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.