Indian dilemmas Part III

This is a sequel to Part I and Part II...
I perused the police woman’s brown eyes. She intentionally drew them away from me, extracting threads of sorrow from my heart. As her doctor, what was my obligation? As a visiting stranger to this society, did that change? Was she my patient, or was it the family, the community? If I opened my mouth, if I tried to change the course of history, if I defended my patient, would I be regarded as an intruder, a foreigner who didn’t understand the social norms? Or as a champion of womens’ rights? Would my impact be positive? And if she remained pregnant, where would she go? Who would accept her?
She could have walked up and left the hospital. She could have refused to come in. But she was a single woman, pregnant out of wedlock, in a small town in rural India. Locked into her place in society by social norms, economic restrictions, familial expectations. She could have walked away from this town, caught a bus to Bombay, given birth to her child. But what is a life disconnected from your family, your love, your village?
A wave of nausea rose from the depths of my gut. Guilt shrouded my skin with a cold, tingling blanket. I swallowed lumps of shame. I squeezed her hand once more and in broken Gujarati, said,
“I’m sorry. I’m sorry they are doing this to you.”
She looked away. Her silence was palpable, like the slowing heartbeats of the fetus inside her.

Indian dilemmas, Part II

This is a continuation from yesterday's post, Indian Dilemmas, Part I...

Two weeks previously, loneliness had grasped me by the cuff of the neck and deposited me in a drab gray room on the other side of the world. It had been nightfall in Jhagadia. Outside I heard the muffled barks of dogs, subdued moos of cows, the shuffling play of children, the hushed arrival of sleep upon a small village in Gujarat. Through my one open window high up in the 10 by 10 foot room wafted in the smell of India—musty, sweaty, humid, yet fresh and crisp—the smell of my shared ancestry.
At first, the walls of concrete encasing me devoured my spirit. A week ago, I had been driving through the latest snowstorm in Boston—navigating the twenty five miles between my home in Somerville and my residency program in Lawrence. A week ago, I had been a second year family medicine resident in a mill-town close to the New Hampshire border. Today, I was a “doctor” here to help and learn at this non-profit hospital. Today I was thousands of miles from anyone, anything I knew. I comforted myself by reminding myself that I was a “doctor in training”—I was here to learn, and could not be held responsible for my mistakes. I wondered if this was the right decision. I wondered what I could do about it if I discovered it wasn’t. My ticket back wasn’t until a month later.
It was my first night in India alone—ever. I had always been here with family. My bones, my blood, my lineage were descendant from the vapors of this air, from the dust of this land; however in that moment I was a foreigner. A foreigner who expected to be at home in a place that birthed her ancestors, germinated her culture, shaped her values from afar over the traditions of centuries echoed into the words and mannerisms of her parents, trickled down into her spirit. And to be alone in a land which metaphorically birthed me was to be inexplicably, interminably lonely.
After all, I had left Somerville, MA almost two days before. Boston to Frankfurt to Bombay, followed by a turbulent flight to Ahmedabad, gorgeous train journey to Jhagadia, a bumpy rikhshaw ride to the SEWA-rural hospital campus. Time eclipsed my short-term memories like a rain cloud on a sunny day, abutting this remembrance against that one, this luggage transfer into that, this meal into that, this day into that—and when had been the last time I had slept more than two hours?
From the first moment I had laid eyes on the poverty of India as an adult during my first year of medical school, my mission had been to ultimately come back to India and work with “my people.” In the interim, I had finished medical school, learned about international health during my Masters in Public Health year, had started my residency in family medicine. I had even worked and delivered health care in Ghana, Ecuador, El Salvador. But in all these places, one thing had always been missing—my desire to give back to my own people, my feeling that somehow delivering healthcare in my native language to my native people would strike a chord even closer to my heart.
Now that I was here, I felt like I was running blindfolded off the edge of a cliff wondering if I would hit warm water or rocks down below....

Indian dilemmas Part I...

