A few years ago, Mexico started anew public health initiative to provide the most basic clinic services to all citizens, among other initiatives. Toward that end, neighborhood clinics were started which provide prenatal care, immunizations, treatment of infectious diseases, regular health checks including screening for high blood pressure or diabetes and other basic primary care services. I doubt that the system is perfect. From my experiences this week, it does seem to be helping and make a difference.I was in a public health clinic in the same neighborhood where I am staying, Colonia Lazaro Cardenas. I walked about half a mile to the clinic in the morning, ate an early lunch with the clinic staff and left in time to catch a collectivo-a shared taxi- to my two hour Spanish lesson. Then, I ran a couple of errands and went home to find that my hostess Estela had created another wonderful meal which is shared with her family. I enjoy her sons teasing each other. It is a nice routine.
I observed Dr. Pablo Garcia, who treated and saw a wide variety of people. From pregnant, to recently born, to lots of children and women, a few men and a few elderly. There were less respiratory infections and more gastrointestinal complaints, many of which he diagnosed as either an infection or an infestation depending on the symptoms. The clinic is very basic with exam rooms (one for each of the two doctors), a front porch for waiting, a reception area for the nurse and his helper and one other room for overflow and storage. Dr. Pablo brought his stethoscope and otoscope and used mostly his interview and physical exam skills to determine what the patient´s problems were and how to help them.
Those with chronic diseases such as diabetes and hypertension are usually seen monthly and often go to the central public health office to have basic lab work done the day before the visit, wait for the results and then bring those results for Dr. Pablo to review. No computer, fax, messenger service or clinic telephone to share results. The clinic staff each had their personal cell phones as did many of the patients. Dr. Pablo used the calender in his cell to calculate when his clients needed to return or due dates for pregnant women. He used the calcluator to establish BMI and to confirm dosage of medication for children.
If a patient which presented with a problem requiring some lab work, Dr. Pablo usually diagnosed the problem and started treatment and then asked them to go quickly to the lab or to wait until the treatment was complete to do a ´test of cure´. Pregnancy tests, urinanalysis, blood counts, blood sugars and stool samples are all available at the central lab. This process does not seem easy or quick. I imagine that many do not follow up on this requested post illness testing.
The clinic is well stocked with generic drugs which are provided to the patient directly. The variety available is sufficient to meet the needs of most patients. The doctor writes his prescription on special NCR triplicate paper, and the original becomes the property of the patient. The nurse using this, dispenses the medications and the patient can use the prescription as the directions for how to take the medications. Dr. Pablo did not order anything ás needed´ but rather even pain medications and fever reducers were ordered for a specific number of days. Dr Pablo saved the other two copies of the prescription and he said he uses them to create reports and manage inventory; which he said he does on weekends. Sometimes he would prescribe something not available in their stock of medications and ask the patient to buy it from a pharmacy. Sometimes this to relieve a symptom that particularly bothered the patient in which case, he would simply ask them to buy it. If the medication was to cure or control the condition and so very important, he would give a little talk about this and stress the need to purchase the medicine.
The visit with the doctor, the medicines provided in clinic and the lab work all are provided without any requirement for payment. Some qualify for serguro popular and somehow that helps with the cost of the clinic. But if someone is over income or if they haven´t gotten around to applying for the basic health care insurance provided by the government, they still seen and there is still no cost. There is a donation box and with this money they are able to buy the 'extras' for the clinic-writing paper, file folders for charts, salary for the nurse´s helper. Currently, they are saving to buy another electric fan as the clinic only has one. That would be quite a luxury.
With Dr. Pablo, I saw patients with Chagas disease(14 mos old, sent to pediatrician to be sure she could start treatment), TB and syphilis (same patient, 26), severe asthma (12 year old), renal failure(sodium very low, referred to hospital with request for two day admission), a poorly healing but not infected incision after a cesarean (her fourth-she did get her tubes tied.)
Dr. Pablo was thorough and complete with his instructions and advice. He explained the purpose of each medicine, how to take it and advised on diet and activity to manage that patient´s specific problem. Many were advised to increase exercise and avoid sweets/fats to loose weight. Basically, he did all the same work that I would expect in a primary care clinic in the United States. I was pleased to see how much he was able to do with so little.
Dr. Pablo is young, he finished his medical education about four years ago, then had one year of internship and another year of mandatory service. He has been at this clnic almost two years. He also has a private practice in the evening in which he works 4 hours more each day (so five 12 hour days per week.) He does not attend patients in the hospital nor does he take call. He said one reason he works so much is because the pay is so poor. He has plans to take a test to be accepted into a residency program and complete a residency and become specialized in one part of medicine rather than do primary care. He would like to become an anesthesiologist. This makes me a little sad, as he displayed so much patience and has a great bedside manner. I know he will use these skills in anesthesia as well, but not to the degree that he does at this time.
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