2019-04-29 MDB Reflection - AJ Millet

AJ Millet (right) with three generations of her host family.

Photos courtesy of the author

I arrived in Ecuador with a vague, stereotyped idea of what global health looks like: lack of resources, over-crowding, poor patient outcomes. Instead, I was greeted by a health care system that, while still developing, was focused on public health, access and cultural humility. In my time at the community health centers and hospitals of Riobamba, I witnessed the ways in which our systems of care overlap and diverge. There was a strong emphasis on maternal-child health, including prenatal care outreach, educational efforts around breastfeeding and childhood malnutrition, and domestic violence screenings at well-child checks. The health center where I was stationed had a delivery room on site for uncomplicated births. An initiative at the birthing center encouraged women to choose the clothing, laboring companions, and laboring positions in line with their familial and cultural traditions. In some of the indigenous communities surrounding Riobamba, women labor while hanging by their hands from a rope, and the health center had installed such a rope from the ceiling of the birthing room for this purpose. I appreciated the recognition of different cultural practices and the efforts to make health care more accessible to members of these communities by acknowledging and validating different customs and beliefs.

Starting a rotation in Riobamba's public hospital with a group of other medical students from the United States.

One of the most challenging ethical issues during my rotation was what I perceived as the overuse of antibiotics, compared to what I have observed in the United States. In Ecuador, prescribing patterns vary substantially from guidelines in the US; in the US, physicians are taught to only prescribe antibiotics when indicated, using the most specific antibiotic for the infection, and continuing the antibiotic course to completion to avoid the development of resistance. In Ecuador, antibiotic prescription practices differed quite a bit, where physicians often prescribed patients two or three different antimicrobial therapies per complaint.  It sometimes felt uncomfortable as a student to witness care that directly contradicted my medical education and it was an interesting challenge to navigate the power dynamics of coming from a more well-resourced country, but at the same time being in the role of student observer wanting to be respectful of the different culture and medical environment I was in as well as the physicians from whom I was learning.

A sign welcomes patients to the public hospital.

I appreciated the chance to talk with the Ecuadorian medical students about their educational experiences throughout my rotations. The medical education system there is different than in the states: students enter directly after high school and complete four years of classroom learning before spending a year rotating in the hospital. They are then assigned to their compulsory "rural year," where they spend a year practicing medicine in a high-need part of Ecuador. The built-in year of service helps provide care to Ecuadorians who otherwise have limited access, though many physicians spoke of the challenges of the rural year: minimal supervision, geographic isolation, and few resources. The sites are scattered throughout the incredibly diverse landscapes of the country, including some in the Amazon only reachable by canoe journey. With the results of my own residency match looming, I was particularly struck by the prospect of being assigned to practice in the rainforest as a new physician without support. For all the challenges of medical residency in the US, it threw into sharp perspective the privilege of training in a system with adequate support.

AJ Millet is a fourth year Stanford medical student. She completed her scholarly concentration in community health, and after graduation will be starting her residency in family medicine at UC San Francisco. She is interested in addiction medicine, maternal-child health, and reproductive health access, and is excited to use her Spanish language skills from her time at Cachamsi to better serve all of her future patients.

Her rotation in Ecuador was supported by the Mary Duke Biddle Scholars Program.