This evening Emily (My successor) and I were the guest of honor at a baci hosted by the IM residents and teachers to welcome Emily and wish me a safe journey home. I was expecting to be asked to make a speach, so I prepared this. However, only Dr. Som Ok, the former President of the University of Health Sciences and the current Vice Minister of Health for medical education and human resources was asked to speak (which is OK with me.) But I will post what I had written here.
I came to Laos because I wanted to live and work outside America, and I had good mentors (Dr. Rosemary and Dr. Jon) who said it was a very nice place to live and work.
When I arrived here almost 16 months ago, I knew very little about Lao people or about Laos. I knew Lao people gin khaw niaw, (eat sticky rice) love spicy food, and that Beer Lao was “the beer of the wholehearted people.” That was about all I knew.
I want to thank you all for truly being the wholehearted people. You have welcomed me with open arms and showed me what that phrase means.
Thank you, Teachers. You have listened politely to my suggestions, even when they may not have been good ideas. You have gently guided me in the right direction when I got too far astray. You have supported me and helped me get things done for the residents and patients. You have taken me seriously, and thought about my suggestions when we did not agree. I want to thank you for recognizing which areas I could help you in and letting me help. And I want to thank you for not changing things solely out of politeness when my ideas were not good.
Thank you, Residents. Thank you for welcoming me to your hospital rounds, your lectures, and free time in the resident room. Thank you for trying to understand my lectures when they were too complicated, and for politely listening when they were too simple. Thank you for staying when my lectures go past 7:30, which they almost always do. You have supported each other well in learning from someone who does not speak Lao, not only translating for each other but also explaining and making sure everyone understands.
Thank you for welcoming visitors with the same warmth you show me, even if sometimes they do clinical teaching or lectures that are hard to understand, or tell you to do things that are not currently possible in Lao. Thank you for teaching me about diseases I knew little about, like Melioidosis or typhus, and guiding me through culturally complex patient interactions. Thank you for taking extra time to learn from me – to present patients in English, make a differential diagnosis even when you already knew what the patient had, and discuss what to do next, even if you had a plan with your Lao teachers that would not change based on our discussion.
I am very proud and lucky to be part of an organization like Health Frontiers. It is amazing to see what a group of dedicated volunteers can do with a little bit of money, a lot of time, and willing colleagues and students. I have a new way to judge NGOs and international health projects. I will look not only at how much they spend, or how many people they help directly, but whether they help local people create independent, sustainable changes. Health Frontiers projects in Laos have been successful because we are working with you, not telling you what to do or doing it for you, and because we have been able to commit far more human resources tha money -21 years of volunteers now.
However, I am even more proud and truly humbled by how hard you all work, and how committed you are to improving yourselves and healthcare for Lao people. You are all very smart people, and there are surely easier jobs, less stressful jobs, and better-paid jobs you could do. But you are committed to the health of the Lao people. The teachers show this commitment – you spend extra time on clinical teaching, lectures, organization of the program, and mentorship, without any extra compensation. And the residents show this commitment – you leave your practice, private clinics, and sometimes your home and family, to come study. Being a student is not easy, especially as an adult. I am very proud that you all chose to become residents and improve your knowledge and skills. You all give so much to your patients, students, and studies, even when you may feel like you have little time or energy for yourselves.
I know that as I go home to new challenges, you will all continue to rise to the challenge of teaching and learning. I am confident that our decision to make the IM residency more independent of day-to-day teaching by Health Frontiers volunteers will not decrease the amount or quality of teaching you get. I hope the residents all continue to work hard and improve their knowledge and skills. Do not get distracted by all the changes around you, but stay focused on becoming great doctors for all the Lao people. I know the teachers will continue to work hard for you, and I hope they will continue to improve their mentorship, teaching skills, assessment and feedback as new resource become available. And I hope the Lao government, University of Health Sciences, and Ministry of Health will continue to support the residents, teachers, and hospitals more and better with equipment, access to tests and treatments, improvements to curriculum and teaching skills, and improvements in undergraduate medical education.
Lao is changing – I have seen it just in the short time I have been here. Many of the changes are improvements. But the Lao people, especially young people like our residents, need to be careful about what parts of Laos you allow to change. I hope the things I have come to love will not change: your openness, gentle politeness, kindness, and honesty. Your willingness to work hard when needed and your appreciation of rest and relaxation, and your love of the Lao country and culture. I will miss these things very much when I go home.
So in conclusion, thank you again for a wonderful year of learning and teaching. I wish you all the best of luck, good health in the coming years, good learning and strong teaching in the future, and much happiness in your personal lives and professional fulfillment. Being a good doctor is hard, but it is also one of the best jobs in the world, and we are all lucky to be able to work together in this wonderful profession.
Now all that's left is writing and giving a goodbye lecture on Tuesday, a few meetings with Emily, Hakon, and Karen, some last minute shopping if my weight allowance permits, and eating as many yellow mangos as possible before Wednesday.
Sunday, December 4, 2011
Friday, December 2, 2011
Letter to the Editor
I always write way to much for any letter to the editor to be published. So in addition to sending this to High Country News I'm posting it here:
Dear HCN,
I’ve been reading back issues of HCN while living and working in Vientiane, Laos for the past year. As a native Coloradan, outdoor enthusiast, and anti-corporate child of hippies, I tend to oppose commercial development of public lands and resources – mining, drilling, etc - pretty categorically. However, on a small point, I found myself agreeing with the mining representative in November 22, 2010’s cover story on mining “Hard Rock Showdown.” Mr. Cornoyer stated that mining in Arizona would be better for the planet than copper mining in Chile or the Congo. When Westerners oppose these projects, we need to ask ourselves where the resources that are not being mined in our states are going to come from, and where they are going to go.
Laos is a beautiful and very mountainous country; filled with steep limestone mountains that are absolutely overgrown by tropical greenery. In size, it’s about 90% as big as Colorado, but stretches out along the Mekong River. The mountains extend well into our neighbors, Vietnam and Cambodia as well. They are great sources of natural resources – both ores and as the substrate for rubber plantations, timber cutting, and other environmentally degrading but profitable ventures.
In Laos, mining, timber cutting, and rubber plantation planting are happening with little or no concern about environmental consequences, even inside national protected areas. I do not know if Lao law requires environmental impact statements, but I do know that bribing the right string of officials will give businessmen access to land, which will likely be completely unregulated or supervised, and there is unlikely to be any legal action for cleanup after the project and damage is done. Corruption is rampant in South East Asia – Laos ranks 154/187 for most corrupt nations on the latest survey from Transparency International. (With 187, Somalia, being the most corrupt) Cambodia is 164, and Vietnam 112. The US holds slot 24. Some of the companies working here are trying to teach the Lao people and government about environmentally responsible stewardship of their natural resources, but many see it simply as a poor country where a bribe here or there can get you access to very profitable natural resources.
So Mr. Cornoyer is sort of right, even though my natural tendency is to assume he is wrong. When we westerners absolutely refuse to allow our own natural resources to be accessed, it likely means that the copper for those hybrid cars, photovoltaic panels and other electronic gadgets we love is coming from somewhere else on our small planet; probably somewhere with much less oversight. (43% of copper comes from Asia according to this site: http://www.lme.com/copper_industryusage.asp, but I’m pretty sure Asia isn’t yet consuming that percentage of electronic gadgets, hybrid cars, etc.) We may not see the unpleasant tailings piles, nor will our water, grazing land, etc be harmed, but if there is a demand for that copper, it will be mined somewhere. And the people affected may be subsistence farmers in the developing world who have neither the time, knowledge and experience to resist development, nor the political clout or legal framework to limit impacts. When we take a NIMBY attitude to resource use in the west, we may really be hurting poor and powerless people in other parts of the world much more than the corporations we think we are obstructing. And that’s not responsible citizenship any more than allowing unrestricted development of our own natural spaces would be.
Thanks for keeping me connected to the west over the past year. Keep up the great work!
Dear HCN,
I’ve been reading back issues of HCN while living and working in Vientiane, Laos for the past year. As a native Coloradan, outdoor enthusiast, and anti-corporate child of hippies, I tend to oppose commercial development of public lands and resources – mining, drilling, etc - pretty categorically. However, on a small point, I found myself agreeing with the mining representative in November 22, 2010’s cover story on mining “Hard Rock Showdown.” Mr. Cornoyer stated that mining in Arizona would be better for the planet than copper mining in Chile or the Congo. When Westerners oppose these projects, we need to ask ourselves where the resources that are not being mined in our states are going to come from, and where they are going to go.
Laos is a beautiful and very mountainous country; filled with steep limestone mountains that are absolutely overgrown by tropical greenery. In size, it’s about 90% as big as Colorado, but stretches out along the Mekong River. The mountains extend well into our neighbors, Vietnam and Cambodia as well. They are great sources of natural resources – both ores and as the substrate for rubber plantations, timber cutting, and other environmentally degrading but profitable ventures.
In Laos, mining, timber cutting, and rubber plantation planting are happening with little or no concern about environmental consequences, even inside national protected areas. I do not know if Lao law requires environmental impact statements, but I do know that bribing the right string of officials will give businessmen access to land, which will likely be completely unregulated or supervised, and there is unlikely to be any legal action for cleanup after the project and damage is done. Corruption is rampant in South East Asia – Laos ranks 154/187 for most corrupt nations on the latest survey from Transparency International. (With 187, Somalia, being the most corrupt) Cambodia is 164, and Vietnam 112. The US holds slot 24. Some of the companies working here are trying to teach the Lao people and government about environmentally responsible stewardship of their natural resources, but many see it simply as a poor country where a bribe here or there can get you access to very profitable natural resources.
So Mr. Cornoyer is sort of right, even though my natural tendency is to assume he is wrong. When we westerners absolutely refuse to allow our own natural resources to be accessed, it likely means that the copper for those hybrid cars, photovoltaic panels and other electronic gadgets we love is coming from somewhere else on our small planet; probably somewhere with much less oversight. (43% of copper comes from Asia according to this site: http://www.lme.com/copper_industryusage.asp, but I’m pretty sure Asia isn’t yet consuming that percentage of electronic gadgets, hybrid cars, etc.) We may not see the unpleasant tailings piles, nor will our water, grazing land, etc be harmed, but if there is a demand for that copper, it will be mined somewhere. And the people affected may be subsistence farmers in the developing world who have neither the time, knowledge and experience to resist development, nor the political clout or legal framework to limit impacts. When we take a NIMBY attitude to resource use in the west, we may really be hurting poor and powerless people in other parts of the world much more than the corporations we think we are obstructing. And that’s not responsible citizenship any more than allowing unrestricted development of our own natural spaces would be.
Thanks for keeping me connected to the west over the past year. Keep up the great work!
Friday, October 21, 2011
On the Road – Brief Impressions.
The next 2 weeks of my trip in brief tidbits:
September 22 – Muang Khua hospital. No 6 year doctors seeing patients, but good facilities and equipment, and polite and engaged staff (3 year doctors and nurses) providing patient care. We didn’t round with them. If they had a pediatrician and an Internist (Ok, and a surgeon and OB) they could be a great small hospital.
September 23 – Travel to Muang Sing – Muang Khua to Udomxai (3 hours), Udomxai to Luang Nam Tha (3 hours) both on lovely roads. Luang Nam Tha to Muang Sing – 3 hours, longer than usual due to several large mud slides on the road. Arrived in Muang sing to Bryan and a crowd of 10-20 Lao children who were super happy to see Leila and shy to meet me. Dinner on their lovely balcony overlooking the army barracks, road, and countryside while the sun set.
September 24 – Market trip and butterfly children’s center in the morning – great to see Leila and Bryan in their element. Bike ride in the afternoon, then made spaghetti sauce from scratch to eat with rice noodles and Chinese cabernet (terrible!) for dinner.
September 25 – Mitchell Montessori Cinco De Mayo paper flowers at the childrens center. Bike ride to Koma’s Akha village in the afternoon – 6 KM up hill and lovely views on the return. Purchasing of large amounts of beautifully woven local handicrafts at a private market put on by local girls in Leila and Bryan’s house in the evening.
September 26 – Bike ride in the morning, children’s center for jump rope and puzzle games in the afternoon.
September 27 – One more walk through the weaving village and a few more purchases in the early afternoon, Last evening at the children’s center.
September 28th – up early and packed 4-5 kilos of new belongings tightly into my travel pack. Minibus to Luang Nam Tha where I rounded with 2010 graduate Veokham, who appears to be doing a fabulous job on his ward. Like recent residency graduates worldwide, he complained that we had not taught him enough musculoskeletal diagnosis and treatment – but he had managed to (accurately, I think) diagnose a patient with spinal chord stenosis anyway. Bike ride in the afternoon during which I took a wrong turn and ended up riding more than 20 KM, much of it on village trails. Luang Nam Tha valley is beautiful with rice fields and mountains, and the last leg was with beautiful late-afternoon lighting (but home before dark despite my miscalcuation.)
September 29th – attended teaching by Dr. Veokham to hospital staff in the morning – Dengue fever with all slides in Lao language! Wow! Gave the staff in the blood bank some excitement by donating blood – several cell phone camera photos were taken to document the occasion. Said a sad goodbye to Leila after lunch and had a relaxed afternoon.
September 30th and October 1st – travel to Mae Sot – LNT to Bokeo, across the Mekong into Thailand, and on to Chiang Rai the first day. Chiang Ria – splurged on Pizza and Salad after 2 weeks of not enough wheat or cheese. Chiang Rai seems like a nice little town. The next day, Chiang Rai -> Chiang Mai (bus station only) where 7-11 provided a safe but unappetizing lunch during my 2 hour layover, then on to Mae Sot. Thai buses and roads are much nicer than Lao, - there are assigned seats and I bought my ticket relatively early! But the movie on the first bus was so disturbingly violent I literally had to keep my eyes shut for much of the first 2 hours. Too bad,t the golden triangle has beautiful karsts. Arrived just in time for dinner with Cindy’s friends, delicious Thai food.
October 2 – Sunday in Mae Sot, a town on the Thai – Myanmar border. Brunch! at a Canadian run diner and a bike ride to the border, where even more beautiful textiles were purchased. The border has been closed for over a year, so no temptation to go across for a day.
October 3 – Got to see the clinic of Dr. Cindy – former HF IM coordinator, Med-Peds doctor, and now doing research and clinical care in very resource limited settings for Burmese migrant workers. Very impressed with the level of care, but more so with the training, skill, and motivation of clinic workers, most of who have less than a high school education, and are themselves ‘undocumented’ workers. Amazing work Cindy and her team are doing!
October 4 – Mailed 6 kg of textiles home to the US from Mae Sot, took the early afternoon bus to Sukothai, where I splurged on a hotel with a pool. Sukothai was in the process of flooding, so I would have gotten wet anyway, but the pool was a much nicer way to do it.
October 5 – trip to Old Sukothai and viewing of the ruins of an early Thai capitol city. Travel through flooding New Sukothai is probably what I will remember most about this day – flood waters are very mobile, and seem almost malicious. (I suppose I had always imagined them as static or slowly rising, not rushing and flowing, or rising quickly after spilling over something. Now I know.) People of New Sukothai for the most part going about their business and children playing in the wakes created by trucks passing through higher (2-3 foot) water areas. Lazy and not wanting to get my feet dirty again after the pool, ate a nice dinner at the hotel.
October 6 – Bus to Chiang Mai, hotelier kind enough to take me to the bus station in his truck, so I remain dry despite worsening flooding in the city and surrounding areas. My friend Ken arrives to find the hotel has cancelled our reservation and finds a nice replacement hotel (with pool!) Swimming, fruit shakes, pancakes, and an evening jaunt around Chaing Mai. Ken is MUCH slower at the night market than I am – isn’t that backwards? I must remember he’s seeing much of this for the first time, while I’ve been in Asian tourist market situations for a year now. Also, he’s pretty sleep deprived by now after an overnight bus.
September 22 – Muang Khua hospital. No 6 year doctors seeing patients, but good facilities and equipment, and polite and engaged staff (3 year doctors and nurses) providing patient care. We didn’t round with them. If they had a pediatrician and an Internist (Ok, and a surgeon and OB) they could be a great small hospital.
September 23 – Travel to Muang Sing – Muang Khua to Udomxai (3 hours), Udomxai to Luang Nam Tha (3 hours) both on lovely roads. Luang Nam Tha to Muang Sing – 3 hours, longer than usual due to several large mud slides on the road. Arrived in Muang sing to Bryan and a crowd of 10-20 Lao children who were super happy to see Leila and shy to meet me. Dinner on their lovely balcony overlooking the army barracks, road, and countryside while the sun set.
September 24 – Market trip and butterfly children’s center in the morning – great to see Leila and Bryan in their element. Bike ride in the afternoon, then made spaghetti sauce from scratch to eat with rice noodles and Chinese cabernet (terrible!) for dinner.
September 25 – Mitchell Montessori Cinco De Mayo paper flowers at the childrens center. Bike ride to Koma’s Akha village in the afternoon – 6 KM up hill and lovely views on the return. Purchasing of large amounts of beautifully woven local handicrafts at a private market put on by local girls in Leila and Bryan’s house in the evening.
September 26 – Bike ride in the morning, children’s center for jump rope and puzzle games in the afternoon.
