Monday, November 21, 2011
Monday, October 17, 2011
Sunday, August 7, 2011
Monday, August 1, 2011
Saturday, June 4, 2011
They had sections where houses, hostels, chairs, tables, and nearly everything was made of salt blocks. I am not sure how it works or what it is mixed up with so that it doesn't melt in the rain. But it looked pretty neat.
This is the largest salt flat in the world. I believe a salt flat is a salt lake that dries up in the dry season and may be a lake during times of rain. Depending on the time of year you go, it is either all lake, all dry white land, or a mix as in the time I went. It looks like you are on another planet, with nothing as far as the eye can see except mountains in the distance and either water or a white snowy looking flat land.
Tuesday, May 10, 2011
Depending on the rotation, I arrive at the clinic or hospital between 8 and 9 am. Until noon or 2 pm I worked with an attending physician. There were days where it was outpatient and days inpatient. On outpatient days, I would often conduct the entire physical exam and report my findings. The attending would sometimes confirm my findings and sometimes just take my word. I only took limited histories from the patients. At times I would assist with the patient records. On inpatient days, I would participate in rounds. I would play the same role as Bolivian medical students. I would usually just participate in discussions and answer questions that the attending asked. I would receive topics to research and present the following day. Only rarely did I receive patients to do history and physicals on who were inpatients.
All physicians ended their day from about 12-2pm and went home for lunch. I would always do the same. I then had 2 hours of Spanish class in the evenings, which would sometimes focus purely on medical spanish, practicing doing histories in Spanish, etc.
The main hospital, Hospital del Nino, was about a 30 minute walk away from my homestay. There were optional other clinics and hospitals which were further. I spent one week at an adolescent clinic service which was a 1 hour combined walking and public transportation commute.
The dress code was very casual. I usually wore khakis and a short-sleeved collared shirt with my white coat as did most other foreign medical students. Bolivian medical students were casual with jeans and sweatshirts with white coats. Attendings were more formal with shirt and ties, slacks.
The attendings were quite attentive. They were always quite busy but all of mine would take the time to answer questions whenever I had them and were very kind. Most would try to find teaching points, give out handouts, and were overall excellent teachers.
The biggest challenge for me was the language. This was the reason I went but my participation was limited by my lack of language ability. My language skills did improve over the month, but I never was able to the point that I could understand all of what was said by the patients or inpatient medical teams.
My first 2 weeks I worked with Dr. Velasco in the depat of pediatriac infectious disease at Hospital del Nino. It was a combination of inpatient and outpatient. The majority of patients were pneumonias, RSV, and other diseases simlar to the US. I did see some disease less common in the US including leishmania, pulmonary and mengineal TB, and ITP.
The 3rd week I worked at the adolescent services clinic. It was mainly a prenatal care for poor, single females aged 16-25. It was primary care on the ground. She spent a lot of time working on prevention of future pregnancies, STD, etc.
The last week I returned to Hospital del Nino working in the pulmonology unit. The attending was a leader in South America for taking care of kids with down syndrome. On our outpatient days, we mainly did normal well child and sick visits for kids with down syndrome rather than a pulmonology clinic. The inpatients were nearly all various types of pneumonias.
I believe this experience will help me in 2 main areas. The first is with my Spanish. I think it has made a huge difference in getting me to a level that I will begin to be able to improve my Spanish by talking and working with patients during my residence and afterwards rather than just no understanding anything and making no improvement. Knowing Spanish may be quite important in my future career goals, as I wish to work with the underserved. My residence is in San Diego, where Spanish is very important and in the future, Spanish will continue to be important to work with underserved Spanish-speaking populations in the US.
The other main area was being able to experience a health care system with limited resources. I can have numerous examples where the care differed than that in the US because of constraints on resources. Some of them were unfortunate, such as the lack of care for most kids with cancer due to the lack of insurance for cancers. Others were good examples of using less expensive but effective drugs, diagnostic techniques, and other choices that would be good examples to physicians in the US.
Friday, April 22, 2011
There were a few differences I saw from the US. They were much more quick to diagnose a disease and give medicine. Nearly all pregnant women with vomiting were diagnosed with hyperemesis gravidarum, a disease of vomiting too much during pregnancy. I rarely saw it diagnosed in the US and have not heard of much medication being given for pregnancy related nausea, but at this clinic anti-nausea medication was given to most people with nausea. Similarly, nearly every pregnant women with a headache (none of whom had any symptoms of a runny nose or cough) were diagnosed with sinusitus and given antibiotics. Vaginal discharge was given a slew of medications to cover yeast, bacteria, and STDs because they didnt have a microscope to diagnose if there were any disease at all.
I cant judge, especially since they have much lower rates of antibiotic resistance.
Next week I will do pulmonology.
Thursday, April 21, 2011
I took a trip to the old capital of the Andean region called Tiwanaku. It is thought to be the most powerful city from roughly 1000 BC to 1000 AD. It was a economic and religious center. It is thought that human sacrifices of the gruesome type were performed. A lot of the buildings and statues were destroyed by the Spanish to "modernize" their cultures. They used the stones of the temples to build churches and beheaded statues, etc. Academics still dont understand how they built a lot of the large temples with the techonolgies at the time.
I personally had a great time as I really haven´t had much experience with ruins this old.
