Neurology Residency Interview Trail (Part 2)

NOLA - Beautiful weather, amazing food, and microaggressions?

Photo from here

I took an overnight Megabus on a Saturday evening from Atlanta to New Orleans for my next interview. It lasted about 8.5 hours. I had a horrible headache the entire day I was in Atlanta at my friend's place and I had no idea why. I'd eaten regular meals, drank a lot of water, napped for a couple of hours that day, and even took an extra-strength Tylenol but nothing worked. I was so afraid that the headache would continue into the following day and worse into Monday during the interview (unlikely, but I was still paranoid). I slept pretty much the entire bus ride except for the couple of times we stopped in Montgomery and Evergreen, Alabama. The headache went away completely by the time we arrived in New Orleans, thank God. 

Once I arrived, I dropped my things off at The Quisby (a fantastic hostel in the area nearby the hospital and bus station) and took a walk around the area. The weather was absolutely gorgeous (60s) at 7AM on Sunday, and the streets were empty. For some reason I felt like I was in another country with the palm trees, warm 'foreign' weather (I'm used to Chicago and NY's nasty winter), and the smell. I can't explain it, but there was something about the smell of the city that tricked my mind into thinking that I was in a more tropical place, like Jamaica.

Photo from here

I stopped at a popular brunch spot called Surrey's Cafe & Juice Bar. I ordered their Bananas Foster French Toast. It was to die for. It felt like heaven in my mouth after the first bite. It was certainly pricey but I wanted to try a popular local meal. 

The staff at this cafe were great. The locals also seemed friendly, but something (smallish) happened that made me think a lot more about microaggressions (Google definition of microaggression = a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority). 

A white couple came into the cafe with their daughter (who couldn't have been older than 2) and sat at a table next to mine. The girl was jabbering and squirming around in her high chair. A key fell from the table underneath the high chair. I was close enough to grab it so I picked it up and handed it over to the mother, "Here you go," I said with a smile. The woman didn't even look at me, mumbled, "Oh, thanks", and snatched the key from my hand before snipping at her daughter to sit down properly in the chair. I went back to perusing a list of fun things to do in the area. I figured that both parents were preoccupied with keeping their daughter from hurting herself. 

The girl continued squirming and a pacifier went flying and landed on the floor nearby my table again. I actually didn't notice it until an older, white woman from another table reached under my chair to pick it up and hand it back to the mother. The mother looked at the woman and said with a big smile, "Thanks so much!" Then she turned to her daughter and said, "What do you say sweetie? Say thank you to the nice lady."

I didn't really give this interaction much thought until I left the cafe. That's when I chuckled and thought to myself, "Wait a minute... That was weird. Does that situation count as a microaggression? Is it possible that the mother was kind of impolite to me because of...well you know....? And maybe she just didn't realize her own actions at all? Am I overthinking this??" I never play the race card, and I honestly don't ever really think about how my race might play a role in the way I am being treated by someone. I'm a human being, that's all that matters. Who cares if I have a little more melanin than you? 

My parents grew up in a country (Jamaica) that is predominantly black, so the issues of racism, prejudice, and micro/macroaggressions were certainly not pervasive in society. The United States is another story, needless to say. Growing up with parents who were not familiar with or had not been exposed to racism or prejudice during their own upbringing, I think this had a lot to do with my oblivion to micro/macroaggressions for most of my life. I have not been aware of them, or perhaps they just haven't happened to me as often as they would in places like the south or say a random majority-white, small town in Wisconsin, for example. Let's be honest. I'm now more aware of microaggressions because I've been having more conversations with friends and family about them. 

Tchoupitoulas Chicken
Grilled chicken breast topped with a Louisiana crawfish
tasso cream sauce and smoked mozzarella cheese, served
over whipped potatoes and asparagus
Photo from here

Anyway, later that day I was able to finally check in to the hostel and head over to Tulane's pre-interview dinner. We went to a place called Superior Seafood. The food was out of this world. It was without a doubt the most delicious food I'd eaten while on the interview trail (and possibly ever). I ordered the Tchoupitoulas chicken (I have no idea how to pronounce that). I also ordered bread pudding with a delicious caramel sauce and whipped cream on the side. Amazing. I felt bad about eating so much but I tried to make up for it by walking 30 minutes to and from the interview the next day. (Weather was in the 60s!). If I could fly back down to NOLA just to have this same meal I would.