September 27 – One more walk through the weaving village and a few more purchases in the early afternoon, Last evening at the children’s center.
September 28th – up early and packed 4-5 kilos of new belongings tightly into my travel pack. Minibus to Luang Nam Tha where I rounded with 2010 graduate Veokham, who appears to be doing a fabulous job on his ward. Like recent residency graduates worldwide, he complained that we had not taught him enough musculoskeletal diagnosis and treatment – but he had managed to (accurately, I think) diagnose a patient with spinal chord stenosis anyway. Bike ride in the afternoon during which I took a wrong turn and ended up riding more than 20 KM, much of it on village trails. Luang Nam Tha valley is beautiful with rice fields and mountains, and the last leg was with beautiful late-afternoon lighting (but home before dark despite my miscalcuation.)
September 29th – attended teaching by Dr. Veokham to hospital staff in the morning – Dengue fever with all slides in Lao language! Wow! Gave the staff in the blood bank some excitement by donating blood – several cell phone camera photos were taken to document the occasion. Said a sad goodbye to Leila after lunch and had a relaxed afternoon.
September 30th and October 1st – travel to Mae Sot – LNT to Bokeo, across the Mekong into Thailand, and on to Chiang Rai the first day. Chiang Ria – splurged on Pizza and Salad after 2 weeks of not enough wheat or cheese. Chiang Rai seems like a nice little town. The next day, Chiang Rai -> Chiang Mai (bus station only) where 7-11 provided a safe but unappetizing lunch during my 2 hour layover, then on to Mae Sot. Thai buses and roads are much nicer than Lao, - there are assigned seats and I bought my ticket relatively early! But the movie on the first bus was so disturbingly violent I literally had to keep my eyes shut for much of the first 2 hours. Too bad,t the golden triangle has beautiful karsts. Arrived just in time for dinner with Cindy’s friends, delicious Thai food.
October 2 – Sunday in Mae Sot, a town on the Thai – Myanmar border. Brunch! at a Canadian run diner and a bike ride to the border, where even more beautiful textiles were purchased. The border has been closed for over a year, so no temptation to go across for a day.
October 3 – Got to see the clinic of Dr. Cindy – former HF IM coordinator, Med-Peds doctor, and now doing research and clinical care in very resource limited settings for Burmese migrant workers. Very impressed with the level of care, but more so with the training, skill, and motivation of clinic workers, most of who have less than a high school education, and are themselves ‘undocumented’ workers. Amazing work Cindy and her team are doing!
October 4 – Mailed 6 kg of textiles home to the US from Mae Sot, took the early afternoon bus to Sukothai, where I splurged on a hotel with a pool. Sukothai was in the process of flooding, so I would have gotten wet anyway, but the pool was a much nicer way to do it.
October 5 – trip to Old Sukothai and viewing of the ruins of an early Thai capitol city. Travel through flooding New Sukothai is probably what I will remember most about this day – flood waters are very mobile, and seem almost malicious. (I suppose I had always imagined them as static or slowly rising, not rushing and flowing, or rising quickly after spilling over something. Now I know.) People of New Sukothai for the most part going about their business and children playing in the wakes created by trucks passing through higher (2-3 foot) water areas. Lazy and not wanting to get my feet dirty again after the pool, ate a nice dinner at the hotel.
October 6 – Bus to Chiang Mai, hotelier kind enough to take me to the bus station in his truck, so I remain dry despite worsening flooding in the city and surrounding areas. My friend Ken arrives to find the hotel has cancelled our reservation and finds a nice replacement hotel (with pool!) Swimming, fruit shakes, pancakes, and an evening jaunt around Chaing Mai. Ken is MUCH slower at the night market than I am – isn’t that backwards? I must remember he’s seeing much of this for the first time, while I’ve been in Asian tourist market situations for a year now. Also, he’s pretty sleep deprived by now after an overnight bus.
Tuesday, September 27, 2011
On the Road
10 days ago I left Vientiane for a trip through Northern Lao. I spent the 48 hours before leaving dealing with a semi-crisis of resident failure on the final exam. (when 6/7 residents fail the test, is the problem the test or the residents?) And trying to convince myself I was ready to be away from home traveling for more than a month. I haven't been on the road for that long in a long time. There were a couple fairly sleepless nights. But I'm doing OK so far!
On Saturday I flew to Phongsali. I had 38 kg of checked luggage - my 12 kg travel backpack (some of the weight was a pencil sharpener, and there was some heavy food.) Then there was a 25kg bag containing 1050 posters in 21 50 poster packets and 100 rolls of colorful paper for a project for the children, 100 pipe cleaners, 1 kg of coffee from Kungs for Bryan, a graduation present for a 2010 graduate, and some chocolate and cookies. I showed the people at the counter Leila's Noma poster and explained it was outreach for sick kids, and they let me ship the heavy bag for free. Lao Airlines is such a pleasure to fly; that would never happen in America. Anyway, I arrived in Udomxai and Leila met me at the airport. Leila is an American pediatrician who now lives and works in Northern Lao, is a former pediatrics coordinator, and helps HF with resident recruiting from rural hospitals.) I carried all 38 KG of luggage to the tuk tuk in one trip by myself! (Leila had my day pack and purse, and has osteoporosis, so I didn't want her doing any heavy lifting.) We went to the guesthouse where we stowed the luggage and then I had a late lunch of pumpkin soup and delicious fried niblets. We delivered 5 packets of posters to a man who works for an NGO in Udomxai and will try to get one to each district for distribution. We walked to a temple mentioned in the Lonely planet and saw a beautiful concrete tree of life sculpture. It rained on the walk back, but we were able to deliver a (slightly wet) Fitzpatrick's guide to dermatology to the 2010 graduate in Udomxai - I had missed seeing him at CME in the spring. Our work done, we found a new hotel recommended by Leila's friends and had a massage and then a late dinner.
Tree of life sculpture, Udomxai.
Saturday we took the bus to Phongsali. In good conditions, it takes 8 hours. We left at 8 AM and arrived at 8 PM. The first part of the road was paved. Then we got to dirt road - windy, muddy (it rained almost all night Saturday night) mountain dirt roads. Our bus driver was great - he didn't try to go too fast - and he had an assistant that sat next to him and helped choose the route. When it was particularly muddy or challenging, he hopped out and walked along giving advice from the front, then got back in when we were through the rough spot. There were some narrow, muddy areas, but I was never _really_ worried the bus would slide off the edge of the cliff. I was sometimes a little bit worried about that. We didn't stop for lunch until well after noon, and we stopped at a little roadside stand that sold chips and soda. Luckily, I had brought bread and cheese from Vientiane, so we didn't go hungry. All the Lao people had packed their own lunches too. Along the way, Leila gave posters to everyone getting off the bus to hang in their towns. The last 60 KM of road (we went between 200-300 km total) was paved, but still windy and it was dark by then, so it was still pretty slow going. We passed on the first guest house we saw and stayed at the second, where we were soon to discover the Lonely planet's description of plumbing problems was correct. We had eaten the second half of the Gouda on the bus, so we just went to bed. Riding the bus all day was somehow pretty exhausting.
Buying bracelets at a roadside bathroom stop.
Monday we had breakfast at the Yee Hua restaurant, where Leila discovered that the proprietor works for an NGO that goes to rural, hard to access districts in Phongsali (which as you can see from the above is already hard to access.) He agreed to distribute posters to many villages in 2 districts. Around 10 Am we finally got the go ahead from MOH to visit the hospital, and we headed out and met with the vice director. We gave him some pocket books and Lao-language Mahosot Microbiology Reviews, and got some information about the hospital. He invited us to come back the next morning at 8:30 for rounds. We walked back to the guest house and packed the peanut butter and a roll and headed up the Phou Faa - sky mountain - for a short hike. It ended up being at least 2 KM up the road (we could have taken 400 stairs, a more direct route, but they were pretty mossy and treacherous looking.) We ate lunch overlooking the city accompanied by several very friendly butterflies. Then Leila convinced me we should go to the viewpoint. We thought it was 30 Meters, but quickly realized the sign had meant 30 minutes. About an hour later, after traveling through thick jungle on an overgrown path we arrived at what was a really fabulous view point. Leila walked first to brush away the spider webs after we found a giant spider over the trail early on. We left the big ones alone and just snuck under their webs. At the viewpoint we had almost 360 degree views of the mountains of Phongsali stretching out away from town. I discovered the friendly brown creatures persistently climbig up my shoes were leaches, not caterpillars, as I had hoped. There was no way I was going back past the giant spider, so our only choice was to go down, through the jungle, on another small trail past the tea plantation. It started to rain on the way down, but I had my poncho. The tea plantation was just a porch full of women sorting green tea from giant incredibly heavy bags, and more women and men carrying the bags up the hill from the surrounding areas of tea bushes. Unfortunately, they weren't set up to let us taste or buy tea, so we just headed on, back around the mountain on the Hat Sa road, to the town. I managed to accost one last leach who had made it to just above my knee inside my capri pants, and scrape several more off my shoes. Leila discovered 3 or 4 that had climbed up her pants when we go home (I thought I saw spots of blood appearing on her jeans, but she didn't want to stop and check) - so while my freaking out seemed kind of silly, it did prevent me from being suckered. By this time it was late afternoon, so after a brief rest we went to a restaurant recommended by the Lonely planet, where we pointed to some vegetables we wanted on their display area, and two lovely stir fries were prepared for us.
Leila at the top of Phu Faa
On Tuesday we returned for rounds. I went with the person in charge of internal medicine - a 3 year trained doctor who went to school in Vietnam. We saw 7 patients, 5 of whom were women with abdominal pain, one man with shortness of breath, and an 8 month pregnant woman who had flank pain and fever that had not improved after 8 days of Ampicillin. I called Leila in to help translate and we talked about urosepsis in pregnant woman and advised they switch to gentamyacin and ceftriaxone, then Leila gave the doctor another copy of the Lao Language MMR with sepsis guidelines. We were done rounding, so I joined Leila in the well child clinic (they had no pediatric inpatients) where she had spent the morning encouraging them to weight the children and found that all of them were underweight, and then counseling the parents about good nutrition. As we were leaving we were invited to come back for the afternoon. So after lunch we returned and spent another half an hour in well child clinic. Then a member of the hospital staff came and told us they were ready for our teaching. We hadn't prepared any teaching. Yikes! Leila talked for 30-45 minutes about weighing children and good nutrition and then for another 15-30 minutes about fever in Laos with some input from me. Leila can lecture in Lao and they understood her, especially with the help of a surgeon sitting at the front of the room who did some extra explaining. Then they said that was great, but they were ready for the adult teaching. So I talked for 15-30 minutes about prevention - I did some speaking in Lao but mostly Leila translated for me. We talked about exercise, healthy diet, not drinking a lot, and not smoking and how these four interventions could decrease diabetes, stroke, heart failure, heart attacks, and liver disease. They agreed that Lao people don't like to take medications every day and so prevention was important, and seemed engaged in my teaching as well. We took a group photo and the day was over at 4 o'clock. Leila was pretty exhausted, so she went to bed almost immediately and I had a snackish dinner.
Doctors, nurses, pharmacists who attended our impromptu teaching in Phongsali.
Wednesday we took the bus from Phongsali 22 km to Hat Sa over a very muddy, under construction dirt road. We had 2 stops - once for a digger truck that was pushing landslide dirt off the road and making it passable - and the second to widen the road where the outside edge had collapsed. The bus driver and some passengers pushed some rocks from the uphill side over the edge so the road was just wide enough for the bus to cross the narrow area. All the passengers got back in once he was across. At Hat Sa, we got in a long boat. We rode down the (very full) river for 4 hours to Meuang Kheua, arriving in mid afternoon. We passed beautiful mountains and saw some lovely birds, and our driver skillfully guided us through the rapids. The guesthouse recommended by lonely planet was full, so we checked into one two doors down which was basic but had fully functional bathroom plumbing. We relaxed for about an hour before wandering around town a bit and then getting dinner at a restaurant overlooking the river and river crossing ferry landing. the sunset was behind us, but it was still a beautiful place to have an early dinner and watch the activities on the river. And the mushrooms with ginger were quite tasty.
View from the long boat.
On Saturday I flew to Phongsali. I had 38 kg of checked luggage - my 12 kg travel backpack (some of the weight was a pencil sharpener, and there was some heavy food.) Then there was a 25kg bag containing 1050 posters in 21 50 poster packets and 100 rolls of colorful paper for a project for the children, 100 pipe cleaners, 1 kg of coffee from Kungs for Bryan, a graduation present for a 2010 graduate, and some chocolate and cookies. I showed the people at the counter Leila's Noma poster and explained it was outreach for sick kids, and they let me ship the heavy bag for free. Lao Airlines is such a pleasure to fly; that would never happen in America. Anyway, I arrived in Udomxai and Leila met me at the airport. Leila is an American pediatrician who now lives and works in Northern Lao, is a former pediatrics coordinator, and helps HF with resident recruiting from rural hospitals.) I carried all 38 KG of luggage to the tuk tuk in one trip by myself! (Leila had my day pack and purse, and has osteoporosis, so I didn't want her doing any heavy lifting.) We went to the guesthouse where we stowed the luggage and then I had a late lunch of pumpkin soup and delicious fried niblets. We delivered 5 packets of posters to a man who works for an NGO in Udomxai and will try to get one to each district for distribution. We walked to a temple mentioned in the Lonely planet and saw a beautiful concrete tree of life sculpture. It rained on the walk back, but we were able to deliver a (slightly wet) Fitzpatrick's guide to dermatology to the 2010 graduate in Udomxai - I had missed seeing him at CME in the spring. Our work done, we found a new hotel recommended by Leila's friends and had a massage and then a late dinner.
Tree of life sculpture, Udomxai.
Saturday we took the bus to Phongsali. In good conditions, it takes 8 hours. We left at 8 AM and arrived at 8 PM. The first part of the road was paved. Then we got to dirt road - windy, muddy (it rained almost all night Saturday night) mountain dirt roads. Our bus driver was great - he didn't try to go too fast - and he had an assistant that sat next to him and helped choose the route. When it was particularly muddy or challenging, he hopped out and walked along giving advice from the front, then got back in when we were through the rough spot. There were some narrow, muddy areas, but I was never _really_ worried the bus would slide off the edge of the cliff. I was sometimes a little bit worried about that. We didn't stop for lunch until well after noon, and we stopped at a little roadside stand that sold chips and soda. Luckily, I had brought bread and cheese from Vientiane, so we didn't go hungry. All the Lao people had packed their own lunches too. Along the way, Leila gave posters to everyone getting off the bus to hang in their towns. The last 60 KM of road (we went between 200-300 km total) was paved, but still windy and it was dark by then, so it was still pretty slow going. We passed on the first guest house we saw and stayed at the second, where we were soon to discover the Lonely planet's description of plumbing problems was correct. We had eaten the second half of the Gouda on the bus, so we just went to bed. Riding the bus all day was somehow pretty exhausting.
Buying bracelets at a roadside bathroom stop.
Monday we had breakfast at the Yee Hua restaurant, where Leila discovered that the proprietor works for an NGO that goes to rural, hard to access districts in Phongsali (which as you can see from the above is already hard to access.) He agreed to distribute posters to many villages in 2 districts. Around 10 Am we finally got the go ahead from MOH to visit the hospital, and we headed out and met with the vice director. We gave him some pocket books and Lao-language Mahosot Microbiology Reviews, and got some information about the hospital. He invited us to come back the next morning at 8:30 for rounds. We walked back to the guest house and packed the peanut butter and a roll and headed up the Phou Faa - sky mountain - for a short hike. It ended up being at least 2 KM up the road (we could have taken 400 stairs, a more direct route, but they were pretty mossy and treacherous looking.) We ate lunch overlooking the city accompanied by several very friendly butterflies. Then Leila convinced me we should go to the viewpoint. We thought it was 30 Meters, but quickly realized the sign had meant 30 minutes. About an hour later, after traveling through thick jungle on an overgrown path we arrived at what was a really fabulous view point. Leila walked first to brush away the spider webs after we found a giant spider over the trail early on. We left the big ones alone and just snuck under their webs. At the viewpoint we had almost 360 degree views of the mountains of Phongsali stretching out away from town. I discovered the friendly brown creatures persistently climbig up my shoes were leaches, not caterpillars, as I had hoped. There was no way I was going back past the giant spider, so our only choice was to go down, through the jungle, on another small trail past the tea plantation. It started to rain on the way down, but I had my poncho. The tea plantation was just a porch full of women sorting green tea from giant incredibly heavy bags, and more women and men carrying the bags up the hill from the surrounding areas of tea bushes. Unfortunately, they weren't set up to let us taste or buy tea, so we just headed on, back around the mountain on the Hat Sa road, to the town. I managed to accost one last leach who had made it to just above my knee inside my capri pants, and scrape several more off my shoes. Leila discovered 3 or 4 that had climbed up her pants when we go home (I thought I saw spots of blood appearing on her jeans, but she didn't want to stop and check) - so while my freaking out seemed kind of silly, it did prevent me from being suckered. By this time it was late afternoon, so after a brief rest we went to a restaurant recommended by the Lonely planet, where we pointed to some vegetables we wanted on their display area, and two lovely stir fries were prepared for us.
