It is when I have just returned from Uganda, at least once the jet lag burns off, that the reason I go to Africa becomes evident. Not while I am there, and certainly not in the unsettled time leading up to my trip; those weeks when I question most why I am going. It is when I resume my “normal” life, my real life, my “day job” when the reason I have just spent a month eating bad food, riding along bumpy dirt roads for hours to see one patient, and feeling adrift in a medical world of uncertainty becomes suddenly clear to me, like the condensation on the windshield evaporating when you turn on the defogger. It is when I return from the humid equatorial climate of Uganda that I finally see where I’ve been and why.
So many people who greet me upon my return offer up their own understanding of why I go:
“It must feel really good to go there and help.”
It does. But that’s not why I travel 7000 miles to a remote country. There are so many people to help right here at home.
“It must be so completely satisfying to go there.”
Sometimes, although a lot less than you’d imagine. But I don’t tell them that. I just smile and nod; avoiding a discussion about the frustration I feel that there isn’t more that I can do for the patients I see there.
“The people you see must really appreciate what you do.”
They do, but again, not why I go.
“We have a new patient to see,” says Prossy, our head nurse, as our 9 member team squeezes into our 7 passenger car, leaving our base of operations at the rural hospital we stay at while in Uganda for our daily trip into the outlying villages to make our palliative care rounds. “Is it far?” I ask, knowing that the roads will be deeply rutted; our aged vehicle’s worn out suspension groaning with every unavoidable bump. “Yes”, she replies. How far? “An hour.” “An hour!” I exclaim, trying unsuccessfully to remove the American whine in my voice. “OK. A half hour,” she smiles.
After an hour and a half of rocking over narrow mud roads, nudging stubborn cows with my horn and bumper, dodging trucks overloaded with sugar cane careening toward us, and as courteously as possible allowing women balancing oversized bundles on their heads to climb up the embankment to allow us to pass, the worn out springs of the driver’s seat imprinted on my butt, we drive up to the patient’s home, a small mudbrick hovel surrounded by a few sprouts of maize, a couple of coffee bushes, and some chickens running amok. There, sitting very quietly on a bench in the dirt yard, drawing hard on his breath, is young Julius, fifteen years old, head hung low, staring at his bare, swollen feet.
My jaw tenses, my stomach twists when I look at the boy. I walk up close to him, his loneliness becomes mine. The discomfort of realizing how very sick he is and how much he is relying on me to relieve his suffering unnerves me. Me, a data driven, tech-addicted doc from the west, stripped bare of his laboratory tests and scans, struggling with only my senses and my knowledge to find my way in the barren rural Ugandan healthcare landscape. No blood tests, scans, or specialists pointing me toward a diagnosis, suggesting a treatment. Feeling exposed, dispossessed of my comfy blanket of technology, I sit down on the bench. This is what it means to me to practice in an underserved, undersupplied area of the third world.
Abraham Verghese, best known as the physician author of the bestselling novel Cutting for Stone, is also known among doctors as a brilliant diagnostician and a vocal proponent of the lost art of the doctor’s hands-on physical examination of patients. He has coined the term “iPatients” decrying the deterioration of the doctor-patient relationship through the ever increasing use of electronic medical records and technology instead of the humanness of personal interaction. In a 2011 New York Times Op-Ed “Treat the Patient, Not the CT Scan”, he wrote, “Rituals are about transformation, the crossing of a threshold, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship, a way of saying: “I will see you through this illness. I will be with you through thick and thin.” It is paramount that doctors not forget the importance of this ritual.”
I was trained in the day when CAT scans were a new and rare commodity, MRI’s were only a sketch on an engineer’s table, and computers were big as rooms and required someone called a “key punch operator” rather than the click of a mouse to make them work. Some people, including my children, both newly minted physicians, might consider that educational background a disadvantage. But sitting on that bench in the dusty air of rural Africa, I thought of how fortunate I was to have been forced to rely on my hands, eyes, and ears, rather than radiation, blood, and microchips to do my diagnostic testing. Humbled, questioning my skills, at that moment I wished that I could make Abraham Verghese appear to help me figure out what was wrong with young Julius.
