Good Jesus

this past weekend, my fiancé and i went to braga which is credited as being the oldest city in porto. it is truly a very beautiful city, and you can tell by how intricate and well kept the cathedrals are that the city is also very rich in culture and tradition. well, that’s what i’m going to imagine about braga anyhows because i was really only there about ½ a day and didn’t get any real opportunity to see the entirety of the city. i was mainly there just to walk around, see the city, and visit the Good Jesus (as opposed to all the other Jesus’s out there)…

for starters, we took the train from campaña to braga, which is actually not that bad of a trip. it gives one the opportunity to really see the country side and the transition in the landscape between porto and braga. mostly, we just saw forests and vineyards, but that’s always cool, so i’m not complaining. once we arrived in the city proper, we made our way up towards the city center, which is a little uphill trek from the braga train station. we were trying to find the tourist office, and we did find it indeed. however, it was easter monday, and as such, the place was closed. great… now how were we going to find a map. no better place to look than the shopping mall, where we did end up finding a completely useless map for our purposes—of finding Bom Jesus. so we not only did not know where exactly Bom Jesus was, we didn’t know how to get there either, but it was okay because we had a drink before starting our climb to the summit and were in good spirits. we asked around, random passers-by and store clerks, but asking around didn’t gain us much of an advantage. i ended up calling the missionary who just told me that i could catch a bus. huh. what an epiphany [insert sarcastic scowl here] because several of the residents in braga managed to think that it was beyond reason to simply mention that we could have taken the bus. apparently without a car we were destined to never get there.

FINally, we caught the bus to the base of the stairway that leads up to the sanctuary. it was a magnificent sight to behold, and mere words don’t do it proper justice. Bom Jesus was built right up the side of a mountain, and though there was a cable car that could have taken us up to the sanctuary, it would have been an ineffably tragic deprivation of experience had we chosen NOT to take the stairs instead…

doenças infecciosas

being that i was able to spend some time in the infectious disease (doença infecciosa ), aka “ID,” department of hospital são joão, i came to realize that there’s not such a big difference after all between medicine in america and medicine in portugal. as it is, i’ve spent time with three infectious disease teams, each very distinct in its own regard. those three being: med team k at unc hospitals (chapel hill), the ID department at madigan army medical center (MAMC—fort lewis, tacoma), and most recently doenças infecciosas at hospital são joão. it’s very interesting that each department works very differently, whether it be from being military versus civilian or american vis-à-vis european (portuguese specifically).

in chapel hill, when i was with the infectious disease team, med team k was a medicine team. we rounded on patients in the mornings, we went to morning report daily, we did any work that needed to be done during the day, and we admitted patients on our call days, as the medicine department was on the long call – short call system (if you don’t know what that means, don’t worry about it). afterwards, the attendings went to clinic, if they had clinic, or they did whatever else they had to do. we didn’t solely admit infectious disease patients to our service; since we shared the floor with the pulmonary department, and since unc is a tertiary care center, we also managed quite a few cystic fibrosis (CF) patients. while we saw patients with COPD exacerbations, patients with CF exacerbations, and patients with cellulitis and/or osteomyelitis, our most interesting and most prevalent patients were our HIV/AIDS patients. these patients comprised the bulk of our patient population, and they presented with some of the more interesting cases.

out at MAMC, the ID department was completely different. ID was still apart of medicine, but worked more or less independently of the medicine department. there at madigan, there were only 3 attendings: the head of the department and two other doctors. one of the doctors was in charge of seeing and following up consults and the other doctor was in charge of seeing patients in the clinic. as opposed to having a maxed-out to maxed-out plus service everyday, as was the case at UNC, the ID department at MAMC had only a few patients per day in clinic (vast majority was HIV/AIDS management), as well as a few patients per day as consults/follow-ups. it was grand. the hours were great, i was able to do a lot of reading, and i received one-on-one lectures daily, as i was the only student on the service.