Houston - talking politics on Greyhound and learning about the most diverse city in the US!

On the Greyhound bus from New Orleans to 

Houston, I was sitting next to a Louisiana

Photo from here

native, a middle-aged white man with a strong Southern accent who worked as a truck driver for many years (let's call him "Steve"). I was hoping to both nap and read "Kennedy and King" during the 6-hour drive, but I didn't mind taking a break, albeit long, to talk to Steve. We ended up chatting for a few hours about a number of things, including the attractions of Louisiana, alligators, "swamp people", New Jersey (my home state), his family, my career goals, and we ended the conversation discussing politics. It was a respectful, genuine conversation about our feelings regarding Trump's policies and his administration. We also touched on Obama's policies a little bit. (I admitted upfront that I don't know a lot about politics and I don't follow it very closely, so I spent much of our conversation Iistening to Steve). It probably won't take you by surprise when I say that he was a strong supporter of Trump's policies, but he wasn't crazy about "Trump himself".

Steve opened up a lot to me and shared that I was the first black person he'd had a genuine conversation with in over two years. In all of that time he adamantly refused to speak to "another black person" because of the negative encounters he'd previously had with them. He gave an example of a time in 2016 when he was the only white person working a construction job somewhere in the south among several other older black men. The black men were having a heated conversation about Trump, and Steve said that he was trying to avoid getting involved. After some more taunting from the men, he couldn't help himself and told them that though Trump was an "a**hole, his policies are sound." The other men boiled it down to a race issue and immediately dismissed Steve, calling him a "racist hillybilly redneck".

I cringed when he shared this. "Ever since then I ain't never spoke to another black person the way I'm speakin' to you. They always say I'ma hillybilly racist and it ain't true! I notice they also always seem to be makin' excuses for not moving forward in life."

I was speechless for a while as I tried to gather my thoughts to formulate some words. I tried to explain to Steve the point of view of the black men, including their anger, the pain they and their families experienced over the years with racial injustice, and the frustration they feel when they encounter a white individual who supports Trump, because it is difficult for the white community to even fathom what black individuals have gone through in our nation's history (and even continues to go through today). At the same time, I tried to comfort him and agreed that the men's dismissal of Steve as a "racist hillybilly redneck" was uncalled for and cruel. They didn't give him a chance to explain himself and that was very insensitive on their part.

Personally, Trump's inflammatory language was enough for me to dislike him from the very beginning. His rhetoric has been mysogynistic, ableist, and incredibly racist over the years. How can one possibly ignore that? For example, referring to Haiti, El Salvador, and a number of African nations as "s***hole" countries during a meeting with a bipartisan group of senators at the White House is absolutely disgusting and vulgar. These words came from the mouth of the President of our country.

I have to admit that by the end of the conversation I grew a little frustrated with Steve but I maintained my composure and didn't say any more to incite an inflammatory discussion. It became obvious that he wasn't bothered by Trump's nasty rhetoric and he wasn't sensitive to or knowledgeable about the ethnic minority's experience. He was very respectful, don't get me wrong, and he certainly opened up my eyes to another perspective. I became more aware of the shortcomings of the Obama administration and the strengths of Trump's. I admit that I don't often have in-depth conversations with supporters of Trump, but it's not because I avoid them; it's honestly because the opportunity doesn't often present itself. I am always open to having a discussion with someone who is willing to gently share their opinions and respect my own.

Houston, TX
Picture from here

When we arrived in Houston in the afternoon, I rushed to get ready for the pre-interview dinner and information session. I learned quite a few nice things about Houston, including that it is now the most diverse city in the country! I didn't know this! It was also nice to be able to tour the hospitals a little bit and see the gorgeous skyline of the city.

We went to a restaurant called Third Coast with the residents. I ordered the Tagrialini (I think this was the name) - it had pasta, shrimp, bacon, and some veggies. It wasn't bad, but I started to wish that I ordered the parmesan chicken instead.



