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.