what we might call
belief systems. Catholicism is infused
with pre-hispanic beliefs and symbols; western medical practices can be mixed
with folk remedies. For that matter, a
visit to a standard MD may take place in an office overlooked by a picture of
la Virgén de Guadalupe or of a suffering Jesus above a beseeching prayer.
I like this softening of
boundaries. It seems representative of a
culture in which people aren’t so quick to put up the barricades between
themselves and groups and thoughts they see as “different.” They are not so quick to start hurling verbal
(and other) weapons. Divisions certainly
exist, but at least on the surface, daily life tends to be less marred by
hostility and distance. In this regard, cultural differences between the US and
at least our part of Mexico are real.
This blurring of boundaries
exists in the world of healing so that our veterinarian, a researcher trained in the US,
might recommend a “folk” remedy for calming our panicky new dog, our dentist
might refer an anxious patient to a “healer.”
As Jim says, if it works, that’s what matters.
Modern scientific medicine has
led to tremendous breakthroughs in the understanding of how the body works, how
diseases affect it, and to cures which once were unimaginable. Public health practices have improved the lot
of billions. It is the only discipline which offers sound treatment for serious
illnesses such as heart disease, cancer, tuberculosis. It is experts in infectious disease that fight epidemics.
It is trauma medicine which saves bodies shattered and torn in car crashes and street fights and wars. It is modern medicine which prevents and then attempts to heal the scourge of fistulas in women who have given birth
But it is generally recognized
that the practice of medicine in the United States today is a messy, unfriendly
affair. It is hamstrung by bureaucracy,
insurance requirements, institutional coldness, high costs, inaccessibility,
and the attendant difficulty of establishing doctor-patient relationships, so
critical in treatment. It is also
damaged by the corruption of doctors and medical research by the involvement of
special interests in funding and driving research, by doctors themselves
fudging in various ways because of the enticements of drug companies and
equipment manufacturers and because of the don’t-treat demands of insurance
companies: not a pretty picture. Publicity attending these problems stains the profession with further mistrust. For us as patients, perhaps the worst aspect of contemporary US medical practice
is the lack of meaningful personal contact with our medical providers. Sometimes it seems that doctors don’t look at
us, don’t listen to us, don’t touch us, don’t like us and don’t want it any
other way. They look at test results on computer screens. Sometimes they look at the computer screens
when they are half a world away from us.
We are told we have to be “informed patients,” have to do our own
computer searches to come up with questions for our doctors. Have to have reasonable questions so we can
hold their attention long enough to get answers we need. This
depersonalization, in fact, is deepened by the fact that many in the helping
professions are told that “professional” behavior means not getting personally
involved. It leads to a kind of pseudo-friendliness
on the part of everyone from receptionists to nurses to doctors themselves. We face
the often necessarily harsh aspects of treatment, such as happens with
chemotherapy, on our own.
When Jim and
I first came to Mexico, we had strong reservations about going to Mexican
doctors. These reservations were based
on ignorance. At this point, we are happy
to be treated here. Most of the doctors
we’ve seen here, in addition to being competent, retain the art skills of
medicine: they don’t examine the patient via tests and machinery in lieu of
personal contact and evaluation (though of course they use tests and modern equipment as well).
In fact, a
friend and I have decided we will never have another mammogram in the United
States if we can help it. In the US, we found, a
pleasant (at best) but impersonal technician slaps your boobs between the x-ray
plates and squeezes till they hurt. She checks the plates in another room while
you wait, and if there are no problems in the photos, she dismisses you. She is
forbidden to tell you ANYTHING about what your mammographs might reveal. You
never ever see the radiologist. You go home and wait for the results which
often come in the mail unless there is some urgency in which case a
receptionist calls you.
Here when we went for our mammograms,
we found the most up-to-date equipment (in this case, Italian digital). But we
found more. The technician took the
pictures which we could then see immediately on a screen. She then said the radiologist will be in shortly. And lo and behold, he was. He did an ultrasound while he asked questions
and educated. He explained what he
saw. He answered questions. Patiently. Gently.
Wow.