(Okay I'm going to try to make the rest of these interview stories quick!):

Providence, Rhode Island - Freezing weather

I arrived in Providence at 1AM the day before my interview. I had a layover in Charlotte, NC (from Houston) and the flight to RI was delayed. Right before we boarded our flight in Charlotte I heard someone say, "If it's 30 degrees here in Charlotte it's probably 10 in Providence!" I chuckled when I heard that but the person ended up being right. It was 15 degrees in Providence when we landed. When I ran outside the airport to catch my Uber, the icy cold air hit me with a fierce slap in the face. It was such a stark contrast to the pleasant 50-60 degree winter weather of the South, and I was so annoyed to be experiencing the cold at that moment. To make matters worse, according to my Uber driver, the airport recently mandated that travelers grab their Lyft or Uber in a parking garage that was a bit of a walk away from the airport. Quite a few people were sprinting through the cold to catch their rides. I was frustrated at this new mandate and the crazy cold temperature that night.

Nashville, TN

Nashville is a great music city (not just country music). The food is great, people are friendly, and it's relatively diverse. Interestingly, Nashville has the largest population of Kurds in the country. The Kurds are a community of people who have migrated from Middle Eastern countries like Turkey, Iran, Iraq, and Syria. 

Vanderbilt has so much to offer, and I really enjoyed meeting the Chair, Program Director, Associate Program Director, and residents. They truly have a wonderful team. 

I stayed in Music City Hostel for one night before flying to New York the following morning. While there I shared a room with three other women (it was very cheap). 

New York, NY

NYC is a stressful place. One morning, on my way to an interview, I walked into the wrong subway station and didn't realize it until after I already swiped my MetroCard to get through the turnstile. That was a waste of $2.75. I exited the station and stood at the corner for several minutes trying to decide what to do. It made me a little anxious to stand there as people rushed by. If I took the next train at the correct station I'd arrive just on time, but if I ordered an Uber/Lyft, I'd get there 10 minutes early though it would cost lots more money. I ended up ordering an Uber because I didn't want to risk arriving late. 

To be honest, as I walked through some of the neighborhoods of Manhattan during the several days I spent there, I couldn't help but wonder why NYC is such a glamorized place. So many people smoke, unfortunately.... and spit! Right on the sidewalk. Also, I wouldn't be surprised if some of the small puddles on the sidewalks are actually urine. The streets and subways are absolutely filthy. At times I had no choice but to put down my duffel bag on the floor of the trains. When I returned to my friend's place at the end of each day I wanted to burn the bag.

I suppose NYC has some nice aspects: it's extremely diverse, Times Square is gorgeous (my friend who I was staying with lives nearby there), and people mind their own business. Although I suppose the latter isn't always a good thing. When I was on the train heading back to my friend's place from an interview one evening, an older woman nearby me was coughing profusely. I was standing and holding on to the handrail. Another young lady sitting next to the older woman frowned, pursed her lips tightly, and tried to scooch away from the woman. The woman furrowed her eyebrows and looked around apologetically. She pulled out a tissue and let out a loud, hacking wet cough, filling the tissue with mucus. The young lady next to her looked absolutely disgusted and quickly turned her head away from the woman.

I scolded myself for not having another tissue or an extra water bottle on me to offer to the woman. Out of all days to forget a bottle of water! I wanted to kneel down, rest a hand on the poor woman's shoulder, and gently ask her, "Are you alright ma'am?". The young lady's behavior towards the woman also bothered me, and I wanted to set things straight by showing her how to treat strangers with compassion.

Let's be patient and kind with strangers. The woman could have had lung cancer, and people were looking at her with disgust on that train. It was so heart-breaking to see. What in the world happened to empathy? Let's do unto others as you would have them do unto you.

Rochester, NY
During my two days in Rochester, I met up with a really good college friend who is currently in medical school at the University of Rochester. It was so nice catching up with her, eating her phenomenal home-cooked Cameroonian food, going to her local church, and binge-watching the first season of "You" with her on Netflix.

Rochester is a nice city. It's fairly diverse, the cost of living is great, and the Neurology residency program has been directed by one of the leaders in Academic Neurology for a while now. I enjoyed my time there.

