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.
Tuesday, April 26, 2011
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.
Sunday, April 3, 2011
Communication Culture Shock
When you move from a medical culture like America’s to a markedly different one (like Laos) you notice stark differences initially, but then you readjust your expectations and things seem normal here that would be totally bizarre at home. I was reminded of this 2 weeks ago. I had seen a confusing patient with the resident at Setta - and 80+ year old woman who had come in with a severe, unilateral temporal headache that had been present for 2 months. She had photophobia and tearing but also had some swelling and redness. She had no fever, though or other infectious symptoms. She had been seen at another hospital, had a head CT, and told she had brain cancer. “Great! Brain Cancer!” I thought. Of course brain cancer is never great, but a mass lesion in that area might explain her confusing array of symptoms. She had some weight loss as well, so malignancy was plausible. And in an 80+ year old, not super surprising or tragic - she has outlived her life expectancy by more than 20 years. Plus, a mass could also be parasites or abscess, and treatable.
Only one problem existed with this theory - we had the CT (non-contrast) and we couldn’t see any mass. No clearly defined mass lesion, no significant unilateral swelling or loss of contours of the fissures, no midline shift. Could it be temporal arteritis? Certainly, though the ESR was near normal, making this far less likely. Also, it hadn’t improved with steroids. This makes other autoimmune/rheumatological conditions lower on my list as well. Could it be an optic nerve / retinal problem? Could it be glaucoma - the time course was wrong, and the external eye exam didn’t quite fit, but then she wasn’t really fitting any clinical syndrome convincingly. After two trips to the opthamology department, it was determined that both her external ocular structures and retina were normal. A chest x-ray showed masses on either side of the mediastinum that looked more like tumor than infection or anything else, and an abdominal ultrasound showed a mass in the liver. Oh, and she still had no pulmonary or infectious symptoms. Basically, we had no idea what was going on with this patient, but malignancy was still highest on our list having ruled out a number of other things.
One day, after she’d been in the hospital for several days, I was on my way out of the room when I was stopped by her daughter and asked (In excellent english) if I could take a few minutes to explain what was going on with her mother. I was taken aback. I hadn’t been approached with a question from a family member since leaving America. It just doesn’t happen here. I often have to encourage the residents to stay and explain the diagnosis and plan to the family after we discuss a patient, because otherwise they just write the orders with little explanation. They do counsel patients about chronic disease, etc, but generally, the patients trust the doctors and don’t request explanations of what is going on. This is mostly bad; patients don’t know what has been done before because no one explains it to them, and they are probably more prone to non-compliance if they get side effects, because no one has explained why their treatment is important. However, I realize I have adjusted to this culture.
Her daughter was from Phoenix, where she had lived for the past 25 years, and had been called home because her mom was sick. She was coming from the American medical culture where patients now demand explanations from their doctors. I explained that I serve mostly a teaching / consultant role for my residents, and I do not make any direct patient care decisions, only recommendations that the staff physicians actually directly supervising the residents can accept or reject, so the residents and Lao staff would actually be the final decision makers regarding treatment and testing. I explained that we think her mom has lung cancer with a paraneoplastic syndrome (Cancer associated) or a mass lesion that we can’t see on the non-contrast CT. We could get more info with a head CT with contrast, and a chest CT, but we still wouldn’t be able to make a definitive diagnosis. For that, they would have to go to Thailand where they could get a biopsy and pathology results on one of the masses. However, that still wouldn’t confirm the cause of the headache, which was her only real symptom, and would be expensive. It might result in offers of chemotherapy which the family would then have to decide about. We were pretty sure it wasn’t infectious at this point, and she was getting steroids for theoretical tumor edema, but in doses that should treat temporal arteritis or other rheumatological diseases. My understanding is that the medication options for pain in Thailand aren’t much better than ours here. Of course, there was a period of shock - there are no oncologists in Lao? Nope. There isn’t anyone who could do a biopsy here? Nope, no IR doctors, only general surgeons, and I sure as heck wouldn’t let anyone near this frail, elderly lady for an open biopsy to confirm something we can’t treat. (I seriously doubt the surgeons would have done it even if we’d asked.)
