The first thing I noticed when I walked into the PT room at the clinic was a skeleton model that had one arm. This one arm was not only on the wrong side of the body, but the scapula protruded from between the 4th and 5th ribs… coming out of the front of the chest cavity! I hoped it was not a bad omen of things to come.
The entire clinic itself is a lot larger than I had expected- over 70 people work there (30 doctors) and it has a 24 hour emergency room. Health professionals from a number of disciplines including gynecology, pediatrics, odontology, trauma, internal medicine, psychology, nutrition and alternative medicine are represented. They’re also are equipped for diagnostic imaging and blood lab work and have a pharmacy on site. It’s a beautiful, clean, facility full of friendly staff!
I was pleasantly surprised to learn upon my arrival that there is actually one PT currently working in the outpatient clinic. However, she is only there 9 hours a week. And, according to the man who is in charge of the Ministry of Health in this area, no full time PT exists in the public sector- serving the poorer individuals- in all of La Esperanza. Nobody!
I learned a lot during my first week of work at the clinic. I am splitting my time between working there, at a school, and on the public health program – “El Proyecto.” Before I get into the details, I just want to say that future commentary on the healthcare system here is by no means meant to incriminate or belittle the practices and culture. Rather, I hope that my observation on cultural differences and their impact on the quality of care will bring light to the challenges that need to be addressed regarding healthcare worldwide.
That being said, I think it’s fair to say that the level of PT here may be compared to the standards of care in the US from many decades ago. Documentation is sparse- one little box in the patient chart listing the day’s treatment, or nothing in the case of a walk-in patient. No evaluation forms, no doctor notes, no daily notes, no insurance paperwork. Definitely no outcome forms, home exercise programs, or even past medical history forms.
Patients here pay the same price regardless of whether they have a doctor referral or not, which is 8-10 soles normally (about $3/visit) or if they see me, only 5 soles since I am a volunteer. $3 sounds great to us, but when you remember that 8 pieces of bread cost 1 sol - 0.33 cents in USD here, it’s not always that affordable. And, if it’s the father of the house who is in for therapy, you’d better believe he is really stressed out – not only is he paying to see me, but he’s out of work due to his injury, and his entire family is depending on him for food. No such thing as worker’s comp here!
Fisioterapistas here go to a technical type of school for 3 years, right after they’ve finished the high school equivalent. There’s one PT program in this area that has about 20 students per year to serve the 1+ million people inhabiting the Trujillo area. Lima has several schools.
Normally I won’t be working at the same time as the other therapist (we have different schedules) but this week she was showing me the ropes, so to speak. The treatment I’ve observed so far includes Infrared, TENS, moist heat, massage, range of motion exercises and PNF’s in supine, and Ultrasound at an intensity of 0.1 w/cm2 (reason = “any higher and the patient may be uncomfortable”). I haven’t observed any initial evaluations yet but was informed that PT’s do not perform special tests; they generally leave the diagnosis for the doctor and stick to modalities for treatment.
Last week I visited one of the two local hospitals in Trujillo and met with some doctors and interns there. One of the doctors informed me that inpatient PT is pretty much unheard of- patients with hip and knee surgeries, for example, receive no post-op rehab and are told by nurses to stay immobile/bedridden for as long as possible after surgery! Yikes… DVT waiting to happen, among other things.
Similar to experiences I’ve had in other countries, I’ve already had a hard time taking this all in. It’s clear that physical therapy in this part of the world lacks evidence-based practice. To confound matters, there is a significant, complete lack of inter-disciplinary communication in outpatient and inpatient care here. I’m planning to incorporate a section of El Proyecto to (delicately, tactfully) attempting to shift the standards with some of these things- whew, good thing I have one year!
If you have any ideas I’d love to hear them, post them here or email me!
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