Leila at the top of Phu Faa
On Tuesday we returned for rounds. I went with the person in charge of internal medicine - a 3 year trained doctor who went to school in Vietnam. We saw 7 patients, 5 of whom were women with abdominal pain, one man with shortness of breath, and an 8 month pregnant woman who had flank pain and fever that had not improved after 8 days of Ampicillin. I called Leila in to help translate and we talked about urosepsis in pregnant woman and advised they switch to gentamyacin and ceftriaxone, then Leila gave the doctor another copy of the Lao Language MMR with sepsis guidelines. We were done rounding, so I joined Leila in the well child clinic (they had no pediatric inpatients) where she had spent the morning encouraging them to weight the children and found that all of them were underweight, and then counseling the parents about good nutrition. As we were leaving we were invited to come back for the afternoon. So after lunch we returned and spent another half an hour in well child clinic. Then a member of the hospital staff came and told us they were ready for our teaching. We hadn't prepared any teaching. Yikes! Leila talked for 30-45 minutes about weighing children and good nutrition and then for another 15-30 minutes about fever in Laos with some input from me. Leila can lecture in Lao and they understood her, especially with the help of a surgeon sitting at the front of the room who did some extra explaining. Then they said that was great, but they were ready for the adult teaching. So I talked for 15-30 minutes about prevention - I did some speaking in Lao but mostly Leila translated for me. We talked about exercise, healthy diet, not drinking a lot, and not smoking and how these four interventions could decrease diabetes, stroke, heart failure, heart attacks, and liver disease. They agreed that Lao people don't like to take medications every day and so prevention was important, and seemed engaged in my teaching as well. We took a group photo and the day was over at 4 o'clock. Leila was pretty exhausted, so she went to bed almost immediately and I had a snackish dinner.
Doctors, nurses, pharmacists who attended our impromptu teaching in Phongsali.
Wednesday we took the bus from Phongsali 22 km to Hat Sa over a very muddy, under construction dirt road. We had 2 stops - once for a digger truck that was pushing landslide dirt off the road and making it passable - and the second to widen the road where the outside edge had collapsed. The bus driver and some passengers pushed some rocks from the uphill side over the edge so the road was just wide enough for the bus to cross the narrow area. All the passengers got back in once he was across. At Hat Sa, we got in a long boat. We rode down the (very full) river for 4 hours to Meuang Kheua, arriving in mid afternoon. We passed beautiful mountains and saw some lovely birds, and our driver skillfully guided us through the rapids. The guesthouse recommended by lonely planet was full, so we checked into one two doors down which was basic but had fully functional bathroom plumbing. We relaxed for about an hour before wandering around town a bit and then getting dinner at a restaurant overlooking the river and river crossing ferry landing. the sunset was behind us, but it was still a beautiful place to have an early dinner and watch the activities on the river. And the mushrooms with ginger were quite tasty.
View from the long boat.
Monday, September 12, 2011
Rites of Passage?
Today I got my first traffic ticket - apparently I turned left at a no-left-turn intersection. Luckily for me Margot (visiting Pediatric ID fellow and former HF peds coordinator) was in the truck with me and helped me be calm. We followed the police officer to the police stand, where we gave him 70,000 kip. Unfortunately, they were all out of bills, so we were unable to get a receipt. (IE: he will split the money with his supervisor.) I am left just feeling lucky I haven’t gotten a ticket before now - I didn’t even see this no left turn sign (apparently it was on the right side of the road; to drive here one violates traffic rules on a pretty much daily basis, (or risk interrupting the flow of traffic and confusing the other drivers) so even if I had seen it, I don’t know if I would have followed it. I’m also glad that after this week, my need to drive the truck should be pretty minimal. The steering is still weird after a couple steering failures (at very low speed) this spring, and I think it’s just ready to retire. I wonder how it will feel to get into Gordon, my geo prism, in December after driving an extended cab Isuzu with a topper for a year - probably pretty weird. I suspect my transition back to American traffic patterns may be just as hard as, or even harder than, my transition to Lao driving was. We shall see. . .
Today Novalinh and I also fixed the phone at the office without any help! Yay independent women power! The phone in Novalinh’s office (in the downstairs of my house) has been working only sporadically for about the last month - sometimes not having a dial tone and then often hanging up on people mid-call. But the fax machine is still reliable. I bought a new phone in Thailand a week ago, but that didn’t fix the problem. So I’ve been thinking about next steps. We were about to give up and call the repair man when it occurred to me to actually open and check all the connections - if it was a wire problem it should never work, so it must be a connection problem, right? The phone line comes into the house and then is split to the fax machine in the living room, and one cord goes over to the office. I had jiggled the wires going in and out of the boxes early in the phone- not working period, but not actually opened them. (And of course I’d unplugged and re-plugged all available connections.) So we opened the one in the office which looked fine, and then the one in the living room where I discovered one of 6 wires had broken and become disconnected. So Novalinh and I fixed it - I showed her how to safely use scissors to strip the insulation - she wanted to use a kitchen knife and her thumb - and we wrapped it around the little terminal and screwed it back in (using my small Phillips head screwdriver from the multi-tool I bought at REI the day I left Denver.) And the phone is working now! So hopefully we saved a few tens of thousands of kip to have someone from the phone company come out. Maybe it’s silly to be proud of such a small accomplishment, but at home I don’t know if I would have solved the problem on my own - I would have asked an electrically inclined friend to take a look at it. Here, I’m probably the HF staff with the most electrical experience of anyone (thanks science fair projects!) and was able to use logic - though it took me long enough - and basic fix-it skills to do it on my own.
I’ve been in Laos for more than a year now. My one year anniversary of life in Laos passed quietly on August 22nd, while Brent (a friend from residency) and I were in Luang Prabang. I didn’t even realize it was an anniversary until the next weekend when my Dad pointed out that I had now been here for more than a year. And now I’m getting ready to come home - the last few weeks have been a whirlwind of planning for when I am no longer teaching (making sure the residents have teaching arranged), getting things ready for the new coordinator (Emily) who will arrive while I am out of town at the end of October, updating sign outs, and planning my travels between now and December, when I come home to Denver. On Saturday I fly to Udomxai and meet up with Leila, and then we’ll go on together to Pongsali - one of the far northern Lao provinces, and one of the hardest to get to. From there, Luang Nam Tha, Muang Sing, Huay Xai, Mae Sot Thailand, and meeting up with my MN friend Ken in Chiang Mai, from whence we will return to Lao and do some ecotourism in the north, and pass through Vientiane again in mid-October on our way to Vietnam. I’m going to be quite the nomad for the next few months. I’ve also been trying to meet with all the relevant teachers, administrators, etc to discuss plans for the next 3 months, help the ID ward get started writing a fellowship curriculum (because I’m an expert on curriculum development. . . um, not.) and make sure the office will continue to function in my absence. So things in sleepy Vientiane, in the Lao PDR (Please don’t rush) have actually been pretty busy for several weeks. We’ll see if everything gets done . . . and I’ll try to blog at least once more before I go off into the wilderness.
Oh yeah, yesterday was the 10th anniversary of 9/11. I managed to almost completely avoid the coverage of the anniversary, just as I managed to pretty much avoid the 24/7 news coverage 10 years ago (I was in Budapest, Hungary studying abroad in September 2001.) I have been lucky to be in a place where I choose how, when, and how much to access US news at both times. Maybe I’m insensitive, but other than New Yorkers and people who lost loved ones or friends in the towers and planes, I’m not sure putting a lot of emotional energy into this anniversary is useful. Rather than focusing on how we were victimized 10 years ago, shouldn’t we be worried about the problems our nation and the world are facing right now? Shouldn’t we be working on economic recovery, universal health care, and thinking about the 2 wars that we started in the aftermath of 9/11/01 and what in the heck we are going to do about them? I don’t want to deny that 9/11 had a huge impact on our nation, but I would like to see us looking forward and working towards peace, reconciliation, prosperity, and human rights rather than looking back fearfully and tearfully.
Today Novalinh and I also fixed the phone at the office without any help! Yay independent women power! The phone in Novalinh’s office (in the downstairs of my house) has been working only sporadically for about the last month - sometimes not having a dial tone and then often hanging up on people mid-call. But the fax machine is still reliable. I bought a new phone in Thailand a week ago, but that didn’t fix the problem. So I’ve been thinking about next steps. We were about to give up and call the repair man when it occurred to me to actually open and check all the connections - if it was a wire problem it should never work, so it must be a connection problem, right? The phone line comes into the house and then is split to the fax machine in the living room, and one cord goes over to the office. I had jiggled the wires going in and out of the boxes early in the phone- not working period, but not actually opened them. (And of course I’d unplugged and re-plugged all available connections.) So we opened the one in the office which looked fine, and then the one in the living room where I discovered one of 6 wires had broken and become disconnected. So Novalinh and I fixed it - I showed her how to safely use scissors to strip the insulation - she wanted to use a kitchen knife and her thumb - and we wrapped it around the little terminal and screwed it back in (using my small Phillips head screwdriver from the multi-tool I bought at REI the day I left Denver.) And the phone is working now! So hopefully we saved a few tens of thousands of kip to have someone from the phone company come out. Maybe it’s silly to be proud of such a small accomplishment, but at home I don’t know if I would have solved the problem on my own - I would have asked an electrically inclined friend to take a look at it. Here, I’m probably the HF staff with the most electrical experience of anyone (thanks science fair projects!) and was able to use logic - though it took me long enough - and basic fix-it skills to do it on my own.
I’ve been in Laos for more than a year now. My one year anniversary of life in Laos passed quietly on August 22nd, while Brent (a friend from residency) and I were in Luang Prabang. I didn’t even realize it was an anniversary until the next weekend when my Dad pointed out that I had now been here for more than a year. And now I’m getting ready to come home - the last few weeks have been a whirlwind of planning for when I am no longer teaching (making sure the residents have teaching arranged), getting things ready for the new coordinator (Emily) who will arrive while I am out of town at the end of October, updating sign outs, and planning my travels between now and December, when I come home to Denver. On Saturday I fly to Udomxai and meet up with Leila, and then we’ll go on together to Pongsali - one of the far northern Lao provinces, and one of the hardest to get to. From there, Luang Nam Tha, Muang Sing, Huay Xai, Mae Sot Thailand, and meeting up with my MN friend Ken in Chiang Mai, from whence we will return to Lao and do some ecotourism in the north, and pass through Vientiane again in mid-October on our way to Vietnam. I’m going to be quite the nomad for the next few months. I’ve also been trying to meet with all the relevant teachers, administrators, etc to discuss plans for the next 3 months, help the ID ward get started writing a fellowship curriculum (because I’m an expert on curriculum development. . . um, not.) and make sure the office will continue to function in my absence. So things in sleepy Vientiane, in the Lao PDR (Please don’t rush) have actually been pretty busy for several weeks. We’ll see if everything gets done . . . and I’ll try to blog at least once more before I go off into the wilderness.
Oh yeah, yesterday was the 10th anniversary of 9/11. I managed to almost completely avoid the coverage of the anniversary, just as I managed to pretty much avoid the 24/7 news coverage 10 years ago (I was in Budapest, Hungary studying abroad in September 2001.) I have been lucky to be in a place where I choose how, when, and how much to access US news at both times. Maybe I’m insensitive, but other than New Yorkers and people who lost loved ones or friends in the towers and planes, I’m not sure putting a lot of emotional energy into this anniversary is useful. Rather than focusing on how we were victimized 10 years ago, shouldn’t we be worried about the problems our nation and the world are facing right now? Shouldn’t we be working on economic recovery, universal health care, and thinking about the 2 wars that we started in the aftermath of 9/11/01 and what in the heck we are going to do about them? I don’t want to deny that 9/11 had a huge impact on our nation, but I would like to see us looking forward and working towards peace, reconciliation, prosperity, and human rights rather than looking back fearfully and tearfully.
Thursday, July 21, 2011
An open letter
Ok, so if you check this you've probably already seen this on Facebook or Google plus, but just in case there are people who look here who aren't on one of those sites:
This Google doc is an open letter I sent to President Obama, and my congressmen and senators. It's about the debt crisis and recent proposed medicare funding changes, which have been inappropriately linked by devious republicans. I've been upset about these issues. (See 2 posts ago.) It's long, but I hope some of you might read it and find my perspective interesting.
https://docs.google.com/document/d/1fbzqePmDkogV-LT0IMqDBwoKVBVaL-NfkLSMuGufMoc/edit?hl=en_US
This Google doc is an open letter I sent to President Obama, and my congressmen and senators. It's about the debt crisis and recent proposed medicare funding changes, which have been inappropriately linked by devious republicans. I've been upset about these issues. (See 2 posts ago.) It's long, but I hope some of you might read it and find my perspective interesting.
https://docs.google.com/document/d/1fbzqePmDkogV-LT0IMqDBwoKVBVaL-NfkLSMuGufMoc/edit?hl=en_US
Monday, July 18, 2011
Planning a trip outside my comfort zone.
I came to Laos with few expectations. Not none, but I really tried to come with an open mind, so that I’d be able to enjoy my time here with lots of surprises - pleasant and odd - but few disappointments. However, if you had asked me before leaving whether I would get involved in helping to organize resident research while I was here, I would have said “No way!” I like research, don’t get me wrong. It guides my practice, and I respect people who are inspired to plan, organize, and complete valuable research projects that add to our collective knowledge base. But I’ve never had the urge to get involved in it before. Sure, I did microbiology research in college - it was fun - there are days when I miss my micropipetter and gels. (Usually these days correlate with some interpersonal relationship/communication issue at work when a patient or colleague is frustrating me, and they have been extremely uncommon since coming to Laos.) But I don’t really miss academic science - the idea of spending my entire career studying a single bacteria, or even a handful of them, just never really grabbed me. And I’m no more a clinical researcher than I am an academic scientist. I don’t think I really have the focus, drive, or organizational skills necessary to make research an integral/important part of my career.
So why am I e-mailing people left and right to help the residents organize a group senior research project? Yes, residents here do research. In fact, they’re required to complete a research project before graduating. This seems pretty crazy. Lots of american residents do research, of course. They tend to be the ones applying for competitive fellowships, and they may take up to 2 months off during residency to work on it. But it’s not a graduation requirement. Our residents get 2 weeks to do theirs. (Really they get a month of vacation/research.)
Unfortunately, they start their class on how to do research in September-October of their 3rd year, and then they’re suppose to write, revise, and have approved a proposal. So most of their actual work takes place in a few months - January-April/May - which limits the amount of valid data they can collect whether they’re doing a cross-sectional survey of behaviors related to a chronic disease or trying to chart review each patient that comes in blood cultures positive for a specific pathogen to find common presentations that should prompt provincial doctors (who don’t have access to cultures) to think of, and treat, that bacteria. This all seems kind of silly to me - but the requirement is theoretically to be sure that residents understand some basic stuff about how good research is done. In a country with very little data about what’s happening here now currently, and where there are lots of people trying to do research who might approach the residents for help once they return to their provincial hospitals, I guess it does make sense for them to have some basic understanding. After all, there is a really good chance they will be asked to participate in research, so it would be good if they had some way to assess whether to do it. But in practice, they are super stressed about finishing their projects, which tend to be small and maybe don’t contribute much to the knowledge base here.
However, this past year, Amy included the pediatrics residents in her Blue book and Oxygen projects, so all the peds residents worked on a component of a bigger project. They still had to understand the same stuff to do and write up their component, but they were able to work together more, with some support from Amy, and the data they gathered will likely be very useful and relevant to Laos. This excellent example is how I came to be e-mailing people about a group project with subcomponents for each of the 3rd year residents this year.
My idea is much less useful than Amy’s project - but it will address a topic I’m interested in - dementia - (Thus the inspiration) and if we can organize it they should come out of it with one useful assessment tool. Chronic disease is under-recognized here as well, so it might generally highlight some neglected topics as well. Now I ‘just’ have to get permission from the university, the medicine teachers, the creator of the test I want to adapt to Lao language and culture, work with the residents to map out a plan, and arrange good support for the residents when I finish work in September. In other words, what have I gotten myself into? We’ll see. . .
Last week at Setta I saw a young woman with fever and pelvic pain. She happened to also be an albino - almost certainly with occulocutaneous albinism, a disease which I only learned about when I searched the literature for “nystagmus albinism.” Her pelvic pain complaint ended up leading to a diagnosis of vaginal candidiasis. Unfortunately, she also had oral candida, and a herpes simplex virus outbreak on her face. And a folliculitis on her neck. And a resolving vasculitic looking rash on her legs. An unpleasant cornucopia of medical problems for a woman so young, and we kept our visiting dermatologist busy for several minutes figuring it all out. She was ‘not married’ but after encouraging my residents to ask again, we determined that she did have risk factors for HIV - she was sexually active. And all of the above problems in a 22 year old sexually active woman are from HIV until proven otherwise. The residents agreed she needed testing, as did the ID doctor when asked Friday afternoon. Unfortunately, the on-call person over the weekend either sent or allowed her to go home, so we’ll never know for sure. Tonight, I’m praying we were wrong.
