Practicing Rural Medicine in Ecuador

MDB Reflection- Alexander Ball

Delivering flu vaccine in Cacha.

Photos Courtesy of Alexander Ball

Spending six weeks rotating through three different outpatient clinics in Riobamba, Ecuador was an excellent opportunity to learn about how the country approaches both rural and urban primary care. The major urban clinic I worked at, Centro de Salud Santa Rosa, was a large, newly constructed, multi-specialty clinic at which trainees worked alongside a number of experienced clinicians within the city of Riobamba. There was a steady stream of patients and they were generally treated the same day by someone with many years experience.

When I visited the clinics in Cacha, the rural community just a 20 minute drive from Riobamba, I found a very different situation, and learned a great deal about medical training in Ecuador. There are a handful of small clinics dotted throughout Cacha, each of which is staffed 1-2 days per week by a rotating team which generally includes one physician, at least one nurse, and a dentist. The physician on this team is typically serving their year of “medicatura rural”, a year of required rural service following completion of inpatient rotations through a variety of surgical and nonsurgical services in the hospital.

I was surprised to learn that physicians in rural regions were thus frequently fresh out of medical school and had not yet begun the equivalent of residency training. I was both surprised and impressed that these first-year doctors were able to manage a practice composed of the neediest patients with the poorest access to care in the area, largely unsupervised. I could not imagine leaving medical school to spend a year practicing alone in rural Humboldt County, for example.

What I soon found, however, was that these physicians were actually not so different from me. I worked with the same doctor off-and-on for two weeks, and as we got to know each other she talked about her awareness that she still had a lot to learn, and that the shortage of physicians in rural areas meant that patients seeing her was still an improvement over seeing nobody. She was inexperienced, but was doing her best within a system that required her to practice beyond what she was really prepared for.

We also discussed the apathy that the required year of service sometimes generated among her colleagues. She was fortunate to still be able to live in Riobamba while practicing in Cacha, but, particularly for physicians with more remote postings, the required rural year could generate resentment which impacted patient care. She said new physicians were understandably frustrated by the lack of medications, equipment, and a robust referral system for their rural patients, and frequently felt helpless, lacking both the expertise and the resources to make meaningful change. Furthermore, many disliked having to live in rural region or make a long commute to their posting. These frustrations meant some first year physicians became cynical and tried to move through their patients as quickly as possible.

Ministry of Health map of Cacha

Before rotating in Ecuador I may have been supportive of a required rural posting in the US, given the challenges our own healthcare system faces serving remote regions; however, after speaking with this young physician and learning more about the reality of this system in Ecuador I am not so sure. Not only is being left unsupervised in your first year a terrifying experience, but it can send ripples of insecurity and apathy which reach into a young physician’s future career.

In studies of Ecuador’s program, many young physicians report a lack of preparation for the program, difficulty adapting medicine learned in school to the low-resource rural clinics, language and cultural barriers (particularly in the Sierra, many patients speak Quechua rather than Spanish), and an overall concern that they were not able to help patients due to inexperience, personnel, or resource shortages. It seems young physicians support the program in concept, but find it flawed in its application. These findings align with my own conversations with physicians in their rural service year—an overall belief in the need and an appreciation of learning-by-doing, but a feeling of being unprepared and unable to do the work that rural patients really need.

As a graduating medical student myself, I would argue a significant portion of this issue is the inexperience of the physicians. I know that I personally lack the adept physical exam and data interpretation skills I see in my attendings and, though I would likely learn a great deal as a rural physician next year, I know that I would be doing a disservice to my patients and would find the stress and frustration emotionally exhausting.

If sending new graduates to rural areas is not the right way to provide care for these underserved areas, what is? Both financial incentives (loan repayment, funding of medical education, etc) and exposure to rural medicine and rural communities can improve the likelihood of a student to subsequently practice in such a community long-term. Looking at Ecuador’s program, it seems likely that the rural placements encourage at least some physicians to stay in rural medicine, but increased administrative and academic support of the program is certainly needed.

Applying these findings to rural physician shortages in the United States, continuing support of financial incentive programs like the National Health Service Corps is crucial. Furthermore, great strides could be made both in recruiting students from rural areas and in exposing students to rural health early in their careers in a low-pressure way. I was able to visit Humboldt County as part of my family medicine rotation and found it to be a very valuable look at care provided in lower resource settings, where patients experience different problems than they do in Palo Alto. This was an optional experience, however, and something only 2-4 students typically took advantage of in any given rotation. I hope the program will be expanded in the future, and that rural settings like Watsonville, CA which are within closer reach of campus will become a more important part of the medical student experience at Stanford.

Methods of recruiting doctors to rural areas are incomplete for different reasons in both the US and Ecuador, but the attention paid to this recruitment is important. It is key that both countries continue to combat the trouble patients face accessing care in underserved regions to ensure that all people have access to a high standard of care.

About the Author

Alexander Ball is a graduating medical student at Stanford School of Medicine who spent six weeks in Riobamba, Ecuador at the Cachamsi Medical Spanish Institute with the generous support of the Mary Duke Biddle Scholars Program. He will begin training at the Stanford Pediatrics Residency Program in June 2018.