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Thank you for reading this long post! I hope you enjoyed it :)

Neurology Residency Interview trail (Part 1)

Friday, March 20 was Match Day 2020. Unfortunately, many medical schools across the nation canceled their Match Day week activities because of COVID-19. We were still able to have a virtual event livestream which my parents and sister joined in on to celebrate with me.

Photo from here

I am very excited to share that I matched into my number 1 choice for residency, Duke Neurology! I am so grateful for the opportunity to train at this amazing institution. I cannot wait to meet my future co-interns and the rest of the team at Duke. I will be in Durham, North Carolina for the next four years, only a four and a half hour drive away from my younger brother, sister and brother-in-law in Maryland.

Before we were pulled out of our clinical rotations, I was on a 2-week Ophthalmology elective in early March and am currently on a 2-week Palliative Care elective. Because our school has ordered us not to come in to the hospital, my attending has offered to meet with me and another student daily through Zoom to update us on patient encounters and to go over a few assignments.

I still have a copious amount of free time, so I decided to pick up a few extra shifts at my new job with Renewal Care Partners (RCP). RCP is a home health and companion care organization that provides assistance to elderly individuals with chronic medical conditions and memory-related disorders, such as Alzheimer's. I found this organization online last December 2019 in my search for opportunities to make a little extra cash (to make up for the expenses I exceeded in my budget for traveling during residency interview season). I was partnered with my first client, a quiet and kind elderly woman with dementia. I had my first shift last week, and I enjoyed helping her out around the home with laundry, dishes, cleaning, meal preparation, feeding the pets, picking up her medications at the pharmacy, and chatting with her and her husband. It is such a rewarding job.

The state of IL has recently issued a shelter-in-place order in response to COVID-19, but workers providing essential services are exempt when traveling to and from work. Essential services include all home care workers, so we will be able to continue serving our clients who need us and depend on us.

~*~*~

Anyway, sorry, I haven't yet gotten to the purpose of this entry: the interview trail. Because I have ample free time and I'm not working today, I thought I'd share some interesting interview experiences with you.

First off, I'm incredibly grateful for the opportunity from Nov 2019 through Jan 2020 to interview at great U.S. programs for Neurology residency. I actually wrote most of these reflections shortly after the interviews during those months, but I thought it would be nice to share now a few quick thoughts on each city/town that I've been to, as well as my random travel and food experiences. From changing out of interview clothing in airport bathrooms to getting lost on the NYC subway on my way to an interview, it's been a crazy season.

I may mention program names in this entry (only in a positive light), but I will not publicly give a thorough impression. I will not say anything negative about a program. That is not the purpose of this entry. You can go to forums like Student Doctor Network or reddit if you're looking for more details than what are provided here. Please e-mail me separately if you'd like my thoughts on program specifics (debk93@gmail.com).

My first couple of interviews were in Boston and Chicago. I've written about both cities in prior entries, so I will not repeat my impressions of these places here.

Each section has a "title" that encompasses a main memory or general impression/takeaway of my trip to that particular location.


New Hampshire - CapeAir has a very small domestic airplane

Photo from here

My third interview was in Lebanon, NH the week before Thanksgiving. I had to fly first from Chicago to Boston, then from Boston to Lebanon. That was the smallest domestic airplane I'd ever been on (there were only 9 seats. See picture on right). It was so small we couldn't put any bags under the seats in front of us. All of our luggage had to be stowed in the plane. They also documented how much both we and our luggage weighed prior to boarding. I took 5 pounds off my actual weight :( I know, I was wrong for doing that, but I was caught off guard by the question and it was asked by a very attractive service clerk!
"Ma'am, how much do you weigh?" He asked.

"Umm..." I stared at him for a moment before subtracting 5 from my actual weight. This made me wonder how often other people flying with Cape Air (especially women) may have "adjusted" their weight when asked.

I was only in NH for a couple of days but it was cold (VERY cold) during my stay. I went to the dinner the night before the interview and got the chance to meet the friendly residents at a great restaurant in Hanover, NH called Murphy's On the Green. The food was pretty good. For appetizers, we had crispy calamari, a special "poutine" dish with bacon and cheese, chicken wings, and mac n' cheese. I ordered the salmon for the main entrée. 

