CMC - Day Three

CMC feels like a city inside a city. And in some ways, it is. All of the physicians that work here, interns, residents and consultants (attendings) live within the walls of this massive complex, demonstrating a commitement to their work that is neither expected nor desired in most of the world's hospitals. At the eastern edge of the campus are tall apartment blocks that house these physicians and their families. So, these doctors not only work together, they live together, and contributes to a familial atmosphere that feels quite special. There is none of the separation between work and home that some of us so cherish in the west. And to be honest, the idea of living with all the people i work with sounds, well, unappealing. Still good health care comes about through good teamwork and this environment of "everyone in it together" might go a long way in making teamwork more effective. Not to pick on surgeons, but every medical student has stories about surgeons being mean/rude/inconsiderate/etc. to residents/medstudents/nurses/etc. The question is, would these surgeons be rude to a person they also knew as their neighbor, someone with whom interactions extended outside the OR. Probably not.

The male interns live in a building called MIQ (male interns quarters), which sounded to me like a branch of British Intelligence, but is actually the place where most of the medical students go for lunch. I payed 300 Rs (about 7 USD) for food credit for the month. If i have any credit left at the end of my stay they'll actually give it back to me. Imagine that. This morning i went for breakfast, taking for myself 4 pieces of untoasted white bread and a small metal cup of butter and jam. Also, pineapple juice and (of course) chai. Indian jam, in my experience comes in a variety of colours, all flourescent, but only one flavor. On my last trip to India, and on account of its colour, we dubbed it "nuclear jam." As i was spreading around my butter and jam i noticed that the gentleman sitting next to me had made a sandwich out of jam and some brown substance that seemed familiar. "Excuse me, can you tell me what kind of sandwich you have?" i asked. "Peanut butter and jam," he replied. Glory glory hallelujah!! What sweet, yet nutty, words. I hadn't had peanut butter, that distinctly American staple, in over a month. I'll tell you i relished my Nuclear PB&J and left the canteen energized for another day on the paediatric wards.

I noticed a sign today outside the Women's and Children's building that i'd seen elsewhere around the campus: "No Tender Coconuts." My first thought was that they mean "No Children," but they were making a literal warning. By tender coconuts they mean young coconuts, those from which they drink the sweet coconut juice that is so ubiquitous in the south of India. Apparently, people would, before the prohibition, bring young coconuts into the multi-story hospital building, drink them and then, as is done in India with any trash, toss them out the window. HA! You can imagine the chaos. While a hospital is a relatively safe place to get hit on the head with a coconut, emergency services being located very close by, this was a practice that was not consistent with good health. So, yesterday i discussed prevantive health; sometimes this can be accomplished very effectively with a well-posted sign.

Our time on the wards this morning was similar to yesterday, if a bit hurried. Our consulting physician had meetings to attend and we'd added a few patients since yesterday. At around 10 o'clock though, we took a coffee break. This happens everyday. Action stops at 10 o'clock and we all head to the child health library for coffee, chai and a snack of some sort. Yesterday was samosas. Today was a type of south Indian snack called a vada, a fried piece of dough with bits of onion and spices. Delicious! This is a very civilized ritual and one that, in an environment in which residents are on call 24 hours a day, 6 days a week, is probably necessary. It's very good for moral and the topics of conversation run from food to travel to film and eventually back to medicine when the break is over. In the west, these punctuations are rare, aside from those set up for morning rounds, attending rounds, noon conferences, etc. We could do with setting aside a few scheduled moments in the morning or afternoon to simply enjoy each others company.

Now, you'll hear me say lots of good things about what i'm seeing here and lots of bad things about our healthcare system. While that has much to do with the fact that we could provide so much better care to our entire population, and not just those with insurance, it's also a bit unfair. There are many things we should be proud of in America, among them our standards of patient care. The physician-patient relationship here is characterized by what ethicists call paternalism. That is, we tell you what to do and you do it. My medical education has emphasized paternalism's ethical opposite, patient autonomy, as taking the highest precedence in clinical care. That is, the patient has control over his care based on sound scientific conveyance of all the available options by his physician. In many ways, this change towards patient autonomy has its roots in legal proceedings as much as humanitarian values. That is, if you choose, I'm less responsible. Anyway, we consider patient autonomy an element of dignity, of respect. It requires exploration of the patients values, his social and financial circumstances. Without taking the time to understand these things, it is more likely that a prescription will never get filled. And this, most often for financial reasons, happens here frequently.

Still, i'm not sure this relationship undermines the notion of a therapuetic alliance, a partnership between patient and physician for better health. It's just a different kind of alliance, one with which the current White House seems very familiar.

More tomorrow. I'm off to Infectious Disease clinic.

justin

ps. for the medical types: today i saw two cases of ricketsial fevers. They get several here, most commonly Rocky Mountain Spotted Fever and that caused by Rickettsii Typhi. The characteristic rash covers the palms and soles. One child had a particular severe form of illness and his skin had started to slough off in large patches. The differential includes Stephens-Johnson Syndrome but, in this case, the mucous membranes were spared. The poor child's outer ears were sloughing off in large chunks. Fortunately, if the skin can be protected from infection, the child should be okay.

pps. please, if you'd rather not have me clogging your inbox, let me know. i'll take you off the list, no offense taken. i'm not sure i'd want to read what i have to say. also, if you want me to add anyone to the list let me know. forward at will.