Phnom Penh Journal VI

February 1 - 5, 2013

Portland, Oregon

Since leaving Phnom Penh I have found it hard to write this final journal.  I have struggled against jet lag and the emotional backwash of stopping in Tokyo and Kyoto for four days on my way back to the US.  

The first day after returning across nine time zones is always deceptively easy:  I am super-energetic, putting away laundry and gear and making lists of what I need to do that extend weeks into the future.  But days two and three were so bad that I nearly fell asleep every time I drove to the medical school; once I barely stopped before driving into a barrier while parking. From dawn to dusk I was either groggy or felt like I had the flu.   My initial attempts at writing were leaden, the stolid laying down of words without any spirit.  

I followed my own advice against making life-changing decisions when I am depressed.  A week later I still cannot bear to listen to the US newscasts on NPR or public television.

I am hoping that the interval between recovering my urge to write a few days ago and the point at which I am too far away from the emotional intensity of living in Cambodia will last long enough to finish this, and that the powerful feelings that left Phnom Penh with me will not have been dissipated by answering the frequent and well-intentioned question, “did you have a good time in Cambodia?” 

Since I was sixteen I have had a difficult time answering the simple question, “so, how are you doing?”  How I am doing is always complicated, and I rarely believe the asker really wants to hear an honest account of my existential ponderings.   In the same way, I cannot say that I had a “good time” in Cambodia—the social disruption, suffering, and ongoing injustices are simply too great.  When I am focused on caring for patients or teaching residents, I have the satisfaction of feeling that I am making a tiny contribution: improving a few patients’ current health, helping a few doctors to become more skillful or knowledgeable or cared about. When I allow my eyes to drift up to the Cambodia beyond Sihanouk Hospital, when I am alone and not with the friends I have made, the needs and sorrow of Cambodia simply overwhelm me. 

* * *

This past summer I invited Kruy Lim to visit OHSU to observe teaching in our residency program.  Kruy's medical education was entirely in Cambodia and she has spent most of her professional life at Sihanouk Hospital.  She sees western teachers frequently at Sihanouk Hospital.  We visitors slip into whatever teaching roles seem useful--usually talking with their staff and residents about patients in their emergency room or clinics, or joining Kruy on her morning inpatient rounds.  And we lecture. 

In March I had seen nothing like the classical "morning reports" which occur in most US medical residency programs--the presentation by a resident of a current patient for discussion by the other residents and students, often facilitated by a chief resident or a faculty member.  In my first visit I often used one of their cases as the starting point for my daily lecture, but neither staff members nor residents presented one of their cases for a structured or extemporaneous teaching exercise.  In March I also did not see a formal program for evaluating residents or faculty members, or giving them feedback.

I thought it would be helpful for Kruy to have her spend two weeks at OHSU, joining our faculty members for their inpatient attending rounds, watching residents being taught in their outpatient clinics, attending "noon reports" and teaching conferences, and watching teaching in the emergency room.  I flew her directly from Phnom Penh to Kalispell Montana, at the peak of Montana’s summer warmth.  She was in sweaters when it was 80, and at night she said she had never been so cold in her life.  She declined to join Margaret and me in our daily swims in Flathead Lake. 

After a week we drove the 600 miles from Flathead to Portland, which I find stunningly beautiful and she found . . . empty. 

At the end of her stay at OHSU I asked Kruy if anything she had seen would be useful at Sihanouk Hospital.  Sihanouk has a nice mixture of direct interactive teaching--discussing diagnosis and management of both clinic and inpatients at the bedside or in the clinic, and daily lectures by the visiting teachers on subjects useful for their patient population--but the clinic teaching done by the Sihanouk medical staff is brief and few of her staff members are able to match her skills as an emergency room or inpatient teacher, with the result that she does most of the bedside teaching without backup. 