Back in the US, Randi and I recently met with the filmmaker doing a documentary about palliative care in rural Uganda and she was telling us how she viewed what we did there. Lucy explained to us that the way she sees it, when we are there, we return to the “heart” of medicine. Stripped of all the modern bells and whistles, in rural Uganda we become doctors from a bygone day, spending great amounts of time patiently listening to patients, talking with patients, examining the patients, looking for clues to their diagnosis, trying our best to understand what was ailing them as people, as a part of a family and a community and to figure out what we could do to help them best with our limited means.
It’s like being in a dark movie theater for a matinee and walking out into the afternoon sun, the light is so much brighter. Coming back to the US after being deprived of all the medical data that I typically rely on to get to the crux of my patient’s problem; my low-tech physical diagnostic skills are sharper, more sensitive to picking up the subtleties. I see each patient more clearly, I hear their complaints more sharply, and I feel their discomforts more personally. Returning to my tech laden medical practice, I find myself ordering fewer tests, calling fewer consults; I am more confident in my abilities as a physician to minister without the crutches of data. Sure I still use tests when I’m back to confirm my instincts; Uganda brings me not only confidence but humility in my abilities to care for people. But my perspective shifts as a result of being in Uganda, and the relative importance of what is available and what is necessary is redefined when I return. Just like the more you use a GPS in your car the harder it is to find your way when you don’t use it, as I reacclimatize to the computerized medical world, I lose my more well-honed sense of direction until I return to Africa.
It is in the weeks that I return that I realize why I have gone and why I will return. Sure it is satisfying to get an email from our team leader that young Julius is doing so much better, happier and more active, since being on the heart medications (and reading the schoolbooks) we brought him. And of course it makes us happy to hear how many of the patients we saw are asking for us and tell our team to thank us yet again for our help. But it is in the weeks following my return that I realize why I keep going back despite all the challenges. Simply, it makes me a better doctor to my patients. All my patients, both in the US and Uganda. And that’s good for everyone.
Howard
August 2016
*Core - from Latin cor (“heart”); or from Old French cors (“body”)
So many people who greet me upon my return offer up their own understanding of why I go:
“It must feel really good to go there and help.”
It does. But that’s not why I travel 7000 miles to a remote country. There are so many people to help right here at home.
“It must be so completely satisfying to go there.”
Sometimes, although a lot less than you’d imagine. But I don’t tell them that. I just smile and nod; avoiding a discussion about the frustration I feel that there isn’t more that I can do for the patients I see there.
“The people you see must really appreciate what you do.”
They do, but again, not why I go.
“We have a new patient to see,” says Prossy, our head nurse, as our 9 member team squeezes into our 7 passenger car, leaving our base of operations at the rural hospital we stay at while in Uganda for our daily trip into the outlying villages to make our palliative care rounds. “Is it far?” I ask, knowing that the roads will be deeply rutted; our aged vehicle’s worn out suspension groaning with every unavoidable bump. “Yes”, she replies. How far? “An hour.” “An hour!” I exclaim, trying unsuccessfully to remove the American whine in my voice. “OK. A half hour,” she smiles.
After an hour and a half of rocking over narrow mud roads, nudging stubborn cows with my horn and bumper, dodging trucks overloaded with sugar cane careening toward us, and as courteously as possible allowing women balancing oversized bundles on their heads to climb up the embankment to allow us to pass, the worn out springs of the driver’s seat imprinted on my butt, we drive up to the patient’s home, a small mudbrick hovel surrounded by a few sprouts of maize, a couple of coffee bushes, and some chickens running amok. There, sitting very quietly on a bench in the dirt yard, drawing hard on his breath, is young Julius, fifteen years old, head hung low, staring at his bare, swollen feet.
