Dr. Ortiz receives his patients in his office, not in the examination room. The patient sits in a designated chair at the end of his desk and wait for him to ask what brings them there.  If more than one patient in the family has come for consultation, when one is through with his interview with the doctor, he or she gets up from the chair and the other one sits in it to talk to the doctor. Emili sat in a corner behind the patients and the physician, and listened. Dr. Ortiz records the patient's complaints briefly with one sentence on a note card that serves as the patient's file, and then all go to the examining room. The physician himself  always takes blood pressure, and then he attends to whatever he determines is appropriate for the patient's complaint and general health.  During this time his assistant is present in the exam room, unless the patient asks for more privacy.  This happens only with men, especially when a rectal exam is needed⁵.  After the physical examination, the procession returns to Dr. Ortiz's  office for a summary, plan of treatment, and payment. 

The patients usually give Dr. Ortiz cash directly, and he puts the cash in his wallet immediately upon receiving it.  Dr. Ortiz did not appear uncomfortable discussing his fees with the patients.  When a patient hesitated over a course of treatment on the basis of cost, Dr. Ortiz was clear in his explanations of the materials to be used, their cost, and the amount of his fee.  The cost of treatment at this clinic is considerably less than for the same procedure in the United States⁶. 

Doctors in the United States are careful to separate the financial aspect of their business from their own direct relationship with their patients.   Dr. Ortiz seems  less delicate about the money part of the relationship, although money  plays a smaller role in it here, than in the United States. 

Payment of the physician services signals the end of the doctor-patient business and the patient leaves with a handshake or by pressing a cheek against Dr. Ortiz's, depending on the gender of the patient. Occasionally during her days at the clinic, Emili got a handshake or a cheek, too. 

 At the end of one week it was clear that Dr. Ortiz is trusted and respected by his patients. They whisper their appreciation of his skills and expertise. They all refer to him in some way as "the good doctor." Many of these patients have been seeing Dr. Ortiz all  their lives. The ones that have not been his patients all their lives have been his patients since he came to Toa Alta.  Even with such familiarity, both doctor and patient use the formal form of address, i.e. usted, and not tú, regardless of the age of the patient.  What would normally have developed into an intimate friendship, marked by a more relaxed use of the formal address, has not been the case here.  The prestige of the physician and the resulting social distance between him and the rest of the community stands the test of time. 
              

In some ways this situation is not unlike that of the Spanish speaking patient who must use an interpreter to communicate with the physician in the United States.  Here too there is a segment of the conversation from which the patient is shut out, and which he must wait for patiently.  Spanish speaking physicians in the United States resolve some of the loss of direct communication with the patient, but due to the immersion of their exchange in the English speaking environment, the moment the physician turns to his English speaking assistant or interacts in any way in front of the patient with anyone who does not speak Spanish, the initial isolation of the patient from the source of care is reinstated. 

At the end of Emili's first full week of working with Dr. Ortiz, she found that she had experienced more than expected. For example, she had seen Dr. Ortiz incise and drain a post-vaccination abscess without anesthesia, tape a sprained back to immobilize it, and counsel a woman about the reality of menopause and childlessness.  Dr. Ortiz is a shrewd diagnostician.  He knows something about almost every medical condition. He can detect when the problem is minor and/or treatable, and when it requires special attention outside his expertise. He  performs some of the more common specialized procedures like earwax removal and wart electro cauterization. He monitors sub-acute conditions over several visits in order to reach a diagnosis, instead of ordering expensive and invasive tests for the quick answer. He never tries to alarm a patient. "A dreary diagnosis on every visit will upset the patients and scare them away," he explains.   His relationship with his patients is built upon time and the trust and understanding it brings. 

One 85 year old man confided to Emili that Dr. Ortiz had treated both his parents and his wife until they died, and was still treating him and his children.  From the most detached point of view, we can appreciate the clinical and diagnostic advantages of caring for an entire family's health. From a more personal vantage, we see the depth of the relationship that develops over time and shared experiences with the patient. After acting as the physician for families for so many years, Dr. Ortiz has become part of the families. 
 

It is interesting to note, though, that none of the patients responded in kind.  All continued to refer to Dr. Ortiz as "el doctor" when he was not present, or "el doctor Ortiz" and usted, when they addressed him.  No one rejects his use of the informal tú; they simply seem to understand that the use of this form is his prerogative. 
 

