Reflections in a Head Mirror
|
|
1/27/2012 Opening the SensesThe hardest hit, as everywhere, are those who have no choice.
- Theodor Adorno During my recent mission trip to East Africa through Kenya Relief, all of the surgeons took turns seeing walk-in patients. The lines were long, but the people were incredibly patient and grateful. A 4-year-old boy had waited for hours with his mother. I sat down and asked her to tell me his story.  Kamau (not his real name) sat quietly, looking back-and-forth from his mother’s face to mine. He appeared very healthy and attentive. Like most of the Kenyan children, he was thin. These kids walk everywhere and have very simple diets. “How can I help?” I asked. The translator spoke. “Kamau does not talk and never responds when he is spoken to. At first we thought he was distracted. One time, though, when a motorbike backfired, he didn’t react. We decided he might be deaf.” Kamau looked around the room and smiled at me. “Have you taken him to see anyone?” I asked, knowing that there were few resources available. “Oh, yes. We saw a local doctor once, but he couldn’t help. We had hoped you American doctors could do something to make him hear.” I looked at Kamau, hoping to find something I could fix or recommend. He reached up and touched my ears after I looked in his. Unfortunately, it appeared that he had profound nerve deafness. In the United States, as soon as a child is found to have hearing loss (often detected in the newborn nursery), a series of events begins and support services begin to take charge. Hearing aids are fitted for appropriate children by the time they are a few months old. Children who need cochlear implants get started with evaluations early and are soon seen by an otologist, audiologist, speech/language pathologist and psychologist. Surgery and the early follow-up including device programming and training can easily cost $50,000 to $100,000.  Sub-Saharan Africa bears 24% of the world’s disease burden but has only 3% of the global health workforce. Health insurance is all but nonexistent. Infrastructure is poorly maintained. Whatever resources exist tend to be aimed at diseases like AIDS, tuberculosis and malaria. There are no cochlear implant programs in Kenya. Hearing aids, even if available, require batteries, something this family would not be able to afford. I tried in vain to think of something I could offer other than suggesting a trip to the capital city of Nairobi, an insurmountable 240 miles away. “What is possible, doctor? What can you do for Kamau?” He was deaf, but I was speechless. “I am sorry, Ma’am. I have nothing to offer Kamau, other than to tell you he is a very handsome boy.” The mother smiled weakly but thanked me profusely. She picked up her son and started the long walk home.
Posted 4:20 PM 12/19/2011 Cancer at the Holidays"Do any human beings ever realize life while they live it? ---Every, every minute?"
-Thornton Wilder His cancer was growing and his symptoms were progressing alarmingly. As holiday music played in the background, I searched the calendar to see how rapidly his surgery could be scheduled. The young man and his wife first looked relieved when we found a surgical opening in the coming week, but their faces fell as they realized that he would spend December 25th in the hospital. Family plans were to be put on hold that year. The future was uncertain. It has always seemed to me that "cancer" causes more life disruption during this time of year. The quickened pace of life and the family expectations, particularly when small children are involved, push people to their limits. On the other hand, it has been my experience that the holidays bring out the best of the people who work in hospitals. This is especially true of those who provide cancer care. While some clinics might slow down a bit, the Cancer Center clinics seem to be open and busy. During my days working as a hospital nursing assistant and then later in medical school and residency, I always enjoyed being in the hospital on the actual holidays. Maybe it was because everyone was resigned to being at work instead of at home with families, but the interactions with even the crankiest staff members seemed unfailingly positive. Everyone was more cheerful. And, of course, as we went about our duties, we kept on the lookout for leftover treats and plates of cookies. As cancer care providers, we are privileged to work with patients and families at the most stressful moments in their lives. Cancer can bring incredible focus, just as the holidays can prompt us to remember what is truly important in our lives and in our relationships. Maybe our calling to be "healers" is reawakened most effectively in December. Happily, my patient recovered from his holiday cancer surgery. Over the following years, we reminisced about the first few days after his cancer diagnosis. It was a Christmas week that he and his family would never forget. Happy holidays to one and all!
