A Story of Trust
CHILE, PHYSICIANS AND TEENAGE GIRLSThe New Physician
Like a row of dolls, they sit in the clinic waiting room, a dozen or so 14- and 15-year-old girls dressed in navy-blue school uniforms. With a television blaring a “reality” show overhead, the clinic staff and I float about getting charts and pill packs, preparing for the next patient. It’s just another morning in the Santiago de Chile adolescent health clinic.
As a fourth-year medical student, I am in the capital of this coastal South American nation interning and treating patients. I call out the next name, Carolina*—a slight girl with frosted-purple eye shadow and the uncertain, gangly gait favored by adolescents and baby deer—and guide her to the exam room. She sits, and with little preamble, the physician of the day, Dr. Alvarez*, asks her excruciatingly detailed questions about her sexual activities. I’m curious to see her reaction to his seemingly invasive interview. To my surprise, Carolina seems comfortable in her responses, reporting she would prefer monthly birth control through inoculations. Alvarez replies curtly that he doubts she needs anything other than standard oral contraceptive pills and points for her to undress for her internal exam.
Behind an inadequate curtain, Carolina calmly undresses while Alvarez finishes his notes, and I scramble to prepare her for the exam. Draped in a gown, she slips into the stirrups. Secretaries and other physicians come in and out of the room without knocking, and the curtain barely shields Carolina from the traffic. As Alvarez talks with me, he also hangs out in the doorway yelling questions at the receptionist. When we finish her exam, Carolina sits up expectantly, and Alvarez tells her she should go on the pill and return to the clinic in two months. With a nod of his head, Carolina is dismissed, dashing out of the exam room and back to school with a backward glance and friendly smile.
Probably the most amazing aspect of this clinical encounter is that Carolina was able to be there at all. As I learned from many conversations with my Chilean colleagues in OB-Gyn and social services, adolescents in Chile face many difficulties and potential barriers in caring for their reproductive health. As in other South American countries, abortion is illegal in Chile, mostly due to the strong influence of the Catholic Church. The abortion law in Chile, however, is one of the world’s most restrictive, forbidding the procedure even if a mother’s life is at risk.
With such strict laws, six illegal abortions occur for every 10 births in Chile, and those abortions—either surgical or through mifepristone, RU-486—frequently have such life-threatening side effects as sepsis or hemorrhage. Chilean adolescents who find themselves pregnant and choose to marry face a lifelong decision without recourse or solution, as the country is the world’s only democracy without a divorce law, another result of the strong influence of the church.
In general, cultural taboos about sex education limit the availability of important information about sexuality and reproduction. Although some colegios in comunas—the secondary schools in diverse and more liberal, urban areas—are more likely to offer inclusive sex education, views on sex and abortion remain predominantly conservative. It should be considered an accomplishment for a young woman like Carolina to have found her way to the clinic before a pregnancy, regardless of the visit’s outcome.
I was also amazed at Carolina’s maturity, in spite of Alvarez’s callousness and paternalism. However, I soon discovered that most patients were fairly comfortable with the extensive questions about their sexual lives, the clinical commotion that frequently disrupted pelvic and other private exams, and the physicians who sometimes made decisions about their care that directly opposed what they might prefer.
The most striking thing about working in Santiago as a health-care provider was the profound cultural differences in the patient–physician relationship. In an effort to explain to me his clinical reasoning during Carolina’s visit, Alvarez said that the physician’s goal in any clinical encounter is to decide what is best for the patient. His job is not to be a friend or an intermediary between her and her parents, but to protect her welfare and do what he thought best. This is the reason why patients come to physicians, he said, adding that this is especially true with female adolescents, because a physician must act in place of the adolescents’ parents in granting them permission to use birth control. While the young women frequently do not want to involve their parents, they do want an adult to take charge of these decisions, he said. Many of my other Chilean colleagues agreed with this reasoning.
So, far from being affronted that her physician was acting—as Ferris Bueller would say—as a parental unit, Carolina was satisfied because she expected that type of patient–physician relationship, and she trusted us to focus on her needs. In fact, most of the patients I saw in Chile seemed to desire this and trusted their physicians—a stunning contrast to the litigation-ridden U.S. health-care industry.
It’s this lack of medical litigation that seems to make all the difference in Chile, although cultural expectations and sexual politics undoubtedly play roles as well.
Furthermore, while there are many profitable hospitals and clinics in Santiago, Chilean physicians are typically not wealthy, especially when compared to their U.S. counterparts. Most struggle for income and must pay high fees in order to pursue their education. As a resident told me during my second week, patients believe their physicians must be dedicated to medicine to pursue it—an attitude toward physicians that, at least in the United States, seems to have been lost long ago.
My experiences in Chile have led me to conclude that perhaps a benefit of the U.S. health-care system’s financial disarray—and physicians’ declining income—will be improved patient– physician relationships and an increase in patients’ trust in their physicians.
Tarayn A. Grizzard is a fourth-year Harvard Medical School student. She spent the 2003 summer in Santiago, Chile, working in adolescent reproductive health and sexual health. Direct comments and questions about this article to firstname.lastname@example.org.