The Importance of Clarity: A Story

Today is fibromyalgia awareness day. I find it quite apt that this happens the day before Mother’s Day.

For as long as I can remember, my mom has suffered from pain. She has always been particularly sensitive to noise, bright lights and abrupt touch. It was only when we were little and clumsy that it didn’t seem to bother her. An overriding maternal instinct I suppose.

I inherited my migraines from Mom. I remember trying to occupy my little sister and baby brother when I was eight and nine, because Mom was in pain and I wanted her to rest and feel better.

 

I remember waking up in the dark hours of the morning with all the lights on, finding that our help had been asked to babysit us in an emergency, so that Mom could go to the ER for pain management. She had severe backaches.

I remember there were nights when Mom went to the ER twice, in tears. Returning with no more than a diclofenac injection.

Mom’s pain is one of the reasons I have trust issues with doctors. For more than a decade, while Mom had exhausting and debilitating pain, she was not referred for a single X-ray. Her hands, swollen with osteoarthritis, were not looked at. She was told, “Ma’am, it could be so many things.”

As if that was a reason not to do a pain workup.

When I came to med school I became more and more convinced that Mom needed a better doctor. Little by little I learned new things: backache is bad. Night pain is bad. Patients deserve a diagnosis.

Last year we learned about fibromyalgia. And I knew, this was it.

In early January, while I was home for the holidays, Mom returned from shopping in tears. She was in pain again. I took her to the new doctors’ complex in town and made an appointment with the youngest doctor on duty.

She was from a school I trust. And I trust the young doctors: they are all too aware of their shortcomings and afraid of litigation. They will rather perform too many investigations than too few. And in this case, it was what Mom needed.

She struggled to get a history because Mom was crying. I don’t know how much of it was pain and how much of it was relief at meeting a doctor who didn’t tell her it was all in her head.

It’s five months later and Mom has a diagnosis. It’s not a diagnosis many people believe exists. There are some doctors who believe that FM doesn’t exist. But I look at my mom – an exceptionally strong woman who gave birth without pain medication and refuses to go for stitches when injured – and I simply can’t agree with them.

Mom is on medication now. It mostly keeps her pain under control. She is part of a Fibro trial, where she is receiving remarkable help.

Mom is emotionally better too. She has a physician that cares about more than just her blood pressure. Oh, and her OA is being managed too.

I want to be like that. I know there are many contentious diagnoses out there, but I want not to be blind to that which I do not necessarily understand.

Here’s to the exceptional people struggling with pain every day. I salute you.

TB Awareness Month

March is South African TB Awareness Month. Tomorrow is World TB Day. I cannot remember a time in my life that I was unaware of this disease, or a time where I was not afraid of it.

I want my patients to be more aware of the risks. I want people to stop thinking that just because they are wealthy or HIV-negative, they cannot get it.

I have seen too many people struggling through horrible drug side-effects.

Today, please do yourself a favour and become more aware of TB warning signs. Night sweats, unexpected weight loss and an unremitting cough should warrant a visit to the doctor.

In Honour of Family Medicine

Today I leave for a two week family medicine rotation in a small rural town in the Western Cape.

This year, family medicine will supposedly be a lot more fun than in third year. Calls will be a mish-mash of every rotation. Lady in labour? We catch it (yay!). Stitches, we do it (uh-oh…).

Here’s something I have learned about family medicine:

If a young lady of reproductive age enters the consulting room with her mother and claims to have a headache, you politely ask the mother to leave the room. You can then expect the girl to admit that she actually has a discharge.

It sounds terribly stereotypical, doesn’t it? But in primary care this is such a common finding. Several times last year I would do a full headache workup, find nothing, counsel the patient, prescribe analgesics and tell her to return should it not improve. And, just before she gets up she would say, “uhm, doc, there’s this discharge…”

First Psych Consult

At a recent community volunteer clinic, I had my first proper psych patient. I have dealt before with suicide attempts, but those were unconscious patients in casualty and thus did not present the opportunity for a consultation.

This patient came for help herself – something I though was a good sign. Her affect was blunted and she was clearly depressed. There was a positive history too.

Nevertheless, I initially assessed her as low-risk. She wanted a referral to a psychiatrist and I was happy to give it to her.

Realising that I have not yet done a practical psychiatry rotation, I asked a senior student for a consult. Good thing too. He assessed her as high-risk. I had forgotten to ask about death ideation and suicidal ideation.

Things I learnt?

1. Know when you don’t know;

2. Brush up on psych;

3. There is a reason they make us study for centuries.

We See a Light

As part of Infectious Diseases, we must learn about Syndromic Management. It is not the best approach for a qualified doctor, but it is important to understand – especially in a primary health care setup.