Posted 2:07 PM 12/4/2011 ShortagesNeither fear the problem – nor trust the solution – too
much.
-Paul Ramsey The headline was clear: the United States is headed for a worsening physician shortage. The Wisconsin Hospital Association and the Association of American Medical Colleges both confirm that Wisconsin and the United States have a shortage of doctors and they predict a deepening hole, particularly in primary care specialties. The solution is not at all obvious; although medical schools can increase class sizes (and UW-Madison has recently done just that), much of the bottleneck is at the level of Medicare-funded residency training positions. The realities of the federal deficit and the looming Medicare crisis make additional funding for training slots very unlikely. Things look bleak. As I was mulling over this predicament, I heard a story on National Public Radio describing a self-sustaining mission hospital at the southern tip of India devoted to eye diseases and to sight restoration. The reporter interviewed an ophthalmologist about the logistics of her operating room. All day long, the staff readies the next patient for her while she is performing surgery. As soon as one operation is finished (each taking about 10 minutes), she turns her chair, adjusts the microscope, and proceeds with the next. She continues moving back and forth, one after the other, completing as many as 40 cases each day. Each ophthalmologist at the hospital performs as many as 2,000 cataract surgeries yearly. By comparison, a busy U.S. ophthalmologist performs 125 cataract operations each year. The report did not discuss it, but I assume that the Indian doctor does not stay up all night completing her dictations, filling out insurance forms, and electronically signing her charts. I am frequently amazed by the amount of time my U.S. colleagues and I spend on tasks that drag us away from providing direct patient care. For example, in response to fraudulent Medicare claims, every home-care form and prescription now requires, by law, a physician’s handwritten signature and date. The threat of billing audits obliges me to include long, irrelevant, never-read passages and specific wordings in already cluttered medical record progress notes. In the name of privacy, electronic records time-out every few minutes and I spend many hours each year simply waiting for double-password-protected medical records and images to pop up on computer screens. In the name of patient safety, hospital charting requires every signature to be accompanied by both a handwritten date and time.  Each little delay, log-in, new requirement, interruption, signature, authorization phone call, form, and re-typed password consumes just a few seconds, but, of course, these moments add up. When combined with all of the moments spent by physicians and health care workers across the country each day, the amount of time consumed is not trivial. Having recently glimpsed inside several hospitals in East Africa, I believe that the overwhelmed doctors there would love to have "shortages" like ours. There are, of course, no simple solutions to the challenges facing the African health care systems, but consider: There is one physician for every 360 Americans. By contrast, Kenya has one physician for every 7,600 people, and Tanzania has only one physician for every 24,000 people. Disturbing, too, is the news that "[a]bout one-fourth of the primary care physicians now practicing [in the United States] are graduates of foreign medical schools." Our shortage in primary care is siphoning off the best and brightest from some of the countries that can least afford to see their young doctors depart. So, can an eye hospital in India that routinely screens 2,000 patients each day tell us a thing or two about efficiency? Is it possible that the East African non-physician Assistant Medical Officers can share some insights into how to take better care of our expanding population of elderly with chronic, stable conditions? What can we do to help the developing countries improve their health care outcomes without plundering their talent? The problems — First World vs. Third World — are very, very different. At the very least, we should be able to discern better ways to help them cope with their overwhelming needs. We, on the other hand, must find ways to better utilize people who now spend their days typing notes, signing forms, constantly logging back into computerized record systems, and waiting for the opportunity to get back to seeing patients.  Share on Facebook
| |
The following is feedback received for this blog:
Hi Bruce - I can appreciate your frustration and hate to see medical professionals hindered from providing all the hands on medical care they trained to do and prefer ...versus handling the sea of paperwork, etc., they are continually inundated with. And speaking from the patient perspective ...I think it is both sad and frustrating that the patient-physician relationship is compromised due to time constraints because of regulations, insurance requirements, technology, etc.
