This week was rather exciting, conversation wise. The topic of using Ritalin came up (one of my classmates is using it to study). Its use is generally widespread in the Health Sciences faculty because many people turn to "self" medicating because they did not get the results that they wanted.
I think that it is not really something that people should mess around with. Firstly, I really do think that it is equivalent to doping in sport. If you really did need the drug, a doctor would prescribe it to you. If it hasn't been prescribed to you, then sit down and work...
Here is a copy of my recent portfolio piece, I'm already tired of them...
They say that it is difficult to appreciate life until you are put in life or death situation. For many people in the renal ward at Charlotte Maxeke Johannesburg Academic Hospital it is very difficult to not appreciate life. With only two hundred dialysis places for the whole of Johannesburg, many people are forced to go home without life-saving treatment. It was after one of the patients had been discharged that I spoke to them about their stay in hospital. Thembi is a middle-aged woman that happily stood at her bedside, all your belongings packed and ready to go home. She had just been told that she didn’t qualify for dialysis because she was HIV positive and had not been on ARVs for at least 6 months. The smile was inexplicable, unless my assumptions were correct in that she didn’t understand what not getting dialysis actually meant.
It came to me then that perhaps this was an example of doctor-centred bias. With so little time to talk to all of the patients in the ward they were unable to address any concerns or questions that they patients may have. Another patient in the ward had recently demised because they had refused dialysis citing that they believed that they could “fight it [renal failure] themselves”. It is beliefs such as this that make me ask questions about the health profession, and not just in South Africa. The dynamic of health care is such that the doctor’s knowledge is usually superior to that of the patient. I think that that is especially a problem in the public health care sector in this country because understaffing often prevents doctors spending more time with their patients.
It is a problem that seems to plague hospitals and clinics around Johannesburg in general. At my community site there are two nurses and one doctor that treat over six thousand patients every month. It was at this clinic that they linked non-adherence to the lack of staff. The nurse in charge said that often she could treat forty patients in less than half an hour. With very little time to spend counselling and providing information, it is understandable that often patients are not given information about side effects and procedures.
When asking my patient how their stay had been in hospital and how they had been treated they didn’t seem to want to say more than that they had been treated well. I am not sure if it was to do with the person trying to come to terms with the fact that they would be going home to die or if the person was afraid that we would tell the staff working at the hospital about their response. I didn’t think that it was appropriate to delve any deeper in this case and I left it at that. I didn’t really feel that it was my place to try and explain the situation. She may have understood it all along.
The renal ward has been a very difficult ward to work and learn in. At times it is not easy to see past the good that the doctors and nurses in the ward are doing. The nature of renal medicine makes it such that life and death decisions are commonplace. Although this is the nature of medicine in general, it is very difficult to work in an environment where the very limited resources often determine, directly or indirectly, whether someone will live or die. It would be a lot easier to accept in an area of medicine where resource use can be maximized, but with something as complex as dialysis, it is usually the patient’s only hope.
I am really bothered by the fact that most doctors go into private practice without even being bothered by the problems currently plaguing the public service. For me it would be unethical and inhuman to practice medicine in the private setting. This case was merely the first of many that could have been solved by there being more doctors in the wards. Even if the person could still not have been given dialysis, the doctor may have been able to come up with another treatment that would have given them a longer life. Medicine by nature is a career about people; perhaps we need more “people” to study medicine.
Although patient-centered care is something that all doctors should be striving for, I do not believe that it is something that will be achieved, at least in the public setting. I think that what doctors should strive for is not a complete hybrid between patient and doctor-centered care, but rather doctor-centered care with only a slight emphasis on the patient side. If one question is answered it is better than none and in an environment where doctors are working 36-hour shifts it seems a little optimistic to assume a completely turn around in patient care. The emphasis on some of the patient-doctor themes in fact seem to be channeling individuals into the private sector which seems a little counter-productive. In all honestly, I believe that the medical school should be showing individuals the current problems with the health care system in South Africa and engaging with the students to solve the problem. One trip to a local clinic should leave most prospective doctors with a social obligation to go into the public sector. Too many medical students are focused on making money. The Wits Medical School currently has three hundred GEMP I businessmen and women; it’s about time that they had three hundred GEMP I doctors.