On the appointed day the patients must arrive as early as possible after the opening of the clinic to put his or her name down on the list for the day.  This list gives each patient an idea of when the doctor will see him, but still only relative to the other patients who have made appointments for that day.  The receptionists and office personnel can often give the patients a fairly good idea of when they should be back in the office, and then most of them leave to return at the time when they are expected to see the physician.  The advantage of this system is that, after the initial substantial wait, the interview, examination, diagnosis, and treatment are all provided during that visit and ideally without interruption.   In Dr. Ortiz's clinic, when he answers the phone or receives calls while he is seeing another patient, he is still forgiven, out of earned respect, but once a patient has the doctor's attention, the doctor is his for the entire length of the visit. 

When he treats his patients, Dr. Ortiz spares every expense. For example, the drains that he placed in the abscess were strips of latex that he cut and sterilized from medical gloves. The medicine that he practices is very inexpensive for him and the patient, while it is also of good quality with high patient satisfaction. 
 

As an example of how a properly trained physician should deal with alternative medicine, Dr. Ortiz told Emili the following true story: A patient heard him cough one day and asked him how he was treating himself. The patient then said that she had a recipe for a cure for coughing that had been in her family for years. She offered to bring him a batch of the cure the next day. Dr. Ortiz accepted her offer, and the next day she brought him the cure. She explained how it was made, castor oil being the most notable and most distasteful ingredient. Dr. Ortiz thanked her for the medicine, and then promptly threw it in the trash after she left.  The next time she saw him, she inquired into the efficacy of her potion. He smiled, told her that it worked wonderfully, and thanked her again. This pleased her, and she continued to be his patient for many years. 
 

From the outside, the house was unremarkable and looked to Emili like many other simple houses in the area. Inside, the living room contained only two pieces of wicker furniture and no decorations. The patient was lying on a mattress on the floor in the former dining room of the house. There was only one window, and this had no screen. The ceiling over his head was beginning to crumble in disrepair. The patient was ninety years old, lived alone, and had no medical insurance. 

The patient was not doing well. His family had called the doctor after finding him in a stupor on the floor for the second time in four days. His skin was very flushed, and Emili records the following: "he did not really respond to our presence. The responses that he did make were strange. He tried to eat the thermometer instead of keeping it under his tongue, and he incessantly ground his teeth when anyone touched him. I took his blood pressure and pulse and examined his ears. Dr. Ortiz quickly and deftly examined his mouth, being sure to keep the tongue depressor out of the grasp of those grinding, hungry teeth."  The doctor sat the patient up and listened to his congested lungs, and finally determined that he needed to be admitted to a hospital. 

 The family expressed concern about the cost of the imminent hospital stay. They said that they would not pay for it out of pocket. No one had time to stay with the patient and take care of him at home, and, as they said, "Social Security" would only pay for health care in extreme emergencies. Dr. Ortiz informed the family that the current situation was indeed an emergency, and proceeded to complete the necessary documents to have the patient's treatment covered by Medicare. Once he had finished all of the paperwork that would ensure Medicate coverage, he urged the family to take the patient to the hospital as soon as possible. Then, Dr. Ortiz packed his bag and left. 

Emili noted in her journal that Dr. Ortiz recognized the inadequacy of care that the patient was receiving, and took the necessary steps to arrange more suitable care. If he had simply told the family that they needed to bring the patient to the hospital without arranging the necessary paper work, they would not have done it.  If Dr. Ortiz had challenged the family on the patient's living arrangements, they would have become offended and defensive, which would have interfered with the patient's care. The physician did everything in a way that maximized the likelihood that the patient would be taken to the hospital and that the family would trust him in the future. 

Poverty places the gravest strain on quality of health care in Toa Alta.  The fact that the house she visited was unremarkable to Emili points to the pervasiveness of the economic depression in the town.  The interior of the house as described, was also normal for the area.   The fact that the physician makes house calls is not related to Dr. Ortiz's age, although the pace of his practice may allow him to accept house calls more than other physicians, but other family doctors in small towns still see patients in their homes.  Most importantly, Dr. Ortiz has taken pains to solve the health problem completely, addressing administrative matters and health matters as one and, most importantly, preserving the family's trust in him and strengthening the ties between him and the community. 

Dr. Ortiz is less subtle with his more animated patients. He was seen to employ two types of medical scare tactics, blatant and covert. In one case, he was trying to convince a diabetic to use insulin. The man was unwilling. He had had Type 2, or non-insulin dependent diabetes, for several months and did not understand how his diabetes had progressed to Type 1, insulin dependent. Explanations were unsuccessful. He wanted to try for one more month another Type 2 medication that had already been ineffective for him. 

