JUN-B-10
AFTER
A STORMY NIGHT, THE SECOND CLINIC DAY
IN TABOBEGINS WITH
A RUN WITH JIM BLIXEN
JUNE 19,2002
The confrontation, when it finally came, was long and loud, with the students being the ones who had to await the resolution. The outcome in the basic question of who was the leader of this team, and who would be writing a book about the expedition seems to be resolved.
I told Ravi that I did not know what his connections were to an old alcoholic who had not one single qualification for being here other than that he was a friend of Ravi, and that was enough for him to pull rank on every occasion he could. Especially very public and ceremonial ones in which he continuously alleged he was proud to be the leader of such a fine group of his worker bees in this expedition he had put together with Ravi based in his vast India experience. This usurpation from the single biggest noncontributor to the overall effort was now at an end. He could write his book about his exciting experience about his solo trip back to Delhi since I was not tolerating this continued chorus. Ravi said that he could not send away his good friend, and he could not stop him from writing a book about my experience, so I said, since I have the untenable position of being responsible without authority, I do not need him or Himalayan Health to do my medical missions, and that I further objected to his repudiation of any Christian mission and specifically the single most inspiring fellow the students would meet besides me and that was Laji Varghese. Since one of the members, albeit the one who did nothing but distract, had already claimed the title of the leader of this group on the basis of knowing Ravi and since he will not make any decisive move to throttle him and his plans for “authoring the first ever book on these humanitarian expeditions he leads” I was making that simple. The new leader of the Expedition is the one who has claimed it, and all patient problems and student accreditation could be taken up with the good Dr. Norton who has assumed my role, and I would be leaving, since they did not need two of us.
Ravi said that was just great—so I went to tell the group just after they were finishing dinner and preparing for their case presentations, when Ravi grabbed Raju for support and the two of them “tried to talk sense into me.” I told them the sense that would be understood: if they objected to any religious mission, how was it that we were here in the most religious place on earth, and that was just fine as long as it was Buddhism? Ravi said there was a difference in religion and preaching, and I asked when either I or Laji had preached to him or any of my students, other than giving good and compassionate care to people of all faiths in front of my students who were Jewish, Christian, and otherwise? He said he was married to a Catholic and objected to anyone praying before dinner or having a beer. He said there was a big difference between being religious and preaching, and I asked him if he had heard me, Laji Varghese or anyone else preaching to him, the students or the patients? Since I told him no one would be forced to pray, nor drink, and I would not interfere with anyone who wanted to do either or both or neither.
I told him that Bill Norton’s little unannounced surprise in circulating handout materials among my student s to contribute to his book, would jeopardize my negotiations with National Geographic and Raghu Rai ---neither of which he had brought in, but I had—since they needed exclusivity, which is why my own completed books have not been published on these missions until these contacts are explored, and I did not want a two-bit aggrandize to torpedo those negotiations. Ravi said that he had talked with both of my contacts at each of these big institutions and neither was worth anything. I told him I would be suing Bill and Himalayan Health would be splattered by it since Ravi had invited this deadweight interference along if the big opportunities were lost because of this interference.
The resolutions were as follows: the students went to bed without a case presentation session, and we had dinner late. Ravi will pull the plug on “Bill’s book” and will pursue the opportunities I had outlined for the publication of my series of books on these missions. And, he will cork Bill Norton’s expansive claims at every opportunity, especially the public ceremonial functions in which he revels---like the one they had just returned from in which they all visited the District Officer, and without my presence, Bill could strut in full pompous glory, as immediately reported to me in caricature by Keith, Jim and Michael. Without me, and with the only other two MD’s there would be no trip, as Ravi well knows, and I do not need the distraction of this prima donna pomposity as we are managing several hundred patient problems and fifteen individual first time clinical growth experiences.
CLINIC
DAY NUMBER TWO: BEGUN
AFTER THE EARLY MORNING
RUN WITH JIM BLITZ, AND THE POSTPONED CLINICAL CASE
PRESENTATIONS BY EACH OF THE PARTICIPANTS SUCCESSFULLY
DONE FOR THEIR FIRST TIME, AND THEN A SMOOTHER
RUNNING RESTRUCTURED CLINIC
The students did well with their first case presentations. We made a good didactic session of it, so that they would each have something to remember about each of their patients and that of the others, with the teaching points extracted from them. Jim came up afterwards and said how thoroughly he had enjoyed it and thought that it was a learning experience for everyone. This followed a very somber breakfast in which everyone knew there had been some sort of administrative showdown in the evening which had canceled their case discussions last night, and the most subdued of these was Bill Norton while the others said little. I gave some administrative announcements regarding the pharmacy and the apothecary scripts they should write with a caution not to use steroids in an uninflamed eye or an infected one. They were all to remain flexible through the day’s clinic and also in our leaving for the Pin Valley tomorrow where there is a higher need and fewer resources, so that we might stop short of the goal of a full clinic in Kaza, since they have a hospital there, and there are lots of people and no facilities in Pin Valley. We may stretch our clinics from two to three days there and just do a guest house stop at Kaza, under the advice of Dr. Bishan who was the one who pointed out how few the resources and great the need in the Pin Valley. Then we thoroughly discussed each of the cases the students had chosen from their cases to present, and they go the full dress grand rounds from their professor, which they seemed to appreciate. This is why there should be more attention paid to students and the patients and less to petty power plays, which have been acted out continuously by those not involved in either.