Saturday, March 26, 2011
Thursday, March 17, 2011
Passion and Nobel Laureates
Today a rather interesting conversation was started regarding passion in medicine. It is very interesting to hear the different points of view. At this stage most people swear that they are studying medicine in the hopes of being able to help people. There are some people that are, however, still interested in the money. It was interesting to meet the doctor at our community site this week. He was the only doctor in a clinic that serves 6000 patients every month. He has probably had every opportunity to move overseas or change to private practice, but the amazing thing is that he didn't. Clearing something else is at work. It was on the verge of tears that he told us that we still had the opportunity to change career.
In this country the health care system faces many challenges. In many cases only a fraction of the qualified doctors stay in the public sector. To not give back to the community and to not make a real difference (since you can touch more lives in public practice) almost seems a little unethical to me. If you go into a career thinking about the money you may make what is the point, if it is not something that you enjoy, or rather if you are not helping as many people as possible then surely you are in the wrong profession? Granted, working in private practice and then working one day a month in a public clinic is noble, but it does not compare to doing it every day. In many cases it is not even a question of money or working conditions. Consultants are paid more than a million rand a year, I don't need to buy my own boat, I don't even want an expensive car, it's enough for me. It's not even a question of whether you should work in private practice so that you can have a family.
Hospitals in the Gauteng area are not even underresourced. On a visit to our community site today we found well stocked consulting rooms and medicine cabinets. The problem was understaffing. It's actually shocking to see because often I think that the medical schools are not pushing the issue enough. Although we are required to do community service it still doesn't quite measure up to making a long term commitment to making a difference. One of my friends brought up an interesting example. People are always so willing to work for MSF when in fact they could make more of a difference in their own country.
For me, job satisfaction is much more than a paycheck. I would be happy just being challenged everyday, challenged to perform at the best of my ability because people depend on it. It's the thrill that I seek, something that I don't see myself ever getting in the private sector. There is also the issue of research that comes into it. If I were to ever move overseas I would move to a socialised country, it's something that I hold close to my heart.
Today a Nobel Laureate came to speak to us at university. It seems to me that not all of the discoveries are that impressive, though I do suppose that many of them occurred almost 30 years ago. Even those things discovered just 30 years ago have become common knowledge (in some cases knowledge from 10 years ago is now being taught in lectures). It was an interesting lecture about viruses and carcinogenesis. It's a rather interesting topic considering that some of the content affects us everyday in hospitals (with Kaposi's Sarcoma in HIV). It would have been a lot better if he had answered my question :) (although we did work it out afterwards).
After a day of revelations...
"How come being easy keeps getting harder?"
"If I’ve learned anything over the past 5 years, it’s that you do not know where you’re going to be tomorrow. You have to make decisions based on that; it’s almost pointless. So, you know, whether I learned, I think I’m pretty aware, pretty conscious of that point to live in the moment. It’s a hard lesson, but it’s like, I’m trying to learn to quiet my mind down, know what I mean?"
I have never been much of a fan of the whole carpe diem crap. It's one thing to say it and a completely different thing to actually put it into practice... So perhaps I have a few decisions to make, it may take a while...
The thought of the world cup still seems to send shivers down my spine, but perhaps it has to do with something my friend said: "Put away your books, your notes, your doubts, your fears and insecurities. Put away your laptops and your pens and pencils, put out of your mind that sneaky freaking suspicion that you just might have left something out. Put away the negativity and anger, put away that feeling of knowing nothing. Just remember how you got here and where you're going. Ke Nako, it's time."
