last days of fourth year, first days of malawi
Fourth year of medicine just wasn't fun. Between turning up for daily teaching and ward work, planning and completing a research project, trudging your way through a spirit crushing box ticking exercise that requires you to write about every patient and procedure you see as if they were steps in a spiritual journey, preparing numerous written and verbal patient presentations, and at the end of it all being given less than a week to concentrate on final examinations, the medical school demanded of me an amount of work that required me to package any extracurricular aspects of my personality up into a guilty treat box at the back of my head, untill I was no longer a person who studied medicine, but a medical student who mourned the loss of his person. I admit, I am prone to melodrama, but this last year really did stretch me pretty thin. And the worst part was how unnecessary it all seemed. Medical school lasts five years, and the only reason I can see for squeezing so much substance (and filler) into a sinle year is as some sort of sadistic test of our ability to cope with unrealistic workloads. And I didn't cope very well. By the end of it I was robbed of the enthusiasm for medicine I once fostered, and I was seriously wondering if my aim of becoming a psychiatrist was really worth selling my soul for. I got stressed, and if it weren't for parental pressures and the time and money already spent on it, there were times I would have just said no and jumped on a plane to India to see my girlfriend for a while and rethink my life. Thankfully, I just don't have the balls for such brave impulsive acts, so I surrendered my will to the medical school's arbitrary life-consuming ways for a year along with 150 other medical students.
And now I can stop moaning and taking my free and really rather priveleged education for granted, as for the time being it's offering my life more exciting opportunities than excessive restrictions. I'm in Malawi, I passed my exams and so will be here for four months rather than two, and while its not exactly a holiday its still a big fat sigh of relief after fourth year.
When I arrived in India last summer, to say I suffered from culture shock would be an understatement. To say I was temporarily paralysed by my sudden transportation to a completely alien world would be more accurate. I expected Malawi to be a bit easier on the brain, purely because I didn't think it would be as busy, but it has been an even softer landing than I would ever have guessed. It is true that I have never been in a city quite like Lilongwe. It even challenges my very understanding of the word city. A city to me is an environment constructed by humans that allows them the convenience of having everything they need close together, while keeping the rest of nature at bay behind the city borders and in selected parks. Lilongwe's buildings however, are scattered loosely over a large area of otherwise natural land, with long, wide, reasonably quiet roads joining them all up. Its possible to walk between places, and so far thats been our mainstay of transport, but even in the winter sun the distance and heat can rapidly drain you of sweat and energy. People are overwhelmingly friendly. If you make eye contact, almost everyone will smile warmly as you pass them, and if you stop them for directions they'll go out of their way to make sure you end up at the right place. Minibuses are common, and the drivers believe there's always room for a couple more sardines in their rusty white tins, so for 50p you get where you want in a jungle of African smiles, legs, suitcases and children, and sometimes even witness the comic tragedy of a driver squeezing the last few days of business out of his bus, laughing everytime the door falls off and worrying for his livelihood in between. We're trying to hunt down some bicycles, and we're looking into renting a car, as all we've heard from travellers, locals and books is that its not safe to go out walking after dark. For food, you can barter vegetables for pennies at the markets, and fill up a shopping trolley of home comforts at the supermarkets. Men and women are rarely seen walking together. Women seem to walk in groups, and at least half of them have babies strapped to their backs with (hopefully!) tight and secure shawls. Madonna was right- the babies are positively kidnappable, and from their mothers backs they stare in peaceful wide eyed wonder at their new world around them. Overall, while it is a different place from home, the very nature of the difference is so relaxed and non threatening that instead of an uncomfortable adjustment period I just instantly settled into the slower, spaced out pace of life.
It is sub-Saharan Africa though. The life expectancy is only 45. On our first trip to the market the first ten stalls demonstrated a highly competitive coffin market. And I am at Kamuzu Central Hospital Monday through Friday. So its not all smiles and psima. Psima is the mashed potato/semolina hybrid that forms the bulk of most Malawian meals, alongside cuts of meat that put our wasteful ways to shame- chicken claws and pigs trotters (manginas in chichewa, the local language, no joke) - its no wonder ive put my vegetarianism on hold!
