A Day in the Life of a Resident: On the front-lines of family medicine in Ecuador

As an MBA/MPH student at Haas, I’ve spent quite a bit of time in hospitals and other medical settings both in the US and developing countries.  Our first week in Quito, for example, was a dream for anyone interested in business and healthcare – we visited with local and national leaders in academia at University San Francisco of Quito (USFQ), health financing for the social security in Ecuador (IESS), Pan American Health Organization (PAHO), and some of the leading hospitals and residency programs in Quito to understand national best practices and patient needs.

Our second week our client, Andean Health and Development (AHD), took us out to their rural hospital in Pedro Vicente Maldonado (PVM) where they focus on providing rural care through a family medicine residency training program. The family medicine specialty model is one that is well suited for rural settings as it mandates a wide range of rotations and vast array of skills of each graduating doctor. In other words, rural physicians must be the “Swiss Army Knife” of primary and secondary care.  After interviewing each resident, it was clear that they handle cases from snake bites to minor surgeries – and AHD believes – can be the key solution to improving access and quality care in rural settings.

Wednesday that week, we were fortunate to spend a day in the life of a family practitioner in Ecuador. Needless to say, this was my first time getting down in the front-lines of rural patient care.

A resident’s schedule is exhausting to say the least but AHD’s model requires that each resident maximize both classroom and experiential learning opportunities every day:

6:30am – Inpatient Case Reviews

Crack of dawn our IBD team wakes up and heads to the hospital to join the residents in their review of their inpatient cases. Each resident “owns” the patients they admit to the hospital. During this time the residents and Dr. Nick, a California physician volunteering as their attending physician mentor, provide feedback on their selected treatment regimen and plan for that patient.

With 8 residents in total this took about an hour to go through and included a delicious breakfast from the hospital cafeteria. It’s impossible to get tired of Ecuador’s fresh and exotic fruits – passionfruit, taxo, banana passionfruit, guayanaba. With a little coffee, the IBD team was ready to push through the day and document life as a resident.

7:30am – Hospital Rounds

Immediately following the patient case reviews, we headed downstairs to the in-patient facility to see the patients themselves. The residents asked them how they were doing and took any additional readings to update them on their status for the day. Dr. Nick also joined the group and was careful to also ask the patients how they were feeling and if they were comfortable in their stays.

8:00am – In-patient/Out-patient Rotations

For the next four hours it’s non-stop patient care for the residents. With a few assigned to the ER, in-patient, and out-patient clinics – we meandered around each to understand how the hospital manages the daily swarm of patients.

The outpatient waiting room began to fill fairly quickly and we used this time to distribute some patient surveys and talk 1:1 with those who visited the hospital.  We learned, for example, that many patients were coming farther than 2-3hrs away to get treated that day and many were repeat customers in PVM. Each waited between 30min to an hour to be seen and most were treated within another 30min to an hour after being seen. Many noted they were happy to wait around for test results as Ministry of Health (MOH) facilities make patients come back 24hrs later for test results – which can be a huge challenge if you’re already several hours from home.

12:00pm – Resident Class #1

All the residents trickle in after their out-patient or in-patient responsibilities are wrapped up for the morning and now – it’s class time! AHD’s curriculum in the hospital (residents also attend classes at Universidad Católica in Quito on Mondays) is very flexible and student-directed. Residents select and present topics to the group (e.g. diabetes, anemia) that usually have an application for one of their recent or current patient cases. Following the theme of experiential learning, residents then talk through a few hypothetical cases and challenge each other on their recommended treatment regimens. Definitely a different experience than classes at Haas!

1:00pm – Lunch

Residents are people too and at this point we were really happy to have lunch ourselves. Traditional Ecuadorian lunch is served daily (usually 1-2 meat options): a rich brothy veggie/meat soup to start; followed by a plate of rice, bean/lentils, pickled veggies, and spiced fried/roasted/seared meat; and finished with fresh fruit with a dollop of chocolate ice cream.  Yum!

2:00pm – In-patient/Out-patient Rotations

After lunch the residents spend another 2.5 hrs of cycling through patients in the waiting rooms. We estimated that each out-patient resident saw between 8-12 patients during this time.

4:30pm – Resident Class #2

The afternoon class is structured very similar to the first with another presentation – this time on a bacterial infection relating to one of the resident’s current cases. Dr. Nick gets up and starts drawing out the biological pathways of the bacteria and antibodies – asking the residents to come up and help characterize the condition at a molecular level. Since I minored in biomedical engineering as an undergrad, this was a treat to see played out in the medical setting!

5:30pm – Catch-up Time

After class the residents usually spend an hour or two catching up on in-patient cases (preparation for the next morning’s meeting), PVM classes (preparing presentations of their own for their daily classes in the hospital), or Quito classes (working on their theses and assignments for class every Monday in Quito).

We were pretty tired at this point ourselves – even as observers – but spent the time catching up as well in preparation for a resident focus group the following day. We fine tuned our presentation to them on our interview findings and picked a location to take them out for some drinks afterwards.

8:00pm – Dinner!

There aren’t many dinner options in PVM, but found a great roasted chicken dinner with fresh juice and soup for $2. Can’t beat that!

9:00pm – Work, Cards, Bed

Most of the residents have families either in PVM or Quito so this is really their time to connect with them on a daily basis. We finished up a few items, played a game of hearts, and started planning out our last weekend in Ecuador.

…and the weekend!

That Friday for our IBD teammate Eileen’s birthday we ventured the cloud forest in Mindo, about 30min from PVM. A late afternoon rainforest hike followed by a visit to El Quetzal chocolate farm (they roast their beans 6 days vs. the average 2 days making them super delicious and dark roasted) was about the best end to our hectic week in the shoes of a family medicine resident.

Then back to Quito for some markets in Otavalo and hot spring baths in Baños for the remainder of the weekend!

—Emily Ewell

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