here at hospital são joão, there was a larger team of doctors dedicated to the infectious disease department, more comparable to that of UNC. there were a couple of doctors on the wards, and there were a few doctors in clinic. i had the opportunity to see both sides of the department. in the clinic i worked with dra. carmela (who was actually of spanish origin), the doenças infecciosas department at hospital são joão was typical, as infectious disease departments go. the vast majority of patients were there for HIV/AIDS management; however, the clinic setup was the same as the other ambulatory clinic setup for portugal, with all patients coming directly to see the doctor in her office. on the wards i worked with two residents: one who was a resident at hospital são joão and the other from another hospital but who was doing an ID rotation there. what was interesting about the wards here was that since portugal has a higher TB patient population, we were managing more TB patients. i had to walk around all morning with an n-95 mask, as i had not been vaccinated against TB, as the rest of the team had been. 

i find the fact that portugal has a higher prevalence of TB peculiar because, thinking of western europe of which portugal is apart, i wouldn’t think of portugal as a higher risk area, as we usually think sub-saharan africa and southeast asia. nevertheless, the entire iberian peninsula is an area of increased (moderate) risk of tuberculosis infection, on par with the majority of the south american continent, and we learn in medical school, as americans, that originating from a south american nation is a risk factor for TB infection. also of note, portugal has the highest prevalence of HIV-TB coinfection in western europe, with rates as high as those found in southeast asia.

in the clinic

administration

today i met with the admin who’s in charge of all the medicine clinics at hospital são joão. it was a very good experience, as she and i talked a lot about how medicine as a system is managed here versus how it is run in america (the united states of). talking to the admin, i was able to learn that the portuguese have a “gateway” system that is supposed to work similarly to how some of our medical communities are supposed to work in america. i say supposed to because, as in america, portugal is suffering from a shortage of physicians who take on the responsibility of primary care. however, we didn’t talk much about specialists, and specialists are also in short supply in some parts of america, and i would wager it’s a pretty safe bet to say that the same applies to portugal.

how it’s supposed to work: if one person goes to a GP (general practitioner), the entire family goes to the same GP. unless one or more of the individuals from a family relocate, they all have the same doctor. if such a move occurs, those individuals are assigned to a new GP. family medicine. if a person needs to be evaluated by a specialist, then that person is referred by his GP. this is what we, in the healthcare field, call the gateway system. people see their GP for routine and urgent care but go to the ER for emergencies (hence, the ‘E’ in ER). this particular aspect of the system breaks down when there aren’t enough primary care physicians, as physicians are overloaded with patients, it may take up to four months to make an appointment. by then, one’s problem probably has spontaneously resolved, or one has resolved this issue in another manner. “what other manner is there?” you ask. welllll… here’s where the ER comes into play. if you have a problem, you KNOW that you have to be seen if you go to the ER, so…

we also talked about who pays for what. portugal has a more socialized system of medicine which pays for the vast majority of health care costs for its constituents. it’s in the portuguese constitution that individuals have the right to healthcare (hint for all you [future] legislators out there). actual healthcare, i.e. visits with physicians and treatments, are free. however, there is a co-pay scale for prescriptions that is income based, but for all major chronic illnesses, such as cancer or HIV/AIDS, the government pays 100% of the medical costs.

in action

yesterday, i was actually in the clinic with my attending dr. pestana and one of the residents, joana (number 1, joana number 2 is gone, as last friday was the last day of this rotation for the med studs). it’s definitely a different atmosphere here in portugal, as i’ve not only seen how dr. pestana works but also dr. carmela who works in the infectious disease department. here’s a basic run down of how an office visit works.

--the attending sits in his office

--the patient enters office, and everyone exchanges salutations

--the patient sits

--the doctor asks all the questions he needs to ask

--the doctor examines the patient

--the patient goes on his way

--the doctor calls for the next patient.

this method is in contrast to the method in america where patients are called back to a room, are seen by a nurse, then wait in whichever room they’ve been called to until the doctor comes in. in my opinion, it’s a much more comfortable system here because the doctor is in his singular office and doesn’t have to run around to all the different rooms he may be working out of. it’s also more comfortable for the patient because the patient knows once he is called back, he is seeing the doctor, not sitting in another room for another half an hour.

