This is a rough overview of the contents of my interview for the University of Washington School of Medicine (UWSOM). I wanted to type up what was said as soon as possible because I knew I would forget most of it if I didn’t, and I know that a lot of people might be interested in hearing some of the questions that were asked. Obviously the interview experience is vastly different for every person- this one is specific to my experiences, but they do ask some stock questions that could be applied to other people. so knock yourself out- I hope this is helpful, or atleast thought provoking. Let me know if you have questions!

The interview panel consisted of three board certified family practice physicians- all Caucasian men in their fiftys. One was an associate dean of Multicultural Affairs at UWSOM, one was a doc in private practice in Port Angeles, WA, and the third was a co-director of the Targeted Rural and Under Served Track (TRUST) to which I was applying. More info about TRUST can be found here: http://depts.washington.edu/fammed/predoc/trust

“So we understand that you just graduated from Evergreen in the summer with a degree in biochemistry. Catch us up to date on everything that’s happened to you between then and now- what have you been doing with your time to prepare yourself for medical school?”

I walked them through everything that had happened to me since graduation- including details like “Taking a road trip down the coast with my parents to San Francisco”, but focused more on the big things that I knew they were looking for; working as a political fundraiser for the first 10 weeks, then interviewing at various clinics and starting the AmeriCorps internship in September. This was a perfect transition into talking about my current work, and how I am doing what I think will prepare me for medicine better than anything else I have done yet.

“How did you find out about this opportunity to work in a low-income clinic?”

Told them about how the daughter of one of the nurses I worked with at the student clinic in junior year went through the same program, is currently in medical school, and that it sounded like an incredible opportunity to get some exposure to “real world medicine” and test out my interests and ability to handle the work. More info about the Community HealthCorps can be found here: http://www.communityhealthcorps.org/healthcorps-americorps.cfm

“What kind of work do you perform at the clinic where you work now?”

Mostly work as a medical assistant- performing basic clinical work (vital signs, making appointments, phlebotomy, immunizations, EKGs), but that I also have the unique opportunity to work on health projects that are of interest to me and beneficial to the community.

“What have you taken away from that experience so far- what’s the biggest lesson you’ve learned?”

I explained how I have learned countless gems of knowledge from the providers, but that overwhelmingly the most important lessons I have learned have come from the patients themselves. They asked me to describe a specific example, and so I told them about an interaction which I had had with a patient about two weeks prior, which stuck with me, and was something of a revelation: I was asked to perform a blood draw on a patient, and when I went into the room, Mr. Green was very agitated, and described to me how all of the nurses and medical staff he had interacted with lately had been unjustifiably rude and unwilling to answer his questions about why certain tests were being performed. He was extremely upset about his last several encounters, and at one point he asked me directly “Tell me, why are you here? What are you and I doing here together right now?” I was a little unsure of what he was actually asking, but I went ahead and answered him anyways, “I’m here to take your blood so the doctor can know how best to help you...” I said. “Exactly! You’re here for me. You’re here to help me out, so why’re all these other people actin’ like I’m inconveniencing them from doing their jobs when I’m askin’ ‘em a question?”

Two days later I was reading about professionalism and what it means for physicians to be professionals, and I came across the term “fiduciary duty”. This concept is what distinguishes business from a profession, and means that professionals have a particularly stringent duty to assure that their decisions and actions serve the welfare of their patients or clients, even at some cost to themselves. As I read more about fiduciary duty, I realized that this was exactly what Mr. Green was talking about, only that he was teaching me about this concept from personal experience, and conveying his thoughts with pure emotion. I had thought about this concept numerous times before, but from a strictly intellectual point of view. It took Mr. Green’s emotional appeal to make the lesson really strike home for me, and now this is something that is constantly in the back of my mind, and I will never forget. Check it out: http://depts.washington.edu/bioethx/topics/profes.html#ques2

“Based on this concept of fiduciary duty that you just mentioned, what would you say is the quality of care being delivered to the 1300 patient population at the Housing and Urban Health clinic?”

Part of the nature of working in a publicly funded community clinic is that we are constantly lacking in the type of equipment that is readily available in most private clinics, or at places like Kaiser. While our EKG looks like it’s from 1985, and we are often out of very basic supplies, I strongly believe that the human component of the care we provide often makes up for what we are lacking in physical resources. Our providers get to know our patients very well, and are very willing to make the necessary phone calls or even home visits on occasion to make sure that continuity of care is upheld, and that our patients do not fall through the cracks.

“So why medicine? There are plenty of other careers that provide ample opportunity to serve people in the ways you have discussed, and also to gain great satisfaction and fulfillment. What is it about medicine that appeals to you”

This was challenging, because I wanted my answer to be unique, honest, and convincing. I told them my very personal ideas of what a fulfilling career would look like for me, and how I have found that I am happiest when I am actively working to build a healthy community of people around me, and that I have talked with several doctors who say that their practice is fulfilling for very similar reasons. I tied my response back to my interest in primary care, and how I look forward to building relationships with patients over time, thus feeding my own emotional and spiritual needs while working for the health of my community.

“You have a great deal of shadowing experience with a wide variety of doctors- mostly family practice. Tell us what you have learned about this profession, and why you are interested in it.”

I told them about how all of the primary care doctors I had worked with shared one trait in common: they were all excellent multi-taskers, and that they needed a broad knowledge base to serve them in any number of situations that may arise.

Follow-up question: “So you’re basically saying that we’re jugglers of tasks, and always have a lot on our plate. Tell us about your ‘juggling ability’- how well do you manage multiple tasks that are simultaneously demanding your time and attention?”

The example I focused on here was specifically when, during my junior year, I worked in the school medical clinic part time, volunteered as a tutor at an elementary school two days per week, was enrolled in night classes four nights per week, and was acting as the lead coordinator for my school’s pre-health student interest group. I explained how I was constantly switching modes throughout the day, and I had to be constantly shifting from the role of employee into student, volunteer into group leader, etc.

“Where do you see yourself working in ten years?”

