Second internship: Wasn’t one enough? (Not in El Salvador!!)

Warm spring greetings to all!

Internship: These last months have erupted with both pleasant and unpleasant excitement.  The upshot is that I am now an intern at the San Juan de Dios Hospital in Santa Ana, El Salvador. That is a short statement with a long history.  (For those of you who know the details of this story, please feel free to skip to the latter part of this letter.)

Even before I came to El Salvador we had been working on and praying for the approval of my Salvadoran medical license. Several months before leaving the US I had sent all my documents ahead of me, hoping to have my license ready when I arrived.  I’m glad I didn’t know the rest of the story then.

The leader of our Salvadoran mission, Arthur,  took the documents to the National Medical School of El Salvador, then the licensing agency in the country.  He was told that the papers could not be processed  until I arrived in the country. He sought advice from other missionary physicians who said they had found licensure in El Salvador impossible and that they were therefore practicing with only their US license.  The government, however, wasn’t checking on the legal status of their clinics or practicioners so they didn’t worry about it.

In the first several years after my arrival Arthur and/or I repeatedly presented my documents at the medical school.  We became familiar with the pattern.  We would present our documentation.  The secretaries would slowly review the papers then brighten and say, “Oh, but this isn’t right!   You must additionally have _______.”  So we’d request the paperwork from the US and then pay for its translation and authentication.  We’d present the papers again and the process would repeat itself.  We were relieved when a secretary finally received our application but disheartened to hear that from we should expect the process to be completed only after several more years.

We heard nothing from the medical school for many months.  In the meantime Arthur befriended a Salvadoran-born, Guatemalan-trained physician who was also trying to obtain his Salvadoran license.  This prominent surgeon was then vice-director of the national Department of Forensic Medicine; he had tried for years to become licensed.  Frustrated with the lack of progress, he finally filed lawsuits against the National Medical School of El Salvador.  He won his case in the Salvadoran Supreme Court, the Central American States Supreme Court, the Central American Court of Human Rights, and 2 other courts.

Jubilant, he hoped to use his case as the landmark case which would make licensure attainable for other foreign medical graduates. His jubilation (and ours) turned to disbelief when the School of Medicine took out a full-page ad in a national newspaper saying that they were under no obligation (nor were they planning to) abide by this Supreme Court decision.

Soon after this Arthur and I were summoned to the same medical school and ushered into a room full of frigid school administrators and staff where I was again told that I needed more documentation; this time they wanted the daily course syllabus from the my medical school days (to see where my training had been inadequate and where they would need to further educate me, they explained).  They ignored my  protests that some of my professors were already dead and some syllabi from my school days were certainly non-existent.

The staff at the University of Kansas School of Medicine rose to the task and produced 1000 pages of syllabus material.  This represented approximately half of the course material, most of which was available only from recent years rather than from the years when I had studied.

Arthur and I looked at the materials from UKSM and agreed that the Salvadoran School of Medicine officials were highly unlikely to receive this material.  It seemed unwise to spend close to $10,000 of mission money for translation and authentication only to have it rejected.  Searching for some alternative route,  we asked advice at the U.S. embassy. Their experience was that only those with friends in high places became licensed—that there was no legal way to do so.  The embassy’s own subspecialists hadn’t even been able to secure temporary licenses.

During this time my mother started praying every morning for my licensure.  Periodically in the next 6 or 7 years she would ask me if she should continue praying.  I would sigh and say, “I suppose so”.

Approximately 18 months ago we were surprised by a physician from the National Licensing Board (Junta de Vigilancia de Profesiones Medicas). She had been investigating another clinic in the area and stumbled upon us.  She summoned us for a hearing.  A stern woman, she was surprisingly sympathetic with our plight and told us that other N. American doctors had stalled out at exactly the same point in the process as we had.  We were thrilled to hear that the laws had changed and that the Ministry of Education was now approving medical diplomas rather than the School of Medicine.

Under the new laws we received the clinic license in less than 2 months. My license was more complicated.  First my elementary and high school diplomas had to be accepted into the system(!) and then the both my college and medical school degrees needed to be approved.  But things progressed amazingly smoothly and in November 2002, with no additional hassles, my University of KS diploma was received by the Salvadoran system.  Awed, I remembered all my mother’s prayers and  had visions of being close to the end of the process.

Alas, that vision ended up being only an illusion.  For,  in the eyes of the Salvadoran system I was only a graduated 4th year medical student and needed to still complete the year of internship (Año Social) in which the graduate donates a year of his time to the country.  No,  the 10 years I had already donated didn’t count.

The Ministry of Public Health (MPH)  is responsible for the placement of each intern.  They refused our request that I be allowed to serve the year in our own clinic and insisted that I participate in the national placement exam in which internship positions would be assigned depending on the test results. This test was to be held in mid-December, three weeks after my medical school diploma was approved.

My next weeks were spent seeing patients as efficiently as possible and then intensely digesting 300 pages of  MPH notes.  I stretched my Spanish vocabulary to learn about construction of latrines, strained my eyes to try to decipher poor photocopies of enlarged lecture slides, and stressed my neurons to memorize long lists of organizations, laws, bills, and procedures.  Sometimes the importance of this test for our clinic, patients, and staff seemed almost suffocating.  If the exam didn’t turn out well, what would happen to my staff?  Where would my patients receive their medical care for the next year?

