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I’m sitting across from my friend Sheila at a booth at Liguria, a favorite bar/restaurant in Providencia, and I can’t help but stare at the bags under her eyes. It’s the first time I’ve seen her in months, and she’s clearly on edge. Distracted, jumpy. She fidgets with the menu. Can’t make up her mind. Doesn’t know what she wants. And frankly, she looks like hell.
“What is wrong with you?” I blurt out. I’ve known her forever and have never seen her like this. Now that I think about it, she’s been out of whack for most of the past year.
“I feel like crap.”
“I can see that… What’s going on?”
“Jonesin’ for benzos…”
“What…?” Shock. Disbelief. Sheila is a responsible adult. A professional. Intelligent. Well-educated. Not your run-of-the-mill junkie type. How could she be going through withdrawals?
“Remember all those stomach problems I had last year?”
“Yeah….?”
“I ended up on and off all kinds of different medications and finally got to a combination that helped. The doctor put me on Nexium for gastritis and Lerogin for IBS, twice a day to start and then said to drop down to once a day as I felt better. It worked, and I’ve been taking them both ever since until about a month ago when I couldn’t get Lerogin anymore. The pharmacist said I needed a new prescription, but I’d been feeling better and didn’t have time to go to the doctor, so it seemed like a good time to stop taking it.”
This was just before she went to see her sick father in Canada.
“I’d been so worried about my dad and work and getting ready for the trip and all, I couldn’t sleep. But then he was doing better and I got back, and I still couldn’t sleep. I’d nod off and then wake up 4 hours later and spend the rest of the night tossing and turning. Night after night—I hate that!”
“And then it hit me,” she said. “I sat bolt upright one day at dawn after yet another sleepless night—and I knew. With everything else on my mind, I hadn’t put it together earlier. All this anxiety started right when I stopped taking the medication! So I googled Lerogin and discovered that it contains chlordiazepoxide—a benzo (benzodiazepine). Everything I read kept going on and on about it being highly addictive, for short-term use only—no more than 2–4 weeks—and that it should never be stopped abruptly. Scared the heck outta me. Jeeze! No wonder I’ve felt so awful!”
Pucha…
Cold turkey benzo deprivation can cause all sorts of nastiness, including anxiety, sleeplessness, racing pulse, splitting headaches, nausea, confusion, difficulty concentrating, depression, achy joints, and the list runs on. She was justifiably miserable.
“It explained all my symptoms. And not only that—the side effects from taking them for over a year explain a lot of everything else that’s been wrong with me for all this time—fuzzy thinking, distractability, procrastination—no, wait—that’s probably just me…” At least she still had a sense of humor
She went to a gastroenterologist, who agreed with her conclusion, gave her sleeping pills to get her through the night, and suggested she go back on Lerogin until a neurologist could set her up with a plan for weaning off it gradually. She refused.
“No way! I was already 4 weeks in, and after I’d already done a month of misery; I wasn’t about to start all over from scratch!
She made the appointment with the first neurologist who would take her and was waiting for the 3 weeks to roll around to get in to see him the last I saw her.
In the meantime, she’s angry. “Why didn’t the doctor tell me that this was a double-barrel drug? Why did the pharmacy keep selling it to me even though I didn’t have a new script? And why the hell didn’t I know enough to check this all out way back when I first started taking it?”
And that’s the point:
In Chile, patients must be particularly proactive about health care.
