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

Doctor.

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.

Eleven Differences I Notice Since Living Overseas

Author note:

It seems everyone is making up their “top ten” lists these days. I thought I’d join the foray with my own few observations. Those of you who’ve spent any length of time in a foreign culture may relate.

~o~

"The world is full of obvious things which nobody by any chance ever observes." 

- Sherlock Holmes in The Hound of the Baskervilles, ACD.

~o~

10 11 THINGS I’VE NOTICED SINCE LIVING IN CAMEROON 

(note the word “Cameroon” -- not “Africa)

1. Television Commercials Are Annoying

How many times do I need to be reminded how I must be unhappy until I buy items that I don’t really need? I have never been a fan of commercials but recently, when I watched the season premiere of a favorite television series I follow, I was seriously put out by the multitude of hyper commercials advertising for services and things I wasn’t even remotely interested in spending money upon. Those commercials for prescription medications were particularly inciting on so many levels.

2. People Are Multicultural

Americans are just that – Americans. The United States is a country of immigrants. I can’t define people as black or white or Hispanic or Asian anymore. Each person has their own unique heritage. The lovely Greek lady at the supermarket was a treat to meet. Her accent brought up sunny memories of Greek island beaches and delicious Feta cheeses.

3. American News Channels Are Terribly Biased

I have been privileged to live in different countries and talk with peoples from a vast array of cultural backgrounds. America is not the only country in the world. There’s so much more. The local news channels strike me as bordering on brainwashing. I want to shake the radio and yell, “Wake up, people! There’s more than three top stories happening in the world!” Ok. Deep breath. I’m thankful for the internet and the opportunity to glean from news agencies outside U.S. borders.

4. There Are A LOT of Choices/Options

OK. So much has already been said about the gigantic variety of choices that Americans are presented with wherever they go. I remember going to PetsMart and wondering to myself, “How many different kinds of flea product are really necessary?” The entire left-hand side of the isle was stocked with an overwhelming plethora of choices. I certainly didn’t have the time to read every label and do a statistical analysis of price versus quality versus reviewer rating before buying a product that would rid my dog of fleas.

 5. The U.S. Is Full of Emptiness

I take my dog for a stroll along the country roads. Each house I pass with manicured lawns and blooming flowerbeds is still and silent. The windows are dark. No dogs bark. No children bounce around the yard. My husband and I drive to the park. One other person with his son walks around the track with their two dogs. We drive along the freeways, only in the centre of Washington DC do the roads seem congested with traffic. Elsewhere the streets have plenty of space between vehicles. No motorcycles or pedestrians crisscross the lanes either. The neighborhoods seem eerie and empty.

6. Excessive Signage

In Cameroon, there are no street signs marking the names of streets/roads/paths/etc. This is generally not a problem since most roadways do not have official names; and, if they do, they’re not very descriptive or unique. Buea is full of streets termed ‘street one’, ‘street two’, street three’, ‘street four’, and such forth. Each different neighborhood/quarter has its own set of street numbers and unless someone specifies the neighborhood, one cannot differentiate which ‘street one’ is being mentioned. There are the basic traffic signs in Cameroon too. A few stately STOP signs grace the intersections suggesting to the taxi drivers that they might want to consider reducing their speed before crossing the thorough-way. I've never heard a foreigner complain about an overabundance of signage though. In contrast, take the intersection her in Virginia where I’m spending a few days. The Interstate 95 bisects Route 17 at the 4-way stoplight. There’s a digital WellsFargo Bank blinking the temperature of the moment. Another sign warns “Do Not Block Intersection”. The Sleep INN proudly boasts a ‘fresh look, complimentary hot breakfast, and wifi’. To my right there are signs directing traffic one direction, other signs announce, ‘End Work Zone’, ‘Over Height Do Not Pass Under Bridge’, “End Road Work’, ‘Left Lane Ends Merge Left’. To my left are more signs declaring, ‘Unmarked Pavement’, ‘One Way’, ‘Stay in Lane’, and ‘Exit’. Every empty patch of dirt appears taken with a signpost and the traffic signal poles are strapped with flyers and notices. There’s even a tiny white plastic spike with the writing ‘Caution Water Valve’ imbedded intoa scruffy tuft of remaining green grass. Signs, signs, and more signs. I’m feeling lost in the exuberant enthusiasm of the written posted verbosity.  Let’s not start on the cereal cartons!

7. America is the ‘Land of Many Toilets’

I’m not claiming the U.S. has more bathrooms than other countries. Cameroon has plenty of unofficial potty spots. In reality, any dim alley can serve as an emergency bladder-relief spot if necessary. However, in general, bathrooms are not as readily accessible, available, and convenient as the States. The supermarkets here in America have multi-stalled bathrooms freely available to their customers. Every Café maintains at least one fresh-smelling toilet. Quaint city parks with mere acres of grass and a tiny walking path still have at least a men & women bathroom facility. There’s nowhere I can go where I’m terribly inconvenienced by my bladder’s demands. I’m not complaining about this, mind you. It’s nice not having to plan my oral intake levels based on future availability. I must admit that I’m still getting used to the new norm of flushing the toilet EVERY time. The old adage, ‘when it’s yellow, let it mellow….’ Is harder to contradict than one might imagine. I find myself still calling out, “Bill, do you need to use the toilet before I flush?” at bedtime. 

8. The Supermarket, A.K.A. Food Supply, Is Far Far Away

In Buea, at the end of my workday, Jordan (our dog) and I would stroll around the neighborhood. I’d get my exercise, Jordan would get her excise, and we’d both find supper. Living on the outskirts of town right now, I find it takes at least fifteen minutes, by car, to reach the nearest supermarket, or really any store for that matter. Shopping and sleeping are much farther apart in the States as compared to life in Cameroon. No wonder everyone owns a car.

