Clinic- A Lesson on Choosing Your Battles

31 Aug 2012

The Pop Wuj clinic is situated below the Spanish school, on the first floor of an old brick building.  The large entrance is closed by bringing down a grilled metal screen that is locked with two padlocks, giving the appearance of a converted garage.  Immediately visible is the waiting area filled with plastic chairs and two triage stations tucked into opposite far corners.  On one side stands the reception desk.  On the other side is the door to the pharmacy and stock room.  At the far end lie three consult rooms where doctors see patients.

There are three roles for students in clinic.  Students triage patients, quickly ascertaining the reason for the visit, their main health history, and their vital signs.  They work in the pharmacy, filling prescriptions then giving patients instructions about how to take their meds.  The most coveted position is being paired with a physician – it is fulfilling to see the whole patient visit from the patient’s story to the physical exam to what the doctor plans to do.  And the Guatemalan doctors on staff, Hugo and Wilder, enjoy having students; there is a lot of learning to be had.

When I started in the clinic the third consult room was occupied by a pediatric nurse practitioner from New Zealand.  Yvette was also seeing patients, with the help of a student-translator.  On the first day of clinic after Yvette left, I was not paired with a doctor as I was expecting.  To my surprise I was partnered with another fourth-year medical student.  We were to take the third consult room and to see patients on our own (with the stipulation that we should ask one of the doctors if we had any questions, of course).  There turned out to be a fourth role for students, as long as one is in their fourth year.

We were slow and saw four patients that morning.  A friendly 16-month old with a viral respiratory infection, a complicated 50-year old with abdominal pain, and two older patients with high blood pressure and diabetes – one in his 60s on at least six medications, the other in his 80s on two.  These maintenance visits were relatively easy.  Their illnesses were well-controlled, especially those of 86-year-old who had 20/20 vision and a blood pressure of 126.  We examined them, refilled their medications up to their next follow-up visits, and sent them on their way.

Soon after they left the other student and I realized that they weren’t on Aspirin.  In the United States it is standard to give low-dose Aspirin to patients who have risk factors for heart disease, such as diabetes and high blood pressure.  It reduces the chance of thrombotic events, developing clots in already less-than-pristine blood vessels.

After clinic we pulled Wilder aside, asking him why these regular Pop Wuj patients hadn’t been given aspirin in the past.  His Spanish is so fast it sounded like boiling water as he tried to explain.  As medical students we are taught to take a patient’s education level, compliance, and socioeconomic status into account when deciding our plan of action for their illnesses.  Wilder cited all of these in his explanation of why Pop Wuj generally doesn’t prescribe Aspirin for this reason.

Though we would be giving aspirin as a preventative measure, it is known as a pain med.  Wilder worries that people would take it inappropriately.  When a patient is on several medications, adding more just gets confusing.  He would rather focus on controlling the high blood pressure and diabetes.  In Guatemala where continuity of care is staccato the Aspirin might not be stopped appropriately, say, before a surgery.  He agreed that the medication was absolutely indicated (non-medical translation: would’ve been quite appropriate to give to those patients).  But still he typically would not.

The message to me was that you have to choose your battles and (for most of our patients) the risks outweigh the benefits.  And yet, I wish I had given it to my 86-year-old who was on two medications and who was totally with it.  I think he has a follow-up appointment in two months.

 

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