Brooklyn, NY - Yucky weather

Vera Bradley Totebag
Photo from here

I had my next interview in Brooklyn a few days after Thanksgiving (Mon, 12/2). I stayed with my aunt and cousin for a night. They helped me hone my ironing skills. I'd only packed my clothes and things in my Vera Bradley tote bag (see right), including my interview attire (blazer and pants). I looked up a youtube video on how to fold/roll them up to minimize creases. I know it sounds insane but hey, it saved me $60 ($30 to check a bag each way/round trip). I ended up having to iron out a bunch of creases in the end but it was worth saving $60. 

The night prior to the interview, the residents and applicants ate at this nice spot called South Brooklyn Foundry. I ordered the Crispy Fried Chicken ("Three Organic chicken boneless breasts served over red skin mashed potatoes, Baby and Devil's corn, and topped with micro greens.") It was pretty fantastic. Like every pre-interview dinner, we had the chance to ask questions in an informal setting with the residents.

Kelly and Katie wedge pumps
Photo from here

Unfortunately the weather was disgusting during the two days I spent in Brooklyn. It was a mixture of rain and snow, and the ground was covered in slush. I had no idea that the weather would be like that (my weather app was deceiving), so I didn't pack any boots! I only had my flats, Toms, and wedges for the interview. After the interview day ended I walked several blocks to catch a couple of trains and a bus to get to LaGuardia airport for my flight back to Chicago. I don't know how my wedges weren't destroyed by the time I left. (I have to put in a plug for these shoes, see left. They are absolutely amazing. I purchased these from DSW specifically for my interviews and I don't regret it. I highly recommend them for work/interviews/any formal event/even going out. I got them for only ELEVEN DOLLARS in store. DSW always has amazing deals going on, so jump on them!).



Charlottesville, VA - Diversity and great food

I was so excited to interview at UVA (University of Virginia) later that week. I'd flown back to Chicago from NY on Monday night (12/2) then to Charlottesville on Thursday morning, a day before my interview on Friday, 12/6. Charlottesville is a nice, cute college town with moderate diversity and an institution (UVA) with a fierce dedication to diversity and inclusion. I think much of these diversity efforts have risen in response to the white supremacist rally that took place in Charlotesville a couple of years ago in 2017, but I do believe that the efforts to retain and recruit a diverse workforce in the institution are genuine. My impression is that things have calmed down quite a bit since that time and multiple people who have lived in Charlottesville for years don't believe that another rally like that one will happen again.

Grilled salmon (with warm ratatouille style salad,
smoked pico, cascabel cream) at Zocalo
Photo from here 

I enjoyed meeting the Neurology residents at the pre-interview dinner the night before. We went to an awesome spot called Zocalo. I ordered the grilled salmon (see right) which was to die for. The residents were among the most outgoing that I'd seen on the interview trail so far. Everyone was very friendly and welcoming.

I stayed with a friend (current med student at UVA) the night after the interview, then attended a special Diversity Day that the UVA Graduate Medical Education office hosted on Saturday morning. It was such a nice event that facilitated deep discussion among the participants (current ethnic minority UVA residents and interviewees across multiple specialties) about the diversity and inclusion efforts at UVA. 

One other tiny interesting (and not totally surprising) encounter in VA: On my flight back to Chicago, the flight attendant began to walk around to ask passengers for drink orders. When she saw me (I was sitting at the front), she stopped and asked, "Did you fly in yesterday?" I told her I flew in a couple of days prior and she replied, "Oh! Your twin must have been here yesterday then." I politely laughed. After this quick exchange, I swung around in my seat to look at the other passengers on the plane. I was the only black person on the flight. The flight attendant must have seen another black woman yesterday with braids and assumed that we were the same person. I chuckled and shook my head at the thought.

Durham, NC <3

Duke University Chapel
Photo from here

I absolutely loved my time in Durham. I'd only been there once before for a pre-med conference in 2016 when I was completing the post-bac program at the NIH (I think I may have actually blogged about it). I learned so much about the town/city that I hadn't known before (all good things honestly). Duke's campus is gorgeous and the beautiful Gothic architecture for some of the buildings (especially the undergrad campus) reminded me so much of Cornell. The architecture is strikingly similar on both campuses.