I see myself working in a community clinic, much like the type of clinic that I shadowed for a week three summers ago in eastern Washington. They Yakima Valley Farm Workers Clinic Association is a network of community clinics in Washington and Oregon, and I got to spend a week there with a doctor who I had met previously, while she was doing her residency in Olympia. I loved the opportunity for collaboration at that clinic. I observed a pediatrician consult with a dentist about an odd growth in the mouth, and saw providers talking over cases with each other routinely. I talked about how I work best in small groups, and I think this would be an ideal setting for me for this reason.

“I see that you spent several months on the Lady Washington. Let’s pretend that all of the crew from the boat that you’ve ever worked with are sitting here at the table with us. What do you think is one thing they might say that you should change about yourself before becoming a doctor?”

This question also sucked. It wasn’t that it was unexpected, but more so that the context was so bizarre- he was basically asking me what my weaknesses were 6 years ago- how is this relevant to me today?! I said something about how I was much more immature then, and how my shipmates would likely want me to gain a bit more composure and dependability. I dunno...

Role-play Scenario: “Ok, I’m a patient of yours down at your clinic in San Francisco with a history of drug use, and now I’m in the hospital with an infection in my heart valves. The nurse has been noticing that I am much more drowsy lately, and a recent urine tox. screening reveals high levels of opiate narcotics that you are not prescribing to me. In addition, my two buddies who you know are friends that I get high with sometimes have been visiting a lot lately, and are in the room now with us (motions to the other interviewers). Now let’s go into a role-play where I am the patient and you are my doctor.”

I actually really liked this question, because it’s not too far off from the type of situation I see on a regular basis with our patient population- huge incidence of substance abuse often coupled to chronic mental illness. I used basic motivational interviewing (MI) strategies that are taught to every person who works in situations where they are required to talk to people about difficult subjects (drugs/alcohol, mental illness, sexual health etc.), and eventually got him to admit that he had been injecting heroin for the past several days because he was bored in the hospital. MI emphasizes the use of open-ended questions, affirmations, reflective listening, and summaries. The goal is to get the patient to come to their own conclusions and decide what course of action is best for them. We then moved on to discussing why injecting drugs might be dangerous given his current condition, and talked about what he desired regarding his care, quality of life etc. There are four things to always keep in mind when dealing with ethical issues, and I made sure to address each one: Medical indications, quality of life for the patient, patient preferences (which can sometimes differ from quality of life), and contextual features (family desires, legal issues, etc.) Read about it: http://depts.washington.edu/bioethx/tools/4boxes.html

“I’m going to shift gears a little bit here. You have probably heard a lot about the current debate over reforming our health care system. Talk to us about what you know about directions that health care is going, and try and tie the new health care reform law in to your discussion. How do you think this style of reform might affect different areas of health care? You can take this anywhere you want to go with it.”

Not health policy! This one was also not unexpected, but very difficult because there was no specific question- he opened up the table for me to talk about any part of the behemoth health care bill, or what I like/don’t like about our current health care system. I began by laying out the problems afflicting our current system: ever-increasing costs ironically coupled with decreasing quality of care, inadequate reimbursement of primary care for preventive services, overburdened emergency services etc. Individual mandate is a necessary step to curb rising costs for the country as a whole, but I think that without increased regulation of the private companies that have gotten us into this ship-wreck, I am not fully confident that they will do what is best for public health, and will exploit this broad new customer base with inflated prices, and continue to profit off of illness in this country- capitalism is very good at doing this.

“Why do you think it is that health care costs so much in our system?”

This is not exactly what I said (I can’t remember), but it captures the general idea. I think that the issue at the heart of so many of the problems strangling health care right now is the concept of choice. Collectively, our culture has come to value choice above all else- and this has been great for the public in many ways: people who can afford basic services don’t have to wait long for treatment- your deluxe, private insurance will pay for this unnecessary test- sure, here you go! Meanwhile, the marginalized members of our society are increasingly stuck with higher costs, or worse- no care at all. Seniors, low-income families, ethnic minorities, the millions of unemployed, people with mental illness, people struggling with addiction. These are the ones who are left out of the game, cannot afford to buy in to the private services, and are thus overloading the limited public insurance programs and benefits that are available. The model of expansion has driven private insurance into a corner, and they are now too large and too complex to fulfill their professional duty to the people they are supposed to serve- health care has become a business dominated landscape, and on the large scale, this idea of fiduciary duty has been forgotten, and doctors are all too often acting as pawns in the pyramid scheme that has become our health care delivery system.

“Lastly- there are many other highly qualified applicants for the TRUST program at UW. Why should we choose you rather than any of them, and what experiences and qualities do you have that make you the ideal applicant for TRUST?"

Well I don’t want to badmouth any of the other applicants- they all seem like great people who would make excellent doctors someday. I just feel like the TRUST program was designed to fit my interests, my background, and my learning style. By growing up in a town of 8,000 people in western Washington, I am inherently familiar with the feeling of being geographically isolated from specialist care, and thus understand the importance of excellent primary care. I remember having to travel two hours just to have a consultation with a hand surgeon when I broke my wrist in high school. I feel that my upbringing, paired with my experiences shadowing and working with physicians in underserved health makes me an ideal applicant for the TRUST program.

“Do you have any questions for us, or anything else you would like to let us know?”

At this point I had taken tours of both the Seattle and Spokane campuses, sat through several lectures at each location, and talked with several medical students and faculty at each location, so in all honesty, all of my questions had been answered at this point, and I couldn’t think of anything that I had not already asked somebody. I did take the opportunity to tell them about some research that I had collaborated with a general surgeon on back in Olympia, and to explain that I had not included this info on either of my applications because the paper has yet to be published. The project was a basic literary review of any possible correlations between placement of arterial stents in the superior mesenteric artery, and superior mesenteric artery syndrome (SMAS)- in which the blood vessel is occluded by compression between the duodenum and the posterior abdominal cavity wall. This condition leads to acute mesenteric ischemia (intestinal death due to lack of blood flow), and was observed in a patient that this surgeon had operated on. He was curious as to whether or not a stent placed by another surgeon had led to the life-threatening condition, and I did the work of searching through databases and reviewing known causes of SMAS. We believe that we found a novel risk factor for the syndrome, and submitted a manuscript in early 2010 to several medical journals.

