Name, Insurance, Neighborhood

What is your name?

Do you have insurance?

What is your neighborhood?


These three questions begin every clinical encounter in Riobamba.


The Ecuadorean health system has undergone an immense and impressive transformation over the last 15 years.  Ecuador has become one of the leading countries in the region (and in the world) regarding healthcare efficiency spending (surpassing the U.S. by at least 30 spots on the world rank list). One of the reasons for this success is the strict adherence to patient centered medical homes. Each Ecuadorean is assigned a doctor/clinic based on his/her address and is expected to visit this clinic first except for in an emergency.


The clinic I'm assigned to this week reminds me of a bustling county clinic. A triage area in the main lobby determines if patients will be seen by a physician in the clinic, if they'll be redirected to their primary clinical site, or if they'll be sent to the ER.  Patients and families sit in metal chairs along hallways awaiting their turn.


Dr. Patricia, the medical director, is gracious and kind enough to orient me to the clinic.  Her office is also the exam room with a table in the far left corner of the room. In the morning, salsa music can be heard right outside the window as the Zumba class starts.  Routinely as she sees patients, staff and colleagues come into ask questions, get paperwork signed, etc.  Rather than disrupting her morning, there seems to be an ease and rhythm to the flow. A few times, Dr. Patricia herself walked into a colleague's office to ask a question while her colleague was in the middle of seeing a patient.  But patients and colleagues alike appear unbothered. This open and genial atmosphere gives the clinic a sense of familiarity and ease.


The clinic sees a variety of patients of all ages but particularly a high number of teenagers - specifically teenage girls. The teen pregnancy rate in Ecuador is high. As Pablo (my medical Spanish institute liaison told me this morning), "if you come to clinic at 19, they will ask how many children do you have. One is normal by 16. If you are 26 and don't have children, it's considered shocking" - (to be fair, Pablo actually just shook his head in a way that conveyed the rarity of the without-child 26 year old) ...duly noted Pablo, I'll keep my child-bearing status to myself :/


Specialty care can be found in the large hospitals but is not always easy to access. As Pablo explained to me, the specialist may have 80 patients to see for the day but will quickly triage them and tell about 60 of these patients to "come back in 21 days" - a polite way of letting the patient know that their issue isn't acute enough to warrant specialty care.


At lunch today, Pablo and Valeria (my Spanish professor for the week) took me to the supermarket to buy groceries for the week.  My bed and breakfast has a kitchen where I can cook lunch and dinner.  I made sure to pick up some summer berries (or maybe they're called golden berries), a quinoa-rice mixture to go with the beans and plantains, and traditional Ecuadorean seasonal berry juice.


As we headed back to my B&B to deposit the groceries, Pablo proceeded to describe to me how I could get back to the market. I was following for the first two turns but then lost my sense of direction so I asked him for the name of the street we were on. He paused: "Oh, I don't think there's a name." He must have seen a slightly panicked look on my face because he quickly explained that I could easily take a taxi there as well.

Always good to have a plan B.


Tomorrow I might be seeing patients in conjunction with a visiting South Carolina physician but I may have missed the full description that was given in rapid-fire Spanish. Having spoken a total of 15 English words in the last two days (and yes, that means ultimately I'm speaking far less than usual), I'm mentally wiped but excited as well.  In a city where English is very limited, I can stumble, mispronounce, and incorrectly conjugate my way through the day in Spanish.  And sometimes, to my surprise, I string together the correct words, in the correct order without extreme difficulty. For this, I must heartily thank my Spanish professor for her patience and encouragement.


Hasta mañana!