Sunday, January 4, 2015

On Doctoring Around the World...

A/N: Well, dear readers, not sure how this blog posting turned out. These are my first patient-client reminiscences since coming back from Africa. Will writing about my experiences in America be interesting and insightful to you or will they lack the exotic African edge?  You’ll have to let me know. Thanks for all your support and encouragement over the years! A new chapter has begun for me.

On Doctoring Around The World


The word is almost universal.
The syllables, rhythm, and enunciation are nearly ubiquitous around the world.
Call out the term, ‘doctor’, in almost any country and any passerby will immediately understand that you want medical attention – and fast. It’s a term that conjures up illness. Urgency. And, hopefully, kindly concern for humanity.

He was sturdy and rugged**. Not young but certainly not elderly and frail. The calluses on his hands bespoke of someone used to daily manual labour.

“Where do you work?” I inquired as I sought to grasp a more complete picture of my new patient. I’d just started work back in the United States and was seeking to figure out how to reintegrate myself as a professional primary care physician. I needed to understand the American culture and how to connect to my new community of Pacific Northwest natives.

“I work at Fred Meyers (huge department store),” he shrugged his shoulders. It was a job and paid his bills. He didn’t seem particularly attached to his job and yet he wasn’t unhappy in it either. “I do a lot of walking. I walk to work. I am on my feet most of the day in retail sales there, and then I walk home too. People ask me how I keep in shape.”

I glanced at his BMI, a healthy 24. “Oh?” I ply him for conversation with genuine curiosity. His success story is one that I may remember to pass on to others after him. “What do you tell people when they ask how you keep your weight under control?”

He smiled at the compliment. “I don’t do anything special. I just walk a lot and started eating more fruits and vegetables. Nothing fancy.”

“You don’t work out at the gym or anything?”

“No. I can’t afford that, doctor.” He laughed nervously. “Till last month, doc, me and my wife, we didn’t have no health insurance. Haven’t seen a doctor in years.”

“Really?” I raised an eyebrow and tried to listen, keeping half an eye on him and the other half focused on the computer screen while I keyed in orders for his blood work. While electronic medical records have many pluses, easing the burden of information data entry is not among them!

PJ graciously allowed me to continue entering information while he related his story. “My wife’s been worried about me since I’ve been having all this numbness in my body. My hands and feet especially. Sometimes my feet get so numb that I don’t really feel them.”

“How so?” I glanced up at him and tried to type and focus at the same time. “When you have these symptoms of numbness, how does it affect your daily activity?”

“My body just feels numb. I can’t feel my legs and hands. Sometimes makes me think I might stumble when I’m walking a long ways.”

“Hum?” I try to sound halfway intelligent, like I have a clue what he’s describing when in actuality my brain is still trying to translate his description of the problem into medical symptomatology that I can sort into a differential diagnosis. It’s a bit like translating from one language to another. English to Latin perhaps? I have to intake the words that he uses in the context of his experience and digest them into a pattern that is recognised in a medical dictionary.

“Tell me more,” I encouraged him as I continued my exploration his problem. “How long has this been going on, PJ? Is it getting better, worse, or staying the same? Anything seem to make the numbness worse?”

Thankfully, PJ is happy to comply with my questions. I am grateful for the extra time I have as I begin my new job at the American clinic.

I remember back five years when I was first starting out in a new culture and language in Cameroon, West Africa. Pidgin was the common language that my patients spoke there. It took me months to begin to comprehend what it meant when an elderly lady complained of ‘ma skin de hot me fo all my body’ or a pregnant woman stated ‘I spit too much’ or a mother said ‘I have fever but it doesn’t come out’. The art of medicine, of listening as a physician, involves so much more than is taught in the lecture halls or the thick dusty medical reference books.

“So this is a problem that’s been going on for about 8 months now, not really getting better or worse, and mainly affecting your feet and hands?” I summarised. “Have you been worked up for this problem anywhere else?”

He shook his head no. His swaying grey hairs assured me he’s not been seen elsewhere for his current concerns.

Almost apologetically, as if he’s afraid I might scold him for not coming in sooner, he continued. “I know it been a while, my wife and I just haven’t been able to afford to see a doctor for a few years.”