So why am I e-mailing people left and right to help the residents organize a group senior research project? Yes, residents here do research. In fact, they’re required to complete a research project before graduating. This seems pretty crazy. Lots of american residents do research, of course. They tend to be the ones applying for competitive fellowships, and they may take up to 2 months off during residency to work on it. But it’s not a graduation requirement. Our residents get 2 weeks to do theirs. (Really they get a month of vacation/research.)
Unfortunately, they start their class on how to do research in September-October of their 3rd year, and then they’re suppose to write, revise, and have approved a proposal. So most of their actual work takes place in a few months - January-April/May - which limits the amount of valid data they can collect whether they’re doing a cross-sectional survey of behaviors related to a chronic disease or trying to chart review each patient that comes in blood cultures positive for a specific pathogen to find common presentations that should prompt provincial doctors (who don’t have access to cultures) to think of, and treat, that bacteria. This all seems kind of silly to me - but the requirement is theoretically to be sure that residents understand some basic stuff about how good research is done. In a country with very little data about what’s happening here now currently, and where there are lots of people trying to do research who might approach the residents for help once they return to their provincial hospitals, I guess it does make sense for them to have some basic understanding. After all, there is a really good chance they will be asked to participate in research, so it would be good if they had some way to assess whether to do it. But in practice, they are super stressed about finishing their projects, which tend to be small and maybe don’t contribute much to the knowledge base here.
However, this past year, Amy included the pediatrics residents in her Blue book and Oxygen projects, so all the peds residents worked on a component of a bigger project. They still had to understand the same stuff to do and write up their component, but they were able to work together more, with some support from Amy, and the data they gathered will likely be very useful and relevant to Laos. This excellent example is how I came to be e-mailing people about a group project with subcomponents for each of the 3rd year residents this year.
My idea is much less useful than Amy’s project - but it will address a topic I’m interested in - dementia - (Thus the inspiration) and if we can organize it they should come out of it with one useful assessment tool. Chronic disease is under-recognized here as well, so it might generally highlight some neglected topics as well. Now I ‘just’ have to get permission from the university, the medicine teachers, the creator of the test I want to adapt to Lao language and culture, work with the residents to map out a plan, and arrange good support for the residents when I finish work in September. In other words, what have I gotten myself into? We’ll see. . .
Last week at Setta I saw a young woman with fever and pelvic pain. She happened to also be an albino - almost certainly with occulocutaneous albinism, a disease which I only learned about when I searched the literature for “nystagmus albinism.” Her pelvic pain complaint ended up leading to a diagnosis of vaginal candidiasis. Unfortunately, she also had oral candida, and a herpes simplex virus outbreak on her face. And a folliculitis on her neck. And a resolving vasculitic looking rash on her legs. An unpleasant cornucopia of medical problems for a woman so young, and we kept our visiting dermatologist busy for several minutes figuring it all out. She was ‘not married’ but after encouraging my residents to ask again, we determined that she did have risk factors for HIV - she was sexually active. And all of the above problems in a 22 year old sexually active woman are from HIV until proven otherwise. The residents agreed she needed testing, as did the ID doctor when asked Friday afternoon. Unfortunately, the on-call person over the weekend either sent or allowed her to go home, so we’ll never know for sure. Tonight, I’m praying we were wrong.
Sunday, July 17, 2011
Politics and Health
Skip this post if you're tired of hearing about American politics particularly the ongoing discussion of health care funding.
I’m a bad blogger. It’s just that things here have been busyish, and I feel like there’s been so much to say that it’s been hard to sit down and just start writing, because then I’ll have to choose what to talk about, and inevitably some important / interesting stuff will be left out.
First, a few words about American politics: it is very tempting for me to completely ignore it. I’m not at home. It’s not my problem right now. I don’t have to seek out information on what’s going on; (because so many of my friends are actively thinking and talking about what’s going on, posting comments and articles on facebook, blogs etc.) but it also wouldn’t be hard for me to ignore it either. In residency I pretty much did that. Taking care of my patients, my team and myself was all I could worry about. I didn’t have the time or emotional energy to invest in worrying about our national health policy, or much other than how I would vote in elections for congress, the senate, and the presidency. But while things have been busy here, I’m still working a normalish work week - in the 40 hour range - and the emotional burden of patient care is much less as I am not directly responsible for any patients. Don’t get me wrong, I still care about these patients and I want to make sure they get the best possible care they can with the resources available, while raising the overall standard of care and trying to get better/ more resources. But I don’t come home and have nightmares or trouble sleeping because of worry that I forgot to order something or missed something the way I did in residency. I come home and look things up if it occurs to me that I should have thought of something else, or if there’s something I want to be able to explain better the next day, but the connection is different. So I have some time an emotional energy to devote to something else, and as a relatively well educated, thoughtful citizen, perhaps the current American political situation should be one of the things I choose.
The incredible amount of time and energy being put into talking about the republican challengers for Obama is distressing to me. The election is more than a year away still, and I think the earlier and earlier start of campaigning for the presidency is both distracting from the very real issues and problems we should be talking about, and skews this discourse when it does happen. The candidates themselves are distressing as well - it seems there is no end in sight to the dominance of the extreme christian right’s focus on ‘conservative values’ and trying to force all Americans to live by them. I would be so delighted to see an “old-school,” small government, civil liberties preserving republican have an actual chance at the nomination that I might forgive them for dominating the discourse for the next 16 months. There are so many real, important problems we could be fixing in that time - of course health care funding being the one nearest and dearest to my heart. In some ways, I’m glad we are finally talking about this in the budget negotiations. However, the direction the debate has taken is also distressing. Cutting funding even further for medicare and medicaid, and especially the proposal to cut GME (Graduate medical education) funding is an incredibly backwards approach to the problem. And I don’t understand why the democrats continually allow the republicans to set the tone and topics available for discussion. Yes, American health care is the most expensive in the world (and not the best quality for all patients) Should we be able to do more with the same amount of money? Absolutely. Should we be able to do the same amount with less money? Absolutely. Should we be talking about whether we want to do more (cover everyone with basic, decent quality care) or the same amount for less? Absolutely. Should we be talking about cuts in corporate welfare for big pharma and maybe malpractice reform, and definitely how much money the people at the top of HMOs and insurance plans are making? Absolutely. Should we be talking about who and how much we pay for various services and what they actually cost and are worth? Absolutely. Should we be cutting funding across the board, most of which goes to pay for the poorest patients, and much of which goes to primary care doctors, nurses, and ‘safety net hospitals’? No.
This is a nuanced, complicate issue and it should be approached as such. Apparently none of the people I elected have the guts to stand up and say that, though, which makes me sad. Residency doesn’t cost hospitals money, it saves them money they would otherwise pay staff physicians to do the same work. Does that mean we can cut GME money without repercussions? No - hospitals with residency programs tend to be those same ‘safety net’ hospitals that are taking care of (often very sick) uninsured or underinsured patients. That money isn’t going into the pockets of the hospital administrators or attending doctors, its going to help pay for high quality care for people who need it. Residents learn from taking care of these patients, everyone wins.
I can’t claim to know how to fix our system. I don’t know how to answer the questions I asked above. After spending 3 years intimately enmeshed in the American health care system and having this year to step back and look at the (bigger) picture and think about how my experiences relate to the bigger issues, all I know is that things are really, really broken, and that this is a complicated, nuanced issue that will take lots of critical thinking, problem solving, compromise from all parties, time, and trial and error to fix. However, it is clear that our leaders beating each other over the head with the cudgels of “you’re wasting money” and “you hate poor people” isn’t helping anything.
Umm, that turned into quite a few words. I think I shall post this with the promise to write another post soon that will have less rant and more cools stories about what’s been going on recently in Laos.
I’m a bad blogger. It’s just that things here have been busyish, and I feel like there’s been so much to say that it’s been hard to sit down and just start writing, because then I’ll have to choose what to talk about, and inevitably some important / interesting stuff will be left out.
First, a few words about American politics: it is very tempting for me to completely ignore it. I’m not at home. It’s not my problem right now. I don’t have to seek out information on what’s going on; (because so many of my friends are actively thinking and talking about what’s going on, posting comments and articles on facebook, blogs etc.) but it also wouldn’t be hard for me to ignore it either. In residency I pretty much did that. Taking care of my patients, my team and myself was all I could worry about. I didn’t have the time or emotional energy to invest in worrying about our national health policy, or much other than how I would vote in elections for congress, the senate, and the presidency. But while things have been busy here, I’m still working a normalish work week - in the 40 hour range - and the emotional burden of patient care is much less as I am not directly responsible for any patients. Don’t get me wrong, I still care about these patients and I want to make sure they get the best possible care they can with the resources available, while raising the overall standard of care and trying to get better/ more resources. But I don’t come home and have nightmares or trouble sleeping because of worry that I forgot to order something or missed something the way I did in residency. I come home and look things up if it occurs to me that I should have thought of something else, or if there’s something I want to be able to explain better the next day, but the connection is different. So I have some time an emotional energy to devote to something else, and as a relatively well educated, thoughtful citizen, perhaps the current American political situation should be one of the things I choose.
The incredible amount of time and energy being put into talking about the republican challengers for Obama is distressing to me. The election is more than a year away still, and I think the earlier and earlier start of campaigning for the presidency is both distracting from the very real issues and problems we should be talking about, and skews this discourse when it does happen. The candidates themselves are distressing as well - it seems there is no end in sight to the dominance of the extreme christian right’s focus on ‘conservative values’ and trying to force all Americans to live by them. I would be so delighted to see an “old-school,” small government, civil liberties preserving republican have an actual chance at the nomination that I might forgive them for dominating the discourse for the next 16 months. There are so many real, important problems we could be fixing in that time - of course health care funding being the one nearest and dearest to my heart. In some ways, I’m glad we are finally talking about this in the budget negotiations. However, the direction the debate has taken is also distressing. Cutting funding even further for medicare and medicaid, and especially the proposal to cut GME (Graduate medical education) funding is an incredibly backwards approach to the problem. And I don’t understand why the democrats continually allow the republicans to set the tone and topics available for discussion. Yes, American health care is the most expensive in the world (and not the best quality for all patients) Should we be able to do more with the same amount of money? Absolutely. Should we be able to do the same amount with less money? Absolutely. Should we be talking about whether we want to do more (cover everyone with basic, decent quality care) or the same amount for less? Absolutely. Should we be talking about cuts in corporate welfare for big pharma and maybe malpractice reform, and definitely how much money the people at the top of HMOs and insurance plans are making? Absolutely. Should we be talking about who and how much we pay for various services and what they actually cost and are worth? Absolutely. Should we be cutting funding across the board, most of which goes to pay for the poorest patients, and much of which goes to primary care doctors, nurses, and ‘safety net hospitals’? No.
This is a nuanced, complicate issue and it should be approached as such. Apparently none of the people I elected have the guts to stand up and say that, though, which makes me sad. Residency doesn’t cost hospitals money, it saves them money they would otherwise pay staff physicians to do the same work. Does that mean we can cut GME money without repercussions? No - hospitals with residency programs tend to be those same ‘safety net’ hospitals that are taking care of (often very sick) uninsured or underinsured patients. That money isn’t going into the pockets of the hospital administrators or attending doctors, its going to help pay for high quality care for people who need it. Residents learn from taking care of these patients, everyone wins.
I can’t claim to know how to fix our system. I don’t know how to answer the questions I asked above. After spending 3 years intimately enmeshed in the American health care system and having this year to step back and look at the (bigger) picture and think about how my experiences relate to the bigger issues, all I know is that things are really, really broken, and that this is a complicated, nuanced issue that will take lots of critical thinking, problem solving, compromise from all parties, time, and trial and error to fix. However, it is clear that our leaders beating each other over the head with the cudgels of “you’re wasting money” and “you hate poor people” isn’t helping anything.
Umm, that turned into quite a few words. I think I shall post this with the promise to write another post soon that will have less rant and more cools stories about what’s been going on recently in Laos.
Tuesday, June 14, 2011
Graduation
You may have seen my photos of our recent graduation ceremony on Facebook. Every year, we have a small ceremony at the US Ambassador’s residence, in addition to the official University of Health Sciences graduation, which is often quite late (in the fall, or even the next January one time) and big - all the residents from every program, plus the medical students. Often foreigners (AKA, HF volunteers) aren’t invited to the UHS ceremony. Having a second ceremony allows us to individually celebrate our residents, if only briefly. It was a lot of work preparing for graduation last week, but it was totally worth all the stress and errand running. I can’t remember the last time I smiled so widely and sincerely for so long. That includes my own residency graduation, about a year ago now.
Me and all 7 of my grads, plus some other residents.
Why did this event seem so much more special to me? I saw my own residency graduation as more of a formality - a “Here, you didn’t kill anyone, or otherwise royally screw up enough for us to notice you and kick you out, so take this diploma and please be on your way.” Some of that jaundiced view may have come from end-of-residency burn out. Some of it may have come from going to a big program where I didn’t really get to know many of my staff that well - I can count on one hand the number of people I had as supervising staff for more than one solid 2 week block. (Don’t get me wrong, my big program had lots of advantages, and I wouldn’t go back and go anywhere else, but being a personal, close-knit program was not one of them.) Some of it may come from the fact that in America, residency is just one more required step on the road to being an independent doctor - an important one, and one I’m glad I completed, but not something special.
The crowd looking on - the fathers of Lao medicine are in the R foreground.
In Laos, I feel like graduation IS special and meaningful. There are more than 100 Lao medical school graduates each year (and the number is growing every year.) Our programs each accept 5-8 new residents each year, and even if you add in the surgery, ob-gyne, family practice, and anesthesia residencies, still most practicing doctors in Lao have not completed a formal residency training, and there aren’t residency spots for everyone graduating from medical school. So our residents are special just by virtue of being in residency - they have taken a test for admission and many have had to move away from their families and live in dorms for 3 years to complete residency. They also give up any income they might have from private clinics during the 3 years they are here, so they have to really want to come. They are, almost uniformly, eager learners, gracious, and very concerned about doing what’s best for their patients. So it was exciting to celebrate the graduates, the new residents, the teachers, and the program in general.
Three of my residents arrived in these dapper suits - Men in Black!
The formal part of the night was relatively short - just over an hour. I welcomed everyone and introduced the Ambassador, who gave a short speech in Lao and English. The current Ambassador, Her Excellency Karen Stewart, was the Charge D’Affairs (interim head of the embassy) when the tradition of having graduation at the Ambassador’s residence was started 10 years ago, and this is her first year back as Ambassador, so that was nice. I was impressed that she spoke in both Lao and English. The Lao people were impressed by how tall she is for a woman - she is quite tall, and towered over (in a very friendly, welcoming way) all the Lao guests. I bet she gets really, really tired of comments about her height.
Libby + Ambassador Stewart
Then, Margie introduced Dr. Bounkong, one of the founders of the IM program, who has supported HF since we started working in Laos, through multiple job changes for him. His most recent promotion was to Vice-Minister of Health, so he spoke on behalf of the Ministry of Health. Then Margie introduced Dr. Alounyadeth from UHS, who welcomed everyone again and spoke briefly about the partnership with UHS. Margie’s introductions included this: “The success of the pediatric and internal medicine residency programs is built on the strong leadership of the Ministry of Health and the long-standing collaboration between the Ministry of Health and Health Frontiers. This year, Health Frontiers celebrates its 20th year of partnership with the Ministry of Health with our mutual goal of improving the capacity of the health care workforce in Lao PDR.” The same is true of UHS, so we were happy to have representative of both organizations in attendance at the ceremony. It’s also great that HF has been in Lao for 20 years this year- not many groups have been working here that long. We are small, and our mission is small, but we keep at it, and every year we finish training a few more pediatricians and internists!
Dr. Bounkong addressing the crowd.
Next, The peds section began. Dr. Khampe, the director of Settathirath hospital, gave a brief speech to the graduates. Then Amy and Margie introduced the new Peds residents and gave them their stethoscopes; each year HF buys decent-quality stethoscopes for the new residents. They gave the award for Best Teacher, and the awards for Best Resident from each class. (Voted by the Lao teachers.) This year, they added a new category - best resident by vote of their peers, and the selections all highlighted residents that Margie and Amy do consider to be excellent residents and leaders in their classes. (Despite my jaundiced view of my own graduation, I will say that our resident awards seemed to go to the appropriate people as well.) Finally, they announced all the Graduates, and gave them otoscope/opthamoscopes, certificates, and flowers.
The graduating class of Peds with the Ambassador
Then it was my turn to MC the IM section. (This was a lot of public speaking for me. I’ve gotten better at it over the years, and lecturing weekly has helped, but I still wasn’t totally comfortable.) I’m going to paste in a few more quotes from the actual ceremony, because they pretty accurately capture what I think was important to say.
“Tonight we celebrate the 7th class of internal medicine residency graduates. Upon graduation, there will be 43 Lao-trained internal medicine specialists working in Vientiane and 11 provinces. This year, we send our first graduates to work in Salavan and Louang Prabang provinces. We now also have 2 graduates who have completed sub-specialty fellowship training in Thailand, and 5 who are in fellowship training currently. It is exciting to see our graduates grow into competent and confident physicians but to also see the impact they make as they teach the next generation of medical professionals. All of this has been made possible through the hard work and dedication of the internal medicine teachers and the Lao Internal Medicine Association.” Then Dr. Vang Chu, Chair of the Cardio ward, president of the Lao Cardioloy association, and another wonderful, long term supporter of the residency program gave a short speech, in which he congratulated the residents and encouraged them to be lifelong learners, come to CME, and call their teachers if they ever needed help.