They thanked me for the info, and said they would make note of it in my file (They actually do appreciate you updating them with things like this at any time throughout the application process).  They thanked me for coming in, and said they would be in touch. And now I wait!

"When I first met the doctor he had this new girlfriend- now he's married to her. Me and the doctor go way back, let me tell you. I've known him longer than almost anybody!"

The T line emerges from the tunnel and glides south along the embarcadero through the light autumn rain. Monty and I are both forced to squint and throw up our hands as our eyes readjust, struggling to adapt to the glare of the sun low over the horizon.

"Wow, this part of town is beautiful- I haven't been here in years..." Hands pressed against the glass like a schoolboy on a field trip, Monty takes it all in- this part of the city less than two miles away from where he has lived for many years. Other MUNI passengers cast sideways glances at this slightly unkempt, off-balance white-haired man who's had years of practice at keeping his word-slurring to a minimum- but you can still tell.

It is 8:30 on a Tuesday morning, and while I would normally be sitting at my tiny desk at a primary care clinic in the tenderloin, I am on a ‘field trip’ with one of the patients of my medical director (the doctor), on the way to get a CT scan. No, you may be thinking, this is not a routine errand that I run, and most patients are expected to show up to these specialty referrals on their own, but then again Monty isn't like most patients. His reality takes place in a near-constant state of alcohol intoxication, and thus, sticking to routine appointments is nearly impossible.

This was no routine appointment however. Today he was scheduled to get the first of a two-part series of Single Photon Emission Computed Tomography (or SPECT/CT) scans in order to determine if he had carcinoids- a type of slow-growing neuroendocrine tumor invading his intestines. First he needed to get an injection with a radioactive imaging dye, followed by a full body scan four hours later. With accurate foresight, his doctor recognized that this task would be impossible if he were sent alone, and so I was enlisted as his guide and timekeeper.

When we arrived at the state-of-the-art UCSF medical imaging center in China Basin, the exceedingly helpful receptionist greeted us, and had us sitting in the imaging waiting room within five minutes. Despite my repeated explanations of what exactly he was here for, and what was going to happen, Monty Green seemed to possess no cognizance of what was happening. He literally did not know what the scan was for, and that his doctor suspected he had a cancer growing within his body. The fact that he did not understand why he was having this procedure done made me anxious that he would underestimate its importance and unintentionally botch the scan. All too soon, my anxiety proved to be for good reason, and before the end of the day I felt like Sisyphus running downhill after his boulder.

I had a prearranged meeting after which, I explained to Monty, I would come straight back with some lunch for him near the end of the necessary four hour waiting period before the first scan. He seemed okay with this, yet I sensed that he still had doubts as to why it was necessary to be here. I took my leave of him, thanked the receptionist, and when I triumphantly returned four hours later with a sandwich, chips, and soda, Monty was gone. Not finished and checked out, just gone. The receptionist thought he was just going out to get a bite, and told him to be back by 1:00- nearly an hour ago. I felt my pulse begin to pick up, even as I tried to keep the panic out of my face. How could I let this happen? I had been trusted with getting this guy safely to and from his appointment , and I had failed- now he was probably wandering the streets- lost and confused. And it was all my fault.

Launching into a methodical search pattern, I began spiraling out from the imaging center, eyes frantically searching for the stooped, white-haired figure of my lost ward. I peeked in the windows of every bar, liquor store, and restaurant I passed, but to no avail. It started to rain, and I began losing hope. I phoned his doctor to see if he had any ideas of where he might be. “Just break out your Geiger counter, and follow the beeping!” This was exactly what I needed to hear, as it helped to instantly add a bit of humor to the situation. “He probably went home. You did your job, let’s just call his building tomorrow and check to make sure he made it safely.” The next day I learned that he had gotten hungry and decided to walk the 15 or so blocks back to his apartment- and somehow made it back safely.

On the way back to the clinic, I called the imaging center, and learned that the most important scan was actually the next morning, and that if we could make it in to this one, much of the damage could be corrected. I made this my top priority the next day, and was at his door promptly thirty minutes before his scheduled scan. When he made his appearance, he squinted at me, and said “You’re Jesse right? What happened yesterday?” It turned out that what had actually happened was that Monty had little to no recollection of any of the events from yesterday- the 20 minute train ride, or the walk back to his apartment. While we were down in the lobby waiting for a taxi, he leaned over to me and confessed, “I took a couple slugs from the bottle before you got here. Just to help me keep it together.” It was 9:30 on Wednesday morning.

We arrived at the imaging center together for the second day in a row. If Monty had any recollection of the place, he did not show it. While the large drum of the multi-million dollar machine slowly spiraled down the length of Monty’s snoring form, the technician remarked “Yesterday’s scan wasn’t actually that important- mostly used for eliminating background noise. It’s a good thing you made in today though- this is the money shot.”

After the scan was complete, Monty and I walked across the street to grab some sandwiches from the Safeway deli. He had awoken from his nap with a vengeful hunger, and I didn’t think he had eaten anything since we had seen each other last. He tore into his sandwich as we crossed the street, and was completely preoccupied with the act of consuming his prize for the major part of the way home. I stashed my half of the sandwich in my coat pocket, planning on giving it to him before we parted.

When he was finished licking his fingers, and cleaning the mustard from his whiskers, he looked at me with watery eyes and asked with genuine curiosity: “Why have you taken such an interest in me? Why are you being so nice to me?” I paused to contemplate his question seriously before replying. “Think of me as an extension of all the people who are in your corner, and who want you to be well. I don’t know you personally, but I want to help you get the care you deserve. I’m fortunate to have a flexible schedule which allows me to go with you to the hospital to make sure you get what you need. Think of me as an instrument of the doctor, and just one of many people who care about you” Seeming satisfied with this answer, he sat back and watched the city glide by, until the train descended into a tunnel, and the day light was blotted out.

