Saturday, 19 January, 2013
At Brown Coffee Shop
An observant student who has read
my journals from last year and then read last week's journal observed "You seem already a bit “hardened” to these patients at the
hospital suffering from illness unparalleled to those we would ever see in a
developed nation. Do you have some remaining shell from your last visit?"
I had written "The first week has been very different than anything
I experienced in March . . . the intensity of sickness at the hospital is
less overwhelming".
Her comment perturbed me,
because I don't want to be hardened. The suffering is as intense this
year; the chaotic and often destructive care many patients receive from
traditional doctors or district hospitals is just as prevalent; the barriers to
providing the care they might receive in most developed countries are just
as impenetrable.
On Monday a 38-year-old man was
admitted because of fever and profound lassitude. He had been sick for a
month. He had received unknown antibiotics and other remedies, but his
family saw that he was getting steadily worse. When we admitted him we
learned that he had been bleeding into his stool ("melena"), that he
was profoundly anemic and that he had neither platelets nor white cells.
He had a large spleen. Twice a day his temperature rose to
38.7 and he had chills that shook his entire body. It seemed likely
that he had an infection we could not detect by an ordinary chest xray or
ultrasound imaging of his abdomen, or a malignancy. Then a blood count
returned with a primitive cell ("blasts") that suggested leukemia
or lymphoma. I was making rounds without Kruy this week and
decided to spend some of the limited money available for CT scans for the poor.
We found massive enlargement of lymph nodes in the center of his chest,
where they would not be revealed by a chest xray. It seemed most likely
that he had a form of lymphoma and had stopped making all of the blood
components. Diagnosis of these conditions is now quite technical and
complex--even biopsying his enlarged lymph nodes would require expertise not
present at Sihanouk Hospital. For patients like this in much of the world
therapy can markedly prolong life and patients are sometimes cured, but we
could offer nothing. The Russian Hospital has an oncology program that
could diagnose and care for him, but that care is for patients who can pay.
Russian Hospital would not accept him by a physician-to-physician phone
call. However sometimes they will admit poor patients who arrive at their
door step. We prepared a summary of what we had discovered, gave him his
CT scan, and his family drove him by motor bike to Russian Hospital. We
have no idea if he was accepted--there is no communication between the
for-profit hospitals and Sihanouk Hospital and no commitment by the private
hospitals to care for the poor.
Half of our patients are
children or young enough to have small children at home. For these
patients I have acquired no shell. The young woman with lupus causing
inflammation of the blood vessels in her brain, heart, and lining of her
abdominal cavity continued to improve through the week. Each day I
examined her abdomen and tested her returning strength, not because she needed
it, but because by touching her every day I could express both my caring about
her and my happiness as she improved: the meaning of a thumb held up is
universal. The day she left I asked if we could take her picture with the
doctors who had cared for her (attached) : she agreed. I printed it
and gave it to her in a plastic sleeve. She said, "the ward
made me unhappy but you have a good camera--it makes me and the ward look
happy." She was glad to leave, and I was glad to see her go--because
two days later an older woman was admitted with the same condition; she
had a swollen face, extensive skin rashes, slurred speech, and severe heart
failure." If our younger patient had known what her lupus might
result in for her, I think she would have lost some of the optimism we had
tried to impart as she left.
This is what I wrote back to
the student:
“I am as broken hearted about
younger patients as last year--I still spend as much time with them as I can
and as my language limitations allow. I still wish there more more
that we could do. I would still would prefer to be able to see them every
few weeks to take care of them, but of course I will leave and not know what
has happened to them. For them, if I could stay to become their doctor, I
would.
”For most of the older patients with advanced cancer or
tuberculosis or renal failure or end stage heart disease I have grown used to
the limitations--often what we would do for them in the US would only squeeze
out a few more months of existence. In the US we have gotten accustomed
to the notion of extending life and endlessly fighting for tiny incremental
improvements--I have never been completely comfortable with that and recognize
that for our Kamai patients, there is not the same drive to live one or
two more months as in the US”
This week two patients with extensive lung destruction from
tuberculosis and smoking were admitted; one had collapsed half his lung, the
other had huge holes (bullae). Both had reached the point where they had
no reserve--a pneumonia or fever or the need to exert themselves would result
in death--and did. One developed delirium tremens, and in the
intense agitation associated with that his lungs could not keep up. The
other climbed on to a bus the day after discharge and probably ruptured one of
his bullae, further collapsing his lung. He died at the side of the road,
and his body, wrapped in a blanket, was pictured in the Phnom Penh newspaper.