During one of these tutorials, the doctor in charge made us close our books and asked us about our approaches to the full waiting room and the possibly accute patient.

We answered well.

She told us we had good seventh senses. The seventh sense? Common sense.

Then she said: “Going by your answers, you are pretty much safe to go work in a clinic.”

We just sat and stared at her. Eventually we realised, “This woman has just complimented us. She just called us almost-doctors.”

I wish someone could take an f-MRI of our brains at the time. I bet you it would be alight and a-buzz and happy.

This doctor probably gave us enough motivation for the rest of the year. Why can’t they all be that nice?

Antibiotics: So Now What?

Reuters reports that antibiotics are not useful for most sinus infections. Excessive prescription of antibiotics has lead to large-scale resistant organisms.

Okay, this I know.

But now what? Antibiotics make patients feel better. A frequent sufferer of sinusitis, I know this. So now my patients walk away from a consultation feeling that their doctor doesn’t care about their suffering. I don’t see many doctors being happy with that.

Secondly, complications of untreated bacterial sinusitis are sever. Think meningitis, abscess formation, cellulitis. What if that happens because I didn’t prescribe antibiotics?

The logical solution seems to be taking a swab. But state healthcare simply cannot afford to process a swab for every sinus infection. Even my own medical aid can’t afford that.

So I ask again: NOW WHAT?

The Anti-Valentine #2

It’s STI/Condom awareness week in South Africa! I find it mildly amusing that this takes place during Valentine’s Week – whether that was intended as a buzz-kill is debatable. 

STIs and especially HIV is huge in South Africa. If you’re new to this blog, click here for more of my related posts.

A lot has been said and asked about our population’s failure to clamp down on our alarming statistics. The poster below gave me one more answer to that question: our health education sucks! This infographic, in my opinion, is excellent. And it is the only of its kind that I have seen.

Health Education Posters are generally too crowded with information, aesthetically displeasing and carry a punitive or patriarchal tone.

Hence, view the miracle below:

Le Document Pour MB.ChB.III

The inspiration for this document came during my second year while studying for an end-of-block test. At the same time, the then-first years were studying for Pathology, aided by “Le Document”. Somewhere in this time period I looked at a fellow second year, threw my hands in the air rather dramatically and exclaimed,

“I wish I had a Le Document for Second Year!”

Le Document pour MB.ChB.II can be found here. It focussed mostly on holistic wellness during a tough theoretical year. Third year is a whole new ballgame, with students finally set wild in the clinical environment. Theory modules are unfortunately still a reality and at my school, third years are haunted by Neurosciences and Musculoskeletal System.

I throughly enjoyed this year and fortunately I had some older friends who had some handy tips. Thus, some advise for new third years:

Do not freak out if you struggle to draw blood. Practice will make perfect. Accept any challenge, but look out for patients with good veins – they will boost your confidence.

Do not freak out if nurses know more than you do – chances are they have been practicing  longer than you have been alive. Respect them: they can either help you a lot, or make life extremely difficult for you.

ARVs are not a joke. Stressing for an HIV-test isn’t either  Never fool around with a contanimated needle or specimen.

OBSTETRICS: wear a mask when delivering a baby, amniotic fluid does not taste very nice. Always remember tbe infection risk. Wear goggles or a visor and an apron too. Note that if a lady comes in crowning it is not always possible. Remember that the mothers do all the work, it is your job to help them. Remember you are working with lives, always. If told to deliver a multipara, check twice with a doctor or matron.

Ask to take a picture of your first baby, you will not regret the memory.

PAEDS: little humans are resilient, but not made of steel. Be sure you know how to do procedures on them – do not attempt to draw blood from a little human with a syringe. Do not perform a procedure in their cot – it is the only safe place they have. For your own emotional well-being, try not to get too attached. And beware the paediatrician - just because they love kids does not mean they love you.

INTERNAL MEDICINE: this rotation is competitive and exhausting. Try to be on your supervisor’s good side. Take initiative. Look interested. Go the extra mile. Wear comfortable shoes. Read up about all cases on your firm, not only those of your own patients. These are good principles anywhere, but especially important in Internal.

Never underestimate the importance of a good history and a basic physical. If you don’t know what to do, start there. Have a method to your investigation, and a structured presentation.

FAMILY MEDICINE: Do not scowl at this rotation, there is a remarkable load you can learn here , especially if you learn to respect the multidisciplinary approach. Be well prepared for site visits, take sturdy shoes and hand- sanitisers. Take the time to understand you patients’ psyche and sociology, there are not many blocks that cater for this.

