More time in the clinics

So I've been in a second pediatrics clinic following the first week of working here and it's quite different than the first. The first was exceptionally poor, a public clinic in Quito and the second is a private quite modern clinic.

In retrospect the care at the first clinic was actually quite impressive given what they had I think. It was an exceptionally poor clinic as I described before, they had little money and they saw tons of patients with limited resources. While limited I still felt like the care of the physicians was very pretty good.

This second week at a private clinic has been quite different. Its has pretty much all the amenities of an american clinic, and even has access to the majority of the labs that we would order in the states(with some exceptions). They are still limited by expenses though.

However while there is more ability to fund things the medical care has been far more lacking from my viewpoint. Like anywhere in the world and in any profession the quality of care that one receives can be variable, and I'm finding that here. I've been quite unimpressed with the approach and knowledge of the current doctor that I have been working with. Our interviews never last more than 2 minutes whatever the chief complaint, and our physical exams are incredibly lacking. For instance take the following scenario the other day:

A 2.5 year old male presents with fever and cough for over one month. Recently the cough has been more productive. The patient was treated with an injection of penicillin at some point recently and previously had also been treated with some bronchitis with no effect for presumed asthma(despite no wheezes). Neither previous treatment had any effect. The patient continues to be febrile and cough. The interview which was being conducted by the physician was completed at this point.

Ok time out... Tb is pretty much endemic here, and this is a case that to me, pretty much screams you must rule out Tb, yet there were no questions asked about exposures, contacts, living conditions etc. ok time in.

So the exam was pretty much limited to a heart, lung and abd exam, which revealed little. Chest was clear for the most part and no real sign of infection was seen except a mildly red throat and fever.

Tx: amoxicillin for a presumed pharyngitis and or pulmonary infection caused by something not covered by penicillin.

Here was the conversation that ensued between the doctor and I:

me: "ummm... Do you ever worry about tuberculosis in your patients?"

d: "not really, see because this is a private clinic, all my patients are from middle class families. Families that provide their kids with good nutrition who do not live in poor crowded conditions. Tb is a disease of the poor, in kids who are malnourished."

me: " Yeah its more common in those situations but you could still get it despite good nutrition and a good living environment right?"

d: " Well this child has had the BCG vaccine."

me: " hmm ...from what I have read the BCG vaccine helps to prevent miliary Tb and menigeal Tb but doesn't really prevent pulmonary Tb"

d: "No it prevents pulmonary Tb"

me "........."

d: "Yes so this patient doesn't have Tb we're going to give him amoxicillian and cover the organism that wasn't killed with penicillin."

me " yeah so i was reading the pediatric infectious disease book last night and it said that the
BCG vaccine doesn't prevent pulmonary Tb........"

d: "yes it does, this patient doesn't have Tb"

me: "oh...."