PEDS 316I, Dr. Paul Wise, MD, MPH
The Student
Experience
The goal of this clerkship is to couple direct clinical care with a broader exposure to the social determinants of health. The student experience is therefore structured to provide precepted clinical activities as well as participation in a variety of community development activities.
Students in this clerkship will have an opportunity to work in both the Parroquial and community-based clinics. Approximately three days a week, the students travel to one of the outlying communities to hold a clinic with the local health promoter. These clinical sessions begin at about 9am and last usually until 3-4pm. The patient load can vary considerably but usually runs from about 25 to100 patients. The clinical conditions likely to be encountered can vary as well, but generally include URI’s and other viral syndromes, diarrhea, dysentery, parasitic diseases, malnutrition, asthma, skin disorders, tuberculosis, and onchocerciasis. Students will also encounter a variety of adult chronic disorders, such as hypertension, diabetes, and arthritis.
Students are supervised by an attending physician at all times in a manner similar to that employed in most US-based continuity clinic experiences. In addition, the students work with the health promoters who provide invaluable insight into local health conditions and translation services between Kaqchiquel and Spanish when needed. The students take a full history, conduct a physical exam, and then present their case to the attending physician. The attending physician reviews the case with the student and they then return to see the patient/parent together. A diagnostic and therapeutic plan is developed and conveyed to the patient/parent. When necessary, the health promoter is brought in for follow-up.
At least one day a week the students spend time in the Parroquial clinic. This includes making rounds on the inpatients with the clinic team as well as seeing patients under the supervision of the clinic director or the visiting attending physician. The students are also able to participate in the care of traumas, birth deliveries, and other emergency cases that arrive at the clinic.
Students are able to participate in an array of community development activities in addition to their clinical work, e.g. assisting with putting in potable water systems in the local communities, and/or working with the reforestation and medicinal herb programs. Precise opportunities can vary from week to week.
Students are also encouraged to explore the local customs and history of the area. Local indigenous leaders are happy to spend time with students, and to convey their perceptions of local political issues and the determinants of health in the area. In addition, they are often quite generous in providing access to local cultural sites and activities not usually available to tourists.
Several didactic sessions will be held for the students during their stay in San Lucas Toliman. The first focuses primarily on the clinical problems the students are likely to encounter in the clinical sessions. The epidemiology, diagnoses, and available therapies would be covered. The second is a broader consideration of the role of clinical medicine in resource poor settings, including public health and larger economic development strategies. In addition, at least one informal “reflection” session will be held early in the experience to share impressions and concerns. All of these sessions are moderated by the attending physician or other appropriate health personnel.
The Community of San Lucas Toliman
San Lucas Toliman is a town of some 15,000 people located on the southern shore of Lake Atitlan, in highland Guatemala. Its primary crop is coffee and the town is surrounded by a series of coffee plantations and affiliated villages that fall within the larger municipality of San Lucas Toliman. The community is made up primarily of descendents of the Maya and speaks the indigenous language, Kaqchiquel, although most students speak Spanish as well. San Lucas is materially a very poor community with an estimated per capita income of less than $1,000 (US) per year. Most families are engaged in agricultural labor with an average daily wage about $3 per day.
The health problems in San Lucas directly reflect the poverty of the community. More than one in every 25 infants will die before their first birthday. Malnutrition affects about a quarter of all children and infections, including diarrhea and pneumonia cause widespread suffering and preventable death. Tuberculosis remains a hidden killer, a cause of chronic lung disease and disability that can affect whole families over a number of years. Trauma, particularly work-related and motor vehicle injuries is also a major contributor to health problems in San Lucas. Children with chronic disorders such as cerebral palsy, birth defects, and developmental delay have emerged as a surprisingly prevalent and constitute a serious health challenge in the community.
The goal of health effort in San Lucas is to couple broader community development initiatives with health strategies that will ensure that the best preventive and treatment interventions are provided to all those in need. The health initiative in San Lucas is a component of a larger community development program begun more than 40 years ago by the local Catholic parish (parroquia in Spanish), with continued support from the Diocese of New Ulm, Minnesota. In addition to the health program, the San Lucas Parroquia has engaged in a variety of activities including land distribution, home construction, potable water system construction, and microeconomic projects. The health program has grown substantially over the past few years and now has several components:
This 20-bed facility serves as the primary source of direct health care services for the town. It is focused on providing high quality outpatient services and emergency care for urgent health problems. Approximately 50-100 patients a day are treated at the clinic. The clinic is the only health facility open 24 hours per day, 7 days a week. Children requiring intravenous and intensive antibiotic therapy are commonly hospitalized here, as are adults with a variety of chronic disorders. Complicated births are delivered at the clinic as well. Emergency patients are brought to the clinic for immediate treatment at all hours and can either be admitted to the clinic or transferred to the National Hospital in the departmental (state) capital, Solola, for major surgery or complex interventions.
In the plantations and villages outside of San Lucas, the best way to ensure the delivery of appropriate preventive and therapeutic health care has been through the training of local community citizens as health promoters. This program now serves 17 communities with the hope of expanding into more. The promoters have basic education but are specially trained in prevention strategies, health education, and the early recognition of serious disorders. They also have the capacity to provide emergency first aid and arrange referral and transport to the Parroquial clinic in the town. The promoter program is coordinated with the Parroquial Clinic and the promoters meet and continue their training on a regular basis. These activities are coordinated by a local, supervising promoter and by an American nurse practitioner with long experience in health promoter programs in Guatemala.
Technical assistance for the Parroquial Clinic and the promoter program are provided by short-term visits of US-based physicians and medical students. Physicians with specialized expertise, such as general surgery, radiology, and pediatrics, as well as generalists participate in the San Lucas health program on a regular basis. In addition, medical students and students also spend time with the program, although they work as they would in any US-based hospital or clinic, always under the direct supervision of an attending physician. Students from a variety of medical schools, including Harvard and the University of Wisconsin, have had remarkable experiences participating in preventive and clinical care as well as learning about the local culture and the determinants of health in resource poor areas of the world.