Doctor as teacher in rural Mexico

Katherine Schiavoni, MD, MPP

Resident in Medicine and Pediatrics

PGY-4

May 2, 2019

¡Saludos! I am about half-way through a one-month rotation with Compañeros en Salud / Partners in Health in the rural Sierra Madre region of Chiapas, Mexico. I am fortunate to return to Chiapas after rotating with Compañeros en Salud (CES) as a resident mentor last year. During my rotation this year, I am visiting 3 different clinics in the communities of Reforma, Capitán, and Letrero.

I am in my final year of medicine and pediatrics residency, and next year will be staying in Boston to practice primary care at a community health center and do a fellowship in population health. I am interested in social determinants of health and caring for adults and children across the life span, particularly in Latino communities. My away rotations in Chiapas have been a tremendous opportunity to learn about the people and culture of this region, understand the health care system in rural Mexico, and develop skills in delivering care in a low resource setting. At its core, rotating with CES also provides great learning in broad spectrum primary care.

Compañeros en Salud (CES) works collaboratively with the Mexican Ministry of Health to support 10 rural clinics in the Sierra Madre region of Chiapas. The clinics are staffed by a social service year physician (pasante), nurses, and community health workers (acompañantes). The primary role of a resident is to see patients with the pasante and to provide mentorship and teaching. CES provides additional teaching, supervision, and clinic supplies/medications beyond what would typically be offered in the social service year. The organization also offers an ever-growing network of mental health, maternal health, and chronic disease services for patients, as well as access to secondary and tertiary care through its referral program.

Sunset on the square in Reforma community 

I have been particularly impressed by the ability of pasantes to serve as teachers to their patients and clinic communities. During our clinic consultations, we spend a significant amount of time talking with the patient about our assessment of their condition and proposed treatment plan. There is significant emphasis on explaining a diagnosis in understandable terms, and relating treatments to familiar touch points, such as taking vitamins. The pharmacy is also located in the clinic space, and therefore pasantes can teach patients about their medications with the actual pills they will take. Particularly for patients who cannot read, it is very helpful to show them the pills, explain the purpose of each, and how to take it. The visual learning seems to improve understanding and adherence. Patients also bring back the physical boxes of medication for follow up visits and medication reconciliation.

The pasantes also lead group visits (consultas compartidas) for chronic conditions, including diabetes. I was able to participate in several diabetes group visits with the pasante Irving at the Reforma clinic. One of the groups had been meeting monthly for a year. During the groups, Irving taught about 1 topic per session such as healthy diet, medical complications of diabetes, or myths about medications. The patients also supported each other with suggestions about dietary changes they had made, or reframing misconceptions. For example, it is often believed that using Insulin will cause blindness and therefore patients are reluctant to use it. Two of the patients in this group had been on insulin for several months and are now doing well, which has changed the perception of other group members and made them more amenable to using insulin if needed. It was inspiring to watch the mutual respect and encouragement in the group.

Doctors in CES have developed a direct role in teaching patients about chronic disease management in a way that is appropriate to the cultural context and health literacy. I look forward to using more of these techniques in my own clinic in Boston!