There is not a program of conferences based on resident presentations of their most challenging patients.  We agreed that when I came in January we would try to start case-based conferences presented by the residents, an "M & M Conference" (discussion of cases where there had been a mistake or a bad outcome), and an evaluation program.

We were never able to develop an M & M conference.  In Cambodia, as in much of Asia, people are very cautious not to cause another to "lose face."  At SH, both the staff and residents said that they would be very reluctant to present or discuss a patient who had suffered a mistake in care, since either being criticized in public or criticizing other physicians would be very painful.

However, the residents responded with enthusiasm to the request for each to prepare a case presentation, using PowerPoint.  For most, this was the first time they had done a formal case presentation or used PowerPoint.  Each produced an outstanding presentation that led to great discussions.  The residents found it easy to engage in asking the presenter for more information or to think through other data they needed or other possible diagnoses. 

In teaching clinical medicine, much of the curriculum is created by the patients that the students and residents are seeing.  We had six world-class subjects: 

    

The first patient had diabetes and sepsis caused by a bacteria we rarely see in the US, Burkholderia (mellioidosis).  Chhor’s patient survived; we saw four other patients with Burkholderia this month--two of them died.

Sokland presented the second patient.  She was a fourteen-year-old girl whose first period lasted for six months.  She had previously been admitted to other hospitals with blood counts of about 20% of normal (Hemoglobin < 3).  Although she was transfused, in neither hospital was there an attempt to stop her menstrual bleeding.  I asked the three male residents what they knew about menstruation.  Before they could answer, the women said, "they know nothing."  The men laughed and agreed.  I asked all the residents what they had learned about the menstrual cycle and puberty and contraception in high school.  "Nothing."  In medical school.  "Nothing."  Her case afforded a wonderful opportunity for them to begin to know something about the physiology of menstruation and about the autoimmune hemolytic anemia and thrombocytopenia the patient developed either due to transfusions or a rare condition called Evans’ Syndrome.  

The third patient was a young woman with heart failure complicating pregnancy (Soklang again).  During the presentation the residents simply accepted that a pregnant woman had carditis (inflammation of the heart) without recognizing that it is fairly common in Cambodia.  From this presentation they learned about its prognosis and treatment, and how to differentiate it from other causes of heart failure in a young woman. 

The fourth patient was a woman with tuberculosis involving the pericardium (the sac surrounding the heart), presented by Muzen.  While the residents see many patients with tuberculosis, they were unfamiliar with how to diagnose pericarditis by physical examination and how having inflammation of the pericardium or fluid in the pericardial sac compromises the ability of the heart to efficiently pump blood. 

The fifth patient was presented by Kimray Tho, an elderly woman admitted because of severe low blood sugar because of being given two oral drugs for diabetes without follow-up monitoring.  When first admitted she was barely able to communicate, and she had a life threatening level of potassium (2.0).  This led to a discussion of how to initiate insulin or oral diabetic treatment to a new diabetic and how to monitor blood sugars to avoid overtreatment.  This is a frequent problem in Cambodia where village doctors may not be able to continue the care started in a Phnom Penh hospital, and where the supplies for monitoring blood sugar at home are too costly for most families. 

ChanKresna presented the final patient, a woman with severe, recent onset of heart failure.  When I asked them what drugs they would use for heart failure they were entirely correct.  What was more complicated was deciding in which order to use the drugs, and how to gradually increase doses and when to add an additional drug.  In the set up of their clinics and inpatient wards, they only infrequently have a chance to follow most patients over time. 

I think the resident case conferences may be able to continue.  This February and March a Neurologist in private practice from Colorado, a third year Endocrinology Fellow from the Mayo Clinic, and Ted Sussman, a veteran SH teacher who practices general medicine in Maine have all agreed to keep the resident case conferences going, and the residents are collecting cases and preparing new PowerPoint presentations. 