The residents and interviewees went to an awesome spot called It's a Southern Thing. I ordered the shrimp & grits. The meal was incredible and so filling that I couldn't finish it all. The residents were friendly and seemed to have a calmer, chiller camaraderie amongst themselves, which was a great feel.

Duke organized a special, guided tour of Durham for the interviewees at the end of the interview day. We had the chance to explore the college campus a little, check out DPAC (Durham Performing Arts Center), the Burt's Bees headquarters (I didn't know it was in Durham! I'm sure you've heard of the chapstick), and the Duke University Chapel, an interdenominational church that is the largest building of Duke's historic West Campus.



Atlanta - Best grits ever, diversity at Emory, and fun facts about Emory

It was great catching up with and crashing for a night with a couple of friends who are current medical students at Emory, both of whom were studying for major exams at the time (Step 1 and the Surgery shelf). I really appreciated their willingness to host me in the midst of their studying for such important exams.

My bus arrived in Atlanta early in the morning so I decided to go for a walk in the area and grab some breakfast. I went to check out this popular local spot called The Flying Biscuit. I was so hungry I ended up ordering grits, a biscuit with jelly, bacon, scrambled eggs, and fresh squeezed orange juice. Those were the best grits I ever had. They melted in my mouth and went great with the rest of the meal.

The Neurology residents at Emory were the most diverse group I'd seen so far on the interview trail. It was amazing to see such an incredible representation of different racial groups.

A few fun random facts that I learned about Emory during the interview day:

• Muhammed Ali’s neurologist is (was?) at Emory! (Muhammed Ali was diagnosed with Parkinson's Disease in 1984, three years after he retired from boxing).

• Grady Memorial Hospital (which is part of the Emory Healthcare Network) has one of the largest thrombectomy programs in the country, with more than 300 procedures performed every year.

• Grady Memorial Hospital was one of the leading sites for enrollment of the groundbreaking DAWN trial, which showed that properly selected patients who suffered an acute ischemic stroke could benefit significantly from a thrombectomy (clot removal) if performed up to 24 hours after symptom onset.

• Emory University is the most diverse neurology residency program in the country.

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I'm going to stop here and continue with the rest of my interview season experiences in another post. Thank you for reading! :)

Medical Spanish elective in Ecuador

Photo from here

I had the opportunity to spend the month of February in Riobamba, Ecuador for an international medical elective with a program called Cachamsi (Cacha Medical Spanish Institute). There were about 20+ other medical students and residents from other institutions (NYU, Stanford, Missouri, Georgetown, Cincinnati, etc) completing the elective this month as well. It was such a great experience.

Cachamsi (Cacha Medical Spanish Institute) offers clinical immersion rotations in a hospital, outpatient, and rural setting in Riobamba, Ecuador. The duration of the program is a month, and students complete rotations in the outpatient and/or inpatient setting from Monday through Thursday in the morning/afternoon, and spend 2.5 hours in Medical Spanish class in the morning/afternoon/evening. One of the main goals of the program is for students to enhance their communication skills and be able to perform a complete medical history and physical examination in Spanish.

I completed a 4-week rotation on the Neurology service at Hospital General Docente de Riobamba. My attending, Dr. Rodriguez, is a Cuban neurologist who trained in his home country before practicing in Ecuador. I learned so much from him, such as conducting a portion of the neurological exam in Spanish and interpreting CTs and MRIs (in Spanish). He pimped me on a number of random things (again, in Spanish, which made it so difficult), including all of the anti-epileptics that I could name off the top of my head, the treatment algorithm for status epilepticus, the dosages for their most commonly prescribed medications such as paracetamol (similar to tylenol) and carbamazepine, and the treatment for West Syndrome, which is "a constellation of symptoms characterized by epileptic/infantile spasms, abnormal brain wave patterns called hypsarrhythmia and intellectual disability." (This was something I'd memorized months ago for Step 2 CK but never ended up getting a question on it, so I forgot it immediately. The answer is ACTH by the way). Dr. Rodriguez was a great attending. I also really enjoyed working with several other interns who took turns rotating through the Neurology service as well.