An "excerpt" from the middle of my new book:
Her 26 week pregnant belly lay still on her recumbent body, a mountain in a motionless room. Although the tiny labor room with two metal stretchers often bustled with activity—women with pregnant bellies wrapped in multi-colored saris moaning quietly on the stretchers, the floors, against the walls—at this moment, it was just her and I—a patient and her physician. I shifted uneasily from one foot to another as my eyes scanned the tiled walls, the linoleum floor, the low ceiling, her gravid abdomen, landing on her lovely face. Her eyes were unmoving, focused on the cracked paint on the white ceiling above her, unblinking, moist with tears that had no beginning nor end.
I had so much to say. Gujarati was my native tongue—the first language I ever spoke. I have memories of trying to communicate in Gujarati with my British kindergarden teacher in London, being met with little understanding. Since those days, my abilities in English have far surpassed those in my ancestral language. In Gujarati, I could say “Does it hurt here?” or “Do you have a cough,” or “Breathe deeply.” But that’s not what I wanted to say to her.
She was different than the other patients I had seen so far at this hospital: her skin was fairer, she had fewer wrinkles under her eyes, she wore a blouse and a skirt instead of a sari. Unlike the other women, she was not exposed to the elements every waking hour of the day. And in her differences, I felt a kinship, a sisterhood. She was a police officer after all—used to disciplining others, serving justice. Like doctors, police officers are servants of the community. Today the tables were turned—it was her moment of judgment. Her crime was amongst the commonest: love Her punishment was to be amongst the harshest. And even in that moment of tragedy, her feminine beauty radiated through.
As she lay powerless on the stretcher, I squeezed her reluctant hand. It was soft and warm. She had short shoulder-length black hair, very untraditional for this tiny village in India. Her neck bore a gold chain with an Om pendant. A gift from him? Her ears had gold stud earrings. A soft touch of pink lipstick had almost faded away from her lips.
An IV bag containing hypertonic saline—salt water in a concentration incompatible with human life— hung on a pole beside her bed. The catheter snaked towards her pregnant belly, disappearing into its depths where her fetus lay curled up in its warm amniotic fluid, naively drinking this newly introduced poison. I had never heard of a hypertonic saline abortion before I came to India. One of the medical residents explained to me that it was the best way to perform a late term abortion in this hospital with few resources.
Late term abortions—actually any abortions—were controversial in the U.S. The idea of the rights of an individual woman were muddled with the desires of society, religion, morality, politics. In a country where individualism was valued, a constant debate lingered about whether a woman ultimately should have control over the insides of her own body. In India—considered “third world” to those in the U.S., abortion access was more widespread. The moral issues there revolved around sex-discrimination abortion which was outlawed—performed upon women whose families preferred sons to daughters, heirs to raising funds for dowries. But alas, in India too, despite being legal in most circumstances, abortion was not an empowerment of the individual, but rather a societal and community decision. Parents brought in their teenage unwed daughters, husbands brought in their wives bearing female fruit, males decided the fate of the lesser educated gender. Perhaps in Bombay, it was different—single women dressed in the latest New York fashions, drinking cosmopolitans and smoking cigarettes as they flirted with men at the trendiest bars probably made their own decisions. But alas, I was not in Bombay, but in the heart of rural India.
This policewoman had been in love with her coworker. Already promised in marriage to her cousin, he had by obligation married this other woman and now had three children with her. Yet, love, with its unstoppable tentacles continued to entwine them both and now she was pregnant—two weeks past legal viability in the U.S. Unless her life were in danger, she would not be allowed to abort her fetus in the country where I lived. Here, in Jhagadia, her family had brought her in—a full-grown woman in her late twenties, with a well-paying job— to have an abortion against her will. Her lover had offered to take her as a second wife to allow the birth of this child, but her father had disapproved, threatening suicide. So here she was—a woman the same age as me—about to be buried in a cave of despair.
I thought back to how I had arrived here—at this tiny hospital in this tribal village—in this place in life where I had more choices than most of the Indian women who lived in the country of the origin of my genes.....

You can only take care of others if you take care of yourself...

Today, I penned February 1st, 2010 on about 50 pieces of paper at work.
In fact, I found myself writing 1/-- and correcting myself to 2/1/2010...at least I'm finally getting used to the 2010 part.
Recently, I wrote a post on physician burn-out and I wanted to update my thoughts on this.
As a caregiver in the service field, I feel I function most effectively when I have taken care of myself first. It involves the same suggestions I have for my patients: being active, eating healthy, sleeping enough, having a good support system. "You can only take care others if you take care of yourself first." How many times have I said this sentence to each of my patients? Actually, not that many times in English. Mostly in Spanish. But you get the idea.

Living by this ideal is sometimes harder than it appears. I had to take a good look at myself near the end of last year, and decided to cut myself some slack--starting January 1st, I cut back my hours slightly--only 3.5 hours less a week. But it has made a world of difference, allowing me to sleep more, exercise more, and most importantly, smile more.
And when I smile when I'm in the room with a patient, I've noticed it makes all the difference in the world.

So to all the other caregivers out there, I hope you are taking good care of yourself. Just a half a day break a week has made me infinitely more emotionally present with my patients. And that makes me love my job more. And after all, I'm in this because I love it, right?

I've started writing my new book...

This is a teaser...a small excerpt from my new book...creative non-fiction about the "Making of a Primary Care Doctor"...This piece will go somewhere in the middle of the book....

**************


Destiny is 15 years old. She is black. She weighs about 200 pounds and is lying naked from the waist down on the exam table. I can barely tell she is seven months pregnant. She is in Gynecology clinic today for a colposcopy because she had an abnormal PAP smear. A colposcopy is a test in which a doctor places a speculum in a woman’s vagina and applies vinegar to her cervix to better visualize any abnormalities that may need to be biopsied. As a third year medical student in my Gynecology rotation, I am mostly watching colposcopies.