I strolled through the site, taking in the enormity of the work that must have been done, and the age of the perfectly stacked stone walls, which have stood strong for centuries. In order to travel between levels, steps were constructed by placing elongated, flat stones at strategic points in the walls of each terrace, so that they jutted outwards and formed perfect, alternating steps. Despite my acclimatization to the altitude, I was soon winded after climbing down, and then up the enormous structures. The sun was hot, and I decided to break for water and lunch, and then stubbornly begin the 13 km trek back to the main road. Luck was with me however, and just after I passed the school on the main road, a different camione stopped and coaxed me to climb up into the cab with the drive, and 2 others. The driver was one of the friendliest, cheeriest people I had met during my travels, and he dedicated atleast half of his concentration on talking, and looking at me, because he found it fascinating that a gringo, especially an American was walking this long road, alongside the local people. We had a pleasant drive, and I told practically my entire life-story while the others laughed, and smiled approvingly, especially at the gratuitous compliments I showered on them about their beautiful country. After a crash-course lesson in Quecha- the local indigenous dialect, and near hysterics at the way I pronounced “common” words, I was dropped off in the town of Maras. After another short walk, I was picked up by a friendly cab driver, who insisted that I climb in, free of charge, and was brought as far as the next turn-off road.

Nothing more of great interst happened, until midway back to Cuzco, as I was doaing in the back seat of a taxi, all the people around me woke me up with exclamations of surprise, and the car suddenly slowed to a halt. I looked wildly around me, and when I was convinced that we had not hit anything, I noticed a motorcycle with two people on it had collided with the guard rail on the side of the road ten meters behind us. It had begun to rain, so the road was wet, and at that moment, hail begain pelting down all around us, making an enormous clatter, which did not simplify the situation. The driver jumped out, and ran back to see if he could help- both people were standing, but not walking. He soon returned, and we reversed backwards, until the hatchback was righ up close to the motorcycle, and opened it for the boy to climb in. It was apparent that his left leg was badly injured, and he had to be lifted into the open car. Blood was visible seeping through his pant leg, and he was clearly in a great deal of pain. The other passenger- the boys mother, was dripping blood from her right hand, but she seemed more concerned with her son’s injuries than with her own. We left the scene in the pouring rain, and sped off to get the boy to medical attention. We arrived after about 15 minutes, at the place- not really a hospital, but more of a clinic outpost, staffed by guarded officials, who opened the gate for us. The kid was lifted out of the back, and carried inside by the guards, and we drove off. I never saw anybody who looked like a medical provider, and there may well not have been one there that day. Soon, I was back safely in Cuzco, only to have my camera (actually my brothers- sorry Morgan) stolen from my backpack when I walked into a crowd of people, watching a parade. I had many great pictures, but because of this, I have been forced to describe them with words, and let you find any of the numerous pictures that are available on the internet if you are so interested.

Rushing to eat my Pomello with a miniature spoon that only delivers a minuscule morsel with every scoop- the clock says I have plenty of time, but I know better than to believe it. I always set my clocks ahead- why in Bolivia do clocks seem to be set behind? I spit out the 27th seed, and exasperated- resort to squeezing the sweet juice out of the rind, rather than playing the fool with my little cucharita. I bite into y egg sandwich, and go to wash it down with my mug of tea- drat! It's too hot to drink! I patiently blow air on it, while my mind pictures the bus leaving without me- my seat given to some other lucky passenger. I down the Pomello juice, wolf the rest o the sandwich, and gulp half of the tea- and then I'm saying my goodbyes in broken spanish, as I hoist my bag on my back. Out the door, halfway across the street and then- agh! I forgot the cheese and yogurt for my trip in the fridge! Back to the front door- ring the intercom to the 3rd floor- "Lo ciento, me olvide el yogurt y queso en la nevera." Up the elevator- I'm met in the hallway by Maryann- one of the women of the house- holding my bag and laughing at me. "Que te vaya bin, ciao!” Back outside, flag the first taxi I see: “Terminal del buses, cuanto cuesta? Ocho bolivianos- perfecto.” As I hop inside, one of the handles on my plastic food bag breaks. I cram myself into the undersized seat, and vamos!”

Two blocks away I realize that I left my Nalgene full of fresh water- my primary reservoir and my constant companion. No matter- I have a backup- no turning back! Traffic is terrible, so we take an alternate route- dipping down into the valley and then winding our way up, along hairpin tight turns on a high-speed road. We arrive at the terminal, I sprint inside as best I can while carrying two heavy bags. “Cuzco?” I confirm. “Si, pase a través de este puerta aquí.” I pass through the door, climb onboard, and…I’m the only person on the bus. Not only is the bus nearly empty, but it is NICE. I’m talking really nice (by Bolivian standards). It is a double decker, and I am sitting on the upper level, with enough leg room to put an emergency exit row in first class to shame. I settle into my throne, with one of the television sets directly above and to my left. A few other passengers filter in, still leaving every person with 10 seats to themselves. A young Brazilian guy named Ricardo, who is spending six months volunteering in Cuzco sits across the aisle from me, and we strike up a conversation in Spanish about traveling, volunteering opportunities, and things to watch out for when I arrive in Cuzco. We both settle in for a beautiful, relaxing ride, which is where I will leave your for the moment.

As promised, a snack and “lunch” was provided on the bus- far better than Greyhound I’ve ever ridden. The snack was a small cup of very sweet, hot tea with a cold empanada- small pastry with cheese inside. As we were departing the lakeside town of Puno, lunch was handed out- a small bread roll, with a slice of ham in between- literally - with a plastic bag filled with peach juice, which you drink by biting off a corner of the bag, and squeezing the juice into your mouth with your hand. For dessert, there was a small pack of wafer cookies, and a small hard candy. I was extremely pleased by all of this, as it was the first complementary service I had seen in my time in South America. Alas, I was not quite filled, and so two hours later, just outside the town of Juanita, I tucked into the cheese roll I had brought with me, accompanied by the last one of the packs of whole wheat crackers I’d purchased in La Paz. The only cheese I have seen while I’ve been down here- apart from the extremely expensive stuff in supermarkets- comes in the form of round, cylindrical wheels- totally white, and with absolutely no flavor, aside from a bit of saltiness. You can buy a medium-sized block for 1 US dollar however, and it makes a great addition to plain crackers- also very cheap. Topped off by a banana and a box of chocolate milk- not a bad fare for 2 dollars total!