Dr. Vang Chu addresses the IM residents
Next, we introduced the new residents. “This is an exciting time of the academic year as we celebrate the graduation of one group of residents, rejoice in the promotion of our continuing residents and welcome a new group of physicians to start this amazing journey. It is a difficult decision to leave your job and for some, your home and family to pursue further medical education and all the hard work that goes with it. But we are pleased that this year, six more physicians have decided to take the challenge.” Residency selection was such a challenge for IM this year, I can sincerely say that I do rejoice in having these 6 residents finally started and learning. I’m glad they all have decent stethoscopes now, too, we can start (gently) pimping them on heart and lung findings. . .
I present Ammala with her stethoscope.
Next, we thanked last year’s chief residents, who have tirelessly, and often thanklessly, worked to make sure they had lectures scheduled (I help with this, but they usually remind the teachers the day before and make the calls for a fill in lecturer when someone cancels.) They also gently and patiently steer me back to the correct path if I’ve gone astray on some planning or communications issue, and translate English lectures into Lao for their classmates who aren’t yet fluent in English. Our chiefs are just second and third year residents, and they don’t get any extra compensation for doing this delicate job. Then the graduating chiefs presented the Best Teacher award. This year, it went to Dr. Bouachanh from the GI ward. Last year too, and probably many years before that. I think the vote was probably unanimous (Novalinh counted it for me.) So no one was surprised by that. :) Dr. Bouachanh did residency in IM in the soviet bloc, and he is a soft spoken man, but also a truly excellent clinical teacher. The GI ward gets all the patients who don’t clearly belong on the Cardio, ID, or Pulmonary wards at Mahosot, so he’s really a great general internist as well, and he knows a lot about Lao presentations of confusing diseases. He is old enough to retire, but still comes to the hospital every single day to check on the patients and teach.
Phanivone and Phonpadith present Dr. Bouachanh with his award.
Then we gave resident awards - to the outstanding residents and most improved residents in each class. Voting for this was close, and the results changed several times in the 2 days before the ceremony as more people called in last minute votes. My introductory statements were: “Each year, the teachers like to acknowledge the most improved resident in each class. I am glad that I was not asked to vote for this award, because I am continually impressed by how much each one of you has learned, and what great questions you ask that require me to learn.” and “Each year the teachers also acknowledge an outstanding resident in each class. Again, I am glad not to have to vote, because each of you exhibits excellence in different areas, and it would have been hard to choose just one.” Both of these statements are sincere - I really don’t know who I would have voted for in either category for most of the classes - because there are so many residents who exhibit a keen ability to learn and / or clinical excellence.
Chief resident Saysavath accepts the best resident award for the 2nd year class.
Finally, in the end of the formal ceremony, we announced the IM graduates. They got a certificate, flowers, and a glucometer as a parting gift. In years past we’ve given them text books, but I think the glucometer is a practical gift that will get used - even by the residents who don’t read English well enough to really make use of a text - so I’m pleased with it. Last year, the presents didn’t get here until after the ceremony, and we ended up giving them at the University ceremony for peds and at CME for IM, so it was also nice to have them to give on the actual night of the ceremony. This is what I said: “We would like to honor and congratulate the Internal medicine graduates of 2010. I have only known them for 9 short months, but I feel confident that each and every one of these doctors will go on to be a teacher and leader in the hospitals in which they practice. Four of them will be returning to provincial or district hospitals this year, and three of them will be the first specialty-trained internists in the hospital when they arrive.” Dr. Bounkong, Dr. Vang Chu, and Dr. Bouachanh presented the certificates and presents to the residents as I read their names, so they were literally each surrounded by their incredible, supportive teachers who are great role models for them as the enter independent practice again.
Dr. Chirapha surrounded by her teachers.
The Ambassador briefly closed the official part of the event, and we proceeded to a flurry of snacking and picture taking. I hope the above description captures some of why it was such a nice event for me. At 8, we cleared out of the Ambassadors house and the peds residents went for karaoke. There, I got to see a very different - less serious, less shy - side of them, which was nice. Plus there were some very inappropriate videos with the English Karaoke songs, which was, well, not so nice, but pretty hilarious.
Ambassador and all IM grads
Me and all 7 of my grads, plus some other residents.
Why did this event seem so much more special to me? I saw my own residency graduation as more of a formality - a “Here, you didn’t kill anyone, or otherwise royally screw up enough for us to notice you and kick you out, so take this diploma and please be on your way.” Some of that jaundiced view may have come from end-of-residency burn out. Some of it may have come from going to a big program where I didn’t really get to know many of my staff that well - I can count on one hand the number of people I had as supervising staff for more than one solid 2 week block. (Don’t get me wrong, my big program had lots of advantages, and I wouldn’t go back and go anywhere else, but being a personal, close-knit program was not one of them.) Some of it may come from the fact that in America, residency is just one more required step on the road to being an independent doctor - an important one, and one I’m glad I completed, but not something special.
The crowd looking on - the fathers of Lao medicine are in the R foreground.
In Laos, I feel like graduation IS special and meaningful. There are more than 100 Lao medical school graduates each year (and the number is growing every year.) Our programs each accept 5-8 new residents each year, and even if you add in the surgery, ob-gyne, family practice, and anesthesia residencies, still most practicing doctors in Lao have not completed a formal residency training, and there aren’t residency spots for everyone graduating from medical school. So our residents are special just by virtue of being in residency - they have taken a test for admission and many have had to move away from their families and live in dorms for 3 years to complete residency. They also give up any income they might have from private clinics during the 3 years they are here, so they have to really want to come. They are, almost uniformly, eager learners, gracious, and very concerned about doing what’s best for their patients. So it was exciting to celebrate the graduates, the new residents, the teachers, and the program in general.
Three of my residents arrived in these dapper suits - Men in Black!
The formal part of the night was relatively short - just over an hour. I welcomed everyone and introduced the Ambassador, who gave a short speech in Lao and English. The current Ambassador, Her Excellency Karen Stewart, was the Charge D’Affairs (interim head of the embassy) when the tradition of having graduation at the Ambassador’s residence was started 10 years ago, and this is her first year back as Ambassador, so that was nice. I was impressed that she spoke in both Lao and English. The Lao people were impressed by how tall she is for a woman - she is quite tall, and towered over (in a very friendly, welcoming way) all the Lao guests. I bet she gets really, really tired of comments about her height.
Libby + Ambassador Stewart
Then, Margie introduced Dr. Bounkong, one of the founders of the IM program, who has supported HF since we started working in Laos, through multiple job changes for him. His most recent promotion was to Vice-Minister of Health, so he spoke on behalf of the Ministry of Health. Then Margie introduced Dr. Alounyadeth from UHS, who welcomed everyone again and spoke briefly about the partnership with UHS. Margie’s introductions included this: “The success of the pediatric and internal medicine residency programs is built on the strong leadership of the Ministry of Health and the long-standing collaboration between the Ministry of Health and Health Frontiers. This year, Health Frontiers celebrates its 20th year of partnership with the Ministry of Health with our mutual goal of improving the capacity of the health care workforce in Lao PDR.” The same is true of UHS, so we were happy to have representative of both organizations in attendance at the ceremony. It’s also great that HF has been in Lao for 20 years this year- not many groups have been working here that long. We are small, and our mission is small, but we keep at it, and every year we finish training a few more pediatricians and internists!
Dr. Bounkong addressing the crowd.
Next, The peds section began. Dr. Khampe, the director of Settathirath hospital, gave a brief speech to the graduates. Then Amy and Margie introduced the new Peds residents and gave them their stethoscopes; each year HF buys decent-quality stethoscopes for the new residents. They gave the award for Best Teacher, and the awards for Best Resident from each class. (Voted by the Lao teachers.) This year, they added a new category - best resident by vote of their peers, and the selections all highlighted residents that Margie and Amy do consider to be excellent residents and leaders in their classes. (Despite my jaundiced view of my own graduation, I will say that our resident awards seemed to go to the appropriate people as well.) Finally, they announced all the Graduates, and gave them otoscope/opthamoscopes, certificates, and flowers.
The graduating class of Peds with the Ambassador
Then it was my turn to MC the IM section. (This was a lot of public speaking for me. I’ve gotten better at it over the years, and lecturing weekly has helped, but I still wasn’t totally comfortable.) I’m going to paste in a few more quotes from the actual ceremony, because they pretty accurately capture what I think was important to say.
“Tonight we celebrate the 7th class of internal medicine residency graduates. Upon graduation, there will be 43 Lao-trained internal medicine specialists working in Vientiane and 11 provinces. This year, we send our first graduates to work in Salavan and Louang Prabang provinces. We now also have 2 graduates who have completed sub-specialty fellowship training in Thailand, and 5 who are in fellowship training currently. It is exciting to see our graduates grow into competent and confident physicians but to also see the impact they make as they teach the next generation of medical professionals. All of this has been made possible through the hard work and dedication of the internal medicine teachers and the Lao Internal Medicine Association.” Then Dr. Vang Chu, Chair of the Cardio ward, president of the Lao Cardioloy association, and another wonderful, long term supporter of the residency program gave a short speech, in which he congratulated the residents and encouraged them to be lifelong learners, come to CME, and call their teachers if they ever needed help.
Dr. Vang Chu addresses the IM residents
Next, we introduced the new residents. “This is an exciting time of the academic year as we celebrate the graduation of one group of residents, rejoice in the promotion of our continuing residents and welcome a new group of physicians to start this amazing journey. It is a difficult decision to leave your job and for some, your home and family to pursue further medical education and all the hard work that goes with it. But we are pleased that this year, six more physicians have decided to take the challenge.” Residency selection was such a challenge for IM this year, I can sincerely say that I do rejoice in having these 6 residents finally started and learning. I’m glad they all have decent stethoscopes now, too, we can start (gently) pimping them on heart and lung findings. . .
I present Ammala with her stethoscope.
Next, we thanked last year’s chief residents, who have tirelessly, and often thanklessly, worked to make sure they had lectures scheduled (I help with this, but they usually remind the teachers the day before and make the calls for a fill in lecturer when someone cancels.) They also gently and patiently steer me back to the correct path if I’ve gone astray on some planning or communications issue, and translate English lectures into Lao for their classmates who aren’t yet fluent in English. Our chiefs are just second and third year residents, and they don’t get any extra compensation for doing this delicate job. Then the graduating chiefs presented the Best Teacher award. This year, it went to Dr. Bouachanh from the GI ward. Last year too, and probably many years before that. I think the vote was probably unanimous (Novalinh counted it for me.) So no one was surprised by that. :) Dr. Bouachanh did residency in IM in the soviet bloc, and he is a soft spoken man, but also a truly excellent clinical teacher. The GI ward gets all the patients who don’t clearly belong on the Cardio, ID, or Pulmonary wards at Mahosot, so he’s really a great general internist as well, and he knows a lot about Lao presentations of confusing diseases. He is old enough to retire, but still comes to the hospital every single day to check on the patients and teach.
Phanivone and Phonpadith present Dr. Bouachanh with his award.
Then we gave resident awards - to the outstanding residents and most improved residents in each class. Voting for this was close, and the results changed several times in the 2 days before the ceremony as more people called in last minute votes. My introductory statements were: “Each year, the teachers like to acknowledge the most improved resident in each class. I am glad that I was not asked to vote for this award, because I am continually impressed by how much each one of you has learned, and what great questions you ask that require me to learn.” and “Each year the teachers also acknowledge an outstanding resident in each class. Again, I am glad not to have to vote, because each of you exhibits excellence in different areas, and it would have been hard to choose just one.” Both of these statements are sincere - I really don’t know who I would have voted for in either category for most of the classes - because there are so many residents who exhibit a keen ability to learn and / or clinical excellence.
Chief resident Saysavath accepts the best resident award for the 2nd year class.
Finally, in the end of the formal ceremony, we announced the IM graduates. They got a certificate, flowers, and a glucometer as a parting gift. In years past we’ve given them text books, but I think the glucometer is a practical gift that will get used - even by the residents who don’t read English well enough to really make use of a text - so I’m pleased with it. Last year, the presents didn’t get here until after the ceremony, and we ended up giving them at the University ceremony for peds and at CME for IM, so it was also nice to have them to give on the actual night of the ceremony. This is what I said: “We would like to honor and congratulate the Internal medicine graduates of 2010. I have only known them for 9 short months, but I feel confident that each and every one of these doctors will go on to be a teacher and leader in the hospitals in which they practice. Four of them will be returning to provincial or district hospitals this year, and three of them will be the first specialty-trained internists in the hospital when they arrive.” Dr. Bounkong, Dr. Vang Chu, and Dr. Bouachanh presented the certificates and presents to the residents as I read their names, so they were literally each surrounded by their incredible, supportive teachers who are great role models for them as the enter independent practice again.
Dr. Chirapha surrounded by her teachers.
The Ambassador briefly closed the official part of the event, and we proceeded to a flurry of snacking and picture taking. I hope the above description captures some of why it was such a nice event for me. At 8, we cleared out of the Ambassadors house and the peds residents went for karaoke. There, I got to see a very different - less serious, less shy - side of them, which was nice. Plus there were some very inappropriate videos with the English Karaoke songs, which was, well, not so nice, but pretty hilarious.
Ambassador and all IM grads
Tuesday, May 31, 2011
Strange
In addition to providing a culturally- contextual ear to chat to, my recent American visitors - Kim and Kate, and then Kristiana, an ER doc from Chicago, have made me think more concretely about here vs home and my time here. People from home often ask me what is different or strange here, and I often have trouble coming up with anything. My life here is radically different from my life in the US, but it’s normal for here, and some how my mind has quite effectively partitioned. I note things that you would never see, hear, or experience in the US, and I chuckle or think “what a shame” or think “I should take a picture”, but I rarely feel shocked or disturbed.
Example: Cats wandering the corridors of the hospital, sneaking under the chairs as I teach lecture in the resident room, or, once, a tiny kitten crouched in the middle of a wide wheelchair. In America, this would be incredibly rare, but it’s normal here, and while I recognize that there is a public health risk, I also like cats and know that they probably kill mice and roaches that would otherwise be infesting the hospital. (The week after Phi Mai, there was a constant stream of roaches from the nurses room at Setta. Someone must have left a lot of food in there, and the cats can’t get in. THAT did disgust me a little, along with just being impressive.)
Cat napping on a transport stretcher at Mahosot hospital - photo credit to Kim.
Example: a man I saw last week with an absent femoral pulse and blue, cold leg. He had been started on a heparin drip without any imaging, and the team was hoping to get an ultrasound that afternoon, but it was in no way perceived as a medical emergency the way it would have been in the US. Did I encourage my residents to talk to the ultrasound tech about what they were looking for and why, and get the scan ASAP? Yes. Did I freak out the way I might have at home? No.
Example: I see a man with a giant, peripherally calcified mass that appears to arise from his pleura and has completely displaced most of the left lower lobe of his lung. You do not see x-rays like this in America. Chronic cough gets an X-ray sooner than this. What is it? Tumor? Could be. . . Infection? Could be. . . but it’s something crazy either way. I’ll probably never know. I hope they find a way to biopsy, but I know that they probably won’t, and it doesn’t really bother me that I will likely never know what it was.
Incredible Lung mass CT - the x-ray is even more impressive.
However, at some point in the last 2 weeks I realized I have been here for 9 months, and have just over 5 months left of my stay. I’m no longer hovering around the halfway mark of my visit, I’m well into the second half. That does seem strange. It is crazy that I’ll be home in significantly less time that the time I’ve already been here. A small part of me is tempted to volunteer to stay on through the spring - we still haven’t found anyone to take over my job when I leave - but I know I need to get home and start preparing for the next stage in my life, and I also know I need the money I can make working at home. This volunteer job has been wonderful - I love my residents, the Lao staff doctors and teachers, teaching has been incredibly rewarding (see previous post), my schedule is much nicer than that of residency, and I am healthier than I’ve been in a long time physically. But it hasn’t been great for the metaphorical pocket book. I’m not accruing interest on my student loans, but I’m not paying them off. And I haven’t made any super close friends here, so I think it will be nice to get back to a familiar social circle as well.
But there’s so much I haven’t done. . . I haven’t learned nearly as much Lao language as I would like to, and have lost most of my motivation to do so. I still haven’t really been to Bangkok, which I’m not excited about, but I know is an experience I’m supposed to have while in SE Asia. I haven’t been to Muang Sing and Luang Nam Tha, Chang Mai, Siem Reip, back to Luang Prabang, or even to the Patu Xai and Korp Jai Der in Vientiane. I know that some of these things will probably not end up happening before I leave. I start feeling that bitter-sweet moving feeling, though my ticket home isn’t till December. I start to buying souvenirs for people at home. (People other than me - if you have a specific request, probably now is the time to get it in.) And I start to realize that I will really really miss many of the things about life here in Vientiane, and I think the transition home will be much harder than the transition here was.