I miss being able to chat with my former pcp. He had to close his practice last March (still in prime) because of expensive overhead and low insurance reimbursements. :(
It would be interesting to hear how these other countries are able to see/treat so many patients. And would be great if all countries could incorporate the best ideas from other countries into their health care systems/practices.
- SeaSpray | Posted 1:26 AM 11/2/2011 Boxes and HyenasMy humanity is bound up in yours, for we can only be human together.
-Desmond Tutu Death is more palpable in this place. We make rounds in the large open wards of a District Hospital in western Kenya. Each bed often holds two people. The sheets are thin. The room is warm despite the open windows and the flies come and go. Mosquito nets hang in tight balls above each bed. We are "wazungu" — white people — even though some of our team is African-American. The Kenyans often believe naively that we are somehow better able to cure their illnesses. I know essentially nothing about the medical management of untreated malaria, tuberculosis, typhoid, or HIV/AIDS and everyone here has one, two, or three of these diagnoses.  One man does not look up when we our group passes. The man’s vacant eyes do not focus. He is gaunt yet his skin is taut — perhaps he is young. He is dead — no — wait — he breathes, but barely. The woman sitting next to him on his bed looks up at us but says nothing. The nurses are friendly but they lack the most basic supplies. The patients here are relatively fortunate because they — or someone they know — can afford the dollar per day charge for the bed or the cost of IVs and antibiotics. Most Kenyans never come at all. As our vehicle leaves the hospital compound, I scan the businesses that line the road. Young men sit next to huge piles of shoes and T-shirts. Battered shipping containers have been converted into small shops and restaurants — called “hotels” here — but they all appear forbidding.  A furniture store catches my eye. There are a few tables out front but, as I look more closely, I see that the tables are actually handmade coffins. These are ribbon-bedecked, freshly-constructed coffins that wait for the young man we just saw up the road. Small boxes wait for the child nearing death we met on the Pediatric Ward. As we travel, I notice other coffin stores and I believe they are clustered near the hospitals. The small cemeteries we see in the cities and rural zones are all well-tended. I think back to our time on safari driving across the Maasai Mara — the vast expanse of grassland in Africa’s Rift Valley that supports the giant  migration of animals each year. Predator and prey, Life and Death – “The Circle of Life” of which we taught our children as they sat transfixed by The Lion King. “Animals die and that is sad,” we told them, “but in death, life is sustained.” They nodded in apparent understanding. The Maasai Mara often stretches to the horizon. I ask our guide, who is not Maasai, about the people who live there. They are nomadic, I recall, so what do they do with their dead? His eyes narrow and he stares at me. “Did you see any cemeteries all the time we were out on safari? Did you?” I try to recall. No, I don’t think so. The Maasai live exposed and difficult lives. They don’t survive long and 40 is “old” for the people of western Kenya. No, I saw no cemeteries.  “The Maasai – they carry their dead outside of the compound at night and leave them in the bush for the scavengers.” I catch my breath. “The ancestors of the Maasai,” he tells me, “they are in the belly of the hyena.” He lets that sink in. “The hyena,” he repeats. Then he falls silent. This is not the "Circle of Life" image I shared with my children when they were young. I spot another row of coffins back in town. They are beautiful despite their ultimate purpose.  We return to the place where we are staying. The sky glows bright orange. Back at the District Hospital, the lights are, no doubt, flickering as the power fails yet again. A man whispers “asante sana” — thank you — as a nurse tucks the mosquito net neatly beneath his mattress. Share on Facebook
The following is feedback received for this blog:
| Haunting. Thank you for finding the ironic and hidden beauty in this place of seeming deprivation.
- Merry Sebelik
You are a gifted healer and author, how important it is to recognize that each circle of life is related to the other circles we are privileged to be a part of.
Asante sana Bruce,
- Aleta Chossek
Dear Aleta,
Thanks so much. I feel fortunate to have had the exposure to the health care issues in Tanzania and Kenya. It put our "first-world problems" into perspective.
-Bruce
Posted 2:24 PM
Show
posts
|
|
|