In the Dominican Republic (DR), more than a quarter of the population lives in rural areas, where many families live below the international poverty line. These families face different health challenges than those living in urban areas. And until recently, many doctors in the DR — most of whom attend medical school in cities and are themselves from urban areas — received little training in how to address these challenges.
Dr. Ramos with his co-residents Drs. Jeyni and Cati
That changed in 2010, when Hospital Infantil Robert Reid Cabral (HIRRC) in Santo Domingo, the premier children’s hospital in the DR, partnered with Children’s Hospital of Philadelphia (CHOP) to establish the HIRRC’s first community rotation for pediatric residents. Since then, every resident in the final year of pediatric residency has spent four weeks at CHOP’s partner site in Consuelo, DR. And in 2017, this “rural pediatric rotation” was expanded to include residents from Hospital Materno-Infantil San Lorenzo de los Mina (HMISLM), the busiest mother and child hospital in the country.
The rotation includes outpatient consultations in clinic and hospital settings, in-depth experience with community-based work, such as home visits and community education, and on-site mentorship with and case presentations to Ingrid Japa, MD, an experienced Dominican pediatrician.
“This rotation [is] important because quality primary care and early detection of illness are the two fundamentals to reduce morbidity and mortality in children,” says Dr. Japa. “We are working hard to ensure that more pediatricians in this country are well trained in a variety of settings.”
A new perspective
Donnie Ramos, MD, is an example of the effect that this training can have on a single trainee, and by extension, in time, on the healthcare system more broadly.
Dr. Ramos, who is originally from Santo Domingo — the DR’s capital and its largest city — first came to Consuelo for his rotation in 2015. He had never spent time in a rural place like Consuelo, where unemployment is high and the nearest city feels a world away. It was different in every way from his work at HIRRC, the largest and best-resourced children’s hospital in the country. And during his rotation in Consuelo, his perspective on being a doctor in his own country began to shift.
Each week, Dr. Ramos cared for patients at the local public hospital and at the Centro de Salud Divina Providencia, an outpatient health clinic that partners with CHOP’s Global Health Center. He also went out several times each week to do home visits, outreach and education in the communities served by CHOP’s program. He received mentorship from the skilled health professionals on staff, including Dr. Japa, his rotation supervisor, and Maria Dunn, DO, CHOP’s Pincus Global Health Fellow at the time.
Dr. Ramos learned as much as he could about the medical conditions he saw and about each patient’s social situation. By talking to patients and families in the clinic and visiting them in their homes, he developed a deep understanding of and empathy for their individual challenges, and was able to work with patients and their health promoters to find viable, pragmatic solutions.
“The rotation allowed me to be in contact with the reality of poverty in our country, as well as the true health needs,” he says.
Sharing knowledge and expertise
L to R: Dr. Dunn, Dr. Ramos and Dr. Japa presenting their xeroderma pigmentosum case at a conference in 2016
As part of their rotation, each resident prepares a presentation about a clinical case they cared for, including discussing the public health challenges that they noticed while working in Consuelo. Dr. Ramos took the standard to another level, preparing an extensive case study of a patient with xeroderma pigmentosum, a very rare genetic condition that affects the skin. The report was accepted for a poster presentation at the national Dominican pediatrics conference, where he presented alongside Drs. Japa and Dunn in 2016.
Dr. Ramos found his Consuelo rotation to be so beneficial that he requested to come back a second time in 2016. “This was an unforgettable experience that really allowed me to integrate myself as a healthcare professional in the Dominican Republic,” he says. “I am so grateful to the whole team. They made this so wonderful.”
Dr. Ramos is now finishing a fellowship in Emergency Medicine at HIRRC, and will join the HIRRC team as a pediatric ED doctor in July 2018. He will be working within the Dominican public health system to provide care to all children free of charge. His rural rotations in Consuelo helped him develop empathy and gave him a deeper understanding of the social determinants of health.
How you can help
Knowledge sharing is an essential element of a successful, sustainable global health partnership. In addition to providing clinical care for patients, the CHOP Global Health Center trains and educates local healthcare professionals like Dr. Ramos. Our partnership in Consuelo is just one example of the enduring impact that this education can have on the next generation of pediatric healthcare providers.
Since 2010, CHOP’s program in the DR has hosted nearly 200 rotating residents from HIRRC and HMISLM, and the experience has deepened their understanding of rural child health in the DR and shaped their careers. With CHOP’s help, this small clinic in the rural town of Consuelo is changing “rural neglect” in pediatric medical education in the DR to an appreciation of “rural reality.”
To help us provide more training opportunities for the next generation of pediatricians in the DR, kindly make a gift to CHOP’s Global Health Center today.