Photo from here

During my month in Ecuador, I lived in the Indigenous community of Cacha. I was specifically in Puraca Tambo, a cultural touristic center. (Pucara is Kichwa for "panoramic view", and Tambo "a place of rest"). The nights and early mornings were quite chilly (we were situated in the heart of the mountains), but the space heaters they provided for us were lifesavers. I'm glad I packed multiple sweaters and a pair of warm, plush socks to wear to bed. I had my own cabin to myself. The showers were hot, the wool blankets cozy, and there was ample room to spread my things throughout the cabin. I enjoyed living in Pucaratambo for the month. The staff was also incredibly accommodating and our cooks "Mama" Luz and Jose were phenomenal. 

Segundo, who I like to refer to as our homestay dad (and the person in charge of Pucaratambo), would take us to our rotations in the morning and our Medical Spanish classes in the afternoon. It's been interesting to take note of some of the profound cultural differences that exist between the U.S. and Ecuador (from what I've seen in Riobamba) in the clinical setting. Here are a couple of things I immediately picked up on during my first week:

• Medicine is still quite patriarchal. Overall, patients are not autonomous and unfortunately many lack a basic understanding of their medical conditions. For example, a 70-year-old man with Parkinson's had never taken any anti-Parkinson's medications (though he'd had the diagnosis for a while). He was simply drinking rosemary and coca tea for his therapy. Our attending firmly said that all of the rosemary and coca tea in the world would not take away his Parkinson's symptoms. Our patient did not understand that these natural 'treatments' would have no effect on his dopamine levels, which is the pathophysiological basis of the disease.

The most autonomous individual we encountered was a family member of an elderly female patient we ended up admitting because she complained of a sudden, severe headache with photophobia and vomiting. Her 20-something-year-old grandson asked a number of things, such as the purpose of several medications we prescribed, what our clinical suspicion was for his grandmother's condition, and what the next steps were for her care. "Excellent," I thought happily to myself. I loved seeing patients and their family members actively engaged in the patients' care. This young man's line of questioning may have been a nuisance to my attending and the interns but I was delighted to see that he was confident enough to ask such well-informed questions. Many of our other patients simply expected to be told what to do, what medications to take, what imaging/labs to obtain outside of the hospital (since we could not offer these things), and when to come back for the next appointment. It is simply part of the medical culture in this region.

• This is my first time volunteering in a medical setting in a developing nation after gaining much exposure to the way medicine is practiced in the U.S. (during the third year of medical school). I believe that my medical training so far in the U.S. has made me especially sensitive to the differences that exist between our healthcare system and that of a developing nation. I admit that there were a few things I found bothersome and horrifying, while others were simply amusing and eyebrow-raising. Of the amusing things, the lack of a sense of urgency was probably the most salient for me. I think of myself as a New Yorker in many ways, so imagine how painful it was to suppress the urge to speed walk to see our inpatient consults and instead walk alongside our attending and interns while they meandered through the hallways as though they were on the beach. Eventually, I got used to walking at this snail pace but to be honest, it is not something I want to get used to during my training or career.

Of the things I found bothersome and horrifying, the lack of medical resources was most significant. This, of course, is not the fault of the physicians, interns, nurses, or other hospital staff. This problem is multifactorial, and it stems from and is interconnected with deeper issues pertaining to politics, the government, the economy, infrastructural instability, and poverty. It was heart-rending to learn from one of my friends (a Physician Assistant student) who completed an Emergency Medicine rotation at the same hospital that a 65-year-old woman passed away from complications of chronic cholecystitis (she went into septic shock) because the emergency room did not have the appropriate supplies on the crash cart. For example, they attempted to intubate her but could not because they did not have anything to suction away her secretions in order to properly visualize the airway. 

I will never forget the 28-year-old man with a new diagnosis of HIV/AIDS who we were consulted for regarding a new-onset headache he developed after taking his anti-retroviral therapy (ART) for the first time (ritonavir, emtricitabine, and tenofovir). He appeared very pale, weak and extremely emaciated. I was told that it had been about a month since his diagnosis, but he didn't start ART until this admission, and he likely had HIV/AIDS for a long time prior to the official diagnosis. My intern shared with me a few days later that he'd passed away from complications of the disease. I was shocked. For much of that evening, I couldn't help but wonder what this patient's story was. I wasn't there during the first encounter when they initially heard his narrative. Perhaps he had sexual relations with men but kept it from his Indigenous family because such relations were absolutely taboo in their community. Maybe he contracted the virus from an unfaithful girlfriend? Could he possibly have visited a brothel? Regardless of the method of contraction of the virus, he should not have died from its complications at such a young age. 