1st 48: a glimpse into porto… and medicine

hospital são joão

so, by now i’ve gotten settled into my new place, so to speak, as i’ll only be there for a month, and i need to make it to my place of work, so to speak. fortunately, porto has a great public transit system. to get from world spru to hospital são joão one must simply take the metro to trindade station (any line going away from estadio do dragão will do) and there transfer to the yellow line in the direction of hospital são joão. no problems there. after a decent night’s sleep and a renewed confidence in my abilities to navigate a foreign city, finding hospital são joão is no overwhelming task. once there, i am picked up from the main entrance by dr. pestana and his current team which includes two residents (joana number 1, and katerina, one resident is actually on vacation when i first arrive) and two medical students (joana number 2 and margarida). the two medical students just happen to be in their final year of medical school, as well, which is not as fortunate as it seems, as 6^th (final in europe) year med studs have to not only complete and present there thesis during this year but also study for what i take to be the equivalent of our step I & II combined. awful, yes, i know. my sympathy goes out to al the 6^th years i encountered at hospital são joão…

reading any of my “predecessors” blogs will inform one that normal days, start at around 8. the residents and med studs see their patients and write notes in the hardcopy charts. afterwards there’s a coffee/snack break, and then the team checks with the nurses and looks over the nurses’ notes and proceeds to write the electronic notes. the attending will see the patients after the team, but before break, when he is not seeing consults that morning.

i meet the team at around 1020, which means their in the middle of their day, but it’s cool. the have already seen their patients, and it’s not time for a coffee/snack break, so we head to refeitória (the cafeteria). we all get snacks and then head back up the office. this is where all the planning, note writing, discussing, and [most of the] teaching takes places. it is here i learn that the 4^th floor medicine team is divided into 4 teams that share the 4^th floor office, and it is here that i meet everyone from all 4 teams…

the rest of the “workday” is spent writing notes and discussing patients, until around 2 o’clock.

downtown (centro do) porto

after i leave the hospital i head downtown. for one, i want to see a bit of the city, and two, there’s still enough time in the day to stop by the international students office. so from the hospital, i take the tram (and i use the terms tram and metro interchangeably here because the porto metro system is more accurately characterized as a tram and not a metro) down to aliados (on the yellow line) and manage my way up to reitoria. finding reitoria was not exactly easy. porto is one of those city’s which is comprised of dozens and hills which means that sometimes if one thinks one knows where one is on a map, one can’t really tell from one’s surroundings how to get where one is going. that being said, i actually did make it to reitoria (where the international student’s office is located) without walking in a ridiculously circuitous route. however, i did stop and ask for directions about every 100 meters. thank goodness for the little bit of portuguese i knew and the hospitality of portuguese.

i get to the reitoria and find the international student’s office within. i get there and i notice two guys sitting in the reception area. i sit down, and what do i notice but that they are speaking french to each other, and not drawled, nasal french of montréal nor the leisurely articulated french of the swiss but true french of france. naturally i butt in and insert myself into their conversation, and who have i met but two parisians here, studying pharmacy for a few months. health care workers unite! lisa dequech finally has everything ready for us and now comes to invite us in to her office. apparently i was supposed to have made an appointment to meet with her, but since one of the other students hadn’t shown up (which had kept the parisians waiting for the last couple hours), she gladly adjusted the packet and presentation to fit me in. in this meeting we are introduced to porto through lisa’s presentation, given the rundown about how erasmus (including myself even though i’m from america) can stay plugged into what’s going on in this city, given a packet with maps, lots of useful information, and our temporary student cards. if you find yourself at this meeting in the near, or far, future make sure to opt in for the moche card. that way you can keep in touch with all the international students for free (minus the cost of buying a cheap european mobile, ~20euros).