Free Right Turn - something I thought was crazy when I got here, and have become totally adjusted to. If I don't get at ticket for turning right on a red within a year of coming home it will be a miracle.
Example: Cats wandering the corridors of the hospital, sneaking under the chairs as I teach lecture in the resident room, or, once, a tiny kitten crouched in the middle of a wide wheelchair. In America, this would be incredibly rare, but it’s normal here, and while I recognize that there is a public health risk, I also like cats and know that they probably kill mice and roaches that would otherwise be infesting the hospital. (The week after Phi Mai, there was a constant stream of roaches from the nurses room at Setta. Someone must have left a lot of food in there, and the cats can’t get in. THAT did disgust me a little, along with just being impressive.)
Cat napping on a transport stretcher at Mahosot hospital - photo credit to Kim.
Example: a man I saw last week with an absent femoral pulse and blue, cold leg. He had been started on a heparin drip without any imaging, and the team was hoping to get an ultrasound that afternoon, but it was in no way perceived as a medical emergency the way it would have been in the US. Did I encourage my residents to talk to the ultrasound tech about what they were looking for and why, and get the scan ASAP? Yes. Did I freak out the way I might have at home? No.
Example: I see a man with a giant, peripherally calcified mass that appears to arise from his pleura and has completely displaced most of the left lower lobe of his lung. You do not see x-rays like this in America. Chronic cough gets an X-ray sooner than this. What is it? Tumor? Could be. . . Infection? Could be. . . but it’s something crazy either way. I’ll probably never know. I hope they find a way to biopsy, but I know that they probably won’t, and it doesn’t really bother me that I will likely never know what it was.
Incredible Lung mass CT - the x-ray is even more impressive.
However, at some point in the last 2 weeks I realized I have been here for 9 months, and have just over 5 months left of my stay. I’m no longer hovering around the halfway mark of my visit, I’m well into the second half. That does seem strange. It is crazy that I’ll be home in significantly less time that the time I’ve already been here. A small part of me is tempted to volunteer to stay on through the spring - we still haven’t found anyone to take over my job when I leave - but I know I need to get home and start preparing for the next stage in my life, and I also know I need the money I can make working at home. This volunteer job has been wonderful - I love my residents, the Lao staff doctors and teachers, teaching has been incredibly rewarding (see previous post), my schedule is much nicer than that of residency, and I am healthier than I’ve been in a long time physically. But it hasn’t been great for the metaphorical pocket book. I’m not accruing interest on my student loans, but I’m not paying them off. And I haven’t made any super close friends here, so I think it will be nice to get back to a familiar social circle as well.
But there’s so much I haven’t done. . . I haven’t learned nearly as much Lao language as I would like to, and have lost most of my motivation to do so. I still haven’t really been to Bangkok, which I’m not excited about, but I know is an experience I’m supposed to have while in SE Asia. I haven’t been to Muang Sing and Luang Nam Tha, Chang Mai, Siem Reip, back to Luang Prabang, or even to the Patu Xai and Korp Jai Der in Vientiane. I know that some of these things will probably not end up happening before I leave. I start feeling that bitter-sweet moving feeling, though my ticket home isn’t till December. I start to buying souvenirs for people at home. (People other than me - if you have a specific request, probably now is the time to get it in.) And I start to realize that I will really really miss many of the things about life here in Vientiane, and I think the transition home will be much harder than the transition here was.
Free Right Turn - something I thought was crazy when I got here, and have become totally adjusted to. If I don't get at ticket for turning right on a red within a year of coming home it will be a miracle.
Saturday, May 28, 2011
Cinco De Mayo (Late)
It’s been a while since my last post. I am going to blame my latest visitors - Kim and Kate, two pediatric residents from Case Western who stayed here at the office house with me. They were smart, easygoing, and fun, and so my dinner out schedule has been pretty full. There’s something about communicating with a fellow American that is much easier than even another native english speaker from elsewhere. Maybe it’s that we all have the same starting context - growing up in the middle of the country in middle class families, or that we speak the same version of English, or just sharing the larger context of American culture. (Some will argue that America is acultural - I disagree - we may not always like our culture, but we do have one.) Whatever it is, I immediately felt like I didn’t have to censor myself with Kim and Kate (and with my last visitor from San Diego as well) in a way that I still do have to with my Australian colleagues that I’ve now known for months or other people that I’ve spent many hour socially with since arriving here. That can be draining. So it was nice to have 3 weeks of totally ‘normal’ conversations and interactions. Plus, they invited me to Vang Vieng and I finally got to go tubing!
Kim and Kate in a cave in Vang Vieng
May 5th was the IM final exam. The teachers set up a 10 station OSCE. (Objective Structured Clinical Exam - practice patients or clinical scenarios that the residents have 10 minutes to assess and answer some questions.) I was impressed that the Lao teachers care enough about their residents progress to organize this time-and man-power intensive evaluation. My last OSCE was during residency orientation on ‘challenging patients’ but after that, there was no formal evaluation of clinical skills during my residency training. (Though I was perhaps a bit more closely supervised on a day-to-day basis on many of my rotations than my Lao residents are on many of theirs.) Another part of me was glad that I didn’t have the stress of an OSCE added to residency - nor any sort of multiple choice testing that actually ‘counted’ towards completion of residency.
Two of 10 OSCE stations in progress
I had 2 very nice moments on May 5th. The first was when I learned that one of the graduating residents had gotten a perfect score on the EKG OSCE station. She is a quite, shy, unconfident resident from one of the most distant, poorest provinces, and she came to residency knowing a lot less than some of the other residents. She has learned a lot, but there have still been questions from the medicine teachers about whether she has learned enough to graduate. And sometimes some of the more confident residents give her a hard time, which I really dislike. I think they think that she is slow to answer questions partly just because she is so shy and unconfident - but when I actually take time to listen to her go all the way through a patient presentation she usually has a decent assessment, differential diagnosis, and plan. I suspect the teachers just get impatient with her and then she probably gets flustered and doesn’t do well. And she is very deferential - she probably doesn’t feel comfortable telling her superiors what she wants to do and is instead happy to have them tell her what to do. So anyway, I have been a bit worried that there will be a fight to have her graduate, and then she got a perfect score on the EKG station (which I think I could not have done.) Only 3 or 4 other residents did this - and none of the residents from the cardio ward who were supposedly teaching the others EKG the day before the test did it. So that will be some leverage if there is a discussion about whether to graduate her. Plus, it is just great to see her quiet, deliberate, methodical work outshine the bolder, more confident approach of some of her classmates.
The second half, waiting for their test to start.
The second was when one of the interns glowingly thanked me for helping to prepare “this competition” (the test.) He was very pleased with the test because it had made him aware of how much he needs to learn. He said he doesn’t care how he does on “the competition”, but he is afraid of not knowing enough and hurting a patient, and so he is grateful for the opportunity to assess his knowledge and maybe realize that he needs to study more or differently. Can you imagine an American resident (or medical student) thanking someone after a test in the same way? I think not - we are too prideful to appreciate (at least out loud) an opportunity to realize how little we know.
The first group in the hospital cafeteria after the OSCE
After the test, I helped the resident arrange review on some of the subjects they found most challenging, and I gave another EKG lecture and started using some of Dr. Wong’s practice EKGs that I brought with me. They were hesitant at first, but they got into reading them pretty quickly, and I think if we do a few more afternoons, they may even be willing to then self-study or quiz each other.
Last, but far from least, I finally have new residents! They started on may 12th, almost 4 weeks late, and I only have 6 (which is fine), and only one from the provinces (not so great), but they are all lovely, and eager to learn. I am very glad to have not failed completely in getting a new class of residents. May was spent doing orientation for them (the Lao teachers teach orientation, since many of the residents have minimal english skills at the start) and filling in other things for the 2nd and 3rd years - review and some pain and symptom management talks (my soap-box, but also something they need to know in a place where they can’t treat cancer and some other diseases, and something they don’t do fabulously currently.) It was nice to be back to lecturing after having most of April for test review and much of March taught by a visiting lecturer. June will be Neuro month, so I will spend the weekend preparing lectures on after-stroke cares, delirium, or dementia. Or maybe I’ll start all 3 and see which one will be the simplest to start with next week.
Me and many lao kids in the swimming hole in Vang Vieng.
Kim and Kate in a cave in Vang Vieng
May 5th was the IM final exam. The teachers set up a 10 station OSCE. (Objective Structured Clinical Exam - practice patients or clinical scenarios that the residents have 10 minutes to assess and answer some questions.) I was impressed that the Lao teachers care enough about their residents progress to organize this time-and man-power intensive evaluation. My last OSCE was during residency orientation on ‘challenging patients’ but after that, there was no formal evaluation of clinical skills during my residency training. (Though I was perhaps a bit more closely supervised on a day-to-day basis on many of my rotations than my Lao residents are on many of theirs.) Another part of me was glad that I didn’t have the stress of an OSCE added to residency - nor any sort of multiple choice testing that actually ‘counted’ towards completion of residency.
Two of 10 OSCE stations in progress
I had 2 very nice moments on May 5th. The first was when I learned that one of the graduating residents had gotten a perfect score on the EKG OSCE station. She is a quite, shy, unconfident resident from one of the most distant, poorest provinces, and she came to residency knowing a lot less than some of the other residents. She has learned a lot, but there have still been questions from the medicine teachers about whether she has learned enough to graduate. And sometimes some of the more confident residents give her a hard time, which I really dislike. I think they think that she is slow to answer questions partly just because she is so shy and unconfident - but when I actually take time to listen to her go all the way through a patient presentation she usually has a decent assessment, differential diagnosis, and plan. I suspect the teachers just get impatient with her and then she probably gets flustered and doesn’t do well. And she is very deferential - she probably doesn’t feel comfortable telling her superiors what she wants to do and is instead happy to have them tell her what to do. So anyway, I have been a bit worried that there will be a fight to have her graduate, and then she got a perfect score on the EKG station (which I think I could not have done.) Only 3 or 4 other residents did this - and none of the residents from the cardio ward who were supposedly teaching the others EKG the day before the test did it. So that will be some leverage if there is a discussion about whether to graduate her. Plus, it is just great to see her quiet, deliberate, methodical work outshine the bolder, more confident approach of some of her classmates.
The second half, waiting for their test to start.
The second was when one of the interns glowingly thanked me for helping to prepare “this competition” (the test.) He was very pleased with the test because it had made him aware of how much he needs to learn. He said he doesn’t care how he does on “the competition”, but he is afraid of not knowing enough and hurting a patient, and so he is grateful for the opportunity to assess his knowledge and maybe realize that he needs to study more or differently. Can you imagine an American resident (or medical student) thanking someone after a test in the same way? I think not - we are too prideful to appreciate (at least out loud) an opportunity to realize how little we know.
The first group in the hospital cafeteria after the OSCE
After the test, I helped the resident arrange review on some of the subjects they found most challenging, and I gave another EKG lecture and started using some of Dr. Wong’s practice EKGs that I brought with me. They were hesitant at first, but they got into reading them pretty quickly, and I think if we do a few more afternoons, they may even be willing to then self-study or quiz each other.
Last, but far from least, I finally have new residents! They started on may 12th, almost 4 weeks late, and I only have 6 (which is fine), and only one from the provinces (not so great), but they are all lovely, and eager to learn. I am very glad to have not failed completely in getting a new class of residents. May was spent doing orientation for them (the Lao teachers teach orientation, since many of the residents have minimal english skills at the start) and filling in other things for the 2nd and 3rd years - review and some pain and symptom management talks (my soap-box, but also something they need to know in a place where they can’t treat cancer and some other diseases, and something they don’t do fabulously currently.) It was nice to be back to lecturing after having most of April for test review and much of March taught by a visiting lecturer. June will be Neuro month, so I will spend the weekend preparing lectures on after-stroke cares, delirium, or dementia. Or maybe I’ll start all 3 and see which one will be the simplest to start with next week.
Me and many lao kids in the swimming hole in Vang Vieng.
Wednesday, May 4, 2011
Nationality, Ethnicity, and Home
Several things have made me think more about the above these past couple weeks. We have a medical student visiting from America. Her parents emigrated to the US during the secret war and she was born and raised there. I’ve been introducing her as “ethnically Lao” - she has two Lao parents, and she’s American, but clearly she has Lao ancestry. Actually, I think one parent’s family would have considered themselves ethnically Chinese, not ethnically Lao, while they were in Laos. (Though several generations of them may have lived in Lao.) So is she ethnically Chinese? Really, she is just as American as me - English was her first Language, and she misses pizza just as much as I do. (But cheese not quite so much. :) ) There’s a temptation to introduce her as Lao so that people here will embrace her - and she does speak some Lao and understand a lot, so she has an advantage there. But at some point I realized this also isn’t fair to her. She’s American - and introducing her as Lao may set up expectations she can’t live up too.
I’ve been hoping she would finish residency and then find some way to come back and help Lao - maybe just short visits, or maybe a longer commitment. Having HF as a connection could help her forge relationships where she could make a lasting difference. But then one evening last week I realized that it’s quite possible she doesn’t feel Lao at all, or feel any connection or obligation to this place. Her parents left a country that was in the middle of a war where they were poor and are now successful and happy in a new home, where they’ve had and raised children. Her family had to leave this place to be happy, and America is the place where she had the opportunities that have allowed her to return here. Maybe she’s just here because her family wanted to come, or out of simple curiosity. But maybe she has no more reason to feel a connection, or want to help here, than someone like me would. (She’s a lovely person, and assures me this is not true and she is interested in helping here in the long run. But the point is, there’s really no reason to assume she would be.)
At the dentist yesterday, the dentist asked me where I was from. “America” Where are you from before that “Um, I’ve always been an American?” No, he wanted to know what my ethnic background - it’s a longer, but in some ways more simple answer. I’m 1/4th German, 1/4 Norwegian, and 1/2 mixed British Empire. One branch of the family can be traced back to the Mayflower, and Dad’s side has been in America so long it can pretty much just be called American. I’ve never felt Norwegian, German, or British - I’m American. I would even say that I’m “ethnically American.” And I’m generally proud to be an American. I don’t agree with everything our government does, or with many of my fellow citizens, but traveling and living abroad always reminds me that there is no other place in the world that I would rather call home. We’re not a perfect nation (no one is) but it’s a good place to be from.
Over the course of my life, I’ve had many friends and colleagues who had different perspectives on this. In primary and secondary school, I had black friends who’s families had also been American for many generations - but who probably had a very different perspective on what that history meant. Certainly being an African American has been much harder than being a white American for much of our history. I also had friends who’s parents had emigrated from Mexico and spoke little English and friends who’s families had lived in the south west for many generations but still spoke Spanish as their primary language. Indeed, the first (and for many years only) settlers in Colorado were Spanish speakers. However, both these groups might be perceived as ‘un-American’ by many of my countrymen.
In medical school and residency, I’ve had friends who considered themselves American, but who were constantly asked where they were from because they didn’t look look or sound exactly like our concept of “American.” Their whole families lived in America, they had done much of their schooling in America, they had American citizenship, some were born in America, but they had tan/brown skin and black hair (and sometimes a slight accent) so they must be “from” somewhere else. I know they got tired of this question - America is their home, probably the only place they’d ever want to live - so why are they perceived as foreign by so many? I also had friends in residency who were from elsewhere and had come to America for training they couldn’t get at home. Some were counting the days till they could go home, and others would be happy to spend the rest of their careers in America. (All of the foreign medical grads I worked with were more knowledgeable, smarter, and harder working than the average American medical grad, so we should be happy to have them should they choose to stay.) After all - that is the American dream - you (or your parents) come here, work hard, contribute, have opportunities you might not have at home (at costs you wouldn’t have at home), and become a successful member of American society. One we constantly ask “where are you really from?” (Oh, wait, that’s not part of the American dream, is it?)
However, I must admit, that a small part of me wished I could claim some other country as my native land yesterday at the dentist. The images I saw on BBC over the weekend of drunk Americans celebrating the death of Osama Bin Laden in front of the White House have stuck with me. Don’t get me wrong, I’m not upset that the US killed Bin Laden. Generally, I am anti-death penalty and I think vengeance in place of justice costs us a lot in American society - morally, and in the actual cost of killing people in the course of ‘justice.’ But I’m also a realist, and in this particular case, I can’t see what capturing him would have done but waste time and money. He was never going to cooperate with a trial, or recant his evil teachings. It seems very unlikely that he was going to have a last minute revelation and see the world as governed by a god of peace - Islamic, Christian, Jewish, Hindi, Buddhist, or otherwise. He might have used a trial / incarceration as an ongoing platform from which to spread a message of hate. And his guilt in instigating terrorist attacks is not questioned, or really questionable - he proudly takes responsibility for them. I am sure he had no intention of being captured, and would not have complied with incarceration, likely ultimately trying to commit suicide, but probably trying to take some captors with him.
So in this case I think the practical choice was, in fact, to go ahead and kill him immediately, and I think this was also just. However, that is certainly not a choice or situation I see worthy of celebration. Relief, yes. Sadness for all the people he has killed over the years, for whom his death does nothing, yes (young Muslims he indoctrinated into suicide missions included.) Joy, no. No one won in this battle, but hopefully some people stopped loosing.