In this country the health care system faces many challenges. In many cases only a fraction of the qualified doctors stay in the public sector. To not give back to the community and to not make a real difference (since you can touch more lives in public practice) almost seems a little unethical to me. If you go into a career thinking about the money you may make what is the point, if it is not something that you enjoy, or rather if you are not helping as many people as possible then surely you are in the wrong profession? Granted, working in private practice and then working one day a month in a public clinic is noble, but it does not compare to doing it every day. In many cases it is not even a question of money or working conditions. Consultants are paid more than a million rand a year, I don't need to buy my own boat, I don't even want an expensive car, it's enough for me. It's not even a question of whether you should work in private practice so that you can have a family.
Hospitals in the Gauteng area are not even underresourced. On a visit to our community site today we found well stocked consulting rooms and medicine cabinets. The problem was understaffing. It's actually shocking to see because often I think that the medical schools are not pushing the issue enough. Although we are required to do community service it still doesn't quite measure up to making a long term commitment to making a difference. One of my friends brought up an interesting example. People are always so willing to work for MSF when in fact they could make more of a difference in their own country.
For me, job satisfaction is much more than a paycheck. I would be happy just being challenged everyday, challenged to perform at the best of my ability because people depend on it. It's the thrill that I seek, something that I don't see myself ever getting in the private sector. There is also the issue of research that comes into it. If I were to ever move overseas I would move to a socialised country, it's something that I hold close to my heart.
Today a Nobel Laureate came to speak to us at university. It seems to me that not all of the discoveries are that impressive, though I do suppose that many of them occurred almost 30 years ago. Even those things discovered just 30 years ago have become common knowledge (in some cases knowledge from 10 years ago is now being taught in lectures). It was an interesting lecture about viruses and carcinogenesis. It's a rather interesting topic considering that some of the content affects us everyday in hospitals (with Kaposi's Sarcoma in HIV). It would have been a lot better if he had answered my question :) (although we did work it out afterwards).
After a day of revelations...
"How come being easy keeps getting harder?"
"If I’ve learned anything over the past 5 years, it’s that you do not know where you’re going to be tomorrow. You have to make decisions based on that; it’s almost pointless. So, you know, whether I learned, I think I’m pretty aware, pretty conscious of that point to live in the moment. It’s a hard lesson, but it’s like, I’m trying to learn to quiet my mind down, know what I mean?"
I have never been much of a fan of the whole carpe diem crap. It's one thing to say it and a completely different thing to actually put it into practice... So perhaps I have a few decisions to make, it may take a while...
The thought of the world cup still seems to send shivers down my spine, but perhaps it has to do with something my friend said: "Put away your books, your notes, your doubts, your fears and insecurities. Put away your laptops and your pens and pencils, put out of your mind that sneaky freaking suspicion that you just might have left something out. Put away the negativity and anger, put away that feeling of knowing nothing. Just remember how you got here and where you're going. Ke Nako, it's time."
Tuesday, March 8, 2011
Steak and kidney pie and the class fashion show
There is something about some of the people in my class, they just tend to irritate me. There are the people that cannot be wrong and then there are the people that (without trying) are able to annoy you to the bone. Thank goodness for thursdays and friends, not sure how I would survive otherwise.
So Wezley was told today that he doesn't have the personality to be a surgeon. Needless to say, Wezley took it upon himself to, in 2 hours, irrevocably prove that he was arrogant enough. Would be interesting to see if there is some sort of correlation between personality and specialty choice (at least at our stage).
Hmmm...being assigned to the renal ward makes me think about steak and kidney pie for some reason (or at the suggestion of my brother). Looking forward to it though. Nursing begins on thursday :).
Judge Cameron is coming tomorrow to speak to us. My brother felt that we would be better served to have a class fashion show and let him judge it. Not sure how well that would go down.
"In this world there are two kinds of people. People like me, with knives and people like you, with eyeballs."