Chile has excellent health care professionals, but the system works differently and has fewer safety nets. Large loopholes and a look-the-other-way attitude make it very easy for honest people to slip through the loose mesh of the “open-weave” health care safety net, so the bottom line is: you must be your own health advocate. This carries over into all areas of health care, but for the sake of focus, let’s just stick to medications for now. That in itself is plenty to get a grip on. Here are a few points to get us started:
1. The “Family Doctor / General Practitioner” concept is not very common.
Most doctors are specialists; there are very few GPs around, so when you have a problem, you have to diagnose it, find a doctor in that specialty, then cross your fingers that your diagnostic skills are on target. Otherwise you’ll be sucked into the hit-or-miss and time-consuming spiral of finding the right physician. Personally, I really miss having one doc who knows me and my family, who knows my life history better than I do, and who is able to put Point A from 2011 together with Point B from 1999 and Point C from my mother’s history and say, “Let’s have Dr. Soandso check this out.” About the closest I’ve been able to get is going to the same medical center so that while I may not see the same doctor twice in a row, at least they all have access to a single chart with all my info.
2. Ask questions… and do follow up research!
Old-school docs are used to being the boss and balk at questions, although thankfully, that is changing. Most younger doctors are much more open to proactive patients. In the end, you are the one who is going to suffer the effects of any errors, so be sure to remind the doctor of any allergies or special conditions you may have, ask how and how long to take the medication, and then look it up when you get home.
3. The pharmacist is following orders.
He or she will fill your prescription, but will not ask you about allergies and will certainly not have your records on file. No one at the pharmacy has any way of knowing that what Dr. González prescribed today is going to cause a major problem with what Dr. Martínez prescribed last week, because none of that information is available to them—unless you tell them. Be safe and ask! Let the pharmacist know what else you’re taking and ask if there is any conflict. Most are very willing to answer questions when asked, although my experience is that few will butt in on their own.
4. Many prescription-only drugs are available “OTC” (over the counter) in Chile.
Chilean pharmacies are rather relaxed, and up until fairly recently, generally pretty willing to hand over whatever you ask for. When I first arrived in Chile antibiotics were dispensed like aspirin—which can be pretty scary for anyone with allergies, although fortunately the names are similar enough (peninsulina vs penicillin, for example) that they’re easy to spot.
My friend Sheila learned the hard way. How about you? Do you have any suggestions for maneuvering through the Chilean medical prescription system? Similar (or very different) experiences in another country?
Cachando Chile: Reflections on Chilean Culture 
Fortunately I don’t need to take much medication, but I do miss the good old times when there were family doctors (at least, we in my family had one). Then came Pinochet’s regime (¡yes!), and it ruined everything—including medical care—. Ever since, health care has become very good business for pharmacies and doctors, but not for patients.
What you can do, if you are young enough, is start from scratch taking only herbal products; they are said to be useful—in the VERY long run.
I’ve always been amazed at the amount of herbal remedies people use here, whether it’s an “agüita” (herbal infusion) after lunch to settle the stomach, palto-miel (avocado leaf with honey) to soothe a cough, or a bit of passiflora for a good night’s sleep. Hierbateros are everywhere, and there are plenty of natural, Mapuche, and homeopathic drug stores around. Anyone who wants to go the natural route certainly can’t complain about availability!
Hadn’t made the association of change of style of medicare with Pinochet, but the timing sounds right. Would love to hear what a doctor has to say about why there are so few GPs these days!
Truly a difference from our culture. I can’t refill a script until 30 days exactly. What a great bit of information to know before a visit!
Really Barb? What if you’re traveling or something?
And this info is helpful for travelers, but even moreso for expats–those who will actually need to enter the system here…
I have always been amazed that I’m usually not asked what other medications I’m on before being prescribed something. Do drug interactions not exist in Chile?
I’ve also been frustrated with the birth control situation here. On the one hand, the fact that it isn’t prescription seems like it would encourage more people to use it since it’s easy to get, and that’s a good thing. On the other, I feel like in the US doctors tend to evaluate patients as individuals when suggesting a particular pill, whereas here when I had to change pills (because mine was “out of fashion” – yes, that’s what the doctor said!) I was given the sample the doc had closest at hand without feeling like she’d taken my history into consideration and tried to find me something similar. Commence process of randomly trying pills with no medical guidance until finding something that works for me.