On the day of the test I felt intimidated by the group of graduates fluent in their native Spanish and accustomed to the memorization that underlies all of El Salvador’s educational system.  As I struggled to answer questions which requiring the memory of an obscure Bill 57a  [was it a:  a)law about adolescent health, b)ruling about adolescent health,  c)regulation about adolescent health, d)b and c],   my heart wandered to my staff and patients and I would pray and turn my mind to the next question.

For the rest of the Salvadoran-graduated medical students, the test results would be available within 2 days.  I needed to wait longer for mine.  In our continuing interaction with the staff of the Ministry of Public Health during those days of suspense we sensed that the animosity toward foreign doctors had really not changed at all in 10 years and we became convinced that the MPH planned to force us to close our clinic in order to assign me to some other remote area regardless of test results.

That animosity reached its height on December 18, when the MPH refused to acknowledge our presence or talk with us.  Suddenly (but it wasn’t so sudden; there was a long night in which hundreds of people were praying for us) on Dec 19 the vice-director of MPH appeared to completely change her attitude,  greeted Arthur warmly,  and told him she had decided to let me do my Año Social at our own clinic. The bells of Christmas started ringing at that moment.

During the Christmas season I thought a lot about incarnation. I thought about what it meant to love my Salvadoran patients enough to be willing to become an unacknowledged and unappreciated intern for them.  I had experienced in those days an almost fierce love and concern for my staff and patients.  And I thought of Another whose fierce love for humans caused Him to shed eternity and climb into a human body.  It made the Christmas celebration more humbling and intimate.

After Christmas I entered Hospital San Juan de Dios in Santa Ana as an intern to receive their instructions for the next year.   I was told to expect to attend classes frequently (requiring closing the clinic frequently—a real problem when one can’t notify patients coming from 8 hours away), limit patient numbers (difficult after 10 years of practice), and fill out masses of paperwork on the practice.  I made many trips to the Administration and Human Resources area of the hospital and couldn’t tell if they were considering me different from the other interns.  I was excepted from the initial classes and by late January I waltzed out of the hospital with a letter to present to the director of the clinic where I would be interning (I humbly presented it to myself) and absolutely no other stipulations except to report to the hospital at the end of the year.  So, though I’m officially an intern, the clinic is functioning as it has for 10 years.  I now have a temporary Salvadoran medical license and, depending on how other details go, may actually have a permanent license in a year from now.  (!!!!!!)

Strikes: The medical strikes of which I spoke in my last letter have caused calamity for many patients.  The doctors’ union, striking against the privatization of medicine in the country,  was so opposed to having their jobs threatened that they burned tires on the PanAmerican highway to jam up traffic, took the national cathedral hostage for several days, and injured police. (I don’t know about you but somehow those activities don’t seem be an intricate part of the healing profession.)  The government finally decided to maintain the nationalized health system but the union continued striking, now demanding that the physicians who had been fired during the strikes be rehired and receive full payment and benefits for the months in which they were striking.  In the meantime (7 months!) entire wards of hospitals were closed.  Two stories  illustrate the loss of medical care our patients suffered during the strikes.

In November a 63-year-old man came to me with a history of 2 years of hoarseness.   His history of smoking and the longevity of symptoms influenced me to send him for an evaluation to the nearest referral hospital.  A laryngoscopy was performed and carcinoma was confirmed.  He was scheduled for surgery at 7 a.m. one day in early December.  On the morning of surgery he was stuck into a small holding room wearing only a hospital gown,  without food or water, and told to wait.  At 3pm an intern came in and told him to get dressed, that the hospital didn’t have the correct equipment after all to operate on him and that he would be sent to the national referral hospital, Hospital Rosales.

When he got to Rosales, the doctors were on strike.  He was told he needed to go to a private hospital because no surgeries were being done at Rosales.

Three weeks ago he came back to our clinic.  He had not been able to afford the private hospital so had been without any further medical care.  He now had lymph nodes of his neck 6 cm. in diameter.  The only treatment option I had to offer him was a referral back to the still-striking Hospital Rosales.  I don’t know if they returned there or not but do know that in his weakened state he fell 2 weeks ago and died without any significant intervention in his cancer.

Another patient, a 45 year old woman,  came to our clinic after having her health care interrupted by the strikes.  She was discovered to have breast cancer and was started on chemotherapy prior to surgery.  When the hospital went on strike her chemotherapy was suspended. By the time she finally was able to have surgery she had 5 positive axillary lymph nodes and will not be able to have chemotherapy for several more months due to ongoing strikes and backup.

Squiggly things: Even routine days here seem to sometimes end up non-routine.  Two days ago we saw the clinic’s third case of myiasis.  For those who may not recognize that term, it means that a fly laid an egg into human skin, this time into a 18-month-old child’s scalp. The egg developed into a larva which periodically came up for air through a small hole in the scalp.  I’m not sure who was most frustrated by the end of the extraction procedure:  the child, the larva, or the staff that was working to keep the child from retreating on the exam table and the larva from retreating into its burrow.

Speaking of squiggly creatures, last night I was in our broom closet-sized bathroom when I noticed that the brown throw rug in front of the door seemed a bit more ragged than usual.  Temporarily cornered,  I called to my roommate, “Marietta, there’s a snake in our house”.  She ran to ask a neighbor for a machete while I escaped to look for other weapons.  Thankfully Marietta’s endeavors brought not only the machete but also the neighbor.   He hesitated while trying to assure a good aim, then while chopping said, “Yep, it was a poisonous one.”   It was one of those occasions when the individual parts seemed better than the whole.

Goodness, along with sending me back to internship someone should send me to retake a college composition class to learn conciseness, don’t you think?!

A God-blessed spring and summer to all!