Here in Mexico we have joined the national
health insurance program, IMSS. All Mexicans
who work in the formal job sector are covered by law. People who don’t, but who can afford it, buy
into it. For people our age, in our mid sixties, it costs about three
hundred dollars a year. There are local
clinics which provide outpatient care.
It is decent care, but there are waits. People like us who can afford it
pay to see doctors privately. Costs per
visit vary from four hundred to five hundred pesos, more or less. In today’s dollars, that is between $27.15 and
$33.67. Medicines are free through IMSS, but the formulary is somewhat limited
so people who can tend to go to drugstores. The
hospitals whose services IMSS covers in our area are good. Interestingly, most of the doctors one sees
privately also work for IMSS so you can arrange to have them treat you through
IMSS should you have to go to the hospital. If they don't also work for IMSS, they refer you to physicians they know and trust.
Physician’s offices here in Mexico, even
those of fancier physicians are basic and plain by American standards. Even shabby.
Our internist is in the same small “suite” as Jim’s eye doctor and three
other doctors. The waiting room is
white-painted cinderblock, the chairs are plastic. Two receptionists answer the phone, take
payment, and make appointments for about five doctors. We pay in cash and don’t get a receipt.
Here doctors perform tasks
generally left to assistants in the US. The doctor is often the one who takes
your pulse and your blood pressure asking questions while he does. The dentist is the one who cleans your teeth
and takes the x-rays. These things
enhance the doctor-patient relationship, providing a setting for getting to
know each other.
Our internist, a tall, handsome, self-assured
man in his forties is patient and authoritative. He answers all our questions. He waits until
we are through, never seems impatient.
When Jim got salmonella which he diagnosed even before Jim went to the
lab – by touch and by questioning Jim, we talked about important habits to
follow. It’s too easy to forget them as
we slip into everyday life: buying fresh diced fruit sprinkled with chili powder
on the street, eating salads, dipping into salsas which may have sat for hours
on tables. He didn’t give Jim a booklet
and simply say, “read this.” He talked
about the medicines he prescribed and what each one did. He explained the likely course of the illness,
and what to watch out for. And he gave us a scholarly discourse on salmonella
because we were interested. I would like to emphasize his keen awareness of public health interests and his efforts to educate patients in them.
Yesterday or the day before in
the NY Times, I read Pauline Chen’s column on pay-doctors-for-their-performance plans for improving efficiency and
quality (actually lowering costs) in the US.
They have not been properly evaluated and are proliferating like
rabbits. It seems to me yet another
effort to slap more bureaucracy onto a very bad system, to find a strange,
pseudo-scientific structure which shows no understanding of the importance of
the human relationships in medicine. In the US, people too often seem compelled
to seek simplistic “systems” solutions to problems. We have lost our way. A misguided bureaucratic
faith in efficiency trumps caring for people.
Mexico’s system is of course
badly flawed: it doesn’t deliver well for everyone. Its resources are strained. Poor people in rural areas and in the midst
of giant cities are screwed. But at the
level of one doctor treating one patient, there is much the people trying to
improve medical care in the US could learn.
Sometimes it is the relationship between doctor and patient, the doctor’s
hands-on exam which can save money by discovering what tests are really
necessary. Sometimes it is this relationship which provides the patience with
reassurance to keep him from panicking and going from test and doctor to test
and doctor. But I suspect we would insult Mexican physicians if we framed what
they do as cost-saving measures.
I just finished reading Cutting
for Stone by Abraham Verghese, one of my heroes. Verghese is a physician, currently
on the faculty at Stanford Medical School as a tenured professor. I have been reading his work for many
years. Cutting for Stone is a novel
about a young boy growing up to become a doctor in Addis Ababa where in fact
Verghese did pretty much the same. Aside
from being an absolutely captivating novel in the sense that it sucks you in so
you can’t put it down, it is an ode, if you will, to the practice of medicine
as art as much as science, the art being the doctor’s skill and intuition, her “feel”
for her patients which she acquires through her relationships with them, and which improve with experience. In the United States, the art part of
medicine, the part that makes us human, which eases treatment and enhances
healing is itself a patient on life support.
It is hard to tell American medical systems to look to practitioners
from developing countries for help, but they should.
Recent Comments