APR-C-10
THE FIRST CLINIC DAY IN BAROT, AND
THE COLD RAIN CONTINUES,
AND THE STUDENTS AND I SEE A WIDE VARIETY OF
PATIENTS IN A FULL DAY WITH A GOOD CASE PRESENTATION AND DISCUSSIONS
April 25, 2002
It is still cold and rainy. I got up reluctantly with no prospect of hot water, since we have a water heater in our small bathroom, but it has a switch without a light to tell if it is on. Next to the switch on the wall, is cord with two sets of bare wires protruding from the cord, and it is easy to see how I might have missed what I should have done for hot water. I first go down to the office that governs such things (at the Head Works Man's Office of the Hydel Channel Project) and say I want hot water. Then I pole the naked wires into each of the tow round pin receptacles and hope they wedge inside, especially after the sparklers set off by the wire connection with the live element in there. Then, I wait to see if the water warms up before or after electrocution. Fire and smoke issued from our room as was reported later, but no damage was seen I could recognize to my meager belongings, but when we came back the Hindi-speaking guide showed us how to turn it on. First you rammed each of these two naked wires into the separate round pins of the wall socket and waited for the sparks to die down, and then you waited as water heated. OK
We were hammered awake at seven to pile into the Mahindra jeeps and went off to the same breakfast we usually have, and then got back in the jeeps to cross the bridge over the river which was roaring even more than usual to get us to the small Borat Clinic. The local “doctors” served as translators, but their medicine (I profoundly hope) is better than their English use, or the meager trickle of information that came through to the students through the faulty language which was either never relayed as questions to the patients or another question put in its place was irrelevantly answered. I scrambled around to cover most of the patient interactions except for the ones conducted by the female physician who was limited mostly to Ob/Gyn and that mainly to the follow-up of pregnancy since her own deliveries amounted to four to five per year in this town of 11,000, most of whose pregnant patients found themselves at home or elsewhere for delivery
As the patients began to crowd in and pile up, a few were brought in that seemed
serious, such as the older woman that one man had carried in to place on the
table with what was said to be a recently acquired paralysis. On repeat questioning
she seemed to have had a chronic illness for four moths but had suddenly stopped
walking two days ago. I stood back and watched the near panic of a barrage
of questions being directed to the son who had carried her, the translator,
and several other waiting patients who chimed in with their impressions of what
was being asked. I timed the frustration as amateur clinicians were flailing
in uncertainty made up for by the fact that they could always formulate yet
another question, what ever the relevance of the reply or its accurate report
might be. They used the random scatter of a hundred more questions to stall
for time and asked about all the tests that she might have gotten somewhere,
but of course, had not and would not get them here. It seemed that they were
getting further rather than closer to coming to some sort of disposition—the
single goal of the primary care physician. He or she is not always expected
to make every diagnosis (often the physician’s view of the climax of the interview).
Nor is it always that he or she gives the right Treatment (the patient’s view
of the therapeutic encounter). It is that something is done to move the process
along toward resolution as the sustained ambiguity of the patients’ condition
that brought them to seek specialized help in the first place. No one doctor
is expected to diagnose all conditions and then immediately drain the subarachnoid
hemorrhage and clip the cerebral aneurysm, for example, and then tell the patient
exactly how long they will live and whether anyone else in the family is likely
to suffer this same problem and what degree of impairment can be prevented by
what means—that would make the primary care doc second guess the expert in lots
of fields as an amateur in all of them. But, the cargo must be moved!
Something must be done that moves this whole process toward cloture, and that
does not mean opening up a score of irrelevant and meddlesome off shoots of
the patient’s primary problem which must be addressed therapeutically if it
is anything that can be treated for cure or mitigation or comfort. Now, out
of desperation, two students had asked over two hundred less and less relevant
detailed questions through imperfect translators and less perfect understanding,
least of all on their parts.
I suggested an alternative: Treat all patients with a concerned and open smile of honest friendliness and focus on their CHIEF COMPLAINT, and then go directly to the physical examination as thought this were veterinary medicine. The continued questions can be misleading and are almost certainly not CRITICAL VALUE-ADDED informative responses, in most instances the negative ones above all.
The lack of experience and confidence in their ability to make anything out of this at all, made them go into a paroxysmal labial flutter about the next question they could think of to ask before they even could hear or process the answer to the least one, and by then the answer would have been apparent by one quick look in most instances, allowing them to stay out of whole areas that took them ten minutes to imperfectly explore. In most common clinical patterns of illness (and, after all, practice by an experienced clinician is just open-minded “pattern recognition”). The Chief Complaint can be narrowed down to a universe of broad general categories by about four to six questions (e.g.: congenital, inflammatory, traumatic, neoplastic, functional) in order while examining the patient, which almost always wipes out at least another hundred options as not even worth asking on the apparent basis of gender, age, ethnic, social or epidemiological factors;
The first patient for each of the teams averaged almost an hour with no resolution except we have to send this patient to someone who would know what to do next—which is why the patient is here. Unless the only thing apparent at the first encounter is the inevitability of the outcome and the inadvisability about doing anything about it, the sustained ambiguity about what was wrong and what we should do about it, became a source of further frustration in the examiners and near-panic in the patients waiting for some answers of their own. Far from spending an enjoyable time in the prolonged interaction with the junior doctors from far away, the patients were alarmed by the stalled process, particularly as the queue lined up in this gridlock and the waiting patients not only sensed they were not going to get to be seen, but that when seen, they would get no more satisfaction out of the interaction than was apparently going on in the prolonged wheel spinning in which they tried to pitch in and get involved shouting even less relevant details about their neighbors or “helping” by further mistranslating overheard Hindi to Hindi. So, I got directly involved, and shortened each of the next interactions to less than five minute each. The patients did not feel short shrifted since the tone of the reception was not brusk, but very welcoming and still we were not there for the impotent sharing of their worries that they had already down with their neighbors before coming here some distance in many cases. That does not mean we fixed everyone, including the woman with the allegedly acute paralysis, which turned out to be part of a much longer chronic disease process. But each patient came in and through an orderly progression had a disposition. In the cases here, that does not mean sending the patient over for a CT scan or some fancy test since they do not exist in this much more real world where you are going to have to find and feel and see what ails them based on the time course over which it has happened. For patients in late stages of disease presentation, through out the developing world—including a lot of places inside the3 first world that are accurately so described—the clinical judgment based on apparent physical findings is so much more useful, that even if the test suggested something otherwise, these distracting data bits would be discarded in any event and the patient would be treated on the basis of what they have demonstrably—with relief to the patient since after all, that is that brought them in.