* * * 

Last  March I had arrived after a series of western physicians had been teaching for months.  The daily program was well-established:  a daily thirty-minute morning "chalk talk" without PowerPoint, and a daily afternoon PowerPoint lecture. Arrival time for both sessions was approximate--I usually came first and a few people drifted in over the first 5 or 10 minutes, and then most of the others arrived after I had begun.  The audience was about equal parts residents and staff.  My talks largely focused on endocrinology, diabetes, nutrition, and digestive disorders.  Copying a handout with 4 or 6 slides in miniature per page wasn't possible--there simply are not funds for what we take as routine at home, and both residents and staff took copious notes and asked for links so that they could download the presentations.  Teaching medicine in that method is dense—almost always too much information--and I found it difficult to stimulate discussion even with slides designed to raise questions and encourage participation.  

When I began on January third I met with the staff and residents and told them that I was going to try to make each conference more interactive.    Whether because the staff had been asked to increase the number of paying patients they were seeing or because of my intention to encourage more participation, few of the staff attended either the morning or afternoon sessions this time--while all the residents were present for each.  

A consequence of spending most of my conference time just with residents was that I got to know them quite well, especially after I worked with each of them to prepare their own case presentations.  From time to time I showed slides of our teaching conferences at OHSU, dinner parties with my inpatient teams in my home, or dinners out with residents in Japan.  A few of the residents said they wanted to come to my house for dinner too. Having no home to which to invite them, I asked them to dinner at my friend Daroth's restaurant.   A few nights before I left we had a giant dinner of Pakistani and Cambodian dishes (Daroth's boss and many of his guest house customers are Pakistani).  When I go to a restaurant I usually race through a menu in two minutes and place my order quickly, but they luxuriated over thinking about each unfamiliar item on the menu and debating its relative merits compared to the merits of all the other dishes.  Ordering took twenty minutes.  One side of my stomach was already beginning to eat the other side, so it was a mistake to suggest that they might want to order a cocktail:  that took another twenty minutes.  It turned out that none had ever had a cocktail (this might be both their first and last time).  A gin fizz and paradise passion and Long Island ice tea and mango moonshot all were strange and strong and probably not something they wanted to drink again. Would you have ordered something call “coconut brain cruncher?”  Would you swallow a cocktail that was deeply and thickly brown?

They each had arrived on motorbikes, men and women alike--there are no gender disparities in transportation in Phnom Penh--and they proposed that they take me out the next night, for a tour of "their Phnom Penh," a dinner at the waterfront, and a night-time boat ride.  At precisely six the next night they arrived as a cortege--six residents, five motor bikes, and a perch for me on the lead bike.  I saw parts of Phnom Penh I did not know existed, had a leisurely, lovely meal of Cambodian dishes which once again took them about twenty minutes to consider and choose, and we lingered for an hour.  Once again I discovered that in Cambodia a dinner out is an event, rare for these young doctors, and something not to be rushed. 

We talked about the entire array of issues that fill the lives of unmarried young people.  I asked if in their families a man and woman could fall in love and choose to marry.  They said that half or more of Cambodian marriages are arranged—even more in villages—and that parents might very well scuttle a marriage for love.  “You are too young to know about marriage and life.”  Only one, the woman who was the lead organizer of our second evening out, said “I will decide for myself and my parents would not tell me no.”  The residents laughed because it is what they would expect of Muzen, the most curious and brave of the bunch.

Could a Cambodian woman have a baby without a husband?  “It is never done.” 

What will be your income when you get your first job?  “Maybe $600-$700 a month.”  Is that enough to have a home and a car and a family?  “No.”  How much would you need?  “Maybe $1100-1200 a month.”  Do you have loans to pay?  “In Cambodia a student cannot get a loan to go to school.  Maybe the parents or other family members can help pay, but if we get into the government medical school it doesn’t cost so much and some of us live with our families.” To go to the private medical school the family has to have money.