Emily- this is exactly the kind of thing I’m talking about–while it’s great that you don’t need to go spend $$ on the doctor every time you need to renew your birth control pills, but on the other hand, it really is discomforting to know that there is no “medical higher power” looking out for you…
Yes, and yes. I have an arrhythmia, which is not going to kill me. I had a cardiologist recommend that I take a medication that interrupts the way your body absorbs sodium, since my “problem” is electrical in nature. I balked at his recommendation since I would rather not take drugs, and the only thing the arrhythmia does is occasionally flutter in my chest. I later researched the med he’d recommended, found that in the states it is only administered in a clinical setting (patient is hospitalized), and that something like 30% of people go off it due to undesirable side effects.
I understand that there is a culture of moneyed (and insured) people who find going to the doctor a sport, and want to be under medical care. I also know that I am not one of these people, and have a family history to back up why I needed to be at the cardiologist to begin with. Why you would want to medicate me with something that could kill me for a problem that is not a problem is totally beyond me. I later took my results and saw another cardiologist who agreed with my self-diagnosis.
So yes, you have to be hypervigilant about medical care in Chile. You must be an advocate for yourself, do copious research and learn to live with the fact that many of your doctors will not like that. However, one doctor in Chile said to me “Why should I mind if my patients are well-informed? That just helps me to do my job.” Needless to say, he’s a keeper.
Thanks Eileen. Brings up just how important it is to find a doctor you trust and who is willing to work with you. Part of the problem–and I know that this is a problem that extends well beyond Chilean borders–is the 15-minute consult issue. Doctors must see a patient–often for the first time–figure out what’s wrong, patch her up and shove her out the door tick-tock-tick-tock… That’s hard enough to do when they KNOW the patient, much less when it’s a one-shot deal. So they hand over a stack full of forms–get this test, that test, take this med, and come back if the problem persists.
Certainly not an ideal situation for anyone–patient or doctor!
How timely-I just read a Huffingtonpost blog post about a woman’s battle to get off some addictive prescription drugs. Many classes of drugs are dangerous long term. This is really common in the US now, many people, especially women have prescriptions and don’t read the warnings. Doctors here in the US won’t tell you side affects many times either-they’re in a hurry, time is money…
And there are less and less family doctors. I tend to think that has happened especially since the Reagan years and slow deregulation, privatization. You wonder about the connection. Chile experienced sudden privatization under Pinochet while in the US, it’s slow and nearly unnoticed. Many times, it feels like Chile was a practice ground for US policies. I agree with Raul, so many good policies were simply destroyed during that time. Part of the new health care reform here is supposed to bring more family doctors back. We hope.
Antibotics were many years ago in Chile over the counter! A friend that lived there for a time under Pinochet told me that.
Also, I wonder if the government system is any better in a way? I read they were putting medical records online to be shared by doctors. Does anyone know more? We have the same problem in the US, people can just go to another doctor and get another prescription. If you go to the local pharmacy, they keep track of all the drugs and are supposed to warn you or the doctor. And often do, I hear from friends.
Lastly, I think the Chilean system, both government and private-Fonasa and Isapre, is what we need in the US. Almost everyone would be happy. (well maybe not but a good system I think)
Surely I´m no doctor, or medic, but my brother and some friends of mine are, and I have asked them about the lack of general practitioners, known in Chile as Médicos Generales or de medicina general.
The explanation in most cases is, that people here tend to bypass the gp, to save money. “Why going to a gp with a stomachache, when I can go directly to a gastroenterologist? After all, I know where my stomach is, and this guy is a stomach specialist, isn´t he?”
In Chile most people use the public system, and waiting weeks or months for the first apointment with a gp, to talk with him 15 minutes and then wait more weeks or months to get to the gastroenterolist is a luxury Chileans can´t have. That would be a really long stomachache.
People in private systems tend to think the same way, and usually they don´t like to pay for a doctor that will just send you to another.