I also keep remembering a young man who was particularly jubilant stating “It’s finally over, after 10 years!” Umm. . . what is over exactly? We still have thousands of troops in Iraq and Afghanistan. All the people Bin Laden trained and the network he set up are still alive, functional, and probably more pissed off than ever. If he didn’t have a plan in place for this very possibility, and a successor chosen, I’ll be surprised. I hope that this can be another step to Afghanistan and Iraq having stable, independent, democratic governments, but it certainly isn’t the last. And I hope it leads to a decreased American presence in Afghanistan and Iraq, but I doubt it will change things immediately or dramatically. These images - celebrating the death of a human being, thinking that killing one many will solve big problems for our nation - bother me because they are wrong - morally, and also just incorrect. But also because this is now the image that is projected to the rest of the world. And that makes a small part of me wish I could claim to be something else. Oh, I’m from America, but I’m. . .
Nationhood/Personhood/Ethnicity seems like it should be simpler in a place like Laos - only 6 million people, relatively stable population. However, Lao citizens identify themselves as being from many different communities or groups. There are people who are Chinese or Vietnamese ethnically, though their families may have been in Lao for generations, they still identify as being from somewhere else. There are the lowland Lao - ethnically Lao, and with the traditions that foreigners perceive as “Lao”. And there are the highland Lao and other tribal/ethnic groups. Many have their own languages - last week one of my residents had to translate from Hmong to Lao (for the other Lao doctors) and Hmong to English (for me) to present a patient . I don’t even know how many actual languages are spoken in Lao. And they certainly have their own values and traditions, some of which may be perceived as very odd by lowland Lao.
I guess who you are and where you are ‘from’ can be complicated anywhere. It can be complicated in America, where you may have been born elsewhere but see America as the land that nurtured you. Or you may have been born in America but raised in a community that was really ethnically and culturally much more aligned with some other nation. Or you could be born in rural Laos and never go more than 100 km from your village, but identify yourself as Hmong or Acca - and see Laos as a contrived politically defined state, not a group you belong to. I suppose I am very lucky that I identify myself as American, and for the most part, no one questions that idea. But it means I have to be even more careful about assumptions I may make about other people.
I’ve been hoping she would finish residency and then find some way to come back and help Lao - maybe just short visits, or maybe a longer commitment. Having HF as a connection could help her forge relationships where she could make a lasting difference. But then one evening last week I realized that it’s quite possible she doesn’t feel Lao at all, or feel any connection or obligation to this place. Her parents left a country that was in the middle of a war where they were poor and are now successful and happy in a new home, where they’ve had and raised children. Her family had to leave this place to be happy, and America is the place where she had the opportunities that have allowed her to return here. Maybe she’s just here because her family wanted to come, or out of simple curiosity. But maybe she has no more reason to feel a connection, or want to help here, than someone like me would. (She’s a lovely person, and assures me this is not true and she is interested in helping here in the long run. But the point is, there’s really no reason to assume she would be.)
At the dentist yesterday, the dentist asked me where I was from. “America” Where are you from before that “Um, I’ve always been an American?” No, he wanted to know what my ethnic background - it’s a longer, but in some ways more simple answer. I’m 1/4th German, 1/4 Norwegian, and 1/2 mixed British Empire. One branch of the family can be traced back to the Mayflower, and Dad’s side has been in America so long it can pretty much just be called American. I’ve never felt Norwegian, German, or British - I’m American. I would even say that I’m “ethnically American.” And I’m generally proud to be an American. I don’t agree with everything our government does, or with many of my fellow citizens, but traveling and living abroad always reminds me that there is no other place in the world that I would rather call home. We’re not a perfect nation (no one is) but it’s a good place to be from.
Over the course of my life, I’ve had many friends and colleagues who had different perspectives on this. In primary and secondary school, I had black friends who’s families had also been American for many generations - but who probably had a very different perspective on what that history meant. Certainly being an African American has been much harder than being a white American for much of our history. I also had friends who’s parents had emigrated from Mexico and spoke little English and friends who’s families had lived in the south west for many generations but still spoke Spanish as their primary language. Indeed, the first (and for many years only) settlers in Colorado were Spanish speakers. However, both these groups might be perceived as ‘un-American’ by many of my countrymen.
In medical school and residency, I’ve had friends who considered themselves American, but who were constantly asked where they were from because they didn’t look look or sound exactly like our concept of “American.” Their whole families lived in America, they had done much of their schooling in America, they had American citizenship, some were born in America, but they had tan/brown skin and black hair (and sometimes a slight accent) so they must be “from” somewhere else. I know they got tired of this question - America is their home, probably the only place they’d ever want to live - so why are they perceived as foreign by so many? I also had friends in residency who were from elsewhere and had come to America for training they couldn’t get at home. Some were counting the days till they could go home, and others would be happy to spend the rest of their careers in America. (All of the foreign medical grads I worked with were more knowledgeable, smarter, and harder working than the average American medical grad, so we should be happy to have them should they choose to stay.) After all - that is the American dream - you (or your parents) come here, work hard, contribute, have opportunities you might not have at home (at costs you wouldn’t have at home), and become a successful member of American society. One we constantly ask “where are you really from?” (Oh, wait, that’s not part of the American dream, is it?)
However, I must admit, that a small part of me wished I could claim some other country as my native land yesterday at the dentist. The images I saw on BBC over the weekend of drunk Americans celebrating the death of Osama Bin Laden in front of the White House have stuck with me. Don’t get me wrong, I’m not upset that the US killed Bin Laden. Generally, I am anti-death penalty and I think vengeance in place of justice costs us a lot in American society - morally, and in the actual cost of killing people in the course of ‘justice.’ But I’m also a realist, and in this particular case, I can’t see what capturing him would have done but waste time and money. He was never going to cooperate with a trial, or recant his evil teachings. It seems very unlikely that he was going to have a last minute revelation and see the world as governed by a god of peace - Islamic, Christian, Jewish, Hindi, Buddhist, or otherwise. He might have used a trial / incarceration as an ongoing platform from which to spread a message of hate. And his guilt in instigating terrorist attacks is not questioned, or really questionable - he proudly takes responsibility for them. I am sure he had no intention of being captured, and would not have complied with incarceration, likely ultimately trying to commit suicide, but probably trying to take some captors with him.
So in this case I think the practical choice was, in fact, to go ahead and kill him immediately, and I think this was also just. However, that is certainly not a choice or situation I see worthy of celebration. Relief, yes. Sadness for all the people he has killed over the years, for whom his death does nothing, yes (young Muslims he indoctrinated into suicide missions included.) Joy, no. No one won in this battle, but hopefully some people stopped loosing.
I also keep remembering a young man who was particularly jubilant stating “It’s finally over, after 10 years!” Umm. . . what is over exactly? We still have thousands of troops in Iraq and Afghanistan. All the people Bin Laden trained and the network he set up are still alive, functional, and probably more pissed off than ever. If he didn’t have a plan in place for this very possibility, and a successor chosen, I’ll be surprised. I hope that this can be another step to Afghanistan and Iraq having stable, independent, democratic governments, but it certainly isn’t the last. And I hope it leads to a decreased American presence in Afghanistan and Iraq, but I doubt it will change things immediately or dramatically. These images - celebrating the death of a human being, thinking that killing one many will solve big problems for our nation - bother me because they are wrong - morally, and also just incorrect. But also because this is now the image that is projected to the rest of the world. And that makes a small part of me wish I could claim to be something else. Oh, I’m from America, but I’m. . .
Nationhood/Personhood/Ethnicity seems like it should be simpler in a place like Laos - only 6 million people, relatively stable population. However, Lao citizens identify themselves as being from many different communities or groups. There are people who are Chinese or Vietnamese ethnically, though their families may have been in Lao for generations, they still identify as being from somewhere else. There are the lowland Lao - ethnically Lao, and with the traditions that foreigners perceive as “Lao”. And there are the highland Lao and other tribal/ethnic groups. Many have their own languages - last week one of my residents had to translate from Hmong to Lao (for the other Lao doctors) and Hmong to English (for me) to present a patient . I don’t even know how many actual languages are spoken in Lao. And they certainly have their own values and traditions, some of which may be perceived as very odd by lowland Lao.
I guess who you are and where you are ‘from’ can be complicated anywhere. It can be complicated in America, where you may have been born elsewhere but see America as the land that nurtured you. Or you may have been born in America but raised in a community that was really ethnically and culturally much more aligned with some other nation. Or you could be born in rural Laos and never go more than 100 km from your village, but identify yourself as Hmong or Acca - and see Laos as a contrived politically defined state, not a group you belong to. I suppose I am very lucky that I identify myself as American, and for the most part, no one questions that idea. But it means I have to be even more careful about assumptions I may make about other people.
Tuesday, April 26, 2011
Number Crunchers
When I was little, I think my mom really wanted me to grow up to be an engineer or mathematician. She pretty much taught me all the math I learned up until trigonometry, and I’m not sure why she stopped there. I didn’t mind math; type A people usually have a good relationship with it - we follow the rules and get the right answer - it’s simple, and rewarding. However, I was never passionate about it, and I never really understood calculus, despite multiple (some halfhearted) attempts to teach me. I could try blame the illness of my high school calculus teacher and subsequent string of subs and then a new teacher who had never taught calculus. But really, I don’t think I ever cared enough to try and learn it. I’m not really a math person. However, I did emerge from a family and education system that insisted I have not only the ability to memorize tables etc, but a basic understanding of math, at least up through geometry.
A couple weeks back we had a patient on the ward who was on prednisone for cancer symptoms, but really dexamethasone was better in that patient's particular situation. We could just give her the standard dose from America, but people are small here, and she was on a lower than standard dose of prednisone for an America-sized patient. Also, steroids tend to come in only tablets of very small doses here, so if you suggest a large dose, you’re recommendation may be ignored simply because it’s too many pills to take. So to decide on a dose I pulled out a handy pocket reference of equivalent steroid doses. 5mg prednisone = 0.75 mg Dexamethasone. She was on 40 mg of prednisone. In my head, (though it took longer than it should have) I calculated that she should get 6 mg dexamethasone daily. The residents whipped out their cell phone calculators. This gave me time to verify my result on paper, though it seemed like a simple enough calculation. After several minutes, we all agreed. Then a resident called the pharmacy and reported that they had 0.5 mg tabs. 6 tabs twice a day, eh? The resident wrote 3 tabs twice a day. It took several minutes and a return to the cell phone calculator to convince them otherwise.
My residents are smart, hardworking people. When they think critically, they ask insightful questions, and they learn quickly. The longer I am in Laos, however, the more I realize that they have been completely let down by the education system. The above example is one of the standard math knowledge/understanding, not of an abnormally low one. They can’t do simple multiplication or division in their heads. They can’t estimate - they are often off by an order of magnitude or more if asked to estimate something with a more complicated formula. (Like calculating a GFR or an accurate sodium in a patient with significant hyperglycemia.) I’ve never seen one do long division or multiplication on a piece of paper either. And Bryan, who lives in Muang Sing and supports and after-school math/computer tutorial there, reports that he recently found a child cheating using a multiplication table on their computer exercises. These are voluntary after school tutoring sessions - in fact, the kids have to sign up on a waiting list to get in - so there should be no pressure to cheat. However, if you really don’t understand multiplication, and rather have simply been told to memorize it, (Maybe by a teacher who doesn’t understand it either) I guess you might.
How do you take someone who has (through never having been exposed to adequate teaching) maybe never learned simple math, biology, chemistry, or physics, and make them a great doctor? Or a great professional in any field that requires critical thinking about science or math? If you don’t understand basic biology and chemistry, and also math, and some grasp on physics - dimensions, properties of liquids, etc - then how can you understand the pathophysiology of disease? And how can you critically think about treatment? You can’t - you have to rely on algorithmic thinking and protocols. (In American medicine we are recognizing the value of algorithms, protocols, and checklists, but these need to be based on an adequate assessment of the patient and understanding of disease process.) So it’s that much more impressive, then, that my residents know and are learning to make these assessments and critical thinking. If you don’t have a basic understanding of physics, then you need to learn about properties of liquids (blood) in tubes of varying diameters (blood vessels) before you can understand shock, and how septic and cardiogenic shock differ. They are learning these things on their own while we’re trying to teach more complicated concepts. And I think it’s incredible how well they are doing.
It’s also a great illustration of the vital importance of getting at least an adequate primary and secondary eduction - so today I thank all of my friends and readers who are teachers. Sometimes we take your hard work for granted, as if these concepts are so simple that any normal human could almost figure them out on their own. But when we actually think about it, someone taught us all of that information we access and use every day (without conscious awareness we are doing it.) And someone encouraged, or even forced, us to think critically about it and learn how to make a plan to solve a problem. So to my Mom, who taught me almost all the math I remember, and to all the people who taught me biology, chemistry, and physics, and to an education system that required me to learn critical thinking and creative problem solving: Thank you! And to my Lao residents and colleagues who somehow manage to be great doctors and learn despite an often incomplete foundation on which to build: thank you for persevering and working harder to learn things I take for granted.
A couple weeks back we had a patient on the ward who was on prednisone for cancer symptoms, but really dexamethasone was better in that patient's particular situation. We could just give her the standard dose from America, but people are small here, and she was on a lower than standard dose of prednisone for an America-sized patient. Also, steroids tend to come in only tablets of very small doses here, so if you suggest a large dose, you’re recommendation may be ignored simply because it’s too many pills to take. So to decide on a dose I pulled out a handy pocket reference of equivalent steroid doses. 5mg prednisone = 0.75 mg Dexamethasone. She was on 40 mg of prednisone. In my head, (though it took longer than it should have) I calculated that she should get 6 mg dexamethasone daily. The residents whipped out their cell phone calculators. This gave me time to verify my result on paper, though it seemed like a simple enough calculation. After several minutes, we all agreed. Then a resident called the pharmacy and reported that they had 0.5 mg tabs. 6 tabs twice a day, eh? The resident wrote 3 tabs twice a day. It took several minutes and a return to the cell phone calculator to convince them otherwise.
My residents are smart, hardworking people. When they think critically, they ask insightful questions, and they learn quickly. The longer I am in Laos, however, the more I realize that they have been completely let down by the education system. The above example is one of the standard math knowledge/understanding, not of an abnormally low one. They can’t do simple multiplication or division in their heads. They can’t estimate - they are often off by an order of magnitude or more if asked to estimate something with a more complicated formula. (Like calculating a GFR or an accurate sodium in a patient with significant hyperglycemia.) I’ve never seen one do long division or multiplication on a piece of paper either. And Bryan, who lives in Muang Sing and supports and after-school math/computer tutorial there, reports that he recently found a child cheating using a multiplication table on their computer exercises. These are voluntary after school tutoring sessions - in fact, the kids have to sign up on a waiting list to get in - so there should be no pressure to cheat. However, if you really don’t understand multiplication, and rather have simply been told to memorize it, (Maybe by a teacher who doesn’t understand it either) I guess you might.
How do you take someone who has (through never having been exposed to adequate teaching) maybe never learned simple math, biology, chemistry, or physics, and make them a great doctor? Or a great professional in any field that requires critical thinking about science or math? If you don’t understand basic biology and chemistry, and also math, and some grasp on physics - dimensions, properties of liquids, etc - then how can you understand the pathophysiology of disease? And how can you critically think about treatment? You can’t - you have to rely on algorithmic thinking and protocols. (In American medicine we are recognizing the value of algorithms, protocols, and checklists, but these need to be based on an adequate assessment of the patient and understanding of disease process.) So it’s that much more impressive, then, that my residents know and are learning to make these assessments and critical thinking. If you don’t have a basic understanding of physics, then you need to learn about properties of liquids (blood) in tubes of varying diameters (blood vessels) before you can understand shock, and how septic and cardiogenic shock differ. They are learning these things on their own while we’re trying to teach more complicated concepts. And I think it’s incredible how well they are doing.
It’s also a great illustration of the vital importance of getting at least an adequate primary and secondary eduction - so today I thank all of my friends and readers who are teachers. Sometimes we take your hard work for granted, as if these concepts are so simple that any normal human could almost figure them out on their own. But when we actually think about it, someone taught us all of that information we access and use every day (without conscious awareness we are doing it.) And someone encouraged, or even forced, us to think critically about it and learn how to make a plan to solve a problem. So to my Mom, who taught me almost all the math I remember, and to all the people who taught me biology, chemistry, and physics, and to an education system that required me to learn critical thinking and creative problem solving: Thank you! And to my Lao residents and colleagues who somehow manage to be great doctors and learn despite an often incomplete foundation on which to build: thank you for persevering and working harder to learn things I take for granted.
Tuesday, April 19, 2011
On the Eve of my 30th Birthday
I spent last week in Southern Lao, reading, relaxing, seeing tons of beautiful waterfalls, the rare (and endangered) Mekong River dolphin, and Wat Phu, a thousand year old Khmer temple. The last couple days were spent just enjoying Phi Mai Lao - Lao New Year. It’s always a little bit hard to travel by yourself. As people who have traveled with me can attest, I LOVE having my picture taken in front of stuff. I’m never going to get the perfect picture of a sight with my lack of photography skills and basic camera, so I should go ahead and buy a book or download a professional one if I want one. It’s not vanity; what I want is a picture proving I was there, and reminding myself what it was like to be there - how big were things? Was it super hot? Was I more interested in the plants or people than the location? - etc. It’s hard to get that picture on your own. I’m an expert at the old 10-second delay shot propped on something (usually my backpack) and I’m improving on my holding my camera up myself shots (though my arm’s aren’t super long, so this is hard). Of course you can always ask a fellow traveler to take the photo for you, but you can’t really direct them the way you would a friend, and if you want a picture with several things, that gets awkward quickly.