Cuzco lies in a region called the Sacred Valley, and scattered throughout the enormous valley are numerous Incan ruins, all within a half-days visit from Cuzco.  On my second day, I decided to visit the ruins of Pisac- about an hour drive by bus, followed by a 4 kilometer hike.  The bus ride was representative of typical Peruvian transportation- buses and cars racing each other along incredibly steep switchbacks, drifting across the yellow lines as if they are only there as a suggestion, and not actually meant to be obeyed.  The town of Pisac lies next to a flowing river, on an uncharacteristically flat swath of land, between two enormously high ridges, parallel to each other, and the river.  Before setting out from the town, I ate a lunch of avocado (the biggest one you've ever seen) and crackers, and purchased a mango and a pepino- a tropical fruit that I had never heard of before, and my new favorite fruit of all time.  It's flavor is that of a mix of mango and pear, yet it almost resembles an apple- green with dark purple stripes.  As I sat, gasping for breath partway up the steep trail, pepino juice dripping from my chin, I felt that it was going to be a good day, and that I was in for an adventure. 

About 30 minutes into the climb, along steep terraces constructed on the hillside- used for farming by the Inca- I caught up to a boy, also walking the path, but taking a break and playing a traditional flute, looking down at the valley and the town below.  He was very friendly and curious about me, as are most Peruvians, and we struck up a conversation, while we both walked along the trail.  He was seventeen, and lived in the next town over- accessible by walking through the mountains apparently.  He also worked as a guide for the exact ruins I was visiting, and so I was given an unofficial guided tour of some of the site’s main features.  When we reached the end of the hike, the conversation changed tone a little bit, and it soon became apparent that he was trying to sell me one of his flutes- he had several more in the bag.  Feeling like I had been trapped, and besides I really did not want to buy a flute, I dodged his craftiness, and was soon left alone to admire the ruins.  I did not have much time though, as the sun was beginning to set, and I still had at least a 30 minute hike down the hill.  The ruins were gorgeous, though they had been defiled by the Spanish years before.  Che describes: 

“After trekking for two long hours along a rough path we reached the peak of Pisac; arriving there as well, though long before us, were the swords of the Spanish soldiers destroying Pisac’s defenders, defenses, and even its temple.” 

The power of the place was still tangible however, and the craftsmanship and design of the structures was astounding.  There was an enormous rock, that functioned as a sort of sun dial, and where the shadow cast by a prominent stone protrusion in the middle of the rock fell, helped to determine the time of day, and was used for a number of rituals- many of which have been lost, and it is up to speculation to determine what may have happened here.

These are some reflections and musings from my visit to the many museums, and especially the cathedrals in the center of Cuzco.  The main cathedral , which sits right on the famous Plaza de Armas, and was built on top of the foundation for the great Incan temple of the sun.  I was consistently fascinated with how the customs and beliefs of the Andean people became infused with Catholicism, and disgusted at how the priests exploited certain aspects of their preexisting beliefs to force Christianity on them, and “help” them to understand the lessons from the gospel.  It is very common, and indeed commonplace, for there to be life-size mannequins in churches and cathedrals, who represent a saint.  These mannequins are fully dressed in exquisite clothing, and are given offerings, and prayed to by all church attendants.  Che Guavera describes the main cathedral in his book The Motorcycle Diaries:

“The glitz of the brilliant interior reflects a glorious past…Gold doesn’t have the gentle dignity of silver which becomes more charming as it ages, and so the cathedral seems to be decorated like an old woman with too much makeup.  There is real artistry in the choir stalls, made from wood by Indian or Mestizo craftsmen.  In their carved scenes of the lives of the saints, they have infused the cedar with the spirit of the Catholic church, and the enigmatic soul of the Andean peoples.”

One of the saints- the patron saint of farming is always depicted in varying levels of indigenous dress, carrying the hand tool used by all farmers.  While the superficial aspects of many of the saints resemble the clothing and customs of the common people, the faces were clearly European, and they were required to worship the Catholic religion, in all it’s completeness. 

This Indians were then forced into acts of subversion, or simply playing dumb, in order to adapt some of their customs and beliefs into the rigid structure of Catholicism, in order to retain some semblance of their own culture.  To use the words “Incan Culture”  is to unconsciously describe the customs, architecture and religion of small tribes, who were either absorbed into the ever-growing, brutally aggressive Inca empire, or who were wiped out, but the best parts of their culture preserved.  The tribes that made up the Inca, and finally the great empire to be sure, are known to have possessed slaves, and to have waged war on peaceful, helpless tribes in the name of conquest and in order to gain territory and power. 

Just before the Incas truly greatest threat arrived on the continent, from across the vast Atlantic ocean, a bloody Incan civil war had ended, in which the two sons of the last great king of a United Inca empire had both been too greedy to share the enormous territory, which extended from modern day Quito in Ecuador, south past today’s Santiago, Chile.  Francisco Pizarro was thus able to march right through the war ravaged region, eventually capturing the successful brother Atahualpa, and murdering him.  Not before, however, the Spaniards promised to release Atuahalpa if he ordered the people to gather a roomful of pure gold- totaling more than 18 tons.  For weeks, people brought gold from all across the empire, so that their king might be saved.  But in the end, the cruelty and greed of the Spanish was greater than anyone could have imagined, and Atuahalpa was killed, followed by a full-on invasion of Cuzco, and the looting of the remaining wealth of the splendid city. 