Kathy is a tall, slender 2nd year OB-Gyn resident. She has blond wavy hair that brushes past her shoulders and pretty blue eyes.

“OK, Destiny, I need you to slide down the table so I can put the speculum in,” she instructs. Destiny shifts her large pregnant body a few inches down the table. Her legs are spread wide open and up in stirrups.

“You need to move down a little more.”

Again, Destiny sluggishly lifts her large buttocks against the edge, her dark ebony skin against the rumpled white paper on the exam table. Kathy opens up a large metal speculum—long and round, shiny and cold, and squirts a couple of drops of lube on top of it. She moves it towards Destiny’s vagina. As soon as Kathy touches her legs, Destiny flinches her body away from the edge again. Kathy lets out a droning sigh.

“C’mon! You need to move down again. And stay still.” Destiny inches towards the edge again. Kathy moves the speculum towards her, like a loaded gun. Destiny jumps.

“You need to stay still!” Kathy raises her voice. “You let a penis in there—this is much easier than that!”

My inner eyes open in horror as I take in the scene. My outer eyes scan the tile floor in embarrassment. I wonder how this teenage girl got to be here—on the South Side of Chicago, on the wrong side of the tracks in the journey of life, pregnant and uneducated and very very young. I wonder who the father of the baby is. I wonder if she was raped. Is it ever really consensual sex at age 15? Does a girl really know what she is getting herself into when she lets a penis navigate her most intimate orifice before she is even legally allowed to drive a car? If she were a different race, if her parents were richer, if she had had better access to birth control, would she be lying here pregnant and with an STD with a tall white woman towering over her trying to molest her with a speculum? Most of all, I wonder—is this what I will turn into when I am a certified doctor? I am ashamed of my profession. I am ashamed that I do not have the courage to speak up against this resident to protect this young girl. Under my breath, I promise myself that I will never be this kind of doctor. But I also know that only time will tell.

Vitamin V

Given that I have had many requests in the past couple of weeks for Vicodin (and a couple more for Viagra), both of which sell for a pretty price on the street, I found myself rolling on the floor with this U-tube video...It's a MUST WATCH for all physicians, and highly amusing for others...

physician burn out

Did you know there are actually studies and scales out there that measure physician burn-out? What exactly is physician burn-out? A lot of studies define it as "emotional exhaustion." And why am I writing about it? Because, on some level, I am worried I may myself be approaching the two words that none of us like to utter.

Now some perspective on this is useful. While working an average of 60 to 80 hour weeks in residency, I saw some physicians who were "burned out," meaning less capable of doing their jobs effectively because their jobs had consumed them emotionally (and perhaps even physically) over the years. This is a common phenomenon in primary care: with very little time per patient spent trying to address complicated patient complaints, and much more time spent charting and addressing paperwork directed at us from patients themselves, the state disability board, pharmacies, insurance companies, the list goes on and on... Burn out is especially common at community health centers like the place I work because our patients are more socially marginized, which means that there is a higher rate of depression/anxiety/chronic disease/psychosomatic complaints. All these issues are much more emotionally exhausting than, for example, taking care of the middle or upper class worried well who come in with their Google articles demanding their brain MRIs for tension headaches. Not that I would prefer to work with the latter--I certainly don't--at least not yet. When I was a resident, and as yet naive and idealistic, I felt that burn-out would never happen to me.

And now, eight years out of medical school (wow, that impresses me even more than you, believe me--am I THAT old?) I feel like I can start to see how burn-out might possibly happen, even to people like me. I love my job. What I love most about it is the time I spend with my patients. Unfortunately, that time is becoming more scarce, and the pressure upon us in primary care to move faster and faster like automated robots is increasing. And with that pressure, and the need to be emotionally present for every patient times 25 patients a day x several days a week takes a lot out of a person.

My friends who are not in medicine joke with me and ask me when I'm getting my next massage or going on my next trip. But in fact, these are the things I do to self-nurture which replenish my emotional gas tank so that I can give again the next day. You can only take care of others if you take care of yourself--I learned that early on, and apparently I learned that very well.

And so, 8 years after I graduated from medical school, I have finally made the decision to slightly cut my hours at work. Starting January, I will be working a half day less a week, meaning that instead of working 55-60 hours a week, it will be closer to 50 hours most week. I know that sounds ludicrous, yet for many years I compared my current life to the crazy more hectic one I had in residency. It is only recently that I have normal friends that I realize that I want to have more nights and weekends off, like normal people and get closer to that magic 40 hours a week which seems like a dream in the horizon.

So, the answer is: No, I'm not burned out. And I'm doing my best to stay that way. Because I still love what I do.
But something in primary care needs to change soon, because this is not a good state of being for people who went into the profession as complete idealists. And my hopes are pinned on Obama. Please don't disappoint.