Only about 20% of the children were "sick" with a common paediatric problem. I saw otitis media (ear infection), bronchitis, urinary tract infection, bacterial gastroenteritis, parasitic gastroenteritis, impetigo, tinea corporis (ringworm), and facial abrasions. For these families, I likely met their needs.
The other 80% all had numerous "complaints," but my sense was that these were mostly "well-child" visits for a routine check up. For these children, I am not sure that I met the needs of their family. I just do not know!
The "complaints" often did not make sense to me.
Assessing a child for a problem is a kind of detective mystery. The clues are the symptoms and the physical examination findings.
I was taught that the history (symptoms) is all important. I recollect a professor in first year medical school who taught us that by the time we started the examination we should know the diagnosis in about 75% of patients. Today, many physicians rely on laboratory and diagnostic imaging for a diagnosis and the history is often neglected. I am "old school" and still believe that the history "rules." In my clinic in Calgary, I have a microscope, a uroflowmeter, and an ultrasound. However, the history is still my main tool to sort out a problem, and I am able to predict the microscope, uroflow, and ultrasound findings based on the history with a high degree of confidence.
For the 80% of children with "complaints," the symptoms and my physical examination findings did not "add up" to an understandable problem. The clues did not make sense.
As the week evolved, when the clues did not make sense, I started to go back over the questions to confirm that the "complaints" really existed, and to my amazement and concern, I found that on repeat questioning, that many mothers admitted that the complaint was not really present.
My interpreter is excellent and this was not the reason for the confusion. Mothers everywhere can misunderstand, but the prevalence of misunderstanding is too high in Gigante for this to be the reason. Another possibility was that the symptoms were not temporally related, but I clarified this with precise questions. After ruling out the common and routine causes of this sort of confusion, I was left with a disquieting possibility. Perhaps the mothers told a story that was not true?
Why would a mother do this?
I asked the more experienced volunteers in the community and they responded that this was likely and that the reason is "cultural."
"Perhaps the mothers thought that they needed an excuse to see you," some responded.
"Perhaps the mothers thought you would be more likely to prescribe a medication if there were more complaints," others responded.
I learned that some of the complaints were "surrogate" complaints. The child was the emissary for another family member (father) who actually had the symptom (headache, chest pain), and the mother presumed that if I prescribed something for the child, that the father could use the medication!
Medications are highly desired solutions to common problems that do not deserve any medication. Over treatment is a major problem in Nicaragua, and while this might be a "cultural" solution for Nicaraguan physicians, this has never been my solution to a problem.
Given all these "cultural" differences in perspective, I am left wondering whether I met the needs of many of the families. I did not offer medications without a reason and I refused to offer medications for a child that would be used in the father. Instead I relied on the provision of information in the hope that knowledge has power.
This is the modern way, the Canadian way, and certainly my way, but this might not have been their way. If not, then I likely didn't meet the needs of some of the families, and as such, I need to learn how to meet their needs and still offer good medicine.
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