Three times this week we thought older patients needed care that we could
not give, and the family said they could not afford to pay for it. The
decision to let life end is made by the family--there simply isn't the money to
pay for what has to be done. I have grown to expect this and it does not
seem altogether a bad thing: the sadness that accompanies a
grandmother's death simply occurs a month or two earlier.
* * *
The residents and my friends here often respond to something I am
saying with a look of puzzlement or surprise. Most speak limited English,
and of course I speak no K'mai.
I found self trying to explain these phrases this week:
--to a friend who seems unhappy, "is there something
bothering you? Is there something on your mind?" I explained
that her "mind" was in her head. She went to look in a mirror.
--to my driver, passing a new large department store, "it
looks brand new."
--to no one in particular, "I think this patient has turned a
corner." To explain this I made wild hand signals indicating a deep
descent, then a grave, then springing out of the grave. This was equally
ineffective.
--to a resident translating for me, "do you have sex with
men, women, or both?" It took three minutes to untangle this one.
You would have thought I had asked if the patient had sex with dogs or
parakeets. I was actually going to ask that question, but after the
uproar over the original question I decided to skip it.
--to a resident, encouraging him to order a test, "we can
kill two birds with one stone." Here, people actually do kill birds
with stones. He both wanted to know why I wanted to kill a bird, and if I
did want to kill a bird, what kind of stone did I need. He has avoided me
the last three days. Other residents have begun to stare.
* * *
My guest house is owned by a young Kamai couple. The woman
lived in Paris from the age of 12 and opened her own restaurant on Rue St.
Germain serving French and Khmer food. A few years ago she moved back to
Phnom Penh and opened a restaurant--le Safran--also serving Khmer and classic
French Food. She is about 30, quite beautiful, and cooks in beautiful
clothes, high heals, and an apron. Her food is the best I have eaten in
Phnom Penh. A few years ago they added the guest house and many of the
amenities are French, including this packet of tea:
La Tisaniere Infusion Drainage et Elimination
Cette nouvelle infusion est un allié précieux pour aider le corps à se
purifier.
ingrédients : Queue de cerise, café vert, racine de chicorée,
feuille de romarin, extrait d'artichaut, oranger.
If any of you are feeling a need to upgrade your drainage and
elimination, let me know; I would be happy to bring you back a Tisane or two.
* * *
Much that I thought I understood about K'mai medical education
last year was incomplete. This year most of my teaching has been with the
residents because the staff are even busier than last year as the hospital has
asked them to take care of ever-increasing numbers of patients who can pay.
Being with the residents has had several advantages--I have started
something like our morning reports--presentations of patients they have
cared for that serve as the basis for clinical reasoning and then
mini-lectures. And they have been showing me the ropes of medical
education in Cambodia.
--Students who have good high school test scores are accepted
into one of three medical schools. There are some funds to help pay for
students who are poor. There seems to be no criteria for admission other
than good tests and in most cases the ability to pay.
--Medical school lasts 6 years, from ages 18-24. It consists
mostly of lectures and there is very little clinical exposure. In this it
is similar to Japan and many other Asian countries.
--At the end of medical school they do a rotating internship in
pediatrics, medicine, surgery, and obstetrics & gynecology. At the
end of each three-month block they have an oral examination.
--If they pass the national examination after the internship, they
can write a thesis or "study" a specialty and then get a certificate.
--After that, they look for a job, either practice or training in
a public hospital, a NGO hospital like Sihanouk Hospital, or a private
hospital. In October each of our seven residents were selected to do a
probationary three-month residency at Sihahouk Hospital, and if they are
approved, they will then do 9 more months of residency in internal medicine,
with their time divided between inpatient wards, the emergency room, and
clinics.
