Consider this post from Monday, 4/16/18 given some posting troubles: I  have completed my first official day at Loma de Luz. I spent it with a family nurse practitioner that has been here for a year. She had me see patients and work with the EMR, and it was fun to do things as a team. That is an emerging theme here-the long term missionaries really rely on each other. I had my typical struggle with getting accustomed to the accent and speed of the patients' speech. Today I was most struck by the tension between limited resources and relatively easy, unchecked access to medications and testing. My most recent rotation was in Sterling, where the doctor with whom I worked was diligent about making sure that the appropriate health maintenance and documentation had been completed for billing purposes. Conversely, in Loma de Luz (LDL), we are working to be thoughtful about the testing and imaging we order for patients-to consider cost/time for them, cost/time for the hospital, and to consider whether or not a test would change our management-stark contrast to the diabetic/hypertensive patients that were getting lipid panels every 3 months in Sterling. At the same time, it was frustrating to see patients that came in with ultrasound results that the providers could not assume to be reliable. We also had patients that were taking medications that would require a prescription in the states. These are medications that should be monitored and medications that might not even be appropriate for them in some cases. So patients struggle to access medical care, but pharmacies and companies are happy to take their money for medications and ultrasounds that they may not even need. Also, patients travel several hours to be seen and usually expect... something. I struggled with prescribing a patient cough syrup for a likely viral URI-it is not something I would even typically do in the states because of the extra cost with minimal benefit to the patient. But here was this patient, who had traveled several hours, for a follow-up on knee pain. She had great results from bilateral joint injections less than 2 months ago and was still doing well. She was understandably frustrated that she came back as instructed 4-6 weeks later to be seen by a different provider (her last one was in the states visiting family) only be told that she was doing well and to come back again when things changed. So she mentioned her cough and wanted something for it.  The NP with whom I was working said that patients often think the meds at LDL work better and their satisfaction is often much higher if they get something. Was this relatively harmless placebo worth this patient's extra money on top of her the cost of her consult? That I struggle to answer. The NP also talked about how patients will get ultrasounds that show gallstones, fibroids, or ovarian cysts even if they do not have symptoms. They often have to explain to patients why surgery is unnecessary and could be harmful in many cases-VOMIT (victim of medical imaging technology) right here in Honduras even without multiple CTs in a lifetime. On a different note, one of the providers here told us about a patient that he had just seen that was diagnosed with heart failure. She was taking amlodipine and had developed lower extremity edema. At a different facility, she was diagnosed with heart failure due to these symptoms and started on Lasix without any further testing. Her chest x-ray and EKG at LDL were normal. He stopped her Lasix and switched her amlodipine, then scheduled her for follow-up. He said that this is not an uncommon occurrence-they often have to correct other providers' diagnoses. So here I struggle with responsible, appropriate medical care for patients-not so different from home but in a different way. I have tremendous respect for the providers that struggle with this daily in their effort to provide the best, sustainable medical care to their patients. More in a couple of days about my first call shift!