500 pesos

In case you were wondering how much it costs to have a baby here in the DR, the answer is DR 500 pesos, equivalent to about US $14.28. The interesting thing to me is that patients have to pay more money if they have a complication, like a retained placenta that needs some help getting out. It seems odd that they have to pay extra for something that they weren’t ever consulted with. Señora, would it be ok if I manually remove your placenta? I am going to have to charge you more for it and you might not have the money, but otherwise you will probably die bleeding to death or because of infection. Is that ok with you? Clearly, these conversations just don’t happen here in any way whatsoever.

Payment based on procedure and patient choices in decision-making got me thinking about some of the inherent differences between medicine in the US and here in the DR. There are so many differences; it’s hard to know where to start. I think a fundamental difference is the doctor-patient relationship. In medicine, there are many ways in which a physician can interact with a patient. First, in the US, we hope to use a deliberative model in which the health care provider hopes to promote health by influencing the patient’s choices using non-coercive approaches to motivate the patient as often as possible. Sometimes we also you other models: the informative model provides all the information in an unbiased manner and the patient chooses from the available options while the interpretive model is used when the physician recommends a treatment option that is most consistent with the patient’s general values and preferences. For the most part, my interaction with patients in the US has been conducted in the following manner: find out the patient’s understanding of what is going on and what they would like to happen, provide as much information about the condition and treatment options as possible, assess the patient’s understanding, see how I can be of more assistance to the patient in helping them make a decision they are happy with. I like to think of all treatment decisions as a discussion with the patient. Unfortunately, during an urgent matter, I don’t always have time to do all of this but I still try to keep my patient informed about what is going on. For example, in the patient discussed before, I would have let her know that her placenta was not coming out normally and the risks associated with this; next, I would tell her that based on what is going on, I was planning to do the following procedure to keep her as healthy and safe as possible. This is at a bare minimum what I try to do with all of my patients in Spanish, English, Polish and regardless of where I am working.

I cannot speak for how medicine is run in any other country, but in the DR based on my experiences solely, I have seen much more use of a paternalistic model of physician-patient dynamics. In this model, the physician is like a parent and recommends what they think is best for the patient. This model is based on the presumption that the physician knows best, something that is, in part, extrapolated from the Hippocratic Oath that all medical students take upon graduation: “for the benefit of the sick according to (the physician’s) ability and judgment.” Although physicians more often than not are an incredibly valuable resource for information, at the end of the day, the patient’s body still belongs to the patient and I think that they should have a say in what happens to them. I think that most of the culture shock that I experiences in the hospital was initial getting used to the paternalist model of health care. I had a hard time realizing that physicians made decisions being made about the patient without ever talking to the patient. I struggled when I heard the way in which physicians talked down and even ridiculed their patient, especially if the patient had a question.

I know that this month abroad was just one month and that I have a long journey ahead as I train to become an OBGYN. I also recognize that it is impossible for me to predict how I will change as a physician and as an individual over the course of my training as I learn more. I strongly hope, however, that I continue to enjoy engaging my patients in their health as much as possible because I have found it to be one of the most rewarding parts of my job.