The saddest case I saw was that of a 7-year-old boy ("Juan"). He was brought into the ED by his parents who reported that he'd become progressively unresponsive and lethargic over the past several days. They presented on a Wednesday, and reported that Juan started appearing weak and unable to walk since the Thursday prior. They waited nearly a week to bring him in. (I learned towards the end of my rotation that the Indigenous community brought sick relatives to a natural healer first before going to the hospital). Juan would not open his eyes to voice, but roused slightly to sternal rubbing. He lacked reflexes throughout and had pinpoint pupils. We asked his father to help us get him to walk, but he was extremely unsteady on his feet. Our attending suspected that Juan ingested a toxic substance, so we sent off a comprehensive toxicology panel. On my way out of the hospital that day, I ran into Juan's mother and four of his siblings. "Por favor, doctorita, cómo está mi hijo?" [Please, Doctor, how is my son?] Juan's mother's Spanish was thickly laced with a Kichwa accent; it sounded staccato and heavy.

I greeted them warmly and shared that Juan was stable and doing fine right now. I told them that we suspected he may have accidentally ingested something toxic so we ordered a toxicology panel to test for a number of different substances. If those results come back positive we'd have a better idea of which exact treatment to start Juan on to reverse the effects of the toxin. They stared at me for a few moments and I feared that I either confused them with poor Spanish or with too much medical jargon in Spanish. Finally the mother, older brother and sister thanked me profusely and scurried away to see Juan.

The next day (Thursday), the panel returned negative and Juan improved significantly. He had improved strength and 1+ reflexes in all extremities (improved from no reflexes the day before), and his pupils had returned to normal. The doctors were still not sure what could have caused Juan to become so unresponsive, but we were mostly relieved that he was doing much better. When I returned to the hospital after the weekend on a Tuesday, I learned from my attending that Juan had passed away the day prior. For a moment I thought  I'd been punched in the stomach. "Se murió?! Pero cómo?" [He died?! But how?] I asked Dr. Rodriguez. He admitted that he had no idea what the cause of Juan's death could have been. The boy was doing much better by the second day of his admission, so he was sent home. He passed away a couple of days later. The family refused an autopsy. Dr. Rodriguez and the intern surmised that Juan may have been hurt by a stranger on his way to or from school. Many children walk on their own to schools in the communities without a vigilant adult guardian to make sure that they're always safe. 

"Pero quién lo habría matado y por que?" [But who would have killed him and why?] I asked. 

My attending and intern shrugged. "Sabes, la gente es mala." [You know, people are evil]. I remember that my attending also said something along the lines of, "Tampoco sería la primera vez que esto ha sucedido." [This also wouldn't be the first time that something like this has happened]. I couldn't believe this. Juan was just a child, a 7-year-old boy who hadn't even begun to experience life yet and already he was snatched away by the clutches of death. I wanted so badly to snatch him back from death's fingers, revive him, and deliver him back into the hands of his heartbroken family. Was Juan hurt by a predator in their community? Did he accidentally ingest something else (or the same substance) that maybe wasn't even picked up by the toxicology screen the first time? I respect the family's decision not to have proceeded with an autopsy, but I hope that they are able to find peace, and importantly, I pray that Juan's soul rests in peace.

~*~*~*~

I will end my entry there. I'm sorry if that was too sad a way to end this entry. I can go on forever about interesting and moving cases I saw during my rotation, but I'll leave it at that. This international experience was incredibly eye-opening. I am very grateful for the opportunity to have spent a month in Ecuador on this Neurology rotation with Cachamsi.


Tomorrow I start my two-week Ophthalmology elective, which I am very excited about. Match Day is March 20, 2020!


My last two weeks of March will be spent on the Palliative Care service, and in April I will finish off the year with a mandatory Emergency Medicine rotation. Is it weird that I'm really excited about these upcoming rotations? 


Thanks for reading! :)