Among the sea of residents dressed in well-fitted white jackets, pressed white pants, and white shoes, I stood out like a sore thumb in my baggy light blue UVM scrubs, navy blue clogs, neon socks, and dirty white coat overstuffed with my stethoscope, Harriet Lane handbook, notebook, pens, hand sanitizer, and tissue paper. Unlike in the United States, the training level of medical residents in the Dominican Republic are identified by the color of their tops with green signifying first-year resident, yellow second-year resident, blue third-year resident, black first-year fellow, etc. There are no specific colors for the interns (equivalent of fourth-year medical students) while the pre-interns (equivalent of third-year medical students) wear light brown scrubs.
My attendance at La Entrega of La Guardia is another abnormality in itself since no other medical students attend these morning reports. I broke even more traditions by not sitting in the designated section for pediatricians, as my attempt to find empty seats often placed me near the senior obstetrician and gynecologists. Yet, no one commented on my attire or asked me to move. I was excused from these customs simply because I am an American.
Being an American medical student gave me unique privileges that did not always sit comfortably with me. For instance, the attendings told me to help myself to the freshly brewed coffee in the office of perinatology, and residents brought or shared their coffee with me on several occasions. I was grateful for their generosity but couldn’t help but wonder if these offerings were “normal” for a medical student, or benefits specific to guests and exchange students. I was also given opportunities to perform newborn exams, place nasogastric tubes, and even draw blood, all of which are valuable learning experiences that I truly appreciate.
However, I mostly saw the clinical duties of the interns from the medical schools in the Dominican Republic limited to recording measurements and bringing blood to the laboratory. Was it fair to the local students that I was offered these additional opportunities? Was I robbing them of essential learning moments? I imagined that I would feel that way if I was in their position and saw that a “foreigner” was privy to extra opportunities. I couldn’t help but feel guilty that I was depriving local students of hands-on experiences that are so invaluable in the medical profession.
Were these extra opportunities given to me because I was perceived as an American doctor rather than a student? I was often referred to as Doctora despite my constant explanation that I had not yet graduated from medical school. That title implies deeper patient care responsibilities that I am still working towards accepting as I approach the start of my residency. I was also concerned that this term would create a false expectation or impression of my medical knowledge and clinical experience. To prevent any misunderstandings, I made sure I was honest with the residents about what I knew and did not know, and that a procedure (i.e. placing a nasogastric tube) was explained clearly to me before performing it.
However, when I debriefed with Dr. Jomar Florenezan, she shared that she had a lot of autonomy and hands-on experiences when she was a medical student in the Dominican Republic. While it is possible that there have been some recent changes to the medical education infrastructure, our conversation also revealed the difficulty and danger of generalizing my narrow experiences as a universal representation of the teaching here. I also later heard other pre-interns and interns referred to as Doctor and Doctora, observations that helped me realized that these terms are culturally used for medical students among residents and fellows.
When the patients and families saw my white jacket and called me Doctora, they truly believed that I was a doctor despite my introduction as a medical student on their health care team. I am not sure if they were able to tell that I was an American or assumed that I could provide higher quality care. If anything, my initial inability to answer their questions on the location of the laboratory or the length of their child’s hospitalization may have implied the opposite. Hopefully this image or assumption changed as I learned more about the hospital, its service, and workflow, and became more integrated with the team.
From the local provider’s perspective, though, I learned that the general perception is that training is better in United States given the available resources, ongoing research, and higher compensation. Many of the students and physicians I spoke with expressed aspirations to obtain further training or practice in the United States. Perhaps it is a case of “the grass is always greener on the other side,” but I would have appreciated the opportunity to complete their pasantía, a year of apprenticeship in an underserved region, before obtaining my medical license. I feel that these extra clinical experiences would have provided greater preparation for my residency.
This idea lead to the question: would incorporation of this extra year of training into the American medical education system improve the mortality rate or clinical outcomes that are often attributed to the new cohort of residents that begin in July?