Thursday, February 5, 2015

Ola! Bom Dia!

I arrived in Lisbon Sunday morning, February 1st, via TAP Portugal. The Portuguese seem to take pride in their country colors as the pillows and blankets were a vibrant green and red, respectively. Dr. Basto, being as nice as he is, gave me clear and complete directions for getting to Porto from Lisbon. The train was a very smooth ride and got me to Porto in about 3 hours. Lucky for me, the stop for this inter-city train is Campanha, which is only a couple minutes walk from the hostel, WorldSPRU. I had grand plans for spending the day exploring Porto, but the jet lag got to me and I quickly fell into a long nap. On the positive side, I was wide awake for an amazing Superbowl between the Patriots and Seahawks!

My room at WorldSPRU. As you can see, there's a kitchenette
with a small fridge under the stove.

I was to meet with Dr. Basto on the first day at 8:15. Conveniently, the stop for the Porto metro is literally below the hostel. While the ride is about 25-30 minutes, it is pretty straightforward. Also, Trindade, the stop where I have to switch metro lines, is one that every metro line stops at so I don't have to wait more than 1-2 minutes to catch the metro at Campanha. Hospital Sao Joao is the last stop on the yellow line so its nice to just sit back and watch as the train bobs above and below ground as it makes its way there.

Hospital Sao Joao
Dr. Felix was right. Dr. Basto is a very nice guy who has our best interest at heart. He is clearly passionate about his work and his enthusiasm showed as he gave me a tour of the old wing and new wing of the hospital. I then met Dr. Pestana,, the attending on the team I will be spending my time with at the hospital. Previous UNC students have worked with him as well. As previous student blogs have mentioned, each team consists of an attending, residents, interns, and medical students. Besides Dr. Pestana, ours had 2 residents, an intern, and 2 medical students. Also, as others have mentioned the days usually start at 8 and go until 2 pm. The residents sometimes stay longer to finish notes, orders.

Some observations from the first week:

- Growing up, I wanted have something about me that set me apart from other people. Yes, mostly fit in, but still something unique, you could say. As I get older, it's funny how people are more similar than different. The subtle neurotic nature of doctors, the sass of the nursing staff, the doctor-nurse interactions, the frustration we feel sometimes when we don't think our interventions are doing anything for the patient. The same things I saw and experiences I had as a new 3rd year student on the wards I see here in Portugal, thousands of miles away. I saw the same when I was in India last year. Is it that we emulate this personality be being around others like that? Or is there some invisible thread that binds those with similar personalities to similar professions?

-One thing, though, that is different is the hours. We cap hours at 80/week for residents and put clear instructions for faculty to exercise that for their residents. Talking to the residents here, the numbers are 40-50 hours a week. This got me thinking: are we really improving care in those additional 30 hours? Sometimes I feel it's made up of idle time, that afternoon lull where notes are done, discharges done, no new admissions, and you are waiting for sign out. On the other hand, there is something to be said about continuity; the 10-12 hours you spend monitoring patients, following up on orders makes you more aware of disease processes. That being said, as I write this, I realize I need to learn more about what happens during the evenings, which residents are on service then, and if/whern there is sign out here.

-We pride ourselves in individualism, but there is something to be said about teamwork. Here, the team stays together for most of the day. The discharges are done together by the residents with Dr. Pestana providing edits and medical students listening in. We go to coffee break together in the morning and no one ever grabs lunch on their own. Part of the reason is the limited resources. There is one physicians' work room where there are 4 computers, one for each team, not one for each resident like it is in the US. On rounds, we are judicious in our use of supplemental oxygen. We are cautious about invasive therapy if quality of life cannot be improved. That is why we are hesitant to rush to coronary cath a lady with multiple strokes and limited mental status. Resource allocation is an issue in the US, but to another degree here in Portugal. We could learn something in the US, but I doubt it'll sink in when we know resources are still available around us. I think we often rush to question ourselves if we are doing enough when we should focus on doing what has the highest yield. Obviously, this is something I've talked about before with colleagues at UNC, but it is interesting how it hits you in the face when you see it in action somewhere else.

The view from my room window. That train is the metro I take to get to the hospital.

-I ran into a couple Erasmus students during this first week from Italy doing the equivalent of their 3rd year clerkships in Porto. To clarify, the Erasmus Programme is a European Union student exchange program. To the more important point: Medical students from Italy doing medical clerkships in a different country, let alone different hospital?? For me, doing my entire 3rd year at CMC in Charlotte was a big deal because I wasn't at my home base, UNC. I know students who have done college, medical school, and then residency all in one state. I will point out, though, that for much of the world medical school starts at 18 and goes for 5-6 years. In essence, college and medical school are combined. Maybe this allows more flexibility for the European students. Whereas we study abroad in college, they do it during their joint college/medical school. That being said, these students are doing core medical school clerkships, not electives for a major in college. A big deal with serious logistical issues since it is medical education across countries. That being said, if the EU can do it, why can't we? Should we create a student exchange program for US medical students to do a few core rotations in other states? You know, as a way to explore this large country we live in? And I'm not saying 4th year 'audition' electives, but core 3rd year clerkships. Language, laws, and government would not be an issue. But still, logistically, can we? Looking back, I remember it being sexy to study abroad in a different country. I am guilty of it now. Maybe we can encourage studying abroad in our own country, one that is larger than all of Europe.

-Man, have I done some digressing on these observations or what? I want to end on the influence of the United States. Here, we follow a lot of the guidelines created in the US; CHF, stroke, diabetes, HTN. We use Up-to-Date. All the research I hear being done at UNC or big journal papers coming out in the US have a world impact. Powerful, huh. Of course, there is research being done at European institutions and we reference it as well back in the states, but it seems that a lot of the paths are paved by US medical guidelines. It's interesting that this goes beyond medicine into pop culture. A kid on the metro was blasting Jay-Z on his headphones. The residents and med students one day started talking about their favorite TV shows: Modern Family, Walking Dead, Breaking Bad, How I Met your Mother. There are posters for "50 Shades of Grey" in Portuguese. I saw and heard the same when I was in India and that is country with a strong culture outlet with Bollywood. I heard the same from Mexican students I met during my year in DC who had come to the US for a 6 month internship. I'm not sure what my point is here. Maybe its just that I'm proud. Proud to call America home.

A week of radiology next! More observations await.

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