Dr. Ortiz did not attempt to hide his frustration, but unleashed the scare tactics. "You will go blind," he told the patient. "You could develop neuropathy and could need amputations," he added. The patient said that he still wanted to try the earlier medication, probably because he had some dosage left and would otherwise have to buy new and expensive drugs.  Dr. Ortiz brought his former nurse and first receptionist, Dávila, into his office in order to coerce the patient into taking insulin. After nearly a half  hour of medical stalemate that peaked in an opthalmologic examination of the patient's retinas, Dr. Ortiz gave up. He gave the patient an information brochure on a simple insulin delivery system and wrote a prescription for one month's worth of the Type 2 medication. 

Covert scaring proved more successful in another case. That situation involved a young man who was concerned about a number of white spots or splotches on his back. Dr. Ortiz asked Emili the diagnosis. She told him that the cause was probably an infection with fungus, namely a Tinea species. He smiled and said that she was correct, and then he pulled his dermatology book off the shelf in order to show her a diagnostic picture. Emili describes the book as "one of those truly horrifying medical books. It has pictures of lepers, skin lesions on every part of the body imaginable, and much more." Dr. Ortiz opened the book on his lap and casually began to turn its ugly pages. The patient could see the pictures from where he sat, across from the doctor, and they had a powerful effect on him. With each turning, his eyes opened wider and his skin paled. Emili tried to calm the patient and discourage Dr. Ortiz by saying several times, "No es serio" (It is not serious.) Dr. Ortiz finally found the picture, and showed it to the patient and her. The patient was obviously not reassured to see a  picture of his condition hidden among the hideous pictures in that book.  Emili repeated her comment again, and Dr. Ortiz looked up from the book and told the patient not to worry, that it was not serious. The patient smiled weakly and swallowed. Dr. Ortiz then launched into the plan of treatment and prevention of reinfection that the patient was to follow. Needless to say, the patient paid very close attention. 
 

During the last week of her stay, Emili finally began to feel like she was a useful, functional part of Dr. Ortiz's clinic. She commented in her journal that this feeling was partly due to her increased familiarity with her surroundings. By the sixth week, she was interviewing and examining patients, developing differential diagnoses and discussing them with Dr. Ortiz, and performing tests and applying treatments that they decided were appropriate.  She had also fixed the clinic's computer, helping to submit claims that had been accumulating for months.  She practiced her Spanish more, venturing to make mistakes in order to explore the language and the patients accepted her as a new, and increasingly familiar, addition to the clinic. Since she had been there for such a long period of time, she saw many of the "regulars" more than once. They welcomed her warmly and inquired about her progress.  Some patients mentioned that they  were impressed that their health and their doctor were so important that an international medical student had come to study them. 

Dr. Ortiz has a personal relationship with his patients. As one patient said, "Dr. Ortiz is like a family member. I share all of my good news and bad news with him. He is often the first to know things!" That particular patient visited the clinic at least once a week.  Sometimes he had his blood pressure taken, but he usually just came to talk with his friend, the doctor who, he claimed, had saved his life with a cardiology referral. Another regular was so thoughtful that he would bring a cold can of soda or coconut milk for Dr. Ortiz whenever he dropped in for a visit. 

At the end of Emili's stay, the clinic began to receive unusual newcomers.  For example, during the first six weeks they saw no pregnant women, but two showed up on the same day of the last week.  Patients with rare illnesses came in, coincidentally all on the same day.  Analyzing this data, we considered again the impact of the observer on the observed, the pitfalls of a study through participant observation.  But even disregarding this incidental week, the experience was a far cry from the world of US clinics.   Significantly, the patients in Toa Alta redefined the term "visit" for us in the health care context.  In time they seem to almost appropriate the clinic and the physician in a way that would not be possible in a US setting.  The patients in Toa Alta forgave climatic and scheduling discomforts, disregarded the physical aspects of space and equipment, in exchange for a fundamentally intimate relationship with the physician.  The caregiver was allowed to coerce and intimidate for the sake of better treatment, and  was expected to treat not only the patient as a whole, but the patient's immediate community as part of the medical problem.  The language used reflected all of this in terms of endearment and forms of address. 

The cost of health care in this community was minimal; the doctor did everything within his skill to limit the cost to the patient, including limiting his own fees.  Financial transactions took place directly between the doctor and his patient.

Alternative medicine was not considered in the treatment provided by this doctor, but was not discouraged by him either. The most important goal for the physician, other than treating his patient's illness, was to keep open the relationship between himself and the community. 

We suspect that future studies will show that doctors in other Spanish speaking nations, in similar settings, relate to their patients in the same manner.  We hope that the physicians of the United States, who work with Spanish speaking patients, will consider and adopt these alternatives of good family medicine.