If you have a baby, can you continue to work?  Uniformly the question caught them by surprise.  “Our mothers want to take care of their grandchildren; of course we would work.”   They could not imagine the situation in Japan, where women doctors are often under strong pressure to leave medicine and become full time mothers.  

Do you have time for fun, to spend time with friends and family?  “Not very much, but we always try to be with our families, and our friends are part of our families.”

Two pairs of the residents seemed to be romantically linked, but they revealed nothing when we were together.  Affection is not seen in public in Phnom Penh.  I have no idea if these couples would be able to marry or have already been approved.   Although Muzen is in one of pairs, the guy I think is her boyfriend remained silent and expressionless during that conversation.

* * * 

Phnom Penh is not a particularly dangerous place right now if you pay attention to where you choose to go and remain aware of what is going on around you.  Every tourist guide and most Cambodian friends will caution you not to leave your camera, purse, or back pack in front of you on a street café table or in the basket of a motorbike.  Hanging them from shoulder is not as good as being sure the strap is around your neck or over both shoulders. 

Last year I initially used one of those little putty colored Eagle Creek pouches that hang from your neck and go under your shirt, or around your waist and down your pants.  Frankly, reaching down the front of my pants to pull out at few dollar bills seems too much like a stripper move or the prelude to flashing:  street food peddlers looked at me as though I was about to produce a cobra from my crotch.  Since then I have taken my chances by carrying my wallet with a little cash in it and leaving the rest at my hotel.  When I go out I usually have a light backpack with my camera, sunglasses, and any other gear I need—often hung from a shoulder but usually with one hand on the strap.

On my next to last night in Phnom Penh (do you want to write the rest of this story??)  I asked my friend Daroth where we could hear some music.  After she closed her restaurant we went by tuk tuk to a riverside hotel and spent an hour on the rooftop overlooking the Mekong and Tonle Sap rivers, listening to a DJ’s assortment of Cambodian pop.  I had a beer and she had some kind of exotic cocktail the color of a sapphire.  I wake early and so we headed back about 11, just one more tuk tuk ride of hundreds.  Traffic is always heavy in Phnom Penh, even at 11; we were surrounded by hundreds of motorbikes and tuk tuks and cars.  As we got near where we would drop Daroth off I reached to my back pocket to get my wallet.  I pulled out the agreed-on two dollars and suddenly was aware that my backpack wasn’t on my left shoulder.  I looked on the floor and seat, but it wasn’t there.  Two motorbike drivers overtook us and started yelling at the tuk tuk driver.  Two blocks later he stopped—Daroth said they told the driver that three boys on a motor bike had pulled up beside us just as I reached for my wallet and lifted the backpack off my shoulder and then raced away. 

I knew I would never see the backpack or its contents again.  The next morning I called the company from which I bought travel insurance.   To file a claim I would need to send them a lot of stuff, but nothing could be done until I had filed a claim with the local police.

On the morning of my last day my guest house arranged for an experienced tuk tuk driver who spoke some English to take Daroth and me to the police station near where the backpack was stolen.  The station was open to the street, with six men sitting in it.  One, who I took to be a judge, listened to my story and then Daroth’s more articulate account in Khmer.  He said we would have to fill out a form detailing everything from the beginning of my life to why I was in Cambodia, what I had been doing that day, the exact circumstances of the theft, and what my future plans were.  I figured I had just enough time to do this and still make it to the airport on time. 

While I wrote fast Daroth whispered in my ear, “you should give them some money.”  I was prepared for this. 

“How much?”

“I don’t know?”

“When?”

“I don’t know.”

I slipped her a twenty dollar bill to give to the judge; he took out his wallet and carefully put the bill inside.  He spoke to her quietly in Khmer to the effect that the men appreciated it, they would use it to buy coffee, it would not go to the government, it was for them. 

Understood.

The judge asked why I was in Cambodia:  “tourist?  Business?”

“I’m taking care of patients at Sihanouk Hospital.” 