The majority of the patients in the hospital have HIV. The majority of them are acutely unwell. While in Scotland we spend a good long time taking a detailed comprehensive history of a patient's presentation, past medical, family, drug and social history, before waving a stethoscope over them to confirm they are in fact in full working order, here we quickly ask what the patients' main symptom is before checking just how many strong clinical signs they're displaying. There tends to be a lot. Conjuctivae are white, necks are stiff, abdomens are swollen, spleens are gigantic, lungs crackle and wheeze, temperatures soar... In comparison to Scotland, investigations are limited. There is a laboratory, and it does process the samples you send it, but its speed and limitations suggest that lab work is actually an expensive, laborious commodity, rather than the magical same day free for all it is in Scotland. Due to the shortage or inefficiency of diagnosis confirming investigations, and also due to the smaller range of drugs available, treatment is largely empirical. And when I say largely empirical, I mean if a patient turns up with a fever they will receive ceftriaxone and quinine almost invariably. The actual manner in which patients are treated differs wildly too. In Scotland, every attempt is made to make patients as comfortable, informed and dignified as possible. Here, patients leave their dignity and comfort at the door. The wards are freezing cold at this time of year, some patients are kept outside on the balcony, attempts to explain to patients what is going on are few and practical procedures such as lumbar punctures involve no local anaesthesia and lots of manhandling the patient into the best position. Basically, conditions that would have Scottish patients screaming for their lawyer are tolerated without so much as a passing complaint. And the way I see it the fundamental difference is what we assume and expect from our healthcare systems. In Scotland, we assume access to the best possible treatments available on the NHS (and they, we assume, at least closely follow the best currently available treatments worldwide), and on top of that we hope (maybe even assume) to be treated like royalty the entire time. Here, patients seem to arrive in hospital simply hoping that some foreign tongued doctor will save them from death a while longer, and any hopes or expectations over and above that seem irrelevant. So different diseases, different presentations, different investigations, different drugs and an overall completely different approach to patient care. Its definately interesting, and if anything its really making me realise just how incompatible much of my western medical education is with practising medicine here. One thing I would really love to do though, is take a full Dundee-style history from a patient, complete with social and occupational details, explanations of how their illness (normally HIV) has affected their life, their perceptions of their illness and any concerns they have. I just don't know how the patients or translating clinical officers would feel about such an unusual, excessive and at times downright nosey history though. Its a shame, because at the moment the patients do not feel like real people with stories and emotions, just broken bags of strong signs and symptoms to be fixed. Maybe it's just easier that way here though.
We also get to do a lot more practical procedures here than at home. I've done two lumbar punctures already, and by the end I should be a pro at them, along with ascitic and pleural taps. It's also very easy to be genuinely useful, as while the ward has plenty of medical students, there are very few doctors and some of the doctors just ain't great.. So you can buzz around checking on patients and find things that have been forgotten or completely overlooked. Today I found a young girl whose IV cannula had fallen out and who had been fitting for 10 minutes, and gave her intramuscular diazepam, and another girl who had been noted to be extremely hypotensive but again whose cannula had fallen out, and so wasnt receiving IV fluids. I might just spend my days going from patient to patient checking cannulas. I wont be out my depth and I might even save a few lives!
So yeah, Malawi's shaping up to be a pretty worthwhile adventure. While I'm sure to forget everything about medicine that isnt HIV, tuberculosis or malaria, by the end of it I should be a bit of an infectious diseases hotshot. More importantly, it's just interesting to put the NHS into perspective. I'm with Amy, Rich and Jennie, and while we all didn't know each other particularly well before we landed in Lilongwe together, they're all very nice and fun and don't seem to find me too annoying (yet!). We all went out last Friday with one of the registrars from the hospital and danced on the grave of fourth year, we sit in the flat at night cooking each other dinner, drinking tea and talking about rubbish, and i'm looking forward to some nice trips away with them.
And now I can stop moaning and taking my free and really rather priveleged education for granted, as for the time being it's offering my life more exciting opportunities than excessive restrictions. I'm in Malawi, I passed my exams and so will be here for four months rather than two, and while its not exactly a holiday its still a big fat sigh of relief after fourth year.
When I arrived in India last summer, to say I suffered from culture shock would be an understatement. To say I was temporarily paralysed by my sudden transportation to a completely alien world would be more accurate. I expected Malawi to be a bit easier on the brain, purely because I didn't think it would be as busy, but it has been an even softer landing than I would ever have guessed. It is true that I have never been in a city quite like Lilongwe. It even challenges my very understanding of the word city. A city to me is an environment constructed by humans that allows them the convenience of having everything they need close together, while keeping the rest of nature at bay behind the city borders and in selected parks. Lilongwe's buildings however, are scattered loosely over a large area of otherwise natural land, with long, wide, reasonably quiet roads joining them all up. Its possible to walk between places, and so far thats been our mainstay of transport, but even in the winter sun the distance and heat can rapidly drain you of sweat and energy. People are overwhelmingly friendly. If you make eye contact, almost everyone will smile warmly as you pass them, and if you stop them for directions they'll go out of their way to make sure you end up at the right place. Minibuses are common, and the drivers believe there's always room for a couple more sardines in their rusty white tins, so for 50p you get where you want in a jungle of African smiles, legs, suitcases and children, and sometimes even witness the comic tragedy of a driver squeezing the last few days of business out of his bus, laughing everytime the door falls off and worrying for his livelihood in between. We're trying to hunt down some bicycles, and we're looking into renting a car, as all we've heard from travellers, locals and books is that its not safe to go out walking after dark. For food, you can barter vegetables for pennies at the markets, and fill up a shopping trolley of home comforts at the supermarkets. Men and women are rarely seen walking together. Women seem to walk in groups, and at least half of them have babies strapped to their backs with (hopefully!) tight and secure shawls. Madonna was right- the babies are positively kidnappable, and from their mothers backs they stare in peaceful wide eyed wonder at their new world around them. Overall, while it is a different place from home, the very nature of the difference is so relaxed and non threatening that instead of an uncomfortable adjustment period I just instantly settled into the slower, spaced out pace of life.