The patient’s daughter absorbed this information. Despite being much more aggressive than a Lao patient or family member, she was relatively reasonable - she agreed that diagnostic testing for something we couldn’t treat was not worth pursuing. Neither doctors nor patients are very comfortable with uncertainty in America. I was feeling uncomfortable about how few answers I could give her, so I was impressed that she didn’t demand a better (or at least more definitive) answer. Then she asked me how long her mom might have.
Doctors everywhere hate being asked this question. Unless your patient clearly is going to die within the next few hours, it’s hard to answer. Even if we have a diagnosis of a specific type of cancer, for example, all we can do is give statistics - most people live about this long - but humans are individuals, and averages are averages - some people will live much much longer, and others might seem fine today and have a serious complication and die tomorrow. And then, of course, any of us could die tomorrow - in a traffic accident on the way to work or from some unknown, asymptomatic but serious medical condition. Everyone know someone who doctors said only had a few weeks or months to live and who exceeded their predicted longevity by multiple times the estimate, making the doctors look foolish for predicting in the first place.
I understand why she wanted to know - she had taken all her vacation/leave time to come and spend with her Mom. Was this the right time to be here? Should she try to go home and come back when her mom was really ill so she could be present for the funeral as well? If she went home, the cost of coming back (>2000$ if your ticket is purchased well in advance) and the transit time (at least 30 hrs each way) would make coming back urgently nearly impossible, especially if all her leave time was used up. I understood the question, but I still resented it. How could I make a prediction about how long this woman would live, not even knowing for sure (or for a strong most-likely) what she had?
So I gave her my standard answer - one that I learned from an experienced Irish hospice doctor. “Of course, we never really know, and doctors are terrible at predicting this. However, generally, if she’s been well and deteriorating slowly over months, she probably has months to live. If you see her getting worse over weeks, she probably has weeks to short months to live, and if she is getting worse day by day, then she has days or short weeks.” I thought given that her mom looked pretty good day by day, that it was unlikely that she would die while the daughter was visiting, but she could be on the verge of a rapid deterioration, so I couldn’t make any guarantees.
Over the next week we tried to get her mom’s symptoms more under control. The steroids helped a little, but not dramatically. IV morphine or pethedine worked briefly, for about 3 hours, but this is not a good solution for a patient who should be working towards going home to spend quality time with her family. Our only oral narcotic here is tramadol - not a strong drug, and one which has a strict dosing limit due to seizure risk. Could we give IV or subQ or IM meds at home? They could have the village nurse come by 3 or even 4 times/day, but we had no way to know if this person would be familiar with IV or sub-Q drug administration, morphine dosing, dose changes etc, so it seemed like a bad idea. (Morphine is only used in the hospital, so it’s unlikely that the neighborhood nurse would be comfortable using it to manage pain.) Not to mention the morphine was only lasting 3 hours, and there is no extended release formula here. I tried to encourage scheduled tylenol and tramadol, and we added amitriptyline, which should help if there was a nerve component of the pain, which the symptoms suggested. We switched the steroids to oral. I had another long talk with the daughter explaining what each medication was for, how much she could take, and how frequently she could take it. I did more medication counseling in that one session that I have done (or seen done) in my entire time in Lao.
The truck wasn’t starting at the end of last week, so I didn’t get back to Setta to see how things were going. I’m not particularly optimistic, since scheduling pain meds is another thing that doesn’t really exist in Lao culture, and since we’re working with such poor choices to start out with. This case did inspire me to put together a lecture on pain and symptom management using medicines available here, which I hope I can give early in May when the new residents are here. (I offered to give it next week but they would rather have exam review, reasonably.)
I think there is a happy medium between the Lao patient / caregiver - almost never questioning or understanding their medications and diagnosis - and the American one - demanding answers (and often tests or treatments). Both cultures often end up with patients who are “non-compliant.” Lao patients who aren’t warned about side effects of important treatments may stop them independently and not return for an alternative. American patients perceive a side effect from a medication and search the internet to confirm that this is possible, stop the med and then blame their doctor for not warning them, even if the side effect has only a few case reports associated with it. Lao patients rely on doctors to order the right tests and treatments without any questioning, while American ones often demand unnecessary testing or treatment that then leads to further anxiety, more money spent on confirmatory tests, and / or side effects. Lao patients should be less trusting and demand more info. American patients should be more trusting - demanding information and explanations, but being willing to accept them when provided, and to work with their doctor to find an alternative.