He doesn’t need to apologise or explain further. I nodded. I understand his plight. Since coming back from service in Cameroon, in a bustling city centre where almost everyone could afford to see a GP at the government hospital or at least a neighbourhood nurse (granted there were some questionable levels of quality medical training and care…) it seems strange to be back in a country where not everyone can get health care if they want. A simple antibiotic for the part-time mother employed at a fast food chain is a near impossible hurdle for some.

My mind bounces back to two days prior when I stout Mexican woman proudly informed me that she’d just finished paying off her debt for her hospitalisation over two years ago. She had no idea what the total cost of the bill was; she shrugged and gave me crooked smile and said she just paid the $75 dollar per month payments that the hospital’s financial department had set up. She’d received word a couple months prior that it had been paid off. She was very happy.

Of course, I’d congratulated her, as she was clearly quite proud of her accomplishment. Inside though, I was a little sad because I have recently learned that too many of my fellow citizens are unable to pay off their hospital debts. Numerous studies that I have read online all have found that the number one reason for bankruptcy in the U.S. is from unpaid medical bills. A study in 2013 by NerdWallet Health analyzing data from the U.S. Census, Centre for Disease Control, the federal court system and the Commonwealth Fund predicts that 1.7 million will file for bankruptcy protection due to medical bills and outside of this another 56 million will struggle with overwhelming medical claims, that’s 20% of the U.S. population between 19-64. It’s hard for a missionary doctor to accept these statistics sometimes. I know it’s the reality but it doesn’t mean I like it.

For now, I concentrated on my new patient, PJ, and understanding his illness in the context of his circumstances. “What is about your symptoms that worry you? What are you afraid you might have?” I asked PJ. “You mentioned you’ve gone on the Internet and talked with your friends and wife? Is there something you’re afraid that you might have? Something your wife is concerned about?”

PJ shrugged a little embarrassed. He’s a private individual. Male reticence perhaps? “I don’t know. I’m still figuring out the culture in my new community. “You’re the doctor.” He hesitated. Clearly he did have some ideas and fears.

“Yes?” I encouraged him to express himself so I could understand.

“Well, you know, doctor,” he paused again. Then finally he added cautiously, “Some people have mentioned diabetes, vitamin deficiency, MS…” his voice trailed off.

“Cancer even?” I gave him words for his worst fears.

He nodded.

I glanced over at him and then finished typing. “Well, now that you are in the system, you’re in.” I assured him with a smile. “Now we can check everything out and figure out why you’re having the symptoms that have been bothering you for too long.”

He gave me a tentative quick smile.

I got up and did my usual physical exam. A head to toe exam that is the same in Africa as America. There is something comforting to using my stethoscope to auscultate the breath sounds of the lungs or the heart rhythm through the chest wall. It’s universal. Healthy bronchial breath sounds are the same anywhere I practice medicine. It makes me feel less homesick when I do my hands on physical.

“So far, everything appears normal.” I straighten up from my exam. “We’ll do some blood work to make sure you don’t have any diabetes. We’ll order all the tests to get you caught up on your cancer screening too. Before you leave, the nurse will give you your flu and tetanus vaccinations.”

He gives me a grateful smile.

“Don’t worry,” I tried to assure him that I cared and convey my desire to help alleviate his health fears. “You’re in good hands with your new health insurance. We’ll get you all caught up on your preventative health care and figure out your health problems now. We’ll take care of you.” I look up at him as I complete all the computer entries for his labs and vaccinations.

PJ is seated on the edge of the exam bed. He is smiling. His clear blue eyes framed by wrinkles formed over years of hard work begin to swim. Tears threaten. He catches himself before they spill over. And yet, his voice cracks ever so slightly. “Thank you, doctor,” he catches my hand as I reach out to solidify our relationship – primary care doctor and client-patient. A strong, firm handshake. Two strangers agreeing to work together toward health. Two strangers both coming back to the organised network of American managed healthcare.

“Thank you,” he huskily echoes.

“You’re most welcome,” I heartily assure him.

Truly, I am grateful for the reminder. He reminds me that I have a mission to care for people no matter what culture or country I find myself serving. My mission is not confined to a particular corner of the world. Sick people are everywhere. And anywhere I go, I will find those underrepresented and underserved who need an advocate to voice their story. They need a translator to hear their fears and address their health concerns. Whether in an “under developed” country or a “developed” country I can still be a missionary, an ambassador for Christ through loving medical ministry.

**Names and identifying information are changed to protect privacy.