It is sub-Saharan Africa though. The life expectancy is only 45. On our first trip to the market the first ten stalls demonstrated a highly competitive coffin market. And I am at Kamuzu Central Hospital Monday through Friday. So its not all smiles and psima. Psima is the mashed potato/semolina hybrid that forms the bulk of most Malawian meals, alongside cuts of meat that put our wasteful ways to shame- chicken claws and pigs trotters (manginas in chichewa, the local language, no joke) - its no wonder ive put my vegetarianism on hold!
The majority of the patients in the hospital have HIV. The majority of them are acutely unwell. While in Scotland we spend a good long time taking a detailed comprehensive history of a patient's presentation, past medical, family, drug and social history, before waving a stethoscope over them to confirm they are in fact in full working order, here we quickly ask what the patients' main symptom is before checking just how many strong clinical signs they're displaying. There tends to be a lot. Conjuctivae are white, necks are stiff, abdomens are swollen, spleens are gigantic, lungs crackle and wheeze, temperatures soar... In comparison to Scotland, investigations are limited. There is a laboratory, and it does process the samples you send it, but its speed and limitations suggest that lab work is actually an expensive, laborious commodity, rather than the magical same day free for all it is in Scotland. Due to the shortage or inefficiency of diagnosis confirming investigations, and also due to the smaller range of drugs available, treatment is largely empirical. And when I say largely empirical, I mean if a patient turns up with a fever they will receive ceftriaxone and quinine almost invariably. The actual manner in which patients are treated differs wildly too. In Scotland, every attempt is made to make patients as comfortable, informed and dignified as possible. Here, patients leave their dignity and comfort at the door. The wards are freezing cold at this time of year, some patients are kept outside on the balcony, attempts to explain to patients what is going on are few and practical procedures such as lumbar punctures involve no local anaesthesia and lots of manhandling the patient into the best position. Basically, conditions that would have Scottish patients screaming for their lawyer are tolerated without so much as a passing complaint. And the way I see it the fundamental difference is what we assume and expect from our healthcare systems. In Scotland, we assume access to the best possible treatments available on the NHS (and they, we assume, at least closely follow the best currently available treatments worldwide), and on top of that we hope (maybe even assume) to be treated like royalty the entire time. Here, patients seem to arrive in hospital simply hoping that some foreign tongued doctor will save them from death a while longer, and any hopes or expectations over and above that seem irrelevant. So different diseases, different presentations, different investigations, different drugs and an overall completely different approach to patient care. Its definately interesting, and if anything its really making me realise just how incompatible much of my western medical education is with practising medicine here. One thing I would really love to do though, is take a full Dundee-style history from a patient, complete with social and occupational details, explanations of how their illness (normally HIV) has affected their life, their perceptions of their illness and any concerns they have. I just don't know how the patients or translating clinical officers would feel about such an unusual, excessive and at times downright nosey history though. Its a shame, because at the moment the patients do not feel like real people with stories and emotions, just broken bags of strong signs and symptoms to be fixed. Maybe it's just easier that way here though.
We also get to do a lot more practical procedures here than at home. I've done two lumbar punctures already, and by the end I should be a pro at them, along with ascitic and pleural taps. It's also very easy to be genuinely useful, as while the ward has plenty of medical students, there are very few doctors and some of the doctors just ain't great.. So you can buzz around checking on patients and find things that have been forgotten or completely overlooked. Today I found a young girl whose IV cannula had fallen out and who had been fitting for 10 minutes, and gave her intramuscular diazepam, and another girl who had been noted to be extremely hypotensive but again whose cannula had fallen out, and so wasnt receiving IV fluids. I might just spend my days going from patient to patient checking cannulas. I wont be out my depth and I might even save a few lives!
So yeah, Malawi's shaping up to be a pretty worthwhile adventure. While I'm sure to forget everything about medicine that isnt HIV, tuberculosis or malaria, by the end of it I should be a bit of an infectious diseases hotshot. More importantly, it's just interesting to put the NHS into perspective. I'm with Amy, Rich and Jennie, and while we all didn't know each other particularly well before we landed in Lilongwe together, they're all very nice and fun and don't seem to find me too annoying (yet!). We all went out last Friday with one of the registrars from the hospital and danced on the grave of fourth year, we sit in the flat at night cooking each other dinner, drinking tea and talking about rubbish, and i'm looking forward to some nice trips away with them.