9. Where Are All the Ants?!

Ok. Ok. I admit, I’m not the most nit-picky house keeper. Our house in Buea was generally swept and the dishes at least in various stages of being cleaned; but, no one would have pinned a blue ribbon on the place giving me a Martha Steward award. Still, I learned to put every open food packaging in the fridge immediately after use. Where’s the sugar for the tea? In the fridge. What about the bread? In the fridge. No matter how minuscule the food particle, if it laid out on the kitchen counter for more than five seconds, the ants would come. Tenacious, persistent, incredibly intelligent little scavengers that could burrow their way into almost every form of packaging…even occasionally the as-yet unopened ‘sealed’ cartons. 

And now? There are freshly baked muffins cooling on the counter top without a hint of an ant. A small amount of sugar from the sugar bowl in the cupboard spilled this morning. Nary an insect has come. The candy sits in the candy dish without disturbance. The biscuits sit in the pantry in an already opened wrapping without a bug. The lights above the dining table shimmer alluringly but no flying six-legged critters fly overhead or fall into our stew. Amazing!

10. Small Change Lasts Forever

Thanks to Visa and MasterCard, the coins and dollar bills sit around in my change purse forever. No more searching for change. No more waiting until the end of the day when the pharmacy might be able to break a 10,000 XAF bill into spendable 1000 and 2000 XAF paper bills. My quarters and nickels wait patiently until the next parking meter, which is the only time I use cold, hard coins these days. The convenience is handy. My math skills in addition and subtraction that I’d use to ensure my purchases added up to a suitable round number that the clerk had change for, and then double-check the leftover change, are dwindling. 

And...since I couldn't contain my list to ten...

11. Fuel Prices Are Variable

My father has an app on his iPhone to help him locate the pumps with the least expensive fuel prices. One doesn’t have to drive too far to pass fuel stations with all sorts of different prices advertised; and, they change daily! Even fuel stations adjacent to each other advertise different unit prices per gallon. In Cameroon, during my five years, due to government regulations, the fuel price changed once. Very standardized. The fuel prices were not cheap but they were consistent. 

Obviously, many other cultural nuances and differences assault my observations these days. I'd love to hear from you and see what differences you've noticed internationally speaking.

Thoughts on being a "Missionary"

I am sent by my religious faith system/denomination to be a "Missionary". Admittedly this word hasn't set well with me. Needless to say - I AM sent by my denomination and accepted as a missionary in Cameroon.

One can think a missionary is sent to convert others to their particular doctrines/dogma/religion/what-have-you. One can think of one sent on a charitable mission somewhere. Wikipedia has a definition that says "one who is sent to witness across cultures."

Am I out to convert people to my personally held doctrines/dogma/religion? Am I here to be charitable? To witness across cultures? Witness to "what" exactly?

We find our faiths in a variety of ways. We are born into families with certain values and we may not depart far from them. We convert. One of the easiest ways for me to think about who I am and what I am doing is to put it in terms of nationalities. I was born in the USA; imprinted with the climate and scenery of New England.

I think my country is beautiful and diverse. My country was founded with particular values. I cannot help it - I get goose bumps when I read or hear the Declaration of Independence and the Bill of Rights. Equally, the music of our national anthem is meaningful, and the words of America the Beautiful stir me.

I was not born with those feelings. I discovered them as I grew up and experienced life. I tested the values against other values to see if they rang true. And to my perspective, the America we have to day is the same but also very different from the one I value in my heart and that I believe was intended at our inception.

We do not always represent those values well. We say one thing and often do another. Still other Americans have differing perspectives from mine - differing opinions of the intent of the founding fathers. This neither makes them or me right or wrong. That is one of our values.

When I travel the world, away from my country, I am a "missionary", an Ambassador if you will. For those who meet me have their own ideas of what America is and what Americans are like. I cannot own their perspectives - they are what they are. I am who I am.

I represent just 1/300 millionth of what America is and I only offer myself as a single perspective. I remember being in Hong Kong, waiting in a hotel for my ride to the boat to Macau. I could hear a "Texan" bellowing through the halls. I tried to hide. I was riding a bus in London. We slowed near a club and there was an American swearing is head off that he was NOT going to remove his tie to go in the club.

I am sure at some point, that I too, have been an ugly American - loud and obnoxious. Though I try to be mindful of such, I am a witness to others about America by how I live and conduct myself. I do not do so from a "legal" basis. I do not live burdened by the obligation. I succeed and I fail. That too is part of being American. Oh, and just because I am American doesn't mean I agree with everything the leaders of America say or do.

I am not out trying to convert others to be American. I would rather see them be excellent citizens of their respective countries. However if one should be unhappy with their country, and I think you might be a good citizen of mine, I may wonder aloud, about the person becoming an American. Should they become an American citizen, I would hope they would value our history. That being an American isn't, in itself the American dream. Being American isn't a surety of success (or failure). Being American doesn't automatically make one an infidel (though I don't doubt there are some among us).

Rather than assuming the best or worst of me, because I am American, I would prefer people to talk with me and explore what it means for me to be American. I too want to understand what it means for you to be a citizen of your country. I get excited when you love your country and can point out the beauty of its values as well as its physical beauty. Don't expect me to convert -- though I hope I can deeply appreciate what it means to be a citizen of your country.

Perhaps together we can break down the walls of misunderstanding and mistrust. Perhaps together we can build each other up through loving acts of kindness, demonstrating the best values of our respective countries. Perhaps together we can make the world a better place.