Tony Stupski

Tony Stupski

 Family Medicine Department of the University of Virginia

 Resident Class of 2006

 Tony Stupski

 Tony Stupski, MD
University of North Texas

The transition to life in medicine outside of residency has proceeded in fits and starts. Guam has been a good place to get my feet wet...I feel that my services are deeply needed and appreciated, while at the same time expectations are low. People expect to wait for hours to see the doctor, to be dealt with brusquely, to have difficulty getting the medications which are prescribed, to get poor follow up (and unfortunately - ultimately to die young). The staff and physicians at public health in Guam are actually very competent and dedicated, but the system here is challenging.

I came to Guam ready to charge in immediately and get to work helping the people of the island with my newly minted medical knowledge. Instead I had a much more appropriate introduction to life and medicine in Guam. I had to wait for the beaurocrats and politicians to sign my contract. I arrived needing only our newly re-elected Governor Camacho's signature and finally got it a month later! I got to be caught in the middle of bureaucratic bickering between Camacho and the attorney general as they wrangled over the petty details of my contract...should there be a termination clause attached or not. I came to find out that this was symptomatic of a larger battle between them over borrowing money to pay the bills for the government of Guam and its bloated bureaucracy. Meanwhile I was tempted by every private doctor I met to join private clinics at better compensation than I could hope for seeing the poor at public health while I was waiting for Camacho's signature. I finally manuevered through the Department of Bureaucracy (Administration) and the Department of Public Health and started work a month after arrival.

The month "break"was nice in some aspects. I enjoyed my time with my family exploring the island and searching for housing. Guam is really very beautiful and we were staying at a hotel which was minutes walk to the beach overlooking Tumon Bay. We got post-card like sunsets over the water every night. We went to the beach regularly and quickly got into snorkeling. The water is warm like bath tub water and is completely loaded with brightly colored tropical fish. There are also interesting areas to hike such as many beautiful waterfalls, rolling hills covered with jungle, and World War 2 battlegrounds. We ended up buying a very affordable house close to the clinic and very near the Eastern coast of the island. My personal favorite spot to walk the dogs and be alone in nature is a mere 5 minute drive from my house. The nature trail leads to a fresh water underground cave swimming hole and also the rocky shoreline where I have spotted sea turtles and sharks from the shore.

The Northern Region Community Health Center is situated in the heart of Dededo which is home to 28% of Guam's 160,000 residents. It's the little ghetto in paradise: full of dead cars on every block and stray "boonie" dogs on every corner. The community health center gets going early in the morning when the patients start showing up around 6-6:30 to get one of the 10-15 cherished morning "walk in" spots. I've heard that there are occasional pushing matches as people vie for the front of the line so they won't be forced to wait all day to see the doctor (if they are even seen at all). Ideally there is a triage nurse to sort patients in order of priority, but I have been surprised to see sick newborns showing up that had been turned away the day before for lack of "slots". The walk ins are worked in amongst the double booked slots of scheduled appointment in a seemingly haphazard manner so that ideally no scheduled appointment is delayed greater than 2 hours after the allotted time.

My day is supposed to begin at 8, but the patients never make it to the exam room before 8:30. This gives me a chance to follow up labs, drink coffee and chat with my co-workers awaiting the onslaught. There are two full time physicians, myself and Dr. Ramasamy an internist who always remarks about how amazingly sick the patients are in Guam while flashing me his broad smile. We also have a nurse midwife, Jim Finch, who has been great at giving me the inside scoop into life in Guam. He manages all the pregnant women in the clinic while 2 full time OB-Gyns work solely as hospitalists cranking out deliveries of the indigent patients at Guam Memorial Hospital. These patients include some gems such as the G15 P14 who is currently on dialysis (when she feels like showing up) and the multitude of gestational diabetics. Jim sees around 40 patients a day. As the only full time provider that can see kids, I get them all except when the part time pediatricians are there. Luckily for me they do the "special needs" clinic, even though I see many special needs kids when there are no pediatricians available. The nurses are almost all Phillipino and really wonderful people. I'm spoiled at lunch time with all kinds of interesting foods and treats.