My brother, my doctor friends and I agree that using a gp, a doctor that also know your personal history, would improve a lot the results for people, but since gp have less appointments, and then earn less money, everyone rushes to get an speciality pronto, and then a sub speciality.
In order to be a cardiologist, for example, you have to pass the Cardiology specialization/internship, and have passed the internal medicine specialization/internship before that, and being a general practitioner to begin with.
At least, I´ve seen that consultorios have a record of the people that geographically depends on them, their condition, treatments and drugs used, so the physicians have a better knowledge about their patients, but again, when their stomachs or heads or whatever hurt, they don´t go to consultorios and try to get an specialist right away.
@Laura-I’d like to read that Huffington Post article! Got the link handy?
I didn’t realize there was a decline in using GPs in the US. What I remember (and it’s been a while) is that the HMO health care system required each patient to have a GP who decided what steps you needed to take. As
@Marmo said, this can be time consuming and expensive when you already know what’s wrong and the system requires an additional step. A bit of a Catch 22!
Regarding Chile’s Fonasa system–my understanding is that it is open to all who are employed, but I don’t think it covers the unemployed… does anyone know for sure?
Interesting comment on changes in health care systems taking place under Reagan and Pinochet–same time frame, same general mindset…
@Marmo–interesting point about doctors wanting a specialty because no one wants to go to a GP. I wonder. On the other hand, obviously there is much more prestige to having a specialty and I’m sure there’s a social-academic-professional-economic push in that direction. At the same time, it would be interesting to see how many people have returned to machis and traditional medicine because they have no GP to turn to?
At least here in Temuco, Mapuche medicine is somehow integrated with western medicine to some degree. It´s not so rare to hear your doctor say “take this pill everynight before sleep, with a cup of bailahuen/tilo/ruda/whatever tea…”
There also are some products that are recognized as effective, If you´re interested, I once translated a small book about Mapuche medicine and traditions, in Spanish and Mapuche, to English.
I could send you one copy or give it to you personally with some blue eggs I owe you some day xD
Very interesting Marmo. Remember my friend Kathleen, the anthropologist who was here in January? She works on issues of traditional medicine and at one point was thinking about researching Mapuche medicine in Chile. She’s done major studies on related issues in the Dominican Republic and how people use western, traditional, a combination of medicinal approaches to illness.
And YES! I would LOVE to see that book!!
Here it is….more interesting than the post is the over 1000 comments-normal is 100-200 on the blog posts.
http://www.huffingtonpost.com/paulina-porizkova/ending-a-midlife-affair-with-meds_b_862442.html
On Fonasa, the unemployed are covered but have to enter the system somehow. The family across the road hired a guy(under the table) to dig holes, gardening etc. Gave him a room over the barn. He fell out (drank a lot) and went to Fonasa, got the arm fixed and was back that day. I knew people in the Fonasa system and just didn’t hear about lines so much. I also knew a couple who were both doctors in the Fonasa system. He is a cardiologist, pacemakers his specialty. She is a pediatrician.
About the HMO system, that is sort of correct but your main referral Dr. doesn’t have to be a GP. I think most of the time (at least back when I worked for a mega corp with lots of insurance plan choices) you can choose an internal medicine Dr. I was younger with a family as were my co-workers and we would hunt in vain, calling the GPs on the list, all of which were full.
So we had to pick someone in Internal medicine. Again, the Obama health (and education) reform is supposed to encourage Drs and teachers by forgiving student loans in exchange for graduating in certain professions and certain public service. Maybe a culture thing too-Drs want to make as much money possible-but if a Dr could be Gp, have school loans forgiven and settle into the modest $168,000 average salary-and have more time for family-this generation might do it.
I think of Chile every time I hear hysterics like “all the doctors will LEAVE because of Obamacare!”…..right, where else do Drs make $1,000,000?
@Marmo
Yes, I loved the herbal remedies. I’m not sure whether mapuche or what but my neighbor(not a Dr)in Pirque was always telling me this plant for a stomach ache or that one for to improve eyesight….