We left for the clinic and I rearranged the set up of this clinic. One group consisting of Deborah (just graduating nurse) Keith (just entering PA schooling) and Matt (my GWU freshman) had been under the local Doctor Kumar Pradeep yesterday, and in the course of the day had seen ten patients. They had a good time, they said, since they were in the clinic building and simply locked the door to avoid “the push of hundreds of patients clambering to be seen.” Well, I pointed out, that door was locked against me also and I was rather unhappy to see them still chatting amiably with a patient I had last seen them talking to an hour before. Most of this interaction was from the doctor to the patient with four people watching in dumb silence since they had no primary interaction at all, with no understanding of what had transpired in a conversation and examination they did not translate. But, it gave them relief from being responsible.
That changed dramatically. I moved the teams under the captains and this time I had myself stationed over them and moved them to at tent outdoors where the full press of the crowd could inspire them to a faster action and with a much more directive prompting from me in managing their patients. This took place with the first ten patients being seen and resolved within the first thirty minutes. All of the students got faster and better and a bit more comfortable as this day went on, and I hovered over them less, as I focused on my “slow team” from yesterday’s isolation. Further, this made a new tent group of Jim Blixen with four students standing by watching as the same Dr. Pradeep carried on his slow conversations with the patients and no interaction-taking place with any student primarily. This bugged Jim, and I tried to get him an extra translator and involve the students primarily, which only happened after lunch.
We will see tonight how this system has improved the flow and the comprehension of the students now much more heavily invested in the care of these patients and not as passive observers. From this group today, we saw a perforated eardrum, a “Baghdad Boil” of the sand fly bite giving leishmaniasis, a young woman pregnant and with a tender corpus luteum cyst, a young child with lobar pneumonia which was clinically diagnosed and treated, a supraspinatus tendonitis or two, and a score of eye problems, including one perforated globe with failing vision after operation two years ago, and a lot of skin rashes and acid peptic disease and GERD with a lesser number of arthritis patients and a greater number of GI and abdominal complaints.
I will talk on a subject of their choosing tonight after the clinical didactic presentations, and have asked Jim to give a talk on biliary tract disease when we are in the Pin Valley and will have Michael give his talk on high altitude mountain sickness when we do our brief overnight in Kaza.
The air seems to have cleared after the blowup confrontation and it was perhaps wise to have done this definitively rather than just smiling and turning away from this obvious passive aggressive game of one-up-man’s-ship by those without responsibility claiming all authority---and authorship. They were genuinely panicked after Ravi had made the statements that Himalayan Health does not need me, and could impress any other doctor into service as team leader, so that I could leave if I wanted to. After all, all of their medical missions except their first have been led by me, and all of them but the first were successes, at least two of those taken up after the Flying Doctors who so badly bungled the first canceled out of the next which I picked up. I was fully prepared to leave and saddle Ravi for his arrogance as the “Owner of Himalayan Health” to allow this noncontributor whom I told him not to ever take along on my teams is so beholden to him somehow that he would allow the continuing undermining of my mission with his pompous aggrandizement of which last night’s ceremonial flourish was his last. I certainly do not need Himalayan Health for my humanitarian medical missions, as proven by forty years of prior experience before connecting with them, and I am not on their payroll and resent his putting down other institutions and physicians who are doing better work because of his prejudice against their religion, while we are steeped entirely in another religion for which he has not animosity, despite the fact that none of the participants are adherents. So, I did not want to strand the students, and especially not endanger the patients, but a situation in which I am bearing all of the responsibility and am detracted from authority is untenable—and that is not for me but for any leader in such a situation in remote areas that are foreign, uncertain, and fraught with many dangers, not the least of which are medical. So, I explained to Ravi, that in both the medical system and in an expedition—about which his alter ego was so eloquent as to the dangers and following the person with vast prior experience on the opening night in Simla—there was no discussion among this alleged democracy, but a single well-defined term: “This is an order.” I do not issue ultimata often, but this situation was calling for one, and it seems to have improved both morale and the operation of the medical mission to both student team and patients’ benefit.