So Wezley was told today that he doesn't have the personality to be a surgeon. Needless to say, Wezley took it upon himself to, in 2 hours, irrevocably prove that he was arrogant enough. Would be interesting to see if there is some sort of correlation between personality and specialty choice (at least at our stage).
Hmmm...being assigned to the renal ward makes me think about steak and kidney pie for some reason (or at the suggestion of my brother). Looking forward to it though. Nursing begins on thursday :).
Judge Cameron is coming tomorrow to speak to us. My brother felt that we would be better served to have a class fashion show and let him judge it. Not sure how well that would go down.
"In this world there are two kinds of people. People like me, with knives and people like you, with eyeballs."
Monday, March 7, 2011
Difficult patients, crazy people and hospital day
The first portfolio task was a good way to reflect on the HPD. Turns out that Joburg Gen was the worst option because of how bad the organisation was. We were kept waiting for 2 of the scheduled 3 hours in the morning. Below is my portfolio task:
Stalking the halls of the concrete jungle that is the Charlotte Maxeke Johannesburg Academic Hospital I find it hard to imagine that quiet ever haunts its wards. Excited medical students followed nurses that daily walk the long corridors blindly. It was on a part of our guided expedition that we met a patient named Mark. Mark was a middle aged, handsome man happily listening to music while staring out of the window of his ward. He had left his family in the Cape to come to Johannesburg looking for work. His voice laced with disappointment, he spoke about how the person that had offered him a job had let him down and he was left out on the street. After six weeks of fighting to find food, Mark decided that he wanted to end his life. He jumped off the roof of a relative’s house, head first onto the concrete below. Partially paralyzed, he now lay before us on his bed.
A now remorseful Mark spoke of how selfish it had been for him to so rashly attempt suicide. There was no hesitation in his voice as he recounted the story, almost as if it had been rehearsed. He spoke of battles to get his life changing surgery that would allow him to sit up (and not remain merely lying on his bed). He seemed to have a new outlook on life, a positive one reflected in his efforts on mastering his archenemy, the wheelchair. He spoke with disappointment as he recounted his attempts to mount his “steed” that morning, with no avail. It was easy to understand his disappointment, but it was difficult to comprehend how a man had changed his outlook on life in merely three weeks.
Lost in the haze of the usual Grey’s Anatomy or House episode, it was difficult to see the reality of the picture in front of me. It seemed like the happy ending to the fairy tale, but I was reminded of the usual twist that usually accompanies stories in real life. Although the man retained eye contact throughout the conversation, many parts of the man’s story did not add up and it was difficult not to wonder about what he had not told us. He had seemed to be extremely open about his ordeal. A colleague’s question (about who had found him) rattled me more than it did the patient. But then it dawned on me that we had perhaps not earned the right to deserve such honesty. “It’s a basic truth of the human condition that everybody lies. The only variable is about what.” – Dr Gregory House. His story seemed too rehearsed, or perhaps I was being too harsh.
The counseling that he had received could have brought about the sudden change in his point of view, but it seemed that perhaps the somewhat “luxury” life inside of the hospital had left him blind to the realities that would await him when he left. After coming from an environment where food, a warm bed and a shower were hard to come by, he moved to an environment where all of his daily needs were provided. Although Mark spoke about having the support of his wife and a job to go to when he left the hospital, I am not sure that he was able to grasp the magnitude of the change that he would have to undergo. He would probably never be able to walk again and, in my eyes, this could almost be viewed as a regression of his previous circumstances rather than an improvement. It will be a true test of his “newfound” character when he is forced to face the world.
This only being my first patient I was left with many questions that I was not able to answer. Many of the questions that I wished to ask seemed to be too invasive and difficult to phrase correctly without seeming judgmental: “Why were you not staying with your relatives here?” “Why did your outlook on life change so quickly?” Although I had become immersed in this man’s story it was still difficult to believe. In my mind I could only think, if I were his doctor then I would be here to treat him and not judge him on his previous actions. The countless prisoners stumbling through the halls echoed this line of thought. Although this is easy in theory, it is very difficult to implement in practice, especially when the hospital’s resources could be better used to save those that in fact wish to live.