He frowned a bit and Daroth explained where the hospital was and who it served.  He seemed to recognize it and nodded at me approvingly.   

From that point all six men were in action, stamping, recording, stamping some more.  Fifteen red thumbprints later I was handed my copy folded carefully inside two sheets of flamboyant pink paper. The only man wearing a uniform carefully recorded the whole transaction in huge black book the size of what I imagine St. Peter would use; as best I could tell he was a general or an admiral.  I solemnly signed.  All six wished me well with the traditional sampeah.  We parted the best of friends.

As the tuk tuk driver drove us back to the hotel Daroth said that without the money nothing would have gotten done.  If you need help from the police, you always have to give them money; it doesn’t really matter how much. 

You could think of this as a corrupt system. Or you could think of it as a different system, one in which the police get paid very little, and those who need their help pay a user fee.  In a country where there is little to tax, a larger government wage seems impossible at the moment.  So those who can pay get help, and those who cannot may not. 

I paid the tuk tuk driver $10 for the two hours he spent with us.  The typical daily income in Cambodia is $1.00.  The camera, lens, glasses, and other gear in the bag were worth about $1000.  I’ll let you know if I get a penny from the travel insurance company.

* * *

During this first week back from Phnom Penh I have tried to answer the “how was Cambodia” question honestly and in less than an hour.  To be honest is not hard; to be brief is close to impossible.  I went to Grand Rounds on Tuesday, hiding out in the back of the amphitheater so that I wouldn’t have to talk to too many people.  My dear friend Tom Cooney sat down beside me. 

“So, I am looking forward to hearing about Cambodia.  How was it?”

I surprised myself by being unable to say a single word.  Anyone who has spent three minutes with me knows that I am rarely at a loss for words. 

Tom looked at me, chuckled.   “I can tell that we need to have a beer.” 

Perhaps more than one beer.

* * *

While I was in Phnom Penh I read three books—“Ru,” the elegant and poetic novel by Kim Thuy about an affluent and well-connected South Vietnamese family that escaped from Vietnam a year after the country was reunited under Ho Chi Minh.  Her story paints scenes of their creation of a new life in French-speaking Canada, a life that started with nothing but what they brought in a paper bag from a refugee camp in Malaysia and what they were given by kind strangers or could purchase with their meager earnings from the most humble kinds of labor. 

The second book was the devastating story of Somaly Mam, “The Road of Lost Innocence.”  Mam was taken out of her northern Cambodia hill village where her parents abandoned her during Cambodia’s civil wars, by a man claiming to be her grandfather.  He rented her out as a work slave and when she was twelve sold her virginity to local men before renting her to a brothel in Phnom Penh when she was about 14.  In her book Mam unsparingly recounts the beatings and rapes that she and other young girls experienced in the brothels of Cambodia, and her eventual escape.  She ultimately created shelters for girls that she and her co-workers rescued from brothels, and started training programs that would allow them to reclaim a life under their own control.  Although I had read Nicholas Kristoff’s articles in the New York Times about sex-trafficking, and I knew that selling children, some as young as five, as sex and labor slaves still occurred, what Mam lays out clearly is the near-total absence both before and after the Khmer Rouge atrocities in Cambodia of social and religious institutions, laws, courts, government agencies, and engaged citizens taking responsibility for what was and still is happening to its poorest and most helpless citizens.  Mam described herself and the thousands of children like her as “money on legs,” totally powerless to prevent a father, an aunt, a cousin from snatching them away from their village and selling them.  Once sold, they belonged to whoever bought them, for whatever purpose they put them to.  If they died or were murdered they were disposed in dumps, unknown, unremembered, uncared about.  Mam write, “we were garbage in life, and we were garbage in death”. 

In Cambodia, now as then, “justice” is a commodity:  those with money can purchase it, those without are powerless.  It is widely alleged that judges and politicians and government officials are already bought; the police may be for sale, although those with power may always win the bid.  