after the meeting the parisians and i exchange contact information and head our separate ways. i take a little stroll around downtown before heading home by foot, just to take in a little more of the area, and i must say that porto is a beautiful place to be. world spru is about half an hour’s walk back from downtown, which is not bad at all with such beautiful weather as we have right now.

when i get back to world spru, i’m certainly hungry but in no mood or disposition to go grocery shopping, so i head to one of the local restaurants around the corner. the local eateries in campaña are decent to good, as i just ended up getting a spinach omelet and fries (which they threw in some rice and bread) with wine of which they gave me half a liter—they really know how to have dinner here in porto.

getting to world spru

sometimes one can find that once on has arrived at a place, one isn't really there yet. i, myself, have had this experience, and thus i will tell you all about it. it all starts with my decision to participate in unc som's (university of north carolina school of medicine) advanced-practice selective in porto (oporto), portugal, and the following chronicle's my arrival in said city.

the evening of april 2, 2011, i'm making the final leg of my journey to portugal, flying overnight from toronto. i sat in the airport right before boarding the plane, gearing up for this journey, i take a special concoction of medications that will prepare my body and mind for the experience. first is taking some anti-inflammatories (NSAIDs), as being cooped up and cramped in the sitting position for 6 hours straight is no fun time at all on an old guy's knees and lower back. for the mind, to aid in my adjustment to the five hour time difference, i managed to acquire some sleep aids: one in the form of a long acting benzodiazepine and the other simply (or not so simply, depending on your level of knowledge of chemistry) melatonin. it's key to take melatonin several hours before you want to start your new sleep-wake cycle so that your body can make the proper adjustments, but i'm going to go into too much detail about that. you can ask your doctor about it... so, fueled for the glorious six-hour slumber i'm about to embark upon, while on a plane crossing the atlantic ocean, i take my seat and promptly pass out... six hours later, "hello, portugal!"

now, i had skimmed over the blogs of my "predecessors," as one preceptor so interestingly described them, and the directions to get to the lodgings (i.e. world spru, which you should absolutely look into) seemed pretty straight forward:

step 1 - fly to porto

step 2 - take metro from airport to campaña

step 3 – take a right out of the metro up to world spru (only taking about 2 minutes and something or other about a glass wall and some taxis and buses)

it is on this third step where an inglorious journey began. step 1, check. step 2, check. step 3… i make a right out of the metro and head up the street. coincidentally, or providentially, i run into a missionary, a group the missionary’s working with, and the missionary’s wife who happens to be from shelby, nc (my hometown). i kid you not. as i would ordinarily stop here and make commentary about shelby, this is neither the time nor the place for such. just google and/or wikipedia it.

“where are you trying to get to?” says the missionary

“world spru…?” i reply. he goes and takes the flabbergasted i-have-no-idea-what-you’re-referring expression, then he calls up someone on his cell who further has no idea to where i’m referring, even getting nowhere when asking the members of his group, some of whom are from the area.

“are you sure you’re going the right way?

“sure. the directions say make a right and go up the hill on the street where the taxis and buses are.” but i don’t really see any taxis or buses.

“oh, but there’s another main road over by the metro that also goes up the hill…”

if ever God had given me a sign, and i refused to acknowledge it, that was the time.

longer story shorter, i ignored a pretty fair warning from the universe that i was going in the right direction, and please spare me the gross-overgeneralizations about men not asking for directions. i ended up walking in quite the circuitous route to basically end up exactly where i had gotten out of the metro, which is where world spru is located. right beside the campaña center, the residence is literally connected to the metro. maybe it was the benzo still in my system. maybe it was the fatigue of not having slept well for the previous week and a half finally catching up to me. maybe it’s the fact that i’m not the sharpest crayon in the box (i know i’m usually not a fan of clichés, but i particularly like that one for some odd inexplicable reasons). when i think about it now, it seems so simple. “when you get off make a right… taxis… and buses to your right behind the glass” doesn’t mean get off the tram and make a right. it means when you get out of the metro station (campaña) make a right, onto the road that is parallel with the glass wall…