Today I learnt that it is not my place to always judge those that find their place advertently or inadvertently in the wards of Charlotte Maxeke. I also learnt that sometimes the difficult questions are the questions that perhaps need to be asked in fulfilling the biopsychosocial analysis. By asking the those questions it allows the patient to think their answers through and allows for the possibility for counseling that I am not currently equipped to perform. Some of these questions could be the tools that prevent the patient from again attempting to commit suicide. I also learnt tolerance, that although perhaps I disagreed with Mark’s methods, I should still be able to try to understand his world view.
In a hospital environment it is very difficult to gauge sincerity. My patients have a story to tell, but I will never know exactly what they are leaving out. I will never find out whether Mark was telling the truth or not. I do believe, however, that the hard questions that I was unable to ask do have a place in the medical field. Mark was a fantastic first patient. In my heart I hope that he was sincere and that he is able to one day support and experience life as it should be experienced, with family and friends always close by. It has finally begun to dawn on me that today was not as surreal as it seemed. Mark was real…
*points finger into the air* [Still the best thing that has happened this week!]
It was great to talk to some of my very good friends this week, a great release after the week that we had.
A quote from A softer world:
"Children are the future which, let's be honest, is way worse than not having hoverboards."
"I get a crazy impulse when you smile at me like I want to step in front of buses, in a good way."
"It's a basic truth of the human condition that everybody lies. The only variable is about what." - Dr Gregory House
Stalking the halls of the concrete jungle that is the Charlotte Maxeke Johannesburg Academic Hospital I find it hard to imagine that quiet ever haunts its wards. Excited medical students followed nurses that daily walk the long corridors blindly. It was on a part of our guided expedition that we met a patient named Mark. Mark was a middle aged, handsome man happily listening to music while staring out of the window of his ward. He had left his family in the Cape to come to Johannesburg looking for work. His voice laced with disappointment, he spoke about how the person that had offered him a job had let him down and he was left out on the street. After six weeks of fighting to find food, Mark decided that he wanted to end his life. He jumped off the roof of a relative’s house, head first onto the concrete below. Partially paralyzed, he now lay before us on his bed.
A now remorseful Mark spoke of how selfish it had been for him to so rashly attempt suicide. There was no hesitation in his voice as he recounted the story, almost as if it had been rehearsed. He spoke of battles to get his life changing surgery that would allow him to sit up (and not remain merely lying on his bed). He seemed to have a new outlook on life, a positive one reflected in his efforts on mastering his archenemy, the wheelchair. He spoke with disappointment as he recounted his attempts to mount his “steed” that morning, with no avail. It was easy to understand his disappointment, but it was difficult to comprehend how a man had changed his outlook on life in merely three weeks.
Lost in the haze of the usual Grey’s Anatomy or House episode, it was difficult to see the reality of the picture in front of me. It seemed like the happy ending to the fairy tale, but I was reminded of the usual twist that usually accompanies stories in real life. Although the man retained eye contact throughout the conversation, many parts of the man’s story did not add up and it was difficult not to wonder about what he had not told us. He had seemed to be extremely open about his ordeal. A colleague’s question (about who had found him) rattled me more than it did the patient. But then it dawned on me that we had perhaps not earned the right to deserve such honesty. “It’s a basic truth of the human condition that everybody lies. The only variable is about what.” – Dr Gregory House. His story seemed too rehearsed, or perhaps I was being too harsh.
