Mandatory Rural Service: A Primary Care Lesson From Peru

Due to mandatory rural service year, every Peruvian doctor is a primary care physician. Learn about one med student’s experiences in the country.

The training requirements for Peruvian physicians are an exceptional experience which link doctors to the culture and circumstances of the country’s impoverished residents. Through that country’s mandatory rural service year, a requirement for anyone who wants to practice in a public Peruvian hospital, there is potential for the physician to develop clinical skills in the most dire of circumstances while forming an intimate relationship with an isolated community. There, it is easy to appreciate and admire the talents of Peruvian physicians and their understanding of their patients’ realities.

In small Peruvian pueblos which house regional hospitals and small health centers, there are neither sufficient technical resources nor procedural and diagnostic capacity for adequate treatment of patients. In response, the Peruvian healthcare system ensures that its physicians are trained, tried, and prepared for any situation. Peruvian doctors, even those who plan to specialize, are obligated to train in general medicine in underserved communities, something done here only by our own volition. First, they receive mandatory exposure to their country’s reality. Then, they pursue their specialty of choice.

Due to their training, every Peruvian doctor is a primary care physician. This benefits them throughout their careers. For example, a surgeon’s abilities go beyond the operating room. On call in the emergency service, the surgeon examines, diagnoses, and prescribes antibiotics for a pediatric case of pneumonia. An obstetrician gynecologist treats a hypertensive crisis in an 86 year-old male. An internal medicine doctor does a full prenatal exam and interprets ultrasonography. It is wonderful to watch specialists revert so fluidly to the foundations of their general training.

Following medical school, Peruvians are employed as general medicine interns at a regional hospital. For 12 months, the physician is at the mercy of the hospital and attending physicians’ needs and demands. They are often the only trainee, a position with great responsibility and incredible potential for personal development. After that intern year they begin something called the SERUM which stands for servicio rural y urbano marginal de salud. A rough translation is “rural and marginalized urban health service.” Their mandatory SERUM work takes place in a rustic community or impoverished urban post in which they are very often the sole authority on medicine.

A secondary benefit of the SERUM is the personal experience the physician enjoys (or endures, depending on both the doctor and the setting) as a member of the community in which he or she works. It is this experience which develops a lifetime understanding of public health in Peru. The SERUM year provides a common touch, as physicians enter into the local customs, food, cultural practices, and economic circumstances that shape a community’s public health profile. These doctors develop both clinical skills and an awareness of their fellow citizens’ conditions, both medical and societal.

It is an intimidating task, but as one Peruvian OBGYN once told me, “That’s where you become a man, but more importantly, that’s where you come to understand.”

Mandatory rural service in primary care insight

It would be pertinent, with state of preventable disease in our country today, if we in America joined with the Peruvian concept of general medical training in which every future specialist becomes a primary care provider first. In fact, we have hundreds of thousands who are dying from illness that can and should be halted before fatality. Heart disease continues to be the number one cause of death and morbidity in America (616,067 lives claimed in 2009 according to CDC data). Stroke and chronic lower respiratory disease are the third (135,952) and fourth (127,924) leading causes of death, respectively. Each of these diseases, in addition to metabolic disorders like diabetes and the cancers that result from tobacco use, stem from patients’ life circumstances. Perhaps if we were first-hand witnesses to the conditions that drive detrimental patient behaviors, our ability as providers to treat and prevent disease would improve.

The expectation that America’s doctors in training should all pursue a primary care residency or spend a year living in Appalachia, or on a Native American reservation, or in a place like Roxbury in Boston or East New York in Brooklyn is not realistic. It is also obvious that we are not ready to require all residents to train in general medicine. We can, however, do more in medical school to expose students to the reality of their patients’ lives prior to graduation.

Some medical schools offer rural rotations and urban immersion in hospitals in underserved neighborhoods, but students do not have adequate time to witness the realities of our future patients. This must take place both inside and outside of the clinical setting. Rotations of weeks and month duration provide a glimpse but are not sufficient for gaining a true understanding of what awaits us. It is important to evaluate if we are in touch with the needs of the American patient: inspiration for behavioral change and the education, organization, and financial capacity for medication compliance and responsible nutrition. We see patients on the wards, in the clinic, and on the mobile health unit, but do we see where they are coming from before they get there? Peruvians doctors do. In fact, through the SERUM, they have to live their patients’ experiences.

Life in medical school is not ordinary. Academic demands and financial stresses are risk factors for isolating medical students in our own world and circumstances. There is a danger in distancing ourselves from reality before we even complete our training. Although we have our student-run clinics, our outreach programs, and our external rotations, our commitments do not always focus on the essential elements of our patients’ lives. Those elements are exposed away from the clinical setting, in schools, neighborhoods, and homes.

Northwestern University is filling this void in our training with the Feinberg “Education-Centered Medical Home,” where students volunteer in a marginalized Chicago neighborhood. The project is in its pilot year, but it recognizes the “fragmented nature of medical student clerkships.” As with many similar programs at medical schools throughout the country, the activity is not a mandatory part of the curriculum. Those who do participate, however, are expected to develop “sensitivity and responsiveness to patients’ culture, age, gender, and disabilities via opportunities to elicit from patients and/or their families, their cultural, spiritual, and ethical values.” This program is a four-year activity. This activity will provide the experience necessary to develop a sense of how the world works apart from the chaotic life of physicians and doctors in training. The Education-Centered Medical Home recognizes that it should be fundamental for practicing physicians in the United States to be cognizant of the circumstances of people before they become patients. Peruvians have already known this for a long time…

Learn more about the importance of primary care.

Annie Mooser

Annie Mooser is a second year medical student at the George Washington University School of Medicine and Health Sciences in Washington, D.C. She has high hopes for the Chicago Cubs.

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