My “familia Boliviana” squeals with delight as the baby of the family claps her hands, and crinkles her face in the purest expression of glee these eyes have ever witnessed. “Arroz con leche, me quiero casar…” The entire family joins hands, and bounces them up and down, to the satisfaction and enjoyment of little Sofia- or Sol for short. “Con este sí, con este no, con este señorita, me caso yo!” The entire table breaks into applause, and Sol just beams and extends both arms- opening and closing both fists in an obvious call for “encore”. She is 1 year and 8 days old, and is the absolute pride and joy of all of the adults of the family. Mom and dad will patiently walk her around the apartment, stooped over, holding both of her hands for support, while she explores, and coos at the people occupying each room, as if she has just won a round of hide-and-seek. She seems to be fascinated with my appearance, and never tires of waving her arms at me, and making a concerted effort to produce the loudest noise her little voice box can, and then waiting transfixedly for whatever expression my face seems to respond with.
In Bolivia, or rather in La Paz atleast, it is customary to eat a small, fruit and bread based breakfast, followed by an enormous 2 or 3 course lunch- which is the main family event, around 1:30 or 2:00 in the afternoon. This generally must suffice until bed time- because dinner is rare, and nearly always consists of bread w/ butter and tea, coffee, or hot, bittersweet chocolate milk. Tea is usually consumed after or during all 3 meals. The given explanation of this sparse nocturnal eating habit is that eating a large meal right before sleep at this altitude (3,660 meters above sea level) interferes with the body’s natural sleep process. I don’t think my body ever quite caught on however- I was always ravished with hunger by 8 o’clock, and took to frequenting the countless cafes, Salteñerias, and street food vendors that can be found just about everywhere.
Salteñas- one of the national pride food items of Bolivia (although they originate in Argentina) are a delicious variation on a standard empanada- essentially fist-sized, baked pastries filled with beef, chicken, cheese, vegetables, tuna- just about anything, although chicken and beef are by far the most common. You do need to be careful not to eat salteñas that have been sitting under a heat lamp for hours or days- I talked to two people who were hospitalized after eating a “bad” salteña. As with just about everything in Bolivia- try to buy as freshly cooked as possible, and you’re usually fine. My personal favorite street food selection- which can be purchased for about $0.60 is called salchipapas- a heaping pile of papas fritas (French fries) covered in thinly sliced chorizo sausage, then smothered with hot sauce, mustard, ketchup, (no mayo for me), and salsa. This is the perfect thing to hit the spot when you haven’t eaten in 7 and a half hours, and you’ve been hoofin’ it around the steep streets of La Paz. Followed by a paceña- the national beer, and also the name of La Paz natives- and you’ve just had yourself a genuine culinary La Paz experience. Now just hope that the diarrhea doesn’t hit you too hard.
I don’t mean to make it sound like people do not eat well in their homes- homecooked Bolivian food is incredible- lunch almost always begins with soup- often quinoa and vegetable, or potato and beef, followed by some large, filling entourage of local dishes- hard to describe, but usually involving some sort of potato or “tuber” that grows well in the Altiplano region surrounding La Paz. There is a delicious potato that is small, and black, with a strong, unique taste, and chewy texture. Then there is some kind of meat dish prepared with rice, or pasta, or beans- making for a very well-rounded, satisfying meal. Drinks are rarely had at lunch- usually Coca-Cola or Fanta if there is one, and as always- tea or coffee is served after the plates have been cleared. From start to finish- lunch is generally an hour or an hour and a half-long ordeal, rich with conversation, and storytelling. The professional work day in La Paz regularly takes 2 hour lunch breaks, thus extending the finish of the work day until 6 or 7PM. In a country that embraces the mid-day siesta, and values time spent with family, it is very easy to relax, and enjoy the company of others, while sharing a meal, and postponing all of the pressing appointments and tasks until after you have had your fill. I find that people´s energy levels are able to endure until much later into the night this way, and it is not uncommon for Paceñas to party until 4,5, or 6 in the morning on the weekends. The nightclub scenes do not start rolling until 11 PM or midnight at the earliest, and indeed there are even clubs that open at 2 AM, and remain open until daybreak. People’s priorities here are clearly different than those in the United States- with rest, family, and pleasure generally taking the priority. I am curious to hear what other people who have spent time in Latin American countries, and Bolivia specifically think about this- maybe it was a unique experience on my part, but I think not. ¡Ciao!