My jaw tenses, my stomach twists when I look at the boy. I walk up close to him, his loneliness becomes mine. The discomfort of realizing how very sick he is and how much he is relying on me to relieve his suffering unnerves me. Me, a data driven, tech-addicted doc from the west, stripped bare of his laboratory tests and scans, struggling with only my senses and my knowledge to find my way in the barren rural Ugandan healthcare landscape. No blood tests, scans, or specialists pointing me toward a diagnosis, suggesting a treatment. Feeling exposed, dispossessed of my comfy blanket of technology, I sit down on the bench. This is what it means to me to practice in an underserved, undersupplied area of the third world.
Abraham Verghese, best known as the physician author of the bestselling novel Cutting for Stone, is also known among doctors as a brilliant diagnostician and a vocal proponent of the lost art of the doctor’s hands-on physical examination of patients. He has coined the term “iPatients” decrying the deterioration of the doctor-patient relationship through the ever increasing use of electronic medical records and technology instead of the humanness of personal interaction. In a 2011 New York Times Op-Ed “Treat the Patient, Not the CT Scan”, he wrote, “Rituals are about transformation, the crossing of a threshold, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship, a way of saying: “I will see you through this illness. I will be with you through thick and thin.” It is paramount that doctors not forget the importance of this ritual.”
I was trained in the day when CAT scans were a new and rare commodity, MRI’s were only a sketch on an engineer’s table, and computers were big as rooms and required someone called a “key punch operator” rather than the click of a mouse to make them work. Some people, including my children, both newly minted physicians, might consider that educational background a disadvantage. But sitting on that bench in the dusty air of rural Africa, I thought of how fortunate I was to have been forced to rely on my hands, eyes, and ears, rather than radiation, blood, and microchips to do my diagnostic testing. Humbled, questioning my skills, at that moment I wished that I could make Abraham Verghese appear to help me figure out what was wrong with young Julius.
Back in the US, Randi and I recently met with the filmmaker doing a documentary about palliative care in rural Uganda and she was telling us how she viewed what we did there. Lucy explained to us that the way she sees it, when we are there, we return to the “heart” of medicine. Stripped of all the modern bells and whistles, in rural Uganda we become doctors from a bygone day, spending great amounts of time patiently listening to patients, talking with patients, examining the patients, looking for clues to their diagnosis, trying our best to understand what was ailing them as people, as a part of a family and a community and to figure out what we could do to help them best with our limited means.
It’s like being in a dark movie theater for a matinee and walking out into the afternoon sun, the light is so much brighter. Coming back to the US after being deprived of all the medical data that I typically rely on to get to the crux of my patient’s problem; my low-tech physical diagnostic skills are sharper, more sensitive to picking up the subtleties. I see each patient more clearly, I hear their complaints more sharply, and I feel their discomforts more personally. Returning to my tech laden medical practice, I find myself ordering fewer tests, calling fewer consults; I am more confident in my abilities as a physician to minister without the crutches of data. Sure I still use tests when I’m back to confirm my instincts; Uganda brings me not only confidence but humility in my abilities to care for people. But my perspective shifts as a result of being in Uganda, and the relative importance of what is available and what is necessary is redefined when I return. Just like the more you use a GPS in your car the harder it is to find your way when you don’t use it, as I reacclimatize to the computerized medical world, I lose my more well-honed sense of direction until I return to Africa.
It is in the weeks that I return that I realize why I have gone and why I will return. Sure it is satisfying to get an email from our team leader that young Julius is doing so much better, happier and more active, since being on the heart medications (and reading the schoolbooks) we brought him. And of course it makes us happy to hear how many of the patients we saw are asking for us and tell our team to thank us yet again for our help. But it is in the weeks following my return that I realize why I keep going back despite all the challenges. Simply, it makes me a better doctor to my patients. All my patients, both in the US and Uganda. And that’s good for everyone.
Howard
August 2016
*Core - from Latin cor (“heart”); or from Old French cors (“body”)
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