Thanks for the link Laura–good overview of life on and off antidepressants. I’ve heard others say the same thing–they don’t feel bad, but they don’t feel anything at all.
You’re right-I misspoke about the lead doctor being a GP, although that’s the way I always thought of them–someone who knows your case and can guide you in the right direction. I can be cumbersome though. Once I cut my finger and needed stitches but couldn’t go to the ER without my Dr’s authorization. He said he would stitch it up himself and to meet me in his office–but then we realized that we were neighbors and he came over and stitched me up at my kitchen table!
Like the idea of giving new doctors incentives to work in less glamorous fields and settings–where they are certainly needed!
Hope this helps your friend Sheila. A good friend of mine has IBS. She became so frustrated with the lack of useful information from traditional medicine, she started her own company to help those with this condition. She has now turned this into a profitable business. She has lots of info on the subject. Here is the link, http://www.wellnessfoods.ca/
If your friend Sheila is interested, I can put her in touch with my friend Cathy. She has dedicated a great part of her life learning about this condition.
Hi John- Thanks–I’ll pass the info on to Sheila. Her main issue right now is getting the junk out of her system and getting back to ground zero!
I don’t know of any place in particular in Chile, but has your friend looked into fasting and detoxifying under supervision? From my limited knowledge on the subject, I’m told this is the healthiest and most effective way of getting back to ‘ground zero’.
Hi John-
Don’t know if she’s tried fasting, but I don’t think that would work for this particular problem. The literature says it takes 6-12 months to clean it out of your system! I was appalled that this still gets prescribed when I saw what its side effects and withdrawal symptoms were!
I´m so glad to have come across this post! This is so good for me to know, being a person with many health problems. I have only been to the doctor twice here but now I know to always ask about the medications I already use and the ones they prescribe! That´s horrible about your friend! I´m sure if that happened in the United States, it would have turned into a really bad lawsuit!
Hi Catherine. It’s a matter of perspective I think. You need to be proactive and search diligently for doctors you feel comfortable with. Unfortunately, Sheila was feeling so bad that she just welcomed the relief in whatever form it took!
I’ve also wondered about the law suit angle, but hearing her story got me so curious that I’ve been doing a lot of reading, and it appears that this is really pretty common in the US and UK!
I’m certainly no expert, but I think that most HMO’s in the US do require a GP visit before being sent off to a specialist, but a GP now isn’t what a GP was 20 or 30 years ago. Back then, the GP was a “family doctor” and truly knew your health history.
Nowadays, many doctors have very little time to study your chart well or to explain any of it to you. They are writing prescriptions for whatever their pharmaceutical rep has convinced them is the “latest and greatest,” some of them unaware of potential problems or contraindications.
Sadly, a GP doesn’t usually know you personally any more. S/he is often just ticking boxes and rushing off to the next patient. I’ve often thought that, if I’d made an appointment for a hangnail check-up, in the course of the visit, the GP might not notice if my head were cut off!
No arguments from me! But what Laura said was that while you do need a lead doctor in an HMO, s/he doesn’t necessarily have to be a GP. Come to think of it, the last GP I had in the US worked closely with a Nurse Practitioner, and I actually saw her more often than him. SHE was the one who knew our names and did what the old-time family doctors did way back when!
Maybe what we need are more Nurse Practitioners… I wonder if they even exist in Chile?? Does anyone know?
Great post. All the best to Sheila, hope she gets better soon.
I currently have a flu vaccine in my fridge door. I bought it last week at a pharmacy, would have waited but it was on the same script at the antibiotics I needed that day. So, it’s been keeping the milk company. I’m waiting til I get over bronchitis and now a cold to take the next steps to get the shot: buying a bono from my ISAPRE, making an appointment at the clinic’s vacunatorio and taking the vaccine to the nurse. I’m waiting at the moment until I’m off the antibiotics and feel better – not because the doc told me to, but because I remember prior indications when I had flu vaccines before. Oh how simple it was back home… my GP used to give me the injection on the spot, free of charge. NHS, all is forgiven.