Doctors in Bolivia treat pediatric patients, and especially the concerns of the parents very differently than most doctors in the United States. There are many reasons for this, and I will attempt to discuss as many of them as possible in the following post. Children come in to see the doctor for very different reasons, than is common in the United States. “Well-child” checkups are not common, and the incidence of many infectious diseases, as well as chronic malnutrition are far higher in this part of the world, and in the poorer population that frequents the public hospitals in La Paz. It is not uncommon to walk into a hospital ward, and for every child to be below healthy weight, and suffering from an infectious disease that is virtually unheard of in most of the United States. Kids suffering from Malaria, Tuberculosis complicated with pneumonia, Noma (a gangrenous disease that destroys tissue of the face), leishmaniasis, Dengue Fever, and Yellow Fever are studied by medical students and doctors not in textbooks, but in their patients. With good reason, Parents tend to be very concerned about the health of their children, and so will often bring them in to see “el doctor” when they have the slightest concern about their development, or anything to do with their health that could be perceived as a problem. For this reason, many doctors spend much of their time dealing with well-intentioned, but often unnecessary concern on the part of the parent.
Many of the complanits and symptoms that bring patients in to see Dr. Velasco at Hospital Del Niño are either self-resolving with time, not problematic to begin with, or the standard treatment is unavailable or too expensive the location and socioeconomic status of the patient’s family, and that of the hospital. In other cases, the commonly recommended remedy may be substituted for something more natural, and which fits into the family’s realm of comfort and does not cause them to feel alienated, and avoid seeking treatment in the future. Often times, the patient will be sent away with something- anything so that the mother feels that her concerns have been addressed, and so that she will not simply go consult another doctor, and avoid returning in the future.
Consider the following example: After a check-up for another issue, the mother of a young girl confides that she is concerned about the growth of her daughter, and she feels that she should be taller by now. During the midst of this exchange, the doctor broke into english, and said to us students: “Look at the height of the mother.” The mother could not have been taller than 5 feet, and her daughter was not far behind. “Parents here have very high expectations for the size their children will reach. She is developing fine, and may even grow to be taller than her mom.” He prescribed the girl an iron supplement, and told the mother not to worry, that the problem would be fixed. She left, thanking the doctor profusely, and would clearly be willing to return in the future, for any other problems. If the doctor had told her she was being silly, she most likely would have not been placated, and would be mistrusting of the doctor.
At another hospital, where sixth year medical students were conducting the exams, and subsequent treatment plans, a student explained to me the reason for prescribing chamomile tea with honey for a cough and fever, rather than a standard cough syrup. “We need to give them advice that they feel comfortable with, so they will come back next time.” In the largely indigenous population in and around La Paz, western medicine is often viewed with suspicion, and hesitation, so if the “white coats” can stick to natural remedies for small things, like coughs and sore throats, then the family will be more likely to accept help when something really serious is at hand. I saw iron and vitamin supplements prescribed more times than I can recall, and in each case, the family was visibly relieved, and left in higher spirits than when they came in to the hospital. If for no other reason, the opportunity to provide this psychological and emotional soothing was worth the effort, and this can have enormous beneficial impacts on the health of an entire family.
In the United States, I think that there is far too much fearof malpractice, appearing not to have the right answer, or simply not wanting to miss the one child out of a million that could be presenting with common symptoms, but who actually has a rare, serious disease. Expensive tests are ordered, drugs are prescribed to try and correct any small problem- from acne to hyperactivity, and often times the stress and expense of the entire process can do more harm to the child than a reassuring smile, and some good advice. What I find most incredible about the clinical skills of Dr. Velasco, and others here, is that they are very effective at treating the concerns of the parents, making them feel heard, while at the same time putting the child’s well being before all else- especially the potential profits to be gained by requesting further diagnostic workups, and expensive medications. These “luxuries” are simply not always available in Bolivia, and for one hesitant moment, I am going to question whether or not there is atleast one upside to this lack of resources- the ability- no, the necessity of serving your patients on an absolutely human level- uncluttered by cold machinery and barrages of prescription medication. A silver lining behind the cloud of a malnourished, and overburdened health care system? I dare say it’s possible.

There are no machines beeping in the delivery room at Hospital de Los Andes, in the city of El Alto, Bolivia. To determine what is happening inside the body, “we have to feel, look, listen, smell what´s going on,” an obstetrician overseeing a group of medical students told me. The point have not have hit closer to home for me that day- a sewer line had ruptured under the street outside, and the foul liquid was flowing directly underneath our wing of the hospitall The heavy odor of sewage mixed with the natural smells of birth, and people went about their jobs as if this were the most natural circumstance. The janitorial staff passed in and out of rooms, dumping buckets of lye mixed with water down drains in an attempt to combat the inevitable odor. Invisible fumes wafted through the air, burning the lining your throat and sinuses when inhaled. “Breath señorita, breath, push, push, push!” Again, nobody seems to notice.
Witnessing my first live human birth was not quite so much a “moving, beautiful experience”, as it was a shocking, and slightly overwhelming one. This is not to say that it was not beautiful, and dare-I-say life changing, but during the actual event, I am pretty sure that my mouth hung open at several points, and all I could think was “whoa!, whoa, this is actually happening. Intense!” I wish that I was spinning poetry in my head as I witnessed a new life being born into this world, but I was much more preoccupied with simply trying to mentally cope with what I was seeing. The first time I saw a new born come into this world, the mother was late in arriving at the hospital, and gave birth literally before she could be undressed and placed on the bed. Let me describe the scene: I had been at the hospital for all of 20 minutes, and was sitting on an empty bed in the “prepartario”, or the preparatory room where 4 women lay in seperate beds while they are in labor, before being transferred to the adjacent delivery room. I was chatting with a medical student and two nurses in spanish, when suddenly, from down the hall came the sound of a screaming woman, obviously in the throes of contractions. The double doors at the end of the hall open, and two men are carrying a woman, supporting her under both shoulders down the hall, her feet dragging underneath her. The student sitting next to me jumps up, and grabs the ankles of the woman, lifting her up, and together, the men lay her down of the bed I had just been sitting on. From my vantage point near the foot of the bed, I can see that her pants are already soaked through, and I am sure some of the liquid is blood.
Moments after the woman is laid down, she calms down considerably, and ceases screaming. We soon discover why: without donning gloves, the medical student pulls the woman’s pants down to her ankles, and there, lying motionless on the top blanket, is the woman’s newborn baby. It is covered in blood, quite pale, with the blue and white umbilical cord winding it’s way across the bed, back into the mother’s recently evacutated womb. There was a brief moment of hesitation, and then the entire medical team broke into action, shouting orders and running to retrieve the necessary tools. The baby was picked up bare-handed, and rubbed vigorously on the back, in order to force it to begin breathing, and crying- both necessary signs of a healthy newborn. The umbilicus was clamped, and cut, and the baby rushed off to the delivery room to be cleaned, and kept warm. The mother was again lifted by several people, and unceremoniously lain on a bed in the delivery room, so that the placenta could be removed, and she could be tended to, incase there were compliations. “This is the most dangerous part of the birth.” A doctor explained to me. “If we don’t get every last piece of the placenta out, the uterus will not contract, and she will continue to bleed until she dies.” And bleeding she was- a steady stream was flowing down the black, plastic that served as the only bed cover, funneling directly into a bucket, for this very purpose. In the end, all was well with the mother and the baby, but I heard several doctors grumbling that she should be punished, for arriving so late, and putting her and the child at risk like that. The next birth I witnessed that day was much more typical- planned well in advance, and performed with the assistance of an episiotomy- an intentional cut through the perineum, in order to allow more room for the baby to exit. Although this birth went completely as planned, watching the baby emerge was still a breath taking spectacle.
Taking part in, and physically removing the baby from the womb, on the other hand, was an incredibly awe-inspiring experience. I was sitting outside, across the street from the hospital, eating lunch with Flor and Christian- a resident, and sixth year medical student. We had just been served lunch, and were about to dig in, when the doctor who had been explaining things to me earlier appeared at the doorway of the small hospital, shouting “Now’s the time, get in here!” I dropped my fork and knife, and sprinted across the street, following the doctor inside. I followed his lead as he took off his white lab coat, and was instructed to put on a sterile smock, that covered my arms, and front, and was tied up in the back. A pair of sterile gloves were held out for me to slide my hands into, and “have a seat.” Was the only communication that I would actually be delivering the baby. There was a small, wooden stool situated directly infront of the woman’s open legs, where the top of the head was just visible. Before I had time to mentally walk myself through the next steps, the baby’s head was out, and my hands were being guided- hold the head securely between both palms, push downwards, to pop out the upper shoulder, then up for the other shoulder, and then- catch! The woman’s body did it’s job well, and the baby came out an an impressive speed. As I was told, I laid the tiny life form on my forearm, and rubbed the back vigorously with my free hand. The baby was then placed on the blanketed stomach of the mother, where the nurses tended to it, while I clamped twice, and then cut, inbetween the two hemostats, to sever the baby from mom. After the placenta was extracted- a difficult process which required much pushing, pulling, and (by the doctor) reaching inside, we set about repairing some small tearing, which the poor woman had suffered during the process. “Have you ever done this before?” He asked me. “One time.” I said with confidence- he did not wait for me to tell him that that one time was on a pig’s foot, and not on a live, conscious person. After thoroughly numbing the patient, the doctor made the first suture, and then guided me through the rest of the 8 stitches. It was without doubt one of the most intense experiences of my life, and I am happy to say that I held up well under pressure, and afterwards was giddy with excitement and relief at not having messed anything up. Whether or not this experience will influence me to pursue a career in obstetrics, I do not know, but it is now most definitely an option that I am sure would provide ample opportunity for deep satisfaction, and professional fulfillment.