I also think that returning to patient care in America, this may be my biggest aspect of culture shock - not the availability of tests we don’t have here, the tremendous expenditure of resources we don’t have here, or the absence of diseases that are common here - but the way I communicate with my patients.
Only one problem existed with this theory - we had the CT (non-contrast) and we couldn’t see any mass. No clearly defined mass lesion, no significant unilateral swelling or loss of contours of the fissures, no midline shift. Could it be temporal arteritis? Certainly, though the ESR was near normal, making this far less likely. Also, it hadn’t improved with steroids. This makes other autoimmune/rheumatological conditions lower on my list as well. Could it be an optic nerve / retinal problem? Could it be glaucoma - the time course was wrong, and the external eye exam didn’t quite fit, but then she wasn’t really fitting any clinical syndrome convincingly. After two trips to the opthamology department, it was determined that both her external ocular structures and retina were normal. A chest x-ray showed masses on either side of the mediastinum that looked more like tumor than infection or anything else, and an abdominal ultrasound showed a mass in the liver. Oh, and she still had no pulmonary or infectious symptoms. Basically, we had no idea what was going on with this patient, but malignancy was still highest on our list having ruled out a number of other things.
One day, after she’d been in the hospital for several days, I was on my way out of the room when I was stopped by her daughter and asked (In excellent english) if I could take a few minutes to explain what was going on with her mother. I was taken aback. I hadn’t been approached with a question from a family member since leaving America. It just doesn’t happen here. I often have to encourage the residents to stay and explain the diagnosis and plan to the family after we discuss a patient, because otherwise they just write the orders with little explanation. They do counsel patients about chronic disease, etc, but generally, the patients trust the doctors and don’t request explanations of what is going on. This is mostly bad; patients don’t know what has been done before because no one explains it to them, and they are probably more prone to non-compliance if they get side effects, because no one has explained why their treatment is important. However, I realize I have adjusted to this culture.
Her daughter was from Phoenix, where she had lived for the past 25 years, and had been called home because her mom was sick. She was coming from the American medical culture where patients now demand explanations from their doctors. I explained that I serve mostly a teaching / consultant role for my residents, and I do not make any direct patient care decisions, only recommendations that the staff physicians actually directly supervising the residents can accept or reject, so the residents and Lao staff would actually be the final decision makers regarding treatment and testing. I explained that we think her mom has lung cancer with a paraneoplastic syndrome (Cancer associated) or a mass lesion that we can’t see on the non-contrast CT. We could get more info with a head CT with contrast, and a chest CT, but we still wouldn’t be able to make a definitive diagnosis. For that, they would have to go to Thailand where they could get a biopsy and pathology results on one of the masses. However, that still wouldn’t confirm the cause of the headache, which was her only real symptom, and would be expensive. It might result in offers of chemotherapy which the family would then have to decide about. We were pretty sure it wasn’t infectious at this point, and she was getting steroids for theoretical tumor edema, but in doses that should treat temporal arteritis or other rheumatological diseases. My understanding is that the medication options for pain in Thailand aren’t much better than ours here. Of course, there was a period of shock - there are no oncologists in Lao? Nope. There isn’t anyone who could do a biopsy here? Nope, no IR doctors, only general surgeons, and I sure as heck wouldn’t let anyone near this frail, elderly lady for an open biopsy to confirm something we can’t treat. (I seriously doubt the surgeons would have done it even if we’d asked.)
The patient’s daughter absorbed this information. Despite being much more aggressive than a Lao patient or family member, she was relatively reasonable - she agreed that diagnostic testing for something we couldn’t treat was not worth pursuing. Neither doctors nor patients are very comfortable with uncertainty in America. I was feeling uncomfortable about how few answers I could give her, so I was impressed that she didn’t demand a better (or at least more definitive) answer. Then she asked me how long her mom might have.
