Although many of the patients that I would see during the week-long clinic in Comasagua had been waiting for several hours in the hot sun, without water, snacks or a place to go the the bathroom, most greeted me with a wide smile. Some of the children were fussy after such a long wait, but many were quick to say hello and to tell me their name and age before ducking behind their mothers shyly. They were all dressed in their finest clothes, the girls in frilly dresses and the boys in slacks and button- down shirts. Often, they were dirt-smudged after having spent all day in the dusty courtyard awaiting their turn. As a fourth year medical student who had just finished applying for a residency in pediatrics, I spent most of the week seeing Salvadoran children, along with Dr. Dale Heisinger, a retired pediatrician with more than 40 years of experience under his belt. We shared a small office and saw patients simultaneously.

Most of the chief complaints that we heard about involved chronic conditions, such as headaches, stomach aches and respiratory issues; there were not as many acute illnesses as I had anticipated. As we saw patient after patient, with some moms bringing five of their children in at once, our little office became hotter and louder. There were hundreds of patients waiting to see us, so our endeavor was to ensure that we listened carefully to every ailment, but that we also saw as many patients as we could. It was a hard balance to achieve. Many mothers were desperate to get their children any kind of medication from “los doctores gringos”. They often lived hours away from the nearest medical clinic, which, if they were to visit, was often understaffed and did not have many resources. For them, this was the opportunity to make their sick kids well. Some moms had very straightforward requests, such as “Please look at my son's rash”. Others had a laundry list of ailments, often not fully unfurled until we had already written prescriptions and discussed in detail many other symptoms.

The first day of clinic, I had adrenaline pumping through my body as I saw patient after patient without tiring. I enjoyed talking with the moms, making the kids giggle, and bouncing the babies on my knees. The second day was a bit harder; I was a little more tired, and taking more time with each of my patients. The third day I truly hit the wall. I had heard so many stories about headaches, stomach aches, constipation, diarrhea and coughs that patients were beginning to blend together in my mind. Fortunately, in the middle of the afternoon, one patient's story helped me step back and learn a valuable lesson.

Her name was Isabel, and she was one and a half years old. She looked at me somberly from her mom's arms, her white dress streaked with dirt. Mom talked about how Isabel suffered from constipation, and how she only stooled every 3 or 4 days. I began my standard constipation recommendations, and talked in depth about increasing fluid intake, and adding fiber to Isabel's diet. Mom listened politely to my long-winded advice, nodding occasionally in agreement. When I finished, I asked her if she had any questions. “Well”, she said softly, “I just wanted to tell you that when my daughter is constipated, her guts fall out”. I was stunned. “Excuse me?” I said. She repeated the same statement, and proceeded to tell me how Isabel had had surgery on her spinal cord at 3 days old (most likely from a neural tube defect), how she couldn't walk now because of lower extremity weakness, and how, when she strained to have a bowel movement, her intestines sometimes spilled out. She told me how she was prescribed a stool softener by a local physician, but that she couldn't afford the $9 it cost, which is why she had come to us. I was completely taken aback and humbled. I had assumed that she was coming in with similar complaints to those I had heard many times in the past few days, yet I was so wrong about what Isabel needed or wanted.

When I talked with Dr. Dale about her after Isabel's family had left with a bag of stool softeners, he said that one of our greatest challenges as physicians is to never assume that we know what our patients' symptoms are, to never assume what their diagnosis is, to never assume how they feel. One of his professors had quoted something that Dr. Dale remembers acutely to this day: “You only see what you know”. What an incredibly true and wise statement. This concept had been taught to me in medical school with less eloquence, but when tired and overwhelmed, it was difficult for me to look beyond what I knew already. We must continually be curious, asking more and more questions, inquiring and wondering out loud, differentiating every new patient's case from other patients we have previously seen and known.

The rest of the week continued to be difficult because of the sheer volume of patients as well as the emotional toll of many of their stories, but overall was quite rewarding as I listened carefully to every narrative that was gently laid before me in the hot office. My outlook had changed; rather than assume that every headache and belly ache that walked in the door was similar in nature, I heard what my patients were telling me, and I tried to comprehend their specific situation, treating each patient as an individual.