“How can you be sure without a test?”
“And what makes you sure with the false confidence you put in the test over the patients' own findings?”
Yes it is different out here. Developing world practice teaches you how one should always operate in the developed world as well, efficiently and compassionately, directed toward solving human problems. If two things look a lot alike and are treated differently, it is critical to distinguish among them for discriminate therapy. If things, no matter how unlike are treated the same, waste none of the patient’s time in such hair splitting since it makes no therapeutic difference and OUTCOME is the single measure of success in this therapeutic encounter.
If you are going to err, err on the optimistic side that this may be a condition that responds to treatment, and give the benefit of the doubt, so that you can fix the fixable and are not that interested in confirming the nihilistic.
Axiom number next: A difference to be a difference must make a difference!
Now, that may be the direct surgical prejudice I carry to any such encounters, and there may be the internist’s predilection for which particular kind of untreatable diagnosis you may be suffering from—but the patient should not pay the tuition for this learning exercise—they cam for rather directed help and advice.
CASE PRESENTAIONS
AND GRILING EACH OF THE STUDENTS
ON THE PATEITNS THEY HAD SEEN AND
THE PRINCIPLES THEY HAD LEARNED
I kept a handwritten list of the cases each student presented each of the clinic days and had them discuss the features of the primary problem they had learned and the efficient resolution of that problem to the extent possible in the setting in with the patient found him or herself. I will detail a few of these later, since the socioeconomic circumstances make several of them fascinating. For example the religious and anthropologic factors in a 26-year-old Hindu woman coming in the ninth month of her seventh pregnancy with uterine prolapse and a brutal drug-addicted husband who insists she do not go to a hospital but must deliver a surviving son, when the first three living children were girls and the last three pregnancies during the increasing prolapse had delivered three dead sons--WHAT TO DO?
Here is almost the easiest one to be addressed, with an unambiguous response in advice. I have one patient before me and a second potential life to be saved. The woman herself was almost lost in the last still birth because of the uterine abnormality, and each of the three last pregnancies were lost at term, so it is not unlikely that at least on of the lives at risk is an assured mortality. There is another potential patient out there who may need help too, and a large social problem to be addressed, but my immediate concern is for the woman who is before me, not for the rehabilitation of a drunken, drug-abusing and abusive husband (by confirmed reports of the OB/GYN doctor who knows this information first hand.) Even if I assume I can understand the background of this imperative to have a son as expressed by both abusive husband and unfortunate wife) to carry on the name, to support the elder parents in their late years, and as a social security system in which they can also choose a potential bride to expand their later family, for starters, and then the religious significance to the woman of having a son who can light her funeral pyre to cremate her body to set her soul free toward a higher development in Hinduism in the second level), I do not have to have this empathetic understanding to come up with a rational advice.
This woman must go to a hospital and must have a C-section, with or without her husband’s approval and especially against his wishes in these circumstances. To have a child at all for the perhaps salvageable pregnancy, and to have a mother for the three girls already here, they need a mother alive. So, she needs a husband in this society to continue support, but she needs a supportive one, who may not actually carry through with his threatened beatings and divorce if she has a successful abdominal delivery of a live child, particularly if it is a surviving son. If she is not going to survive the home delivery through a very badly prolapsed uterus, it is all a moot point what her husband wishes to do to her or the next child. (My own prejudice might be that if she loses an abusive drug-addicted husband as a consequence of her action, that is the single most therapeutic part of my advice, but I do not live here and do not make that the first supporting plank in the platform under my final advice.) The options I recommend for her to consider are singular. Behind Option A there are no others, and she must decide now to go to a hospital for a C-section and treatment for the uterine decensus; she and the child that may survive are the only patients before me as I make this judgment to advise her, but even considering a sick husband upon whom she is dependent, this advice would be therapeutic in the community interest, whichever way the outcome of his reaction to this advice taken as a decision on her part.
So, amid unusually rainy chilly days in the meager facilities of the Borat primitive clinic around us and a limited stock of carefully used drugs that are dispensed at no cost and even more carefully considered advice for the patient’s presumed benefit, a few lessons about ideal practice under less than ideal circumstances are reinforced in remote India to be carried back to each of the very different clinical environments: Sabrina of UC Irvine, Lorie of MCP/Hahnemann—USF/Tamps, Yoshi of Tokyo and Univ. of .Rochester/Univ. of Maryland, Lena of UMDNJ Patterson NJ, Kathryn of the University of Cincinnati, Marita, technology lawyer from the Univ. of Maryland and medical student of GWUMC Washington DC/Baltimore, and a few assorted Sikhs and Singhs from Simla to Borat. This is the ideal world to teach clinicians how to act in the best interests of the patients rather than in the defensive interest of the physician, hospital or state medical/industrial complex!