I have been in Bolivia now for just over two weeks, and I have only written once about the primary reason for my being here- my time spent in public hospitals, observing doctors and learning about the public health system.  Let me catch up to the present- the first week I was here was spent at Hospital del Niño- a public, nationalized, strictly pediatric hospital, where I spent the majority of my time in the infectious disease department.  By nationalized- I mean that it participates in the Seguro Universal Materno Infantil program (Universal maternal and infant health insurance) - which provides FREE health care to pregnant women, and children of under five years old.  In addition, all, or the majority of doctors in Bolivia are required to work part-time at public hospitals, and provide subsidized care to patients.  Most doctors also have prívate practices, which cater to the rich, and this is where their real income comes from.   

I had the great fortune of meeting and working with a fantastically caring and patient doctor- Victor Hugo Velasco.  While there, I accompanied several doctors, medical students, as well as 3 other CFHI participants on morning rounds, visiting with various patients, afflicted with a variety of maladies- anemia, tuberculosis, leishmaniosis, down´s syndrome,  malformations at birth, many of which were complicated by malnutrition.  On my second day there, I was asked to compile a brief summary of a Young boy afflicted with leishmaniosis, by Reading through his medical history, and to orally present to the medical team the following day.  This was meant to be an exercise in medical dictation, and though I have not yet presented my information because of necessary schedule adjustments, I learned a great deal, and have greatly expanded my medical spanish vocabulary and knowledge. 

                Following morning rounds, we would generally head downstairs to the bottom floor of the hospital, and squeeze our way through the throngs of people crowding the waiting area, into Dr. Velasco´s “consultario”, or physical exam and appointment room.  There, patients would come in with their parent, and the occasional sibling, and Dr. Velasco would oversee the physical exam and diagnosis of the patient, while allowing us students to do as much of the practical work as possible.  This generally included auscultation (listening to the internal sounds of the body using a stethoscope) of the heart, lungs, and occasionally the intestines, visible inspection of the back of the throat, reading the patient´s pulse, noting signs of dehydration (such as dry lips or mouth, or lack of tears and mucus when crying), and inspection of any other specified injury or part of the body under question.  This is generally very easy to conduct on adolescent patients, of children who are comfortable with the process, but the vast majority of infants, and very sick children tend to put up quite a fight when you press a cold piece of metal to their bare skin, or try to put a piece of wood in their mouth, and shine a light in there.  For these more difficult patients, the help of the mother is often employed, and the little one can occasionally be placated by breastfeeding of simple methods of distraction using toys.

                One morning, we were instructed on how to visually identify various abnormal chest X-rays, specifically relating to fluid in the lungs.  We looked at textbook examples of alveolar, interstitial, and alveolar-interstitial fluid infiltration, and then were shown X-rays of patients currently in the hospital, and kindly asked to identify which type of fluid infiltration was present.  We saw examples of chest X-rays of people afflicted with tuberculosis, and pneumonia, and also what the forced breathing of a person with these conditions looks like- flaring nostrils, subcostal contractions, and flexing of the entire torso, in an attempt to allow more air to pass through the compromised lungs, and into the bloodstream.

                Each week, we have the opportunity to spend our time at a different public hospital, in order to experience different aspects of the medical industry, and to observe doctors of different specialties.  The second week here, I spent my time in the gynecology and obstetrics department, making rounds and attending lectures with about 20 other medical students and residents at Arco Iris Hospital.  On my third day there, I witnessed the contractions of a woman in the throes of labor, and the top of the head of her baby just barely visible inside her.  Unfortunately, there were too many medical students who also wanted to be present for the delivery, that I was not allowed into the “quirófano” (delivery/operating room) to witness the entire thing. 

                In short, I am having a multitude of incredible experiences that are surely changing me more than I can know at this time, and ontop of all this, I am fully immersed in the beautiful, wildly different culture of Bolivia!  I have a private one-on-one spanish tutor for two hours per day for the first three weeks I am here, and my verbal and written skills are improving at a steady rate, aided by the fact that the Bolivian family I am staying with speaks solely spanish in the house, and I am basically forced to learn if I want to be understood, or understand anything that is going on around me.  Tomorrow, I head to another public hospital- Juan 23, and what experiences await me there, I can only guess.