The next day, I went to a soccer game. There are 2 teams in Bolivia, Bolivar and The Strongest. They were playing each other making for a big rivalry so some of us students decided to go. We got about the best seats in the place for 10 dollars. I bought a jersey for 5 dollars and of course routed for that team, Bolivar. Bolivar did win so it was a good day. The ends of the stadium held the hard core cheerers that were constantly singing, jumping up and down in unison in support of their teams. While certain areas of Souther America are a little famous for violence at soccer games, Bolivia seems to be pretty tame. I was surrounded by families with little kids. It was an excellend venue.
Next trip on the schedule: Uyuni salt flats.
Wednesday, April 13, 2011
Tuesday, April 12, 2011
Sunday, April 10, 2011
Saturday, April 9, 2011
Thursday, April 7, 2011
Friday, April 1, 2011
Thursday, March 31, 2011
Sunday, March 20, 2011
Sunday, March 13, 2011
I had a very thoughtful and detailed schedule set up for me before I arrived to the hospital. I rotated in the pediatric department. I worked Mon-Fri, 9-5pm on average. It was divided into 10 half day blocks. Keio has 3 pediatrics wards: the NICU/step down unit, hem-onc and cardiology, and general pediatric floor. I would generally show up for morning rounds and then would have a discussion or see patients for the rest of the half-day block. Many days had special conferences or meetings that I would attend. The schedule was very flexible so that I could change it as I wanted. I requested more outpatient time and was given several days to see various outpatient pediatric clinics. I requested to see the ED and was able to spend a day in the ED. On my application, I made it known that I was interested in infectious disease and public health. I was included in the weekly infection control rounds and weekly HIV rounds. I sometimes attended the infectious disease outpatient clinic, also. Every day was different so it is hard to describe the “typical day.” Regular rounds I attended were morning NICU rounds 1x/week, daily review rounds in the pediatrics general ward, and the most educational rounds were probably the teaching rounds that happen twice a week. Once a week the chief and associate chief of pediatrics each take a half a day and have most of the pediatrics patients presented by a student or resident to them and the rest of the rotating medical students. The professor then critiques the presenting and asks questions about the patients while making educational points. Other attendings and specialists are present to answer questions as needed. When a very interesting teaching point or something that no one knows the answer to comes up, the topic is assigned to a resident to present to the department later. I feel that these rounds were very educational and could be quite useful in
Most visiting students are given living quarters a short walk from the campus. Since I brought a wife and child with me, we had to find our own living quarters. It was about a 30 minute walk from campus. The dress code is the same as most hospitals in
I was assigned a specific mentor during my time there. He was a pediatrics infectious disease specialist. He provided me with his home and cell number and went 110% to make sure I was comfortable 24 hours/day. He invited me to conferences that were in neighboring prefectures that he thought I might be interested in and paid for my train fare if we travelled together. He answered all my medical and Japanese medical policy questions, or referred me to someone else who could answer them. He created my whole schedule and adjusted it. Since I trained at the CDC, he even pulled some strings so that I could talk to people at the CDC equivalent at
At other times, there was usually someone there to help answer questions when I didn’t understand the language or just had something I wanted to know in each ward I rotated at.
Since I had studied Japanese for 10 years and lived there previously, my language made it possible for me to participate in rounds. I am not sure what adjustments are made for those with limited Japanese language skills. All physicians have English skills and there are a good proportion that have trained in
I did not get to see patients independently. You only can observe patient-physician interactions as far as I know.
My wife and I would love to live in
There are some aspects of working in
I am very interested and may be involved in public policy at one point so the following are things I learned about the Japanese health care system that may affect how I approach health care policy or possible practice in the future.
Japan’s healthcare program has become the standard for multi-payer national health insurance systems due to its consistently low costs, easy access to healthcare, and comprehensive benefits package. Ranked 10th for overall health system performance, 1st in level of health attainment, and 6th in level of responsiveness by the World Health Organization in 2000, Japan possesses among the longest life expectancies at birth at 82 years (2003) and highest per capita number of physician visits (WHO 2005). Moreover, Japan only devotes 7.9% of its Gross Domestic Product to health expenditures while simultaneously maintaining one of the highest computed tomography (CT) and magnetic resonance imaging (MRI) technology distribution rates per capita (WHO 2005; Yoshikawa and Bhattacharya 2002).
So how does a country with an aging population provide such great care and spend so little? I am not 100% certain of the answer, but I asked everyone I talked to. The government sets the rates of payment. Hospitals or insurance companies cannot change how much is charged for 1 hospital day or a medicine. These costs are extremely low compared to
There are many things I experienced that made me wonder how they managed to spend so little. They keep patients in the hospital for very long periods of time, especially for end-of-life care. I’m not sure of the laws of DNR orders and such, but it seems very hard to impossible for doctors to pull the plug on patients. I was told that even if there is a DNR order, they could still be sued. So there are patients in the hospital for 16+ years, some in comas the whole time. Even for less severe disease, people stay in the hospital longer. Women regularly stay in the hospital for over 1 week after giving birth. 1 week is common for influenza or any common pediatrics infection. CT scans and MRI scans seem pretty common and easy to order.
They also order lots of medicine for everything. Anyone who has a cough gets special cough medicine that decreases the amount of fluid secreted by the airway. Every patient with influenza gets anti-viral medication. I was told that patients strongly desire medicine so they have to give something to them.
-Adjust schedule to student’s preference
-Excellent attending supervision
-Lots of educational rounds, meetings
-Heavy student involvement in rounds and discussions
-Good food in area
-Might be hard with limited Japanese skills
-Little patient interaction (if you stress you want more, you can get more though)
-Expensive cost of living