Libby taking a picture of herself at a waterfall.
Eating is another hard part of traveling alone. I have a great imagination and vivid internal dialogue, but I still get kind of bored/lonely when I’ve eaten 3 meals alone for several days. There’s always the read a book option - read the guidebook for you next destination, or something else you brought along. This is good, but often requires odd arrangements of condiments to keep the book open, and it’s distracting from both the book and the meal. There’s really nothing like sharing a good meal with a good conversation partner.
My hammock in the four thousand islands - the correct place to read a book
That said though, I had a great time. I imagine it would be hard to find a better place to be a solo woman traveler. Lao people are generally super friendly, honest, polite, and there is absolutely no overt sexism. It’s also a small place, without a lot of business travelers or white people who live there full time, so it’s easy to ID your fellow tourists and engage with them. Even local people who try to ‘take advantage’ of tourists never more than double the price they’d charge a Lao person. And in a country where the average income is less than a dollar a day, I can hardly be angry at them for charging a bit more from the white people who have clearly spent hundreds or thousands of dollars to be here. (I know young people like to travel in SE Asia because it’s cheap, but it does frustrate me when I see someone haggling or complaining about a markup 12.5 cents, or even a few dollars. That is a lot of money to the sales person and if 2 dollars is going to break your budget as a traveler, you probably shouldn’t be this far from home. Especially when I _regularly_ see patients leave the hospital with easily, and inexpensively treatable conditions because they can’t afford to be treated.) So if I had to pick a place to travel alone, this is a great one. And I’d rather see interesting things alone than stay at home.
Wat Phu, Champassak, Laos
As an aside - Phi Mai Lao may be my new favorite holiday. It’s like a cross between the world’s most innocent and sincere wet t-shirt contest and the world’s biggest water fight. It was 3 days of people at the side of the road throwing water (or hosing down) people in trucks, on motorbikes, on bicycles, or walking. People in trucks reciprocate with their own buckets of water, and people riding pillion on motorcycles and bicycles and people walking shooting each other with water guns. As we drove through town one afternoon, half the town was gathered in their front driveways with music playing, the hose and buckets out, the girls dancing and swinging the hose around in the air above their heads, dousing and washing each other, the guys taking the lookout for (and drenching of) passers by more seriously. The other half the town was in the back of pickup trucks in groups of 5-10 with buckets and water guns, and on their motorbikes. The best part is: they all slow down as they approach one another so they can be sure they have a good opportunity to drench and be drenched. Even passing motorists not engaged in the festivities would, for the most part, cheerfully slow down to have the hose held over them for a few moments. And when I say drench, I mean drench. I stood outside with the girls who worked at the hotel for 45 minutes, and when it became clear that I was joining them the first thing they did was hold the hose over my head and rotate me for a minute. Oh, and it’s 90-100+ outside, so even if someone dumps a bucket of ice water over you, you’re still not ever really cold.
Hundreds of Lao people frolic in Tat Lo, Salavan. The water felt great, and they loved splashing the falang.
Two weeks ago my Mom sent me a link to the obituary of Carla Madison. Carla moved in across the alley from my family when I was in elementary school. She was 54 and a Denver City Council member when she died of metastatic colon cancer. We weren’t close friends, or even still neighbors, but I know she will be missed greatly in Denver. She was a massage therapist when she moved in, and she was so good she would be the one called when a famous band was in town. (I seem to recall a weekend spent working on the Rolling Stones, but maybe my childhood memories have exaggerated that.) She always had a crazy new shade of red hair, she had a home-made evil monkey chandelier in her dining room, had gargoyles installed on her front steps, and she couldn’t stop adopting stray dogs. I remember being kind of scared and in awe of Carla - she was pretty cool but also a bit mysterious and maybe her life was a bit dangerous in addition to being exciting. (I actually doubt it was, but that was my impression in elementary school.) When I learned in medical school that she had metastatic colon cancer, it was my first experience being uncomfortable knowing more about a diagnosis than I could share with parents/friends, and not knowing if someone I was in no way a caregiver for understood what a diagnosis meant. This continues to be an awkward situation when it occurs, and probably always will be. I know that Carla understood her cancer for a long while before she died, though, I saw her last summer during a visit and she was pretty open about it. I wasn’t surprised - she was a smart woman who stuck up for herself and made her own assessment of things, so of course she would have asked the right questions and wanted to understand. I don’t know, but I would guess that she was also at peace with her life and death, although it was clearly terribly unfair. (My impression is that) Carla was a person who lived life fully, completely, without being reckless, but experiencing, giving, and receiving as much as she could. She lived more in 54 years than many people do in a full lifetime. As I approach 30, I hope that my friends would be able to say the same of me - whether I die next week or at 90. Working in medicine makes you aware of the preciousness of life, and makes you want to preserve your own, but you also realize how crazy, terrible things happen to people all the time, so you don’t want to put off or pass up opportunities when they present themselves.
Kayaking to see the dolphins. I think Carla would approve.
Work has been frustrating the last few weeks. I am trying to negotiate resident selection for the next class in a political climate I don’t fully understand, and a language I understand maybe a third of. (For the record, understanding 1/3 words is absolutely not enough to understand the nuances of a conversation between native speakers. General gist, maybe.) The residents were supposed to start today and we still don’t have a final list. And they have to move from all over the country. There are at least 2, if not 3 factions with drastically different ideas of who should be chosen. Time I spend calling, e-mailing, and attending meetings about this is often time away from clinical work, which is the really fun part of this volunteer job. Then I spent quite a bit of time making the schedule for next year work, including trying to make sure people didn’t have vacation too early, etc. Of course, almost none of the residents are happy with it and many want changes. It’s not a simple process to make sure that 21 people each have the correct rotations and all the wards have the correct number of residents from each year working on every ward each month. (Hats off to Julie Cole, who did this for 30+ people per class in my residency program, by the way. I have a whole new level of sympathy for her, and I’m glad I never requested changes to my schedule once it was made. Of course, she did a good job.)
My best attending English students. Poor suckers, I barely understand the language myself.
Even at my most frustrated/confused about work, or at my loneliest while traveling alone, I haven’t regretted the decision to be here now. I haven’t even come close. This has been a great year for me. I’ve solidified clinical skills and critical thinking skills that I had at residency graduation, but was accustomed to having a supervising doctor to confirm or correct. I’ve learned about disease I had heard of only in passing (Meliodosis) or not at all (Capillariasis). I’ve worked normal-length weeks, and I’m exercising regularly. I hope my time here has also been valuable for my residents - I think they are learning, and they aren’t complaining about my teaching, but then again people here generally don’t complain. I think the part of my day that I value the most - clinical rounds with the residents - is also the part they benefit from the most. Prompting them to get the whole story, make a differential diagnosis, and then think critically about what we should test, treat, and think about for later is not something their Lao supervising doctors always have time to do.
Residents and staff at the end of CME. Why I am here.
A friendly old hippie from San Francisco who I met at the Pakse Hotel had 2 pieces of wisdom regarding turning 30; the first was that you should not wake up alone, because it can be a hard day, the second was that whatever you’re doing at 30 will be what you do for the rest of your life. I’m going to bed alone tonight, so unless something crazy happens, I will be waking up alone. I’m OK with that; I do have a birthday card my parents mailed March 26th (So it would arrive in time) to open. And I have a full day planned, so I don’t think I’ll have time for much melancholy. As for the second, I don’t think I’ll be in Lao for the rest of my life (in fact, I hope to be home at this time next year - my next home tentatively being Denver). I do hope that I’ll continue to be involved in global health, teaching, learning, and taking good, compassionate, care of my patients for the rest of my life. I hope I’ll continue to enjoy life and take care of myself as well. So I hope he was right about the second piece of “wisdom.”
Enjoying another sunset over the Meekong - this one from the rooftop bar of the Pakse Hotel with a Margarita! I've never before seen so many fabulous sunsets in one year.
Yesterday I got this message in an e-mail about the schedule from one of the chief residents: “Occasion in your birthday and Laos new year, I wish you have good healths, do not ill or do not fever. Have successful in your life all of your family too. Have a lot of money, but do not forget to share me! Itdermair, and Chief of resident” You couldn’t ask for a nicer sentiment. I wish it back to my Lao residents and colleagues, friends in Lao, and of course all of you, dear readers, who have supported me through these first 30 years. I look forward to sharing the ongoing journey with you!
Jonty, 2, sweeping the yard in his dress. He still knows how to follow his dreams without fear of judgment.
Libby taking a picture of herself at a waterfall.
Eating is another hard part of traveling alone. I have a great imagination and vivid internal dialogue, but I still get kind of bored/lonely when I’ve eaten 3 meals alone for several days. There’s always the read a book option - read the guidebook for you next destination, or something else you brought along. This is good, but often requires odd arrangements of condiments to keep the book open, and it’s distracting from both the book and the meal. There’s really nothing like sharing a good meal with a good conversation partner.
My hammock in the four thousand islands - the correct place to read a book
That said though, I had a great time. I imagine it would be hard to find a better place to be a solo woman traveler. Lao people are generally super friendly, honest, polite, and there is absolutely no overt sexism. It’s also a small place, without a lot of business travelers or white people who live there full time, so it’s easy to ID your fellow tourists and engage with them. Even local people who try to ‘take advantage’ of tourists never more than double the price they’d charge a Lao person. And in a country where the average income is less than a dollar a day, I can hardly be angry at them for charging a bit more from the white people who have clearly spent hundreds or thousands of dollars to be here. (I know young people like to travel in SE Asia because it’s cheap, but it does frustrate me when I see someone haggling or complaining about a markup 12.5 cents, or even a few dollars. That is a lot of money to the sales person and if 2 dollars is going to break your budget as a traveler, you probably shouldn’t be this far from home. Especially when I _regularly_ see patients leave the hospital with easily, and inexpensively treatable conditions because they can’t afford to be treated.) So if I had to pick a place to travel alone, this is a great one. And I’d rather see interesting things alone than stay at home.
Wat Phu, Champassak, Laos
As an aside - Phi Mai Lao may be my new favorite holiday. It’s like a cross between the world’s most innocent and sincere wet t-shirt contest and the world’s biggest water fight. It was 3 days of people at the side of the road throwing water (or hosing down) people in trucks, on motorbikes, on bicycles, or walking. People in trucks reciprocate with their own buckets of water, and people riding pillion on motorcycles and bicycles and people walking shooting each other with water guns. As we drove through town one afternoon, half the town was gathered in their front driveways with music playing, the hose and buckets out, the girls dancing and swinging the hose around in the air above their heads, dousing and washing each other, the guys taking the lookout for (and drenching of) passers by more seriously. The other half the town was in the back of pickup trucks in groups of 5-10 with buckets and water guns, and on their motorbikes. The best part is: they all slow down as they approach one another so they can be sure they have a good opportunity to drench and be drenched. Even passing motorists not engaged in the festivities would, for the most part, cheerfully slow down to have the hose held over them for a few moments. And when I say drench, I mean drench. I stood outside with the girls who worked at the hotel for 45 minutes, and when it became clear that I was joining them the first thing they did was hold the hose over my head and rotate me for a minute. Oh, and it’s 90-100+ outside, so even if someone dumps a bucket of ice water over you, you’re still not ever really cold.
Hundreds of Lao people frolic in Tat Lo, Salavan. The water felt great, and they loved splashing the falang.
Two weeks ago my Mom sent me a link to the obituary of Carla Madison. Carla moved in across the alley from my family when I was in elementary school. She was 54 and a Denver City Council member when she died of metastatic colon cancer. We weren’t close friends, or even still neighbors, but I know she will be missed greatly in Denver. She was a massage therapist when she moved in, and she was so good she would be the one called when a famous band was in town. (I seem to recall a weekend spent working on the Rolling Stones, but maybe my childhood memories have exaggerated that.) She always had a crazy new shade of red hair, she had a home-made evil monkey chandelier in her dining room, had gargoyles installed on her front steps, and she couldn’t stop adopting stray dogs. I remember being kind of scared and in awe of Carla - she was pretty cool but also a bit mysterious and maybe her life was a bit dangerous in addition to being exciting. (I actually doubt it was, but that was my impression in elementary school.) When I learned in medical school that she had metastatic colon cancer, it was my first experience being uncomfortable knowing more about a diagnosis than I could share with parents/friends, and not knowing if someone I was in no way a caregiver for understood what a diagnosis meant. This continues to be an awkward situation when it occurs, and probably always will be. I know that Carla understood her cancer for a long while before she died, though, I saw her last summer during a visit and she was pretty open about it. I wasn’t surprised - she was a smart woman who stuck up for herself and made her own assessment of things, so of course she would have asked the right questions and wanted to understand. I don’t know, but I would guess that she was also at peace with her life and death, although it was clearly terribly unfair. (My impression is that) Carla was a person who lived life fully, completely, without being reckless, but experiencing, giving, and receiving as much as she could. She lived more in 54 years than many people do in a full lifetime. As I approach 30, I hope that my friends would be able to say the same of me - whether I die next week or at 90. Working in medicine makes you aware of the preciousness of life, and makes you want to preserve your own, but you also realize how crazy, terrible things happen to people all the time, so you don’t want to put off or pass up opportunities when they present themselves.
Kayaking to see the dolphins. I think Carla would approve.
Work has been frustrating the last few weeks. I am trying to negotiate resident selection for the next class in a political climate I don’t fully understand, and a language I understand maybe a third of. (For the record, understanding 1/3 words is absolutely not enough to understand the nuances of a conversation between native speakers. General gist, maybe.) The residents were supposed to start today and we still don’t have a final list. And they have to move from all over the country. There are at least 2, if not 3 factions with drastically different ideas of who should be chosen. Time I spend calling, e-mailing, and attending meetings about this is often time away from clinical work, which is the really fun part of this volunteer job. Then I spent quite a bit of time making the schedule for next year work, including trying to make sure people didn’t have vacation too early, etc. Of course, almost none of the residents are happy with it and many want changes. It’s not a simple process to make sure that 21 people each have the correct rotations and all the wards have the correct number of residents from each year working on every ward each month. (Hats off to Julie Cole, who did this for 30+ people per class in my residency program, by the way. I have a whole new level of sympathy for her, and I’m glad I never requested changes to my schedule once it was made. Of course, she did a good job.)
My best attending English students. Poor suckers, I barely understand the language myself.
Even at my most frustrated/confused about work, or at my loneliest while traveling alone, I haven’t regretted the decision to be here now. I haven’t even come close. This has been a great year for me. I’ve solidified clinical skills and critical thinking skills that I had at residency graduation, but was accustomed to having a supervising doctor to confirm or correct. I’ve learned about disease I had heard of only in passing (Meliodosis) or not at all (Capillariasis). I’ve worked normal-length weeks, and I’m exercising regularly. I hope my time here has also been valuable for my residents - I think they are learning, and they aren’t complaining about my teaching, but then again people here generally don’t complain. I think the part of my day that I value the most - clinical rounds with the residents - is also the part they benefit from the most. Prompting them to get the whole story, make a differential diagnosis, and then think critically about what we should test, treat, and think about for later is not something their Lao supervising doctors always have time to do.
Residents and staff at the end of CME. Why I am here.
A friendly old hippie from San Francisco who I met at the Pakse Hotel had 2 pieces of wisdom regarding turning 30; the first was that you should not wake up alone, because it can be a hard day, the second was that whatever you’re doing at 30 will be what you do for the rest of your life. I’m going to bed alone tonight, so unless something crazy happens, I will be waking up alone. I’m OK with that; I do have a birthday card my parents mailed March 26th (So it would arrive in time) to open. And I have a full day planned, so I don’t think I’ll have time for much melancholy. As for the second, I don’t think I’ll be in Lao for the rest of my life (in fact, I hope to be home at this time next year - my next home tentatively being Denver). I do hope that I’ll continue to be involved in global health, teaching, learning, and taking good, compassionate, care of my patients for the rest of my life. I hope I’ll continue to enjoy life and take care of myself as well. So I hope he was right about the second piece of “wisdom.”
Enjoying another sunset over the Meekong - this one from the rooftop bar of the Pakse Hotel with a Margarita! I've never before seen so many fabulous sunsets in one year.
Yesterday I got this message in an e-mail about the schedule from one of the chief residents: “Occasion in your birthday and Laos new year, I wish you have good healths, do not ill or do not fever. Have successful in your life all of your family too. Have a lot of money, but do not forget to share me! Itdermair, and Chief of resident” You couldn’t ask for a nicer sentiment. I wish it back to my Lao residents and colleagues, friends in Lao, and of course all of you, dear readers, who have supported me through these first 30 years. I look forward to sharing the ongoing journey with you!
Jonty, 2, sweeping the yard in his dress. He still knows how to follow his dreams without fear of judgment.
Subscribe to:
Posts (Atom)