The counseling that he had received could have brought about the sudden change in his point of view, but it seemed that perhaps the somewhat “luxury” life inside of the hospital had left him blind to the realities that would await him when he left. After coming from an environment where food, a warm bed and a shower were hard to come by, he moved to an environment where all of his daily needs were provided. Although Mark spoke about having the support of his wife and a job to go to when he left the hospital, I am not sure that he was able to grasp the magnitude of the change that he would have to undergo. He would probably never be able to walk again and, in my eyes, this could almost be viewed as a regression of his previous circumstances rather than an improvement. It will be a true test of his “newfound” character when he is forced to face the world.
This only being my first patient I was left with many questions that I was not able to answer. Many of the questions that I wished to ask seemed to be too invasive and difficult to phrase correctly without seeming judgmental: “Why were you not staying with your relatives here?” “Why did your outlook on life change so quickly?” Although I had become immersed in this man’s story it was still difficult to believe. In my mind I could only think, if I were his doctor then I would be here to treat him and not judge him on his previous actions. The countless prisoners stumbling through the halls echoed this line of thought. Although this is easy in theory, it is very difficult to implement in practice, especially when the hospital’s resources could be better used to save those that in fact wish to live.
Today I learnt that it is not my place to always judge those that find their place advertently or inadvertently in the wards of Charlotte Maxeke. I also learnt that sometimes the difficult questions are the questions that perhaps need to be asked in fulfilling the biopsychosocial analysis. By asking the those questions it allows the patient to think their answers through and allows for the possibility for counseling that I am not currently equipped to perform. Some of these questions could be the tools that prevent the patient from again attempting to commit suicide. I also learnt tolerance, that although perhaps I disagreed with Mark’s methods, I should still be able to try to understand his world view.
In a hospital environment it is very difficult to gauge sincerity. My patients have a story to tell, but I will never know exactly what they are leaving out. I will never find out whether Mark was telling the truth or not. I do believe, however, that the hard questions that I was unable to ask do have a place in the medical field. Mark was a fantastic first patient. In my heart I hope that he was sincere and that he is able to one day support and experience life as it should be experienced, with family and friends always close by. It has finally begun to dawn on me that today was not as surreal as it seemed. Mark was real…
*points finger into the air* [Still the best thing that has happened this week!]
It was great to talk to some of my very good friends this week, a great release after the week that we had.
A quote from A softer world:
"Children are the future which, let's be honest, is way worse than not having hoverboards."
"I get a crazy impulse when you smile at me like I want to step in front of buses, in a good way."
"It's a basic truth of the human condition that everybody lies. The only variable is about what." - Dr Gregory House
Tuesday, March 1, 2011
Playgrounds, nurseries and lonely children
Today turned out to be a rather interesting day. We started off with the usual microbiology and laboratory techniques and continued into another lecture by our rather eloquent microbiology lecturer on bites. Who knew that human bites were the worst bites to get? The story of the panty hamster will begin to haunt me as well, who knew that hamsters were so comfortable living in playgrounds.
The patient doctor theme seems to be another one of the "fluffy" themes. It's still rather interesting and I have been told that it is important by one of the older students. I'm not sure that methods of consultation are best taught in the lecture environment, but it is a start at least. We will be learning, however, to remove nurseries while keeping playgrounds in place. Not sure how much use a playground is without children though. We will have to see. :)
I was assigned to Charlotte Maxeke for the LOTS block. I see this almost as winning the lottery (due to the fact that I can wake up slightly later).
Often people consider small talk to be the order of the day. I don't. I have something to tell you, are you listening?
http://xkcd.com/222/
The patient doctor theme seems to be another one of the "fluffy" themes. It's still rather interesting and I have been told that it is important by one of the older students. I'm not sure that methods of consultation are best taught in the lecture environment, but it is a start at least. We will be learning, however, to remove nurseries while keeping playgrounds in place. Not sure how much use a playground is without children though. We will have to see. :)
I was assigned to Charlotte Maxeke for the LOTS block. I see this almost as winning the lottery (due to the fact that I can wake up slightly later).
Often people consider small talk to be the order of the day. I don't. I have something to tell you, are you listening?
http://xkcd.com/222/
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