The third book was “In the Shadow of the Banyon” by Vaddey Ratner.  In her brilliant novel, Ratner describes the social chaos following the Khmer Rouge victory over the post-Vietnam war Cambodian government, and the almost instantaneous forced evacuation of everyone living in Phnom Penh and the killing of all the educated class—anyone who could read or write (those wearing glasses were presumed to be literate), along with those who could speak French or English and most artists and musicians and people of Chinese or Vietnamese ethnicity.  Families and friends were forcibly separated so that there could be no resistance. 

The murders or starvation of what has been estimated to be one to three million people has meant that for thirty years Cambodia has been without most of the leaders and those with skills acquired through education who could have helped reconstruct a decimated landscape and culture.  There have been few internal voices raised to protest the continuing inequities—the continued human trafficking; farmers pushed off their land that is then sold to international corporations, with the profits reported to be pocketed by developers, politicians, and government employees; boys lured or sold into labor who are purposefully addicted to amphetamines and other drugs so that they cannot stop working, many of whom become permanently disabled by their addiction or strokes.   Some of the members of the current government were at the heart of the now collapsed Khmer Rouge reign and they can and do neutralize their critics.  The reestablishment of the monarchy has not yet resulted in the creation of a just or progressive state.  

I said when I started to write this journal about leaving Phnom Penh

I cannot say that I had a “good time” in Cambodia—the social disruption, suffering, and ongoing injustices are simply too great.  When I am focused on caring for patients or teaching residents, I have the satisfaction of feeling that I am making a tiny contribution: improving a few patients’ current health, helping a few doctors to become more skillful or knowledgeable or cared about. When I allow my eyes to drift up to the Cambodia beyond Sihanouk Hospital--when I am alone and not with the friends I have made--the needs and sorrow of Cambodia simply overwhelm me. 

I imagine that perhaps a third of the world has issues very similar to what I have experienced by living in Cambodia -- I know that Cambodia is not a unique case. 

It troubles me that I have no capacity to deal with most of the other problems facing this country and I am therefore grateful that there are others in NGO’s that are focused on the sex trafficking and poor education in rural areas and people being pushed off their land. 

* * *

A few days ago I was talking with a medical student who asked me about Cambodia.  I told him that most physicians who teach medicine in the United States contribute very little to a particular student or resident’s development.  Graduating residents are like a piece of fine cloth densely interwoven with fibers that have been contributed by a hundred parents and grandparents and friends and teachers.  If I spend two weeks with a student I might add a few threads.  It is possible that if I were to work with one of my students ten years after graduation I would recognize at most a thread or two as having come from me.  But while I and all the other teachers have contributed very little to a particular student, all of us and all of the patients and experiences of medicine and life taken together have added thousands of threads that have helped a talented student become a skillful and compassionate and fulfilled physician. 

When I said goodbye to the seven residents and dozen staff physicians with whom I cared for patients in Phnom Penh, I knew that for a few I had added a little knowledge or a better way to examine a thyroid gland or liver or heart or a way of asking a patient if it was alright for me to examine them.  I have left them with a few threads. 

They are not nearly enough.  At present there simply are not enough teachers or educational structure-- standards and evaluation and feedback and certification of competency--to assure that a resident who begins to practice after one year of training in medicine will be competent or able to sustain renewal over a lifetime of practice.  There are not enough teachers and more senior residents contributing threads now, and there are no systems of health care delivery or screening or prevention to support them.  

This is a problem that the Cambodians will have to solve for themselves, but something to which a visitor—even one who spends only a few weeks—can contribute.  Let me know if you are interested. 

Now I am asked not if I will go back, but when I will go back.  

I will go back as soon as possible, but it will not be until the late fall or winter.  That is a long time to wait and I will miss the friends that I have made and the chance to add a little more structure to this particular hospital’s residency program, offer a few threads to these particular earnest and inspiring young doctors.