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.

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.

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.