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Zuni Pueblo elective: Lessons learned, from singing to sonography

Ilona Csapo, the first DMS student to take advantage of a new elective at the Zuni Indian Hospital in New Mexico, did a fourweek family practice rotation there last fall. Her experience encompassed more than just medicine, however.

"The place is really special," Csapo says. The hospital is located on the Zuni Pueblo, a few miles from the town of Zuni and within sight of Dowa Yalanne, a large mesa sacred to the Zuni people. She spent a month there—working at the hospital, learning from the doctors who live in Zuni, exploring the Southwest's buttes and mesas, and gaining insight into a culture that retains elements of pre- Columbian times.

Rotations: "We go through all these one-month rotations or two-month rotations," says Csapo, a fourth-year student, "and none of them really change you—but that one did."

She describes, for example, meeting her preceptor on her first night in Zuni. "Somebody at the hospital told me where his house is, and I go to the house, and the door is open, so I just walk in. . . . Everyone is out in the backyard and they're having . . . a bonfire and a party." There was music and singing. "It made me immediately feel comfortable," she recalls.

The Zuni Hospital serves as the primary source of medical care for the Zuni people, and Csapo was involved in all aspects of this care. The hospital primarily provides outpatient services, but it also has about 30 inpatient beds. It has a fully staffed lab, as well as x-ray and sonography services, although patients with serious conditions and those requiring advanced diagnostic services are transferred to larger hospitals in Gallup or Albuquerque.

Range: As a family practice student, Csapo worked with patients ranging from "babies to 100-plus," serving on the inpatient wards as well as rotating through the hospital's specialty clinics—such as prenatal care, well-child services, diabetes care, and elder care—and its general clinics.

The differences between New Mexico and New Hampshire in terms of the case mix weren't as significant as Csapo had expected, although she did see more severe diabetes and more trauma at the Zuni Hospital than she had seen on her rotations at Dartmouth- Hitchcock.

However, Csapo did observe some major cultural differences. She was struck, for example, by one young woman who came into the clinic suffering from a cold and never mentioned that she was pregnant. "You kind of have to ask," Csapo explains. "Or maybe she was embarrassed. . . . So that was my ignorance of the culture."

Unique language: Some of the older patients do not speak English, she adds, but translators were readily available. Zuni is a unique language, unrelated to any other native Southwestern tongue. Csapo notes that young children in Zuni are still taught the ancient language—a practice that is representative of the efforts at cultural preservation that the community makes.

"It's very interesting that the religion still lives very strongly," Csapo notes. She saw one patient who, when doctors at the hospital weren't able to ease his pains, informed them that he was going to see a traditional healer. "I think that was one of the neater things about the culture," Csapo adds. "They're in some ways straddling the old and the new."

She also had a chance to accompany a caseworker on home visits to patients with chronic diseases. "We spent an hour or two [at each patient's house]. And so you're sitting in their kitchen and you get to talk to them about them—rather than so much talking to them about their condition. That's what I enjoy about medicine."

Festival: In addition, Csapo got to explore the town on her own. She attended a festival in the town plaza, where she saw a ritual dance depicting the Zuni creation myths, as well as the mission church, where murals depict the same mythic tale, about how the Zuni people emerged from a lake and wandered to find their homeland.

Beyond the town, Csapo explored the landscape of mesas and wide-open skies. "It was stunning. . . . September is the perfect month to go, because all of the flowers are in bloom."

She even hiked all around the sacred Dowa Yalanne, although she was careful to heed the injunction not to climb to the top of it. Three hundred years ago, the Zuni people sought shelter on this mesa after Coronado led the Spanish to the Zuni land in search of the fabled Seven Cities.

Opportunity: DMS Dean John Baldwin, M.D., was instrumental in establishing this new elective for DMS students. According to Allen Dietrich, M.D., one of the directors of the Zuni clerkship, the quality of the medical care and the first-rate community service at the hospital are "an excellent model for Dartmouth students to see."

Dietrich, who has been a family practitioner at Dartmouth since 1990, was the clinical director at the Zuni Hospital about 20 years ago. He and his wife, pediatrician Ardis Olson, M.D., who is also now on the DMS faculty, "left part of our hearts there," he says. "We are great admirers of the Zuni people."

Csapo says that she would love to return to Zuni or a similar situation someday. The example that she saw there of how medicine can be practiced has changed her perspective. "I felt how much you can personalize [medicine]," she says, "rather than having this 'doctor-patient relationship.'"

Mindful: Furthermore, she adds, the doctors she worked with in Zuni "were absolutely models for being doctors and being people. . . . Besides doing a good job at work, they were very mindful of doing things to help the community."

-Jonathan Weisberg

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