SURGERY: not my favourite rotation. Apparently doctors fall into one of two groups: those who love surgery and those who despise it. Surgeons can be scary and temperamental, but try to learn as much as possible. Attend tutorials even if it is easy to slip out. Assist in surgeries even if other students are willing to relieve you of your duties. Do not stress about assisting, you will be told what to do. Most importantly, know how to scrub in and practise your suturing.

With so much practical, theory becomes mundane. Do not lose sight of your goal. Attend classes. If you get bored, look for blogs, student sites or books to pique your interest. For example, The Brain that Changes Itself promises to be a great addition to neurosciences. A Life in Pieces is exceptional for psychiatry. Three Letter Plague as well as Disease are gripping. Musculoskeletal system requires great effort. Colour in, draw, use your friends’ anatomy and don’t let the skeleton stay in the closet.

Third year is wonderful and can ignite your passion for medicine once more. However, you must take good care of yourself. Sleep often, eat well.

And don’t forget your stethoscope.

Grouchy Smurf is Grumpy: On Globally Relevant Research

I’m a bit of a Grinch. Or a grump, or maybe just a cynic.

Anyway, I read this article about how poor dental health can lead to pneumonia, therefore you must brush your teeth twice a day and floss once a day. The research was done by the Yale University School of Medicine, so I don’t for a moment doubt its legitimacy. They were also open-minded enough to mention that the precise relationship between oral bacteria and pneumonia must still be determined.

However, I fail to see the importance of such research in the context of health in the 21^st century.

The countries where the general standard of living is high enough to worry about regular teeth brushing also happen to be the countries where health care is of such quality that pneumonia need no longer be a death sentence.

It is the countries where the majority population is so poor that they can hardly afford porridge – never mind toothpaste – that pneumonia is also a much greater threat to a person’s health.

In my country – which happens to be considered one of the wealthier African countries – it is thought that at least 40% individuals live on less than ZAR8 (that’s 1USD) a day. A loaf of bread costs ZAR9,50. A carton of milk costs ZAR10.

So where on earth are they supposed to get ZAR18 for a toothbrush, or ZAR12 for a tube of toothpaste, or heaven forbid, ZAR30 for some dental floss?

All practical considerations aside, there is another reason that other health considerations are more important than oral health. Remember Maslow’s Hierarchy? The theory is that only once basic needs are fulfilled, can one move on to social needs and eventually self-actualisation. And when one has to choose between feeding your crying child a bowl of porridge or keeping their pearly whites pearly… you know what’s gonna win.

Then there’s public healthcare, which is in many areas not up to scratch. I daresay an inpatient has a greater chance of contracting nosocomial pneumonia than getting it from poor dental hygiene. Never mind the incidence of AIDS-related pneumonia.

I get that this research was done in a different country, but I believe that in the 21^st century medical research should aim to be globally relevant if we want to improve the state of our large, interwoven society.

Inspired by the Elderly

After you’re older, two things are possibly more important than any others: health and money. 

Helen Gurley Brown

I am currently on my Family Medicine Rotation. We visited a nearby old-age home yesterday. I was not really looking forward to it, but it blew my mind.

I love old people. I love hearing their life stories and when I was little, my granny and I often visited a nearby old-age home. I like to think I brought some joy to some old people who could no longer talk and who had no other visitors than Grandmother and the tiny blond-haired girl.

Anyway, the old-age home my group visited yesterday is a sub-economical home. One-hundred-and-forty of their 153 residents are state patients. It has three levels, but no elevator. It has one registered nurse on duty at any one time.

I did not like the smell as we walked through the corridors. And I did not like the way the hope dimmed in some of their old eyes when they realised that we weren’t visiting grandchildren.

The geriatrician had some patients talk to us.

We met someone with Parkinson’s Disease – the first time I have ever encountered this. We met a lady who looks and sounds like she is in her 60s, but is actually 86 and has raised eight children. And we met a gentleman who grew up in the Congo and has the biggest smile and the most adorable raspy voice.

He was quite funny. The doctor told him, “These are young doctors, tell them what is your problem.”

To which he gave us a quizzical look and demanded, “What is your problem?”

He told us that he was born in 1914 and when he saw our amazement he laughed, “Mandela is a little behind, yes!”

"Vetmaak Hoekie" or "fattening corner": the sign above the tuck shop in the home.

South Africa is very behind with geriatric care. Do you know that there are only ten geriatric specialists in the entire country? Surgeons here will not touch an “old person”, even though it has been shown that the elderly simply need to be prepared better for surgery.

South African politicians do not care much for the elderly – they do not hold many votes or much money either.

I find this so sad. Every elderly citizen contributed somehow to our country. They deserve some more respect.

I enjoy Family Medicine – it is so much more than science. This is ART.