Once we get rolling there is always a line of 4-5 charts of people waiting to be seen. The patients are a wonderful mixture of "outer islanders," Filipinos, local Chamorros and the occasional Korean and marooned caucasian.. I find the "outer islanders" the most interesting. Guam is the gateway to Micronesia and is certainly Micronesia's economic hub. People from the array of tiny islands scattered all over the pacific come here for jobs and economic opportunity. There are a number of pacific entities with "free association" with the United States which guarantees them passage into US territories such as Guam, but denies them social services that citizens are entitled to such as Medicaid and Medicare. Guam has created its own public health system called MIP (Medically Indigent Program) to serve people from Marshall Islands, The Federated States of Micronesia (comprised of Yap, Pohnepei, Kosrae and Chuuk), Palau, and the Northern Marianas who all have sizable populations on Guam Each has their own unique characteristics. Without question the group that dominates services are the Chukese... Chuuk is evidently an incredibly overcrowded series of blips in the ocean mainly famous as a Dive location for people wishing to see WW2 wrecks from the Japanese fleet sunk in the harbor there. Many of the smaller Chukese islands have no electricity and people live a subsistence lifestyle from coconuts, fresh fish, and "canned meat" (I love Spam stickers are everywhere). I also discovered first hand another interesting supplement to the Chukese diet from my next door neighbors the day we moved into the house I bought. There was some sort of birthday party and they were butchering dogs in the backyard for the barbecue. The Chukese tend to live in extended families with sometimes a single wage earner supporting the family. This allows the majority of the family to stay home keeping their traditional ways and language intact.

The variety of cases range from the typical colds and "Guam Sores" (impetigo and abscesses) to the surprisingly common Rheumatic Heart kids and Varicella outbreak. Infectious disease and dermatology are without question the topics I have been learning the most about while here. There are some really virulent strains of Strep here and some very confusing "tropical Rashes." I am also getting a much deeper appreciation for the economics of medicine while treating poor people. If you order tests, the patients likely will not be able to fill medicine due to lack of money! Specialists that accept the public health patients are rare...there is no dermatologist, ophthalmologist, or endocrinologist (or gastroenterologist). There is 1 cardiologist who is completely overwhelmed and therefore not very helpful. I have seen some really dramatic peds cardiology cases (2 yr old with tetralogy of Fallot and a multitude of Rheumatic Heart Disease) with little hope for specialist input except for "off island referral" which can take months to accomplish. There are some good pediatricians, general internists and surgeons around who I can ask questions of. Ancillary services such as the Early Intervention team and the Audiologists are actually quite good. Guam Memorial Hospital - despite its lack of credentialing - has by my estimation actually been pretty good.

I'm finally getting settled in and have developed a new circle of friends here. Of course having my kids has provided a rapid peer group as we end up hanging out with their friends' parents! Hana and Nadia are really enjoying school. Nadia goes to Montesorie school and has a "boyfriend" Jackson. Nadia explained that because Jackson is her boyfriend, he has to "always be nice to her and love her forever." You gotta admire pre-school love. Hana is going to St. Johns which is the very nice private school on the island. She has made some good friends and really enjoys her teacher who has instilled in her a love for Star Wars and the Chronicles of Narnia. They are both taking gymnastics and looking forward to joining soccer after the holidays. Sajeda has joined a women's group in Guam and helped organize a big fund raiser for the Salvation Army. She has been keeping our social life going. We have very fortunately been adopted by our Chamorro neighbor (who is a nurse in my clinic) to be part of her Chamorro family which means being included on Thanksgiving and baby christenings. Guam is very Catholic (meaning they love big families) so we will probably have many baby Christenings to attend.

My mom and sister in law came for the holidays. I have been eating extremely well and doing lots of swimming and hiking. We would love to host anyone else adventurous enough to set out across the Pacific for Micronesia. We hope to visit Australia (or maybe China) in March. The other islands are really beckoning me, especially Palau and Pohnpei. I'm thinking of exotic locales for continuing medical education...Hawaii and Singapore in particular. Send e-mail if you have time. I have plenty more stories to tell!