7 Feb 2013
When one of our doctors noticed that Isaías’ heart murmur had gotten stronger he became one of Pop Wuj’s chronic patients. Because of his family’s limited means, for specialty cardiology care his mother Gloria was instructed to take him to the university/public hospital clinic where an appointment costs less than USD $1. Dr. Garrías, their cardiologist, recommended that Isaías receive an echocardiogram. There was one hiccup. The university’s equipment was out of service.
“No problem. Bring Isaías to my private clinic. As a university patient he’ll get a discounted rate,” Dr. Garrías told Gloria. All this was before I began working with the family.
When I became his de facto health advocate I took Isaías to the private clinic for the echo. The cardiologist was, in a word, unprofessional. He arrived an hour and a half after the start of his posted clinic hours, did not apologize, clearly didn’t remember Isaías and Gloria.
The worst part: After he performed the echo he handed the report to his secretary in a sealed envelope. He then went into his office, shutting the door behind him. The secretary called me over to give me the report and tell me how much to pay for the visit.
“Pero doesn’t the doctor want to talk with us?” I asked.
“La cosa es que this visit just covers the test. You should take the results back to the doctor who originally referred you.”
First, it’s basic protocol for a physician to discuss test results with his/her patient. Second, just because we’re paying a discounted rate doesn’t mean we should get treatment that’s below the standard of care. Finally, he’s the referring doctor. He’s one who told us to come here.
But I didn’t argue. I didn’t know the system well enough and I didn’t want to burn any bridges. Instead I brought the report back to Pop Wuj. The Christmas holidays were coming up so it sat for a little while. Finally Carmen, the director of Pop Wuj’s social outreach programs, became sufficiently non-busy to have a great idea. “Nicki, why don’t you bring Isaías back to Dr. Garrías in his university clinic. Then he’ll have to interpret the result for less than a dollar.”
Sneakily smart, Carmen. Why didn’t I think of that sooner?
Medical students dressed in all white –pants with fully-buttoned coats – were the entire staff of the clinic. They looked like chefs wearing thick white pajama pants. The medical student working in reception asked me for Isaías yellow card with his patient number. I had no idea what he was talking about.
“Perdón, pero no la tenemos.” I’m sorry but we don’t have one.
“Has he been seen here before?”
“Yes, he’s a patient of Dr. Garrías’.”
“Without the card, we won’t be able to find Isaías’ records.”
I put on my best pathetic face and said, “Could you please try looking by his name?”
He nodded his assent. Standing up he walked over to the medical student working in records to explain what to look for, before directing us to one of the consult rooms.
After several minutes two different people dressed in white came in. Angélica and Veronica. It quickly became apparent that Angélica was the older medical student, Veronica the younger.
“They haven’t found Isaías’ chart yet, so were going to re-fill out parts of the new patient intake form. First, why is he here?” Veronica asked.
“He’s had a heart murmur for a while but it recently got louder. He was seen here by Dr. Garrías who had him to go his private clinic for an echo. We just want to know what the doctor has to say about the echo.”
“But why is he here?”
“Um… ¿Cómo?” I thought I just told you why.
“What symptoms does he have?”
“Uh, none.” In my head: But he doesn’t need to have symptoms. He had a murmur that got louder, which should be enough of an indication to see a cardiologist.
She turned to Isaías. “Do you have any breathlessness? Get tired easily? How about palpitations?”
Isaías glanced at me with a confused look, then back at Veronica. “No.”
Well, who doesn’t? I wondered if Gloria said that to satiate Veronica, or if the questions had made the mother in her more nervous than she already was.
Veronica finished her questions. The two began to examine Isaías. They were looking at his eyes with an ophthalmoscope when the student working at records popped in. He had Isaías’ chart in hand.
Yes! I thought.
Eventually, Veronica asked me about the echo again. “So Dr. Garrías did the echo in his clinic?”
“Yes, would you like to see it,” I said as I reached into my bag. It was a rhetorical question. Her answer should have been yes.
“No, that’s okay. As long as you have it.”
That’s odd. In the US I’d get chewed out as a medical student if I didn’t look at all the information, especially available test results.
Veronica used the patient bed as a table while she refined her notes, with Angélica guiding her along. It warmed my heart to see that some things cross international borders, including stressed-out medical students frantically putting together presentations for their attendings.
Eventually, only 45 minutes late this time, Dr. Garrías did arrive.
Veronica presented Isaías’ case. She got through his history, was on to describing his physical exam, when Dr. Garrías interrupted her. “Wait, why is he here.”
She explained his fatigability symptoms again.
“No, that would be why he first came. You said that I had seen him before, so why did he come back.”
Veronica looked blankly at me.
I said, “You sent him to have an echo in your private clinic. We’d like to know what your recommendations are based on the results.”
“Did you bring the echo report?”
Turning back to Veronica he asked, “Did you look at it?”
Veronica mumbled, “Ehh…”
“Ay, Veronica.” He bemusedly shook his head. “You have to look at everything.” Dr. Garrías took the echo from me. “And who are you, exactly?” he asked.
“I’m a volunteer with a project that’s supporting the family.”
“You work in healthcare in the US?”
“Yes, I’m a medical student.”
After reading the report he pulled out his stethoscope to listen to Isaías’ heart. When he finished he began to ask Isaías and Gloria more questions.
“So Isaías gets tired?”
“Sometimes,” replied Gloria. “When he’s active.”
“But not all the time?”
“If his heart were the cause the symptoms should happen consistently, all the time, not just sometimes. Does Isaías have any issues at home or in school? Are there problems in the family? It may be worthwhile to take him to a psychiatrist. But before we do that we can test his thyroid function…”
“Entonces doctor,” I interrupted, “based on the echo, you don’t think Isaías needs further treatment for his heart? No surgery, no medications?”
“No, he’s fine. The few things that came up on the echo were mild. They should not be causing his symptoms. Just keep following the murmur.”
Dr. Garrías wrote an order for thyroid function tests. He then bid us goodbye and exited, the two students following behind him.
“Did you hear that, Isaías? He said your heart is fine!”
Isaías smiled and raised his right arm. We clapped hands loudly in a high-five.
As we checked out we were told we’d have to pay for a replacement yellow card. I started to open my bag when Gloria stayed my hand with hers, paying the fee herself.
For details of the beginning of Isaias’s story, see: https://naranetacrossing.wordpress.com/2012/11/30/isaias/