Wednesday, July 20, 2011

13-June-2011: A Year of...Service?

The next few days I'll be based in Puyo and traveling daily to the rural settlement of Pitirishca (1.5 hours by bus) to work in the Subcentro there.  The clinic is staffed by a nurse, a local administrator (w/ nursing-equivalent training), and a doctor and dentist in their year of service.  This is an interesting aspect of Ecuadorian health care, so let me take a moment to elaborate. 
Here's a side-by-side comparison with the US system:

USA                                    Ecuador
High School                         High School
4 years Undergrad               6 years Medical School
4 years Medical School       1 year of service
3 years Residency                --Attending Physician--
--Attending Physician--

A few points: First, the six-year medical school following basic education is not uncommon throughout the world, and likely foreign only to us.  Many Western countries (England, France, etc.) have similar systems in which the student plunges into a career track without "the luxury of a liberal arts education".  The first two years include all basic science requirements (effectively a pre-Med curriculum), and the later four more closely resembling the medical school we estadounidenses have come to know and love (although ecuadorianos start intensive clinical work in their fourth year).  Another big difference's free.  As you would imagine, that makes admission competitive, although probably for the better...presuming the state is still able to train enough physicians for the country's needs.

While this strategy of medical training is all well and good, I struggle not to take issue with the "year of service".  On paper the approach seems a banner idea, and perhaps even an indication of strong national values, but in reality the practice creates a number of sticky ethical issues.  For one, graduating students are placed in their respective sites in much the way the match system in the States works.  Not all sites have attending physicians, and those that do are often in larger, more popular, and thus more competitive towns.  This means that many sites (including Pitirishca) have fresh medical school graduates practicing with only the supervision of an administrator and/or nurse for advice.  There is typically a two month (or so) overlap with the previous year's physicians, but still...that's not a lot of oversight for young doctors still very much in the learning stage of their careers.  Further, one of the primary goals of the "year of service" is to provide medical care for the poorest (often indigenous) rural communities.  This may be achieving that goal in an explicit sense, but one has to question the quality of care received and the population receiving it.  You can make the argument that some care, even not top-quality is better than none, but that's not a statement I'm prepared to stand behind (and one that sounds vaguely reminiscent of...oh...every civil rights/inequality struggle ever).

Most of the physicians I've spoken with have described their years of internship/residency as one of the most intensive periods of growth in their medical educations.  While that's not to say that the world should mimic our approach, it's hard to see how young physicians can expect to continue learning, or even recognize mistakes, without some form of guidance.  I believe there's great value in encouraging, and possibly mandating, a year of service from highly-trained professionals, but unless those professionals are appropriately trained and ready, their practice is a disservice to the communities they treat.

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