--Following the one year residency at Sihanouk, the residents will
either become junior staff at Sihanouk or another hospital or clinic, or
compete for the very few specialty training programs (Cardiology, Pediatrics,
Emergency Medicine). Few seem to do this.
I asked the residents the other day what their dream is. Two
want to train in the US or another western country, one wants to be a
pediatrician, another an endocrinologist, and a third an emergency medicine
physician (I think EM training is "on the job," not a residency).
I showed them the distribution and number of foreign students who do
residencies in the US. It looks like this:
India 51,447
20.7%
Philippines
20,601 8.3%
Mexico 13,834
5.6%
Pakistan 12,111
4.9%
Dominican Republic
7,979 3.2%
Grenada 6,749
2.7%
USSR 6,450
2.6%
Dominica 5,854
2.4%
China 5,375 2.2%
Egypt 5,266
2.1%
Iran 4940 2.0%
South Korea
4,845 2.0%
Italy 4,732
1.9%
Spain 4,343
1.8%
Germany 4,197
1.7%
Syria 3,869
1.6%
United Kingdom
3,698 1.5%
Montserrat
3,569 1.4%
Colombia 3,343
1.3%
Ireland 3,302 1.3%
What is striking is how few doctors from east and southeast Asia
seek training in the US--the exceptions being Korea and China. It is rare
for a student from Cambodia to seek residency training in the west except for
the few from wealthy families who go to college in the US. When I
explained what would be entailed in getting a US residency--at least one more
year of clinical training and then passing the tests of basic science and
clinical knowledge and clinical skills that American students take, passing a
test of English competency, and then interviewing at ten or
fifteen or twenty residency programs (if they can even get invitations), there
was a sense of discouragement. Almost none have any money, and probably
none speak English well enough to easily pass the language examination.
One resident showed me the fee schedule for the best English Language
schools in Phnom Penh (ACE). Ten weeks of advanced language training
would cost $210. She cannot afford it. Her monthly salary at
Sihanouk Hospital is $400, from which she pays for a room in which to live, her
electricity and water, her food, and gas for her motor bike. She has
nothing left at the end of the month. There are no loans for students or
residents who don't have collateral (property). She works too hard to
moonlight.
When I asked what she would do, she said "In Cambodia, for
those who do not have money, there is nothing."
I asked one of the young women who works at Le Safran who
has graduated from college with a degree in accounting if there were jobs other
than desk work. She said, there are many people trained in accounting.
I asked how much she would be paid if she found an accounting job.
"$100 a month."
* * *
I have found the best coffee drink ever. In the little shop
outside the medical clinic I can buy Cambodian iced coffee with milk.
From a little coffee pot about a half cup of cold, oil-black coffee is
poured into a plastic cup, and then a few tablespoons of thick condensed milk
is spooned in. This is filled with water and ice cubes. It can be
very sweet to just barely sweet and has a intense coffee flavor. It cost
2500 real, 60 cents. Served with a straw. Devine.
* * *
I have just a few more days here. It has taken much of the
three weeks just to get comfortable. I have taken Kruy's place as the
inpatient attending for six days. There are so many loose ends, so many
tasks not completed or left to the next day or forgotten entirely that my sense
of responsibility kept me awake at night. Finally I simply began to spend
the entire day sitting in the middle of the ward with the nurses and doctors,
with charts strewn over four desks, thumbing through to see if orders had been
written, results returned, medications given. Now that I am about to
leave I want to stay.
Tonight I am taking all the residents to dinner at Daroth's
restaurant, where the average entree costs $6.00. I will miss them.
As Daroth would say, they have good hearts. We have talked about
the future of medical education in Cambodia, and I have told them that they
will be the generation that will create a new paradigm. I asked them what
they thought it should look like. What they want is more training--more
than a year of residency, a chance to see medicine as it is practiced in other
countries. That is how medicine in the US developed, with US physicians
going to Europe in the '20s and '30's to study and then come back as teachers.
and scientists. And European physicians came to the US and
brought change with them. The next steps for Cambodia are likely to
involve both, physicians from other countries coming to teach, and Cambodian
physicians going to train in other countries. The money to do both will
have to come from elsewhere, at least for the present.
I will be sad to leave.