Doctors everywhere hate being asked this question. Unless your patient clearly is going to die within the next few hours, it’s hard to answer. Even if we have a diagnosis of a specific type of cancer, for example, all we can do is give statistics - most people live about this long - but humans are individuals, and averages are averages - some people will live much much longer, and others might seem fine today and have a serious complication and die tomorrow. And then, of course, any of us could die tomorrow - in a traffic accident on the way to work or from some unknown, asymptomatic but serious medical condition. Everyone know someone who doctors said only had a few weeks or months to live and who exceeded their predicted longevity by multiple times the estimate, making the doctors look foolish for predicting in the first place.
I understand why she wanted to know - she had taken all her vacation/leave time to come and spend with her Mom. Was this the right time to be here? Should she try to go home and come back when her mom was really ill so she could be present for the funeral as well? If she went home, the cost of coming back (>2000$ if your ticket is purchased well in advance) and the transit time (at least 30 hrs each way) would make coming back urgently nearly impossible, especially if all her leave time was used up. I understood the question, but I still resented it. How could I make a prediction about how long this woman would live, not even knowing for sure (or for a strong most-likely) what she had?
So I gave her my standard answer - one that I learned from an experienced Irish hospice doctor. “Of course, we never really know, and doctors are terrible at predicting this. However, generally, if she’s been well and deteriorating slowly over months, she probably has months to live. If you see her getting worse over weeks, she probably has weeks to short months to live, and if she is getting worse day by day, then she has days or short weeks.” I thought given that her mom looked pretty good day by day, that it was unlikely that she would die while the daughter was visiting, but she could be on the verge of a rapid deterioration, so I couldn’t make any guarantees.
Over the next week we tried to get her mom’s symptoms more under control. The steroids helped a little, but not dramatically. IV morphine or pethedine worked briefly, for about 3 hours, but this is not a good solution for a patient who should be working towards going home to spend quality time with her family. Our only oral narcotic here is tramadol - not a strong drug, and one which has a strict dosing limit due to seizure risk. Could we give IV or subQ or IM meds at home? They could have the village nurse come by 3 or even 4 times/day, but we had no way to know if this person would be familiar with IV or sub-Q drug administration, morphine dosing, dose changes etc, so it seemed like a bad idea. (Morphine is only used in the hospital, so it’s unlikely that the neighborhood nurse would be comfortable using it to manage pain.) Not to mention the morphine was only lasting 3 hours, and there is no extended release formula here. I tried to encourage scheduled tylenol and tramadol, and we added amitriptyline, which should help if there was a nerve component of the pain, which the symptoms suggested. We switched the steroids to oral. I had another long talk with the daughter explaining what each medication was for, how much she could take, and how frequently she could take it. I did more medication counseling in that one session that I have done (or seen done) in my entire time in Lao.
The truck wasn’t starting at the end of last week, so I didn’t get back to Setta to see how things were going. I’m not particularly optimistic, since scheduling pain meds is another thing that doesn’t really exist in Lao culture, and since we’re working with such poor choices to start out with. This case did inspire me to put together a lecture on pain and symptom management using medicines available here, which I hope I can give early in May when the new residents are here. (I offered to give it next week but they would rather have exam review, reasonably.)
I think there is a happy medium between the Lao patient / caregiver - almost never questioning or understanding their medications and diagnosis - and the American one - demanding answers (and often tests or treatments). Both cultures often end up with patients who are “non-compliant.” Lao patients who aren’t warned about side effects of important treatments may stop them independently and not return for an alternative. American patients perceive a side effect from a medication and search the internet to confirm that this is possible, stop the med and then blame their doctor for not warning them, even if the side effect has only a few case reports associated with it. Lao patients rely on doctors to order the right tests and treatments without any questioning, while American ones often demand unnecessary testing or treatment that then leads to further anxiety, more money spent on confirmatory tests, and / or side effects. Lao patients should be less trusting and demand more info. American patients should be more trusting - demanding information and explanations, but being willing to accept them when provided, and to work with their doctor to find an alternative.
I also think that returning to patient care in America, this may be my biggest aspect of culture shock - not the availability of tests we don’t have here, the tremendous expenditure of resources we don’t have here, or the absence of diseases that are common here - but the way I communicate with my patients.
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