My current other oddity is that I’m about to be diagnosed with asthma for the second time in a month so I can get on the GES scheme and get 80% off my asthma meds. That’ll be worth the running around, taking the same tests again and all the paperwork, I think. Even though I’ve had asthma since I was very little.
All this said, if you have a good ISAPRE plan, can get electronic bonos, and have your wits about you, the system is, for me at least, pretty darn good. Just not so good if you’re feeling so ill that you can’t look out for yourself, like poor Sheila…
Margaret, there are. A friend there told me that Nurse Practitioners do home visits, especially for the elderly and mothers with babies.
Nat, interesting about the flu vaccine. One of the things that impressed me in Chile was that flu shots were free in the Fonasa (govt) system-or so I thought.
More GPs and Nurse Practitioners!
Hi Nat- good point about the vaccines–I don’t think we can buy vaccines over the counter in the US… and CERTAINLY can’t by the hypodermic needles to inject them!
Laura- Do remember what the nurse practitioner is called in Chile? Are you sure she wasn’t talking about an Enfermera Matrona? (that’s a nurse-midwife with a 4 or 5 year degree). A nurse practitioner is pretty darned close to an MD–at least in the family medicine sense.
Margaret-
I don’t remember-and am not sure! It would be interesting to know how the different levels in each country translate/compare. I did a quick google search and found people in the US who claimed to have graduated with a “nurse practitioner” degree but, as you said, that may not be the same as in the US.
Yes, it WOULD be interesting to know how they compare. I know that here, if you say someone is an “enfermera” she (or he) will often insist that the correct title is “enfermera matrona.” There’s a difference in the number of years of study. Maybe something like the difference between an LPN and RN in the US (not sure).
Nurse Practitioner most certainly exists in the US. It requires a BA in nursing first and then additional post graduate study (2 years, I think). As I understand it, it is the highest degree in the nursing field.
A similar field is a Physician’s Assistant, which also requires post graduate study and is often what paramedics aspire to. (…Paramedics–now there’s a whole different topic to tackle in another post, because what a paramedic is the the US, at least in NY, is quite different from what it is here in Chile!)
Thanks for this article, it’s a good reminder that we should always be extremely proactive when it comes to something as important as our health.
After spending the past 10 years working in the healthcare industry in the US, my perspective is that healthcare in the US today is not very different from healthcare in Chile. The main difference is that in Chile people realize that they should be proactive in their approach to medical care, whereas many are more trusting of their physicians in the US (when it would be wiser to be more proactive.)
That said, HMOs have gone out of vogue over the past 10 years, especially outside of California, as many Americans were frustrated with the bureaucracy around needing to coordinate their care through one doctor in order to get a referral to a specialist. PPO products, where you make appointments directly with specialists, are much more common, and are very expensive. Additionally, if you use too much medical care, your rates may increase and/or you’ll have trouble qualifying for a plan if you decide to switch carriers. The longer I spend working in healthcare, the more convinced I’ve become that the entire industry is broken in the US.
I’m still just settling into Chile, and signed the final paperwork on my Isapre yesterday, so am just getting to know how Chilean healthcare works. So far, though, I have been very impressed with both the transparency around costs, the relative affordability of medical plans, and even the customer service. Thanks for sharing the story of your friend, as it’s a good reminder to always, always be vigilant around healthcare decisions.
Hi Jen-Thanks so much for you comments and bringing me up to date. It’s been a long time since I’ve needed medical care in the US. Sounds like health services have become more rushed, less thorough, and more expensive on a pretty wide-spread basis. Kind of scary. I hope your experience in Chile is positive.
BTW, I spoke with Sheila yesterday and she’s doing much better. Tried to get her to leave a comment, but said she’d rather not.
hahaha the family doctor thing is so twin peaky sounding